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Summary Introduction Vesicoureteral reflux (VUR) after renal transplant in the pediatric population may be associated with an increased incidence of urinary tract infection (UTIs) leading to increased morbidity, including graft dysfunction and graft loss. The non-orthotopic location of the transplanted ureter, and lack of submucosal tunnel may pose challenges in correcting the VUR using endoscopic injection techniques. Herein we report the results of a systematic review evaluating the outcomes of endoscopic treatment of VUR using Deflux® in this population. Methods Pubmed and Embase databases were searched from October 2001 to April 2019. Full-text English articles involving patients less than 18 years old at the time of transplant, with a diagnosis of VUR post-transplantation, who underwent Deflux® treatment were included. Figure 1 outlines our PRISMA-compliant search strategy. Results We found 6 eligible studies describing Deflux® treatment outcomes in 67 pediatric patients with post-transplant VUR where voiding cystourethrogram (VCUG) confirmed the diagnosis and resolution of VUR. The mean success rate was 36.8%. Ureteral obstruction occurred in 7/67 cases (10.4%). In all these 7 cases of obstruction, ureteric stenting was the initial management, but was only successful in 1 patient. Open ureteroneocystostomy (UNC) was performed in 4/7 cases, while 2/7 were managed expectantly (unknown outcomes). Persistent VUR with UTI despite Deflux® were reported in 20 out of 67 cases. Of these, 7 were managed with prophylactic antibiotics, and 13 with UNC. Success rates were consistently low for UNC after failed Deflux® in comparison to redo UNC in transplant ureters without prior injection. Conclusion Low success rates are seen following injection techniques for VUR after pediatric renal transplant. Although an appealing option, Deflux® may prove counterintuitive due to the high rate of obstruction and suboptimal results if open reimplantation is required. A multi-institutional prospective study with a larger population size may further elucidate these results.

Objective To describe the experience and technique of zero-ischemia laparoscopic-assisted partial nephrectomy at The Hospital for Sick Children, as an alternative to the traditional open approach for nephron-sparing surgery (NSS) in selected children with Wilms tumor (WT). Materials and Methods Patients with diagnosis of WT treated with neoadjuvant chemotherapy and who underwent laparoscopic-assisted NSS at the Hospital for Sick Children from 2012 to 2016 were identified and their charts were reviewed retrospectively. Patients underwent laparoscopic exploration, lymph node sampling, kidney mobilization, vascular control, and adrenal sparing. This was followed by open NSS through a small flank incision; no clamping of the hilum or major renal branches was performed. Results Six patients were identified; all patients underwent successful resection. One patient required radical nephrectomy due to inability to safely define negative margins. Tumors ranged in size from 0.9 to 5.6 cm in diameter. Mean operating time was 293 ± 50.2 minutes, with an average duration of pneumoperitoneum of 216 ± 27 minutes. Intraoperative blood loss was negligible. No tumor spillages occurred. Postoperative pathology revealed negative margins in all resected specimens. One case of urine leak occurred postoperatively, which resolved spontaneously. Renal function was preserved in all children. At a mean follow up of 11.5 months, all patients have been recurrence free. Conclusion The herein presented strategy allows for safe nephron-sparing resection of selected WT with acceptable morbidity, good short-term disease-free survival, and potentially better cosmesis and recovery than traditional open surgery. This preliminary experience suggests that minimally invasive options for NSS in children merit further evaluation.

Objective To provide a comprehensive overview of genital anomalies encountered among adolescents, including late effects of problems addressed earlier in childhood. Materials and Methods The major congenital genital anomalies encountered in pediatric urology were identified. They include hypospadias, exstrophy-epispadias, cloacal malformations, disorders of sexual development, undescended testes, and some acquired penile anomalies seen in adolescence (priapism, adolescent varicocele). Recommendations of the International Consultation on Urological Diseases are provided on various aspects of these conditions, such as postpubertal cosmesis and function, fertility implications, and long-term nephrological considerations (when relevant). Results Specific recommendations for care, including strength of clinical recommendation, are provided in this paper. Whereas the basis of this paper is to discuss specific management recommendations as they relate to several heterogeneous conditions, general recommendations include patient-centered discussions regarding operative treatment be deferred until the patient is able to articulate goals and participate in shared decision-making and utilization of multidisciplinary teams for conditions where multiple organ systems may be involved. Conclusion Congenital abnormalities of the genitalia are common and widely heterogeneous. Late effects and concerns often emerge after puberty, and patients should be followed throughout their adult lives to address such concerns.

Summary Introduction and objectives Continence enemas for the purpose of bowel management may be delivered via trans-anal retrograde irrigations, and via antegrade conduits including surgical appendicostomy or placement of cecostomy tube (CT). An appreciation of the relative advantages and disadvantages of each antegrade continence enema (ACE) procedure allows clinicians, parents and children to make an informed decision regarding which procedure is most appropriate in individual cases. The objective of this study was to evaluate the differences in in-hospital resource utilization, surgical outcomes and radiation exposure between children undergoing appendicostomy creation and CT placement at our institution. Methods We conducted a retrospective chart review of children undergoing these procedures at our institution over a 10-year period. All patients 0–18 years of age undergoing either procedure for any indication were included. Data on demographics, length of stay (LOS), radiation exposure events (REE), and surgical outcomes were collected. Results One hundred fifteen (63 appendicostomy/52 CT) patients were included. Those undergoing CT placement had significantly increased post-procedural LOS, catheter exchanges and REE compared to those undergoing appendicostomy (see Table). Reported rates of bowel control were similar between the two groups, and there was no significant difference in rates of surgical complications, although each group had unique, procedure-specific complications. Discussion and conclusion In our study, appendicostomy holds a clear advantage over CT in terms of post-procedural LOS, as well as REE. In general, children with CTs require more planned and unplanned device maintenance procedures than those with appendicostomy. These findings aside, the rates of success for bowel control between the two groups are similar, and the incidence of complications does not differ significantly between the two groups. CT remains a safe and effective conduit for delivery of ACEs, and is a particularly good option in patients whose appendix has been lost or used for another conduit. However, patients wishing to avoid repeated procedures and radiation exposure may find the option of appendicostomy more attractive. Summary Table 1 . Length of stay, catheter exchanges and radiation exposure metrics. Appendicostomy n = 63 (%) Cecostomy n = 52 (%) p-value Post-operative LOS (days) All patients 2.8 ± 3 5 ± 5 Isolated ACE-procedure (n = 38/44) a 2.1 ± 1 4.7 ± 4 Outlier excluded (n = 63/44) a 2.8 ± 3 4.9 ± 4 Duration of antibiotic therapy Intravenous (all patients) 1.2 ± 1.3 4 ± 13 0.02 Total (all patients) 2.7 ± 5 5 ± 13 0.16 Intravenous(isolated-ACE a ) 0.9 ± 0.9 2 ± 3 0.28 Total (isolated-ACE a ) 1.7 ± 3.5 2.6 ± 4 0.46 Intravenous (outlier excluded a ) 1.2 ± 1.3 2.2 ± 3 0.26 Total (outlier excluded a ) 2.7 ± 5 2.8 ± 4 0.58 Catheter Exchanges No. catheter exchanges per patient per year of follow-up 0.3 1.1 Total no. patients requiring unplanned catheter exchanges (entire group) 6 (10) 21 (40) Radiation Exposure Total REE (whole group) 71 407 Total number of patients with REE 17 (27) 51 (98) Average REE per patient 1.1 c 7.8 Radiation exposure metrics b Total number of REE 50 136 Mean DAP d per event (mGy.cm2) 1003 488 Median DAP per event (mGy.cm2) 396 185 Mean reference air kerma e per event (mGy) 5.0 3.0 0.0013 Median reference air kerma per event (mGy) 2.8 1.2 0.0013 a Outlier who had 95 days of antibiotics related to cecal detachment and cardiac lesion excluded. b Radiation exposure metrics for REE with complete radiation data (50 events out of 71 events in the appendicostomy group and 136 events out of 407 events in the cecostomy group). c Represents average REE for all appendicostomy patients: average REE in appendicostomy patients with any event at all (17/63) was 4.1. d DAP refers to ‘Dose Area Product’ and assesses radiation risk using the absorbed radiation dose and the area irradiated during the procedure. e Air kerma is the sum of the initial kinetic energies of all the charged particles liberated by uncharged ionizing radiation (i.e: indirectly ionizing radiation such as photons and neutrons) in a sample of matter. It represents the absorbed dose or gray (Gy). Unlike DAP it is not related to the area radiated, only the dose of radiation.

