Search

Summary Background Lymph node (LN) involvement is an important prognostic indicator for patients with Wilms tumor (WT), and there have been previous reports of utilizing LN density (LND = positive LN/LNs examined) as an advanced metric to risk-stratify patients with WT. Objective The purpose of this study was to describe patient characteristics that affect LN yield and assess the effect of LND on the overall survival (OS) in patients with WT, with the expectation that patients with LNDs above a critical cut-point would demonstrate lower OS. Study design The Surveillance, Epidemiology, and End Result (SEER) database was queried for all patients diagnosed with unilateral WT from 2004 to 2015. Patient and disease characteristics were collected, and Poisson regression was used to identify characteristics correlated with LN yield. LND was calculated for LN-positive patients, and multivariable survival analysis was performed, including patient demographics and LND as variables. Results 1489 patients with unilateral WT were identified for analysis, 231 (15.51%) of whom were LN-positive. Median patient age at diagnosis was three years (IQR 1–5). On Poisson regression, the year of diagnosis, patient age, tumor size and laterality, and stage were found to impact LN yield. For patients with positive LNs, five-year OS of patients with LNDs above 0.4 was worse than those below 0.4 (76.1% vs 89.6%, p = 0.041). On multivariable analysis, tumor size and LND remained significant predictors of OS. Discussion Administrative databases such as SEER provide an excellent resource for studying conditions where large patient numbers for analysis are difficult to obtain. Unfortunately, the SEER database is unable to account for every factor that could affect LN sampling patterns. Additionally, favorable vs unfavorable histology is not available in SEER, and SEER utilizes its own staging system, which makes comparison to Children's Oncology Group staging difficult. Despite these limitations, the findings of this study are similar to those previously published using administrative databases analyzing LN sampling patterns and the effect of LND on OS in WT. Conclusions Analysis of the SEER database confirms that there are several patient- and disease-specific factors that affect the number of LNs sampled during nephrectomy for WT, and that LND may be a predictor of OS. These findings highlight the need for standardization of LN sampling patterns for pediatric renal tumors and support the investigation of LND in future studies to further risk-stratify WT patients to tailor therapy intensity.

Pediatric cystic renal lesions are challenging to manage as little is known about their natural course. A modified Bosniak (mBosniak) classification system has been proposed for risk stratification in pediatric patients that takes ultrasound (US) and/or computed tomogram (CT) characteristics into account. However, literature validating this system remains limited.To determine if the mBosniak classification system correlates with pathologic diagnoses. The hypothesis is that mBosniak classification can stratify the risk of malignancy in children with renal cysts.Patients treated for cystic renal masses with available imaging and pathology between 2000 and 2019 from five institutions were identified. Clinical characteristics and pathology were obtained retrospectively. Characteristics from the most recent US, CT, and/or magnetic resonance imaging (MRI) were recorded. Reviewers assigned a mBosniak classification to each scan. mBosniak scores 1/2 were considered low-risk and 3/4 high-risk. These groups were compared with pathology (classified as benign, intermediate, malignant). Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), positive likelihood ratio (+LR), and negative likelihood ratio (-LR) were calculated to assess this categorization as a screening tool to guide surgical intervention. Agreement between imaging modalities was also explored.99 patients were identified. High-risk imaging findings were correlated with malignant or intermediate pathology with a sensitivity of 88.3%, specificity of 84.6%, PPV of 89.8%, NPV of 82.5%, +LR of 5.7, and -LR of 0.14. The sensitivity for detecting malignant lesions only was 100%. There was substantial agreement between US/CT (n = 55; κ = 0.66) and moderate agreement between US/MRI (n = 20; κ = 0.52) and CT/MRI (n = 13; κ = 0.47).The mBos classification system is a useful tool in predicting the likelihood of benign vs. intermediate or malignant pathology. The relatively high sensitivity and specificity of the system for prediction of high-risk lesions makes this classification applicable to clinical decision making. In addition, all malignant lesions were accurately identified as mBosniak 4 on imaging. This study adds substantial data to the relatively small body of literature validating the mBosniak system for risk stratifying pediatric cystic renal lesions.Pediatric cystic renal lesions assigned mBosniak class 1/2 are mostly benign, whereas class 3/4 lesions are likely intermediate or malignant pathology. We observed that the mBosniak system correctly identified pathology appropriate for surgical management in 88% of cases and did not miss malignant pathologies. There is substantial agreement between CT and US scans concerning mBos classification.

