Tips and tricks for the extravesical robotic-assisted laparoscopic ureteral reimplantation for pediatric vesicoureteral reflux.

Over the past few years, robotic-assisted laparoscopic ureteral reimplantation (RALUR) has gained popularity as an acceptable alternative for the traditional open approach if surgery is elected for children with vesicoureteral reflux (VUR). We present our technique including the tips and tricks for both male and female patients, including a stepwise approach for ureteral identification in female patients depending on the level of technical difficulty. Our series include 30 patients who represent a spectrum in which we presented the different tips and tricks included in this video.

Poorer patient-reported outcome and increased risk of revision at a 5-year follow-up among patients with septic arthritis following anterior cruciate ligament reconstruction: a register-based cohort study of 23,075 primary anterior cruciate ligament reconstructions.

PURPOSE: The primary aim of this study is to analyse the patient-reported outcomes after ACLR complicated by septic arthritis. The secondary aim is to examine the 5-year risk of revision surgery after primary ACLR complicated by septic arthritis. The hypothesis was that patients with septic arthritis after ACLR are more likely to have lower PROMs scores and an increased risk of revision, compared with patients without septic arthritis. MATERIALS AND METHODS: All primary ACLRs, with a hamstring or patellar tendon autograft (n = 23,075), in the Swedish Knee Ligament Register (SKLR) between 2006 and 2013 were linked with data from the Swedish National Board of Health and Welfare to identify patients with postoperative septic arthritis. These patients were verified in a nationwide medical records analysis and compared with patients without infection in the SKLR. The patient-reported outcome was measured using the Knee injury and Osteoarthritis Index Score (KOOS) and the European Quality of Life Five Dimensions Index (EQ-5D) at 1, 2 and 5 years postoperatively and the 5-year risk of revision surgery was calculated. RESULTS: There were 268 events of septic arthritis (1.2%). The mean scores on the KOOS and EQ-5D index were significantly lower for patients with septic arthritis on all subscales on all follow-up occasions compared with patients without septic arthritis. Patients with septic arthritis had a revision rate of 8.2% compared with 4.2% in patients without septic arthritis (adjusted hazard ratio 2.04; confidence interval 1.34-3.12). CONCLUSION: Patients suffering from septic arthritis following ACLR are associated with poorer patient-reported outcomes at 1-, 2- and 5-year follow-ups compared with patients without septic arthritis. The risk of revision ACL reconstruction within 5 years of the primary operation for patients with septic arthritis following ACLR is almost twice as high, compared with patients without septic arthritis. LEVEL OF EVIDENCE: III.

Double versus single diaper technique after hypospadias repair, does it really matter?

INTRODUCTION: Double-diaper technique with an open-drainage catheter is a common practice after hypospadias repair. However, double-diapering may increase the burden of postoperative care and has not been compared to single-diapering with an open-drainage catheter. OBJECTIVES: This study investigates whether the single-diaper technique is associated with inferior surgical outcomes compared to the double-diaper technique. MATERIALS AND METHODS: A single surgeon database was retrospectively reviewed for patients who underwent hypospadias repair between 2013 and 2021. Patients who were lost to follow-up and those in whom the type of diaper care (single- or double-diaper) was not documented were excluded. Patients in the single-diaper technique received the same type of dressing and discharge instructions, as those in the double-diaper group, except for leaving the catheter freely draining into a single-diaper. Short-term complications including surgical site infection (SSI), urinary tract infection (UTI) and wound dehiscence, were the primary outcome; whereas the long-term urethroplasty complications (urethrocutaneous fistula and meatal stenosis) were secondary outcomes. Outcomes were analyzed according to the type of diaper care. RESULTS: Among 323 patients reviewed, 219 patients met the inclusion criteria (72 patients in the double-diaper and 147 in the single-diaper group). Both study groups were similar regarding patient demographics, hypospadias characteristics and surgical technique. Looking at the primary outcomes, there was no statistically significant difference in SSI, UTI or wound dehiscence. For the secondary outcomes, the incidence of meatal stenosis (8.3 vs. 1.4%, p = 0.044), and fistula formation (15.3% vs 5.4%, p = 0.037) was significantly higher in the double-diaper than the single-diaper group, respectively (Table 2). CONCLUSION: Single-diaper technique following hypospadias repair is not associated with increased risk of complications compared to double-diaper technique.

