Nephrectomy improves both antihypertensive requirement and left ventricular mass for pediatric renal hypertension.

BACKGROUND: Renal hypertension causes left ventricular (LV) hypertrophy leading to cardiomyopathy. Nephrectomy has been utilized to improve blood pressure and prepare for kidney transplantation in the pediatric population. We sought to investigate antihypertensive medication (AHM) requirement and LV mass in patients undergoing nephrectomy with renal hypertension. METHODS: We performed a single institution retrospective review from 2009 to 2021 of children who have undergone nephrectomy for hypertension. Primary outcome was decrease in number of AHM. Secondary outcomes included change in LV mass and elimination of AHM. LV mass was measured using echocardiogram area-length and linear measurements. Non-parametric analyses were utilized to assess significance. RESULTS: Thirty-one patients underwent nephrectomy. Median age was 12.5 years (0.8-19 years). Median of 3 AHM (range 1-5 medications) were used pre-operatively and patients had been managed for median 2.5 years. Twenty-nine had preoperative echocardiogram. Forty-eight percent of patients had LVH at nephrectomy. Median AHM after surgery was 1 (range 0-4 medications) at 30 days and 12 months, (p < 0.001). By 12 months after nephrectomy, 79.2% of patients had decreased the number of AHM. Eight (26%) patients were on no AHM 30 days after surgery, and 13 (43%) at 12 months. Systemic vascular disease and multicystic dysplastic kidney were the only factors associated with lack of improvement in AHM (p = 0.040). Fourteen patients had pre- and post-operative echocardiogram and 11 (79%) had improvement in LV mass (p = 0.016, 0.035). CONCLUSIONS: Nephrectomy is effective in improving LV mass and reducing AHM for children with renal hypertension. Improvement is less likely in patients with systemic vascular disease and multicystic dysplastic kidneys. A higher resolution version of the Graphical abstract is available as Supplementary information.

Pyeloplasty with ureteral stent placement in children: Do prophylactic antibiotics serve a purpose?

OBJECTIVES: Ureteral stents are commonly used during pyeloplasty to ensure drainage and anastomotic healing. Antibiotic prophylaxis is often used due to concerns for urinary tract infection (UTI). Although many surgeons prescribe prophylactic antibiotics following pyeloplasty, practices vary widely due to lack of clear evidence-based guidelines. We hypothesize that the rate of stent UTI does not significantly vary between children who receive antibiotics and those who do not. METHODS: We reviewed the medical records of 741 patients undergoing pyeloplasty between January 2010 and July 2018 across seven institutions. Exclusion criteria were: age older than 22 years, no stent placed, externalized stents used, and incomplete records. Surgical approach, age, antibiotic use, stent duration, Foley duration, and urine culture results were recorded. Patients were categorized into two groups, those younger than four years of age and those four years and older as proxy for likely diaper use. Univariate logistic regression was conducted to identify variables associated with UTI. Multivariable backward stepwise logistic regression was used to identify the best model with Akaike information criterion as model selection criteria. The selected model was used to calculate odds ratios and 95% confidence intervals summarizing the association between prophylactic antibiotics and stent UTI while controlling for age, gender, and intra-operative urine cultures. RESULTS: 672 patients were included; 338 received antibiotic prophylaxis and 334 did not. These groups differed in mean age (3.91 vs. 6.91 years, P < .001), mean stent duration (38.5 vs. 35.32 days, P < .001), and surgical approach (53.25% vs. 32.04% open vs. laparoscopic, P < .001). The incidence of stent UTI was low overall (7.59%) and similar in both groups: 31/338 (9.17%) in the prophylaxis group and 20/334 (5.99%) in the non-prophylaxis group (P = .119). Although female gender, likely diaper use, and positive intra-operative urine culture were each associated with significantly higher odds of stent UTI, prophylactic antibiotic use was not associated with significant reduction in stent UTI in any of these groups. Surgical approach, stent duration, and Foley duration were not associated with stent UTI. CONCLUSION: Incidence of stent UTI is low overall following pyeloplasty. Prophylactic antibiotics are not associated with lower rates of stent UTI following pyeloplasty even after controlling for risk factors of female gender, likely diaper use, and positive intra-operative urine culture. Routine administration of prophylactic antibiotics after pyeloplasty does not appear to be beneficial, and may be best reserved for those with multiple risk factors for UTI.

