Testicular catch-up growth in the non-operative management of the adolescent varicocele.

INTRODUCTION: Adolescent varicocele is a common urologic condition with a spectrum of outcomes, leading to variations in management. Testicular hypotrophy is a common indication for surgery Routine monitoring may be an appropriate form of management for many adolescents with testicular hypotrophy, as studies have shown that a large proportion of these patients may experience catch-up growth of the ipsilateral testis. Furthermore, there are few longitudinal studies which have correlated patient specific factors to catch-up growth. We aimed to determine the frequency of testicular catch up-growth in adolescents with varicocele while also examining if patient specific factors such as BMI, BMI percentile, or height correlated with testicular catch-up growth. METHODS: A retrospective chart review found adolescent patients who presented to our institution with varicocele from 1997 to 2019. Patients between the ages of 9 and 20 years with left-sided varicocele, a clinically significant testicular size discrepancy, and at least two scrotal ultrasounds at least one year apart were included in analysis. Testicular size discrepancy of greater than 15% on scrotal ultrasound was considered clinically significant. Testicular size was estimated in volume (mL) via the Lambert formula. Statistical relationships between testicular volume differential and height, body mass index (BMI), and age were described with Spearman correlation coefficients (ρ). RESULTS: 40 patients had a testicular volume differential of greater than 15% at some point during their clinical course and were managed non-operatively with observation and serial testicular ultrasounds. On follow-up ultrasound, 32/40 (80%) had a testicular volume differential of less than 15%, with a mean age of catch up growth at 15 years (SD 1.6, range 11-18 years). There were no significant correlations between baseline testicular volume differential and baseline BMI (ρ = 0.00, 95% CI [-0.32, 0.32]), baseline BMI percentile (ρ = 0.03, 95% CI [-0.30, 0.34]), or change in height over time (ρ = 0.05, 95% CI [-0.36, 0.44]). DISCUSSION: The majority of adolescents with varicocele and testicular hypotrophy exhibited catch-up growth with observation, suggesting that surveillance is an appropriate form of management in many adolescents. These findings are consistent with previous studies and further indicate the importance of observation for the adolescent varicocele. Further research is warranted to determine patient specific factors that correlate with testicular volume differential and catch up growth in the adolescent varicocele.

The Inequitable Experiences of Left-Handed Medical Students in Surgical Education.

PURPOSE: Left-handed medical students contend with unique educational barriers within surgery, such as lack of educational resources, lack of left-handed-specific training, and widespread stigmatization of surgical left-handedness. This study aimed to highlight the surgical experiences of left-handed medical students so educators may be empowered to act with greater care and appreciation of these students' circumstances. METHOD: In this qualitative study, the authors conducted semistructured interviews on surgical experiences during medical school between January 31, 2021, and June 20, 2021, on 31 current surgical residents and fellows from 15 U.S. institutions and 6 surgical specialties. Left-handed trainees were included regardless of their surgical hand dominance. RESULTS: The authors identified 3 themes related to left-handed medical students' surgical experience: (1) disorienting advice from faculty or residents, (2) discouraging right-handed pressures and left-handed stigmatization, and (3) educational wishes of left-handed medical students. Trainees describe dialogues during medical school in which their handedness was directly addressed by residents and faculty with disorienting and nonbeneficial advice. Often trainees were explicitly told which hand to use, neglecting any preferences of the left-handed student. Participants also described possible changes in future surgical clerkships, including normalization of left-handedness, tangible mentorship, or granular and meaningful instruction. CONCLUSIONS: Left-handed medical students encounter unique challenges during their surgical education. These students report being disoriented by the variability of advice provided by mentors, discouraged by how pressured they feel to operate right-handed, and burdened by the need to figure things out by themselves in the absence of adequate left-handed educational resources. Surgical education leadership should detail the unique problems left-handed learners face, impartially elicit the learner's current operative hand preference, take responsibility for their left-handed students, promote acceptance and accommodation strategies of left-handed surgical trainees, and endeavor to improve the breadth of left-handed surgical resources.

Should we screen for Müllerian anomalies following diagnosis of a congenital renal anomaly?