DIAGNOdent versus International Caries Detection and Assessment System in detection of incipient carious lesions: A diagnostic accuracy study.

Aim: The present investigation aimed at assessing the diagnostic accuracy of DIAGNOdent compared to the International Caries Detection and Assessment System-II (ICDAS-II) in the detection of facial, smooth surface noncavitated carious lesions. Settings and Design: Sixty patients were enrolled in the current study according to the eligibility criteria. There were 161 teeth with noncavitated, white spot carious lesions and 32 sound teeth. Materials and Methods: Before examination, teeth were cleaned and polished and all patients were assessed under standardized operating conditions: preset dental unit position, operating light, and prolonged air drying (approximately 5 s). All teeth were assessed by two calibrated examiners individually without any contact using ICDAS-II and DIAGNOdent. Statistical Analysis: The diagnostic accuracy of DIAGNOdent device was determined, including sensitivity, specificity, overall accuracy, positive and negative predictive values, and receiver operating characteristic curve analysis. Chi-square test was conducted to compare the distribution of ICDAS-II and DIAGNOdent scores. Inter-observer agreement between assessors was evaluated using Cohen's kappa test. Results: In the current study, DIAGNOdent had an overall accuracy of 84.45% with sensitivity and specificity of 87.58% and 96.87%, respectively, and +PV and -PV of 97.7% and 83.9%, respectively, when score 0 represented sound tooth surface, while scores 1 and 2 were considered clinically noncavitated carious lesions. Moreover, when only ICDAS score 1 was considered representing first visual change in enamel, DIAGNOdent had an accuracy of 74.15% with sensitivity and specificity of 83.53% and 90.62%, respectively, and +PV and -PV of 93% and 78.6%, respectively. In the present study, when only ICDAS score 2 was considered representing distinct visual change in enamel, DIAGNOdent had an accuracy of 100% with sensitivity and specificity of 100% and 100%, respectively, and +PV and -PV of 100% and 100%, respectively. Conclusions: The overall performance of DIAGNOdent was equivalent to the visual inspection using ICDAS-II. DIAGNOdent might be considered a useful adjunctive device for detection and monitoring development of noncavitated carious lesions on facial smooth surfaces.

Pediatric renal trauma at a level 1 trauma center in a rural state: A 10-year institutional review and protocol implementation.

INTRODUCTION: Unintentional injury is a leading cause of mortality and morbidity in children. There is no consensus on the ideal, discrete management of pediatric renal trauma (PRT). Therefore, management protocols tend to be institution-specific. OBJECTIVE: This study aimed to characterize PRT at a rural level-1 trauma center and subsequently develop a standardized protocol. STUDY DESIGN: A retrospective review of a prospectively maintained database of PRT at a rural level 1 trauma center between 2009 and 2019 was conducted. Injuries were characterized regarding renal trauma grade, associated multi-organ involvement and the need for intervention. The benefit of patient transfer from regional hospitals and length and cost of stay were evaluated. RESULTS: Of 250 patients admitted with renal trauma diagnosis 50 patients <18 years were analyzed. Of those, the majority (32/50, 64%) had low-grade (grade I-III) injuries. Conservative management was successful in all low-grade injuries. Of 18 high-grade PRT, 10 (55.6%) required intervention, one prior to transfer. Among patients with low-grade trauma, 23/32 (72%) were transferred from an outside facility. A total of 13 (26%) patients with isolated low-grade renal trauma were transferred from regional hospitals. All isolated, transferred low-grade renal trauma had diagnostic imaging before transfer and none required invasive intervention. Interventional management of renal injury was associated with a longer median LOS [7 (IQR = 4-16.5) vs 4 (IQR = 2-6) days for conservative management, p = 0.019)] and an increased median total cost of $57,986 vs. $18,042 for conservative management (p = 0.002). DISCUSSION: The majority of PRT, particularly low-grade, can be managed conservatively. A significant proportion of children with low-grade trauma are unnecessarily transferred to higher level centers. Review of pediatric renal trauma at our institution over a decade has allowed us to develop an institutional protocol which we believe allows for safe and effective patient monitoring. CONCLUSION: Isolated, low-grade PRT can be managed conservatively at regional hospitals without needing transfer to a level 1 trauma center. Children with high-grade injuries should be closely monitored and are more likely to need invasive intervention. Development of a PRT protocol will help to safely triage this population and identify those who may benefit from transfer to a tertiary care center.