INTRODUCTION Pediatric renal transplantation has been heavily published since the 1950s. Herein, we describe the bibliometrics and impact of the 200 most-cited pediatric renal transplantation manuscripts. METHODS We identified pediatric renal transplantation publications from 1900 onwards. Year, citations, h-index, geographic origin, impact factor, topic, and design of the 200 top-cited papers were extracted. Impact index was calculated, adjusting for citation volume and time since publication. RESULTS Of the top 200 papers, mean citation count was 80 ± 40, impact factor 3.9 ± 3.7, h-index 35 ± 20, and impact index 25 ± 13. Studies were mostly retrospective (31%) or observational (32%). Most papers originated from the United States (58%), Germany (9%), and Italy (6%), which did not correlate with citation counts. Transplantation (18%), Pediatric Nephrology (16%), and American Journal of Transplantation (11%) had the highest publication volume, which did not correlate with citation count. The main topics were medical renal disease, drug monitoring, compliance, and viruses. Most of the top-cited papers (179; 90%) were published after 1991. The difference in the number of times cited between papers published before and after 1991 was insignificant (75 ± 24 vs 80 ± 42; P = 0.59). There was a difference in impact index for the same period (48 ± 15 vs 22 ± 10; P

OBJECTIVE To review the robustness of hydronephrosis literature with the application of fragility index (FI) and fragility quotient (FQ) calculations. METHODS A literature review was conducted using Pubmed, Medline, and Ovid for “hydronephrosis” and associated terms and we included all studies with at least 2 groups being compared. FI was calculated by populating study results into a 2-by-2 contingency table and generating a P value using Fisher's exact test. Next, events were manually added to the group with the fewest events, while removing a nonevent from the same group and Fisher's exact test repeated until the P value was >.05. FQ was calculated by dividing FI by the total sample size. RESULTS The 130 included articles were published between 1986 and 2018 in 32 journals. Median citation count was 14 (0-252), 30% were RCTs and most papers originated in the United States (28%), Turkey(10%), and Canada(9%). Median FI was 2 (1-112), FQ was 0.023 (0.0010-0.55), and 60 papers (46%) had a FI of 1, indicating extremely fragile results. There was a significant difference in the FI between observational studies and RCTs (10 ± 17 vs 4 ± 5; P = .02); however, there was no difference in FQ (0.032 ± 0.030 vs 0.053 ± 0.080; P = .09) between them. CONCLUSION Nearly half of studies in hydronephrosis literature reporting significant results are extremely fragile, requiring addition of only a couple of events in 1 treatment arm to significantly modify the results. As such, objective reporting of robustness of results should include FI and FQ which may help diminish over-reliance on P values as the main indicator of clinical significance in comparative studies.

In today’s era of evidence-based medicine, personalized and value-based care have become critical goals. Seeking to attain these goals amidst skyrocketing healthcare costs, preventable errors have become a target for the quality improvement and patient safety (QIPS) movement. For surgeons, in particular, this has resulted in a constantly changing playing field requiring the balance of patient safety and outcome concerns along with institutional pressures and cultural shifts. This chapter presents a clinical case scenario to illustrate current situations pertinent to the use of quality improvement and patient safety (QIPS). Relevant history is reviewed from its foundation with Ernest Amory Codman at the turn of the twentieth century to the development of the Joint Commission on Accreditation of Healthcare Organizations and the National Surgical Quality Improvement Program. Subsequently, the current framework and methodologies for QI, such as continuous process improvement and the plan-do-study-act model, are reviewed, along with research applications. The chapter concludes with a discussion on the broader healthcare cultural and practice implications of moving towards a blameless, evidence-based QIPS arena.

Since its development in 1989, the ACE procedure has become widely accepted as a valuable addition to the therapeutic regimens available for treating intractable faecal incontinence associated with conditions such as myelomeningocele and anorectal malformations. Thousands of patients around the world have undergone ACE procedures with success rates in excess of 80% reported.

The finding of ambiguous genitalia in the newborn creates the need for a team of experts, the DSD (disorder of sexual differentiation) team, to be assembled in order to determine the genetic sex, identify any underlying biochemical abnormalities, and provide education and support for the family. This team may include a neonatologist, a pediatric endocrinologist, a geneticist, a pediatric surgeon or pediatric urologist, a social worker, and a psychiatrist. Whereas DSD was once considered to be a medical and surgical emergency, today it represents more of a social urgency, but prompt medical evaluation is also necessary because of potential metabolic and electrolyte disturbances.

Hospitals fail for many reasons. An intimate knowledge of the factors leading to poor performance or failure is vital for all those working to enhance quality and optimize care. Factors that lead to failure include leadership, vision, culture, planning process, and information systems.

In recent years, our understanding about how to manage pediatric urology patients has improved substantially. This has resulted in this population receiving better long-term care, thus allowing these patients to live well into adulthood. This chapter explores how well the medical community has been adapting to this evolution in pediatric medicine, both in the broad context of complex pediatric care as well as within the realm of pediatric urology. Several existing initiatives for transitional pediatric and pediatric urologic care will be discussed, along with opportunities for collaboration to generate novel innovations specific to the pediatric urologic patient approaching transition into adulthood. Finally, the basic tenets of quality improvement work and its applicability to transitional care will be reviewed. Recommendations will be provided regarding how to develop, measure, refine, and spread quality improvement initiatives.

Summary Objective The objective of this video is to illustrate feasibility of the ureteral ligation for the treatment of massive ureteroceles associated with non-functioning upper kidney moieties in duplex kidneys. Materials and methods In this video, one case is presented to demonstrate this novel technique. A nine-year-old boy presented with progressive lower urinary tract symptoms. Radiological workup depicted a duplex kidney on the left side with the absence of function on the upper pole and hydroureteronephrosis with a massive ureterocele. Laparoscopic ureteral transection, drainage, and ligation of both extremities of the enlarged ureter (upper pole ureter) were performed. Results Immediately after ureteral ligation, ultrasonic evidence of ureterocele decompression and improved hydroureteronephrosis was observed. This patient remained asymptomatic without postoperative complications after 3 years. De novo reflux was not observed. Conclusion Ureteral ligation, as demonstrated in the video, is a good approach for the treatment of massive ureteroceles associated with non-functioning upper kidney moieties in duplex kidneys. Compared with the current standard techniques (incision/puncture), ureteral ligation has the clear advantage of not causing ‘de novo reflux’ or unsuccessful de-obstruction, and is not as surgically demanding as other reconstructive/ablative techniques. The disadvantage is the need of regular clinical and ultrasonographic follow-up.

