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Objective Reducing readmissions has become a focal point to increase quality of care while reducing costs. We report all-cause unplanned return visits following urologic surgery in children at our institution. Materials and methods Children undergoing urology procedures with returns within 30 days of surgery were identified. Patient demographics, insurance status, type of surgery, and reason for return were assessed. Results Four thousand and ninety-seven pediatric urology surgeries were performed at our institution during 2012, with 106 documented unplanned returns (2.59%). Mean time from discharge to return was 5.9 ± 4.9 days (range, 0.3–24.8 days). Returns were classified by chief complaint, including pain (32), infection (30), volume status (14), bleeding (11), catheter concern (8), and other (11). Circumcision, hypospadias repair, and inguinal/scrotal procedures led to the majority of return visits, accounting for 21.7%, 20.7%, and 18.9% of returns, respectively. Twenty-two returns (20.75%) resulted in hospital readmission and five (4.72%) required a secondary procedure. Overall readmission rate was 0.54%, with a reoperation rate of 0.12%. Conclusions The rate of unplanned postoperative returns in the pediatric population undergoing urologic surgery is low, further strengthening the argument that readmission rates in children are not necessarily a productive focal point for financial savings or quality control.

Purpose: We determined whether radiographic evaluation is indicated in all children with traumatic hematuria.Materials and Methods: We retrospectively reviewed the records of 110 children from 1992 to 1999 diagnosed with blunt trauma and hematuria. It is routine practice at our emergency department to perform radiographic evaluation in all children with hematuria regardless of the degree. Each chart was evaluated for the mechanism of injury, degree of hematuria, hypotension, imaging studies, renal injury, renal anomalies, associated injuries and outcome.Results: A total of 110 patients 1 to 18 years old (mean age 9) were identified. The most common mechanism of injury was motor vehicle accident in 37 children (34%), followed by a fall in 32 (29%). Grades I to V renal injury was present in 5, 6, 6, 6 and 1 cases, respectively (22%), while 1 (0.9%) involved ureteropelvic junction avulsion. No child had renal pedicle injury. In 9 patients renal anomalies were detected incidentally. Of the 110 patients 101 un...

Purpose: Acute urinary retention is relatively infrequent in children. There are a variety of causes that are poorly defined in the literature, and they differ greatly from those seen most frequently in adults. We review our experience with pediatric patients presenting with urinary retention to 2 major metropolitan children’s hospitals.Materials and Methods: Records from Egleston and Scottish Rite Hospitals for Children were reviewed for a 6-year period for the diagnosis of urinary retention. Urinary retention was defined as inability to empty the bladder volitionally for greater than 12 hours with a volume of urine greater than expected for age ([age in years + 2] × 30 cc) or a palpably distended bladder. All cases resulting postoperatively and believed secondary to surgical dissection, narcotic use or immobility, and children previously diagnosed with chronic neurological disorders and voiding dysfunction or with reduced mental status were excluded from study. The majority of these encounters were emer...

The surgical management of stress urinary incontinence in the pediatric population includes various surgical techniques of which the simplest is outpatient transurethral or periurethral injection of a bulking agent. Currently purified bovine dermal collagen cross-linked with glutaraldehyde (Contigen) is the only Food and Drug Administration approved bulking agent available. Patients with stable detrusor function are ideal candidates. We review our initial experience with children.Between January 1994 and June 1995, 23 boys and 9 girls 4 to 17 years old (mean age 9) consecutively underwent submucosal bladder neck injection with cross-linked bovine dermal collagen. Incontinence was secondary to spinal dysraphism in 24 patients, complete epispadias in 4, classic bladder exstrophy in 3 and neurogenic bladder secondary to a sacral teratoma in 1. Preoperative video urodynamics documented intrinsic sphincteric deficiency in all patients with leak point pressure of 15 to 60 cm. water (mean 37). Injection volumes ranged from 2.5 to 17 cc (mean 10). Continence results were defined as dry-requiring no protection while on a 4-hour clean intermittent catheterization program, good-improved but requiring 1 to 5 pads daily and failure-no postoperative improvement or still requiring diapers.Of the children with neurogenic bladder 20% became dry following the first injection and an additional 28% had a good result. Furthermore, of the 6 children with exstrophy or epispadias who underwent a Young-Dees-Leadbetter procedure 50% were dry and 17% had a good result after the first injection. Complications were limited to a febrile urinary tract infection associated with urinary retention in 1 patient and transiently worse continence in 2.Despite the limited success rate, we believe that transurethral collagen injection therapy has a viable role in the treatment of intrinsic sphincteric deficiency in select pediatric patients, particularly since the procedure has low morbidity and can be performed on an outpatient basis. Preoperative counseling should be given with realistic expectations.

