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• Photoactivated methylene blue pretreated masks inactivate SARS-CoV-2 Beta variant. • Methylene blue formulation is simple, safe, and cost-effective. • The technique inactivates >99.9% SARS-CoV-2 on community masks and surgical masks. • No specialized equipment is needed, making it useful in low-resource settings. Methylene blue (MB) and riboflavin (RB) are light-activated dyes with demonstrated antimicrobial activity. They require no specialized equipment, making them attractive for widespread use. Due to COVID-19-related worldwide shortages of surgical masks, simple, safe, and effective decontamination methods for reusing masks have become desirable in clinical and public settings. We examined the decontamination of SARS-CoV-2 Beta variant on surgical masks and Revolution-Zero Environmentally Sustainable (RZES) reusable masks using these photoactivated dyes. We pre-treated surgical masks with 2 MB concentrations, 2 RB concentrations, and 2 combinations of MB and RB. We also tested 7 MB concentrations on RZES masks. Photoactivated MB consistently inactivated SARS-CoV-2 at >99.9% for concentrations of 2.6 µM or higher within 30 min on RZES masks and 5 µM or higher within 5 min on disposable surgical masks. RB alone showed a lower, yet still significant inactivation (∼93-99%) in these conditions. MB represents a cost-effective, rapid, and widely deployable decontamination method for SARS-CoV-2. The simplicity of MB formulation makes it ideal for mask pre-treatment in low-resource settings. The results demonstrate that MB effectively decontaminates SARS-CoV-2 at concentrations above 5 µM on surgical masks and above 10 µM on RZES masks. [ABSTRACT FROM AUTHOR]

• Methylene blue inactivates SARS-CoV-2. • Methylene blue decontaminates PPE (mask and N95 respirator) when sprayed onto PPE against SARS-CoV-2. • Methylene blue decontaminates PPE (mask and N95 respirator) when sprayed onto PPE against SARS-CoV-2. Global shortage of personal protective equipment (PPE), as consequence of the COVID-19 global pandemic, has unmasked significant resource inequities prompting efforts to develop methods for safe PPE decontamination for reuse. The World Health Organization (WHO) in their Rational Use of PPE bulletin cited the use of a photodynamic dye, methylene blue, and light exposure as a viable option for N95 respirator decontamination. Because WHO noted that methylene blue (MB) would be applied to surfaces through which health care workers breathe, we hypothesized that little to no MB will be detectable by spectroscopy when the PPE is subjected to MB at supraphysiologic airflow rates. A panel of N95 respirators, medical masks, and cloth masks were sprayed with 5 cycles of 1,000 uM MB solution. Mask coupons were subjected to the equivalent of 120 L/min of 100% humidified air flow. Effluent gas was trapped in an aqueous solution and the resultant fluid was sampled for MB absorbance with a level of detection of 0.004 mg/m3. No detectable MB was identified for any mask using Ultraviolet-Visible spectroscopy. At 500-fold the amount of MB applied to N95 respirators and medical masks as were used for the decontamination study cited in the WHO Rational Use of PPE bulletin, no detectable MB was observed, thus providing safety evidence for the use of methylene blue and light exposure for mask decontamination. [ABSTRACT FROM AUTHOR]

• PPE reuse necessitates reliable respiratory and oral human pathogen decontamination. • Equitable decontamination technologies must be available in low-resource settings. • Methylene blue photochemical treatment decontaminates noroviruses on surgical masks. • Norovirus inactivation predicts inactivation of any less resistant viral contaminant. • Role of low-cost – low-tech photochemical decontamination in pandemic preparedness. In the context of the SARS-CoV-2 pandemic, reuse of personal protective equipment, specifically that of medical face coverings, has been recommended. The reuse of these typically single-use only items necessitates procedures to inactivate contaminating human respiratory and gastrointestinal pathogens. We previously demonstrated decontamination of surgical masks and respirators contaminated with infectious SARS-CoV-2 and various animal coronaviruses via low concentration- and short exposure methylene blue photochemical treatment (10 µM methylene blue, 30 minutes of 12,500-lux red light or 50,000 lux white light exposure). Here, we describe the adaptation of this protocol to the decontamination of a more resistant, non-enveloped gastrointestinal virus and demonstrate efficient photodynamic inactivation of murine norovirus, a human norovirus surrogate. Methylene blue photochemical treatment (100 µM methylene blue, 30 minutes of 12,500-lux red light exposure) of murine norovirus-contaminated masks reduced infectious viral titers by over four orders of magnitude on surgical mask surfaces. Inactivation of a norovirus, the most difficult to inactivate of the respiratory and gastrointestinal human viruses, can predict the inactivation of any less resistant viral mask contaminant. The protocol developed here thus solidifies the position of methylene blue photochemical decontamination as an important tool in the package of practical pandemic preparedness. [ABSTRACT FROM AUTHOR]