Purpose Little is known regarding post-transplant renal function following pediatric pre-emptive KT. Therefore, this study aims to determine whether there is a difference in 1 year post-transplant renal function outcomes between pre-emptive and post-dialysis KT in pediatric transplant recipients. Methods A retrospective review of patients who underwent kidney transplant at our institution between 2000 and 2015 was performed. Kidney transplant recipients were divided into four groups: pre-DD, post-DD, pre-LD, and post-LD. The clinical outcomes, measured in eGFR (mL/min/1.73 m2 ), acute rejection episodes within 1 year, and hospitalization within 1 year were compared to between groups in their respective donor types (pre-DD vs post-DD; pre-LD vs post-LD). Results The 324 patients were identified (21 pre-DD, 151 post-DD, 54 pre-LD, and 98 post-LD). Post-DD group had more females (P = 0.018) and post-operative complications (P = 0.023), although there was no difference in complications requiring intervention (P = 0.129). Post-LD patients were more likely to be females (P = 0.017) and those with intrinsic renal (non-urological/structural) ESRD etiology (P = 0.003). The 1-year eGFR was similar between pre-DD and post-DD groups (70.3 [IQR 53.5-88.5] vs 74.3 [IQR 62.3-90.5], P = 0.613), as well as pre-LD and post-LD groups (66.6 [IQR 47.8-73.7] vs 63.9 [IQR 55.0-77.1], P = 0.600). There were no significant differences in rates of acute rejection episodes or hospitalization within 1 year of transplantation for in LD/DD groups. Conclusion There is no significant difference in renal function at 1 year post-transplant in pediatric patients receiving pre-emptive or post-dialysis kidney transplants.

Introduction: Despite the widespread use of circumcision, there is little understanding regarding risk factors associated with its complications. This investigation assesses potential risk factors contributing to complications of circumcision. Methods: A retrospective review of all males who underwent a neonatal circumcision in our institution’s pediatric urology clinic between January 2015 and June 2017 was performed. Continuous variables were dichotomized to determine a clinically relevant cutoff value. Multivariate regression analyses were used to identify risk factors for primary outcomes (early/late complications) and secondary outcomes (emergency room [ER] visitation, return to operating room, post-circumcision communications). Results: A total of 277 patients were identified. The mean age and weight were 28.4 days and 4.3 kg, respectively; 93.1% of cases were elective and 12.3% of patients had comorbidities. Circumcisions were performed using Mogen (61.4%) or Gomco clamps (39.6%) under local anesthesia. Overall, 35 patients experienced complications (12.6%). There were 18 patients (6.5%) with bleeding requiring sutures at time of circumcision. Twenty-six patients (9.4%) experienced long-term complications, with penile adhesions being the majority (84.6%). One (0.4%) of these patients had a Clavien-Dindo 3 complication requiring surgery for a skin bridge that could not be separated. One patient (0.4%) visited the ER due to postoperative bleeding from the circumcised area, which was managed conservatively. Multivariate regression analysis identified weight >5.1 kg as a risk factor for bleeding requiring sutures (odds ratio [OR] 4.145; 95% confidence interval [CI] 1.246–13.799) and long-term complications (OR 3.738; 95% CI 1.356–10.306). No risk factors were identified for other outcomes (return to operating room, ER visitation, postcircumcision email/telephone communications). Conclusions: This investigation of neonatal circumcision revealed that patients weighing >5.1 kg may be at higher risk of bleeding and long-term complications, such as adhesions.

Renal transplantation is the treatment of choice in children with end-stage renal failure. Limitations in patient anatomy or a short donor renal vein may necessitate intraoperative inversion of the kidney. There is little evidence to support the use of this surgical technique, and no evidence in the pediatric population. This study identifies the perioperative and post-operative outcomes of inverted renal transplants in pediatric patients. We reviewed all patients having a renal transplant between January 2012 and December 2016 and collected short- and long-term outcomes of patients who received an inverted allograft. Early graft function was defined as the time to reach creatinine nadir. During this time, our hospital performed 81 transplants, and 50 (62%) were from deceased donors, including the 6 (12%) patients who received inverted renal grafts. Half (3/6) were female, 5/6 (83%) were dialysis-dependent, and the median age at surgery was 13 years (range 9-16 years). There was no significant difference in mean creatinine nadir values (P = 0.518) and the time to creatinine nadir mean values (P = 0.190) between the upright and inverted renal transplant groups. There were also no significant differences in rates of post-operative complications between the upright and inverted allograft recipients. Inversion of renal allografts in pediatric patients is a viable surgical technique to compensate for shortcomings in patient anatomy or in special cases of renal transplantation involving a short donor renal vein. Future research should focus on outcomes of a larger group of pediatric inverted renal transplant patients.

This investigation aims to assess the variability in practice patterns regarding management of children with cryptorchidism (UDT) among pediatric urologists (U) and pediatric surgeons (S) practicing in Canada.All active members of Pediatric Urologists of Canada (PUC) and Canadian Association of Pediatric Surgery (CAPS) were invited to participate in an online multiple-choice type questionnaire with clinical scenarios in management of UDT. Responses were compared between U and S using Fisher's exact test.The response rates were 74% and 79% among CAPS members (54/73) and PUC members (27/34) respectively. CAPS members were more likely to order diagnostic ultrasounds prior to surgery (44.4% vs 18.5%, p = 0.027). For palpable testis, most (80%) CAPS members favored the classic inguinal approach, while most PUC members did not demonstrate a clear preference, and were flexible with their approach depending on the position of the palpated testes (55%; p 0.001). There was no statistically significant difference in preferred approach to unilateral or bilateral nonpalpable testis. However, for both palpable and nonpalpable bilateral UDT, more CAPS members preferred metachronous correction, compared to PUC members who opted to approach them synchronously (p = 0.008, 0.002, respectively).Preferences with regard to use of diagnostic tools such as US, surgical approach for palpable testes and bilateral UDTs were not consistent between the two surgical specialties who perform orchidopexy across Canada. Both groups were compliant with guideline recommendations, with the exception of utilizing preoperative ultrasounds, which is uniformly not recommended by the most recent guidelines.This is a level II evidence study.