INTRODUCTION: Despite the well-established embryological relationship in the development of renal and Müllerian structures, no clear guidelines exist regarding screening for Müllerian anomalies (MA) in the setting of a renal anomaly (RA). Delayed diagnosis of MA can have significant reproductive consequences. OBJECTIVE: To investigate the prevalence of coexisting MA in patients with congenital RA. STUDY DESIGN: This is a retrospective cohort study of females age 12-35 years with a diagnosis of RA, identified by diagnosis codes, who were followed for care between 2013 and 2020. Data were collected on demographics, medical history, clinical presentation, and imaging studies. Descriptive statistics were used to summarize the data. This study was IRB approved. RESULTS: A total of 465 patients were included in this study, of whom 326 patients (70.3%) had a pelvic evaluation during the study period. Of these 326 patients, 125 (38.3%) were found to have coexistent MA. About one-third of patients who underwent pelvic evaluation due to pain were found to have MA. For 69.6% (87/125) of patients with MA, the RA was diagnosed prior to the MA. The average age at time of RA diagnosis was 6.4 ± 8.8 years and the average age of MA diagnosis was 16.4 ± 6.9 years. Forty-eight (38.4%) patients had obstructive anomalies. Of the Müllerian obstructions, 93.8% were treated with urgent surgery and the remainder started on hormonal suppression. The prevalence of MA was dependent on the RA diagnosis (Figure). Of patients with a solitary kidney, 67.1% were diagnosed with MA. For other parenchymal RA, the prevalence of MA was 20-23%. In patients with solitary kidney, uterus didelphys was the most common MA (52.1%). Thirty percent of patients with a solitary kidney were diagnosed with an obstructive MA. CONCLUSIONS: In this study, 38% of patients with RA who underwent a pelvic evaluation were found to also have MA. Our study shows the strongest association between MA and solitary kidney, but also emphasizes a significant risk with other RA. Almost 40% of patients with diagnosed MA were found to have an obstruction that required urgent treatment. Delays in diagnosis and treatment of Müllerian obstructions can be detrimental for future reproductive health, due to risk of chronic pain, infertility, infection, and endometriosis. Given the high prevalence of MA in patients with RA, especially those with congenital solitary kidney, routine screening with pelvic ultrasound should be performed around the age of expected menarche.

The effect of preoperative tamsulosin on ureteroscopic access in school-aged children.

INTRODUCTION: Flexible ureteroscopes are not tailored for pediatric ureteral size and may not pass at first attempt into the pediatric ureter. Administration of tamsulosin preoperatively in adults has been shown to facilitate ureteral access sheath placement. Several studies have shown tamsulosin to be safe and effective when utilized for medical expulsive therapy in pediatric patients, but its utility for preoperative ureteral dilation has not been studied to date. OBJECTIVE: We hypothesized that preoperative tamsulosin reduces failed ureteroscopic access in children. MATERIALS AND METHODS: We conducted a retrospective review of patients aged 0-18 years undergoing flexible ureteroscopy (URS) from 2014 to 2019 at a single institution. Patients were divided into those taking 0.4 mg of tamsulosin daily for at least 1 week prior to surgery and those not taking tamsulosin. The primary outcome was failure to pass a 7.95 Fr flexible ureteroscope on initial attempt, requiring stent placement and staged management. Patients undergoing URS or stent placement within the prior year, requiring semi-rigid URS, or with genitourinary anomalies were excluded. RESULTS AND DISCUSSION: A total of 49 patients met inclusion criteria. The tamsulosin group (n = 13) and non-tamsulosin group (n = 36) were similar with respect to demographic data. The percentage of prepubertal patients was 53% vs 33% (p = 0.19). The tamsulosin group had lower failed URS (38% vs 61%, p = 0.20). When stratified by age, both prepubertal and postpubertal patients in the tamsulosin group had lower failed URS (43% vs 67%, p = 0.67 and 33% vs 58%, p = 0.38). These clinically significant results suggest initial passage of a flexible ureteroscope is more successful in pediatric patients on preoperative tamsulosin. This study was largely limited by its low power and flaws inherent to its retrospective design. CONCLUSION: Our results have implications for prescribing tamsulosin preoperatively to reduce multiple procedures and anesthetics in children. Adequately powered prospective trials are warranted to confirm preoperative tamsulosin reduces failed first-attempt flexible URS in children.

Is There a Urologist in the House? Trends in the Management of Consults Based on Shift, Location and Resident Organization.