Recommendations for antibiotic prophylaxis prior to cystourethroscopy with manipulation are based on limited evidence and may not be applicable to procedures without tissue resection such as ureteral stent removal. Our objectives were to investigate and compare practice patterns among adult and pediatric urologists on antibiotic prophylaxis for stent removal. An online survey was distributed to members of the Endourological Society (EUS) and Societies for Pediatric Urology (SPU) including questions about provider demographics and practice patterns. Adult urologists were defined as EUS member respondents and pediatric urologists were defined as SPU member respondents. Comparisons were made using Pearson's Chi-Square analysis. Of 2544 adult urologists surveyed, 258 (10%) completed the survey and of 714 pediatric urologists surveyed, 180 (25%) completed the survey (Table 1). Pediatric urologists report using antibiotic prophylaxis "most of the time" (i.e. ≥ 75% of the time) more often than adult urologist when removing stents by string or operating room cystoscopy but less often when removing stents by office cystoscopy. Pediatric urologists report using antibiotic prophylaxis "most of the time" more often than adult urologists after pyeloplasty, ureteroscopy and ureteral reimplantation. There is no difference in reported duration of prophylaxis between adult and pediatric urologists, with 64% giving a single dose. Pediatric urologists report obtaining a urine culture (UC) "most of the time" more often than adult urologists (32% vs 15%, p < 0.001), but there is no difference in reported use of antibiotic treatment by UC result. Sixty-four percent of survey respondents report giving patients with negative UC antibiotic treatment, and 93% of survey respondents report treating patients with asymptomatic bacteriuria (defined as patients with a positive urine culture but no symptoms) with antibiotics. There is variation in reported practice among surveyed adult and pediatric urologists regarding antibiotic prophylaxis prior to stent removal. Overall, pediatric urologists report using antibiotic prophylaxis prior to stent removal more often than adult urologists. This variation in practice combined with lack of evidence to support the use of antibiotic prophylaxis prior to ureteral stent removal underscores the need for additional research to guide the development of evidence-driven guidelines for both adult and pediatric patients. Summary Figure Proportion of adult and pediatric urologists reporting prescribing antibiotic prophylaxis prior to ureteral stent removal "most of the time" by method of stent removal (stent on a string, office cystoscopy, or operating room (OR) cystoscopy) and surgery leading to stent placement (pyeloplasty, ureteroscopy, or ureteral reimplantation). Summary Figure [ABSTRACT FROM AUTHOR]

Summary Background Overuse of computed tomography (CT) in the initial evaluation of children with upper urinary tract calculi (UUTC) has been well documented. Follow-up imaging patterns, however, remain undefined. Sequential imaging following an acute episode of UUTC represents additional opportunity for enacting good imaging stewardship, with the optimal goal to reduce unnecessary radiation exposure and cost while ensuring appropriate follow-up. Objective We explored nationwide imaging patterns for children following emergency department (ED) evaluations for UUTC, hypothesizing that initial imaging choice and complicated visits for UUTC increase the risk of follow-up CT scans. Study design Claims from Marketscan (2007–2013), an employer-based dataset of privately insured patients, were used to assess children aged 1–18 years presenting to the ED an acute UUTC event. The primary outcome was any imaging within 90 days. Using logistic regression, odds for follow-up CT or plain film kidney–ureter–bladder/ultrasound (KUB/US) imaging were calculated adjusting for patient demographics, initial imaging modality, need for admission, and return ED visits. Results A total of 821 children met the inclusion criteria, of whom 261 (31.8%) received no follow-up imaging. Overall follow-up imaging patterns, including the proportions of children receiving CT scans, KUB/US imaging, or no imaging are shown in the Summary Table. Of the children receiving follow-up imaging, KUB/US was obtained in 363 (65.0%) and CT obtained in 197 (35.0%) children. Risk factors for follow-up CT imaging include hospital admission and return ED visits. Children with ureteral calculi and index US evaluation were more likely to receive KUB/US imaging only at follow-up. For children with ureteral calculi, the median time to first follow-up imaging was 9 days (25th–75th percentiles, 2–26 days). Discussion One-third of all children with follow-up imaging after an acute presentation for UUTC will receive a CT. Up to 28% of children with a ureteral calculus will not receive any follow-up imaging within 3 months of presentation. These findings suggest imaging strategies for children following acute evaluation for nephrolithiasis are suboptimal in two ways. First, children receive potentially unnecessary additional radiation burden, an alarming finding considering the high rates of CT scan in the index evaluation for these children. Second, many children with ureteral calculi fail to receive follow-up imaging to document stone passage. Conclusions Our findings identify follow-up imaging as another area for quality improvement within the care of children with UUTC. Clinical pathways directing imaging strategies for pediatric nephrolithiasis should focus on follow-up imaging practices and initial evaluation, especially with for those children presenting with ureteral calculi. Summary Table Follow-up imaging within 90 days of an ED visit for nephrolithiasis. Summary Table [ABSTRACT FROM AUTHOR]