Purpose To determine whether there is a benefit to pre-emptive kidney transplantation in reducing surgical complications in pediatric population. Methods A retrospective review of kidney transplantations in our institution from 2000 to 2015 was performed. Intra- and postoperative complication rates and one-year graft survival were compared in their respective donor type groups (pre-emptive DD vs post-dialysis DD; pre-emptive LD vs post-dialysis LD). Results A total of 318 patients were identified (pre-emptive DD, n = 21; post-dialysis DD, n = 145; pre-emptive LD, n = 54; post-dialysis LD, n = 98). Between the DD groups, post-dialysis DD group was more likely to be female (P = 0.017). There was no difference in rates of intraoperative complications or graft loss (P = 0.365 and 1.000, respectively). Post-dialysis DD groups were more likely to have postoperative complications (9.5% vs 35.1%, P = 0.023), but no difference in complications with Clavien-Dindo grade 3 or higher was found (P = 0.130). Between the LD groups, post-dialysis LD group was more likely to be females (P = 0.017) and with intrinsic renal (non-urological/structural) ESRD etiology (P = 0.003). There was no difference in rates of intra-and postoperative complications or graft loss (P = 0.353, P = 0.605, and P = 0.616, respectively). Conclusions Overall, there are similar perioperative complication rates between pediatric pre-emptive and post-dialysis kidney transplant recipients.

Our study aims to assess the clinical implication of RAV/rBSA ratio in PRT as a predictor for attained renal function at 1 year post-transplantation and its association with surgical complications. A retrospective cohort was performed for PRT cases from January 2000 to December 2015 in our institution. Extracted clinical information includes the recipient's demographics, donor type, renal allograft characteristics, arterial, venous and ureteral anastomoses, vascular anastomosis time while kidney off ice, overall operative time, and estimated blood loss. The RAV/rBSA was extrapolated and assessed for its association with renal graft function attained in 1 year post-transplantation and surgical complications within 30-day post-transplantation. A total of 324 PRTs cases were analyzed. The cohort consisted of 187 (52.4%) male and 137 (42.3%) female recipients, with 152 (46.9%) living donor and 172 (53.1%) deceased donor renal transplants, and an overall median age of 155.26 months (IQR 76.70-186.98) at time of renal transplantation. The receiver operating characteristic identified that a RAV/rBSA ratio of 135 was the optimal cutoff in determining the renal graft function outcome. Univariate and multivariate analyses revealed the relative OR for RAV/rBSA ≥ 135 ratio in predicting an eGFR ≥ 90 attained within 1 year post-transplant was highest among younger pediatric recipients (

Summary Introduction Penile and genital keloids are uncommon despite frequent surgeries in the genital area. Keloid scar pathogenesis is not well understood, and a uniform effective therapeutic regimen for keloids has not yet been established. In the present study, the clinical features and subsequent management in cases of severe keloid formation after pediatric genital surgery are described. Methods A retrospective review of keloid cases that had developed after genital procedures between 2000 and 2017 was conducted. Pre-operative characteristics, operative procedures, postoperative management, and follow-up were reviewed for each case. All cases were managed by a multidisciplinary team that included plastic surgeons and dermatologists. Result Six cases developed genital keloids. The mean age at surgery was 5.6 years (± standard deviation 4.6 years). Procedures included phalloplasties, penile curvature correction, penoscrotal transposition, redo hypospadias repair, and circumcision. Treatment options included excision of the keloid ± topical steroid injections and postoperative use of silicone gel. Two cases of severe keloid lesions developed after using posterior auricular grafts. Ultimately, a successful outcome was achieved in all cases. Conclusion Genital keloids are rare and difficult to treat. Many therapeutic options are available with varying degrees of proven clinical success. As a result, pediatric urologists must be aware of advances in other fields such as plastic surgery and dermatology to treat and ideally prevent the occurrence of this serious complication. Summary Table . Summary of keloid treatment cases after penile surgery. Case Age at presentation (years) Initial surgery Treatment options used for the keloid lesion Follow-up (Years) Success 1 2.5 Phalloplasty and correction of penoscrotal transposition Intralesional steroid injections 5 Yes 2 1.5 Phalloplasty and correction of penile curvature Surgical excision followed by silicone gel application 3.5 Yes 3 2 Phalloplasty and correction of penoscrotal transposition Surgical excision followed by intralesional steroid injections 2 Yes 4 8 Multiple redo hypospadias repair Multiple surgical excisions and use of different grafts 3 Yes 5 7 Multiple redo hypospadias repair Multiple surgical excisions and use of silicone gel application 4 Yes 6 13 Circumcision Excision of the keloid and intraoperative injection of dexamethasone 3 Yes

Summary Background Unplanned postoperative return visits to the emergency department (ED) and readmission represent a quality bench outcome and pose a considerable cost burden to health-care systems. Objective The aim of this study is to evaluate ED return visits after pediatric urology procedures in a tertiary care children's hospital, trying to identify potential causes. This may constitute a platform for future improvement areas. Materials and methods A Quality Board–approved retrospective study was performed identifying all urologic cases completed between October 2012 and September 2015. Baseline demographics, American Society of Anesthesia class, operating surgeon, type of admission, type and duration of surgical procedure, and type of anesthesia given were evaluated. Patients who returned to the ED within 30 days of the surgery date were identified. The ED records were reviewed for time of return, etiology for visit, and management received. Univariate and subsequent multivariate logistic regression statistical analyses were performed to identify variables associated with ED return. Odds ratio (OR) and 95% confidence intervals (95% CIs) were generated to determine the significance of relationships. Results Total of 4125 cases was identified. Median age was 32.9 months, with 85.1% of them being male. 349 (8.5%) cases returned to the ED within 30 days of the surgery. The majority of the returned patients, 295 (84.5%), managed conservatively with medications or reassurance, whereas 54 (15.5%) required readmission, and of those readmitted, 15 (4.3%) cases needed further surgical interventions, mainly urinary tract drainage procedures. Multivariate logistic regression analysis identified that the age, residence, admission type, inguinoscrotal surgery, and duration of surgical procedure were significantly associated with ED return (Table). The most common reason for the ED visit was UTI in 17.2%, followed by stent and catheter issues in 14.3%, wound-related in 14.3%, and bleeding in 11.7%. Discussion Pediatric literature show varying rates of ED return ranging from 2.4% to 2.6% after urologic procedures. Our return to ED rate exceeds that found in US studies, which can perhaps be attributed to the differences between the Canadian and US health-care systems. As found with other studies, age, inpatient admission, procedure type, and increased operative time were related to ED returns, possibly because of the difficulty of young children expressing themselves and the presumed complex nature of longer operations that mostly need inpatient admission. The most common reason for ED return in this study as in others was presumptive UTI. A known limitation of this study is its retrospective nature, along with the possible missed visits of patients who presented to outside hospitals. Conclusion We present an account of the status of ED return visits after pediatric urology procedures in our institute. The majority of ED returns can be managed conservatively and are probably preventable. ED return variables p-value Odds ratio 95% CI for odds ratio Lower Upper Gender: Female 0.932 1.016 0.707 1.459 Age in month 0.002 0.997 0.995 0.999 Residence in Toronto 2.171 1.700 2.772 Admission type: inpatient 0.010 1.487 1.100 2.009 Endoscopic procedures 0.707 1.108 0.648 1.896 Penile procedures 0.989 0.997 0.640 1.553 Inguinoscrotal procedures 0.298 0.177 0.501 Upper tract procedures 0.369 0.766 0.429 1.369 Lower tract procedures 0.873 1.052 0.566 1.955 Duration of surgical procedures (minutes) 0.005 1.002 1.001 1.003