INTRODUCTION: Consultations represent a significant workload for inpatient urology providers, yet consult patterns are poorly described. We report trends in billable urology consult activity by location, time and organization of consult residents at a single institution. METHODS: Using a secure database urology consults between 2011 and 2018 at an academic center were recorded. Consult time, location and management were documented. Consults were considered eligible for billing if seen by faculty at time of consult in the emergency room or within 24 hours in the inpatient or operating room settings. Furthermore, in 2016 consult responsibilities overnight were given to an in-house resident. An interrupted time series was used to evaluate trends in consultations. RESULTS: Ultimately 18,431 consults were seen, 40.8% in the inpatient setting and 55.2% in the emergency room setting. The overall number of consults increased annually. The majority of consults (64.8%) were made during the day. Around 88.7% of inpatient and 88.2% of operating room consults were eligible for billing, yet only half (54.43%) of emergency room consults were eligible. After the addition of an in-house consult resident there was a significant (12%) increase in the number of billable consults. CONCLUSIONS: Ultimately, nearly half of emergency room consults were not eligible for billing. Initiation of an in-house overnight consult resident significantly increased the fraction of total billable consults. Understanding patterns in consult data offers insight into quality improvement measures that maximize departmental labor efficiency.

Urodynamic and imaging findings in infants with myelomeningocele may predict need for future augmentation cystoplasty.

INTRODUCTION: Urologic issues are persistent and important causes of morbidity and mortality in patients with myelomeningocele. Classically, patients with elevated bladder pressures despite adherence to clean intermittent catheterization (CIC) and pharmacotherapy undergo augmentation cystoplasty (AC). Currently, there is little understanding of which infants are more likely to require AC later. OBJECTIVE: In this context, the authors studied whether unfavorable urodynamic or imaging findings in patients with myelomeningocele during infancy could predict future AC. The authors hypothesized that infants born with elevated bladder pressures, vesicoureteral reflux (VUR), and/or hydronephrosis would be more likely to undergo AC. STUDY DESIGN: The authors retrospectively identified patients with myelomeningocele at their institution who were followed-up since infancy (<1 year of age), with a minimum of eight continuous years of follow-up. Standard care protocol included cystometrogram, voiding cystourethrogram (VCUG), and renal ultrasound during infancy. The primary outcome was AC for elevated bladder pressures despite attempts at more conservative management with medical therapy and CIC. Specifically, the authors evaluated for differences in augmentation rates based on gender, level of lesion, presence of detrusor leak point pressure (DLPP) or end-fill pressure (EFP) greater than 40 cm H2O, presence of hydronephrosis, VUR, initiation of CIC, and initiation of antimuscarinics in infancy. The authors excluded patients who underwent surgical intervention for urinary incontinence. RESULTS: A total of 97 patients met the inclusion criteria. The median follow-up time was 13.8 years. Augmentation cystoplasty was performed for 17 patients (17.5%) at a median age of 114 months (9.5 years). Detrusor leak point pressure/EFP was greater than 40 cm H2O in 34.0% (33/97) of infant cystometrogram studies, while 30.9% (30/97) had VUR on infant VCUG and 20.6% (20/97) had hydronephrosis on infant renal ultrasound. Patients with DLPP/EFP greater than 40 cm H2O or VUR during infancy were more likely to undergo AC (P = 0.02 and P = 0.03, respectively). Binomial logistic regression revealed that DLPP/EFP greater than 40 cm H2O (odds ratio [OR]: 4.28, 95% confidence interval [CI]: 1.34-13.62) and VUR (OR: 3.73, 95% CI: 1.18-11.77) were independent risk factors for future AC. DISCUSSION: Infants with myelomeningocele and elevated bladder pressures and VUR should be closely monitored by urodynamic testing and imaging studies. Parents can be counseled regarding the potentially higher risk for future AC in these patients. Nonetheless, the majority of high-risk infants will safely avoid AC with conservative management.

Impact of the Timing of Ureteral Stent Placement on Outcomes in Patients with Obstructing Ureteral Calculi and Presumed Infection.

Objective: To understand how time to stent placement impacts outcomes in patients with obstructing ureteral stones and concern for infection. Materials and Methods: Using a prospective urology consult institutional database (2011-2016), we identified patients who presented to the emergency department (ED) with an obstructing ureteral stone, met two or more systemic inflammatory response syndrome (SIRS) criteria (temperature [T] >38°C or <36°C, heart rate >90 beats per minute, respiratory rate >20 breaths per minute, white blood cell count >12 k/µL or <4 k/µ), and underwent stent placement. The primary outcome of interest was impact of stent timing on intensity of care (need for intensive care unit [ICU]) as well as overall length of stay (LOS). Results: Forty-eight patients were identified who met the study criteria. Overall, 58.3% had positive urine cultures. There was no difference between groups with across a range of clinical variables. While the need for ICU admission did not differ between groups, those patients who had a ureteral stent placed within 6 and 10 hours of ED arrival had a significantly decreased LOS (35.6 hours vs 71.6 hours, p = 0.01; 45.7 hours vs 82.4 hours, p = 0.04) relative to those patients who were stented outside these intervals. Conclusion: In patients with an obstructing ureteral calculus and concern for infection, there is a beneficial effect to timelier stent placement in the form of decreased overall LOS.

