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- We report five patients with normal diuretic renograms who underwent Whitaker pressure perfusion testing. They were found to have normal pressure at low flow rates (2-4 ml/min) and an abnormally elevated pressure at high flow rates (8-10 ml/min). Because of persistent symptoms, two patients underwent surgery, while the other three have been followed up. Our findings indicate that a negative diuretic renogram in a well hydrated patient with good renal function may not rule out low grade obstruction. Renal pelvic perfusion at low flow rates as well as high flow rates is recommended to determine better the function of the pelviureteric junction. [ABSTRACT FROM AUTHOR]

Importance: Few stroke survivors meet recommended cardiovascular goals, particularly among racial/ethnic minority populations, such as Black or Hispanic individuals, or socioeconomically disadvantaged populations., Objective: To determine if a chronic care model-based, community health worker (CHW), advanced practice clinician (APC; including nurse practitioners or physician assistants), and physician team intervention improves risk factor control after stroke in a safety-net setting (ie, health care setting where all individuals receive care, regardless of health insurance status or ability to pay)., Design, Setting, and Participants: This randomized clinical trial included participants recruited from 5 hospitals serving low-income populations in Los Angeles County, California, as part of the Secondary Stroke Prevention by Uniting Community and Chronic Care Model Teams Early to End Disparities (SUCCEED) clinical trial. Inclusion criteria were age 40 years or older; experience of ischemic or hemorrhagic stroke or transient ischemic attack (TIA) no more than 90 days prior; systolic blood pressure (BP) of 130 mm Hg or greater or 120 to 130 mm Hg with history of hypertension or using hypertensive medications; and English or Spanish language proficiency. The exclusion criterion was inability to consent. Among 887 individuals screened for eligibility, 542 individuals were eligible, and 487 individuals were enrolled and randomized, stratified by stroke type (ischemic or TIA vs hemorrhagic), language (English vs Spanish), and site to usual care vs intervention in a 1:1 fashion. The study was conducted from February 2014 to September 2018, and data were analyzed from October 2018 to November 2020., Interventions: Participants randomized to intervention were offered a multimodal coordinated care intervention, including hypothesized core components (ie, ≥3 APC clinic visits, ≥3 CHW home visits, and Chronic Disease Self-Management Program workshops), and additional telephone visits, protocol-driven risk factor management, culturally and linguistically tailored education materials, and self-management tools. Participants randomized to the control group received usual care, which varied by site but frequently included a free BP monitor, self-management tools, and linguistically tailored information materials., Main Outcomes and Measures: The primary outcome was change in systolic BP at 12 months. Secondary outcomes were non-high density lipoprotein cholesterol, hemoglobin A1c, and C-reactive protein (CRP) levels, body mass index, antithrombotic adherence, physical activity level, diet, and smoking status at 12 months. Potential mediators assessed included access to care, health and stroke literacy, self-efficacy, perceptions of care, and BP monitor use., Results: Among 487 participants included, the mean (SD) age was 57.1 (8.9) years; 317 (65.1%) were men, and 347 participants (71.3%) were Hispanic, 87 participants (18.3%) were Black, and 30 participants (6.3%) were Asian. A total of 246 participants were randomized to usual care, and 241 participants were randomized to the intervention. Mean (SD) systolic BP improved from 143 (17) mm Hg at baseline to 133 (20) mm Hg at 12 months in the intervention group and from 146 (19) mm Hg at baseline to 137 (22) mm Hg at 12 months in the usual care group, with no significant differences in the change between groups. Compared with the control group, participants in the intervention group had greater improvements in self-reported salt intake (difference, 15.4 [95% CI, 4.4 to 26.0]; P = .004) and serum CRP level (difference in log CRP, -0.4 [95% CI, -0.7 to -0.1] mg/dL; P = .003); there were no differences in other secondary outcomes. Although 216 participants (89.6%) in the intervention group received some of the 3 core components, only 35 participants (14.5%) received the intended full dose., Conclusions and Relevance: This randomized clinical trial of a complex multilevel, multimodal intervention did not find vascular risk factor improvements beyond that of usual care; however, further studies may consider testing the SUCCEED intervention with modifications to enhance implementation and participant engagement., Trial Registration: ClinicalTrials.gov Identifier: NCT01763203.

