Effect of core preventative screening on kidney stone surgical patterns.

PURPOSE: In the surgical treatment of kidney stones, decreased access to healthcare has been shown to exacerbate stone burden, often requiring more invasive and extensive procedures. The objective of this study is to evaluate the effects of preventative health screening on kidney stone surgical treatment patterns. METHODS: We performed a retrospective analysis of data from the Healthcare Cost and Utilization Project (HCUP) Florida state-wide dataset and the PLACES Local Data for Better Health dataset from the Centers of Disease Control and Prevention (CDC). ZIP Code Tabulation Areas (ZCTAs) identified from the PLACES data were merged with the HCUP dataset to create a single dataset of community-level stone outcomes and community health measures. We included adult patients 18 years or older who underwent at least one urologic stone procedure from 2016 to 2020. RESULTS: 128,038 patients from 885 communities were included in the study. Patients underwent an average of 1.42 surgeries (Median = 1.39, SD = 0.16). Increased core preventative screening was associated with increased surgical frequency (Estimate: 0.51, P < 0.001). The low core preventative screening group had a higher prevalence of PNL than SWL while the high core preventative screening group had a low PNL prevalence compared to SWL. CONCLUSION: Increased core preventative screenings are associated with less invasive kidney stone surgeries, suggesting that preventative screenings detect stones at an earlier stage.

Inflammatory myofibroblastic tumor of the bladder in an adolescent: Case report.

Inflammatory myofibroblastic tumors of the bladder (IMTB) are rare neoplasms that can occur in children. These tumors have uncertain malignant potential and can present similarly to bladder sarcomas. It is important to differentiate between IMTB and bladder sarcomas using a careful immunohistochemical approach. We report a case of IMTB in a 12-year-old girl who presented with presyncope and gross hematuria. IMTB was diagnosed through immunohistochemical analysis, and clinical improvement was observed after resection of the tumor.

Standardization of mineral density maps of physiologic and pathologic biominerals in humans using cone-beam CT and micro-CT scanners.

OBJECTIVES: The lack of standardized X-ray imaging remains a challenge for comparative studies on spatial scans acquired from different clinic-specific X-ray scanners. The central objectives of this study are: 1) to delineate mineral density (MD) values, and 2) generate spatial MD maps of various physiologic and pathologic biominerals, and 3) propose a standardization protocol within the safe-operating zone of a CT scanner that underpins normalization of absorbed dose to shape and density of tissues. METHODS: A systematic approach to propose a standardization protocol for CT imaging in vivo included: 1) estimation of pathologic MD ranges by performing a comparative meta-analysis on 2009-2019 data from the PubMed database; 2) calibration of cone-beam CT (CBCT) and micro-CT scanners with phantoms of known mineral densities (0, 250, 500, 750 and 3000 mg/cc) and shapes (cylinders and polyhedrons); 3) scanning craniofacial bones (N = 5) and dental tissues (N = 5), and ectopic minerals from humans (N = 3 each, pulp, salivary gland, kidney and prostrate stones, and penile and vascular plaques); 4) underscoring the effect of shape-factor (surface area-to-volume ratio) on MD of biominerals. RESULTS: Higher MDs of physiologic and pathologic cortical bones (504-1009 mg/cc) compared to trabecular bone (82-212 mg/cc) were observed. An increase in shape-factor increased the CBCT error in MD measurement and revealed that the scanner resolution is dependent on the absorbed dose and shape-factor of detectable features. SIGNIFICANCE: CT scanners should be calibrated with phantoms containing segments of known shape-factors and mineral densities to identify safe-operating zones. The calibrated approach will narrow the gap between length-scale dependent measurements, and will permit spatiotemporal quantitative and reliable detection of pathologies.

Delayed Diagnosis of Iatrogenic Bladder Perforation in a Neonate.

Iatrogenic bladder injuries have been reported in the neonate during umbilical artery/vein catheterization, voiding cystourethrogram, urinary catheterizations, and overwhelming hypoxic conditions. Patients with iatrogenic bladder perforations can present with acute abdomen indicating urinary peritonitis, septic-uremic shock, or subtle symptoms like abdominal distension, pain, hematuria, uremia, electrolyte imbalances, and/or difficulty urinating. The following neonatal case report of perforated bladder includes a review of the signs, symptoms, diagnostic tools, and management of bladder injury in neonates.

Torsion of the Appendix Testis in a Neonate.

Torsion of the appendix testis is a rare cause of scrotal swelling in the neonatal period. We present a case of torsion of the appendix testis in a one-day-old male. We discuss the physical examination and radiologic studies used to make the diagnosis. Nonoperative therapy was recommended and the patient has done well. Recognition of this condition in the neonatal period can prevent surgical intervention and its associated risks.

Assessment of pediatric Malone antegrade continence enema (MACE) complications: Effects of variations in technique.

