Adherence to Perioperative Antibiotic Prophylaxis Recommendations and Its Impact on Postoperative Surgical Site Infections.

Introduction Surgical site infections (SSIs) are common and carry a significant risk of morbidity and mortality and lead to increased healthcare costs. Perioperative antibiotic prophylaxis decreases the risk of SSIs. There are several guidelines on the use of perioperative antibiotic prophylaxis. The American College of Surgeons (ACS) recommends weight-based antibiotic administration within 60 minutes prior to (two hours for vancomycin/fluoroquinolones) incision and redosing by drug half-life. There are limited data regarding adherence to existing recommendations. Furthermore, there are scarce data on the relationship between adherence to recommendations and the risk of postoperative SSI. Objectives In this study, we aimed to assess the adherence to ACS guidelines for perioperative antimicrobial prophylaxis in the Seattle Children's Hospital (SCH) National Surgical Quality Improvement Program (NSQIP) pediatric cohort and to determine whether adherence to ACS guidelines is associated with a decreased risk of SSI. the secondary objective was to identify risk factors associated with SSI in our patient population. Materials and methods We conducted a secondary analysis of an institutional NSQIP pediatric data cohort between Jan 1, 2012, and Dec 31, 2017. We calculated summary statistics to assess adherence to ACS recommendations and fit a logistic regression model to identify factors associated with the risk of SSI. Patients who did not receive antibiotic prophylaxis were excluded. Results  A total of 6,072 surgeries among 5,532 patients met the inclusion criteria. Adherence was achieved for weight-based dosing in 35% of surgeries, administration prior to the incision in 91%, administration within 60 minutes (two hours for vancomycin/fluoroquinolones) in 86%, correct redosing in 97%, and to all recommendations in 29%. There were no significant associations between any adherence metrics and SSI, although confidence intervals were wide for some metrics. Factors associated with SSI when adherence was met included urgent case status, wound class 2 or 4, the American Society of Anesthesiologists (ASA) class 2-5, and surgery duration. Conclusion There was varying adherence to ACS recommendations on antibiotic prophylaxis in our cohort. More evidence is needed to better understand the effects of adherence to any or all components of the recommendations on SSI. We identified a group of pediatric patients at risk of SSI and a need for further research and targeted interventions.

Impact of Healthcare Disparities on Time to Surgery for Pediatric Urologic Patients.

Introduction Healthcare disparities are differences in health outcomes reflecting social inequalities. We aim to identify healthcare disparities in pediatric urologic patients by analyzing the time from surgical scheduling to completion of procedure at a single center and identify variables associated with increased time to surgery. Materials and methods We reviewed all patients aged 0-18 years who underwent surgery with one of three pediatric urologists at our institution from January 1, 2018, to December 31, 2019. We collected or calculated variables including age, sex, race, ethnicity, caregivers' primary language, insurance status, zip code, median distance to hospital, clinic visit date, and time to surgery (calculated as days between surgery request and date of surgery). Data analysis included bivariate analysis and linear regression with all variables of interest presented with 95% confidence intervals (CIs), where log-transformed time to surgery was the outcome. Because the practice at our institution is to delay elective surgeries until after six months of age, we excluded patients who were less than six months of age at the time of surgery request date. Results A total of 697 patients were included in the final analysis. Patients' caregivers who spoke languages other than English or Spanish had a lower model-adjusted mean log-days to surgery (-0.44; 95% CI: -0.85, -0.03) relative to English-speaking caregivers. Uninsured patients had increased time to surgery compared to Medicaid patients (0.28; 95% CI: 0.03, 0.53). Income was also associated with increased time to surgery, meaning patients from higher-income backgrounds had a longer time to surgery (0.04; 95% CI: 0.00, 0.08). Conclusions In our patient population, primary language spoken and insurance status were associated with increases in time from initial evaluation to surgical intervention among pediatric patients undergoing urologic surgery. Additional research is needed to better understand variations in access to pediatric urologic surgery.

Current Practice in Robotic Surgery Among Pediatric Urologists: A Survey Study.