Objective Extravesical robot-assisted laparoscopic ureteral reimplantation (RALUR) is a popular alternative to open surgery. We report our experience with RALUR and evaluate clinical variables as predictors for failure. Methods We retrospectively evaluated the records of patients who underwent RALUR by a single surgeon for treatment of primary vesicoureteral reflux. Clinical and demographic variables were determined. Clinical variables were compared with surgical outcomes using the Student two-tailed type 2 t test. Results Fifty patients underwent a combined 78 extravesical RALURs. Median (range) age was 6.2 (1.9–18.0) years; median (range) preoperative reflux grade was 3 (0–5). Dysfunctional elimination syndrome (DES) was present in 32 (64%). Ten (20%) patients had prior deflux, and two (4%) had prior ureteroneocystostomy on the ipsilateral side. Postoperative cystogram was performed in 100% at a median (range) of 55 (27–133) days. Median (range) follow-up was 286 (27–2238) days. Febrile urinary tract infection occurred in five (10%), none of whom had reflux on initial follow-up postoperative cystogram. All five had a history of DES and were female. Six complications occurred in five (10%) patients, including ileus (2), ureteral obstruction (2), ureteral injury (1), and perinephric fluid collection (1). Transient urinary retention occurred in one. Five of 22 (22.7%) patients undergoing unilateral surgery had contralateral de novo reflux. Six of 78 ureters (7.7%) had persistent reflux postoperatively. Neither persistent nor de novo reflux was associated with any of the clinical variables assessed. Conclusions RALUR is an effective and safe option for patients with primary vesicoureteral reflux requiring surgery. [ABSTRACT FROM AUTHOR]

Background: Preoperative simulation warm-up has been shown to improve performance and reduce errors in novice and experienced surgeons, yet existing studies have only investigated conventional laparoscopy. We hypothesized that a brief virtual reality (VR) robotic warm-up would enhance robotic task performance and reduce errors. Study Design: In a 2-center randomized trial, 51 residents and experienced minimally invasive surgery faculty in General Surgery, Urology, and Gynecology underwent a validated robotic surgery proficiency curriculum on a VR robotic simulator and on the da Vinci surgical robot (Intuitive Surgical Inc). Once they successfully achieved performance benchmarks, surgeons were randomized to either receive a 3- to 5-minute VR simulator warm-up or read a leisure book for 10 minutes before performing similar and dissimilar (intracorporeal suturing) robotic surgery tasks. The primary outcomes compared were task time, tool path length, economy of motion, technical, and cognitive errors. Results: Task time (−29.29 seconds, p = 0.001; 95% CI, −47.03 to −11.56), path length (−79.87 mm; p = 0.014; 95% CI, −144.48 to −15.25), and cognitive errors were reduced in the warm-up group compared with the control group for similar tasks. Global technical errors in intracorporeal suturing (0.32; p = 0.020; 95% CI, 0.06−0.59) were reduced after the dissimilar VR task. When surgeons were stratified by earlier robotic and laparoscopic clinical experience, the more experienced surgeons (n = 17) demonstrated significant improvements from warm-up in task time (−53.5 seconds; p = 0.001; 95% CI, −83.9 to −23.0) and economy of motion (0.63 mm/s; p = 0.007; 95% CI, 0.18–1.09), and improvement in these metrics was not statistically significantly appreciated in the less-experienced cohort (n = 34). Conclusions: We observed significant performance improvement and error reduction rates among surgeons of varying experience after VR warm-up for basic robotic surgery tasks. In addition, the VR warm-up reduced errors on a more complex task (robotic suturing), suggesting the generalizability of the warm-up. [Copyright &y& Elsevier]

Abstract: Wilms'' tumor is the most common malignant renal tumor of childhood. Surgical resection is an important aspect of therapy and is traditionally performed through an open transabdominal approach. The advent of advanced laparoscopic techniques for benign renal lesions has led to interest in applying a minimally invasive approach to Wilms'' tumors in children. We describe a 2-year-old girl who presented with a right renal mass measuring 18 × 13 cm with peritoneal seeding and pulmonary metastatic disease. Wilms'' tumor was confirmed on open biopsy. After neoadjuvant chemotherapy, a laparoscopic resection of the tumor with right radical nephroureterectomy, retroperitoneal lymph node dissection, and resection of peritoneal metastases was achieved using one 12-mm and four 5-mm ports. The specimens were removed in an endoscopic retrieval bag through a small Pfannenstiel incision by extending the 12-mm port site. The patient had an uncomplicated recovery and was discharged on the fifth post-operative day. She remains disease free at 19 months postoperatively. Minimally invasive techniques may be considered for resection of Wilms'' tumor provided oncologic principles are carefully followed. [Copyright &y& Elsevier]