Summary Introduction The advent of open access publishing has allowed for unrestricted and rapid knowledge dissemination and can generate higher citation levels. However, the establishment of predatory journals exploits this model and may lead to publication of non-peer reviewed work. Objective The objective of this study was to compare the characteristics and trends of indexed publications in paediatric urology. The primary outcomes were to compare open access vs non-open access publishing. The secondary outcome was to assess whether any open access publications in this cohort could be classified as predatory based on journal data basing and external peer review policies. Methods PubMed, MEDLINE and Embase reviews were carried out for any publication using the terms ‘p(a)ediatric urology’ over a 5-year period (October 2012–2017). These publications were individually accessed, assessed for relevance and cross-checked using the ISI Web of Knowledge Journal Citation Report. Bibliometric data, journal type and access model were all individually assessed, ranked and compared using descriptive and non-parametric statistical methods. Results From an initial total of 4075 indexed publications, 2244 journal publications across 51 countries were included based on relevance, of which 611 were open access. Open access journals were significantly more likely to publish basic science/laboratory versus clinical publications (10.9% vs 3.3%). They were more likely have higher average citations/publication (17 vs. 8), but there was no difference between open and closed journal impact factors (3.1 vs. 2.7). The overall rate of open access, indexed publications that were not peer reviewed and/or included in open access databases was 6.5% Discussion The overall numbers of paediatric urological articles appearing on PubMed between 2012 and 2017 have increased by approximately 75%, while the number of open access articles has remained relatively static (25%). Researchers may prefer to publish in specific journals to disseminate results to a particular audience or fear in the current climate that an open access journal may not be considered legitimate, and possibly even predatory, thus having a negative impact on the data and the author's reputation. The impact factor status and route/method of publication may be less important. Conclusions Open access, peer reviewed publishing allows rapid international knowledge dissemination. The exact objective definition of what constitutes a predatory journal remains controversial. We have identified a time-stable prevalence of 6.5% open access publications that could meet proposed criteria for a ‘borderline/predatory journal’; however, this should not influence the decision to publish in open access journals. Summary Table . Top 10 journals publishing paediatric urological articles 2012–2017 Impact factor Eigen factor Journal name Open access option (yes/no) Included publications, 2012–2017 1.611 0.00443 Journal of Paediatric Urology Yes 581 2.309 0.02603 Urology Yes 292 5.157 0.05533 Journal of Urology Yes 242 1.082 0.0038 Canadian Urological Association Journal Yes 62 1.976 0.01754 Journal of Pediatric Surgery Yes 58 2.27 0.00987 Journal of Endourology Yes 38 1.739 0.00656 International Urology & Nephrology Yes 29 2.124 0.00269 Current Urology Reports Yes 26 2.172 0.00209 Frontiers in Pediatrics Yes 23 1.844 0.00602 International Journal of Urology Yes 21

Intra-operative arterial vasospasm during pediatric renal transplantation is an urgent clinical situation resulting in end-organ ischemia, associated changes in parenchymal turgor and color, diminished flow on ultrasound, and if left untreated, allograft loss. We hypothesized that intra-operative intra-arterial injection of nitroglycerin would reverse vasospasm and improve renal perfusion. A three-yr-old girl with end-stage renal disease due to autosomal recessive polycystic kidney disease on peritoneal dialysis underwent deceased donor renal transplantation. After optimal immediate reperfusion and hemodynamic parameters, the kidney lost turgor and became mottled in appearance despite adequate hilar arterial and venous Doppler waveforms. Two aliquots of 40 μg (0.4 mL of a 100 μg/mL) nitroglycerin solution were injected directly into the renal artery 10 min apart. Nitroglycerin resulted in dramatic change in the consistency and appearance of the allograft. An improvement in renal blood flow was demonstrated by ultrasound after the second intra-arterial nitroglycerin injection with only a transient decrease in systemic arterial blood pressure. The child experienced normal allograft perfusion on serial postoperative ultrasounds, with a prompt decrease in serum creatinine and excellent diuresis. Intra-arterial nitroglycerin is a promising option for intra-operative arterial vasospasm during pediatric renal transplantation with objective improvement in blood flow and perfusion.

Indirect expenses for accessing health care may place significant fiscal strain on Canadian families. Telemedicine alternatives, using email, telephone, and video conferencing, can mitigate such financial burdens by reducing travel and related costs. Our objectives were to assess costs that families incur visiting an outpatient pediatric surgical clinic, and family attitudes toward telemedicine alternatives.A survey was offered pre-consult to all families who attended pediatric urology and general surgery outpatient clinics over a three-month period.A total of 1032 of 1574 families screened participated (66.0%). Less than half (18.5%) of participants traveled over 200 km, and 32.9% spent over 4 hours in transit, round-trip. The proportion of participants who spent over $50 on travel and ancillary expenses was 33.0%. In 74.0% of families, 1 or more adults missed work. The proportion of families who perceived costs as somewhat high or high was 29.1%. Perceived cost was positively correlated to distance traveled, money spent, and missed work (p0.01). Most were comfortable with medical communication using technology; and 34.3%-42.7% would avoid an in-person clinic visit utilizing email, telephone, and video conferencing. Higher perceived cost (p0.001) and distance traveled (p0.01) were only weakly associated with greater willingness to substitute a clinic visit with video conferencing.Many families face high costs related to routine outpatient clinical visits, and there is a substantial willingness by them to access telemedicine alternatives, rather than the traditional face-to-face clinical visit.

Introduction: Circumcision is one of the most widely performed procedures in the world. One of the indications for circumcision is lichen sclerosis (LS). The natural history of LS in children is not as well-documented as in adult patients. Surgeons use the appearance of the foreskin or meatus to predict the diagnosis of LS.1 Indeed, if the diagnosis of LS is made in childhood, does it change management in the long-term? Pathological analysis of the excised foreskin is routinely done if there is suspicion of LS. Our aim is to assess the concordance between the clinical and pathological diagnosis of suspected LS and to assess the need for sending the foreskin for pathological examination.Methods: We conducted a retrospective chart review of 64 of 420 boys who underwent circumcision in a tertiary children’s hospital from June 2005 to June 2014, and who had their foreskin sent for pathology due to the clinical suspicion of LS. Demographics, presenting symptoms, presumed clinical diagnosis, pathological findings, and followup data were collected and analyzed. Results: Over the review period, 64 patients underwent circumcision for presumed LS. The mean age of the children was 9.7 years (range 3‒16.5). All the children who had circumcision for presumed LS diagnosis were symptomatic. LS was confirmed in 47 of 64 foreskins (73.5%). Balanitis xerotica obliterans (BXO) was clinically suspected in 40 (85%) of the 47 patients. The mean followup was 10 months (range 1–15), with seven recurrences (15%) during that period. The recurrences required revision surgery in two patients and five were managed with steroids only. Conclusions: In our series, the clinical diagnosis correlated with the pathological diagnosis in most cases. A clinical suspicion of LS without routine foreskin pathological assessment will reduces the overall cost to the healthcare system. Appropriate counselling of the patient/parents and their primary caregiver is imperative, as recurrence is common.