Summary Purpose To identify the factors associated with a shorter postoperative stay, as an initial step to develop a care pathway for children undergoing extirpative kidney surgery. Study design This study retrospectively reviewed patients managed with upfront open radical nephrectomy for renal tumors between 2005 and 2016 at a pediatric tertiary care facility. Univariate and multivariate logistic regression were performed to identify factors associated with early discharge (by postoperative day 4). Results A total of 84 patients met inclusion criteria. Median age was 28.1 months (range 1.8–193.1). Thirty-four (40.5%) patients had a nasogastric tube postoperatively. The patients were advanced to a clear liquid diet on a median postoperative day 2 (range 0–7) and regular diet on a median postoperative day 3 (range 1–8). Median time from surgery to discharge was 5 days (range 2–12), with 38 (45.2%) discharged early. Univariate and multivariate logistic regression analyses showed that earlier resumption of regular diet (OR 0.523, P = 0.028) was positively associated with early discharge. Other analyzed factors were not significant (see Table). Discussion Timely initiation of adjuvant therapy is a specific requirement of Children's Oncology Group (COG) protocols. Chemotherapy and radiation therapy are ideally initiated simultaneously, as early as possible, within 2 weeks of surgery. Thus, factors that can facilitate early discharge from the hospital can maximize protocol adherence with respect to timing of adjuvant therapy initiation and optimize patient outcome. This study shed light on several postoperative factors and how these relate to postoperative stay and recovery. Specifically, tumor size, pre-operative bowel preparation, extent of lymph node sampling, stage, operative time, estimated blood loss, surgical service, postoperative nasogastric tube use, transfusion, and chemotherapy prior to discharge were not associated with discharge timing. Early re-feeding was associated with early discharge. Thus, it seems reasonable that, when developing a postoperative care pathway for these patients, these factors be considered and specifically encourage early re-feeding. In pediatrics, data on early recovery after surgery protocols are limited, and high-quality studies are unavailable. Within pediatric urology, early recovery after surgery protocols in children undergoing major urologic reconstruction have been shown to reduce hospital stay and can decrease complication rates. It seems reasonable that a similar pathway can be applied to children undergoing radical nephrectomy for suspected malignancy. Conclusions For children with renal tumors who underwent radical nephrectomy, early re-feeding was associated with a shorter time to discharge. Use of bowel preparation and nasogastric tube did not appear to shorten time to discharge. These data are important for developing postoperative care pathways for these patients. Table . Logistic regression for postoperative discharge by postoperative day 4. Univariate Multivariate OR 95% CI P-value OR 95% CI P-value Age (continuous) 0.992 0.98–1.005 0.209 0.992 0.976–1.009 0.359 Year of surgery (continuous) 1.027 0.909–1.16 0.673 Tumor diameter (continuous) 0.91 0.809–1.024 0.118 0.983 0.844–1.144 0.824 Malignant histology 0.372 0.086–1.601 0.184 0.784 0.137–4.482 0.784 Stage I/II 1 III/IV 0.676 0.278–1.643 0.388 Pre-operative bowel preparation 0.595 0.052–6.821 0.676 Surgical service Surgery alone 1 1 Urology involved 3.25 1.149–9.196 0.026 1.061 0.219–5.126 0.942 Operating room time (continuous) 1 0.993–1.006 0.919 Number of lymph nodes examined (continuous) 1.072 1.003–1.145 0.039 1.06 0.977–1.149 0.162 Estimated blood loss (continuous) 0.993 0.0985–1.001 0.095 0.997 0.988–1.005 0.416 Postoperative nasogastric tube 0.407 0.164–1.011 0.053 0.996 0.323–3.075 0.994 Postoperative day clears started (continuous) 0.451 0.267–1.764 0.003 Postoperative day regular diet started (continuous) 0.435 0.264–0.715 0.001 0.507 0.279–0.921 0.026 Chemotherapy prior to discharge 0.352 0.122–1.017 0.054 0.566 0.166–1.93 0.363