Background: Validating assessment tools in surgical simulation training is critical to objectively measuring skills. Most reviews do not elicit methodologies for conducting rigorous validation studies. Our study reports current methodological approaches and proposes benchmark criteria for establishing validity in surgical simulation studies. Methods: We conducted a systematic review of studies establishing validity. A PubMed search was performed with the following keywords: “validity/validation,” “simulation,” “surgery,” and “technical skills.” Descriptors were tabulated for 29 methodological variables by 2 reviewers. Results: A total of 83 studies were included in the review. Of these studies, 60% targeted construct, 24% targeted concurrent, and 5% looked at predictive validity. Less than half (45%) of all the studies reported reliability data. Most studies (82%) were conducted in a single institution with a mean of 37 subjects recruited. Only half of the studies provided rationale for task selection. Data sources included simulator-generated measures (34%), performance assessment by human evaluators (33%), motion tracking (6%), and combined modes (28%). In studies using human evaluators, videotaping was a common (48%) blinding technique; however, 34% of the studies did not blind evaluators. Commonly reported outcomes included task time (86%), economy of motion (51%), technical errors (48%), and number of movements (25%). Conclusion: The typical validation study comes from a single institution with a small sample size, lacks clear justification for task selection, omits reliability reporting, and poses potential bias in study design. The lack of standardized validation methodologies creates challenges for training centers that survey the literature to determine the appropriate method for their local settings. [Copyright &y& Elsevier]

Dermoid cysts of the cecum are very rare; including this report only three cases have been described in pediatric patients. We describe a case of a girl found to have a cecal dermoid cyst with no previous history of abdominal trauma or intraabdominal operations. Unlike acquired dermoid cysts that likely result from epithelial implantation following a surgical procedure or trauma, congenital dermoid cysts of the abdominal viscera are thought to result from ectodermal implantation during embryogenesis. We discuss the distinction between acquired and congenital dermoid cysts, their presentation as well as differential diagnoses. [ABSTRACT FROM AUTHOR]

Objectives: To describe a simple method of using a readily available portable ultrasound device to confirm distal stent placement for antegrade placed stents. Antegrade placement of internal double-J ureteral stents during open or laparoscopic pyeloplasty has become an alternative to retrograde placement but might be less reliable owing to the lack of confirmation of the distal stent position. Methods: The SonoSite S-Nerve ultrasound system was used with a L38 × 10-5 MHz linear array transducer to evaluate the distal curl of the double-J stent within the bladder intraoperatively during da Vinci robotic-assisted pyeloplasty. The patient did not require repositioning or removal of the robotic arms. Results: Visualization of the stent was successful in all patients with an age range of 8 months to 17 years. Conclusions: We present the first published method of using ultrasonography to assess and confirm distal stent placement intraoperatively during antegrade stent placement. This simple method uses off-the-shelf equipment available within most operating rooms. In addition, intraoperative ultrasound confirmation of double-J stent placement allows for the ease of antegrade placement with the distal visual confirmation of the stent position without necessitating fluoroscopy or patient repositioning. [Copyright &y& Elsevier]

Caudal epidural analgesia (CEA) is a common analgesic technique performed for pediatric penile surgeries; however, it has associated morbidity. The pudendal nerve block (PNB) has been described as an effective analgesic alternative to CEA. In this quality improvement study, we aim to assess the efficacy of PNB as compared to CEA within our ambulatory surgery center (ASC). We demonstrate our initial experience employing PNB for ambulatory pediatric urology procedures. Using retrospective, non-randomized, time-series, observational data, a comparative effectiveness study of CEA and PNB was performed. Patients less than three years old, who underwent circumcision, hypospadias repair, congenital chordee repair, correction of penile angulation/torsion, and buried penis repair with or without scrotoplasty, between January 1, 2015–September 9, 2019 with either CEA or PNB in an ASC at a single institution were included. Standard protocols for local and postoperative analgesia were used. Outcome measures were post anesthesia care unit (PACU) pain scores, morphine rescue rates, and PACU length of stay (LOS). These were analyzed using statistical process control (SPC) charts; standard SPC rules were used to detect special cause variation. A total of 999 patients were identified; 746 (74.7%), 172 (17.2%) and 81 (8.1%) received CEA, ultrasound guided PNB (US-PNB) and landmark directed PNB (LD-PNB), respectively. Demographic data was comparable between the three cohorts. There was no special cause variation in the outcome measures between the CEA, US-PNB and LD-PNB cohorts for maximum pain score, morphine rescue rates and PACU LOS. Pain outcomes and PACU LOS were similar between the CEA, US-PNB and LD-PNB cohorts, suggesting equivalent postoperative pain control between these techniques within our cohort. Previous published data has reported lower postoperative pain scores with PNB as compared to CEA for patients undergoing circumcision and hypospadias repair. PNB is non-inferior to CEA for analgesia for pediatric penile surgery, with LD-PNB being as effective as US-PNB. Given the simplicity and documented lower risk profile, PNB may be preferred to CEA for ambulatory pediatric urology procedures. Summary Table Comparison of Primary and Secondary Outcome Measures Summary Table Outcome Measure (n) CEA (746) US-PNB (172) LD-PNB (81) Mean of PACU Maximum Pain Score (0–10) 2.50 2.98 2.16 PACU Morphine Administration (%) 2.80 6.94 2.47 PACU Length of Stay (Minutes) 57.77 59.05 57.37 Abbreviations: CEA, caudal epidural anesthesia; PACU post anesthesia care unit; US-PNB, ultrasound guided pudendal nerve block; LD-PNB, landmark directed pudendal nerve block. [ABSTRACT FROM AUTHOR]