The first female authors of the Journal of Urology.

INTRODUCTION: In 1917, Alma Hiller became the first woman to publish in the Journal of Urology (JU). Her contribution was followed by articles from Carol Beeler and Isabel Mary Wason. This study explores their careers and contributions. METHODS: We reviewed JU articles from 1917 to 1925 and identified Hiller, Beeler, and Wason as the first three women authors. Using public records, we obtained information of their educations and careers. RESULTS: Hiller demonstrated resilience in obtaining training and ultimately contributed to innovation in clinical chemistry. Beeler worked on research on metabolic physiology. Wason influenced both lab work and national policy. CONCLUSIONS: For female scientists entering the workforce in the late 1800s/early 1900s, reception was contingent upon the acceptance of male colleagues. Despite these barriers, Hiller, Beeler, and Wason contributed to novel discoveries. Their most influential contributions remain their historic presence as early female researchers and the first female authors in JU.

Impact of Clinical Guidelines on Voiding Cystourethrogram Use and Vesicoureteral Reflux Incidence.

PURPOSE: To prevent over diagnosis and overtreatment of vesicoureteral reflux the 2007 NICE (National Institute for Health and Care Excellence) and 2011 AAP (American Academy of Pediatrics) guidelines recommended against routine voiding cystourethrograms in children presenting with first febrile urinary tract infections. The impact of these guidelines on clinical practice is unknown. MATERIALS AND METHODS: Using an administrative claims database (Clinformatics™ Data Mart) children who underwent voiding cystourethrogram studies or had a diagnosis of vesicoureteral reflux between 2001 and 2015 were identified. The cohort was divided into children age 0 to 2 and 3 to 10 years. Single and multiple group interrupted time series analyses (difference-in-difference) were performed with the guidelines as intervention points. The incidence of vesicoureteral reflux was compared across each period. RESULTS: Of the 51,649 children who underwent voiding cystourethrograms 19,422 (38%) were diagnosed with vesicoureteral reflux. In children 0 to 2 years old voiding cystourethrogram use did not decrease after the 2007 NICE guidelines were announced (-0.37, 95% CI -1.50 to 0.77, p = 0.52) but did decrease significantly after the 2011 AAP guidelines were announced (-2.00, 95% CI -3.35 to -0.65, p = 0.004). Among children 3 to 10 years old voiding cystourethrogram use decreased during the entire study period. There was a decrease in the incidence of vesicoureteral reflux in both groups that mirrored patterns of voiding cystourethrogram use. CONCLUSIONS: The 2011 AAP guidelines led to a concurrent decrease in voiding cystourethrogram use and incidence of vesicoureteral reflux among children 0 to 2 years old. Further studies are needed to assess the risks and benefits of reducing the diagnosis of vesicoureteral reflux in young children.

Ambulatory Care Use among Patients with Spina Bifida: Change in Care from Childhood to Adulthood.

PURPOSE: We examined the ambulatory health care visit use of children with spina bifida, adults who transitioned to adult care and adults who continued to seek care in a pediatric setting. MATERIALS AND METHODS: We evaluated use during a 1-year period of patients with spina bifida who visited any outpatient medical clinic within an integrated health care system. Patients were categorized as pediatric (younger than 18 years) or adult (age 18 or older). Adults were divided into those who did not fully transition to adult care and patients who fully transitioned (adult). Frequency and type of health care use were compared. Subanalysis was performed for patients 18 to 25 years old to examine variables associated with successful complete transition to adult care. RESULTS: During 1 year 382 children, 88 patients who did not transition and 293 adult patients with spina bifida had 4,931 clinic visits. Children had greater ambulatory care use (7.25 visits per year) compared to fully transitioned adults (5.33 visits per year, p=0.046). Children more commonly visited surgical clinics (52.3% of visits) and adults more commonly visited medical clinics (48.9%) (p <0.005). Adult transitioned patients were more likely to be female (p=0.004). Of the patients 18 to 25 years old, those who did not transition to adult care had similar outpatient visit types but greater use of inpatient and emergency care than those who transitioned. CONCLUSIONS: Children with spina bifida used more ambulatory care than adults and were more likely to visit a surgical specialist. Adult patients with spina bifida who successfully transitioned to adult care were more likely to be female, and patients who failed to transition were more likely to receive more inpatient and emergency care.

Comparison of 30-day emergency department bouncebacks after pediatric versus adult urologic surgery.

