Risk Factors for Catheter Associated Urinary Tract Infections in a Pediatric Institution.

PURPOSE: Catheter associated urinary tract infections are an essential measure for health care quality improvement that affects reimbursement through hospital acquired condition reduction programs in adult patients. With the mounting importance of preventing such infections we evaluated risk factors for acquiring catheter associated urinary tract infections in pediatric patients. MATERIALS AND METHODS: All catheter associated urinary tract infections were identified at 1 pediatric institution from September 2010 to August 2014 from a prospective database maintained by the infection control office. To identify risk factors patients with a catheter associated urinary tract infection were individually matched to control patients with a urinary catheter but without infection by age, gender, date and the hospital location of the infection in 1:2 fashion. RESULTS: A total of 50 patients with catheter associated urinary tract infection were identified and matched to 100 control patients. Compared to controls the patients with infection were more likely to have a catheter in place for longer (2.9 days, OR 1.08, 95% CI 1.01, 1.15, p = 0.02). They were also more likely to be on contact precautions (OR 4.00, 95% CI 1.73, 9.26, p = 0.001), and have concurrent infections (OR 3.04, 95% CI 1.39, 6.28, p = 0.005) and a history of catheterization (OR 3.24, 95% CI 1.55, 6.77, p = 0.002). Using a conditional multivariate regression model the 3 most predictive variables were duration of catheter drainage, contact isolation status and history of catheterization. CONCLUSIONS: Longer duration of urinary catheter drainage, positive contact precautions status and a history of catheterization appear to be associated with a higher risk of catheter associated urinary tract infection in hospitalized pediatric patients. Physicians should attempt to decrease the duration of catheterization, especially in patients who meet these criteria, to minimize the risk of catheter associated urinary tract infection.

Biodegradable-Polymer-Blend-Based Surgical Sealant with Body-Temperature-Mediated Adhesion.

The development of practical and efficient surgical sealants has the propensity to improve operational outcomes. A biodegradable polymer blend is fabricated as a nonwoven fiber mat in situ. After direct deposition onto the tissue of interest, the material transitions from a fiber mat to a film. This transition promotes polymer-substrate interfacial interactions leading to improved adhesion and surgical sealant performance.

Bi-Institutional Comparison of Robot-Assisted Laparoscopic Versus Open Ureteroureterostomy in the Pediatric Population.

PURPOSE: Ureteroureterostomy (UU) is a useful surgical option for the management of duplication anomalies as well as obstructed single system ureters for children. We aimed to evaluate the safety, efficacy, and outcomes of robot-assisted laparoscopic UU (RALUU) compared with open UU (OUU) in the pediatric population. PATIENTS AND METHODS: A retrospective review was performed at two institutions including six surgeons' experience with all cases of RALUU and OUU from January 2005 to June 2014. Indications for a surgical procedure included duplex systems with an upper pole ectopic ureter, obstructed ureterocele or lower pole vesicoureteral reflux, and obstruction in a single system. Transureteroureterostomy, laparoscopic UU, and major reconstruction cases where UU was the secondary procedure were excluded. RESULTS: There were 25 RALUU and 19 OUU cases included. All cases involved duplex systems except two proximal to distal anastomoses in single system obstructed kidneys. RALUUs were more likely to be performed proximally (P = 0.01) and with the use of cystoscopy and stent placement (P = <0.0001). Operative times and estimated blood loss were similar between the two groups. Postoperative complications included four febrile urinary tract infections in each group, one recurrence of nonfebrile urinary tract infection in the open group, and one postoperative obstruction at the ureterovesical junction because of attempted stent placement necessitating nephrostomy tube placement in the open group. This OUU patient was the only one to demonstrate more severe hydronephrosis after surgery on initial follow-up imaging that was again unrelated to the open UU procedure. RALUU had shorter hospital stays by 0.5 days (P = 0.04). CONCLUSION: Robot-assisted laparoscopic UU is a safe and effective alternative to open UU in children with duplication anomalies and single system obstructed ureters. Operative times and complication rates were comparable with slightly shorter length of hospitalization in robotic cases.

Evaluation of prenatal hydronephrosis: novel criteria for predicting vesicoureteral reflux on ultrasonography.