Summary Introduction Successful surgical therapy for pediatric upper urinary tract calculi (UUTC) minimizes the need for repeat surgical interventions. However, staged procedures, whether planned or unplanned, are sometimes necessary. We assessed predictors of repeat intervention for children with UUTC using a nationwide administrative dataset. Methods Using the Pediatric Health Information System (PHIS) dataset, we assessed children with UUTC undergoing shock wave lithotripsy (SWL) or ureteroscopy (URS) for an index stone from January 2010 to June 2015. Primary outcome was additional treatment for nephrolithiasis within 90 days. Patient and procedural variables were assessed as potential risks for retreatment. Multivariable logistic regression models were used to compare the risk of retreatment adjusting for potential confounding factors. Results A total of 2788 patients undergoing URS (2,216, 79.5%) and SWL (572, 20.5%) were identified. SWL, stenting at the index operation without pre-index stenting, chronic comorbidities, renal calculi, and age <5 years were independent risk factors for retreatment. Use of ureteral stenting, most commonly employed in URS, was also a strong predictor of retreatment. Odds for reintervention, adjusted by multivariate modeling, are shown in the Figure. Conclusions Adjusting for measured confounders, SWL is associated with a 2.6-fold higher risk of repeat stone-related interventions. Additional patient-related factors also increase likelihood of retreatment. Intra-operative stent placement is a strong predictor of retreatment, perhaps serving as a marker for complex cases or planned staged procedures. Prospective studies are needed to assess comparative effectiveness of SWL and URS and improve mono-therapeutic success for children with UUTC. Figure Odds of repeat intervention, adjusted on multivariate analysis. [ABSTRACT FROM AUTHOR]

Summary Background Robot-assisted laparoscopic extravesical ureteral reimplantation (RALUR-EV) is a minimally invasive alternative to open surgery. We have previously reported retrospective outcomes from our study group, and herein provide an updated prospective analysis with a focus on success rate, surgical technique, and complications among surgeons who have overcome the initial learning curve. Objective To assess the safety and efficacy of RALUR-EV in children, among experienced surgeons. Design and methods We reviewed our prospective database of children undergoing RALUR-EV by pediatric urologists at eight academic centers from 2015 to 2017. Radiographic success was defined as absence of vesicoureteral reflux (VUR) on postoperative voiding cystourethrogram. Complications were graded using the Clavien scale. Univariate regression analysis was performed to assess for association among various patient and technical factors and radiographic failure. Results In total, 143 patients were treated with RALUR-EV for primary VUR (87 unilateral, 56 bilateral; 199 ureters). The majority of ureters (73.4%) had grade III or higher VUR preoperatively. Radiographic resolution was present in 93.8% of ureters, as shown in the summary table. Ureteral complications occurred in five ureters (2.5%) with mean follow-up of 7.4 months (SD 4.0). Transient urinary retention occurred in four patients following bilateral procedure (7.1%) and in no patients after unilateral. On univariate analysis, there were no patient or technical factors associated with increased odds of radiographic failure. Discussion We report a radiographic success rate of 93.8% overall, and 94.1% among children with grades III–V VUR. In contemporary series, alternate management options such as endoscopic injection and open UR have reported radiographic success rates of 90% and 93.5% respectively. We were unable to identify specific patient or technical factors that influenced outcomes, although immeasurable factors such as tissue handling and intraoperative decision-making could not be assessed. Ureteral complications requiring operative intervention were rare and occurred with the same incidence reported in a large open series. Limitations include lack of long-term follow-up and absence of radiographic follow-up on a subset of patients. Conclusions Radiographic resolution of VUR following RALUR is on par with contemporary open series, and the incidence of ureteral complications is low. RALUR should be considered as one of several viable options for management of VUR in children. Summary Table Outcomes, overall and by preoperative vesicoureteral reflux (VUR) grade Radiographic resolution by preoperative VUR grade n a (%) I 15/16 (93.8) II 24/26 (92.1) III 49/52 (92.4) IV 38/41 (92.7) V 10/10 (100.0) Overall 136/145 (93.8) a Number of ureters without VUR present/number of ureters studied with voiding cystourethrogram or radionuclide cystogram. [ABSTRACT FROM AUTHOR]

