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To compare the surgical outcomes and complications of boys who underwent double-face onlay-tube-onlay transverse preputial island flap (DFOTO) one-stage repair vs. two-stage repair for proximal hypospadias. Males with proximal hypospadias who underwent DFOTO or two-stage repair at a single institution from 2008 to 2021 were identified. Patients who had prior hypospadias surgery were excluded. Outcomes were surgical complications, number of surgical procedures, operative time, and post-operative uroflowmetry results. Fifty-three males who underwent DFOTO and 39 who underwent two-stage repair were included. Median age at surgery was 1.1 years (IQR 0.83–1.6) and median follow-up was 3.0 years (IQR 1.2–6.8). Although not statistically significant, the DFOTO group had higher rates of urethrocutaneous fistula (30% vs. 15%, p = 0.10), urethral stricture (15% vs. 3%, p = 0.07) and urethral diverticulum (8% vs. 3%, p = 0.39). Although the unplanned re-operation rate was higher in DFOTO (58% vs. 33%, p = 0.02), the mean number of procedures and median total surgical time were lower in DFOTO (1.8 ± 0.9 vs. 2.4 ± 0.8, p = 0.0004; 337 min [IQR 278–460] vs. 468 min [IQR 400–563], p = 0.008). There were no significant differences between groups for mean peak flow rates and post void residuals. In males who underwent DFOTO, 42% achieved completion of their proximal hypospadias repair with one operation, while the remainder had largely minor complications. Accounting for reoperation rates, the mean number of procedures per patient was lower in the DFOTO group. Comparable results can be achieved with both techniques; the risks of higher unplanned operation rates in the DFOTO group should be considered with the benefit of fewer total procedures. [Display omitted] [ABSTRACT FROM AUTHOR]

Purpose Open dismembered pyeloplasty is the preferred repair for ureteropelvic junction obstruction. Minimally invasive techniques have been applied to the original open approach but no clear advantage has been demonstrated for these technological advances. We evaluate outcomes between transperitoneal laparoscopic and open pyeloplasty in children. Materials and Methods All children 1 to 18 years old with ureteropelvic junction obstruction requiring operative repair were offered enrollment in the study. Patients were prospectively randomized to either laparoscopic or open pyeloplasty through a flank incision. Results A total of 50 patients in the laparoscopic group and 48 in the open group were enrolled from 2005 to 2014. Mean followup was similar between the groups (13.7 months in the laparoscopic group vs 12.3 months in the open group, p = 0.54). The only significantly different outcomes were for mean operative time, which was 139.5 minutes (range 94 to 213) in the laparoscopic group and 122.5 minutes (83 to 239) in the open group (p <0.01), and mean length of stay, which was 25.9 hours (18 to 143) in the laparoscopic group and 28.2 hours (16 to 73) in the open group (p = 0.02). Analgesic usage, success rate, total charges and all parameters in children older than 11 years were similar between the groups. Conclusions Open and laparoscopic dismembered pyeloplasty are comparable and effective methods for repair of ureteropelvic junction obstruction. Although operative time was statistically shorter in the open group and length of stay was shorter in the laparoscopic group, the clinical significance of these variables is questionable. The approach to repair may best be based on family preference for incision aesthetics and surgeon comfort with either approach, rather than more classically objective outcome measures. [ABSTRACT FROM AUTHOR]