Introduction: Since its introduction, robotic surgery has gained most traction among urologists. Pediatric urologists have been slower to adopt the technology than their adult counterparts. Our objectives were to understand current practice patterns for robotic surgery among pediatric urologists, to identify perceived barriers, and to identify factors associated with the use of robotic surgery. Methods: An anonymous online survey was administered using Research Electronic Data Capture (REDCap) to members of the Societies for Pediatric Urology (SPU) including questions about provider demographics and personal practice patterns. Comparisons were made using Pearson's chi-squared analysis. Results: Of 351 SPU members surveyed, 95 completed the survey (27%): 55 (58%) reported performing robotic surgery and 40 (42%) reported not performing robotic surgery. Twenty-seven (28%) reported receiving robotic training in residency, 26 (27%) in fellowship, 34 (36%) in a robotics course, and 30 (32%) with proctored surgery. Cited reasons for not performing robotic surgery were lack of training, referring to practice partners, and lack of benefit. Of those performing robotic surgery, most reported performing 0-1 or 2-4 per month. Thirty-one (56%) reported having selection criteria for use of the robot: 26 (47%) cited an age cutoff, 12 (22%) cited a weight cutoff, and 14 (26%) cited an abdominal size cutoff. Eighteen (33%) reported using hidden incisions endoscopic surgery (HIdES) approach and 40 (42%) reported using an assistant port. Factors associated with using the robot included surgeon age, years in practice, practice setting, having robotic training, and having practice partners who perform robotic surgery. Conclusions: Practice variation exists in the use and application of robotic surgery among pediatric urologists. The main self-reported barriers to performing robotic surgery are lack of training, referring to practice partners, and no perceived benefit to robotic surgery. Factors associated with performing robotic surgery were surgeon age, years in practice, practice setting, and having practice partners perform robotic surgery. There is no Clinical Trial Registration number associated with this study.

A survey of adult and pediatric urologists on current practice in antibiotic prophylaxis for ureteral stent removal.

INTRODUCTION: Recommendations for antibiotic prophylaxis prior to cystourethroscopy with manipulation are based on limited evidence and may not be applicable to procedures without tissue resection such as ureteral stent removal. OBJECTIVES: Our objectives were to investigate and compare practice patterns among adult and pediatric urologists on antibiotic prophylaxis for stent removal. STUDY DESIGN: An online survey was distributed to members of the Endourological Society (EUS) and Societies for Pediatric Urology (SPU) including questions about provider demographics and practice patterns. Adult urologists were defined as EUS member respondents and pediatric urologists were defined as SPU member respondents. Comparisons were made using Pearson's Chi-Square analysis. RESULTS: Of 2544 adult urologists surveyed, 258 (10%) completed the survey and of 714 pediatric urologists surveyed, 180 (25%) completed the survey (Table 1). Pediatric urologists report using antibiotic prophylaxis "most of the time" (i.e. ≥ 75% of the time) more often than adult urologist when removing stents by string or operating room cystoscopy but less often when removing stents by office cystoscopy. Pediatric urologists report using antibiotic prophylaxis "most of the time" more often than adult urologists after pyeloplasty, ureteroscopy and ureteral reimplantation. There is no difference in reported duration of prophylaxis between adult and pediatric urologists, with 64% giving a single dose. Pediatric urologists report obtaining a urine culture (UC) "most of the time" more often than adult urologists (32% vs 15%, p < 0.001), but there is no difference in reported use of antibiotic treatment by UC result. Sixty-four percent of survey respondents report giving patients with negative UC antibiotic treatment, and 93% of survey respondents report treating patients with asymptomatic bacteriuria (defined as patients with a positive urine culture but no symptoms) with antibiotics. DISCUSSION: There is variation in reported practice among surveyed adult and pediatric urologists regarding antibiotic prophylaxis prior to stent removal. Overall, pediatric urologists report using antibiotic prophylaxis prior to stent removal more often than adult urologists. CONCLUSIONS: This variation in practice combined with lack of evidence to support the use of antibiotic prophylaxis prior to ureteral stent removal underscores the need for additional research to guide the development of evidence-driven guidelines for both adult and pediatric patients.