Testicular microlithiasis (TM) is a condition characterized by calcium deposits within the testis, usually detected incidentally during ultrasonography of the scrotum. TM has been associated with the presence of, and possibly the development of, testicular malignancy. Our aim was to document international clinical management practices for TM and to analyze what factors and perception of risk influence conservative versus active management and follow-up.European Society for Paediatric Urology (ESPU) and Society for Pediatric Urology (SPU) members were invited to complete an online case-based survey of clinical management practices of TM. Eight cases had a single variable changed each time (classic versus limited TM, unilateral versus bilateral, prior cryptorchidism versus no cryptorchidism) to ascertain the provider's perception of risk. The respondents completed multiple choice questions on initial management, follow-up plan, length and interval of follow-up. Multivariate logistic regression was performed to determine factors associated with decisions on management and follow-up.There were 265 respondents to the survey from 35 countries (Table). Median time in practice was 13 years. Factors that were significantly associated with more aggressive initial management (more than counseling on self-examination) included: not yet in independent practice, low volume TM cases per year, those practicing pediatric and adult urology, classic appearance of TM and cryptorchidism. Factors that were significantly associated with urologist follow-up and active investigation included: European practitioners, low TM case volume per year, those practicing both pediatric urology and pediatric surgery, classic TM appearance and a case history of cryptorchidism. Interval and length of follow-up was wide-ranging, with most respondents favoring annual follow-up.Management of TM varies and a mix of surgeon and case factors significantly influences management strategies. This baseline understanding of the lack of systematic management suggests the need for the development of consensus guidelines and prospective study.

Objective The aim was to assess the feasibility and outcomes of pediatric urological laparoendoscopic single site (LESS) surgery. Materials and methods A retrospective review was performed of all children who underwent LESS surgery at a single pediatric institution from September 2010 to July 2013. Patient demographics, intraoperative details, narcotic usage, and complications were reviewed. The umbilicus was used as the surgical site in all cases. All procedures were performed with a flexible tip laparoscope, a multichannel port, standard 3- or 5-mm laparoscopic instrumentation, and articulating instruments. Results Sixty-one patients (50 male, 11 female) were identified. Procedures included 18 orchidopexies, 15 nephrectomies, 11 varicocelectomies, nine nephroureterectomies, four partial nephrectomies, one ureterectomy, one ureterolithotomy, one orchiectomy, and one utricle excision. The ureterolithotomy was converted to open surgery for failure to progress. The utricle excision was converted to conventional laparoscopy by adding one accessory port and one skin puncture because of the close proximity of the vas deferens to the utricle. Intraoperative complications included one vas deferens injury during orchidopexy in a postpubertal male. Postoperative complications occurred in six patients: five grade II and one grade IIIb. Conclusions Pediatric urological LESS procedures are technically feasible, safe, and effective. Further evaluation is warranted to better define its role in pediatric urological surgery.

Objective Female congenital abnormalities and concomitant ambiguous genitalia constitute the primary reason for female genital reconstruction, however, objective data describing normal female anatomy is lacking. The aim of this study is to describe the normal anatomical relationships and size of the external genital structures in prepubescent females. Materials and methods Data were collected prospectively from consecutive Tanner stage 1 females undergoing surgery unrelated to the genitalia. Recorded measurements included: clitoris length and width, length from clitoris to anus, clitoris to urethra, clitoris to posterior labia majora, mucosa behind vagina or posterior fourchette, and radius to labia minora at vagina. Patients were stratified by age into four age groups: 11 years. Results Fifty-six patients met inclusion criteria. Clitoral width was similar in all age groups. The regression plots for the remaining measurements modeled on age all show a significant linear growth distribution. Conclusions The average clitoral width was 3.8 mm, which remained constant between age groups. Clitoral length, length from clitoris to anus, clitoris to posterior labia majora, clitoris to urethra and posterior fourchette length increased across age groups. This study provides insight into the dimensions of normal external genitalia in tanner stage 1 females.

Objective Our aim was to assess the outcomes of infant robot-assisted laparoscopic (RAL) upper urinary tract reconstruction. Materials and methods The medical records of all infants who underwent RAL upper urinary tract reconstruction were reviewed. Patients less than 1 year of age at surgery were included. Patient demographics, intraoperative details, narcotic usage, and complications were reviewed. Results Ten infants met the study criteria. There were five right and five left-sided procedures. Eight pyeloplasties (4 right, 4 left) and two ureteroureterostomies (1 right single system, 1 left duplex system) were performed. The median age was 8 months (range 3–12 months). Median weight was 7.7 kg (range 5.8–10.9 kg). Median operative time was 128 min (range 95–205 min). There was no significant blood loss or intraoperative complications. One (10%) patient received a regional block. Eight (80%) patients did not receive postoperative narcotics. Median hospital stay was 1 day (range 1–2). Median follow-up was 10 months (range 3–18 months). Complications included one urinary leak, one ileus, and one urinary tract infection. Hydronephrosis improved in all patients. Conclusions Infant RAL upper urinary tract reconstruction is technically feasible, safe, and effective. It can be applied for duplication anomalies and single system obstructions in infants.

