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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]

Introduction Recent reports have suggested that caudal anesthesia may be associated with an increased risk of postoperative surgical complications. We examined our experience with caudal anesthesia in hypospadias repair to evaluate for increased risk of urethrocutaneous fistula or glanular dehiscence. Methods All hypospadias repairs performed by a single surgeon in 2001-2014 were reviewed. Staged or revision surgeries were excluded. Patient age, weight, hypospadias severity, surgery duration, month and year of surgery, caudal anesthesia use, and postoperative complications were recorded. Bivariate and multivariate statistical analyses were performed. Results We identified 395 single-stage primary hypospadias repairs. Mean age was 15.6 months; 326 patients had distal (83%) and 69 had proximal (17%) hypospadias. Caudal anesthetics were used in 230 (58%) cases; 165 patients (42%) underwent local penile block at the discretion of the surgeon and/or anesthesiologist. Complications of urethrocutaneous fistula or glanular deshiscence occurred in 22 patients (5.6%) and were associated with caudal anesthetic use (OR 16.5, 95% CI 2.2-123.8, P = 0.007), proximal hypospadias (OR 8.2, 95% CI 3.3-20.0, P < 0.001), increased surgical duration (OR 1.01, 95% CI 1.01-1.02, P < 0.001), and earlier year of practice (OR 3.0, 95% CI 1.2-7.9, P = 0.03 for trend). After adjusting for confounding variables via multivariable logistic regression, both caudal anesthetic use (OR 13.4, 95% CI 1.8-101.8, P = 0.01) and proximal hypospadias (OR 6.8, 95% CI 2.7-16.9, P < 0.001) remained highly associated with postoperative complications. Conclusions In our experience, caudal anesthesia was associated with an over 13-fold increase in the odds of developing postoperative surgical complications in boys undergoing hypospadias repair even after adjusting for urethral meatus location. Until further investigation occurs, clinicians should carefully consider the use of caudal anesthesia for children undergoing hypospadias repair. [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 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 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 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: 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: 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: 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]

Vesicoureteral reflux is a common cause of pediatric morbidity. Though traditionally managed using a limited number of therapeutic modalities, the last decade has witnessed countless surgical innovations for treating reflux. A major force behind this innovation is the increasing use of endoscopic injection, which currently constitutes nearly half of all anti-reflux procedures performed in the United States. However, published success rates for injection vary dramatically. Despite a relative lack of comparative data, multiple studies have attempted to define the most important prognostic factors for injection success. This article is an attempt to summarize these findings. [Copyright &y& Elsevier]

Objectives: To examine patterns of ketorolac use and its association with hospital outcomes. Although ureteral reimplantation (UR) reliably corrects vesicoureteral reflux, postoperative pain and bladder spasm often occur. Multiple studies show that ketorolac markedly reduces postoperative pain after UR, but there is no information on whether ketorolac is routinely used. Methods: The Pediatric Health Information System is a national database collected by over 40 US children''s hospitals. We identified children with primary vesicoureteral reflux who underwent UR between 2003 and 2008. Billing data were reviewed to identify patients who received ketorolac during hospitalization. Multivariate models were used to examine ketorolac use and postoperative outcomes including complication rates, length of stay, and hospital costs. Results: We identified 12 239 children undergoing UR, 6362 (52%) of whom received ketorolac postoperatively. Factors associated with ketorolac use include older age, female gender, and decreased disease severity (all P <.0001). Ketorolac use was associated with reduced length of stay (2 vs 3 days, P <.0001) and decreased hospital costs ($14 223 vs $16 382, P <.0001). Complication rates were slightly higher in patients not receiving ketorolac (4% vs 3%). After adjusting for confounding factors, ketorolac use remained highly associated with decreased length of stay (P = .01) and decreased costs (P = .002), with no significant differences in complication rates (P = .4). Conclusions: In a contemporary nationwide sample, only half of children undergoing UR received ketorolac. Ketorolac use is independently associated with reduced procedure costs and reduced length of stay after UR, without increased complications. This suggests underutilization of ketorolac after UR. [Copyright &y& Elsevier]