We performed a critical retrospective analysis of the records of all consecutive children who underwent sling cystourethropexy at our institutions. We particularly assessed the incidence and outcome in children who underwent enterocystoplasty in addition to a sling procedure.Between May 1992 and August 1994, 24 girls and 15 boys 4 to 17 years old (mean age 9) consecutively underwent 1 of 4 techniques of sling cystourethropexy for stress urinary incontinence using rectus fascia via an abdominal approach. Diagnoses included spinal dysraphism in 34 patients, spinal trauma in 2, cecoureterocele in 1, epispadias in 1 and classic bladder exstrophy in 1. All children underwent preoperative video urodynamics. In 4 patients only a sling procedure was performed (group 1), while in 9 others a sling procedure was performed after enterocystoplasty (group 2). In 26 patients a sling procedure and concomitant enterocystoplasty were performed (group 3).Patients who underwent concomitant enterocystoplasty had more hyperactive preoperative urodynamics than those who did not. Postoperative continence was subcategorized in terms of patient age, sex, diagnosis (neurogenic versus nonneurogenic), preoperative video-urodynamics, surgeon technique, group (that is with or without cystoplasty) and type of enterocystoplasty (that is stomach versus ileum). Of these factors only concomitant enterocystoplasty was predictive of postoperative dry continence (73% of group 3, 33% of group 2 and 25% of group 1). In most patients who were not dry postoperative video urodynamics suggested suboptimal outlet resistance overcome by a hyperactive detrusor. No patient had postoperative upper tract deterioration.These results suggest that concomitant enterocystoplasty should be critically considered for pediatric patients undergoing sling cystourethropexy.

Purpose: We identified the urological anomalies seen in patients with Down syndrome.Materials and Methods: We reviewed the literature on Down syndrome and its associated genitourinary pathology.Results: Associated defects have been reported throughout the genitourinary tract. The most common renal anomalies seen are renal hypoplasia, obstructive uropathy and glomerular microcysts. Decreased creatinine clearance has also been noted. Developmental anomalies, such as megaureter and vesicoureteral reflux, have been reported. Dysfunctional voiding and urinary retention have been found in these patients. Posterior urethral valves and hypospadias have also been seen. The testicular abnormalities most frequently reported are cryptorchidism, testicular cancer and infertility.Conclusions: Improved understanding and identification of the various urological anomalies associated with Down syndrome will aid in the care of these patients. In addition, an awareness of perioperative issues will further facilitate ...

Ten neonates and infants with 11 ectopic ureteroceles prospectively underwent transurethral puncture as the primary form of therapy. Of the 10 patients 6 had a prenatal diagnosis of uropathy and 4 presented postnatally with urinary tract infection. One patient had bilateral single system ectopic ureteroceles and 9 had a single ectopic ureterocele in a duplex system. Significant associated ipsilateral and/or contralateral urological pathology was noted in addition to the ectopic ureterocele in 7 patients. Transurethral puncture adequately decompressed 10 of the 11 ectopic ureteroceles (91%) and improved drainage of nonureterocele moieties in 3 cases. Iatrogenic reflux was found in 3 of the 11 ureterocele ureters. Urinary tract infection developed in 6 infants (4 with fever). Of the 10 patients 8 (80%) eventually required secondary surgical intervention because of recurrent urinary tract infections, persistent or iatrogenic reflux, or unresolving hydronephrosis. Although transurethral puncture rarely constitutes definitive treatment for ectopic ureterocele, there appears to be immediate benefit in cases of bilateral hydronephrosis or significant ipsilateral lower pole hydronephrosis. Decompression of the ureterocele is reliably obtained but it seldom obviates the need for more definitive reconstruction.

The association of limb loss with antenatal urologic intervention has recently been questioned. At present, no such cases have been reported. We present a case of antenatal vesicoamniotic shunting for posterior urethral valves in which the shunt entered the right lower extremity and coursed subcutaneously over the femoral triangle and inguinal canal and into the bladder. Although the limb was intact, we present images and a discussion of the potential for extremity injury with antenatal urologic intervention.

