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Purpose: Behavioral economics is the study of human behavior in the context of irrationality, self-control and self-interest. It has been leveraged in a variety of ways in health care, including efforts to decrease smoking, encourage weight loss and promote medication adherence. Concepts from this field can be used to help urologists better understand and improve behavior-dependent clinical outcomes. Our objective in this scoping review was to assess the current state of behavioral economics in the urological literature. Materials and Methods: We conducted a scoping review of behavioral economic research in urology by performing a broad search in MEDLINE, Embase and Scopus databases from inception to August 30, 2021. Abstracts were screened, assessed for relevancy and selected for full-text review. A qualitative synthesis of selected manuscripts was then performed. Results: A total of 1,855 articles were identified. Sixty-one articles were selected for full-text review. Of those, 13 were selected for qualitative synthesis. The selected articles included reports of prospective trials (6), ongoing prospective trial methods (1), abstracts without a published manuscript (4) and commentaries (2). A variety of topics were covered: prostate cancer (5), resident education (2), hematuria (1), incontinence (1), surgical costs (1), care pathways (1), nephrolithiasis (1) and bladder cancer (1). Conclusions: There is a very limited number of articles, and even fewer trials, in urology that leverage behavioral economic concepts. Given this, and the successful application of behavioral economics in other medical disciplines, there is a need for behavioral economic informed urological interventions and welldesigned trials to evaluate behavioral economics outcomes in urology. [ABSTRACT FROM AUTHOR]

Purpose: We systematically reviewed the variability in definitions of kidney abnormality (KA) outcomes in individuals with spina bifida (SB). Materials and Methods: A systematic scoping review was conducted using MEDLINE, Embase, Cochrane Library, CINAHL, PsycInfo, Web of Science and ClinicalTrials.gov for articles from time of database inception to September 2020. No language or patient age restrictions were applied. Primary research articles involving individuals with SB where KA was assessed as an outcome were included. Means of assessing KA and defining KA severity were abstracted. Results: Of 2,034 articles found, 274 were included in the review. Most articles were published after 1990 (63.5%) and included pediatric-only populations (0e18 years; 60.5%). KA outcomes were identified by imaging-based anatomical outcomes (84.7%), serum-based outcomes (44.9%), imaging-based functional outcomes (5.5%), urine-based outcomes (3.3%) and diagnoses of end-stage kidney disease (2.6%) or chronic kidney disease otherwise unspecified (1.8%). Hydronephrosis was the most commonly used specific outcome (64.6%, 177/274) with 19.8% (35/177) of articles defining hydronephrosis severity. Hydronephrosis was used more frequently in articles with pediatric-only populations. Creatinine and cystatin-C were used in 82.1% (101/123) and 17.9% (22/123) of articles reporting serum-based outcomes, respectively, with 32.7% and 50.0% of articles defining estimated glomerular filtration rate (GFR) severity. Serum-based outcomes were more common in articles including adults >18 years. Measured GFR was assessed in 9.9% (27/274) of articles, with 44.4% (12/27) of articles defining GFR severity. [ABSTRACT FROM AUTHOR]

Purpose: Cystectomy with a vaginal-sparing approach may be associated with unique complications specific to the female population. The objective of this study was to estimate the incidence of vaginal complications (defined to include vaginal prolapse, vaginal fistula, dyspareunia and vaginal cuff dehiscence/evisceration) after cystectomy and to determine risk factors for these complications. Materials and Methods: Women 65 years or older undergoing cystectomy for any indication were identified by procedural codes in the Medicare Limited Data Set 5% sample from January 1, 2011 to December 31, 2017. Patients experiencing a vaginal complication after cystectomy were compared to those who did not. Demographic and biological factors that could increase likelihood of complications were identified and time to development of complications determined. Cumulative incidence was calculated using cumulative incidence function. Multivariable cause-specific Cox proportional hazards model assessed risk factors for vaginal complications. Results: In all, 481 women undergoing cystectomy were identified during the study period, and 37.2% were younger than 70 years old. The majority (378, 79%) had bladder cancer, and 401 (83.4%) underwent an incontinent conduit or catheterizable channel diversion. Within 2 years of cystectomy, 93 patients (19.5%) had 1 or more complications on record. Vaginal cuff dehiscence had the highest cumulative incidence, occurring in 49 patients (10.2%). Over the entire study period (2011e2017), 102 women (21.2%) were diagnosed with a vaginal complication, and 27 (5.6%) received an intervention. Conclusions: Among women who undergo cystectomy, vaginal complications occur at rates higher than expected with over 20% of women experiencing a complication and over a quarter of those diagnosed undergoing intervention. [ABSTRACT FROM AUTHOR]

Purpose Most children with spina bifida now survive into adulthood, although most have neuropathic bladder with potential complications of incontinence, infection, renal damage and diminished quality of life. In this study we sought to 1) describe contemporary bladder management and continence outcomes of adults with spina bifida, 2) describe differences from younger individuals and 3) assess for association with socioeconomic factors. Materials and Methods We analyzed data on bladder management and outcomes in adults with spina bifida from the National Spina Bifida Patient Registry. A strict definition of continence was used. Results were compared to young children (age 5 to 11 years) and adolescents (12 to 19). Statistical analysis compared cohorts by gender, ethnicity, spina bifida type, lesion level, insurance status, educational attainment, employment status and continence. Results A total of 5,250 patients with spina bifida were included, of whom 1,372 (26.1%) were adults. Of the adult patients 45.8% did not take medication, but 76.8% performed clean intermittent catheterization. Continence was decreased in adults with myelomeningocele (45.8%) vs those with nonmyelomeningocele spina bifida (63.1%, p <0.0001). Continence rates were higher in the older cohorts with myelomeningocele (p <0.0001) but not in those with nonmyelomeningocele spina bifida (p = 0.1192). Bladder management and history of urological surgery varied among age groups. On univariate analysis with spina bifida related or socioeconomic variables continence was significantly associated with educational level but on multivariable logistic regression analysis bladder continence was significantly associated with employment status only. Conclusions Bladder management techniques differ between adults and children with spina bifida. Bladder continence outcomes were better in adults, with nearly half reporting continence. Continence was significantly associated with employment status in patients age 25 years or older. [ABSTRACT FROM AUTHOR]

Purpose Urodynamic findings often guide treatment for neuropathic bladder and are reported as objective data points in multi-institutional trials. However, urodynamic interpretation can be variable. In a pilot study pediatric urologists interpreting videourodynamics exhibited only moderate agreement despite similar training and practice patterns. We hypothesized the pilot study variability would be replicated in a multi-institutional study. Materials and Methods We developed an anonymous electronic survey that contained 20 scenarios, each with a brief patient history, 1 urodynamic tracing and fluoroscopic imagery. All videourodynamics were completed during routine care of patients with neuropathic bladder at a single institution. Pediatric urologists from Centers for Disease Control and Prevention Urologic Protocol sites were invited to complete an interpretation instrument for each scenario. Fleiss kappa and 95% confidence limits were reported, with Fleiss kappa 1.00 corresponding to perfect agreement. Results The survey was completed by 14 pediatric urologists at 7 institutions. Substantial agreement was seen for assessment of fluoroscopic bladder shape (Fleiss kappa 0.73), while moderate agreement was observed for assessment of bladder safety, end filling detrusor pressure and bladder capacity (Fleiss kappa 0.50, 0.56 and 0.54, respectively). Fair agreement was seen for electromyographic synergy and presence of detrusor overactivity (Fleiss kappa 0.21 and 0.35, respectively). Conclusions Experienced pediatric urologists demonstrate variability during interpretation of videourodynamic tracings. Subjectivity of assessment of electromyographic activity and detrusor overactivity was confirmed in this expanded study. Future work to improve the reliability of videourodynamic interpretation would improve the quality of clinical care and the quality of multi-institutional studies that use urodynamic data points as outcomes. [ABSTRACT FROM AUTHOR]

Purpose Achieving bladder continence in individuals with spina bifida is a lifetime management goal. We investigated bladder continence status through time and factors associated with this status in patients with spina bifida. Materials and Methods We used National Spina Bifida Patient Registry data collected from 2009 through 2015 and applied generalized estimating equation models to analyze factors associated with bladder continence status. Results This analysis included 5,250 participants with spina bifida in a large, multi-institutional patient registry who accounted for 12,740 annual clinic visit records during the study period. At last followup mean age was 16.6 years, 22.4% of participants had undergone bladder continence surgery, 92.6% used some form of bladder management and 45.8% reported bladder continence. In a multivariable regression model the likelihood of bladder continence was significantly greater in those who were older, were female, were nonHispanic white, had a nonmyelomeningocele diagnosis, had a lower level of lesion, had a higher mobility level and had private insurance. Continence surgery history and current management were also associated with continence independent of all other factors (adjusted OR and 95% CI 1.9, 1.7–2.1 and 3.8, 3.2–4.6, respectively). The association between bladder management and continence was stronger for those with a myelomeningocele diagnosis (adjusted OR 4.6) than with nonmyelomeningocele (adjusted OR 2.8). Conclusions In addition to demographic, social and clinical factors, surgical intervention and bladder management are significantly and independently associated with bladder continence status in individuals with spina bifida. The association between bladder management and continence is stronger in those with myelomeningocele. [ABSTRACT FROM AUTHOR]