Purpose The increasing incidence of pediatric nephrolithiasis is a growing concern and its association with obesity continues to be an area of debate. We present data on urine chemistries of overweight/obese children compared to those with a normal body mass index and history of urolithiasis treated at a single institution in the United States, and assess risk factors. Materials and Methods We retrospectively identified 110 stone forming patients who underwent 24-hour urine collection and stratified them according to the Centers for Disease Control and Prevention definitions of overweight/obese (body mass index above 85th/95th percentile). Absolute urine collection quantities were compared between groups. Stone risk factors were analyzed according to Litholink® specified reference ranges. Results Compared to patients with low or normal body mass index, overweight and obese patients had lower body surface area adjusted citrate (242 mg/1.73 m 2 vs 315 mg/1.73 m 2 , p = 0.03), lower urine phosphate (12 mg/kg vs 14 mg/kg, p = 0.04), lower urine magnesium (1.2 mg/kg vs 1.6 mg/kg, p = 0.01) and increased incidence of hypercalciuria (31% vs 11%, p = 0.02). Differences in urine citrate, phosphate and magnesium were not apparent when analyzing stone risk factors. There was no association between body mass index and urine pH. Conclusions Overweight and obese stone forming children have decreased levels of urine citrate, phosphate and magnesium compared to patients with normal body mass index. The incidence of hypercalciuria is increased in overweight/obese patients. In contrast to findings in adults, there is no association between urine pH and body mass index. [ABSTRACT FROM AUTHOR]

Purpose Although the Clavien-Dindo classification of surgical complications has been evaluated using adult surgical patients, it is being applied to pediatric populations. We hypothesized that this instrument is not well suited to children and sought to determine the reliability of the tool in a pediatric urological population. Materials and Methods We replaced adult surgical cases in the “Survey to Assess Acceptability and Reproducibility of the Classification” from the original Clavien-Dindo study with pediatric urology cases and mimicked original study methods. The survey was distributed with the REDCap (Research Electronic Data Capture) tool, and Krippendorff α coefficients of reliability were calculated from the responses. Results There were 51 respondents and 40 complete responses. The Krippendorff α coefficient of reliability for the Clavien-Dindo classification (α = 0.487) did not achieve the minimum level of acceptable agreement (α = 0.667) with the pediatric urological cases, even when the disability suffix (α = 0.266) was excluded from the analysis (α = 0.632). The accuracy of the grading system with the pediatric urological surgical cases when excluding the disability suffix (410 of 550, 75%) was significantly less than the accuracy had been with the original adult cases (1,816 of 2,016, 90%, p <0.0001). While 89% of respondents (32 of 36) thought the system was appropriate for adults, only 49% (17 of 35) found it appropriate for children (p <0.001). Conclusions The Clavien-Dindo classification of surgical complications is not a reliable tool for use in pediatric urology, where its accuracy is significantly decreased compared to adult surgical cases. Further study is needed to determine if findings are similar across all pediatric surgical groups. [ABSTRACT FROM AUTHOR]

Patients with spina bifida are at risk for developing bladder and renal deterioration secondary to increased bladder storage pressures. To determine the association of home bladder volume and pressure measurements (home manometry) to: 1) detrusor storage pressures on urodynamics (UDS); and 2) the presence of Society of Fetal Urology (SFU) grades 3–4 hydronephrosis on renal bladder ultrasound in patients with spina bifida. Data were prospectively collected on patients with spina bifida and neurogenic bladder requiring clean intermittent catheterization. Patients used a ruler and typical catheterization equipment to measure bladder pressures and volumes at home. Home measurements were compared to UDS detrusor pressures and SFU hydronephrosis grade. Detrusor pressure <20 cm H 2 O at 50% maximal cystometric capacity (MCC) on UDS was used as a measure of safe storage pressures on UDS; conversely, detrusor pressure >20 cm H 2 O was used a measure to capture both unsafe storage pressures and those with potential for unsafe storage pressures. Receiver-operator characteristic curves and area under curve (AUC) were calculated to depict the association between home manometry variables with detrusor pressures on UDS and SFU grades 3–4 hydronephrosis. Included were 52 patients with a median age of 10.3 years (interquartile range 6.3–14.4 years). Three home manometry measurements (maximum bladder pressure, bladder pressure at maximum catheterized volume, and mean bladder pressure) > 20 cm H 2 O were sensitive for Pdet >20 cm H 2 O at 50% MCC. Maximal bladder pressure >20 cm H 2 O was the most sensitive among home manometry measures (sensitivity 100%, specificity 70%, AUC 0.92 for Pdet >20 cm H 2 O at 50% MCC on UDS; sensitivity 100%, specificity 62%, AUC 0.89 for SFU grade 3–4 hydronephrosis). None of the patients who had maximum home bladder pressure <20 cm H 2 O had SFU grades 3–4 hydronephrosis; conversely, individuals with maximal home bladder pressure >20 cm had a wide range of hydronephrosis grades. None of the patients with maximal home bladder pressure <20 cm H 2 O had grade 3–4 hydronephrosis. Home measurements of maximal bladder pressure, bladder pressure at maximum catheterized volume and mean bladder pressure of >20 cm H 2 O were all sensitive for Pdet >20 cm H 2 O at 50% MCC on UDS. Home manometry is an inexpensive and simple technique to identify patients at risk for and to monitor individuals at high risk of upper tract dilation, without incurring significant cost or morbidity. [Display omitted] [ABSTRACT FROM AUTHOR]