To present our experience with infant pyeloplasty, comparing outcomes between robotic-assisted laparoscopic pyeloplasty (RALP) and open pyeloplasty (OP).A retrospective review was performed of all children1 year of age who underwent unilateral dismembered pyeloplasty at a single pediatric institution since January 2007. Patients with standard laparoscopic pyeloplasty were excluded. Patient demographics, intraoperative details, narcotic usage, and complications were reviewed.A total of 70 infants (51 boys and 19 girls) were identified, with nine RALP and 61 OP performed. Median age was 9.2 months (range, 3.7-11.9 months) for RALP and 4.1 months (range, 1.0-11.6 months) for OP (p = 0.005). Median weight was 8 kg (range, 5.8-10.9 kg) for RALP and 7 kg (range, 4-14 kg) for OP (p = 0.163). Median operative time was 115 min (range, 95-205 min) for RALP and 166 min (range, 79-300 min) for OP (p = 0.028). Median hospital stay was 1 day (range, 1-2 days) for RALP and 3 days (range, 1-7 days) for OP (p0.001). Median postoperative narcotic use of morphine equivalent was0.01 mg/kg/day (range, 0-0.1 mg/kg/day) for RALP and 0.05 mg/kg/day (range, 0-2.2 mg/kg/day) for OP (p0.001). Median follow-up was 10 months (range, 7.2-17.8 months) for RALP and 43.6 months (3.4-73.8 months) for OP (p0.001). The success rate was 100% for RALP and 98% for OP.Infant RALP was observed to be feasible and efficacious with shorter operative time, hospital stay, and narcotic utilization than OP.

Summary Introduction Renal cell carcinoma (RCC) is rare in the pediatric, adolescent, and young adult (PAYA) population. PAYA patients with RCC have a high rate of lymph node (LN) involvement, regardless of primary tumor size, yet data to guide surgical LN management in this group are limited. Objective The objective of this study was to determine what factors are associated with LN sampling (protocol adherence) in PAYAs with RCC. Methods The National Cancer Database (NCDB) between 2004 and 2013 was queried for patients aged ≤30 yrs with non-metastatic, unilateral RCC managed with surgery. Logistic regression analyses were performed to evaluate factors associated with LN sampling. Results A total of 2857 patients met study criteria. Pathologically, 2510 (87.8%) patients were Nx, 278 (9.7%) N0, and 69 (2.4%) N1. Older age was associated with omission of LN sampling (odds ration [OR]: 1.065, 95% confidence interval [CI]: 1.04–1.1, P 10 cm (OR: 0.27, 95% CI: 0.12–0.57, P = 0.001), and radical nephrectomy (OR: 0.245, 95% CI: 0.16–0.38, P Discussion Lymph node sampling is performed in Data from administrative databases are helpful for rare diseases such as PAYA RCC, but comes with limitations such as missing data. There are several factors that could contribute to LN sampling utilization (National comprehensive cancer network (NCCN) or Children's Oncology Group institution designation, surgeon experience, annual volume, specialty, operative approach, etc.) that cannot be further examined using the NCDB. Conclusion Pediatric, adolescent, and young adult patients with localized RCC are less likely to undergo surgical LN sampling if they are older, have tumors Univariate and multivariate analyses of factors associated with omission of LN sampling (pNx status). Factor Univariate Multivariate OR 95% CI P-value OR 95% CI P-value Facility case volume (continuous) 0.984 0.975–0.993 0.971 0.957–0.986 Age at diagnosis (continuous) 1.109 1.087–1.132 1.065 1.036–1.096 Gender Male 1 Female 0.822 0.656–1.029 0.088 Race White 1 1 Black 0.401 0.305–0.526 0.789 0.531–1.173 0.242 Other 1.106 0.601–2.035 0.745 1.573 0.647–3.829 0.318 Unknown 0.532 0.232–1.219 0.136 0.977 0.271–3.516 0.971 Insurance Private 1 1 Government 0.81 0.626–1.047 0.108 1.242 0.858–1.798 0.251 None 0.868 0.569–1.324 0.51 1.396 0.742–2.628 0.301 Unknown 0.438 0.254–0.755 0.003 0.504 0.195–1.304 0.158 Laterality Right 1 1 Left 0.709 0.565–0.889 0.003 0.744 0.542–1.02 0.066 Histology Papillary RCC 1 1 Clear cell RCC 3.671 2.573–5.237 1.649 0.994–2.737 0.053 RCC NOS RCC 1.596 1.133–2.249 0.008 0.28 0.783–2.093 0.325 Cyst-associated RCC 2.172 0.633–7.458 0.218 0.768 0.177–3.332 0.725 Chromophobe RCC 1.372 0.917–2.052 0.124 1.402 0.781–2.516 0.258 Sarcomatoid RCC 0.099 0.030–0.321 0.164 0.016–1.707 0.13 Stage 1 1 1 2 0.164 0.122–0.22 0.637 0.299–1.357 0.243 3 0.057 0.041–0.078 0.192 0.113–0.326 Tumor size ≤4 cm 1 1 4–≤7 cm 0.461 0.341–0.622 0.765 0.510–1.15 0.198 7–≤10 cm 0.171 0.120–0.244 0.510 0.233–1.114 0.091 >10 cm 0.074 0.053–0.104 0.266 0.124–0.567 0.001 Clinical nodal status cN0 1 1 cN1 0.052 0.023–0.115 0.320 0.119–0.86 0.0224 Type of surgery Partial nephrectomy 1 1 Radical nephrectomy 0.130 0.096–0.178 0.245 0.159–0.377 CI, confidence interval; LN, lymph node; OR, odds ratio; RCC, renal cell carcinoma.