Infantile Primary Hyperoxaluria Type 1 Treated With Lumasiran in Twin Males.

Primary hyperoxaluria type 1 (PH1) is a rare genetic disease that results in oxalate overproduction leading to nephrolithiasis (NL), nephrocalcinosis (NC), kidney failure, and systemic oxalosis. Infantile PH1 is its most severe form, and it may require intensive hemodialysis followed by a liver-kidney transplant. Lumasiran is an RNA interference (RNAi) therapeutic agent that reduces hepatic oxalate production, which has been recently approved for the treatment of PH1. In this report, we present a case of twin males with infantile PH1 and bilateral NL and NC who were treated with lumasiran at 12 months of age. Their symptoms abated after therapy was started without disease progression. To the best of our knowledge, this is the first report of PH1 occurring in twins and the first report on using lumasiran to treat infantile PH1 outside of a clinical trial. Lumasiran appears to be a successful therapeutic option for infantile PH1.

Dysfunctional Voiding- Presentation of a Rare Case of Pediatric Non Muscle Invasive Urothelial Bladder Carcinoma.

Bladder cancer is rare in children, with 86.8% of pediatric patients diagnosed not carrying any of the common risk factors commonly seen in adults. Here, a 16-year-old female presented to the ED with in urinary retention. A renal bladder ultrasound revealed an echogenic focus in the bladder wall. On diagnostic cystoscopy a small papillary bladder lesion was appreciated and resected. Final pathology of the bladder mass resulted as non-invasive low grade papillary urothelial carcinoma (pTa). This report demonstrates bladder cancer in the pediatric age group, and should be considered as a possible differential diagnosis in patients with dysfunctional voiding.

Bridging the Gap-Building Surgical Subspecialty Telemedicine Clinics in the Rural Setting.

INTRODUCTION: Pediatric urology is a much-needed subspecialty with a breadth of complex disorders that can often prove challenging to diagnose and manage. Exacerbating this need is the minimal exposure medical trainees receive to pediatric urology. Pediatric urology arrived in West Virginia in 1983 but the subspecialty has been inconsistently represented since then. Currently there are 2 fellowship-trained pediatric urologists in the state of West Virginia, which has an area of approximately 24,038 square miles. We review our experience with the use of telemedicine in providing outreach to the wider parts of our medically underserved state and ultimately evaluate its efficacy from a patient-centric cost analysis and diagnosis concordance perspective. We hypothesized that the use of telemedicine would be cost and time-effective for patients in our rural state. METHODS: We retrospectively reviewed our series of patients presenting from outside telemedicine "referral centers" in Martinsburg, Parkersburg and Wheeling for pediatric urological consultation. We evaluated reason for consultation, geographic driving distance, drive time and travel cost saved from telemedicine consultation. RESULTS: A total of 92 patients presented to outside designated telemedicine centers from August 2018 to April 2020. The mean driving time saved utilizing telemedicine consultation was 4 hours and 46 minutes, and mean driving distance saved was 299.8 miles. Travel costs saved in terms of fuel averaged $173.88 per patient. The most common reason for consultation was undescended testis, followed by recurrent urinary tract infection and nocturnal enuresis. Of the 23 patients who required surgery, only 2 (8.7%) had an initial diagnosis that was not concordant with their operating room examination. CONCLUSIONS: While modest, our data indicate a modern solution to a historical need in our state. Our high diagnosis concordance rate (91.3%) shows that a well-trained advanced practice provider can adequately perform an operative evaluation via telemedicine.