Purpose We performed an exploratory analysis of data from the NSBPR (National Spina Bifida Patient Registry) to assess variation in the frequency of bladder reconstruction surgeries among NSBPR centers. Materials and Methods We queried the 2009-2014 NSBPR to identify patients who had ever undergone bladder reconstruction surgeries. We evaluated demographic characteristics, spina bifida type, functional level, mobility and NSBPR center to determine whether any of these factors were associated with reconstructive surgery rates. Multivariable logistic regression was used to simultaneously adjust for the impact of these factors. Results We identified 5,528 patients with spina bifida enrolled in the NSBPR. Of these patients 1,129 (20.4%) underwent bladder reconstruction (703 augmentation, 382 continent catheterizable channel, 189 bladder outlet procedure). Surgical patients were more likely older, female, nonHispanic white, with a higher lesion level, myelomeningocele diagnosis, nonambulators (all p <0.001) and nonprivately insured (p=0.018). Bladder reconstruction surgery rates varied among NSBPR centers (range 12.1% to 37.9%, p <0.001). After correcting for known confounders NSBPR center, spina bifida type, mobility, gender and age (all p <0.001) were significant predictors of surgical intervention. Race (p=0.19) and insurance status (p=0.11) were not associated with surgical intervention. Conclusions There is significant variation in rates of bladder reconstruction surgery among NSBPR centers. In addition to clinical factors such as mobility status, lesion type and lesion level, nonclinical factors such as patient age, gender and treating center are also associated with the likelihood of an individual undergoing bladder reconstruction. [ABSTRACT FROM AUTHOR]

Purpose Objective data on patterns of oncology practice among pediatric urologists are lacking. We reviewed surgical case logs submitted to the American Board of Urology by those self-reporting as pediatric urologists. We hypothesized that logs would reveal a low oncology volume (fewer than 5 cases) and identify orchiectomy as the most common oncology cases, and that less than 25% of logs would show nephrectomy for renal tumor. Materials and Methods Case logs submitted for American Board of Urology certification, recertification or pediatric subspecialty certification were reviewed and standardized to represent 12-month practice. Data were collected on pediatric oncologic surgeries as noted by procedure codes linked with oncologic diagnosis codes for patients up to age 30 years. Results We identified 281 case logs meeting study criteria. A total of 364 oncology cases were logged and 131 logs (46.6%) listed at least 1 oncology case, while 150 (53.4%) contained no oncology cases. The 75th, 90th and 95th percentiles of oncology volume were represented by reporting 2, 3 and 4 cases, respectively. A total of 13 logs (4.6%) accounted for more than a third of all oncology cases (35.9%). The most frequent oncology case logged was orchiectomy, which was documented in 83 logs (29.5%). On Poisson regression surgeon variables associated with higher oncology volume included male gender (IRR 2.8, 95% CI 2.1−3.9), 2010 log year (IRR 2.4, 95% CI 1.3−4.4), 2015 log year (IRR 3.7, 95% CI 2.1−6.4) and nonpediatric subspecialty certification log (IRR 1.6, 95% CI 1.2−2.3). Conclusions Few pediatric urologists perform a high volume of oncologic surgeries based on surgical case logs submitted to the American Board of Urology. A small cohort of pediatric urologists logged the majority of such cases. [ABSTRACT FROM AUTHOR]

Purpose Parents of children with vesicoureteral reflux are presented with a variety of management options, which in many cases offer a similar risk-benefit ratio. To facilitate shared decision making, parental preferences regarding vesicoureteral reflux treatment options need to be acknowledged. We aimed to characterize the clinical experience of parents and elicit core themes affecting decision making in regard to managing vesicoureteral reflux in their child. Materials and Methods A semistructured, qualitative interview script was developed and vetted by 25 pediatric urologists to discuss treatment options for vesicoureteral reflux. Additional patient interviews were conducted until new themes failed to arise. Content analysis was performed to extract all statements that described treatment options. Similar statements were combined until a final list of unique themes emerged. Results A total of 26 interviews were performed, yielding 689 statements about overall parent experiences with managing vesicoureteral reflux in the child and 450 statements (65%) pertaining to treatment options. Of the 13 themes that emerged, those most commonly considered were the prevention of future urinary tract infections by 85% of parents, the efficacy rate of treatment options by 85%, the burden of daily maintenance or compliance by 77%, antibiotic resistance by 69%, chronic kidney damage by 62% and invasiveness by 58%. Conclusions Our study emphasizes that when choosing a treatment option for vesicoureteral reflux in their child, parent preferences regarding risks and benefits are variable. However, their chief concerns include whether a method decreases the risk of urinary tract infections, has an acceptable efficacy rate and aligns itself with the capabilities of the family. These themes help frame discussions between families and clinicians regarding vesicoureteral reflux management, and they can facilitate shared decision making. [ABSTRACT FROM AUTHOR]

Purpose Data are lacking on the current perception of oncology care among pediatric urologists. Thus, we developed, pilot tested and administered a survey on this topic to SPU (Society for Pediatric Urology) members. Materials and Methods Approval for this proposal was granted by SPU leadership prior to developing or distributing the survey instrument. The survey was developed and pilot tested by the PUOWG (Pediatric Urologic Oncology Working Group). Response data were collected and descriptive statistics were used for analysis. Logistic regression analysis was performed to correlate surgeon reported factors with higher volumes of reported oncology surgery. Results A total of 426 surveys were distributed via email to SPU members and 212 individual surveys (49.8%) were returned with the background/introduction section completed. Of these surveys 200 (94.3%) were completed by practicing pediatric urologists. Overall, 155 respondents (77.5%) reported performing 5 or fewer oncology related surgeries per year and 74.9% reported that less than 25% of renal tumor surgery at their institution was performed through the pediatric urology service. On multivariate analysis the self-reported factors significantly associated with increased oncology surgical volume (more than 5 cases per year) were greater than 50% attendance at institutional tumor board meetings (OR 4.8, 95% CI 1.4–16.9) and practicing at a hospital with a higher volume of renal tumor surgery (OR 2.6, 95% CI 1.2–5.8). Conclusions Few surveyed pediatric urologists reported performing a high volume of oncology surgery. Respondents expressed interest in ways to increase pediatric urology involvement in oncology care, including opportunities for increased education. Self-reported factors that correlated with higher volume were regular attendance at the institutional pediatric tumor board and practice at a higher volume institution. [ABSTRACT FROM AUTHOR]

Purpose The advent of online task distribution has opened a new avenue for efficiently gathering community perspectives needed for utility estimation. Methodological consensus for estimating pediatric utilities is lacking, with disagreement over whom to sample, what perspective to use (patient vs parent) and whether instrument induced anchoring bias is significant. We evaluated what methodological factors potentially impact utility estimates for vesicoureteral reflux. Materials and Methods Cross-sectional surveys using a time trade-off instrument were conducted via the Amazon Mechanical Turk® ( https://www.mturk.com ) online interface. Respondents were randomized to answer questions from child, parent or dyad perspectives on the utility of a vesicoureteral reflux health state and 1 of 3 “warm-up” scenarios (paralysis, common cold, none) before a vesicoureteral reflux scenario. Utility estimates and potential predictors were fitted to a generalized linear model to determine what factors most impacted utilities. Results A total of 1,627 responses were obtained. Mean respondent age was 34.9 years. Of the respondents 48% were female, 38% were married and 44% had children. Utility values were uninfluenced by child/personal vesicoureteral reflux/urinary tract infection history, income or race. Utilities were affected by perspective and were higher in the child group (34% lower in parent vs child, p <0.001, and 13% lower in dyad vs child, p <0.001). Vesicoureteral reflux utility was not significantly affected by the presence or type of time trade-off warm-up scenario (p = 0.17). Conclusions Time trade-off perspective affects utilities when estimated via an online interface. However, utilities are unaffected by the presence, type or absence of warm-up scenarios. These findings could have significant methodological implications for future utility elicitations regarding other pediatric conditions. [ABSTRACT FROM AUTHOR]

Purpose Care of children with spina bifida has significantly advanced in the last half century, resulting in gains in longevity and quality of life for affected children and caregivers. Bladder dysfunction is the norm in patients with spina bifida and may result in infection, renal scarring and chronic kidney disease. However, the optimal urological management for spina bifida related bladder dysfunction is unknown. Materials and Methods In 2012 the Centers for Disease Control and Prevention convened a working group composed of pediatric urologists, nephrologists, epidemiologists, methodologists, community advocates and Centers for Disease Control and Prevention personnel to develop a protocol to optimize urological care of children with spina bifida from the newborn period through age 5 years. Results An iterative quality improvement protocol was selected. In this model participating institutions agree to prospectively treat all newborns with spina bifida using a single consensus based protocol. During the 5-year study period outcomes will be routinely assessed and the protocol adjusted as needed to optimize patient and process outcomes. Primary study outcomes include urinary tract infections, renal scarring, renal function and bladder characteristics. The protocol specifies the timing and use of testing (eg ultrasonography, urodynamics) and interventions (eg intermittent catheterization, prophylactic antibiotics, antimuscarinic medications). Starting in 2014 the Centers for Disease Control and Prevention began funding 9 study sites to implement and evaluate the protocol. Conclusions The Centers for Disease Control and Prevention Urologic and Renal Protocol for the Newborn and Young Child with Spina Bifida began accruing patients in 2015. Assessment in the first 5 years will focus on urinary tract infections, renal function, renal scarring and clinical process improvements. [ABSTRACT FROM AUTHOR]