Summary Introduction Early data support the use of medical expulsive therapy (MET) in children. However, little is known regarding use or outcomes associated with MET outside of pediatric-specific practices. Using a national administrative dataset, we sought to characterize utilization patterns of MET as well as assess outcomes associated with MET exposure. Study design We interrogated the MarketScan Commercial Claims and Encounters database to identify children under the age of 18 presenting to the emergency department (ED) with any diagnosis of upper urinary tract calculi (UUTC, including renal and ureteral calculi). MET exposure was defined as having a prescription filled for a MET agent within 1 week of the ED encounter. Characteristics of children receiving MET were defined and outcomes compared between children with and without MET exposure. Results Of 1325 children included in the study, 13.2% received MET, including 15.4% of children with a diagnosis of “calculus of the ureter.” MET use increased significantly throughout the study period ( p = 0.004), although only 30.4% of children considered potential MET candidates received MET in the final year of the study (2013). Among all patients, receipt of MET was associated with male gender, presence of comorbidity, provider-type (urologist), and year of diagnosis, although among those with a specific diagnosis of “calculus of the ureter,” only year of diagnosis remained a significant factor. Rates of unplanned physician visits and surgical interventions were similar between groups. Children receiving MET were more likely to receive follow-up imaging, although only 46% of children with ureteral calculi had appropriate follow-up imaging within 90 days, regardless of MET exposure. Odds ratios of factors and outcomes associated with MET exposure are shown in the Table . Discussion Although early data support safety and efficacy MET in children, nationwide use in children is low among potential candidates for MET. For children with ureteral calculi, only year of diagnosis was a significant factor associated with MET use. No difference in unplanned physician visits or surgical interventions was noted. Most notable, however, was the low rate of follow-up imaging within 90 days for children presenting acutely with UUTC. Conclusions Use of MET for children with ureteral calculi is increasing, although still fewer than a third of children considered potential candidates receive this treatment. Follow-up imaging is not obtained for many children with ureteral calculi. Future work is needed to standardize management and follow-up protocols for children with acute renal colic. Table OR and CI for factors associated with use of MET. Table Demographic Whole group ( n = 1325) Calculus of the ureter ( n = 527) OR (95% CI) OR (95% CI) Factors associated with receipt of MET Age 1.05 (1.00–1.10) 1.02 (0.95–1.10) Female 0.64 (0.46–0.90) 0.77 (0.47–1.28) Urologist provider 2.04 (1.32–3.15) 1.60 (0.88–2.90) Year of diagnosis 1.31 (1.19–1.44) 1.34 (1.15–1.56) Outcomes associated with receipt of MET ED visit 0.63 (0.34–1.19) 1.36 (0.59–3.12) Hospital admission 0.94 (0.59–1.48) 1.28 (0.64–2.56) Appropriate imaging 1.67 (1.21–2.32) 1.69 (1.03–2.77) Surgical intervention 1.11 (0.77–1.60) 0.96 (0.57–1.63) Top of table shows factors associated with initial MET exposure. Bottom of table shows 90-day outcomes associated with MET exposure at initial visit. [ABSTRACT FROM AUTHOR]

