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Introduction: The first description of epididymal cysts in children appears from a 1976 case study. Since then, there have been a total of 24 indexed publications relating to pediatric epididymal cysts. Risk factors that may exist for children presenting with epididymal cyst remain unknown, as has the best method of management. And there have not been any studies looking at the cost implications of this diagnosis. The aim of this study was to assess the incidence, clinico-demographics, outcomes, and costs of epididymal cysts in pre-pubertal boys compared with a post-pubertal epididymal cyst cohort, and to assess whether this cohort requires continued surveillance. Methods: Our institutional ultrasound (US) database was searched for all scrotal US. From these, a filtered, institution review board-approved search was performed for any reports containing the word “cyst.” These were then cross-referenced with a retrospective chart review (October 2006 to September 2017). Clinico-demographics, cyst characteristics, and outcomes were analyzed for both pre- and post-pubertal boys using descriptive and non-parametric statistical methods. Results: Of 4508 boys undergoing scrotal US during the study period, 191 were indicated to contain cysts. This was manually reduced to 109 scans (2.4%) that met inclusion criteria (85 pre-pubertal; 24 post-pubertal). Thirty-one scans were ordered by urology, including all those with abnormal testicular echotexture (n=5). The average age of the post-pubertal cohort was 15.8 years, compared with 3.8 years in the pre-pubertal cohort. Most (70.5%) epididymal cysts were incidental. There was no difference between the pre- and post-pubertal cohorts in terms of presence of hydrocoeles (p=0.9), symptoms (p=0.9), ordering service (p=0.61), rate of resolution (4.2% vs. 8.2%; p=0.68), or length of followup (4 vs. 4.5 years; p=0.44). Pre-pubertal cysts were significantly smaller in size (3.35 vs. 14.52 mm; p=0.025) and more likely to trigger repeat scanning (67 vs. 10; p=0.008). There were no operative interventions and no subsequent clinical deterioration occurred with observation. At a cost of $71.10 CAD per US, $15 002.10 CAD was expended on epididymal cyst surveillance in direct cost to the healthcare system. Conclusions: Epididymal cysts are comparable in both pre- and post-pubertal boys and can be safely managed non-operatively without the use of continued US surveillance or urological referral. The higher than expected rate of detection may be a result of the improved ultra-resolution of modern scanners. These children should not require continued followup with repeat surveillance imaging solely for epididymal cysts and could be managed in the primary care setting as part of routine clinical examination

Background Many primary care physicians order an ultrasound (US) before referral to specialist care for suspected undescended testis; however, the value of this practice is questionable. Objective To determine the proportion of boys referred for suspected undescended testis who had accompanying US, the cost of this practice and the accuracy of US for testis localization when compared with physical examination by a pediatric urologist. Methods This was a retrospective chart review at a pediatric urology service, including all patients referred for suspected undescended testis from 2008 to 2012. We determined the cost of US ordered, and calculated Cohen's kappa, sensitivity and specificity, and positive and negative predictive value. Results We identified 894 eligible patients; 32% (289/894) were accompanied by US. In 77% (223/289), the urologist was able to palpate the testis: 51% (147/289) had a normal/retractile testis and 26% (76/289) had a palpable undescended testis. At a cost of 71.10 CAD per US, 20 547.90 CAD was expended on this practice. Of the 223 patients with palpable testes, we were able to gather detailed US and physical examination results for 214 patients. Cohen's kappa was 0.06 (95% CI -0.005, 0.11; P = 0.10). US had 92.8% sensitivity (95% CI 84.1, 96.9%) and 15.2% specificity (95% CI 10.2, 21.9%) to detect an undescended testis. The positive predictive value was 34.2% (95% CI 27.8, 41.3%), while the negative predictive value was 81.5% (95% CI 63.3, 91.8%). Conclusions Referral of patients for suspected undescended testis should not be accompanied by an US study as US is not useful in these cases.

Introduction: There are a small number of reports in the literature describing bladder rupture during cystograms in children. We hypothesized that children undergoing cystograms may have their bladder overfilled during the test. We aimed to evaluate the current practice when performing cystograms in our institution, contrasting actual volume used to fill the bladder to the ageadjusted bladder capacity. Methods: We performed a retrospective review of all voiding cystourethrograms (VCUG) and radionuclide cystograms (RNC) performed at the Children’s Hospital of Eastern Ontario from 2006– 2013. Formulas used to estimate age-adjusted bladder capacity: 1) infants 1 year: capacity (mL) = (2 + age [years]) x 30 (Koff et al, 1983). Results: A total of 2411 cystograms were done (1387 VCUG; 1024 RNC) in 817 infants and 1594 children older than one year — 1113 boys and 1298 girls. Generally, bladders tended to be overfilled with 32% more volume in mL than the expected age-adjusted bladder capacity — VCUG 151 (122) mL vs. 120 (97) mL (p