Purpose Wilms tumor is the most common childhood renal malignancy and the fourth most common childhood cancer. Many biomarkers have been studied but there has been no comprehensive summary. We systematically reviewed the literature on biomarkers in Wilms tumor to quantify the prognostic implications of the presence of individual tumor markers. Materials and Methods We searched for English language studies from 1980 to 2015 performed in patients younger than 18 years with Wilms tumor and prognostic data. The protocol was conducted per PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Two reviewers abstracted data in duplicate using a standard evaluation form. We performed descriptive statistics, then calculated relative risks and 95% confidence intervals for markers appearing in multiple level II or III studies. Results A total of 40 studies were included examining 32 biomarkers in 7,381 patients with Wilms tumor. Studies had a median of 61 patients, 24 biomarker positive patients per series and a median followup of 68.4 months. Median percentages of patients with stages 1, 2, 3, 4 and 5 tumors were 28.5%, 26.4%, 24.5%, 14.1% and 1.7%, respectively, and 10.2% had anaplasia. The strongest negative prognostic association was loss of heterozygosity at 11p15, with a risk of recurrence of 5.00, although loss of heterozygosity at 1p and gain of function at 1q were also strongly linked to increased recurrence (2.93 and 2.86, respectively). Conclusions Several tumor markers are associated with an increased risk of recurrence or a decreased risk of overall survival in patients with Wilms tumor. These data suggest targets for development of diagnostic tests and potential therapies. [ABSTRACT FROM AUTHOR]

Purpose Shock wave lithotripsy has been commonly used to treat children with renal and ureteral calculi but recently ureteroscopy has been used more frequently. We examined postoperative outcomes from these 2 modalities in children. Materials and Methods We reviewed linked inpatient, ambulatory surgery and emergency department data from 2007 to 2010 for 5 states to identify pediatric admissions for renal/ureteral calculi treated with shock wave lithotripsy or ureteroscopy. Unplanned readmissions, additional procedures and emergency room visits were extracted. Multivariate logistic regression using generalized estimating equations to adjust for hospital level clustering was performed. Results We identified 2,281 admissions (1,087 for shock wave lithotripsy and 1,194 for ureteroscopy). Ages of patients undergoing ureteroscopy and those undergoing shock wave lithotripsy were similar (median 17.0 years for both cohorts, p = 0.001) but patients were more likely to be female (63.4% vs 54.7%, p <0.0001), to be privately insured (69.8% vs 62.2%, p <0.0005) and to have a ureteral stone (81.0% vs 34.8%, p <0.0001). Patients undergoing ureteroscopy demonstrated a lower rate of additional stone related procedures within 12 months (13.6% vs 18.8%, p <0.0007) but a higher rate of readmissions (10.8% vs 6.3%, p <0.0002) and emergency room visits (7.9% vs 4.9%, p <0.0036) within 30 days postoperatively. On multivariable analysis patients undergoing ureteroscopy were nearly twice as likely to visit an emergency room within 30 days of the procedure (OR 1.97, p <0.001) and to be readmitted to inpatient services (OR 1.71, p <0.01). Conclusions Ureteroscopy is now used more commonly than shock wave lithotripsy for initial pediatric stone intervention. Although repeat treatment rates did not differ between procedures, ureteroscopy patients were more likely to be seen at an emergency room or hospitalized within 30 days of the initial procedure. [ABSTRACT FROM AUTHOR]

Purpose Bladder dysfunction in patients with spina bifida can lead to significant morbidity due to renal insufficiency. Indications for surgery vary among institutions and the impact is unclear. We examined trends and variations in urological interventions and chronic renal insufficiency in patients with spina bifida. Materials and Methods We reviewed NIS (Nationwide Inpatient Sample) for all patients with spina bifida treated from 1998 to 2011. We used ICD-9-CM codes to identify urological surgery and chronic renal insufficiency. We calculated the Spearman correlation coefficients between rates of spina bifida related bladder surgeries and rates of chronic renal insufficiency outcomes by state. Linear regression models were fitted to investigate the associations between rates of spina bifida related surgery and chronic renal insufficiency across treatment years. Results We identified 427,616 spina bifida hospital admissions. Mean patient age was 26 years and 56% of patients were female. Of the admissions 35,249 (8%) were for chronic renal insufficiency and 11,078 (3%) were for surgery. During the study period chronic renal insufficiency rates doubled from 6% to 12% and surgery rates decreased from 2.0% to 1.8%. There was a moderately weak inverse association between surgery and chronic renal insufficiency rates with time (r = –0.3, p = 0.06) and by state (r = –0.3, p = 0.04). On multivariate analysis higher rates of surgery were associated with the state in which the patient was treated (p <0.001), and with younger age (p <0.001) and hospital teaching status (p <0.001). In contrast, chronic renal insufficiency was not associated with spina bifida related surgery (p = 0.67). Conclusions We observed a temporal and geographic trend toward decreasing urological surgery and increasing chronic renal insufficiency rates in spina bifida and a wide variation in urological surgical rates among states. Further study is needed to determine the factors behind these trends and variations in spina bifida management. [ABSTRACT FROM AUTHOR]

Purpose Hospital and provider surgical volume have been increasingly linked to surgical outcomes. However, this topic has rarely been addressed in children. We investigated whether hospital surgical volume impacts complication rates in pediatric urology. Materials and Methods We retrospectively reviewed the Nationwide Inpatient Sample (1998 to 2011) for pediatric (18 years or younger) hospitalizations for urological procedures. We used ICD-9-CM codes to identify elective urological interventions and NSQIP® postoperative in hospital complications. Annual hospital surgical volume was calculated and dichotomized as high volume (90th percentile or above) or non-high volume (below 90th percentile). Results We identified 158,805 urological admissions (114,634 high volume and 44,171 non-high volume hospitals). Of the hospitals 75% recorded fewer than 5 major pediatric urology cases performed yearly. High volume hospitals showed treatment of significantly younger patients (mean 5.4 vs 9.6 years, p <0.001) and were more likely to be teaching hospitals (93% vs 71%, p <0.001). The overall rate of NSQIP identified postoperative complications was higher at non-high volume vs high volume hospitals (11.6% vs 9.3%, p = 0.003). After adjusting for confounding effects patients treated at non-high volume hospitals remained more likely to suffer multiple NSQIP tracked postoperative complications, including acute renal failure (OR 1.4, p = 0.04), urinary tract infection (OR 1.3, p = 0.01), postoperative respiratory complications (OR 1.5, p = 0.01), systemic sepsis (OR 2.0, p ≤0.001), postoperative bleeding (OR 2.5, p <0.001) and in hospital death (OR 2.2, p = 0.007). Conclusions Urological procedures performed in children at non-high volume hospitals were associated with an increased risk of in hospital, NSQIP identified postoperative complications, including a small but significant increase in postoperative mortality, mostly following nephrectomy and percutaneous nephrolithotomy. [ABSTRACT FROM AUTHOR]

Purpose The management of upper urinary tract stones in patients with spina bifida is challenging but poorly described in the literature. We compared urolithiasis interventions and related complications in patients with spina bifida to those in other stone formers using a national database. Materials and Methods We retrospectively reviewed the NIS to identify hospital admissions for renal and ureteral stones from 1998 to 2011. We used ICD-9-CM codes to identify urological interventions, including shock wave lithotripsy, ureteroscopy, percutaneous nephrolithotomy and ureteral stent placement. NSQIP data were used to identify postoperative complications. Results We identified 4,287,529 weighted stone hospital admissions, including 12,315 (0.3%) of patients with spina bifida. Compared to those without spina bifida the patients with spina bifida who had urolithiasis were significantly younger (mean age 34 vs 53 years), more likely to have public insurance (72% vs 44%) and renal vs ureteral calculi (81% vs 58%), and undergo percutaneous nephrolithotomy (27% vs 8%). After adjusting for age, insurance, comorbidity, treatment year, surgery type, stone location and hospital factors patients with spina bifida were more likely to have urinary tract infections (OR 2.5), urinary complications (OR 3.1), acute renal failure (OR 1.9), respiratory complications (OR 2.0), pneumonia (OR 1.5), respiratory insufficiency (OR 3.2), prolonged mechanical ventilation (OR 3.2), sepsis (OR 2.7), pulmonary embolism (OR 3.0), cardiac complications (OR 2.4) and bleeding (OR 1.6). Conclusions Compared to those without spina bifida the patients with spina bifida who were hospitalized for urolithiasis were younger, and more likely to have renal stones and undergo percutaneous nephrolithotomy. Urolithiasis procedures in patients with spina bifida were associated with a significantly higher risk of in-hospital postoperative complications. [ABSTRACT FROM AUTHOR]

Purpose Controversy exists regarding the use of continuous antibiotic prophylaxis vs observation in the management of children with vesicoureteral reflux. The reported effectiveness of continuous antibiotic prophylaxis in children with reflux varies widely. We determined whether the aggregated evidence supports use of continuous antibiotic prophylaxis in children with vesicoureteral reflux. Materials and Methods We searched the Cochrane Controlled Trials Register, clinicaltrials.gov , MEDLINE ® , EMBASE ® , Google Scholar and recently presented meeting abstracts for reports in any language. Bibliographies of included studies were then hand searched for any missed articles. The study protocol was prospectively registered at PROSPERO (No. CRD42014009639). Reports were assessed and data abstracted in duplicate, with differences resolved by consensus. Risk of bias was assessed using standardized instruments. Results We identified 1,547 studies, of which 8 are included in the meta-analysis. Pooled results demonstrated that continuous antibiotic prophylaxis significantly reduced the risk of recurrent febrile or symptomatic urinary tract infection (pooled OR 0.63, 95% CI 0.42–0.96) but, if urinary tract infection occurred, increased the risk of antibiotic resistant organism (pooled OR 8.75, 95% CI 3.52–21.73). A decrease in new renal scarring was not associated with continuous antibiotic prophylaxis use. Adverse events were similar between the 2 groups. Significant heterogeneity existed between studies (I 2 50%, p = 0.03), specifically between those trials with significant risk of bias (eg unclear protocol descriptions and/or lack of blinding). Conclusions Compared to no treatment, continuous antibiotic prophylaxis significantly reduced the risk of febrile and symptomatic urinary tract infections in children with vesicoureteral reflux, although it increased the risk of infection due to antibiotic resistant bacteria. Continuous antibiotic prophylaxis did not significantly impact the occurrence of new renal scarring or reported adverse events. [ABSTRACT FROM AUTHOR]