Compensation claims following anterior cruciate ligament injuries reported to the patient insurance company in Sweden in 2005-2014.

Background and purpose - Patients in the Swedish healthcare system are insured against avoidable adverse events via Landstingens Ömsesidiga Försäkringsbolag (LÖF). We assessed the reasons for compensation claims reported to LÖF following an ACL injury. Patients and methods - We searched the LÖF database for compensation claims related to ACL injuries reported in 2005-2014, and cross-matched claims with the Swedish National Knee Ligament Register. We then performed a review of the medical records. Results - We identified 530 eligible claims in 2005-2014. 352 (66%) claims were accepted by LÖF and 178 claims were rejected. Accepted claims corresponded to fewer than 1% of ACL surgeries performed in the same period. The most common reasons for an accepted claim were postoperative septic arthritis followed by suboptimal surgery and delay in diagnosis and treatment. Interpretation - There are different reasons for accepting a compensation claim following an ACL injury, which represents different treatment errors that can be avoided.

Evaluation of ICCMS versus CAMBRA Caries Risk Assessment Models Acquisition on Treatment Plan in Young Adult Population: A Randomized Clinical Trial.

PURPOSE: To evaluate the difference between ICCMS and CAMBRA models on treatment plan of young adults. SETTINGS AND DESIGN: A total of 104 young adult patients were randomly divided into two groups, either ICCMS or CAMBRA. PATIENTS AND METHODS: Patients were examined according to the criteria of the ICDAS-II and caries risk was analyzed according to CAMBRA and divided into two equal groups according to treatment protocol. Caries incidence was assessed according to ICDAS-II criteria after 6 and 12 months. Statistical analysis used Chi-square test. A value of P ≤ 0.05 was considered statistically significant. Relative risk (RR) was used to determine the clinical significance. RESULTS: The current study has revealed no statistically significant difference between both caries risk assessment models tested at baseline (P = 0.317), 6 months (P = 0.164) and 1 year (P = 0.287). Intra-group assessment of CAMBRA group showed a statistically significant difference in ICDAS scores (P = 0.002) after 12 months in high- and moderate-risk groups while low-risk group did not show statistically significant difference in ICDAS scores between different follow-up periods (P = 0.593) and (P = 1.000), respectively. ICCMS groups did not show statistically significant differences in any group along follow-up periods. CONCLUSION: ICCMS and CAMBRA were equivalent in preventing new decay. The ICCMS treatment plan is a safe approach and its preventive products are available over the counter. However, it is more complicated than CAMBRA. While CAMBRA is simpler, it is less comprehensive, some of its products are not available over the counter worldwide (e.g. Duraphat 5000 ppm) and some of them may be accompanied by several side effects (e.g. chlorhexidine mouthwash), which may weaken its management protocol.

Surgical Correction of True Diphallia in a Newborn Male.

Diphallia is an exceedingly rare anomaly characterized by partial or complete duplication of the phallus. Approximately 100 cases have been reported worldwide since its initial documentation, and incidence is estimated at 1 in 5 to 6 million live births. Therapeutic management is dependent on the extent of the anomaly, ranging from phallic excision to complex reconstructive procedures in cases of broader systemic involvement. We present the case of congenital true diphallia with associated penoscrotal transposition, bifid scrotum, partial urethral duplication, ventral chordee, large scrotal lipoma and sacral dimple. We further present a review of available literature pertaining to diphallia.

The Impact of Targeted Education of American Urological Association Cryptorchidism Guidelines in a Rural State: Improvement Still Needed.

