Correlation between surgical booking by a PA and surgical procedure performed.

OBJECTIVE: This study evaluated the concordance between clinical evaluation and diagnosis by a physician associate/assistant (PA) and the preoperative and intraoperative evaluations by a pediatric urologic surgeon. METHODS: A retrospective chart review was performed for patients independently evaluated and scheduled for surgery by a single PA between 2017 and 2020. Concordance was measured by comparing the PA's office note with the surgeon's preoperative note and operative report. RESULTS: Of the 242 patients scheduled for surgery, 11 underwent an operative report procedure change and 11 others underwent a preoperative note procedure change. Concordance increased from 89.09% in 2017 to 92.31% in 2020; this was not statistically significant ( P = .230). Urologic conditions evaluated demonstrated an increase in the variety and complexity of conditions. CONCLUSIONS: A supervisory/collaborative model involving a well-trained PA yields excellent outcomes in terms of concordance with surgical scheduling and procedure performed.

Impact of Florida Medicaid guidelines on frequency and cost of delayed circumcision at Nemours Children's hospital.

INTRODUCTION: In 2003, Florida Medicaid discontinued coverage of routine neonatal circumcision (NC) resulting in an increase in nonneonatal circumcisions. Florida Medicaid is one of 16 state healthcare plans that do not cover NC. Florida Medicaid covers male circumcision in a child ≥3 years for a defined medical indication or persistent phimosis refractory to topical steroid therapy (TST). We sought to assess the economic impact of the evaluation and management of phimosis/circumcision in Florida Medicaid males ≥3 years treated at Nemours Children's Hospital. STUDY DESIGN: We performed an IRB approved retrospective chart review of all male Florida Medicaid patients ≥3 years seen at NCH for phimosis/circumcision from Sept. 2016-Sept. 2019. Data extracted included demographics, age at presentation, prior treatment with TST, response to TST, and surgical interventions. The patients were stratified into three management groups. Total costs for each group were based upon estimated Medicaid reimbursement rates. Data were analyzed using descriptive analysis on SPSS. RESULTS: Seven hundred and sixty-three males were evaluated. Age at presentation ranged from 3 to 17 years and 59% of patients were 3-6 years at initial presentation. Three hundred and forty patients underwent circumcision. The total estimated cost of care for all patients was $1,345,533.90. This compares to an estimated cost of $171,675 if all individuals underwent NC at 2020 costs. CONCLUSIONS: The total estimated cost associated with the evaluation and management of 763 patients ≥3 years for phimosis/circumcision was 7.8 times the estimated cost of NC for all these patients and likely is an underestimation of the true difference in cost as we did not account for additional visits outside of the initial consultation and follow-up, post-operative visits outside of the global period, emergency room visits, and returns to operating room. Of the circumcisions performed, only 18.5% met Florida Medicaid defined medical indications. Success rates for TST range from 53.8 to 95% in the literature, however, our success rate was 34.3%. The reason for the variation in response rate between our results and the literature may reflect that caretakers desiring circumcision may be less compliant with TST use. Only 6.6% of patients had a documented failure of TST prior to initial presentation. Further education of PCPs on current Medicaid/MCG guidelines for the evaluation and management of phimosis, as well as PCP adoption of TST, could reduce the number of unnecessary office visits, healthcare costs, and family burden.

Neonatal Circumcision Trends from a Pediatric Urology Perspective: Results from a Survey of Members of the Societies for Pediatric Urology.

INTRODUCTION: Neonatal circumcision remains controversial, with rates varying over the years. The Centers for Disease Control and Prevention and the American Academy of Pediatrics acknowledge the health benefits of neonatal circumcision and support access to the procedure for families who choose it. Although more commonly performed by nonurological providers, pediatric urologists are often involved with pre-procedural or post-procedural concerns. Neonatal circumcision trends and perspectives were evaluated as determined by members of the Societies for Pediatric Urology nationwide. METHODS: A 20-question survey was distributed electronically via SurveyMonkey to members of the Societies for Pediatric Urology. The survey was developed to assess pediatric urologists' roles in and criteria for neonatal circumcision as well as attitudes towards nonurological provider circumcisions. Of the 20 questions 16 formed the basis of this study. Four questions evaluated "perceptions" and were excluded from study analysis due to subjectivity. RESULTS: Of the surveys 223 (37.2%) were returned. Most responders (80.1%, 177) perform neonatal circumcision. Significant differences exist across geographical regions nationally including common practices, techniques, and financial coverage of neonatal circumcision. However, 70.6% of responders noted a maximum age at time of circumcision of 12 weeks or younger and 48.9% noted a maximum weight of 12 pounds (5.44 kilograms) or less. CONCLUSIONS: This study assessed pediatric urologists' roles in and criteria for neonatal circumcision. The development of universal best practices as determined by pediatric urologists, as experts in the field, may prove beneficial for optimizing patient care and nonurological circumcision provider education and training.

Experience and outcomes for PAs in a neonatal circumcision clinic.

OBJECTIVE: To evaluate the outcomes of neonatal circumcision performed by a PA in pediatric urology. METHODS: A retrospective review was performed of infants evaluated for neonatal circumcision by a single PA in pediatric urology over 30 months. Technique, age and weight at circumcision, presence or absence of genital anomalies, and complications were gathered. RESULTS: Of the 371 male infants evaluated for neonatal circumcision, 276 underwent the procedure. Complications included retained Plastibell (2.1%), penile adhesions (1.1%), swelling (1.8%), and cosmetic concerns (0.73%). Eighteen unanticipated postprocedure visits occurred-four in the ED and 14 in the outpatient clinic. No acute procedural complications occurred. One patient (0.3%) underwent lysis of penile adhesions at age 19 months. CONCLUSION: Neonatal circumcisions are commonly performed by nonsurgeons with variable formal circumcision training. These data support that well-trained PAs can perform neonatal circumcisions with low complication rates.

Intermittent Urinary Incontinence Secondary to Inverted-Y Ureteral Duplication With Perianal Ectopia.

Inverted-Y ureteral duplication is one of the rarest anomalies of ureteral branching, which has been found to be more prevalent in females.2 Females commonly present with urinary incontinence often associated with distal limb ectopia to the bladder neck, uterus, or vagina.2 We present the case of a 7-year-old female with intermittent urinary incontinence who was found to have an inverted-Y ureteral duplication with perianal ectopia. We highlight the role of magnetic resonance urography in the evaluation of females with urinary incontinence and a normal renal/bladder ultrasound who are refractory to behavioral therapy.