OBJECTIVE: The Malone antegrade continence enema (MACE) procedure is performed for patients with fecal incontinence and constipation who do not respond to medical therapy. The MACE procedure provides antegrade catheter access to the right colon and allows administration of enemas to help evacuate the bowel regularly. The objective of this study was to identify risk factors for surgical complications in children who undergo the MACE procedure. METHOD: Records from 97 pediatric patients who underwent MACE procedure were reviewed retrospectively. Data collected included age, sex, weight (obese/not obese), stomal location, presence of a permanent button/catheter in the stoma, open vs. laparoscopic surgery, and etiology of fecal incontinence/constipation. The complications reviewed included stomal stenosis, leakage, and stomal site infection. The relationships between the independent variables and complications were assessed using chi-square tests and Fisher's exact test. Statistical significance was set at p < 0.05. RESULTS: Overall, 66 (68%) patients had at least one complication. Twenty-three (23.7%) patients developed stomal stenosis, and 27 (27.8%) patients had significant stomal leakage. Insertion of a stomal button/catheter device was associated with an increased risk of developing stomal leakage and stomal infection. The presence of a stomal button/catheter was also associated with a decreased risk of stomal stenosis (Figure). The non-intubated, imbricated sub-population, preteen patients (<12 years old) experienced more stomal leakage than teenage patients. In this subgroup, patients with umbilical stomas also experienced more leakage than patients with right lower quadrant (RLQ) stomas. CONCLUSION: The prevalence rates of stomal complications in our study were consistent with previously reported series. In our study, however, stomal leakage had a higher prevalence in comparison with stomal stenosis. This seems to be related to the heterogeneity of the study group, which contained two variants of the MACE procedure; non-imbricated, intubated MACE and imbricated, non-intubated MACE. The use of stomal buttons in conjunction with MACE has previously been reported without changes in complication rates. We found the use of stomal buttons/catheters to be associated with changes in the prevalence of stomal complications. Stomal complications are common in the MACE procedure. The use of a permanent stomal button/catheter is associated with changes in the rates of stomal complications. While many find an umbilical stomal site is more cosmetically appealing, there is an increased risk of leakage with imbricated, non-intubated stomas. In the non-intubated, imbricated sub-population, the MACE procedure results in a higher risk of stomal leakage in preteen patients in comparison with teenage patients.

Transurethral neo-orifice (TUNO) a novel technique for management of upper pole obstruction in infancy.

INTRODUCTION AND OBJECTIVE: Ureteral duplication is the most common urologic abnormality. The upper pole ureter can sometimes be associated with a ureterocele. In rare cases the ureteral insertion is extravesical and can result in significant hydroureteronephrosis. Patients can present with urinary tract infection, abdominal mass or urinary obstruction. Traditional procedures include ureteral reimplantation, ureteroureterostomy or heminephroureterectomy. These reconstructive procedures are technically challenging in small infants, especially when the hydroureteronephrosis is severe. In some cases a distal cutaneous ureterostomy is performed for immediate drainage followed by definitive surgery when the child is older. We describe our initial experience with a novel cystoscopic technique which provides drainage of the upper pole ureter and avoids the need for an incision or stoma. MATERIALS AND METHODS: A 3 month-old boy presented with urinary tract infections and failure to thrive. Ultrasound revealed severe upper pole hydroureteronephrosis. Voiding cystourethrography did not reveal vesicoureteral reflux or the presence of a ureterocele. The patient underwent cytoscopy. The ectopic ureteral orifice was not identified. A transurethral, transvesical needle puncture and confirmatory ureteropyelography was used to access the dilated upper pole ureter. Guidewire passage, followed catheter dilation then allowed creation of a new ureteral orifice using a holmium laser. RESULTS: The patient tolerated the procedure well. He was discharged after overnight observation. The hydronephrosis improved, urinary tract infections have not recurred and the patient rapidly improved feeding and weight gain. CONCLUSION: Trans-Urethral Neo-Orifice creation is a minimally invasive option for initial decompression for patients with obstructive ureteral ectopia.

Stentless pediatric robotic pyeloplasty.

OBJECTIVES: Open dismembered pyeloplasty remains the standard of care for the correction of ureteropelvic junction obstruction in children. We describe our experience with a tubeless, stentless pediatric robotic pyeloplasty technique. METHODS: Between October 2008 and September 2009, 12 consecutive children underwent robotic dismembered pyeloplasty. Ureteral stents or nephrostomy tubes were not used. Operative time, hospital stay, days of Jackson-Pratt drainage, and complications were analyzed. Postoperative renal ultrasonography was obtained at 4-6 weeks after surgery. RESULTS: The mean patient age was 9.1 years (3.5-16). The mean operative and console times were 178 (122-250) and 129 (96-193) minutes, respectively. The Jackson-Pratt drain was removed after a mean of 1.8 days (1-4). The mean hospital stay was 2.4 days (1-4.5). There were no complications. Mean follow up was 16 months (12-24 months). All patients had complete resolution of symptoms. Hydronephrosis either completely resolved or significantly decreased in all cases. In cases without complete resolution of hydronephrosis, 99m Tc-MAG-3 diuretic renography showed preservation of renal function without obstruction. CONCLUSIONS: Robot-assisted laparoscopic pyeloplasty can be safely performed without internal indwelling stent drainage. In children, this avoids the need for additional anesthesia and stent-related morbidity.