The COVID-19 pandemic has brought the long-standing public health practice of contact tracing into the public spotlight. While contact tracing and case investigation have been carefully designed to protect privacy, the huge volume of tracing which is being carried out as part of the pandemic response in the United States is highlighting potential concerns around privacy, legality, and equity. Contact tracing during the pandemic has gained particular attention for the new use of digital technologies-both on the consumer side in the form of Exposure Notification applications, and for public health agencies as digital case management software systems enable massive scaling of operations. While the consumer application side of digital innovation has dominated the news and academic discourse around privacy, people are likely to interact more intensively with public health agencies and their use of digital case management systems. Effective use of digital case management for contact tracing requires revisiting the existing legal frameworks, privacy protections, and security practices for management of sensitive health data. The scale of these tools and demands of an unprecedented pandemic response are introducing new risks through the collection of huge volumes of data, and expanding requirements for more adept data sharing among jurisdictions. Public health agencies must strengthen their best practices for data collection and protection even in the absence of comprehensive or clear guidance. This requires navigating a difficult balance between rigorous data protection and remaining highly adaptive and agile., Competing Interests: Conflict of interestThe author is employed by a company which develops digital case management software and supports multiple public health agencies., (© The Author(s), under exclusive licence to Springer Nature B.V. 2021.)

Background: Advancing technology has increased functionality and permitted more complex study designs for behavioral interventions. Investigators need to keep pace with these technological advances for electronic data capture (EDC) systems to be appropriately executed and utilized at full capacity in research settings. Mobile technology allows EDC systems to collect near real-time data from study participants, deliver intervention directly to participants' mobile devices, monitor staff activity, and facilitate near real-time decision making during study implementation., Objective: This paper presents the infrastructure of an EDC system designed to support a multisite HIV biobehavioral intervention trial in Los Angeles and New Orleans: the Adolescent Medicine Trials Network "Comprehensive Adolescent Research & Engagement Studies" (ATN CARES). We provide an overview of how multiple EDC functions can be integrated into a single EDC system to support large-scale intervention trials., Methods: The CARES EDC system is designed to monitor and document multiple study functions, including, screening, recruitment, retention, intervention delivery, and outcome assessment. Text messaging (short message service, SMS) and nearly all data collection are supported by the EDC system. The system functions on mobile phones, tablets, and Web browsers., Results: ATN CARES is enrolling study participants and collecting baseline and follow-up data through the EDC system. Besides data collection, the EDC system is being used to generate multiple reports that inform recruitment planning, budgeting, intervention quality, and field staff supervision. The system is supporting both incoming and outgoing text messages (SMS) and offers high-level data security. Intervention design details are also influenced by EDC system platform capabilities and constraints. Challenges of using EDC systems are addressed through programming updates and training on how to improve data quality., Conclusions: There are three key considerations in the development of an EDC system for an intervention trial. First, it needs to be decided whether the flexibility provided by the development of a study-specific, in-house EDC system is needed relative to the utilization of an existing commercial platform that requires less in-house programming expertise. Second, a single EDC system may not provide all functionality. ATN CARES is using a main EDC system for data collection, text messaging (SMS) interventions, and case management and a separate Web-based platform to support an online peer support intervention. Decisions need to be made regarding the functionality that is crucial for the EDC system to handle and what functionality can be handled by other systems. Third, data security is a priority but needs to be balanced with the need for flexible intervention delivery. For example, ATN CARES is delivering text messages (SMS) to study participants' mobile phones. EDC data security protocols should be developed under guidance from security experts and with formative consulting with the target study population as to their perceptions and needs., International Registered Report Identifier (irrid): DERR1-10.2196/10777., (©W Scott Comulada, Wenze Tang, Dallas Swendeman, Amy Cooper, Jeremy Wacksman, Adolescent Medicine Trials Network (ATN) CARES Team. Originally published in JMIR Research Protocols (http://www.researchprotocols.org), 14.12.2018.)