PURPOSE: Radiographic evaluation for prenatal hydronephrosis often includes voiding cystourethrography to ascertain whether vesicoureteral reflux is present. We sought to determine whether use of voiding cystourethrography could be limited to those patients at greatest risk for vesicoureteral reflux. We hypothesized that vesicoureteral reflux could be predicted by findings on renal/bladder ultrasonography of hydroureter, renal dysmorphia and/or duplication. MATERIALS AND METHODS: We reviewed the records of patients with prenatal hydronephrosis who underwent initial postnatal ultrasonography and voiding cystourethrography during a 3-year period. The presence of vesicoureteral reflux on voiding cystourethrogram was correlated to ultrasound findings, including hydronephrosis grade, presence of hydroureter, renal dysmorphia or duplication, with ultrasound considered positive for any of the latter 3 findings. RESULTS: Of 262 patients 47 (18%) had vesicoureteral reflux. Ultrasound was positive in 24 of 29 patients (83%) with high grade reflux and 12 of 18 (67%) with low grade reflux. If ultrasonography showed any of the 3 positive findings, the odds ratio of detecting vesicoureteral reflux was 8.07 (95% CI 3.86, 16.87). Using these criteria, among all cases of prenatal hydronephrosis 5 (2%) with high grade vesicoureteral reflux and 6 (2%) with low grade reflux would have been missed. Among the 47 cases of reflux overall 5 of 29 high grade (17%) and 6 of 18 low grade cases (33%) would have been missed. CONCLUSIONS: By using ultrasonography criteria of hydroureter, duplication and renal dysmorphia for patients with prenatal hydronephrosis, vesicoureteral reflux can be detected more specifically. Using our criteria, 165 of 262 voiding cystourethrograms (63%) could have been avoided in patients with prenatal hydronephrosis during a 3-year period. Reducing these evaluations may decrease risks regarding radiation exposure, family anxiety and health care costs.

Single surgeon's experience with laparoscopic versus robotic partial nephrectomy: perioperative outcomes/complications and influence of tumor characteristics on choice of therapy.

INTRODUCTION: Laparoscopic (LPN) and robotic partial nephrectomy (RPN) may offer similar advantages for nephron-sparing surgery (NSS). We evaluated the perioperative outcomes and complications of LPN versus RPN and sought to evaluate if one technique may have more favorable outcomes over another based on tumor characteristics. MATERIALS AND METHODS: All patients who underwent LPN and RPN by a single surgeon were retrospectively reviewed. The surgeon almost exclusively performed LPN from February 2009 to January 2011 and RPN from January 2011 to January 2012. Patient demographics, tumor characteristics, perioperative outcomes, short term renal functional data, and complications were reviewed. Operative time (OT), warm ischemia time (WIT), and estimated blood loss (EBL) were evaluated for each technique when tumor characteristics were divided by size, location, distance to collecting system, and overall tumor complexity based on nephrometry scoring. RESULTS: Of 39 laparoscopic cases and 30 robotic cases, there were no significant differences in perioperative outcomes, short term renal functional data, or complications between the two groups except for WIT which was shorter in the LPN group (p = 0.006). For medium complexity tumors, OT was less for LPN compared to RPN (p = 0.04); for high complexity tumors, EBL was reduced for RPN compared to LPN cases (p = 0.003). When tumor characteristics were individualized, LPN may be superior to RPN for WIT for small, anterior and exophytic tumors, and tumors located > 5 mm from the collecting system. LPN and RPN appear more equivocal for WIT in posteriorly located tumors. Reduced EBL may be a benefit with RPN for larger tumors. CONCLUSIONS: Although WIT was less in patients undergoing LPN compared to RPN, perioperative outcomes and complications remain similar. RPN may be beneficial for approaching more difficult, posterior tumors, whereas LPN may be a better technique for WIT for simple, accessible renal tumors. Reduced EBL may be a benefit for RPN for highly complex tumors.

In utero closure of myelomeningocele does not improve lower urinary tract function.