Summary Introduction Children with renal cysts often undergo ultrasound (US) monitoring to identify malignant transformation or polycystic kidney disease (PKD). However, the utility of ongoing surveillance is uncertain. Objective The objective of this study was to assess the natural history of simple or minimally complex cysts and the proportion of progression to autosomal dominant polycystic kidney disease (ADPKD), autosomal recessive polycystic kidney disease (ARPKD), or malignancy. Study design The institutional review board approved retrospective chart review at one institution between 2004 and 2014. Eligible patients had ≤3 simple or minimally complex cyst(s) discovered on US without an initial diagnosis of multicystic dysplastic kidney, genitourinary malignancy, ADPKD, or ARPKD. Patient demographics and cyst details were recorded at identification and follow-up visits. Logistic regression was used to examine univariate association between diagnosis of ADPKD/ARPKD and each recorded variable. Results Eighty-seven eligible patients were identified. Twenty-two patients were identified antenatally or in the first year of life; the remaining 65 were identified at >1 year of age, median 7.6 years (interquartile range [IQR]: 4.2, 10.6). Most (60/87, 69%) had a solitary cyst at initial US. The median length of follow-up was 4.1 years (IQR: 1.9, 6.8) with median 3 follow-up US (IQR: 2, 5). Eleven patients (12.6%) were diagnosed with ADPKD. One patient (1.2%) was diagnosed with ARPKD. A median 2 follow-up US (IQR: 1, 4) procedures were performed over a median of 2.2 years (IQR: 1.0, 3.9) to obtain diagnoses of ADPKD or ARPKD. No patients developed malignancy. Discussion This study's results reveal that children identified to have a small number of simple or minimally complex renal cysts on initial US are unlikely to require additional treatment for these cysts as transformation to PKD or malignant condition is rare. Supporting this are results from literature that although simple cysts in childhood may evolve over time, most do not require any surgical or invasive treatment in the long term. Limitations include retrospective design and single institution. Conclusions Autosomal dominant polycystic kidney disease/autosomal recessive polycystic kidney disease diagnosis occurs early in follow-up evaluation in children with simple or minimally complex cysts. Malignant transformation did not occur in any patients in this study. Patient summary This study examines the natural history of renal cysts in childhood. Following up simple renal cysts routinely beyond 2–3 years after initial detection may not be optimal due to the use of limited medical resources. Summary Table . Summary of final diagnoses Final diagnosis a n (%); (95% CI) ADPKD 11 (12.6) (7.2–21.2) ARPKD 1 (1.1) (0.2–6.2) Minimally complex cyst 5 (5.7) (2.5–12.8) Renal dysplasia 1 (1.1) (0.2–6.2) Simple cyst 1 (1.1) (0.2–6.2) Renal cyst NOS b 75 (86.2) (77.4–91.9) Resolution 10 (11.5) (6.4–19.9) Malignancy 0 (0) (0–4.2) ADPKD = autosomal dominant polycystic kidney disease; ARPKD = autosomal recessive polycystic kidney disease; NOS = not otherwise specified. a Multiple diagnoses possible. b Not otherwise specified.

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Summary Background Patient-reported outcomes have the potential to provide invaluable information for evaluation of hypospadias patients, aid in decision-making, performance assessment, and improvement in quality of care. To appropriately measure patient-relevant outcomes, well-developed and validated patient-reported outcome (PRO) instruments are essential. Objective To identify and evaluate existing PRO instruments designed to measure quality of life and/or satisfaction of individuals with hypospadias that have been developed and validated in a hypospadias population. Methods A systematic search of MEDLINE, EMBASE, PsycINFO, CINAHL and Health and Psychosocial Instruments was conducted in April 2016. Two reviewers independently assessed studies and identified PRO instruments for inclusion. Data were extracted on study characteristics, instrument development and validation, and content domains. Results A total of 32 studies were included that used or described five PRO instruments: Hypospadias Objective Scoring Evaluation (HOSE), Pediatric Penile Perception Score (PPPS), Penile Perception Score (PPS), Genital Perception Scale (GPS) for adults, and GPS for children/adolescents. Instrument development and validation was limited. The majority of identified instruments focused on postoperative cosmetic satisfaction, with only one instrument considering urinary function, and no instruments evaluating sexual function and psychosocial sequelae. Conclusions While many hypospadias studies have acknowledged the necessity of a patient-reported element, few have used validated PRO instruments developed in a hypospadias population. Existing instruments to measure patient-reported outcomes in hypospadias require improvement in both the breadth of content and in their development and validation methodology.