OBJECTIVE: Published success rates of dextranomer/hyaluronic acid (Ox/HA) injection for pediatric vesicoureteral refiux (VUR) vary widely. Our objective of this study was to assess whether underlying patient or study factors could explain the heterogeneity in reported Dx/HA success rates. METHODS: We searched the Cochrane Controlled Trials Register and Medline, Embase, and Scopus databases from 1990 to 2008 for reports in any language, along with a hand search of included study bibliographies. Articles were assessed and data abstracted in duplicate, and differences were resolved by consensus. Conflict of interest (COl) was determined by published disclosure. Meta-regression was performed to adjust for patient as well as study-level factors. RESULTS: We identified 1157 reports, 89 of which were reviewed in full with 47 included in the pooled analysis. Of 7303 ureters that were injected with Ox/I-lA, 5633 (77%) were successfully treated according to the authors' definition. Injection success seemed to vary primarily on the basis of the preoperative reflux grade. After adjustment for VUR grade, other factors, such as the presence or absence of COl disclosure, were not significant. Studies were markedly heterogeneous overall. CONCLUSIONS: The overall per-ureter Dx/HA success rate was 77% after 3 months, although success rates varied widely among studies. Increased VLIR grade negatively affected success rates, whereas C0I, patient age, and injected Ox/HA volume were not significantly associated with treatment outcome after adjustment for VUR grade. There is a significant need for improved reporting of VIJR treatments, including comparative studies of Dx/HA and other VUR treatments. [ABSTRACT FROM AUTHOR]

Objectives: To evaluate nonoperative management of grade IV blunt renal trauma in pediatric patients by performing a systematic review and meta-analysis of published studies. Methods: MEDLINE, EMBASE, Cochrane, and Scopus databases were searched between January 1992 and June 2008 for studies of pediatric renal trauma management. Inclusion criteria were patient age ≤ 18 years and use of the American Association for the Surgery of Trauma renal injury scale. Results: A total of 95 children with grade IV injuries were identified. No intervention was required in 72% (68/95). Hemodynamic instability necessitated surgical exploration in 11% of patients (11/95). Of these, 46% (5/11) required a partial nephrectomy, 27% (3/11) underwent nephrectomy, and 27% (3/11) were salvaged. Angiographic infarction was not used for patients with delayed or persistent hemorrhage. Symptomatic urinoma developed in 17% (16/95). Of these patients, 81% (13/16) were successfully managed by percutaneous drainage or ureteral stent placement, and open intervention to manage complications became necessary in the remaining 19% (3/16). Partial renal preservation was possible in 95% of patients (90/95). Conclusions: Nonoperative management of children with grade IV blunt renal injuries is highly successful, with at least partial renal preservation possible in 95% (90/95) of patients. [Copyright &y& Elsevier]

Objectives: To detail a percutaneous technique of sacral nerve neuromodulation (SN) that eliminates the first-stage incisions and the need for second-stage fluoroscopy. Our group has previously described the results of SN in children with medically refractory dysfunctional elimination syndrome. The drawbacks to SN include the use of fluoroscopy and the need to reopen recent skin incisions during the second stage. This results in increased radiation exposure, poor cosmesis, and possible wound infection. Methods: The incisionless first stage consisted of percutaneously tunneling the temporary external appliance to the contralateral axillary line at the buttock after localization of the S3 nerve root and placement of a quadripolar tined lead under fluoroscopic guidance. A subcutaneous bolus of methylene blue marked the lead connector site, obviating the need for later fluoroscopic localization to place the implantable pulse generator at the second stage. Results: A total of 27 children with refractory dysfunctional elimination syndrome underwent SN using the InterStim device. Of the 27 patients, 19 underwent our modified technique. The operative time for our modified tunneling and placement technique was ≤2 minutes. The mean hospital stay was 0.6 day, with no patient requiring postoperative intravenous narcotics. At a mean follow-up of 35.9 months, no wound infections had occurred in the incisionless cohort compared with 1 postoperative wound infection requiring device explantation in the conventional lead placement group. Conclusions: The incisionless technique of SN device implantation is technically simple, quick to perform, and results in decreased radiation exposure, excellent pain control, and improved cosmesis without compromising the outcomes. [Copyright &y& Elsevier]