Idiopathic non-ischemic priapism in an infant: A case report.

Priapism is a pathologic erection lasting >4 hours that is unrelated to or persists beyond sexual stimulation. Priapism is rare in children, and rarely reported in infants. Although a small number of cases have been reported in neonates, even fewer have been reported in infants outside of the neonatal period. Due to its rarity and poorly understood pathophysiology, the diagnosis and management of priapism in infants is challenging. We report a rare case of idiopathic non-ischemic priapism in a 9-month-old highlighting some of the challenges in diagnosis and management of priapism in this age group.

Eosinophilic Ureteritis in a Child With Ureteropelvic Junction Obstruction and Vesicoureteral Reflux.

Eosinophilic ureteritis is a rare cause of ureteral obstruction, and to date the diagnosis can only be made on pathologic examination. The true underlying cause is not well understood, but there may be some association with eosinophilia, atopy and/or trauma. We present a case of a two-year-old boy with ureteropelvic junction obstruction (UPJO) and ipsilateral vesicoureteral reflux (VUR) found to have eosinophilic ureteritis. To our knowledge, this is the youngest reported patient with this finding, and the only patient with eosinophilic ureteritis causing UPJO with concomitant VUR.

Simulation Training in Urology: State of the Art and Future Directions.

There has been a major shift from the old paradigm of 'see one, do one, teach one' in medical training due in large part to resident work-hour restrictions and required oversight in the operating room. In response to this, advancements in technology have allowed for the introduction of more objective measures to assess the skill competency and proficiency of surgical trainees. Patient safety and trainee well-being are important drivers for this new model, and so surgical training programs are adopting simulation into their curriculum. Urology is uniquely positioned at the forefront of new emerging technologies in surgery, because of the field's commitment to safe and efficient minimally invasive surgery and endourological procedures. Due to these technically challenging procedures, urological training must incorporate these educational technologies to allow for objective skills assessment, skills transfer, and ultimately providing optimal patient care with the production of proficient and competent urological trainees.

Massively Dilated Lower Pole Ectopic Megaureter with Involuted Lower Pole Renal Moiety and Collecting System: An Exception to the Meyer-Weigert Rule.

Duplicated collecting systems have a predictable draining pattern that is described by the Meyer-Weigert rule. When there are abnormalities associated with duplicating collecting systems, the upper pole moiety drains inferomedially (most commonly associated with obstruction), and the lower pole moiety drains superolaterally (most commonly associated with vesicoureteral reflux). We present a case of an infant with a duplicated collecting system that violates the Meyer-Weigert rule with lower pole megaureter with massive dilation, ectopic insertion, and associated involuted lower pole renal moiety. To our knowledge, this is the only reported case of a lower pole ectopic ureter with an involuted lower pole renal moiety.

Validation of an Electronic Surveillance Algorithm to Identify Patients With Post-Operative Surgical Site Infections Using National Surgical Quality Improvement Program Pediatric Data.

BACKGROUND: Surgical site infections (SSIs) are common, but data related to these infections maybe difficult to capture. We developed an electronic surveillance algorithm to identify patients with SSIs. Our objective was to validate our algorithm by comparing it with our institutional National Surgical Quality Improvement Program Pediatric (NSQIP Peds) data. METHODS: We applied our algorithm to our institutional NSQIP Peds 2015-2017 cohort. The algorithm consisted of the presence of a diagnosis code for post-operative infection or the presence of 4 criteria: diagnosis code for infection, antibiotic administration, positive culture, and readmission/surgery related to infection. We compared the algorithm's SSI rate to the NSQIP Peds identified SSI. Algorithm performance was assessed using sensitivity, specificity, negative predictive value (NPV), positive predictive value (PPV), and Cohen's kappa. The charts of discordant patients were reviewed to understand limitations of the algorithm. RESULTS: Of 3879 patients included, 2.5% had SSIs by NSQIP Peds definition and 1.9% had SSIs by our algorithm. Our algorithm achieved a sensitivity of 44%, specificity of 99%, NPV of 99%, PPV of 59%, and Cohen's kappa of 0.5. Of the 54 false negatives, 37% were diagnosed/treated as outpatients, 31% had tracheitis, and 17% developed SSIs during their post-operative admission. Of the 30 false positives, 33% had an infection at index surgery and 33% had SSIs related to other surgeries/procedures. CONCLUSIONS: Our algorithm achieved high specificity and NPV compared with NSQIP Peds reported SSIs and may be useful when identifying SSIs in patient populations that are not actively monitored for SSIs.