Objective To assess the awareness and readiness of both spina bifida patients and parents regarding the transition process before transitioning, with a secondary aim that included identifying potential factors associated with successful transition. Methods All children aged ≥14 years requiring long-term care were prospectively enrolled. Questions designed by pediatric and adult urologists and an adolescent health specialist addressing the awareness of long-term follow-up and the desire to learn more about transitioning were administered by nursing staff at regularly scheduled clinic appointments. All spina bifida patients evaluated in the past 5 years were identified, and clinical factors associated with transitioning were compared. Statistical analysis using the Fisher exact test and the chi-square test were used to compare patients' and parents' responses and categorical variables between patients transitioned and those eligible. P <.05 was considered significant. Results A total of 33 surveys were prospectively collected. Twenty-two percent of parents and 40% of patients said they never wanted to transition ( P = .28). Parents had thought about transitioning more than the patients (88.9% and 40%, respectively; P = .002). Of the 97 patients eligible for transition, 34% had a transition plan. The only significant predictor of transitioning to adult care was a previous history of stones ( P = .03). Conclusion Transitioning to adult urologic care is a necessity for many, and parents are significantly more aware of transitioning than the patient. Acknowledging and understanding the concerns of patients and families will help optimize the transition to adult urologic care. [ABSTRACT FROM AUTHOR]

Objective A major hurdle in management of any chronic pain syndrome is understanding the population in which it occurs. We describe our pediatric population of patients with peripubertal and postpubertal chronic orchialgia. Patients and methods Pediatric patients ≥10 years of age seen between 2002 and 2012 were identified by ICD code 608.9, Male Genital Disorder NOS. Patients were included if they had orchialgia without identifiable cause lasting >3 months. Patient history, diagnostic evaluations, treatments, and outcomes were assessed. Results Seventy-nine pediatric patients were identified. The mean age was 13.3 years (range 10–18); mean duration of orchialgia was 16.3 months (range 3–85). Thirty-three of 79 (42%) had concomitant medical conditions and/or psychiatric-behavioral issues. The mean follow-up was 7.1 months (range 0–70.4) with 41/79 (52%) having more than one office visit follow-up. Eleven patients were referred to a pediatric pain clinic; 10 out of 11 (91%) were evaluated there. Overall, 16 out of 41 (39%) had resolution of pain: nine out of 41 (22%) responding to conservative management vs seven of 10 (70%) responding to pain clinic management (3 to anti-neuropathic medications, 4 to nerve block). Conclusion Many pediatric patients with chronic orchialgia have co-morbidities amenable to multidisciplinary collaborative coordination of care. Referral to pediatric pain clinic can be of significant benefit. [ABSTRACT FROM AUTHOR]