Summary Introduction Testicular germ cell tumors (GCTs) are the most common solid tumor among adolescent and young adult (AYA) males. AYA patients with GCTs most typically have non-seminoma compared with seminoma, and accordingly there are fewer data reported on the AYA experience with testicular seminoma. Objective To evaluate national trends in postoperative treatment and overall survival (OS) outcomes in testicular seminoma by age group, specifically comparing AYAs with older adults. Study design The National Cancer Data Base (NCDB) was queried for patients with testicular seminoma diagnosed between 2004 and 2012, who underwent orchiectomy followed by observation or adjuvant therapy (chemotherapy, radiation (RT), or both). Patients were grouped by age: AYA (15–39 years), adults between 40 and 55 years, and adults >55 years. Overall survival (OS) was presented using Kaplan–Meier curves and groups compared via a log-rank test. Univariate (UVA) and multivariate (MVA) analyses were performed using Cox proportional hazards regression models. Binary multiple logistic regression identified differences in variables by age category. Results Of the total 22,361 patients the majority were AYAs (12,880, 57.6%), followed by adults 40–55 years (8,022, 35.9%), and >55 years (1,459, 6.5%). Unadjusted 5-year OS was significantly better for AYAs versus adults 40–55 years and >55 years (98.0%, 96.4%, 87.7%; p 55 years. AYA patients were also more commonly treated at centers with greater clinical volume. Additionally, AYA patients were less likely to present with metastatic disease. Accordingly, AYA patients were less likely to undergo retroperitoneal lymph node dissection (OR 0.81; p = 0.001) and were less often managed with adjuvant therapy including chemotherapy (OR 0.91; p = 0.027), RT (OR 0.93; p = 0.025), or both (OR 0.68; p = 0.020). Discussion AYA patients with testicular seminoma present with earlier stage disease and in the clinical Stage I setting are more often are managed with active surveillance following orchiectomy when compared with older adults in this population-based analysis. Among AYA patients, OS was modestly better when compared with adults 40–55 years and significantly better when compared with adults >55 years. Conclusion Our objective to describe the patterns of care and survival outcomes for AYA patients with testicular seminoma in the USA was met by reviewing this large national dataset. These results may inform future guidelines for management of AYA seminoma. Table . Cox regression for predictors of overall survival (OS) for testicular seminoma Variable Univariate Multivariate HR 95% CI p HR 95% CI p Age, years 15–39 1 1 40–55 1.81 1.53–2.14 1.80 1.52–2.13 >55 6.13 5.06–7.44 4.26 3.47–5.23 Logistic regression for variables associated with adolescent young adults (AYAs) compared with older adults Variable Univariate Multivariate OR 95% CI p OR 95% CI p Facility case volume, tertiles Low 1 1 Middle 1.13 1.06–1.21 1.14 1.07–1.21 Upper 1.18 1.10–1.26 1.17 1.09–1.25 Stage I 1 1 II 0.82 0.75–0.89 0.86 0.78–0.95 0.002 III 0.69 0.61–0.78 0.72 0.64–0.83