Pre-operative skin antisepsis with chlorhexidine gluconate baths and wipes does not prevent postoperative surgical site infection in outpatient pediatric urologic inguinal and scrotal surgery.

INTRODUCTION: To reduce surgical site infections (SSI), many institutions utilize pre-operative antisepsis with chlorhexidine gluconate (CHG) baths and/or wipes. CHG reduces bacterial colonization of the skin, but it is unclear whether this reduces SSI, and current guidelines from the American College of Surgeons, the Centers for Disease Control, and the World Health Organization do not support this practice. There are several factors that increase the risk of SSI in adults, but there is limited understanding of these factors in pediatric patients. OBJECTIVES: The primary objectives were to describe the proportion of pediatric patients undergoing hernia/hydrocele repair and/or orchiopexy who develop a postoperative (postop) SSI and to determine whether pre-operative CHG baths/wipes were associated with SSI. The secondary objectives were to identify other factors associated with SSI and to estimate the cost of CHG baths/wipes in this population. STUDY DESIGN: Pre-operative antisepsis with CHG baths/wipes was implemented at the authors institution in 2006. The authors performed a retrospective cohort study of patients aged 0-18 years undergoing hernia/hydrocele repair and/or orchiopexy by a pediatric urologist at their institution before (2004) and after (2008) the introduction of CHG. The authors compared the proportion of patients with SSI in the no CHG and CHG groups and evaluated for factors associated with SSI. Statistical analysis included Wilcoxon rank-sum test, Chi-squared test, and Fisher's exact test. The cost of CHG baths and wipes was estimated using institutional fees in 2018 US dollars. RESULTS: A total of 543 patients met inclusion criteria, 203 in the no CHG group and 340 in the CHG group. The overall rate of SSI was 0.92%. There was no association between use of CHG and SSI. No patient or peri-operative factors were associated with development of SSI. There were no CHG-associated adverse events. The cost of materials was estimated at $3.29/patient ($1118.60 for 340 cases in 2008) in 2018 US dollars. DISCUSSION: SSI is not common in pediatric patients undergoing hernia/hydrocele repair or orchiopexy. In the present study, pre-operative antisepsis with CHG baths/wipes is not associated with a reduction in SSI and carries additional cost. CONCLUSIONS: To the authors knowledge, this is the first study to evaluate the use of pre-operative antisepsis with CHG baths/wipes in an exclusively pediatric population. In the study, CHG baths/wipes add cost with no clear benefit for reducing SSI in pediatric patients undergoing hernia/hydrocele repair and/or orchiopexy.

Antibiotic prophylaxis at the time of catheter removal after radical prostatectomy: A prospective randomized clinical trial.