Children undergoing outpatient complex penile surgery and hypospadias repair may not require opioid analgesics.

BACKGROUND/PURPOSE: Pain control is important after penile surgery, and opioid use should be minimized as able. We sought to describe our experience performing complex penile surgeries with vs without post-operative opioids. METHODS: A retrospective review of penile surgeries, including 3998 between 2009 and 2019. We identified patients <8 years who underwent outpatient penile surgery requiring either penile degloving or hypospadias repair. Patients who were or were not prescribed opioids were matched 1:1 by age and type of penile surgery. Primary outcomes of interest were pain-related encounters, delayed opioid prescription, and predictors of pain. RESULTS: 200 children were identified, 100 per group, with mean age 1.3 ± 0.8 years. 48% were penile degloving procedures, 31% hypospadias repairs with catheters, and the remaining 21% hypospadias repairs without catheters. Perioperative features were comparable between groups(p > 0.05). 59% of patients without opioids had an impromptu post-operative encounter vs 41%, and 20% had an associated pain complaint vs 9%(p = 0.026). Two patients in both groups received delayed opioid prescription(p = 1.00). The presence of a catheter (OR 2.9) and no opioid prescription (OR 2.6) were independent predictors for pain complaint. CONCLUSIONS: Patients discharged without an opioid were more likely to contact a provider postoperatively and were more likely to endorse pain complaint (number needed to treat: 9).

Acute urinary retention in pediatric cerebral palsy: Is there an optimal management strategy?

INTRODUCTION AND OBJECTIVE: Cerebral palsy (CP) patients commonly have lower urinary tract dysfunction. Urinary retention (UR), which has been associated with dysfunctional voiding in CP can correlate to chronic upper tract dysfunction. We sought to provide insight into the pediatric presentation of acute UR in patients with CP and subsequent outcomes in this at-risk population. STUDY DESIGN: All children with perinatally acquired CP presenting to a regional health network were identified from 2009 to 2019. Retrospective analysis of a hospitalized subset concurrently diagnosed with a first episode of acute UR was performed. Factors associated with new-onset UR are described, as well as management. Using follow-up data, we also assessed the risk for recurrent UR and/or abnormal renal imaging after an initial UR presentation. RESULTS: 3404 CP patients were analyzed with only 33 fulfilling inclusion criteria. Median age was 10(IQR 7.5-16; range 1-22) years, 87.9% were GMFCS-V. 39.4% had a reported history of decreased urinary frequency. At presentation, median maximal time without void prior to catheterization was 13 h, and catheterized volume was a median 120% expected capacity-for-age. 84.8% of presentations were associated with a known transient/reversible etiology. 51.5% were post-anesthesia at median 3.5 days, 33.3% had associated constipation, 30.3% had received exacerbating medications. 11/33 were taught clean intermittent catheterization (CIC) after the initial presentation (all pro re nata [PRN] except one). At a median follow-up of 37 months: 50% of those without a CIC PRN no void plan had a repeat episode, at a median of 10.8 months later. Of the patients who had follow-up renal imaging at a median 22.0 months after presentation, 45% had abnormalities: 7 with debris or suspected stones and 2 with collecting system dilation. No factors associated with the initial UR presentation were found to be significantly predictive of recurrence or abnormal follow-up imaging. DISCUSSION: Patients with CP presenting with acute UR are often those with the most severe limitations and have a history of decreased urinary frequency. They usually have transient or reversible factors associated with UR presentation, however UR recurrence and abnormal imaging in this population subset is common. CONCLUSIONS: Pediatric patients with CP who present with acute UR usually present in the context of recent anesthesia and in the setting of exacerbating factors. They are at risk for recurrence and may be best managed with caretaker education of CIC PRN no void to address recurrent episodes. Providers should consider surveillance of these patients for the development of abnormal renal imaging.

Renal Transplants Due to Congenital Anomalies of the Kidney and Urinary Tract (CAKUT) Have Better Graft Survival Than Non-CAKUT Controls: Analysis of Over 10,000 Patients.