Integrating care at the home and facility level is a critical yet neglected function of healthcare delivery systems. There are few examples in practice or in the academic literature of affordable, digitally-enabled integrated care approaches embedded within healthcare delivery systems in low- and middle-income countries. Simultaneous advances in affordable digital technologies and community healthcare workers offer an opportunity to address this challenge. We describe the development of an integrated care system involving community healthcare worker networks that utilize a home-to-facility electronic health record platform for rural municipalities in Nepal. Key aspects of our approach of relevance to a global audience include: community healthcare workers continuously engaging with populations through household visits every three months; community healthcare workers using digital tools during the routine course of clinical care; individual and population-level data generated routinely being utilized for program improvement; and being responsive to privacy, security, and human rights concerns. We discuss implementation, lessons learned, challenges, and opportunities for future directions in integrated care delivery systems., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Background: Recurrent strokes are preventable through awareness and control of risk factors such as hypertension, and through lifestyle changes such as healthier diets, greater physical activity, and smoking cessation. However, vascular risk factor control is frequently poor among stroke survivors, particularly among socio-economically disadvantaged blacks, Latinos and other people of color. The Chronic Care Model (CCM) is an effective framework for multi-component interventions aimed at improving care processes and outcomes for individuals with chronic disease. In addition, community health workers (CHWs) have played an integral role in reducing health disparities; however, their effectiveness in reducing vascular risk among stroke survivors remains unknown. Our objectives are to develop, test, and assess the economic value of a CCM-based intervention using an Advanced Practice Clinician (APC)-CHW team to improve risk factor control after stroke in an under-resourced, racially/ethnically diverse population., Methods/design: In this single-blind randomized controlled trial, 516 adults (≥40 years) with an ischemic stroke, transient ischemic attack or intracerebral hemorrhage within the prior 90 days are being enrolled at five sites within the Los Angeles County safety-net setting and randomized 1:1 to intervention vs usual care. Participants are excluded if they do not speak English, Spanish, Cantonese, Mandarin, or Korean or if they are unable to consent. The intervention includes a minimum of three clinic visits in the healthcare setting, three home visits, and Chronic Disease Self-Management Program group workshops in community venues. The primary outcome is blood pressure (BP) control (systolic BP <130 mmHg) at 1 year. Secondary outcomes include: (1) mean change in systolic BP; (2) control of other vascular risk factors including lipids and hemoglobin A1c, (3) inflammation (C reactive protein [CRP]), (4) medication adherence, (5) lifestyle factors (smoking, diet, and physical activity), (6) estimated relative reduction in risk for recurrent stroke or myocardial infarction (MI), and (7) cost-effectiveness of the intervention versus usual care., Discussion: If this multi-component interdisciplinary intervention is shown to be effective in improving risk factor control after stroke, it may serve as a model that can be used internationally to reduce race/ethnic and socioeconomic disparities in stroke in resource-constrained settings., Trial Registration: ClinicalTrials.gov Identifier NCT01763203 .

Background: Acute malnutrition is linked to child mortality and morbidity. Community-Based Management of Acute Malnutrition (CMAM) programs can be instrumental in large-scale detection and treatment of undernutrition. The World Health Organization (WHO) 2006 weight-for-height/length tables are diagnostic tools available to screen for acute malnutrition. Frontline workers (FWs) in a CMAM program in Dharavi, Mumbai, were using CommCare, a mobile application, for monitoring and case management of children in combination with the paper-based WHO simplified tables. A strategy was undertaken to digitize the WHO tables into the CommCare application., Objective: To measure differences in diagnostic accuracy in community-based screening for acute malnutrition, by FWs, using a mobile-based solution., Methods: Twenty-seven FWs initially used the paper-based tables and then switched to an updated mobile application that included a nutritional grade calculator. Human error rates specifically associated with grade classification were calculated by comparison of the grade assigned by the FW to the grade each child should have received based on the same WHO tables. Cohen kappa coefficient, sensitivity and specificity rates were also calculated and compared for paper-based grade assignments and calculator grade assignments., Results: Comparing FWs (N = 14) who completed at least 40 screenings without and 40 with the calculator, the error rates were 5.5% and 0.7%, respectively (p < .0001). Interrater reliability (κ) increased to an almost perfect level (>.90), from .79 to .97, after switching to the mobile calculator. Sensitivity and specificity also improved significantly., Conclusion: The mobile calculator significantly reduces an important component of human error in using the WHO tables to assess acute malnutrition at the community level., (© The Author(s) 2016.)