Purpose Individuals with spina bifida are typically followed closely as outpatients by multidisciplinary teams. However, emergent care of these patients is not well defined. We describe patterns of emergent care in patients with spina bifida and healthy controls. Materials and Methods We reviewed Nationwide Emergency Department Sample data from 2006 to 2010. Subjects without spina bifida (controls) were selected from the sample using stratified random sampling and matched to each case by age, gender and treatment year at a 1:4 ratio. Missing emergency department charges were estimated by multiple imputation. Statistical analyses were performed to compare patterns of care among emergency department visits and charges. Results A total of 226,709 patients with spina bifida and 888,774 controls were identified. Mean age was 28.2 years, with 34.6% of patients being younger than 21. Patients with spina bifida were more likely than controls to have public insurance (63.7% vs 35.4%, p <0.001) and to be admitted to the hospital from the emergency department (37.0% vs 9.2%, p <0.001). Urinary tract infections were the single most common acute diagnosis in patients with spina bifida seen emergently (OR 8.7, p <0.001), followed by neurological issues (OR 2.0, p <0.001). Urological issues were responsible for 34% of total emergency department charges. Mean charges per encounter were significantly higher in spina bifida cases vs controls ($2,102 vs $1,650, p <0.001), as were overall charges for patients subsequently admitted from emergent care ($36,356 vs $29,498, p <0.001). Conclusions Compared to controls, patients with spina bifida presenting emergently are more likely to have urological or neurosurgical problems, to undergo urological or neurosurgical procedures, to be admitted from the emergency department and to incur higher associated charges. [ABSTRACT FROM AUTHOR]

Purpose Nephron sparing surgery is the standard of care for many adults with renal tumors and has been described in some children with Wilms tumor. However, beyond case series the data concerning nephron sparing surgery application and outcomes in patients with Wilms tumor are scarce. We examined nephron sparing surgery outcomes and factors associated with its application in children with Wilms tumor. Materials and Methods We retrospectively reviewed the 1998 to 2010 SEER database. We identified patients 18 years old or younger with Wilms tumor. Clinical, demographic and socioeconomic data were abstracted, and statistical analysis was performed using multivariate logistic regression (predicting use of nephron sparing surgery limited to unilateral tumors smaller than 15 cm) and Cox regression (predicting overall survival) models. Results We identified 876 boys and 956 girls with Wilms tumor (mean ± SD age 3.3 ± 2.9 years). Of these patients 114 (6.2%) underwent nephron sparing surgery (unilateral Wilms tumor in 74 and bilateral in 37). Median followup was 7.1 years. Regarding procedure choice, nephron sparing surgery was associated with unknown lymph node status (Nx vs N0, p <0.001) and smaller tumor size (p <0.001). Regarding survival, only age (HR 1.09, p = 0.002), race (HR 2.48, p = 0.002), stage (HR 2.99, p <0.001) and lymph node status (HR 2.17, p = 0.001) predicted decreased overall survival. Survival was not significantly different between children undergoing nephron sparing surgery and radical nephrectomy (HR 0.79, p = 0.58). Conclusions In children with Wilms tumor included in the SEER database nephron sparing surgery has been infrequently performed. Nephron sparing surgery application is associated with smaller, bilateral tumors and with omission of lymphadenectomy. However, there are no evident differences in application of nephron sparing surgery based on demographic or socioeconomic factors. Despite lymph node under staging, overall survival is similar between patients undergoing nephron sparing surgery and radical nephrectomy. [ABSTRACT FROM AUTHOR]

Purpose: Anecdotal evidence suggests that complex congenital genitourinary anomalies are occurring less frequently. However, few epidemiological studies are available to confirm or refute this suggestion. Materials and Methods: The Kids' Inpatient Database (KID) is a national, all payer database of several million inpatient pediatric hospitalizations per year, including complicated and uncomplicated in-hospital births. We reviewed the 1997 to 2009 KID to determine the birth prevalence of spina bifida, posterior urethral valves, bladder exstrophy, epispadias, prune belly syndrome, ambiguous genitalia and imperforate anus. For posterior urethral valves and prune belly syndrome we limited our search to newborn males only. Results: During the study period, there was a diagnosis of spina bifida in 3,413 neonates, bladder exstrophy in 214, epispadias in 1,127, ambiguous genitalia in 726, prune belly syndrome in 180, posterior urethral valves in 578 and imperforate anus in 4,040. We identified no significant change in the birth prevalence of spina bifida (from 33.9 new spina bifida births of 100,000 uncomplicated births to 29.0/100,000, p = 0.08), posterior urethral valves (from 10.4/100,000 to 11.0/100,000, p = 0.51), prune belly syndrome (from 4.8/100,000 to 3.3/100,000, p = 0.44) or ambiguous genitalia (from 5.82/100,000 to 5.87/100,000, p = 0.38). There was a significant decrease in the birth prevalence of bladder exstrophy (from 2.4/100,000 to 1.6/100,000 uncomplicated births, p = 0.01) and a significant increase in epispadias (from 8.0/100,000 to 11.6/100,000) and imperforate anus (from 33.6/100,000 to 35.0/100,000, each p = 0.04) during the study period. Conclusions: The birth prevalence of spina bifida, posterior urethral valves and prune belly syndrome appears to have been stable in the last 12 years. Epispadias, ambiguous genitalia and imperforate anus diagnoses in newborns became more common in the same period, while bladder exstrophy diagnoses became less common. [ABSTRACT FROM AUTHOR]

Purpose: Dietary factors have a role in stone disease in adults but little is known about the relationship in children. We tested whether diet could alter urine and serum parameters in a pediatric mouse model. Materials and Methods: We randomized 30 female BALB/c mice at age 3 weeks to mouse chow, a complex carbohydrate Western diet or a high fructose, high sodium Western diet. Body weight was measured twice weekly. Urine was periodically collected and mice were sacrificed on day 30. Samples were pooled to analyze serum and urine electrolyte factors. Results: There was no significant difference in body weights among the groups at any time or in kidney weight at sacrifice (each p >0.15). There was no observable increase in urine stone forming analytes across the arms except uric acid, which tended to be higher in the Western diet and high fructose, high sodium Western diet groups. There was a substantial decrease in urinary stone inhibitors (magnesium and citrate), a decrease in urinary potassium and an increase in serum calcium in the 2 Western diet groups. Conclusions: This pilot study suggests that consuming a Western diet, especially one composed of high fructose and sodium, may alter parameters that predispose to stone formation in children by decreasing stone inhibitors. Results require validation in larger studies and ultimately in humans. [Copyright &y& Elsevier]

Purpose: A minority of children with Wilms tumor will experience tumor recurrence. In a previous pilot study we found an association between expression of an immune costimulatory molecule, B7-H1, and tumor recurrence in favorable histology Wilms tumor. We sought to verify the prognostic value of B7-H1 as a biomarker in favorable histology Wilms tumor. Materials and Methods: We performed a nested case-control study of tumors from the Fifth National Wilms Tumor Study. We randomly selected 44 children unsuccessfully treated (cases) and 49 who were successfully treated for favorable histology Wilms tumor (controls). Cases and controls were matched based on tumor stage, and the analysis was restricted to children who underwent initial resection. We excluded patients with stage IV or V disease and those treated with chemotherapy or radiation. Tumor specimens were stained for B7-H1 expression. Results: Of the 93 total samples analyzed 60 (65%) demonstrated B7-H1 staining, with staining diffusely present in 13 (22%) and blastema predominant in 34 (57%). B7-H1 expression was associated with failure of initial therapy (p = 0.006). Patients with tumors showing less than 20% B7-H1 positive cells were at lower risk for treatment failure, while those with tumors exhibiting greater than 60% B7-H1 positive cells were at greater risk for treatment failure. This association appeared to be independent of tumor stage. Conclusions: B7-H1 expression by favorable histology Wilms tumor is associated with an increased risk of failure of initial therapy. [ABSTRACT FROM AUTHOR]

Purpose: Ureteral complications of renal transplantation can dramatically impact renal outcomes. We studied whether complications are associated with preexisting genitourinary pathology or transplant using a deceased donor allograft. Materials and Methods: We retrospectively reviewed all patients undergoing renal transplantation at our institution between 2000 and 2010. We abstracted patient demographic details, donor type (living vs deceased), end-stage renal disease etiology, reimplant technique, stent use, preoperative and postoperative imaging, history of lower genitourinary pathology and postoperative complication management. Results: A total of 211 kidneys were transplanted into 206 patients (mean age 13.7 years, mean followup 4.6 years). Most patients (89%) underwent extravesical ureteroneocystostomy without stenting (97%), with roughly half (47%) of transplants being from living donors. Preexisting urological pathology was present in 34% of cases. Postoperative obstruction or extravasation occurred in 16 cases (7.6%), of which 15 were acute. Complications were not associated with donor type, preexisting urological pathology other than posterior urethral valves, surgical technique, etiology of end-stage renal disease or patient age. However, posterior urethral valves or other preexisting genitourinary pathology was not associated with an increased likelihood of genitourinary complications. Posterior urethral valves were associated with development of postoperative vesicoureteral reflux (OR 6.7, p = 0.004) but were not associated with stent placement, surgical technique, donor type or etiology of end-stage renal disease. Conclusions: Patients with posterior urethral valves undergoing renal transplantation are at increased risk for postoperative vesicoureteral reflux but not for other acute surgical complications. There is no association between donor type, etiology of end-stage renal disease, surgical technique or patient age and increased complications. [ABSTRACT FROM AUTHOR]