Purpose: Ileovesicostomy is a reconstructive option in complex urological cases but pediatric specific outcomes are lacking. We report our results with pediatric ileovesicostomy. Materials and Methods: We retrospectively evaluated patients younger than 18 years undergoing incontinent ileovesicostomy at Vanderbilt University. History, urinary tract management and operative course were reviewed in the electronic medical record. Particular attention was given to immediate and long-term postoperative complications. Results: Nine patients underwent incontinent ileovesicostomy between 2000 and 2013 at a mean age of 10.3 years (range 1.4 to 15.5). Surgical indication was sequelae of neurogenic or nonneurogenic neurogenic bladder (such as infection or worsening hydronephrosis) in 5 patients, reversal of vesicostomy in 3 and closure of cloacal exstrophy in 1. All 9 patients were thought incapable of reliable clean intermittent catheterization due to family unwillingness, poor social support or patient refusal. Median followup was 11.5 months (mean 48.2, range 1.3 to 144.8). Immediate postoperative complications included ileus requiring total parenteral nutrition and a wound infection in 1 patient. Long-term complications included urinary tract infection in 2 patients (febrile in 1 and positive culture for foul smelling urine in 1), stomal issues in 2 and temporary urethral leakage in 1. Constipation affected 3 children in long-term followup (all with neurogenic bowel preoperatively). Postoperative creatinine was stable or improved in all patients. Conclusions: Ileovesicostomy is a viable approach in children left with few other options, particularly those who are noncompliant or physically/socially unable to handle catheterization. This operation can help keep such patients out of diapers. [ABSTRACT FROM AUTHOR]

Skin entrance doses for voiding cystourethrogram (VCUG) have not been well characterized in the literature. Radiation exposure is measured as either dose area product (DAP) or air kerma, which estimates the effective dose, but does not accurately reflect absorbed dose at skin level. The objective of this study was to measure the skin entrance dose during fluoroscopic VCUG study in pediatric patients using single point dosimeters. Pediatric patients undergoing fluoroscopic VCUG were prospectively enrolled in our study. Landauer NanoDot™OSLD dosimeters were affixed to the skin overlying the sacrum to measure skin entrance dose. The fluoroscopic unit was set to the following parameters: low dose setting, skin-to-source distance of 54 cm, pulsed fluoroscopy at 3 frames/sec. Forty-four patients with a median age of 13.6 months (IQR 3.7–42.3) were enrolled. Median fluoroscopic time was 54 s (IQR 36–72). The median values absorbed dose by dosimeter and air kerma were 0.32 mGy (IQR 0.13–0.56, range 0.01–2.9) and 0.24 mGy (IQR 0.14–0.37), respectively. There was a positive correlation between the air kerma and absorbed dose (r = 0.69, p < 0.001) and fluoroscopy time and absorbed dose mGy (r = 0.60, p < 0.001). Absorbed dose was independent of age, body mass index and body surface area (p = 0.19, p = 0.57 and p = 0.16, respectively). Median whole body effective dose was 0.04 mSv (IQR 0.02–0.7). Overall, the absorbed dose received by the dosimeter remained low at a median of 0.32 mGy (range 0.01–2.91). These values are remarkably low and well within the accepted radiation exposure norms. Our radiologists follow a strict protocol to reduce the overall radiation emitted during a VCUG. These measures include setting the x-ray source at a low dose mode, collimating to the smallest area possible, and using pulsed fluoroscopy at 3 frames/sec. Limitations to this study include a slight variability in technique of VCUG between different technicians and providers, for which we cannot control. The radiation dose absorbed at the skin entrance and uniform whole body effective dose is low for a single VCUG when utilizing strict parameters. While newer non-ionizing technologies continue to emerge, our data is encouraging and will serve as a valuable tool when educating parents regarding radiation doses associated with a VCUG. Summary Table Radiographic parameters with VCUG measuring dose area product, air Kerma, dose absorbed at skin level and effective dose. Summary Table Mean Median Fluoro time (sec) 55.6 ± 29.6 54 (IQR 36–79.8) Dose area product (mGy∗m2) 12.8 ± 22.7 5.3 (IQR 3.1–8.3) Air Kerma (mGy) 0.57 ± 1.0 0.24 (IQR 0.14–0.37) Dose absorbed (mGy) 0.55 ± 0.66 0.32 (IQR 0.13–0.56) Effective dose (mSv) – whole body 0.09 ± 0.20 0.04 (IQR 0.02–0.07) [ABSTRACT FROM AUTHOR]