Summary Introduction Symptomatic pediatric ureterocele has diverse manifestations, making evidence-based management impractical. Thus, detailed visualization of ureterocele anatomy prior to first surgical incision is invaluable. Retrograde ureterocelogram (RUC) is a simple, underutilized radiologic technique that can be performed during cystoscopy. This study sought to determine whether RUC changes surgical management by more accurately depicting the complex ureteral and ureterocele anatomy, compared with renal ultrasound (US) and voiding cystourethrography (VCUG). Methods Patients who underwent surgical management of ureterocele from 2003 to 2015 were identified; those who received concomitant fluoroscopic RUC were selected for the case series. Data collected included: demographics, pre-operative evaluation, surgical interventions, and outcomes. The RUC images were individually examined, and the anatomic impression compared with previous renal US and VCUG. Novel RUC findings not previously appreciated by the pre-operative evaluation were noted. The RUC was performed by cystoscopically inserting a needle into the ureterocele and injecting contrast retrograde. If indicated, simultaneous PIC (Positioning the Instillation of Contrast) cystography was performed. Results Of the 43 patients that underwent surgery for suspected ureterocele, 28 underwent cystoscopy + RUC (10 M: 18 F) at a median age of 4.6 months and median follow-up of 37.0 months. All patients had prior US, 25 had prior VCUG, and 20 had prior radionuclide studies. Ureteroceles were either duplex system (n = 21) or single system (n = 7); 17 were ectopic into the bladder neck or urethra; seven were intravesical; and four were pseudoureteroceles. Fourteen patients underwent concomitant transurethral incision of the ureterocele (TUIU); two were deferred for surgery; and 11 received concomitant definitive surgery (e.g., nephrectomy). The RUC illuminated novel aspects of the anatomy in 20 of the 28 patients. No adverse events occurred. Notably, in nine of the 28 children, significant observations from RUC prompted change to the pre-operative surgical plan. Discussion Retrograde ureterocelogram clearly revealed ureterocele ectopy, pseudoureterocele, ureterocele disproportion, and unsuspected duplex systems, making it a useful adjunct to standard US and VCUG studies. Retrograde ureterocelogram can also be used to fluoroscopically verify decompression of the ureterocele post incision, document severity of ureteral dilation, and teach residents about the great damage generated by ureterocele variations. Limitations of RUC included increasing radiation dose and overall cost. The study design was limited by its small size, retrospective approach, selection bias, and availability of RUC images. Conclusions While not indicated in routine ureterocele management, intraoperative RUC further defined ureterocele anatomy in nearly all cases and yielded changes to the original surgical plan frequently enough to merit greater use in complex patients. Download : Download high-res image (79KB) Download : Download full-size image Figure . Example of RUC to illustrate complex ureterocele anatomy. In a 6-week-old febrile male with a right renal mass and grade IV VUR, RUC was performed to clarify the anatomy concomitant with a planned right nephrectomy. RUC revealed an ectopic right ureter and ureterocele, which appeared to have ruptured and opened into the posterior wall of the prostatic urethra. This did not change the nephrectomy but provided valuable reference for subsequent lower tract interventions.

We report surgical technique and outcomes in consecutive patients with primary distal hypospadias.A prospectively maintained database of all patients operated by WS in 2000-2008 was reviewed for pertinent data in consecutive patients.A total of 551 consecutive patients of mean age 17 months underwent distal tubularized incised plate hypospadias repair by urethral plate tubularization with (459) or without (92) midline incision. Follow up occurred for 426 (77%) at a mean of 8.2 months. Calibration and/or uroflowmetry were obtained in 279 (65%). Complications developed in 19 (4%), including nine fistulas, nine glans dehiscences and one delayed meatal stenosis from balanitis xerotica obliterans. These complications could not be attributed to meatal location, urethral plate configuration or incision, suture materials or methods for urethroplasty and glansplasty, or to use or not of a dartos flap barrier layer.No contraindication to urethral plate tubularization with or without incision was found in 551 consecutive patients operated for distal hypospadias. Reliability of the procedure was confirmed by the low complication rate and success using varied suture materials and methods.