PURPOSE: Recent data comparing prenatal to postnatal closure of myelomeningocele showed a decreased need for ventriculoperitoneal shunting and improved lower extremity motor outcomes in patients who underwent closure prenatally. A total of 11 children whose spinal defect was closed in utero were followed at our spina bifida center. We hypothesized that in utero repair of myelomeningocele improves lower urinary tract function compared to postnatal repair. MATERIALS AND METHODS: Eleven patients who underwent in utero repair were matched to 22 control patients who underwent postnatal repair according to age, gender and level of spinal defect. Urological outcomes were retrospectively reviewed including urodynamic study data, need for clean intermittent catheterization, use of anticholinergic agents and prophylactic antibiotics, and surgical history. The need for ventriculoperitoneal shunting or spinal cord untethering surgery was also reviewed. RESULTS: Mean followup was 7.2 years for patients who underwent in utero repair and 7.3 years for those who underwent postnatal repair. Mean patient age at compared urodynamic studies was 5.9 years for in utero repair and 6.0 years for postnatal repair. The in utero repair group was comprised of 5 lumbar and 6 sacral level defects with equal matching (1:2) in the postnatal repair cohort. There were no differences between the groups in terms of need for clean intermittent catheterization, incontinence between catheterizations or anticholinergic/antibiotic use. Urodynamic parameters including bladder capacity, detrusor pressure at capacity, detrusor overactivity and the presence of detrusor sphincter dyssynergia were not significantly different between the groups. There was no difference in the rate of ventriculoperitoneal shunting (p = 0.14) or untethering surgery (p = 0.99). CONCLUSIONS: While in utero closure of myelomeningocele has been shown to decrease rates of ventriculoperitoneal shunting and improve motor function, it is not associated with any significant improvement in lower urinary tract function compared to repair after birth.

Trends and attitudes in surgical management of benign prostatic hyperplasia.

INTRODUCTION: Surgical management of benign prostatic hyperplasia (BPH) has changed over the past 15 years with newer techniques emerging such as laser therapy that can be used with anticoagulation, an increasing issue with modern patients. We sought to evaluate current trends in procedure utilization based on age, location, type of practice, and experience. We also hoped to determine what factors influence surgeons' decisions to choose or reject particular surgical techniques. METHODS AND MATERIALS: A 90-item on-line survey was sent via electronic mail to the American Urological Association (AUA), Veterans Administration, Society for Government Service Urologists, and Endourological Society. Data concerning utilization of 12 BPH surgical techniques were analyzed and compared to the surgeons' demographics using categorical data analysis and logistic regression. RESULTS: Of approximately 5500 urologists contacted, 600 urologists replied with 570 currently performing BPH surgery. The two procedures that continue to be utilized by urologists are open prostatectomy (OP) at 78% and monopolar transurethral resection of prostate (TURP) at 73%. When stratified by urologist age and year of residency completion, there were no differences in procedure utilization. There were no differences in types of procedures utilized between AUA sections except in the Northeastern AUA section which utilized less monopolar TURP and the New York section which utilized less photoselective vaporization (PVP). Higher volume surgeons were more likely to perform holmium laser enucleation of the prostate (HoLEP), diode laser vaporization of the prostate, holmium laser ablation of the prostate (HoLAP), and thulium laser ablation. There were no trends for low volume surgeons. There were no differences in types of procedures performed in full time academic versus non-academic settings except for robotic prostatectomy and button TURP which were utilized more often in academic settings. Urologists were more likely to accept a technique that produces good clinical outcomes, is safe in practice, and minimally invasive. Urologists reject procedures most frequently due to preference for another technique or lack of training/equipment. Interestingly, reimbursement/cost issues were never reported as primary reasons for acceptance/rejection of any approach. CONCLUSIONS: Change in technology has led urologists to change their approach to surgical treatment of BPH. OP and monopolar TURP are still the procedures utilized by most urologists, however, laser therapy is emerging as a commonly used technique. As more high-risk patients are treated, laser therapies may become a more popularized technique. Further larger scale studies evaluating surgeon attitudes might clarify how changing technology influences practice patterns.

Urodynamic findings in patients with Currarino syndrome.