Summary Background Robotic techniques are increasingly being used for reconstructive procedures in the pediatric population. Objective The present study reported the functional and perioperative outcomes of a multi-institutional cohort of pediatric patients who underwent robotic-assisted laparoscopic Mitrofanoff appendicovesicostomy (RALMA). Study design Pediatric patients who underwent RALMA at five different centers were included. Positioning is shown ( Summary Figure ). Demographics were gathered, and intraoperative parameters included concomitant procedures, detrusor tunnel length, estimated blood loss (EBL) and operative time. Perioperative outcomes included length of hospital stay (LOS), morphine use and 30-day complications. Outcomes were reported in terms of stomal continence and surgical revisions. Results Eighty-eight patients with a mean age of 10.4 ± 4.0 years were included in the analysis. Median follow-up was 29.5 months (IQR 11.8–45.0). Bladder augmentation was performed concomitantly in 15 (17%) patients, and bladder neck procedures in 34 (39%). Mean detrusor tunnel length was 3.9 ± 1.0 cm, EBL was 54 ± 70 ml, and operative time was 424 ± 120 min. Postoperatively, mean LOS was 5.2 ± 2.8 days. Patients who underwent concomitant augmentation had higher EBL and operative times (both P < 0.05). At 90 days, complications occurred in 26 patients (29.5%) with six Clavien grade ≥3 (6.8%). During follow-up, 11 (12.5%) patients required appendicovesicostomy revision. Regarding functional outcomes, 75 (85.2%) patients were initially continent. After additional procedures, 81 (92.0%) patients were continent at last follow-up. Discussion Compared to previous open series, initial stomal continence rates with RALMA were acceptable, with a minority of patients requiring subsequent procedures to manage complications and achieve continence. Conclusion RALMA is safe and effective in a pediatric population with regard to perioperative complications and stomal continence. Summary Figure Adapted from Chang et al. with permission [1] . [ABSTRACT FROM AUTHOR]

Background: Robotic-assisted gynecologic surgery is common, but requires unique training. A validated assessment tool for evaluating trainees' robotic surgery skills is Robotic-Objective Structured Assessments of Technical Skills.Objective: We sought to assess whether crowdsourcing can be used as an alternative to expert surgical evaluators in scoring Robotic-Objective Structured Assessments of Technical Skills.Study Design: The Robotic Training Network produced the Robotic-Objective Structured Assessments of Technical Skills, which evaluate trainees across 5 dry lab robotic surgical drills. Robotic-Objective Structured Assessments of Technical Skills were previously validated in a study of 105 participants, where dry lab surgical drills were recorded, de-identified, and scored by 3 expert surgeons using the Robotic-Objective Structured Assessments of Technical Skills checklist. Our methods-comparison study uses these previously obtained recordings and expert surgeon scores. Mean scores per participant from each drill were separated into quartiles. Crowdworkers were trained and calibrated on Robotic-Objective Structured Assessments of Technical Skills scoring using a representative recording of a skilled and novice surgeon. Following this, 3 recordings from each scoring quartile for each drill were randomly selected. Crowdworkers evaluated the randomly selected recordings using Robotic-Objective Structured Assessments of Technical Skills. Linear mixed effects models were used to derive mean crowdsourced ratings for each drill. Pearson correlation coefficients were calculated to assess the correlation between crowdsourced and expert surgeons' ratings.Results: In all, 448 crowdworkers reviewed videos from 60 dry lab drills, and completed a total of 2517 Robotic-Objective Structured Assessments of Technical Skills assessments within 16 hours. Crowdsourced Robotic-Objective Structured Assessments of Technical Skills ratings were highly correlated with expert surgeon ratings across each of the 5 dry lab drills (r ranging from 0.75-0.91).Conclusion: Crowdsourced assessments of recorded dry lab surgical drills using a validated assessment tool are a rapid and suitable alternative to expert surgeon evaluation. [ABSTRACT FROM AUTHOR]

Summary Introduction Robot-assisted laparoscopic pyeloplasty (RALP) has been gaining acceptance among pediatric urologists. Over 300 have been described in the literature, but few studies have evaluated the role of RALP in infants alone. Objective We sought to examine the operative experience and outcomes of RALP in a cohort of infants treated at multiple institutions across the United States. Our primary aim was to describe the safety and efficacy of RALP within this cohort. We recognize the challenges of performing minimally invasive surgery in small patients. In our paper, we address some technical considerations for the infant population. Study design This multi-centered observational study collected data on subjects one year of age or less who underwent RALP between April 2006 and July 2012 at five institutions. The primary outcome was resolution of hydronephrosis, and secondary outcomes included surgical time and complications. Results A total of 60 patients (62 procedures) underwent RALP by six surgeons during the study period. All surgeons had >5 years of experience beyond fellowship training. Mean surgical age was 7.3 months (SD ± 1.7mo), 56 patients (95%) were diagnosed prenatally, and 59 patients (95%) had follow up imaging. Of these patients, 91% showed resolution or improvement of hydronephrosis. Two patients had recurrent obstruction and required additional surgery. Mean surgical time was 3 hours 52 minutes (SD ± 43 minutes). Seven (11%) patients reported intra-operative or immediate post-operative complications. Gender (male) 44 (73) Prenatal Diagnosis 56 (93) Laterality Left 32 (53) Right 26 (43) Bilateral 2 (3) Surgical Age (months) 7.29 (±1.7) Surgical Weight (kg) 8.1 (7.1–9.2) Surgical Time (hr:mm) 3:52 (±0:43) Length of Stay 1 (1–2) Intra-operative Complication 1 (2) Immediate Post-op Complication 6 (10) Resolution (n = 59) Resolved 1 (1.7) Improved 53 (89.8) Stable 4 (6.8) Worsening 1 (1.7) Data in table given as n (%), mean (±SD), or median (25th – 75th percentile). Discussion This series found a 91% success rate for reduction or resolution of hydronephrosis, and an 11% complication rate. This is equivalent to modern series comparing open pyeloplasty to pure laparoscopic and robotic-assisted laparoscopic pyeloplasty, which report success rates ranging from 70–96%, and complication rates ranging from 0–24% for open pyeloplasty. We lacked a standardized technique amongst institutions. This was not surprising since there are not established technical benchmarks for this surgery. However, we specified multiple technical considerations for this unique patient population. Conclusion The advantages of using robot-assistance to perform pyeloplasty in infants remain to be defined. This study cannot make that assessment due to small sample size. Nonetheless, this cohort is the largest robotic pyeloplasty series in infants to date. Seeing an excellent success rate and a low complication rate in this infant cohort is encouraging. [ABSTRACT FROM AUTHOR]