Robotic assisted laparoscopic treatment of gonadal vein syndrome in a boy.

PURPOSE: Gonadal vein syndrome, with ureteral obstruction and compression by an overlying testicular vein is a controversial and rare diagnosis. Open, laparoscopic, and robot-assisted laparoscopic repairs have been described. We report the first case of robot-assisted gonadal vein ligation for treatment of gonadal vein syndrome in a nine year-old boy. MATERIALS AND METHODS: A 9 years-old boy presented with a four to six month history of worsening intermittent flank pain, nausea and vomiting. Ultrasound revealed moderate hydronephrosis. Diuretic renography and intravenous pyelography reproduced his pain and demonstrated left-sided hydronephrosis and obstruction. The patient underwent left robot-assisted surgery via a four port approach. The colon was reflected medially. The gonadal vein was dissected off the underlying ureter and ligated using laparoscopic clips. Segmental vein excision and ureterolysis was performed. Inspection of the renal hilum did not reveal any other crossing vessels. RESULTS: Operative time was 94 minutes. The patient was discharged 36 hours after surgery. His hydronephrosis has resolved completely. He remains pain-free nine months after surgery. CONCLUSION: Robot-assisted laparoscopic vein excision and ureterolysis is a safe option for the management of ureteral obstruction caused by the gonadal vein.

Cost-utility analysis of treatment algorithms for moderate grade vesicoureteral reflux using Markov models.

PURPOSE: The optimal treatment algorithm for vesicoureteral reflux remains controversial. Previous decision analyses have attempted to determine the best approach solely from the cost or cure perspective but have not combined the goals of minimizing treatment and disease burden. We incorporated these considerations into a contemporary, comprehensive analysis of treatment for vesicoureteral reflux. MATERIALS AND METHODS: We examined costs from the perspective of the medical institution, and utility from the perspective of parents of children with grades II and III vesicoureteral reflux. Cost-utility analysis using Markov modeling was performed to ascertain which of 5 treatment algorithms best minimized morbidity and cost. A higher utility value was based on minimizing treatment and disease burden. Measures of treatment and disease burden included duration of suppressive antibiotics, number of invasive studies, pyelonephritis episodes, endoscopic treatments and open operations. All variables were varied spanning realistic ranges during sensitivity analyses to determine threshold values. RESULTS: The protocol of no antibiotics or followup imaging yielded the best cost-utility for vesicoureteral reflux grades II and III. Sensitivity analysis of variables spanning realistic ranges demonstrated that utility penalties for invasive imaging and outpatient pyelonephritis were particularly important in determining the highest utility protocols, with threshold values ranging from -0.5 to -0.8. CONCLUSIONS: In our models of treatment for vesicoureteral reflux a noninterventional approach constitutes the highest utility and least costly treatment for moderate grade reflux. Given the relative dearth of randomized trials, these analyses provide guidelines for current management of vesicoureteral reflux.

Hallucinations after hypospadias repair.

The authors report a case of a 4-year-old child who developed hallucinations after hypospadias repair. He was brought to the emergency department the morning after outpatient surgery where the diagnosis of central anticholinergic syndrome was made. We review oxybutynin overdose and the importance of providing clear instruction to parents and caregivers about the administration of medications.

Prenatal intervention for urinary obstruction and myelomeningocele

Widespread use of ultrasonography has resulted in an increase in the recognition of fetal hydronephrosis. The enthusiasm that accompanied early interventions has been tempered by the experience and results obtained over the past 2 decades. The goal has remained the same: to identify patients with serious prenatal obstruction and to identify those which may benefit from intervention. Myelomeningocele remains a devastating congenital anomaly. Fetal and experimental studies suggested that patients with myelomeningocele could benefit from prenatal intervention. Advances in technology and perinatal management have made intervention for more complex malformations such as myelomeningocele possible. This article will review current knowledge and will detail rational management for the management of prenatal hydronephrosis. The current state of antenatal myelomeningocele repair and the urologic implications will be described as well.

Prenatal intervention for urinary obstruction and myelomeningocele.

Widespread use of ultrasonography has resulted in an increase in the recognition of fetal hydronephrosis. The enthusiasm that accompanied early interventions has been tempered by the experience and results obtained over the past 2 decades. The goal has remained the same: to identify patients with serious prenatal obstruction and to identify those which may benefit from intervention. Myelomeningocele remains a devastating congenital anomaly. Fetal and experimental studies suggested that patients with myelomeningocele could benefit from prenatal intervention. Advances in technology and perinatal management have made intervention for more complex malformations such as myelomeningocele possible. This article will review current knowledge and will detail rational management for the management of prenatal hydronephrosis. The current state of antenatal myelomeningocele repair and the urologic implications will be described as well.