OBJECTIVE: To evaluate the role of antibiotic prophylaxis with oral ciprofloxacin prior to urinary catheter removal after radical prostatectomy in preventing urinary tract infection (UTI). MATERIALS AND METHODS: Patients undergoing radical prostatectomy were prospectively enrolled and randomized to either the antibiotic prophylaxis group (2 doses of oral ciprofloxacin prior to urinary catheter removal) or the control group (no antibiotics given prior to urinary catheter removal). Neither patients nor study providers were blinded to the group. The primary objective was to assess for development of UTI. The secondary objective was to assess for development of Clostridium difficile (C diff) enterocolitis. Continuous variables were compared using a 2-sample t test. Categorical variables were compared using Pearson's chi-squared test or Fisher's exact test. RESULTS: One hundred seventy-five patients were enrolled and randomized (90 control and 85 antibiotic prophylaxis). After randomization, 4 patients were excluded and 4 patients withdrew voluntarily. One hundred sixty-seven patients (84 control and 83 antibiotic prophylaxis) completed the study and were available for analysis. There were no significant differences in baseline characteristics, perioperative data, or complications. There was no significant difference in the rate of UTI between the control group and antibiotic prophylaxis group (5.95% vs. 6.02%, P = 1). There was also no significant difference in the rates of C diff infection between the control and the antibiotic prophylaxis groups (3.57% vs. 0%, P = 0.21). CONCLUSIONS: In this prospective, randomized, controlled trial, the use of antibiotic prophylaxis with oral ciprofloxacin prior to urinary catheter removal after radical prostatectomy did not decrease the rate of UTI, and was not associated with an increased incidence of C diff enterocolitis.

Expression of the Long Non-Coding RNA HOTAIR Correlates with Disease Progression in Bladder Cancer and Is Contained in Bladder Cancer Patient Urinary Exosomes.

Exosomes are 30-150nM membrane-bound secreted vesicles that are readily isolated from biological fluids such as urine (UEs). Exosomes contain proteins, micro RNA (miRNA), messenger RNA (mRNA), and long non-coding RNA (lncRNA) from their cells of origin. Although miRNA, protein and lncRNA have been isolated from serum as potential biomarkers for benign and malignant disease, it is unknown if lncRNAs in UEs from urothelial bladder cancer (UBC) patients can serve as biomarkers. lncRNAs are > 200 nucleotide long transcripts that do not encode protein and play critical roles in tumor biology. As the number of recognized tumor-associated lncRNAs continues to increase, there is a parallel need to include lncRNAs into biomarker discovery and therapeutic target algorithms. The lncRNA HOX transcript antisense RNA (HOTAIR) has been shown to facilitate tumor initiation and progression and is associated with poor prognosis in several cancers. The importance of HOTAIR in cancer biology has sparked interest in using HOTAIR as a biomarker and potential therapeutic target. Here we show HOTAIR and several tumor-associated lncRNAs are enriched in UEs from UBC patients with high-grade muscle-invasive disease (HGMI pT2-pT4). Knockdown of HOTAIR in UBC cell lines reduces in vitro migration and invasion. Importantly, loss of HOTAIR expression in UBC cell lines alters expression of epithelial-to-mesenchyme transition (EMT) genes including SNAI1, TWIST1, ZEB1, ZO1, MMP1 LAMB3, and LAMC2. Finally, we used RNA-sequencing to identify four additional lncRNAs enriched in UBC patient UEs. These data, suggest that UE-derived lncRNA may potentially serve as biomarkers and therapeutic targets.

Effectiveness and safety of extended-duration prophylaxis for venous thromboembolism in major urologic oncology surgery.

PURPOSE: To examine the association between extended-duration prophylaxis (EDP), low-molecular-weight heparin prophylaxis for 28 days after surgery for urologic cancer in patients at high risk of developing a venous thromboembolism (VTE), the risk of VTE, and the complications resulting from VTE prophylaxis. MATERIALS AND METHODS: The cohort included 332 patients at high risk for VTE who were surgically treated for urologic cancer from June 2011 to June 2014. Adherence to VTE prophylaxis protocol, VTEs, and complications within 365 days from surgery were tracked. Patients were grouped as follows: (1) per protocol in-hospital prophylaxis with EDP (n = 107), (2) per protocol in-hospital prophylaxis without EDP (n = 42), (3) not per protocol in-hospital prophylaxis with EDP (n = 83), and (4) not per protocol in-hospital prophylaxis without EDP (n = 100). The risk of VTE was compared between the 4 groups using the Cox model, with adjustment for baseline risk factors. RESULTS: The rates of VTEs and median times to VTE were 7% and 58 days in group 1, 17% and 44 days in group 2, 17% and 46 days in group 3, and 21% and 15 days in group 4, respectively. Adjusted hazard ratios (HR) for VTE were HR = 0.27 (95% CI: 0.11-0.70) for groups 1 vs. 4; HR = 0.66 (95% CI: 0.25-1.60) for groups 2 vs. 4; and HR = 0.66 (95% CI: 0.29-1.26) for groups 3 vs. 4 with a trend of P = 0.002. The incidence of complications from VTE prophylaxis was not significantly different between the groups, with a rate of 8% in group 1, 17% in group 2, 6% in group 3, and 12% in group 4 (P = 0.33). CONCLUSIONS: In high-risk urologic cancer surgery patients, a clinical protocol, with perioperative and EDP, is safe and effective in reducing VTE events.