PURPOSE: Currarino syndrome is an inherited disorder consisting of a triad of anorectal anomaly, sacrococcygeal defect and presacral mass. We evaluated the urological issues in patients with Currarino syndrome and sought to determine whether spinal cord detethering improves urinary tract function. MATERIALS AND METHODS: We retrospectively reviewed 14 patients diagnosed with Currarino syndrome. We evaluated urinary signs/symptoms and urodynamic findings before and after spinal cord detethering. RESULTS: All patients with Currarino syndrome having a sacral defect and presacral mass were diagnosed between birth and 6 years. Of the patients 86% had a tethered spinal cord that was surgically detethered between 8 months and 6 years (average 3 years). Overall 10 of 12 children who underwent surgery had voiding complaints postoperatively, including urgency, frequency and incontinence. Five patients had recurrent urinary tract infections, of whom 3 had vesicoureteral reflux that resolved spontaneously. Three patients had mild unilateral hydronephrosis without reflux. Ten of 12 patients who underwent spinal cord detethering underwent comprehensive urodynamic evaluation. Of the 5 patients who underwent preoperative and postoperative urodynamic evaluation 3 showed improvement with resolution of detrusor overactivity or dyssynergia postoperatively, and 2 demonstrated no change. Of the 5 patients who underwent only postoperative urodynamic evaluation 4 had abnormal findings, including small capacity, poor compliance, detrusor overactivity, detrusor sphincter dyssynergia and/or high voiding pressure. No progressive denervation was seen on electromyography preoperatively or postoperatively. CONCLUSIONS: Currarino syndrome is a rare congenital disorder with few published reports regarding the long-term implications. Although no solid conclusions could be drawn regarding urodynamic improvement postoperatively due to our small sample size, spinal cord detethering did not lessen ongoing voiding complaints in the study patients.

Activation of the insulin-like growth factor-1 receptor induces resistance to epidermal growth factor receptor antagonism in head and neck squamous carcinoma cells.

Epidermal growth factor receptor (EGFR) tyrosine kinase inhibitors (TKI) have poor efficacy in head and neck squamous carcinoma cells (HNSCC). Because the IGF-1 receptor (IGF1R) generates potent prosurvival signals and has been implicated in therapeutic resistance, its ability to induce resistance to EGFR-TKIs was studied in vitro. Five HNSCC cell lines showed reduced sensitivity to the EGFR-TKI gefitinib when the IGF1R was activated. In SCC-25 and Cal27 cells, gefitinib inhibited basal and EGF-stimulated EGFR, extracellular signal-regulated kinase (Erk), and Akt phosphorylation and reduced cell number. This correlated with initiation of apoptosis based on a 4-fold increase in PARP cleavage and a 2.5-fold increase in Annexin V positivity. The apoptotic response and reduction in cell number were blocked by IGF1R activation, which resulted in phosphorylation of both Erk and Akt. In both the cell lines, IGF1R-induced Erk, but not Akt, activation was eliminated by gefitinib. IGF1R-induced gefitinib resistance was unaffected by MAP/Erk kinase inhibition with U0126 but was partially impaired by inhibition of phosphoinositide-3-kinase with LY294002. The IGF1R-TKI PQ401 inhibited growth of SCC-25 and Cal27 cells alone and also acted synergistically with gefitinib. Thus, the IGF1R can make HNSCC cells resistant to EGFR-TKI treatment via a prosurvival mechanism. Of the 8 HNSCC tumor samples studied, all samples expressed the IGF1R and 5 showed detectable IGF1R phosphorylation, suggesting that this receptor may be relevant in vivo, and thus, combined EGFR/IGF1R inhibition may be necessary in some patients for effective targeted molecular therapy.

Renal Inflammatory Myofibroblastic Tumor: A Case Report and Comprehensive Review of Literature.

Inflammatory myofibroblastic tumor (IMT) is a rare benign tumor found in various organs with a sparse number of cases reported in the kidney. We report a case of IMT in a 48-year-old male who underwent laparoscopic partial nephrectomy for a 2.4 cm renal mass suspicious for renal cell carcinoma. Pathologic findings revealed spindle shaped cells in a myxoid background with lymphoid aggregates consistent with inflammatory myofibroblastic tumor.