OBJECTIVE: To determine whether graft survival for patients with congenital anomalies of the kidney and urinary tract (CAKUT) is impaired compared to non-CAKUT counterparts. METHODS: The United States Renal Data System (USRDS) is a national data system that has collected information about end stage renal disease (ESRD) and renal transplantation since 1995. We identified 10,635 first-time renal transplant patients with ESRD attributed to a CAKUT diagnosis transplanted between 1995 and 2018, with follow-up of 7.9 ± 5.8 years. We matched 1:1 with non-CAKUT transplant recipients, using age at transplant, sex, race, year of transplant, and donor-type. We compared renal transplant death-censored graft survival between CAKUT vs non-CAKUT controls, with further stratification for age at transplant and lower urinary tract malformations (LUTM) vs upper urinary tract malformations (UUTM). RESULTS: Graft survival was better in CAKUT patients with a 5-year survival of 83.3% vs 79.3% (P< .001), and CAKUT status infers a hazard ratio of 0.878 for graft failure on multivariable analysis with Cox regression. Favorability of CAKUT status persisted when stratifying for both pediatric (80.3 vs 77.6% P< .001) and adult (84.5 vs 81.4% P< .001) age groups. Looking within the CAKUT population: comparison of LUTM to UUTM yielded no difference, implying that LUTM is not a risk factor for graft failure. Examining pediatric LUTM alone, graft survival was not better than matched non-CAKUT counterparts with 5-year graft survival of 69%-75% for LUTM adolescents. CONCLUSION: Renal transplant graft survival is better overall in CAKUT patients as opposed to non-CAKUT counterparts. Pediatric LUTM patients have similar graft survival to controls.

New-onset ESRD secondary to reflux nephropathy has decreased in incidence in the United States.

INTRODUCTION AND OBJECTIVE: Vesicoureteral reflux (VUR) has been associated with the development and progression of reflux nephropathy (RN). Management of VUR has become more conservative over time as therapies have not been reliably proven to prevent renal scarring. We sought to examine the incidence of end stage renal disease (ESRD) due to RN over recent decades in the United States. STUDY DESIGN: The United States Renal Data System (USRDS) is a national data system that collects information about chronic kidney disease and ESRD. Since 1995, the USRDS has mandated that all dialysis centers enroll and submit data on new-onset ESRD patients. Of the over 2.5 million patients enrolled since 1996, 7314 were enrolled with a diagnosis code for RN as the primary cause of ESRD. We examined the trends seen in this patient population from 1996 to 2014 and used US census data to calculate incidence. RESULTS: The incidence of patients with new-onset ESRD attributed primarily to RN saw a steady decrease over time: from 1.9 per million in 1996 to 0.6 per million in the US population in 2014 (exp(B) = 0.941, p < 0.001). 58.8% of the patients were female, 87.4% white. The mean age at the time of ESRD onset was 47 years (IQR 30-65) and this did not significantly vary over the period (P > 0.05). When comparing pediatric new-onset ESRD to adult-onset, a non-significant trend (p = 0.093) was seen with a decrease in incidence of adult ESRD, but a relatively stable incidence of pediatric ESRD (mean age 12, incidence 0.2-0.6 cases per million US children/year). 44.5% of patients received renal transplantation at a mean age of 36 years, 18.9 months (IQR 5-40) after ESRD diagnosis. The mean age of mortality was 62 years old (IQR 50-76), and 5-year survival after RN ESRD diagnosis was 65.8%. DISCUSSION: As with any public database study, our findings may be limited by disease coding or reporting practices. Medical and surgical management trends practiced since the 1960s may have contributed to a decrease in the incidence of ESRD primarily attributed to RN in the United States between 1996 and 2014. Our findings may also reflect changes in diagnostic practices. CONCLUSIONS: ESRD attributed primarily to RN has gradually decreased in incidence in the United States between 1996 and 2014, but the age of ESRD onset has been unchanged.

Predictors of Postoperative Urinary Incontinence After Holmium Laser Enucleation of the Prostate: 12 Months Follow-Up.