RNA interference targeting hypoxia-inducible factor 1α via a novel multifunctional surfactant attenuates glioma growth in an intracranial mouse model.

OBJECT: High-grade gliomas are the most common form of adult brain cancer, and patients have a dismal survival rate despite aggressive therapeutic measures. Intratumoral hypoxia is thought to be a main contributor to tumorigenesis and angiogenesis of these tumors. Because hypoxia-inducible factor 1α (HIF-1α) is the major mediator of hypoxia-regulated cellular control, inhibition of this transcription factor may reduce glioblastoma growth. METHODS: Using an orthotopic mouse model with U87-LucNeo cells, the authors used RNA interference to knock down HIF-1α in vivo. The small interfering RNA (siRNA) was packaged using a novel multifunctional surfactant, 1-(aminoethyl) iminobis[N-(oleicylcysteinylhistinyl-1-aminoethyl)propionamide] (EHCO), a nucleic acid carrier that facilitates cellular uptake and intracellular release of siRNA. Stereotactic injection was used to deliver siRNA locally through a guide-screw system, and delivery/uptake was verified by imaging of fluorescently labeled siRNA. Osmotic pumps were used for extended siRNA delivery to model a commonly used human intracranial drug-delivery technique, convection-enhanced delivery. RESULTS: Mice receiving daily siRNA injections targeting HIF-1α had a 79% lower tumor volume after 50 days of treatment than the controls. Levels of the HIF-1 transcriptional targets vascular endothelial growth factor (VEGF), glucose transporter 1 (GLUT-1), c-MET, and carbonic anhydrase-IX (CA-IX) and markers for cell growth (MIB-1 and microvascular density) were also significantly lower. Altering the carrier EHCO by adding polyethylene glycol significantly increased the efficacy of drug delivery and subsequent survival. CONCLUSIONS: Treating glioblastoma with siRNA targeting HIF-1α in vivo can significantly reduce tumor growth and increase survival in an intracranial mouse model, a finding that has direct clinical implications.

Urologic synechiae.

Synechiae are intracavitary adhesions; although rarely reported, they may occur within the urinary tract. They are well recognized within the gynecologic literature but are rarely reported as a cause of urologic pathology. We describe the endoscopic appearance of two such lesions, describing their pathologic role and the endoscopic management in two patients.

Primary plasmacytoma of the testicle: a case report.

INTRODUCTION: Extramedullary plasmacytoma is a rare plasma cell neoplasm. Plasmacytomas are most commonly found in the head and neck region, but can occur in many other locations. They rarely occur in the testis, and are commonly associated with concurrent multiple myeloma at the time of diagnosis. Isolated plasmacytoma of the testis is exceedingly rare, with few cases reported in the literature. CASE PRESENTATION: A 72-year-old Caucasian man presented with a painless testicular mass treated by orchiectomy. The mass was determined to be plasmacytoma on pathological examination. At the time of diagnosis, our patient did not have multiple myeloma, and is currently undergoing chemotherapy for treatment of his disease. CONCLUSION: Isolated plasmacytoma of the testicle is a rare cause of testicular mass, and is seldom reported in the literature. Patients with this disease require careful monitoring because of their high risk of progression to multiple myeloma. The diagnosis of testicular plasmacytoma can be challenging for primary care doctors and urologic specialists. This condition should be in the differential diagnosis in elderly men.