Background: Hydronephrosis (HN) is an imaging state affected by multiple factors, including: hydrodynamic inflow (e.g., hydration), hydrodynamic outflow (e.g., obstruction) and renal tissue compliance (e.g., elasticity). Changes in the degree of HN significantly influence clinical and surgical decision-making. Without standardized assessment, there may be risk of false positive/negative changes in degree of HN. We hypothesize that the degree of hydronephrosis seen on ultrasound is impacted by the state of relative hydration at the time of the study. Objective: To determine if the degree of HN seen on renal ultrasound (US) is impacted by …

In pediatric RT, donor allograft size often exceeds the expected recipient norms, especially in younger recipients. An "oversize" graft might not only present a technical- and space-related challenge, but may possibly lead to increased demands in perioperative volume requirements due to the disparity between donor and recipient in renal blood flow. We evaluated transfusion practices at a single tertiary institution with special consideration of kidney graft size, hypothesizing that oversize graft kidneys might lead to a quantifiable increased need of blood transfusion in smaller recipients. Retrospective analysis of all patients who underwent pediatric RT from January 2004 to June 2014 at a tertiary pediatric centre was performed. Variables analyzed included patient age, weight, pre- and postoperative Hb concentration, graft size, EBL, amount of intraoperative blood transfusion, and preoperative use of erythropoietin. Based on graft size in relation to patient's age, a SMR and an OvR were identified. A subcohort of age-matched pairs was used to allow for comparison between groups. We calculated the expected procedure- and transfusion-induced changes in Hb and compared these changes to the observed difference in pre- vs postoperative Hb to assess the influence of graft size on transfusion requirements. RT was performed in 188 pediatric recipients during the study period. In the matched cohort, percentage of transfused patients during transplantation in the OvR group was more than double compared with SMR (89% vs 39%, P

Objective To determine the differences in perioperative and postoperative outcomes between laparoscopic-assisted approach and open approach for appendicovesicostomy operations without concomitant procedures, among patients with prior abdominal surgeries. Methods A Research Ethics Board-approved retrospective cohort study was performed to review all laparoscopic-assisted vs open appendicovesicostomy procedures performed without concomitant procedure in patient with prior abdominal surgeries from January 2000 to January 2015 in our institution. We evaluated the baseline characteristics, perioperative and postoperative outcomes such as operative time, hospital stay, estimated blood loss, complications, and long-term continence. Fisher exact test and Mann-Whitney U test were performed to compare the 2 surgical groups. Results A total of 23 patients (11 open and 12 laparoscopic-assisted) were included. Baseline characteristics between the groups were not significantly different. Procedure time was comparable (Open median 289 [interquartile range {IQR} 230-335] vs laparoscopic-assisted median 231 [IQR 170.5-284]; P = .090). Significantly lower estimated blood loss and shorter hospital stay were noted among the laparoscopic-assisted group (median 100 [IQR 75-200] vs 50 [IQR 25-100], P = .048; median 6 [IQR 5-8] vs 3.5 [IQR 3-5], P = .029; respectively). Complication rates of Clavien-Dindo class 3 in both groups were not significantly different (6 of 11 vs 8 of 12, P = .68). Stomal stenosis and continence rates were also not significantly different between the groups (36.4% vs 25%, P = .667 and 63.3% vs 83.3%, P = .371). Conclusion Laparoscopic-assisted approach to create catheterizable stomas among patients with prior abdominal surgeries seems to be comparable to the open technique with the advantage of lower blood loss and shorter hospital stay.

A growing body of evidence suggests that it is safe to ligate the ureter of poorly functioning renal moieties during renal transplantation. We present clinical outcomes and data on hydronephrosis progression in pediatric cases associated with ectopic ureters and obstructive ureteroceles.We prospectively collected data for 35 consecutive patients (23 females and 12 males) who underwent ureteral clipping between February 2011 and August 2016. Patients were divided into 4 groups consisting of 1) duplex system with ectopic ureter (45.7%), 2) duplex system with a large ureterocele (11.4%), 3) other duplex system (8.6%) and 4) single system kidneys (34.3%). Patients were followed for clinical outcomes and hydronephrosis trends. Comparisons included preoperative and postoperative anteroposterior diameter, maximal ureteral diameter and ureterocele size.Median age at surgery was 59 months (IQR 11 to 120, range 5 to 216). Median ± SD operative time was 108.9 ± 31.1 minutes (range 20 to 180) and median length of stay was 7.5 hours (IQR 6 to 19, range 5 to 336). Immediate resolution of urinary incontinence was observed in all 16 ectopic ureter cases. After a median ± SD followup of 20.8 ± 13.8 months (IQR 8.5 to 30, range 6 to 50) 97.2% of the patients remained asymptomatic. No significant differences were observed between initial and last anteroposterior diameter measurements except in group 1 (p = 0.001). All ureteroceles demonstrated a significant decrease in median ± SD size after clipping (from 2.7 ± 0.41 to 0.53 ± 0.92 cm, p = 0.003). Pyonephrosis developed in 1 patient, who underwent laparoscopic nephrectomy.Ureteral clipping appears to be a reasonable, safe and effective option for pediatric patients in the reported settings, with the potential to be simpler and quicker than extirpative or reconstructive procedures.

Limited efforts have been made in assessing the qualities of clinical practice guidelines (CPGs) on cryptorchidism (UDT). This appraisal aims to determine the quality of recent CPGs on the management of UDT.After systematic literature search, all English-based CPGs providing recommendations for the management of UDT from 2012 to 2017 were reviewed. Using the AGREE II (Appraisal of Guidelines and Research Evaluation) instrument, eligible CPGs were independently appraised by 5 reviewers. Domain scores were calculated and summarized. Intraclass coefficient (ICC) was used to assess for interrater reliability.Five CPGs from Agency for Healthcare Research and Quality (AHRQ), American Urological Association (AUA), British Association of Pediatric Surgeons/British Association of Urologic Surgeons (BAPS/BAUS), Canadian Urological Association (CUA), and European Association of Urology/European Society for Pediatric Urology (EAU/ESPU) were assessed. There was a solid agreement (ICC: 0.749) among the 5 reviewers (p0.001). Most recommendations for diagnostic and treatment approaches were consistent across CPGs. For most guidelines, the domains of 'clarity of presentation,' 'scope and purpose,' 'stakeholder involvement,' and 'rigor of development' were high, while 'applicability' was low.Most guidelines on UDT score high in the AGREE II domains and have consistent recommendations. To improve the 'applicability' domain, future guidelines should improve on aspects that facilitate implementation of the recommendations.Systematic review.V (based on the lowest level of evidence utilized by the assessed guidelines).

Introduction: We sought to compare the surgical outcomes of hypospadias repair with correction of inguinal pathology using a single penile incision vs. conventional approach using two incisions.Methods: This is a retrospective study that reviewed all patients who underwent concurrent surgical repair for both hypospadias and inguinal pathologies between January 2003 and November 2015. Patients were classified into Group A, conventional (inguinal or scrotal and penile incision) approach; or Group B, single penile incision approach. Baseline characteristics, including age, degree of hypospadias, type and laterality of inguinal pathology, operative time, and surgical outcomes, were collected. Between groups, variable comparisons were analyzed using Mann-Whitney U-Test and Fisher-exact test. Statistical significant set at

Quality improvement and patient safety (QIPS) has become increasingly important in the practice of medicine, particularly since the Institute of Medicine's report, "To Err is Human." Despite surgery having been initially at the forefront in instituting QIPS, there has been a lag in promoting its importance until recently. A short history of QIPS is presented along with an introduction to the SQUIRE guidelines used for standardizing QIPS publications. As surgeons we are becoming even more accountable in promoting value in health care. As such, knowledge of QIPS will become an increasingly important component of our future practices and publications.