Summary Introduction There is controversy about the role of lymph node (LN) sampling or dissection in the management of favorable histology (FH) Wilms tumor (WT), specifically how it performed and how it may impact survival. Objective The objective of this study was to analyze factors affecting LN sampling patterns and the impact of LN yield and density (number of positive LNs/LNs examined) on overall survival (OS) in patients with advanced-stage favorable histology Wilms tumor (FHWT). Methods The National Cancer Database (NCDB) was queried for patients with FHWT during 2004–2013. Demographic, clinical and OS data were abstracted for those who underwent surgical resection. Poisson regression was performed to analyze how factors influenced LN yield. Patients with positive LNs had LN density calculated and were further analyzed. Results A total of 2340 patients met criteria, with a median age at diagnosis of 3 years (range 0–78 years). The median number of LNs examined was three (range 0–87). Lymph node yield was affected by age, race, insurance, tumor size, laterality, advanced stage, LN positivity, and institutional volume. A total of 390 (16.6%) patients had LN-positive disease. Median LN density for these LN-positive patients was 0.38 (range 0.02–1) ( Summary Figure ). Estimated 5-year OS was significantly improved for those with LN density ≤0.38 vs. >0.38 (94% vs. 84.6%, P = 0.012). In this population, on multivariate analysis, age and LN density were significant predictors of OS. Discussion It is difficult to compile large numbers of cases in rare diseases like WT, and fortunately a large administrative database such as the NCDB can serve as a great resource. However, administrative data come with inherent limitations such as missing data and inability to account for a variety of factors that may influence LN yield and/or OS (specimen designation, pathologist experience, surgeon experience/volume, institutional Children's Oncology Group (COG) association, etc.). In this specific disease, the American Joint Committee on Cancer staging (captured by the NCDB) is different than the COG WT staging system that is used clinically, and the NCDB does not capture oncologic outcomes beyond OS. Conclusions In a review of the NCDB, various factors associated with LN yield and observed LN density were identified to be significantly associated with OS in patients with LN-positive FHWT. This reinforces the need for adequate LN sampling at the time of WT surgery, to maximize surgical disease control. It was proposed that LN density as a metric may allow for improved risk-stratification, and possibly allow for therapeutic reduction in a sub-set of patients with low LN density. Download : Download high-res image (145KB) Download : Download full-size image Summary Figure . Kaplan Meier curve of overall survival in patients with lymph node-positive disease based on lymph node density ≤0.38 vs. >0.38.