Objective: To evaluate the nationwide practice patterns of the management of acute urinary retention (AUR) secondary to urethral stricture (US) in an emergency department (ED) setting.Materials and Methods: We used the 2006-2010 Nationwide Emergency Department Sample to identify men with US who received treatment for AUR. We excluded patients with benign prostatic hyperplasia, vesicourethral anastomotic stenosis, neurogenic bladder, and bladder cancer. Primary outcome was urethral dilation or suprapubic tube (SPT) placement as initial AUR management. Patient demographics and hospital factors were also examined. Multivariate logistic regression was performed to examine factors associated with initial AUR management.Results: We identified 4794 weighted ED encounters of men with US who underwent urethral dilation or SPT placement for AUR. Mean age was 58.6 ± 0.8 years. A total of 4084 (85%) men received urethral dilation, whereas 710 had SPT (15%) placement. In bivariate analysis, patients who received SPT were likely to be younger (P <.001), treated in recent years (P = .002), and in hospitals in the West region (P = .003). In multivariate analysis, SPT placement was significantly associated with younger age (P = .004), public insurance (P = .03), recent treatment years (P = .02), and hospitals in the West region (P = .02). Income and hospital teaching status did not have significant association with initial treatment choice.Conclusion: Urethral dilation remains the most common urologic intervention in the ED for AUR due to US; however, there is an increasing trend toward SPT placement. Patients who are younger, publicly insured, or who receive care in the West region are more likely to receive a SPT for initial treatment of AUR due to US. [ABSTRACT FROM AUTHOR]

Objective: To quantitatively evaluate parental preferences for the various treatments for vesicoureteral reflux using crowd-sourced best-worst scaling, a novel technique in urologic preference estimation.Methods: Preference data were collected from a community sample of parents via 2 best-worst scaling survey instruments published to Amazon's Mechanical Turk online community. Attributes and attribute levels were selected following extensive review of the reflux literature. Respondents completed an object case best-worst scaling exercise to prioritize general aspects of reflux treatments and multiprofile case best-worst scaling to elicit their preferences for the specific differences in reflux treatments. Data were analyzed using multinomial logistic regression. Results from the object-case provided probability scaled values (PSV) that reflected the order of importance of attributes.Results: We analyzed data for 248 and 228 respondents for object and multiprofile case BWS, respectively. When prioritizing general aspects of reflux treatment, effectiveness (PSV = 20.37), risk of future urinary tract infection (PSV = 14.85), and complication rate (PSV = 14.55) were most important to parents. Societal cost (PSV = 1.41), length of hospitalization (PSV = 1.09), and cosmesis (PSV = 0.91) were least important. Parents perceived no difference in preference for the cosmetic outcome of open vs minimally invasive surgery (P = .791). Bundling attribute preference weights, parents in our study would choose open surgery 74.9% of the time.Conclusion: High treatment effectiveness was the most important and preferred attribute to parents. Alternatively, cost and cosmesis were among the least important. Our findings serve to inform shared parent-physician decision-making for vesicoureteral reflux. [ABSTRACT FROM AUTHOR]