Objective A simplified approach for the surgical management of symptomatic ectopic ureters, associated with a non-functioning upper moiety, with laparoscopic ureteric clipping is presented in this research paper. Materials and methods Prospectively collected data on nine consecutive girls with ectopic ureters associated with urinary incontinence who underwent laparoscopic clipping between February 2011 and December 2013. Surgical technique consisted of cystoscopy and insertion of ureteral catheter in the lower pole ureter to aid in identification and clipping of the ectopic ureter, which was achieved by standard trans-peritoneal laparoscopy. Results Median age was eight years (range 4–17 years). Diagnosis was based on clinical findings, which were supported by: ultrasound (US), nuclear scans and magnetic resonance urography in Cases 9, 8 and 5, respectively. Bilateral complete duplication was present in two patients; the combination of cystoscopy and laparoscopy allowed adequate identification of the ectopic ureter causing incontinence in both. All nine patients were immediately dry after surgery and remain asymptomatic after a maximum follow up of 27 months. Eight out of nine patients had developed some degree of asymptomatic upper pole hydronephrosis on follow-up US. Conclusion Laparoscopic clipping holds promise as a simple alternative to other more-complex surgical procedures in the treatment of incontinence due to an ectopic ureter. Despite favorable and encouraging initial results, further follow up is warranted in order to determine the fate of expected associated upper-pole hydronephrosis.

There is a lack of national data describing the demographics and nature of pediatric renal trauma. We used the National Trauma Data Bank to analyze mechanisms and grades of injury, demographics and treatment characteristics of pediatric renal trauma cases.Renal injuries were identified by Abbreviated Injury Scale codes and converted to American Association for the Surgery of Trauma renal injury grades. Patients were stratified by age (0 to 1, 2 to 4, 5 to 14 and 15 to 18 years) for more specific analyses of mechanisms and grades of injury. Data reviewed included mechanisms and grades of renal injury, demographics, and setting and type of treatment.A total of 2,213 pediatric renal injuries were converted to American Association for the Surgery of Trauma grade. Mean ± SD age at injury was 13.7 ± 4.4 years, with 2,089 patients (94%) being 5 to 18 years old. Of the injuries 79% were grade I, II or III. Penetrating injury accounted for less than 10% of all pediatric renal injuries. A majority of patients (57%) were admitted to university hospitals with a dedicated trauma service (73%) and only 12% of patients were admitted to a pediatric hospital. A total of 122 nephrectomies (5.5%) were performed.Most renal trauma in children is low grade, is blunt in nature and occurs after age 5 years. The majority of these cases are managed at adult hospitals. Although most patients are treated conservatively, the rate of nephrectomy is 3 times higher at adult hospitals than at pediatric centers.

The child with lower urinary tract symptoms, in the absence of neurological abnormalities, represents an increasingly common source of referral to the pediatric urologist. Patients with lower urinary tract dysfunction are at increased risk of urinary tract infections (UTIs), which can be a potential source of expense, inconvenience, and even morbidity and renal impairment. Many of these patients present with concomitant bowel dysfunction in the form of constipation and encopresis. As a result, the term “bladder and bowel dysfunction” (BBD) has been introduced and refers to the close relationship of the bladder and bowel and their interrelated disturbances. An in-depth understanding of BBD and its role in recurrent UTI is the key to treatment and prevention of further morbidity in these patients. We present an updated review of the literature on BBD and UTIs in children, including its pathogenesis, evaluation, and management.

Background/Purpose A uniquely Ugandan method of holding surgical "camps" has been one means to deal with the volume of patients needing surgery and provides opportunities for global partnership. Methods We describe an evolved partnership between pediatric surgeons in Uganda and Canada wherein Pediatric Surgical Camps were organized by the Ugandans with team participation from Canadians. The camp goals were to provide pediatric surgical and anesthetic service and education and to foster collaboration as a way forward to assist Ugandan health delivery. Results Three camps were held in Uganda in 2008, 2011, and 2013. A total of 677 children were served through a range of operations from hernia repair to more complex surgery. The educational mandate was achieved through the involvement of 10 Canadian trainees, 20 Ugandan trainees in surgery and anesthesia, and numerous medical students. Formal educational sessions were held. The collaborative mandate was manifest in relationship building, an understanding of Ugandan health care, research projects completed, agreement on future camps, and a proposal for a Canadian–Ugandan pediatric surgery teaching alliance. Conclusion Pediatric Surgical Camps founded on global partnerships with goals of service, education, and collaboration can be one way forward to improve pediatric surgery access and expertise globally.

Hypospadias repair is a commonly performed procedure. Little is known about decisional regret in parents who agree to proceed with this surgical reconstruction. We present data on this previously underexplored issue.We performed followup analysis of 100 couples prospectively evaluated after counseling for surgical correction of distal hypospadias in their son with assessment of complications and decisional regret 1 year after surgery. Findings were contrasted with baseline demographics, hypospadias knowledge and decisional conflict at the time of counseling.Decisional regret was found in 116 parents, including mild regret in 41.4% and moderate to severe regret in 8.6%. There was no statistically significant difference in paired regret analysis between mothers and fathers. Complications were strongly associated with decisional regret (p0.001). On regression analysis postoperative complications (OR 14.7, 95% CI 1.6-131.6), parental desire to avoid circumcision (OR 7.4, 95% CI 1.1-49.4) and initial decisional conflict level (OR 1.06, 95% CI 1.02-1.09) were statistically significant predictors of moderate to strong decisional regret. These findings remained robust after imputation strategies to address missing data. The impact of decisional conflict and preference for circumcision were significant even after excluding families who experienced complications.To our knowledge this is the first study demonstrating parental decisional regret after providing consent for surgical correction of distal hypospadias in their son. Based on the described risk factors efforts aimed at minimizing complications and counseling about foreskin preservation techniques may be prudent to ameliorate decisional regret. The novel association between decisional conflict and regret suggests that conflict assessment during counseling may help screen families at risk for postoperative regret.