Summary Introduction Anecdotally, renal tumor (RT) surgery makes up a limited portion of the practice for most pediatric urologists and pediatric surgeons. Data are lacking on the current perceptions of RT surgery, both volume of surgery and issues related to surgical practice, among pediatric surgeons (PS) and pediatric urologists (PU). Objectives To describe practice patterns of pediatric renal tumor (RT) surgery and identify factors related to higher reported volumes of RT surgery. Study design The survey was developed and pilot-tested by the Children’s Oncology Group (COG) RT surgery committee. The survey was distributed to APSA and SPU members. Logistic regression was performed to correlate surgeon-reported factors with higher reported volumes of RT surgery. Results The survey was sent to 1,282 APSA and 426 SPU members, 367 (21.5%) surveys were completed from eligible responders, 244 (65.2%) and 123 (32.9%) from APSA and SPU invitations, respectively. Overall, 33.9% reported being part of a practice group in which RT surgical care is sub-specialized. A majority (50.7%) of respondents reported personally performing one to two RT surgeries annually, and 16.7% reported performing none. Multivariate logistic regression identified the following significant factors associated with increased individual RT surgical volume: group sub-specialization, COG/SIOP membership, regular tumor board attendance, and annual institutional volume >10 RT surgeries (Table). Accurate responses on the need for lymph node (LN) sampling in RT surgery were reported by 89.9%. Overall, 15.8% and 24.5% of respondents failed to correctly correlate local stage III disease in Wilms tumor (WT) with open or percutaneous biopsy, respectively (p Discussion While we found that reported RT surgery volume is low among both pediatric urologists and surgeons, we did identify surgeon-specific factors which correlated with higher RT surgical volume. Interested pediatric urologists and surgeons may use these data to tailor their practice if their goal is to increase RT surgery volume. Additionally, based on less than ideal rates of correct responses to nuance in the staging and treatment of WT, there are clear opportunities to increase education in this content area. However, the study is limited by use of a non-validated survey instrument and the relatively low response rates. Conclusion Reported individual RT surgery volume is low. Factors associated with increased volume include sub-specialty practice, tumor board involvement, and higher institutional volume. Responses on LN sampling and biopsy in WT demonstrate opportunities for educational initiatives. Table. Multivariate logistic regression analysis of factors associated with higher reported renal tumor surgery volume (>2 per year). Univariate Multivariate OR 95% CI p OR 95% CI p Lower limit Upper limit Lower limit Upper limit Practice specialty Pediatric urology 1 (Reference) 1 (Reference) Pediatric surgery 2.567 1.532 4.301 1.497 0.598 3.748 0.389 Are you one of the sub-specialty providers Yes 7.624 4.091 14.206 8.293 3.465 19.848 No 1 (Reference) 1 (Reference) Personally a COG or SIOP member Yes 5.076 3.164 8.143 2.630 1.348 5.133 0.0015 No 1 (Reference) 1 (Reference) Personal tumor board attendance I never go 1 (Reference) 1 (Reference) 4.4 1.579 12.257 0.005 6.364 1.283 31.572 0.024 25–50% of the time 7.68 2.58 22.86 6.835 1.294 36.103 0.024 50–75% of the time 8.4 2.739 25.764 15.145 2.752 83.329 0.002 >75% of the time 19.096 7.139 51.08 19.930 4.066 97.698 Average institutional renal tumor volume 0–10 cases per year 1 (Reference) 1 (Reference) >10 cases per year 3.243 1.996 5.271 3.829 1.929 7.599 Correct answer on impact of open biopsy on staging Yes 2.152 1.056 4.384 0.035 1.132 0.347 3.693 0.838 No 1 (Reference) 1 (Reference) Correct answer on impact of percutaneous biopsy on staging Yes 2.562 1.397 4.699 0.02 1.131 0.422 3.030 0.807 No 1 (Reference) 1 (Reference) Bold indicates factors with p

Summary Background In adolescents, approximately 90% of testicular germ cell tumors (T-GCTs) are non-seminomas (NS T-GCTs). Few studies have evaluated the impact of age, specifically in adolescence, on outcomes of NS T-GCTs. Objective The purpose of this study was to review all patients diagnosed with NS T-GCTs in the Surveillance, Epidemiology, and End Results (SEER) database to evaluate the association between age (adolescents vs. adults) and survival outcomes. Method The SEER database was queried for individuals ≥13 years old diagnosed with NS T-GCTs from 1995 to 2012. Patients were categorized into adolescent (13–19 years) and adult (≥20 years) cohorts. A Cox proportional hazards model was used for multivariate analysis (MVA). Results A total of 13,963 patients (1496 adolescents, 12,467 adults) was included. Median follow-up was 71 months (range 1–215). Five-year overall survival (OS) for adolescent and adult patients was 94% and 92%, respectively (p = 0.007); 5-year cancer-specific survival (CSS) was 95% and 94%, respectively (p = 0.139). Under MVA, adolescent patients had improved OS (HR 0.61; 95% CI 0.50–0.75; p Conclusions To our knowledge, this is the largest population-based comparative analysis in NS T-GCTs comparing outcomes between these two age groups. Adolescent patients with NS T-GCTs had slightly improved survival compared with adults, despite presenting with more advanced disease. While adolescent patients present at more advanced stage, they achieve excellent survival outcomes possibly at the cost of a greater therapeutic burden. Table . Multivariate analysis of predictors of cancer-specific survival (CSS). Variable Multivariate HR 95% CI p Age, years ≥20 1 13–19 0.65 0.51–0.82 Histology Non-seminomatous germ-cell, NOS 1 Embryonal 0.46 0.34–0.62 Yolk sac 0.91 0.62–1.35 0.646 Choriocarcinoma 1.43 1.04–1.96 0.027 Teratoma 0.94 0.63–1.39 0.753 Mixed 0.71 0.54–0.92 0.009 Summary stage Localized 1 Regional/distant 10.35 8.78–12.20 Unknown 2.37 1.19–4.72 0.014 HR, hazard ratio; CI, confidence interval; NOS, not otherwise specified.