Objective: To identify risk factors for recurrent urinary tract infection (UTI) in patients who perform clean intermittent catheterization (CIC).Methods: A 6-year retrospective chart review of patients with spina bifida or tethered cord who perform clean intermittent catheterization (8 months to 58 years) was conducted. A strict case definition for UTI was applied, and per-subject UTI events, demographic, and clinical data were abstracted. Data were compared between groups defined by no or infrequent UTI (≤1.0 UTI/study year) and frequent UTI (>1.0 UTI/study year).Results: Of 194 total patients, 146 (75%) had no UTIs or infrequent UTIs, and 48 (25%) patients had frequent UTIs. On univariate analysis, only younger age and suprasacral cord lesions were associated with frequent UTIs (P = .002 and P = .007, respectively). Among the 128 patients with urodynamic studies, bladder capacity, compliance, detrusor overactivity, and detrusor leak point pressure were not associated with frequent UTI on univariate analysis. On multivariate analysis, increasing age was found to be associated with decreased odds of UTI by 7% per year (odds ratio 0.93, P = .016).Conclusion: The risk of UTI among individuals with spina bifida or tethered cord declines with increasing age. Bladder function based on urodynamic parameters did not correlate with frequent UTIs. [ABSTRACT FROM AUTHOR]

Objective: To define rates of priapism diagnosis and inpatient admission among males with sickle cell disease (SCD).Patients and Methods: We retrospectively reviewed the Pediatric Health Information System database for males aged <21 years treated 2004-2012. We identified patients with SCD and priapism based on the International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis codes. Logistic regression and generalized estimating equation models were used to control for confounding and to adjust for within-hospital clustering of similar patients.Results: We identified 17,186 males who were admitted 137,710 times during the study period. Of these, 362 (2.1%) were diagnosed with priapism on 748 admissions. There was a significant decrease in the number of priapism admissions among patients with SCD over time (0.81% in 2004 to 0.44% in 2012, P  <  .001). The number of patients diagnosed with SCD-related priapism varied over time without a statistically significant trend (2.3% in 2004, 2.69% in 2008, 1.01% in 2012, P  =  .34). Rates of priapism admissions (0-4.4%) varied widely between hospitals. Older patient age was associated with an increased likelihood of a priapism admission in the multivariate logistic regression model after adjusting for treatment year, hospital region, and for hospital-level clustering of similar patients.Conclusion: From 2004 to 2012, the number of admissions for SCD-related priapism declined whereas the number of individual patients diagnosed with SCD-related priapism did not. Rates of priapism-related admissions in males with SCD vary widely among PHIS hospitals. [ABSTRACT FROM AUTHOR]

Introduction: Radical nephrectomy (RN, or total nephrectomy) is the current gold-standard surgical treatment for children with Wilms tumors (WT). However, nephron-sparing surgery (NSS, or partial nephrectomy) has recently been gaining increasing attention. The objective of this systematic review is to compare the effectiveness of NSS as compared with RN for the treatment of children with WT.Methods: We searched the Cochrane Controlled Trials Register, clinicaltrials.gov, MEDLINE, EMBASE, Google Scholar, and recently presented meeting abstracts for reports in English. The bibliographies of included studies were then hand-searched for any missed articles. The protocol was prospectively registered. Manuscripts were assessed and data abstracted in duplicate with differences resolved by the senior author. Owing to high heterogeneity among the final included studies, only a qualitative systematic review was performed; no formal meta-analysis was undertaken.Results: We identified 694 articles, 118 of which were selected for full-text review and 66 of which were included in the final analysis. Most studies were single- or multi-institution retrospective case series (60, 91%), with a small number of prospective cohort studies (6, 9%) and 1 administrative database analysis. Most studies were from Europe (27, 41%) or North America (21, 32%). Nearly half (32, 48%) of studies those were included were dated from 2010 or later. In total, data on 4,002 patients were included, of whom 1,040 (26%) underwent NSS and 2,962 (74%) underwent NSS. Reported rupture rates were similar between RN and NSS (13% vs. 7%), as were recurrence rates (12% vs. 11%) and survival rates (85% vs. 88%). However, these comparisons are limited by inherent biases in the design and reporting of most included studies.Conclusions: Most contemporary studies reporting the use of NSS in children with WT report similar long-term outcomes to RN. However, most existing studies are limited by their small numbers, inconsistent reporting, and methodological biases. There are significant opportunities for future research on the use of NSS in children with WT, including issues related to surgical quality, optimal technique, timing and duration of chemotherapy, and variation in the use of NSS among centers. [ABSTRACT FROM AUTHOR]