Purpose: Malone antegrade continence enemas are used in the management of neurogenic bowel to attain fecal continence. Several different irrigation solutions have been described but glycerin, an osmotic laxative that promotes peristalsis, has rarely been mentioned or studied. We assessed clinical outcomes in our patients with a Malone antegrade continence enema using glycerin based irrigation. Materials and Methods: We retrospectively reviewed patients with neurogenic bowel who underwent a Malone antegrade continence enema procedure between 1997 and 2011. Glycerin diluted with tap water followed by a tap water flush is our preferred irrigation protocol. Bowel regimen outcomes examined included fecal continence, emptying time, leakage from stoma, enema volume, frequency and independence. Results: Of the 23 patients with followup greater than 6 months 19 used glycerin based irrigation. Average age at surgery was 8.8 years. Patients using glycerin instilled a median of 30 ml (mean 29) glycerin and 50 ml (131) tap water. Fecal continence rate was 95% and stoma leakage rate was 16%, and only 16% of patients required daily irrigation. Conclusions: Glycerin is a viable and effective alternative irrigant for antegrade enemas of neurogenic bowel, with an excellent fecal continence rate. The volume of irrigant needed is typically less than 90 ml, which is much less than in published reports using tap water alone. [Copyright &y& Elsevier]

Purpose: Definitions of continence following surgery in children with exstrophy-epispadias complex vary widely. We assessed the most common definitions of continence and evaluated the clinical significance of usage patterns for those definitions. Materials and Methods: We searched MEDLINE and EMBASE (2000 to 2011) for English language reports describing postoperative continence outcomes in children with exstrophy-epispadias complex. Articles were evaluated and data were abstracted by 2 reviewers. We assessed patient level factors such as age, preoperative diagnoses and use of additional therapies, as well as study level factors such as continence definition(s), country of origin and method of data collection. Results: We identified 884 articles, of which 87 met inclusion criteria. In total these studies included continence outcomes data on 2,681 patients (57% male). Only 59 studies (68%) clearly defined the term “continence.” The most common definition of continence was dry with voiding/catheterization every 3 hours (used in 23 studies, or 39%, defining continence). There was no association between publication date (p = 0.17), study location (p = 0.47) or study size (p = 0.81) and continence definition. There was a trend toward improved reporting of methods for continence ascertainment in more recent years (p = 0.02). Of the 2,681 children included 1,372 (51%) were dry by the definition used in their study. Conclusions: The most frequent definition of continence was “dryness with voiding or catheterization at 3-hour intervals.” However, definitions were highly variable and many authors did not define continence at all. To better define outcomes, we recommend that a standardized definition of continence be established and used in future reports. [ABSTRACT FROM AUTHOR]

Purpose: Urolithiasis is associated with systemic medical conditions in adults but associations have not been well studied in children. We investigated the association of urolithiasis with diabetes mellitus, hypertension and obesity among children with and without urolithiasis. Materials and Methods: We performed a matched case-control study using the PHIS (Pediatric Health Information System) database. ICD-9 codes identified urolithiasis cases from 2004 to 2009. Four randomly selected controls were matched by age, hospital, patient care setting and year of treatment. Diagnoses from all hospital encounters were ascertained for comorbid conditions. Univariate and multivariable conditional logistic regression was used to assess the associations of urolithiasis with diabetes mellitus, hypertension and obesity. Results: We identified 9,843 urolithiasis cases and 39,047 controls. On univariate analysis stone formers had significantly higher odds of obesity (OR 1.44, 95% CI 1.27–1.64) and hypertension (OR 2.12, 95% CI 1.88–2.40) compared to controls. The odds of type I diabetes mellitus was lower among cases compared to controls (OR 0.38, 95% CI 0.30–0.48). After adjusting for gender, race, insurance type and number of visits using logistic regression, children with urolithiasis still had higher odds of obesity (AOR 1.30, 95% CI 1.12–1.51) and hypertension (AOR 1.61, 95% CI 1.40–1.86) as well as lower odds of type I diabetes mellitus (AOR 0.32, 95% CI 0.25–0.41) compared to controls. Conclusions: Among pediatric patients at freestanding children''s hospitals, urolithiasis is associated with higher odds of obesity and hypertension and lower odds of type I diabetes mellitus. These findings may be helpful in further elucidating the etiology of pediatric urolithiasis. [Copyright &y& Elsevier]

Purpose: The impact of diagnostic genitourinary imaging on patients and families is poorly understood. We measured patient and family reaction to commonly performed genitourinary imaging studies using a standardized measurement tool. Materials and Methods: We surveyed families undergoing genitourinary imaging (renal ultrasound, voiding cystourethrography, radionuclide cystogram, static renal scintigraphy and diuretic renal scintigraphy) using a Likert scaled 11-item survey to assess impact across 4 domains (pain, anxiety, time, satisfaction). Survey scores were analyzed using ANOVA and linear regression. Results: A total of 263 families were surveyed (61 renal ultrasound, 52 voiding cystourethrogram, 55 radionuclide cystogram, 47 mercaptoacetyltriglycine dynamic renal scintigraphy, 48 dimercaptosuccinic acid static renal scintigraphy). Mean patient age was 2.1 years old. Of the patients 45% were male and 77% were white. Patient age, gender and prior genitourinary imaging experience varied by study type. Study type was significantly associated with total and weighted scores on the genitourinary imaging survey (both p <0.0001). Renal ultrasound was scored as better and mercaptoacetyltriglycine dynamic renal scintigraphy was worse than voiding cystourethrogram, radionuclide cystogram and dimercaptosuccinic acid static renal scintigraphy, which did not differ from each other. Other factors associated with worse total scores included patient age 1 to 3 years (p <0.001) and nonwhite race (p = 0.04). Gender, prior testing history, wait time and parent education were not associated with total scores. In the multivariate model renal ultrasound remained the best and mercaptoacetyltriglycine dynamic renal scintigraphy the worst (p <0.0001). In a direct comparison dimercaptosuccinic acid static renal scintigraphy and voiding cystourethrogram total scores did not differ (p = 0.59). Conclusions: There were significant differences among genitourinary imaging studies regarding the patient/family experience, but there was no overall difference between dimercaptosuccinic acid static renal scintigraphy and voiding cystourethrogram. These findings may be useful to aid decision making when considering genitourinary imaging for children. [Copyright &y& Elsevier]

Purpose: Few data have been reported regarding radiation exposure during pediatric endourological procedures, including ureteroscopy. We measured radiation exposure during pediatric ureteroscopy and identify opportunities for exposure reduction. Materials and Methods: We prospectively observed ureteroscopy procedures as part of a quality improvement initiative. Preoperative patient characteristics, operative factors, fluoroscopy settings and radiation exposure were recorded. Our outcomes were entrance skin dose and midline dose (both mGy). Specific modifiable factors were identified as targets for potential quality improvement. Results: Direct observation was performed in 54 consecutive ureteroscopy procedures. Mean ± SD patient age was 14.8 ± 3.8 years (range 7.4 to 19.2), with 9 children being younger than 12 years. Mean ± SD entrance skin dose was 46.4 ± 48 mGy. Mean ± SD midline dose was 6.2 ± 5.0 mGy. The most important major determinant of radiation dose was total fluoroscopy time (mean ± SD 2.68 ± 1.8 minutes) followed by dose rate setting, child anteroposterior diameter and source to skin distance (all p <0.01). Analysis of factors affecting exposure levels revealed that use of ureteral access sheaths (p = 0.01) and retrograde pyelography (p = 0.04) were significantly associated with fluoroscopy time. We also found that dose rate settings were higher than recommended in up to 43% of cases and ideal C-arm positioning could have reduced exposure by 14% (up to 49% in some cases). Conclusions: Children receive biologically significant radiation doses during ureteroscopy procedures. Several modifiable factors contribute to dose and could be targeted in efforts to implement dose reduction strategies. [ABSTRACT FROM AUTHOR]

Purpose: Although shock wave lithotripsy has long been considered the gold standard for treatment of kidney stones in children, ureteroscopy has become increasingly common. The factors determining procedure choice at individual centers are unclear. We sought to identify patient and hospital factors associated with the choice between shock wave lithotripsy and ureteroscopy. Materials and Methods: We searched the Pediatric Health Information System hospital database to identify patients with renal calculi who underwent inpatient or outpatient shock wave lithotripsy or ureteroscopy between 2000 and 2008. We used multivariate regression to evaluate whether procedure type was associated with hospital level factors, including treating hospital, region, size and teaching status, or patient level factors, including age, race, gender and insurance type. Results: We identified 3,377 children with renal stones, of whom 538 (16%) underwent surgery (shock wave lithotripsy in 48%, ureteroscopy in 52%). Procedures in 445 patients at hospitals performing both procedures were included. The relative proportion of ureteroscopy increased during the study period (24% from 2000 to 2002 vs 50% from 2006 to 2008, p = 0.0001). Procedure choice was not significantly associated with patient age (p = 0.2), gender (p = 0.1), race (p = 0.07), insurance (p = 0.9), hospital size (p = 0.6) or teaching status (p = 0.99). Procedure choice varied significantly by geographical region (p = 0.05), regional population (p = 0.002) and stone location (p <0.0001). On multivariable analysis controlling for stone location, gender and treatment year the treating hospital was still highly associated with procedure choice. Conclusions: There is wide variation in procedure choice for children with kidney stones at freestanding children''s hospitals in the United States. Treatment choice depends significantly on the hospital at which a patient undergoes treatment. [ABSTRACT FROM AUTHOR]