OBJECTIVE: To identify pre- and perioperative factors associated with incontinence after holmium laser enucleation of the prostate for benign prostatic hyperplasia. METHODS: Retrospective review of our single-surgeon database identified 88 patients with 12 months' follow-up who underwent surgery between December 2014 and November 2016. Postoperative urinary incontinence was defined as 1 or more pads per day. Patients were evaluated at 6 weeks, 6 months, and 12 months postoperatively. RESULTS: Preoperative variables associated with incontinence at all follow-ups included pre-existing incontinence and higher detrusor voiding pressure. Higher maximum urinary flow and lower postvoid residual were predictors of transient urinary incontinence. On multivariate analysis, pre-existing incontinence remained significant as a 12-month predictor, whereas a higher detrusor voiding pressure was only significant as a 6-week predictor. De novo incontinence at 12 months was identified in only 1/44 patients (2%). Among patients with pre-existing incontinence, 30/40 (75%) reported resolution of their incontinence at 12 months. Numerous demographic, urinary, urodynamic, and operative factors were not significant for predicting incontinence. The mean decrease in pads per day between 6 weeks and 6 months was -1.6 and between 6 months and 12 months was -0.75. Medical management did not significantly impact rates of postoperative incontinence when compared to observation alone. CONCLUSION: Pre-existing urinary incontinence and/or higher detrusor voiding pressure may predict urinary incontinence 12 months after holmium laser enucleation of the prostate.

Primary tumor size, not race, determines outcomes in women with hormone-responsive breast cancer.

INTRODUCTION: We sought to determine if there was a difference in outcomes in African-American compared with Caucasian women with hormone-responsive breast cancer, and whether this was related to race or other tumor and treatment variables. METHODS: We included 1,205 patients with hormone-responsive breast cancer were identified in the Kentucky Cancer Registry (1996-2007). The effect of race on survival was evaluated using Kaplan-Meier and Cox regression methodologies. RESULTS: In this cohort, 76.9% were Caucasian and 21.7% were African American. Compared with Caucasians, African-American women were older (57 vs 55 years; P = .032) and more likely to have larger tumors (19 vs 17 mm; P = .009). No significant racial differences in grade, operative, or systemic treatment were noted. Univariate analysis found no significant differences in disease-specific overall survival (DSS) or disease-free survival (DFS) between Caucasians and African Americans (5-year actuarial DSS, 93.6% vs 90.7%, respectively; P = .205; 5-year actuarial DFS, 91.5% vs 90.4%, respectively; P = .829). On multivariate analysis, only tumor size remained an independent predictor of DSS (odds ratio [OR], 1.021; 95% confidence interval [CI], 1.013-1.028; P < .001). Controlling for age, tumor size, and insurance status, race did not influence DSS or DFS (P = .913 and P = .857). CONCLUSION: African Americans present with larger tumors than Caucasians; treatment is similar. Tumor size, not race, affects disease-specific outcomes in patients with breast cancer.

The impact of lymphovascular invasion on lymph node status in patients with breast cancer.

Lymphovascular invasion (LVI) is not uniformly found or reported in breast cancer tumor reports. We sought to determine the impact of the finding of LVI on various parameters of lymph node status in patients with breast cancer. A chart review was performed of 400 node-positive patients from a cohort of patients in a prospective multicenter national sentinel node registry. The finding of LVI was then correlated to number of positive sentinel nodes, the number of positive nonsentinel nodes, the lymph node ratio, and the size of the largest metastatic deposit. Of the 400 patients, data regarding LVI were missing in 98 (24.5%) cases. Although all of these patients were node-positive, LVI was noted to be present in 155 patients (38.8%) and absent in 147 (36.8%). LVI was found to correlate with more positive sentinel nodes (mean, 1.72 vs 1.35; P < 0.001), more positive nonsentinel nodes (mean, 2.16 vs 0.54; P < 0.001), and a higher lymph node ratio (0.29 vs 0.16; P < 0.001). LVI also correlated with size of largest metastatic deposit (P = 0.002). Although LVI is known to be associated with lymph node status, it is not frequently noted on pathology reports. Given its prognostic value, LVI should be carefully evaluated and reported.