BACKGROUND: The American Urological Association published guidelines in 2014 regarding management of undescended testicles (UDT). Despite these guidelines, prior studies have indicated discordance between guidelines and actual practice, especially in rural states. This study aims to identify if educating referring providers improves management of UDT. METHODS: Patients with UDT referred to our institution were divided into two groups: those referred prior to (Group 1) and after (Group 2) targeted education. A retrospective review was performed to compare the groups in terms of age at time of referral and surgery, laterality, specialty, and practice setting of referring provider, and whether or not ultrasound (US) was performed prior to referral. RESULTS: A total of 100 patients were identified in Group 1 and 168 in Group 2. No significant differences were noted between groups regarding age, variability of referring provider, or those receiving US prior to referral. Median age at referral was 20.7 months (range=0-194) and 33 months (range=0-205.1) in Groups 1 and 2, respectively (p=0.26). Sixty-two (37%) patients underwent surgical evaluation within 18 months of age or younger in Group 1 compared to 39 (39%) in Group 2 (p=0.73). Private practice pediatricians comprised the majority of referring providers in both cohorts. US was performed prior to referral in 41% of patients in Group 1 compared to 35.8% in Group 2 (p=0.51). The number of US ordered prior to referral significantly decreased from 10 (50%) to six (19%) following education among academic providers (p=0.02). No significant difference was found following education for private practice physicians (p=0.27). CONCLUSION: Targeted education did not improve age at referral in the short-term, which may reflect suboptimal healthcare access. Additionally, more research is needed to evaluate whether more diverse targeted education provided on a regular basis to both physician and mid-level providers would have a meaningful impact.

Choosing the Right Catheter for Pediatric Procedures: Patient Considerations and Preference.

Determining the need for bladder decompression and urinary diversion in the perioperative pediatric surgical patient can cause a clinical conundrum for the surgical team. Add in the several different types of urinary diversion devices possible, and the various materials associated therein and the process can suddenly seem unnecessarily daunting given the lack of concise recommendations and broad consensus. The decision to divert urine, though seemingly trivial, is associated with inherent risks. Managing and mitigating certain risks are best approached through proper education, selection, and technique. We provide a broad overview of pediatric catheter selection, indications, and pitfalls to streamline the process so that energy and attention can best be focused on the planned intervention at hand.

Prenatally Diagnosed Testicular Torsion: A Rare Condition That Causes Dilemma in Management.

BACKGROUND: Prenatal testicular torsion (PTT) is exceedingly rare in intrauterine development, often diagnosed at the time of birth and very rarely diagnosed in utero during routine gestational ultrasound. As a result, incidence is unknown, and there exists no consensus regarding the pathophysiology of this phenomenon nor universally recognized algorithms and guidelines regarding its diagnosis and management. Case Presentation. We present the case of an antenatally diagnosed torsion and our subsequent management which included ipsilateral orchiectomy and prophylactic contralateral orchiopexy via a scrotal approach. CONCLUSION: While controversy regarding surgical intervention in patients with unilateral PTT exists due to poor salvage rates-estimated to be less than 1%-the risk of anorchia is higher in affected patients due to limitations in the accuracy of detecting bilateral testicular involvement. Risk of misdiagnosis of bilaterality may lead to lasting sequelae such as infertility and devastating psychological consequences for affected patients, supporting the need for surgical exploration, as was performed in our case.

True partial diphallia with associated penoscrotal transposition of two hemi-scrotums.

Diphallia or duplication of penis is extremely rare condition with a reported incidence of 1 in 5-6 million live births. Approximately around 100 cases of diphallia have been described in literature, each case have a unique presentation from associated anomalies. Clinically these patients can be classified into complete (true diphallia) or partial duplication. In true diphallia, each penis has 2 corpora cavernosa and 1 corpus spongiosum. If the duplicate penis is smaller or rudimentary with complete structure, it is described as true partial diphallia. The term bifid phallus is used if there is only one corpus cavernosum in each penis. Due to low incidence and varied presentation, not much is known about the underlying pathophysiology, management options, and outcomes. Here, we report a case of partial diphallia with associated penoscrotal transposition of 2 hemi-scrotums.

Rare late presentation of bilateral single system intravesical ureteroceles complicated with ureterolithiasis: Case report and literature review.