Purpose: We have previously shown that nonwhite patients with ureteropelvic junction obstruction undergo pyeloplasty at a younger age than white patients. The mechanisms behind this finding are unclear, since there is no known racial variation in the natural history of ureteropelvic junction obstruction. We used a detailed clinical database to explain this phenomenon. Materials and Methods: We retrospectively reviewed all patients undergoing primary pyeloplasty at our institution between 1992 and 2008. More than 360 data points were abstracted for each patient, including self-reported race, socioeconomic status, symptom duration and presentation. Results: Of 847 patients undergoing pyeloplasty during the study period 741 met inclusion criteria. Nonwhite patients underwent surgery at a younger age (0.6 years) than whites (2.6 years, p <0.0001). When stratified by timing of clinical presentation (prenatal vs postnatal), there was no significant difference in race among patients presenting prenatally (0.37 vs 0.36 years, p = 0.22). Nonwhite patients presenting postnatally were significantly younger than white patients (6.3 vs 8.2 years, p = 0.03). This finding appeared to be due to differences in age at initial clinical presentation (5.4 vs 7.0 years, p = 0.03) and in time from initial clinical presentation to urological evaluation (0.6 vs 3.2 months, p = 0.03). These differences persisted after correcting for other factors, including markers of socioeconomic status. Conclusions: Consistent with previous studies, we found that nonwhite patients underwent primary pyeloplasty at a younger age than whites. This difference is limited to patients presenting after birth. Prenatally diagnosed patients underwent surgery at similar ages regardless of race. [ABSTRACT FROM AUTHOR]

Purpose: The use of ureteral access sheaths during ureteroscopy is common but there are sparse data on the safety and outcomes of ureteral access sheath use in children. We compared the outcomes of ureteroscopy with vs without a ureteral access sheath in children. Materials and Methods: We retrospectively reviewed all ureteroscopy procedures for urolithiasis in patients younger than 21 years at our hospital from 1999 to 2009. The primary outcome was intraoperative complications. Secondary outcomes were postoperative hydronephrosis, emergency room visit/hospital readmission within 90 days, stone-free status and need for re-treatment. We analyzed associations of a ureteral access sheath with outcomes. Results: A total of 34 boys and 62 girls with a mean age of 13 years underwent ureteroscopy. A ureteral access sheath was used in 40 of the 96 patients (42%). The mean stone burden was 9.6 mm. Median followup was 11 months (range 0.2 to 110). Intraoperative complication occurred in 7 cases, including perforation/extravasation in 4, a submucosal wire in 2 and stent migration in 1. Intraoperative complications were more common when a sheath was used (15% vs 2%, adjusted OR 8.2, 95% CI 1.3–50.9, p = 0.02). Postoperative hydronephrosis was observed in 7 of 73 cases (10%) but it was not significantly more common when a sheath was used. No ureteral stricture was identified. Sheath use was not associated with postoperative telephone calls, emergency room visits or rehospitalization. Although the stone-free rate tended to be higher in cases without a sheath (78% vs 59%, p = 0.09), this association was not significant in a multivariate model (p = 0.6). Conclusions: Although intraoperative complications occur more commonly during ureteroscopy with a ureteral access sheath, no increase in longer term adverse effects were observed. Future prospective studies of ureteral access sheath use in children with longer followup are warranted. [Copyright &y& Elsevier]

Purpose: Augmentation cystoplasty is the mainstay of surgical treatment for medically refractory neurogenic bladder in patients with spina bifida. Concerns regarding an increased risk of malignancy have prompted many centers to consider routine postoperative screening. We examine the potential cost-effectiveness of such screening. Materials and Methods: A Markov model was used to compare 2 screening strategies among patients with spina bifida after cystoplasty, namely annual screening cystoscopy and cytology and usual care. Model parameters were informed via a systematic review of post-augmentation malignancy and cost estimates from published reports or government sources. Results: In a hypothetical cohort the individual increase in life expectancy for the entire cohort was 2.3 months with an average lifetime cost of $55,200 per capita, for an incremental cost-effectiveness ratio of $273,718 per life-year gained. One-way and two-way sensitivity analyses suggest the screening strategy could be cost effective if the annual rate of cancer development were more than 0.26% (12.8% lifetime risk) or there were a greater than 50% increase in screening effectiveness and cancer risk after augmentation. After adjusting for multiple levels of uncertainty the screening strategy had only an 11% chance of being cost effective at a $100,000 per life-year threshold or a less than 3% chance of being cost effective at $100,000 per quality adjusted life-year. Conclusions: Annual screening for malignancy among patients with spina bifida with cystoplasty using cystoscopy and cytology is unlikely to be cost effective at commonly accepted willingness to pay thresholds. This conclusion is sensitive to a higher than expected risk of malignancy and to highly optimistic estimates of screening effectiveness. [Copyright &y& Elsevier]

Purpose: Urology continues to be a highly desirable specialty despite decreasing exposure of students to urology in American medical schools. We assessed how American medical schools compare to each other in regard to the number of students that each sends into urological training. We evaluated the reasons why some medical schools consistently send more students into urology than others. Materials and Methods: We obtained American Urological Association Match data for the 5 match seasons from 2005 to 2009. We then surveyed all successful participants. The survey instrument was designed to determine what aspects of the medical school experience influenced students to specialize in urology. Bivariate and multivariate analysis was then done to assess which factors correlated with more students entering urology from a particular medical school. Results: Between 2005 and 2009 a total of 1,149 medical students from 130 medical schools successfully participated in the urology match. Of the 132 allopathic medical schools 128 sent at least 1 student into urology (mean ± SD 8.9 ± 6.5, median 8). A few medical schools were remarkable outliers, sending significantly more students into urology than other institutions. Multivariate analysis revealed that a number of medical school related variables, including strong mentorship, medical school ranking and medical school size, correlated with more medical students entering urology. Conclusions: Some medical schools launch more urological careers than others. Although the reasons for these findings are multifactorial, recruitment of urological talent pivots on these realities. [ABSTRACT FROM AUTHOR]

Purpose: The optimal method for neovagina creation in patients with vaginal agenesis is controversial. Progressive perineal dilation is a minimally invasive method with high success rates. However, the economic merits of progressive perineal dilation compared to surgical vaginoplasty are unknown. Materials and Methods: We performed a Markov based cost-effectiveness analysis of 3 management strategies for vaginal agenesis—progressive perineal dilation with and without subsequent vaginoplasty, and up-front vaginoplasty. Cost data were drawn from the Pediatric Health Information System database (2004 to 2009) for inpatient procedures and from governmental cost data (2009) for outpatient procedures and clinical followup. Other model parameters were derived from a systematic literature review and comparison with other congenital and acquired pediatric and/or adolescent gynecologic conditions. Bounded and probabilistic sensitivity analyses were used to assess model stability. Results: Including all procedures, equipment and physician visits, progressive perineal dilation had a mean cost of $796, while vaginoplasty cost $18,520. Up-front vaginoplasty was strongly dominated at any age, ie was more expensive but no more effective than other options. In cases of progressive perineal dilation failure the incremental cost-effectiveness ratio of progressive perineal dilation with subsequent vaginoplasty was $1,564 per quality adjusted life-year. Only the utility weights of life after treatment impacted model outcomes, while frequency of followup and probability of treatment success did not. Conclusions: Initial progressive perineal dilation followed by vaginoplasty in cases of dilation failure is the most cost-effective management strategy for vaginal agenesis. Initial vaginoplasty was less cost-effective than initial progressive perineal dilation in 99.99% of simulations. [ABSTRACT FROM AUTHOR]

Purpose: Little is known of current practice patterns for pediatric urolithiasis. We examined recent trends in imaging and surgical management. Materials and Methods: The Pediatric Health Information System database is a national database collected at American pediatric hospitals. We searched the database from 1999 to 2008 to identify children diagnosed with urolithiasis. Inpatient hospital admissions, and emergency department and outpatient medical/surgical short stay visits were included. We examined imaging and surgical management trends during the study period using bivariate and multivariate logistic regression models. Results: We identified 7,921 children diagnosed with urolithiasis during the study period, of whom 1,712 (22%) underwent stone related surgery and 6,318 (80%) underwent stone related diagnostic imaging. The surgery rate remained stable during the study period (p = 0.15), as did the overall imaging rate (p = 0.2). However, computerized tomography use increased (26% to 45%) and plain x-ray of kidneys, ureters and bladder plus excretory urogram use decreased (59% to 38%) during the study period (each p <0.0001). Surgery was associated with older patient age, female gender, white race and private insurance. Computerized tomography use was associated with older patient age, nonwhite race and public insurance. After adjusting for other factors, including hospital region, the treating hospital was most important for predicting surgery or computerized tomography (each p <0.0001). Conclusions: Surgery and imaging for pediatric urolithiasis remained stable at pediatric hospitals in the last decade, although computerized tomography use has increased. The hospital where a patient receives treatment is the single most important feature driving computerized tomography and surgery use. Patient age, race and insurance status have a smaller but significant role. [Copyright &y& Elsevier]