INTRODUCTION: More pediatric patients seem to present to the emergency department (ED) for non-urgent matters after urologic procedures than adult patients. Under new and expanding healthcare reform, pediatric urologists may be penalized for these visits. We compare our 30-day postoperative bounceback rates to the ED and the acuity of the concerns in these populations. MATERIALS AND METHODS: All urology consults at our institution are maintained on a prospectively tracked database. We identified all patients who presented to our adult or pediatric ED between July 2013 and June 2015 within 30 days of a urologic procedure. We investigated the patient demographics including age, race, insurance, distance from the home zip code to the ED, procedures performed, chief complaint in the ED, diagnosis, and treatment required. RESULTS: In our pediatric group, there were 67 visits for 56 patients (19 female, 37 male, mean age 6.8 years), which represents an overall bounceback incidence of 2.7%. Of those, 19% required admission (0.60% overall readmission rate), 10% underwent a procedure (0.32% reoperative rate, 18% required catheter manipulation/placement, 13% were given a prescription (most commonly for constipation), 6% required local wound care, and 33% were reassured only). Most pediatric patients had private insurance (62.5%) and those with private insurance or who were uninsured tended to require only reassurance compared to those with Medicare/Medicaid (p = 0.053). In the adult population, there were 369 visits in 310 patients (111 female, 199 male, mean age 55.4 years) for an incidence of 4.4%. Of those, 42% were admitted (2.2% overall readmission rate), 14% underwent a procedure (0.74% reoperative rate), 11% required catheter manipulation/placement, 14% were given medication (most commonly antibiotics and narcotics), 4% were given local wound care, and 12% were reassured. Most adult patients had Medicare/Medicaid (48.7%), but insurance type was not related to treatment required (p = 0.382). On multivariable analysis, pediatric patients, closer proximity to the hospital, and earlier postoperative day at presentation to the ED were predictive of requiring only reassurance. CONCLUSIONS: Compared to adults, pediatric patients are less likely to return to the ED postoperatively (p < 0.001), but they are significantly more likely to require only reassurance (p < 0.001) while adults are significantly more likely to require hospital admission (p < 0.001). In both groups, nearly one-third of patients required only catheter care or medication. This difference could have significant implications for new healthcare policy.

Bladder perforation after augmentation cystoplasty: Determining the best management option.

INTRODUCTION: Delayed bladder perforation is a well-described complication after augmentation cystoplasty. Although the frequency, risk factors, and diagnostic challenges are well documented, discussions regarding management strategies are sparse. OBJECTIVE: We evaluated our experience of managing augmented bladder perforation to interrogate the hypothesis that non-operative management can be used effectively. STUDY DESIGN: We retrospectively evaluated the management of 10 patients with augmented bladder perforations over a 16-year period (Jan 2000-Jan 2016). Patients who demonstrated clinical deterioration, severe peritonitis, or extensive extravasation on imaging underwent exploratory laparotomy and primary closure. Clinically stable patients with minimal extravasation were managed non-operatively with maximal bladder drainage, and those with loculated fluid collections in feasible locations for drainage underwent an image-guided percutaneous drain placement. RESULTS: Underlying diagnoses included four patients with myelomeningocele, three with sacral agenesis, two with spinal cord injuries, and one with bladder exstrophy. Three of the four patients with myelomeningocele had concomitant ventriculoperitoneal shunts. Six patients had continent catheterizable channel creation and two patients had bladder neck reconstructions during the original operation. Four patients were managed with exploratory laparotomy and primary closure. Among the six patients managed non-operatively, three underwent image-guided drain placement in addition to maximal bladder drainage. Four patients developed re-perforation. Two of the four surgically managed patients developed re-perforation. Two of the three patients managed only with maximal bladder drainage developed re-operation. None of the patients managed non-operatively with drain placement suffered from re-perforation. Four perforation episodes were alcohol-related, two occurred after high-impact sporting activity, and two patients reported non-compliant catheterization. DISCUSSION: Non-operative management with maximal bladder drainage and selective image-guided drain placement can be successfully deployed in clinically stable patients with limited extravasation. Ensuring low intraluminal detrusor pressures and empty bladder with maximal drainage is critical for spontaneous sealing of the perforation site. Exploratory laparotomy and primary closure remains our approach for those presenting with clinical deterioration or significant extravasation on imaging. The majority of our perforations and re-perforation episodes seemed to stem from preventable behavioral risk factors. CONCLUSIONS: Our findings support the hypothesis that non-operative management with maximal bladder drainage and image-guided drain placement can be effective in stable patients with limited extravasation.