Summary Introduction and objective For patients who require self-intermittent catheterization, a continent catheterizable stoma is a viable option. This patient population often has had previous abdominal surgery (PAS), a risk factor for complicated laparoscopic procedures. Therefore, the authors aim to determine whether PAS has an impact on the peri-operative outcomes of the laparoscopic-assisted Mitrofanoff procedure in children. Materials and methods A research ethics board–approved retrospective review was performed to assess peri-operative outcomes among pediatric patients who underwent laparoscopic-assisted Mitrofanoff procedures in the authors institution from May 2000 to March 2016. Patients with no PAS were compared with those with intraperitoneal PAS. Demographic/baseline characteristics and peri-operative outcomes such as operative time, estimated blood loss, hospital stay, unanticipated additional operations, stomal stenosis, and urinary continence were compared. To ensure there is no confounding based on PAS characteristics, subgroups were created to compare the recency (PAS Results Thirty-four patients (15 no PAS and 19 PAS) were included in the analysis. No significant difference in demographics and baseline characteristics was noted between the patient groups. The median age was 6.5 years (interquartile range [IQR] 4.8–14.0) and 9.9 years (4.2–14.3), respectively (NS). Peri-operative outcomes of operative time, estimated blood loss, and hospital stay were similar between the PAS and no PAS groups. There was no statistical difference in complications requiring surgical intervention (n = 3, 20.0%; n = 9, 47.4%). The median follow-up period was 25.9 (IQR 7.7–47.2) months and 28.0 (IQR 13.0–53.0) months, respectively (NS). Patients with VP shunts as their only PAS had higher estimated blood loss compared with no PAS group (50 [IQR 25-150], 25 [IQR 25-50], respectively) but without other differences in peri-operative outcomes. Discussion Findings support the use of a minimally invasive approach in this patient population as it is feasible, comparable, and safe but with careful consideration for risk factors that may predispose PAS patients to postsurgical complications requiring intervention. Although limited by small sample size, this study provides valuable insight into performing laparoscopic operations in children who have undergone prior surgeries and invites future studies to compare the outcomes between patients undergoing open, pure laparoscopic, and robotic-assisted laparoscopic Mitrofanoff procedures for children with PAS. Conclusion Laparoscopic-assisted Mitrofanoff creation may be safely performed in children with PAS. Summary Table . Comparison of peri-operative outcomes. Laparoscopic Mitrofanoff procedure patients (n = 34) No previous abdominal surgery (n = 15) Previous abdominal surgery (n = 19) P-value N (%), median (IQR) N (%), median (IQR) Operative time (min) 267 (255–340) 255 (196–292) 0.256 Estimated blood loss (mL) 25 (25–50) 50 (25–100) 0.089 Conversion to open surgery 0 (0.0) 0 (0.0) – Length of stay (days) 4 (4.0–5.0) 4.0 (3.0–6.0) 0.302 Follow-up (months) 25.9 (7.7–47.2) 28.0 (13.0–53.0) 0.477 Stoma continence 13 (81.3) 17 (89.5) 0.634 Patients with stoma stenosis 2 (13.3) 4 (21.1) 0.672 Patients with complications requiring intervention (Clavien-Dindo classification ≥3 complication) 3 (20.0) 9 (47.4) 0.152 IQR, interquartile range.

Summary Introduction Ischemia times in kidney transplantation have shown to be predictive for future graft function. Preservation solutions and anticoagulation protocols have improved the management of pediatric kidney transplantation. Nonetheless, there is no current tool for intra-operative graft monitoring. The aim of this project is to present a novel technique for intra-operative real-time assessment of graft perfusion using a non-invasive infrared camera. Methods Prospectively, the authors included 10 pediatric patients. Surgical procedure followed their institutional protocol. Infrared imaging was captured at graft preparation, vascular anastomosis, unclamping, and at 30 s, 1, 5, and 10 min after unclamping. Analyzed variables included type of transplant, ischemia and procedure times, type of anastomosis, and results of doppler/ultrasound. Postoperative variables included creatinine levels during first 72 h. Any complications were also recorded. Delta analysis was calculated to establish the variation of temperature after unclamping. Results Average age at transplant was 9.9 years. Five cases were living donor transplants. Mean overall ischemia time was 395.6 (SD 64.4 min). Two patients had poor graft perfusion after unclamping. Of those, one had torsion of the arterial anastomosis and the other was a graft from a donor that required cardiopulmonary resuscitation for 45 min. Thermal imaging showed a correlation of 0.318 between graft temperature change and creatinine decrease. Cut-off delta for temperature for good reperfusion was above 0.2 at 1 min Conclusion Real-time infrared imaging shows to be a promising option for non-invasive graft perfusion monitoring. Initial results show good correlation between intra-operative temperature changes, graft perfusion, and postoperative graft function. Download : Download high-res image (432KB) Download : Download full-size image Summary Fig . A) Thermal image of kidney graft after unclamping. (B) Digital reconstruction of the kidney graft after unclamping.

Summary Introduction While voiding cystourethrogram (VCUG) is a widely-accepted test, it is invasive and associated with radiation exposure. Most cases of primary vesicoureteral reflux (VUR) are low-grade and unlikely to be associated with acquired renal scarring. To select patients at greatest risk, in 2011 the American Academy of Pediatrics (AAP) published guidelines for evaluation of children ages 2 - 24 months with urinary tract infections (UTIs). Similarly, in 2010 the Society for Fetal Urology (SFU) published guidelines for patients with hydronephrosis. Herein a prospectively-collected database was queried through the Institute of Clinical Evaluative Sciences (ICES), exploring trends in VCUG ordering within the Ontario Health Insurance Program (OHIP), which guarantees universal access to care. Material and methods A dedicated ICES analyst extracted data on all patients younger than 18 years in Ontario, Canada, with billing codes for VCUG and ICD-9 codes for VUR, from 2004-2014. The baseline characteristics included patient age, gender, geographic region, specialty of ordering provider and previous diagnoses of UTI and/or antenatal hydronephrosis to determine the indication for ordering the test. Of these, patients were subsequently incurred OHIP procedure codes for endoscopic injection or ureteral reimplantation. Patients who had a VCUG in the setting of urethral trauma, posterior urethral valves, and neurogenic bladder were excluded. Results and discussion Trend analysis demonstrated that the total number of VCUGs ordered in the province has decreased over a decade (Figure 1), with a concurrent decrease in VUR diagnosis. On multivariate regression analysis, the decrease in VCUG ordering could not be explained by changes in population demographics or other baseline patient variables. Most VCUGs obtained per year were ordered by pediatricians or family physicians (mean 2,022+523.8), compared with urologists and nephrologists (mean 616+358.3). Interestingly, while the rate of VCUG requests decreased, the annual number of surgeries performed for VUR (endoscopic or open) did not show a significant reduction over time. Conclusions We present a large population-based analysis in a universal access to care system, reporting a decreasing trend in the number of cystograms and differences by primary care versus specialist providers. While it is reassuring to see practice patterns favorably impacted by guidelines, it is also encouraging to note that the number of surgeries has remained stable. This suggests that patients at risk continue to be detected and offered surgical correction. These data confirm previous institution-based assessments and affirm changes in VCUG ordering independent of variables not relevant to the healthcare system, such as the insurance status.

PURPOSE RT remains the best available strategy for addressing stage 5 chronic kidney disease in children and adolescents. Technical aspects of the procedure can have a clear impact on complications and health of the allograft, including DGF. Immediate optimal perfusion is paramount, thus choosing a target vessel has to take into account the flow demands imposed by an adult-size kidney in a proportionally smaller recipient. Herein, we explore the hypothesis that vascular anastomosis location can impact DGF adjusting for patient age and body size. METHODS Retrospective review of a single institution referral center transplant database, including information on 156 patients. We collected data on patient characteristics (age, height, BSA, gender, preoperative need for dialysis), donor source (deceased vs living), WIT/CIT, hemodynamics during the procedure, use of inotropes or diuretics, and location of the arterial and venous anastomoses. The primary outcome, DGF, was assessed by measuring the ttNC (in days), adjusting for age and BSA. RESULTS Location of the arterial anastomosis was clearly impacted by age and donor size (Figure 1A). On univariate analyses, longer ttNC was associated with deceased vs living donor (11.8 ± 11.5 and 4.3 ± 5.0; P