Purpose: Prognostic information is limited on children with congenital anterior urethral valves or a diverticulum. We reviewed the literature and examined our clinical database to identify clinical features predicting a poor renal outcome, defined as azotemia, renal failure or death. Materials and Methods: We reviewed 97 English language studies of patients 18 years old or younger. Seven patients from our institutions were also included in analysis. After data abstraction we used multivariate models to define factors associated with outcomes of interest. Results: We identified 239 male patients with anterior urethral valves, of whom 139 had adequate data available for study inclusion. Of these patients 108 (78%) had normal renal function after treatment. On bivariate analysis vesicoureteral reflux (OR 22.4, p <0.0001), pretreatment azotemia (OR 17.1, p <0.0001), urinary tract infection (OR 3.3, p = 0.006), hydronephrosis (OR 10.0, p = 0.0004) and bladder trabeculation (OR 7.3, p = 0.01) were associated with renal failure or death while treatment method (p = 0.9), obstruction type (valve vs diverticulum, p = 0.4) and valve location (p = 0.6) were not. After adjusting for other factors only pretreatment azotemia (p = 0.0005) and vesicoureteral reflux (p = 0.01) remained associated with renal failure and/or death with a trend toward significance for urinary tract infection (p = 0.06). When all 3 factors were present, the odds of a poor renal outcome increased 25-fold (p = 0.005). Conclusions: Congenital anterior urethral obstruction in children has a generally good prognosis but may occasionally result in a poor renal outcome. The combination of pretreatment azotemia, vesicoureteral reflux and urinary tract infection is highly predictive of a poor renal outcome. [Copyright &y& Elsevier]

Purpose: Anecdotal and lay press reports suggest that the incidence of pediatric urolithiasis is increasing but reliable data are lacking. The objective of this study was to examine trends in the epidemiology of urolithiasis at pediatric hospitals nationwide. Materials and Methods: The Pediatric Health Information System database is a national database covering 42 freestanding United States pediatric hospitals that captures inpatient admissions, and emergency department and outpatient surgery visits. We searched the Pediatric Health Information System database to identify children (18 years old or younger) treated for urolithiasis between 1999 and 2008. Patients with urolithiasis were measured as a proportion of the total number of patients seen per hospital annually. Trends were verified by comparing results to 2 other common pediatric diagnoses—appendicitis and viral bronchiolitis. Results: We identified 7,921 children diagnosed with urolithiasis during the study period. The total number of children with urolithiasis seen in Pediatric Health Information System hospitals increased from 125 in 1999 to 1,389 in 2008. Mean number of stone cases per hospital per year increased from 13.9 to 32.6. Compared to total hospital patients, the proportion of patients with pediatric urolithiasis increased from 18.4 per 100,000 in 1999 to 57.0 per 100,000 in 2008, an adjusted annual increase of 10.6% (p <0.0001). Urolithiasis also increased compared to appendicitis (p <0.0001) and bronchiolitis (p <0.0001). Conclusions: Even after correcting for increases in total patient volume at Pediatric Health Information System hospitals, there has been a significant increase in the number of children diagnosed with and treated for urolithiasis at these hospitals in the last decade. [ABSTRACT FROM AUTHOR]

Purpose: An increasing number of parents and practitioners use the Internet for health related purposes, and an increasing number of models are available on the Internet for predicting spontaneous resolution rates for children with vesicoureteral reflux. We sought to determine whether currently available Internet based calculators for vesicoureteral reflux resolution produce systematically different results. Materials and Methods: Following a systematic Internet search we identified 3 Internet based calculators of spontaneous resolution rates for children with vesicoureteral reflux, of which 2 were academic affiliated and 1 was industry affiliated. We generated a random cohort of 100 hypothetical patients with a wide range of clinical characteristics and entered the data on each patient into each calculator. We then compared the results from the calculators in terms of mean predicted resolution probability and number of cases deemed likely to resolve at various cutoff probabilities. Results: Mean predicted resolution probabilities were 41% and 36% (range 31% to 41%) for the 2 academic affiliated calculators and 33% for the industry affiliated calculator (p = 0.02). For some patients the calculators produced markedly different probabilities of spontaneous resolution, in some instances ranging from 24% to 89% for the same patient. At thresholds greater than 5%, 10% and 25% probability of spontaneous resolution the calculators differed significantly regarding whether cases would resolve (all p <0.0001). Conclusions: Predicted probabilities of spontaneous resolution of vesicoureteral reflux differ significantly among Internet based calculators. For certain patients, particularly those with a lower probability of spontaneous resolution, these differences can significantly influence clinical decision making. [Copyright &y& Elsevier]

Purpose: The Internet has become a widely used resource for patients and families to obtain medical information but the quality of information available is highly variable. We sought to determine if Web pages addressing common and uncommon pediatric urology topics differ in terms of quality or characteristics. Materials and Methods: We performed an Internet search using 5 common conditions (vesicoureteral reflux, hypospadias, prenatal hydronephrosis, cryptorchidism, enuresis) and 5 uncommon conditions (exstrophy, prune belly, posterior urethral valves, Wilms tumor, ureterocele). We recorded total hits, presence of sponsored links, page owner and author type, last update, content quality, readability, accreditation and advertising. Content quality was graded on a 5-point scale for accuracy and completeness of natural history, diagnosis and treatment. Results: We evaluated 100 sites on 10 topics. Common topics had more hits (980,000 vs 194,000) and were more likely to have sponsored advertisements (40% vs 0%) than uncommon topics. No difference was seen between topics in time from last update, owner/author type, financial disclosure, accreditation or advertising. Median quality grade was 4.0. Common topics had higher quality grades for disease natural history and diagnosis. Reading grade level was high and was similar between the groups. Conclusions: Web sites devoted to common pediatric urology topics have higher quality information for disease diagnosis and natural history. Otherwise, the quality of pediatric urology information on the Internet is high for common and uncommon topics. A high reading level is required to use these resources. [Copyright &y& Elsevier]

Purpose: Infections due to methicillin resistant Staphylococcus aureus are becoming increasingly prevalent in hospitals and in the community. We reviewed our institutional experience to determine whether methicillin resistant S. aureus is becoming a more common cause of bacteriuria and to determine if there are specific risk factors that may predict the development of methicillin resistant S. aureus bacteriuria. Materials and Methods: We reviewed all urine cultures with a pure growth of a single organism obtained at our institution from 1997 and 2007. Patients with urine cultures positive for methicillin resistant S. aureus were compared to a cohort with cultures positive for methicillin sensitive S. aureus, and to a third cohort with cultures positive for Escherichia coli to determine patient characteristics and associated risk factors. Results: We identified 7,100 and 9,985 positive urine cultures performed in 1997 and 2007, respectively. The most common urinary organism was E. coli. The number of patients with methicillin resistant S. aureus bacteriuria increased from 18 (0.3%) to 74 (0.8%) (p <0.001). On multivariate analysis older age (p = 0.004), catheter use (p = 0.004), hospital exposure (p <0.001) and patient comorbidity (p <0.001) were associated with methicillin resistant S. aureus bacteriuria compared with E. coli bacteriuria. Conclusions: Methicillin resistant S. aureus remains rare as a cause of bacteriuria but its incidence has increased during the last decade. Risk factors for methicillin resistant S. aureus bacteriuria include increased age, patient comorbidity, hospital exposure and catheter use. For patients with these risk factors and new onset urinary symptoms, methicillin resistant S. aureus should be considered a possible cause of urinary tract infection. [Copyright &y& Elsevier]

Purpose: The prevalence of methicillin resistant Staphylococcus aureus is increasing. However, little is known about methicillin resistant S. aureus in the genitourinary tract, particularly in children. We assessed the incidence of pediatric genitourinary methicillin resistant S. aureus superficial abscess requiring surgical intervention. Materials and Methods: We reviewed the records of all children undergoing surgical debridement of superficial abscess at a single institution between 1995 and 2007. We assessed surgical site, organism identity, patient comorbidity, methicillin resistant S. aureus risk factors, number of procedures and patient outcome. Results: Surgical debridement of a superficial genitourinary abscess was performed in 60 children. Patient age ranged from 29 days to 17 years (median 3 years). A single debridement was generally curative, with only 5 patients (8.3%) requiring more than 1 procedure. One patient (1.7%) died of sepsis postoperatively due to Pseudomonas infection. One patient had myelomeningocele, 1 had undergone renal transplant and 2 were undergoing chemotherapy at the time of debridement. None of these 3 patients had a methicillin resistant S. aureus infection. Methicillin resistant S. aureus was more common in the groin/genitalia and less common in the perineum (p = 0.007). The incidence of methicillin resistant S. aureus increased during the study period, accounting for none of 40 infections between 1995 and 2003, and 8 of 20 (40%) from 2004 to 2007 (p <0.001). Conclusions: Methicillin resistant S. aureus has become the predominant organism causing pediatric superficial genitourinary abscesses at our institution, accounting for three-quarters of all surgically managed infections in the last 2 years. Methicillin resistant S. aureus was more common at the groin and genitalia. One debridement was generally curative, and patient morbidity was low with aggressive treatment. [Copyright &y& Elsevier]

Purpose: Despite tremendous gains in improving prognosis, 10% of patients with Wilms tumor will ultimately experience disease recurrence. The identification of novel prognostic markers and tumor associated targets for patients at risk could enable clinicians to treat recurrences more aggressively and, thus, optimize outcomes. We have previously shown that tumor expression of the T cell coregulatory ligand B7-H1 portends a poor prognosis for adults with renal cell carcinoma and represents a promising target to improve therapy. We hypothesize that this finding may be true for Wilms tumor. Materials and Methods: We identified 81 patients with Wilms tumor treated at 1 institution between 1968 and 2004. Histopathological features, including Wilms tumor B7-H1 expression, were correlated with clinical observations and outcome. Results: Tumor recurrences were noted in 22% of patients with Wilms tumor and 14% died. B7-H1 was expressed in 11 tumors (14%) and was more likely to occur in anaplastic Wilms tumor (p = 0.03). Tumor B7-H1 expression was associated with a 2.7-fold increased risk of recurrence, although this difference did not achieve statistical significance (p = 0.06). However, in favorable histology tumors B7-H1 expression was associated with a 3.7-fold increased risk of recurrence (p = 0.03). Conclusions: B7-H1 is expressed by Wilms tumor, correlates with tumor biology and is associated with an increased risk of recurrence in patients with favorable histology tumors. B7-H1 may prove useful in identifying high risk patients who could benefit from more aggressive initial treatment regimens, and may represent a promising therapeutic target. Multi-institutional studies to elucidate the role of B7-H1 in the treatment of Wilms tumor are warranted. [Copyright &y& Elsevier]