Summary Introduction Historically, ureteroceles were surgically treated, as patients were diagnosed after developing symptoms. However, with the advance of fetal medicine, antenatal detection has provided an opportunity to look at the natural history of ureteroceles. Objectives With data derived from a retrospective chart review of patients with ureteroceles that were detected antenatally, the current study aimed to determine which group of children would be at risk for failure on active surveillance. It was hypothesized that single system ureteroceles (SSU) and male patients with duplex system ureteroceles (DSU) would be ideal for observation. Methods Outcomes were assessed by descriptive statistics. Kaplan–Meier curves were utilized to estimate median duration on active surveillance in both single and duplex cohorts. Breakthrough febrile urinary tract infection (fUTI) and surgery were determined by Cox regression in the duplex system cohort. Surgery was considered surveillance failure. Results A total of 102 patients (64 females/38 males) met the criteria: 78 (76.5%) had DSU and 24 (23.5%) SSU. The overall median observation was 1.2 years (range 0.7–3.1). Follow-up ranged from 0.3 to 11.7 years for SSU, and from 0.02 to 17.3 years for DSU. The predictors of failure of active surveillance (AS) in DSU (surgical intervention) were male gender (HR 1.8, 1.0–3.3, P = 0.037), or fUTI (HR 3.1, 1.7–5.8, P = 0.002). Predictors of fUTI were contralateral hydroureter or ipsilateral hydronephrosis ± hydroureter (OR 9.5, 1.2–71.7, P = 0.028). Interestingly, vesicoureteral reflux (VUR) was not a predictor of fUTI. The SSU patients were ideal for AS, while in DSU, surveillance was successful in 30% of patients who were primarily females without contralateral hydroureter or ipsilateral hydronephrosis ± hydroureter. However, in contradiction to the hypothesis, males were at higher risk for surgical intervention in the DSU cohort. Conclusion Active surveillance is an option for patients with antenatally detected ureteroceles, but careful long term follow up is mandatory. Parents should be advised that surgical intervention may still be necessary, particularly in males with DSU. Summary table . Patient characteristics Total, n = 102 SSU, n = 24 DSU, n = 78 Gender Female 6 58 Male 18 20 Circumcision Yes 5 4 No 11 13 Not reported 2 3 Interval on AS 252 days to 3.1 years 100 days to 11.2 years 7 days to 17.2 years Hydronephrosis of the lower moiety (ipsilateral to ureterocele) No N/A 11 Hydronephrosis only N/A 47 Hydroureteronephrosis N/A 20 Ipsilateral reflux (any grade) 4 34 Surgery Male 5 17 Female 0 36 AS, active surveillance; SSU, single system ureterocele; DSU, duplex system ureterocele; N/A, not available.

The Society for Fetal Urology introduced a subjective grading system for classifying hydronephrosis that has important implications in patient diagnosis, treatment and outcome. The grading system is frequently used to standardize the severity of hydronephrosis, and compare results among patients and centers. Despite widespread use to our knowledge no groups have investigated the reliability of the grading system since its introduction. We assessed the intrarater and interrater reliability of the Society for Fetal Urology grading system for hydronephrosis and examined levels of agreement by the degree of hydronephrosis (grades 0 to 4) and level of experience (staff vs trainee).A series of 50 pediatric renal ultrasound images from patients with a diagnosis of hydronephrosis were assessed by 4 staff individuals and 4 trainees using the Society for Fetal Urology grading system. Ultrasound images included the kidneys, ureters and bladder to be consistent with practice. After 7 to 14 days each rater repeated the assessment. The nonweighted Cohen kappa statistic was used to estimate intrarater and interrater reliability by Society for Fetal Urology grade and training level.Staff and trainee raters independently assigned Society for Fetal Urology grades to 50 patients (99 renal units). The average number of images per ultrasound was 41, including the right and left kidneys. Overall interrater agreement for staff individuals was substantial for grade 0, moderate for grades 1, 2 and 4, and only slight to fair for grade 3. Intrarater agreement was substantial to almost perfect for staff agreement (range 69% to 94%, kappa 0.56 to 0.89) and trainees (range 63% to 90%, kappa 0.48 to 0.85).Our study suggests that the Society for Fetal Urology grading system has good intrarater but modest interrater reliability. Individual rater interpretations of the grading system may explain the modest interrater agreement. Proposed modifications to the Society for Fetal Urology classification system, such as distinguishing between diffuse and segmental cortical thinning, may improve reliability.