In 8 children with cystometric evidence of bladder instability and marked systemic side effects to oral oxybutynin we investigated the efficacy of intravesical instillation and compared the pharmacokinetics of both routes of delivery. In addition, 4 healthy dogs underwent intravesical instillation for pharmacokinetic studies. Intravesical oxybutynin was well tolerated, efficacious and rapidly absorbed, resulting in plasma concentrations markedly higher than after oral administration. In only 2 patients did this method of instillation result in side effects, and both had previously undergone bladder augmentation. This lack of significant systemic side effects despite high plasma concentrations suggests that a metabolite may be generated after oral administration that is responsible for the side effects. These studies demonstrate that the mode of administration affects the mechanism of action, side effects, pharmacokinetics and metabolism of oxybutynin, and that intravesical instillation is clinically effective and results in minimal side effects.

We report 2 cases of unilateral Wilms tumor associated with contralateral intralobar nephrogenic rests. This disease complex may be confused with bilateral Wilms tumor, which may alter therapeutic decision-making.

We report on 30 consecutive patients (mean age 9 years) who underwent gastrocystoplasty (21) or received a continent urinary reservoir with stomach (9). A successful outcome, defined as complete urinary continence for intervals greater than 3hours, preservation or improvement of the upper tracts and renal function, and normal electrolyte and acid base balance, was achieved in 90% of the patients who received continent urinary reservoir and 72% of those who underwent gastrocystoplasty. Urodynamic data were obtained in 17 patients in the gastrocystoplasty group and 7 in the continent urinary reservoir group at a mean of 6 months postoperatively. Metabolic alkalosis associated with hypergastrinemia occurred in 2 children. Partial excision of the gastric segment was necessary in 1 patient refractory to medical treatment.

The pathophysiology of fetal urinary obstruction has not been elucidated. Using a unique, reproducible and easily reversible animal preparation, we studied the acute hemodynamic and endocrinological responses to partial fetal bladder obstruction in 16 ovine fetuses at 115 days of gestation (term 147 days). After partial obstruction blood pressure and renal weight increased significantly for at least 72 hours. Renal blood flow trended upwards, particularly from 24 to 72 hours, although this change was not statistically significant. Plasma renin activity was significantly increased during the first 24 hours after obstruction but it returned to baseline thereafter. Plasma cortisol or catecholamine concentrations remained unchanged. The time course and pattern of hemodynamic changes in this fetal sheep preparation of partial urinary obstruction differ significantly from those reported in other preparations.

Testicular biopsy samples from 3 boys 5.5, 6 and 7 months old with the prune belly syndrome and intra-abdominal testes were examined morphologically and phenotypically for the presence of alkaline phosphatase. Findings were compared with those in age-matched autopsy controls. All patient specimens demonstrated atypical germ cells with large nuclei and prominent nucleoli, and intense alkaline phosphatase staining localized to the cytoplasmic membrane. The presence of these testicular abnormalities suggests that a developmental arrest is fundamental to the pathogenesis of the undescended testes associated with the prune belly syndrome. The similarity of the histological appearance of these testes to that of intratubular germ cell neoplasia suggests that long-term followup of these patients for the development of invasive germ cell tumors is important.

Histological findings of muscle, collagen and elastin in obstructed fetal bladders were compared with those of age-matched controls. Muscle thickness was markedly increased, however, the relative collagen content in the muscle was decreased. The ratio of thick-to-thin collagen fibers was markedly increased as was the amount of elastin. These findings suggest that the ratio of thick collagen to elastin has an important role in determining the compliance of the obstructed fetal bladder.

Purpose: We determined the need for urological screening in children with neurofibromatosis.Materials and Methods: Of 96 children with neurofibromatosis treated at our institution 6 (6.2 percent) had a symptomatic tumor that affected the urinary tract.Results: There were 5 plexiform neurofibromas and 1 prostatic rhabdomvosarcoma. Five children had a palpable abdominal mass and 3 required urinary diversion.Conclusions: Since most morbidity resulted because tumors were advanced by the time symptoms developed, we suggest that children with neurofibromatosis be screened annually with medical history, physical examination, urinalysis and serum chemistry studies for tumors that affect the urinary tract.

Prenatal ultrasound scanning of a 20-year-old woman at 17 weeks of gestation revealed findings suggestive of bladder outlet obstruction, including bladder distension, dilated bilateral ureters, urinary ascites, and oligohydramnios. Vesicoamniotic shunts were placed with decompression of the bladder and correction of the amniotic fluid levels. Labor was induced at 36 weeks' gestation. At birth, the infant was noted to have prune-belly syndrome with severe urethral hypoplasia, a variant usually associated with a poor prognosis, necessitating vesicostomy for bladder drainage. We present a case of a patient with prune-belly syndrome and bladder outlet obstruction in whom early intervention resulted in an excellent outcome with preservation of renal and pulmonary function.