Bilateral intravesical ureteroceles is a rare condition where both ureters terminally end in cystic dilations in the urinary bladder. Herein, a 31-year-old male patient presented with severe right flank pain and gross hematuria. Upon computed tomography imaging, a right ureterocele with an entrapped stone was revealed. Direct visualization also showed a smaller ureterocele at the left ureterovesical junction. Both ureteroceles were unroofed using rigid resectoscope with cold knife resulting in rapid bilateral efflux. The treatment was well tolerated with no known complications. Albeit uncommon, this case highlights the need to consider ureteroceles in adult patients with urinary tract symptoms.

A 24-Month Evaluation of Self-Adhering Flowable Composite Compared to Conventional Flowable Composite in Conservative Simple Occlusal Restorations: A Randomized Clinical Trial.

BACKGROUND: Self-adhering flowable composite (SAFC) simplified restorative procedures, especially when compared to conventional techniques. Self-adhering composite revolutionized restorative dentistry by merging advances of adhesive and restorative materials to generate the so-called "eighth generation." AIMS: The objective of this clinical trial was to assess the clinical performance of SAFC compared to conventional flowable composite in minimally invasive occlusal cavities. SETTINGS AND DESIGN: A total of 18 patients with conservative occlusal cavities received randomly two types of restorations in a split-mouth design. MATERIALS AND METHODS: Vertise™ Flow or Filtek™ Z350XT Flowable was applied according to the manufacturer's instructions. All restorations were evaluated at baseline and after 24 months, respectively, by two blinded assessors using modified USPHS criteria. STATISTICAL ANALYSIS USED: Chi-square test was used for intragroup comparison between time points and intergroup comparison within each time point. A value of P ≤ 0.05 was considered statistically significant. Relative risk was used to determine the clinical significance. RESULTS: The results of the current study have revealed no statistically significant difference between both materials for all tested outcomes at baseline and after 24 months. CONCLUSIONS: SAFC revealed satisfactory clinical performance in restoration of minimally invasive occlusal cavities after 24-month follow-up.

Evaluation of Preoperative Tamsulosin Role in Facilitating Ureteral Orifice Navigation for School-Age Pediatric Ureteroscopy.

PURPOSE: To address whether preoperative tamsulosin increases the rate of successful ureteral orifice navigation for ureteroscopy (URS) without prestenting in school-age pediatric patients. METHODS: We retrospectively reviewed all pediatric patients who had undergone ureteroscopy (URS) at our institution from 2013 to 2020. Patients were divided into two groups: those who had received tamsulosin 0.4 mg daily ≥48 hours preoperatively and those who had not. Statistical analysis was done using independent-sample t-tests and Mann-Whitney U tests for continuous variables, and χ2 and Fisher's exact tests were used for categorical variables. Multivariate analysis was done using binary logistic regression test. RESULTS: Overall, successful ureteral orifice navigation occurred in 44 of 50 patients (88%) who had received tamsulosin and 17 of 26 (65.4%) who had not (p=0.019). On further subanalysis based on stone location and instrumentation used, successful ureteral orifice navigation had occurred in 21 of 24 patients (87.5%) in the tamsulosin group and one of five (20%) in the no-tamsulosin group for semirigid ureteroscopy for mid-distal ureterolithiasis (p=0.007). For proximal ureteral and renal stones, successful ureteral orifice navigation with a flexible ureteroscope or ureteral access sheath had occurred in 23 of 26 patients (88.5%) in the tamsulosin group and 16 of 21 (76.2%) in the no-tamsulosin group (p=0.437). Multivariate analysis showed no significant difference between success rates in the two groups after controlling for patient weight, height, BMI, and stone location. We did not observe any adverse effects from tamsulosin. CONCLUSION: This is the first study to evaluate preoperative tamsulosin on successful ureteral orifice navigation in school-age pediatric patients. Although not reaching statistical significance, further evaluation should be done on larger cohorts. Patient height was found to be an independent predictor of successful ureteral orifice navigation.