Menkes disease, or Kinky Hair Syndrome, is a rare disorder of copper metabolism that causes fatal neurodegenerative disease in infancy. This X-linked disorder results from mutations in the ATP7A gene. Along with neurological decline, characteristic coarse appearance of the hair is seen. Urological issues are prevalent in this patient population, with bladder diverticula being the most common. Herein, we describe a unique male patient with genetic mosaicism and osseous metaplasia found in a ruptured bladder diverticulum. [ABSTRACT FROM AUTHOR]

Objective: To report a novel approach of pediatric robot-assisted redo pyeloplasty with buccal mucosa graft (BMG).Methods: An Institutional Review Board-approved retrospective review of all patients undergoing robot-assisted redo pyeloplasty with BMG at our institution was performed.Operative Details: For all patients, the following ports were used: one 8.5 mm camera, two 8 mm robotic, and one 5 mm assistant. Initial dissection was performed laparoscopically and robotically, and the ureter was incised longitudinally along the anterior surface. The robot was undocked, and BMG was harvested from the inner cheek. The robot was then redocked, and grafts were delivered via the 8 mm robotic port and anastomosed as anterior onlay grafts using 5-0 or 6-0 absorbable monofilament suture. Omentum was quilted over the graft as a vascular backing. Ureteral stents were placed intraoperatively and left in situ for 8 weeks. Foley catheters were removed on postoperative day 3. All patients received intravenous ampicillin and gentamicin preoperatively, with antibiotics discontinued within 24 hours.Results: Three patients underwent robot-assisted redo pyeloplasty with BMG. Patient characteristics are seen in Table 1. Mean number of prior surgeries for ureteropelvic junction obstruction repair was 2 (1-3), and mean length of stricture was 4.3 cm (2.5-6). At a median follow-up of 10 months (5-26), all patients are asymptomatic with stable or improved ultrasound.Conclusion: Robot-assisted redo pyeloplasty with BMG is safe and feasible in the pediatric population. Long-term follow-up is needed to determine the durability of these grafts. [ABSTRACT FROM AUTHOR]

Because surgical skill may be a key determinant of patient outcomes, there is growing interest in skill assessment. In the Michigan Urological Surgery Improvement Collaborative (MUSIC), we assessed whether peer and crowd-sourced (ie, layperson) video review of robot-assisted radical prostatectomy (RARP) could distinguish technical skill among practicing surgeons. A total of 76 video clips from 12 MUSIC surgeons consisted of one of four parts of RARP and underwent blinded review by MUSIC peer surgeons and prequalified crowd-sourced reviewers. Videos were rated for global skill (Global Evaluation Assessment of Robotic Skills) and procedure-specific skill (Robotic Anastomosis and Competency Evaluation). We fit linear mixed-effects models to estimate mean peer and crowd ratings for each video. Individual video ratings were aggregated to calculate surgeon skill scores. Peers ( n = 25) completed 351 video ratings over 15 d, whereas crowd-sourced reviewers ( n = 680) completed 2990 video ratings in 38 h. Surgeon global skill scores ranged from 15.8 to 21.7 (peer) and from 19.2 to 20.9 (crowd). Peer and crowd ratings demonstrated strong correlation for both global ( r = 0.78) and anastomosis ( r = 0.74) skills. The two groups consistently agreed on the rank order of lower scoring surgeons, suggesting a potential role for crowd-sourced methodology in the assessment of surgical performance. Lack of patient outcomes is a limitation and forms the basis of future study. Patient summary We demonstrated the large-scale feasibility of assessing the technical skill of robotic surgeons and found that online crowd-sourced reviewers agreed with experts on the rank order of surgeons with the lowest technical skill scores. [ABSTRACT FROM AUTHOR]