Purpose: Few studies have examined the medium and long-term histological changes associated with periureteral injection of dextranomer/hyaluronic acid copolymer (Deflux®). We present the results of a histological review of a series of distal ureteral excisions in patients undergoing ureteroneocystostomy after failed dextranomer/hyaluronic acid injection. Materials and Methods: All patients undergoing ureteroneocystostomy after failed dextranomer/hyaluronic acid injection(s) at 1 institution were eligible for this study. Excised ureteral segments were histologically examined by a single urological pathologist. An immunohistochemical battery was used for each specimen, including hematoxylin and eosin, CD3, CD20, MIB-1 and trichrome stains. Pathological criteria included the presence, location and intensity of fibrosis, giant cell reaction, chronic inflammation, free dextranomer/hyaluronic acid, and CD3, CD20 and MIB-1 staining. Pathological features were correlated with the time from injection to surgical excision. Results: The ureters of 16 children with a mean age of 4.5 years were examined. Median time from injection to implant excision was 8 months. Giant cell reaction was present in 94% of patients and it was typically located in the serosa. No histological or immunophenotypical feature correlated with the duration of implantation except CD3+ and CD20+ lymphocyte counts, which increased with time from injection (p = 0.06 and 0.02, respectively). Conclusions: Dextranomer/hyaluronic acid appears to be stable and safe for use after 3 to 22 months of followup of subureteral injection. The periureteral inflammatory reaction increases with time, although no increases in nuclear turnover or fibrosis were detected. [Copyright &y& Elsevier]

Purpose: Numerous factors have been postulated to increase success rates for dextranomer/hyaluronic acid injection for vesicoureteral reflux. Ureteral hydrodistention combined with intraureteral injection reportedly improves injection success rates. We combined the results of 5 pediatric urologists to evaluate the efficacy of this technique compared to that of subtrigonal-only injection in relation to other factors. Materials and Methods: Patients with primary vesicoureteral reflux undergoing dextranomer/hyaluronic acid injection from April 2002 to December 2005 at 2 institutions were eligible. Only patients with primary vesicoureteral reflux were included in the study. Injection success was defined as the complete absence of reflux on followup voiding cystourethrogram or radionuclide cystogram. Predictors of a successful outcome were analyzed statistically with logistic regression. Factors included in our analysis were gender, age, vesicoureteral reflux grade, dysfunctional voiding, amount of injected dextranomer/hyaluronic acid, injection technique (intraureteral vs subureteral) and surgeon. Results: A total of 301 patients (453 ureters) with a median age of 5.5 years met inclusion criteria, of whom 199 (66%) were cured at 3 months of followup. Of the patients 145 (48%) underwent subureteral injection and 156 (52%) underwent ureteral hydrodistention combined with intraureteral injection. On multivariate analysis only vesicoureteral reflux grade (p <0.001) and surgeon (p = 0.01) were significantly predictive of injection success. There was a trend toward significance with ureteral hydrodistention combined with intraureteral injection (p = 0.056). Conclusions: In our multivariate model only vesicoureteral reflux grade and surgeon were independently predictive of injection success in patients with primary, uncomplicated vesicoureteral reflux. There was a trend toward improved results with ureteral hydrodistention combined with intraureteral injection, although this did not achieve statistical significance. [Copyright &y& Elsevier]

Purpose: Urachal anomalies are often recognized in children but they may persist into adulthood and cause considerable morbidity. We reviewed the clinical findings associated with these embryological structures and evaluated risk factors for cancer to define the optimal timing for intervention. Materials and Methods: We examined the medical records of 176 patients diagnosed with a urachal anomaly between 1951 and 2005. Association of clinicopathological features with malignancy for adults was evaluated using univariate and multivariate logistic regression studies. Results: Urachal remnants were identified in 46 children and 130 adults. Of the 46 children 20 (43%) presented with umbilical drainage and 23 (50%) could be diagnosed by physical examination. A total of 34 children (74%) underwent simple excision. In contrast, 65 of the 130 adults (50%) presented with hematuria, 78 (60%) required cystoscopy and 53 (41%) required computerized tomography. A total of 66 adults (51%) required more extensive surgical intervention with partial or radical cystectomy. Of adult urachal anomalies 66 (51%) were malignant. Patient age 55 years or older and hematuria were the strongest predictors of urachal malignancy (each p <0.001). Cancer risk increased with advancing adult age. Conclusions: Urachal anomalies present and progress differently in pediatric and adult populations. Adults are at high risk for urachal cancer but children usually incur lower morbidity. Urachal lesions noted early in childhood should be excised to prevent problems in adulthood. [Copyright &y& Elsevier]

Purpose: In the last several years the use of the tubularized incised plate hypospadias repair has greatly increased. The most significant complication after this mode of urethroplasty is urethrocutaneous fistula development. Tunneled tunica vaginalis flap is a well described technique for repair of urethrocutaneous fistula. However, to our knowledge its use after tubularized incised plate repair has not yet been described. We present our results with this technique. Materials and Methods: We retrospectively reviewed all patients undergoing repair of urethrocutaneous fistula after initial tubularized incised plate repair between January 2001 and December 2005. We analyzed the initial number and location of fistulas, number of previous urethrocutaneous fistula repairs, duration of surgery, and intraoperative and postoperative complications. Results: A total of 16 boys (median age 2.2 years) underwent tunica vaginalis flap repair at our institution for urethrocutaneous fistula following initial failed tubularized incised plate repair. Of these patients 4 had not previously undergone urethrocutaneous fistula repair and 12 had undergone 1 to 4 failed repair attempts. All boys had a subcoronal fistula and 8 had additional fistulas along the penile shaft, 4 each with 3 and 4 fistulas, including 1 penoscrotal fistula. Mean surgical time was 45 minutes, and no intraoperative or postoperative complications occurred. After a mean followup of 18 months (range 4 to 36) no patient had recurrence of urethrocutaneous fistula. Conclusions: Tunneled tunica vaginalis flap repair is a highly successful technique for the treatment of urethrocutaneous fistula after initial failed tubularized incised plate repair. The technique is technically simple to perform, and we encountered no complications. Tunneled tunica vaginalis flap repair should be considered for treating urethrocutaneous fistula following initial failed tubularized incised plate hypospadias surgery, particularly in a repeat surgical setting. [Copyright &y& Elsevier]

Purpose: Dx/HA copolymer was approved by the Food and Drug Administration in 2001 for the treatment of VUR in children. Published results have varied widely, prompting us to report our single center experience with 300 consecutive patients. Materials and Methods: All patients undergoing Dx/HA injection (300 children, median age 5.4 years) at our institution were eligible for this study. We examined several parameters to determine which variables influence the success of Dx/HA injection, including preoperative reflux grade, bladder diverticula, neurogenic bladder, ureteral duplication, perioperative urinary tract infection, dysfunctional voiding, laterality of reflux and amount of Dx/HA injected. Results: A total of 225 patients (75%) underwent postoperative studies, and, thus, were eligible for study inclusion. Reflux was cured in 144 patients (64%) and improved in 44 (20%). A total of 20 patients had ureteral duplication anomalies. Cure rates in this subgroup were significantly decreased compared to nonduplicated cases (40% vs 66%). Injection in low grade (I to II) reflux was significantly more successful than in high grade (III to IV) reflux (72% vs 54%). A total of 10 patients (8.3%) with unilateral reflux had development of de novo contralateral reflux. Of the patients who failed initial injection 10 (4%) underwent repeat injection, of whom 5 (50%) were cured after the second injection. Two patients (0.9%) had development of temporary ureteral obstruction. Conclusions: We report a large short-term single center experience with endoscopically injected Dx/HA. Although our cure rate of 64% was less than published rates for open surgery, the minimal morbidity and low complication rate of endoscopic treatment make it an attractive first line therapy for patients with VUR. Longer followup is required to better evaluate this technique. [Copyright &y& Elsevier]

Purpose: Traumatic bladder neck lacerations extending into the urethra are devastating injuries that occur more commonly in children than in adults. It is unclear whether immediate repair of these injuries decreases long-term complications, such as urinary incontinence. We report our long-term results with immediate operative repair of these injuries. Materials and Methods: Since 1986, we have primarily repaired all individuals sustaining traumatic longitudinal bladder neck lacerations extending into the urethra within 24 hours of injury. All patients were followed a minimum of 2 years. Results: A total of 12 patients 2 to 16 years old sustained longitudinal bladder neck lacerations extending into the proximal urethra. Median followup was 7 years (range 2 to 13). Postoperatively none of the 12 patients recovered complete urinary continence. Periurethral bulking agents were attempted in all 12 patients with no long-term improvement. Eight patients (75%) pursued additional surgery. Three boys underwent artificial urinary sphincter placement, of which all subsequently eroded. Three girls underwent bladder neck reconstruction with fascial sling procedures, of whom 2 became continent but experienced urinary retention, while 1 became partially continent. Five patients, including the 3 boys with artificial urinary sphincter erosion, ultimately underwent bladder neck closure and continent diversion. Conclusions: Traumatic longitudinal bladder neck and proximal urethral lacerations are devastating injuries fraught with long-term complications and the need for additional surgery despite immediate surgical repair. Bladder neck closure and continent diversion should be considered in girls with substantial traumatic urethral loss and in boys with persistent urinary incontinence following primary repair. [Copyright &y& Elsevier]