Purpose: Little has been reported concerning the efficacy of endoscopic injection of dextranomer/hyaluronic acid for the treatment of residual incontinence following bladder neck reconstruction. We present the experience of 2 institutions using endoscopic submucosal injection of dextranomer/hyaluronic acid to correct incontinence in patients who had previously undergone bladder neck reconstruction with or without concomitant enterocystoplasty., Materials and Methods: A retrospective chart review was performed with patient demographics, indications for treatment and outcomes recorded. All patients had adequate bladder capacity and compliance on maximized medical therapy before injection. Continence was defined as at least a 3-hour daytime dry interval, while improvement was defined as an increase in the daytime dry interval to at least 2 hours., Results: A total of 14 patients (10 females and 4 males) underwent 21 injections. At a median followup of 17 months 10 patients had successful results (6 continent, 4 improved)., Conclusions: Endoscopic injection of dextranomer/hyaluronic acid to correct incontinence following bladder neck reconstruction appears safe and can increase the daytime dry interval in more than 70% of carefully selected patients. Continued followup is necessary to evaluate the long-term effectiveness of this treatment.

Purpose: The efficacy of endoscopic injection of dextranomer/hyaluronic acid to correct primary vesicoureteral reflux is well documented. We present experience at 2 institutions with endoscopic treatment for vesicoureteral reflux after failed ureteroneocystostomy., Materials and Methods: A retrospective review was performed of the records of all patients who underwent endoscopic dextranomer/hyaluronic acid injection to correct vesicoureteral reflux following ureteral reimplantation between April 2002 and July 2005. De novo ipsilateral vesicoureteral reflux was noted after repair of primary nonrefluxing megaureters or renal transplantation and persistent vesicoureteral reflux was noted following attempted vesicoureteral reflux repair. Injection was performed using the standard technique if the ureteral orifice was easily accessible, and percutaneously if access was difficult., Results: Nine male and 9 female patients were identified. Median age was 1.9 years at reimplantation and 6.5 years at injection, and median followup was 19 months. Ten patients underwent extravesical detrusorrhaphy and 8 underwent cross-trigonal reimplantation. Six patients underwent reimplantation for primary megaureter repair and all had resolution of vesicoureteral reflux with injection. Of the 20 renal units 16 (80%) and 15 of 18 patients (83%) had complete resolution of vesicoureteral reflux after 1 injection. One patient had improvement in vesicoureteral reflux and 2 had no improvement. There were no complications resulting from injections., Conclusions: Endoscopic treatment of vesicoureteral reflux with dextranomer/hyaluronic acid following extravesical or cross-trigonal reimplantation is safe and efficacious, at least at short-term followup. Endoscopic injection should be considered first line treatment for this situation.

Purpose: We present our experience performing ureteroscopy in prepubertal children., Materials and Methods: We performed a retrospective cohort study of children 12 years or younger who underwent ureteroscopy at 2 institutions between 1993 and 2003. Patient demographics, indications for surgery, operative technique, surgical outcomes and complications were recorded., Results: A total of 39 boys and 32 girls underwent 34 flexible and 47 rigid ureteroscopies. Retrograde access was obtained in 77 procedures, while 4 were performed via an antegrade approach. Mean age was 7.5 years (range 1 to 12) and mean followup was 2.2 years (0.5 to 10). Endoscopic lithotripsy was performed in 65 cases, with a success rate of 98%. A ureteral stent was placed postoperatively in 55 patients. Endoscopic incision was performed for a ureteral stricture in 3 patients and for ureteropelvic junction obstruction in 6. An obstructing fibroepithelial polyp was found in 2 patients, 1 underwent removal of a foreign body and 4 did not have intraluminal pathology. Dilation of the ureteral orifice was required in 23 cases (30%). There were no intraoperative ureteral injuries. One patient had development of a ureteral stricture (complication rate 1.3%) that was successfully treated endoscopically., Conclusions: Rigid and flexible ureteroscopy can be performed safely and effectively in prepubertal children. Successful outcomes can be obtained for calculi that are similar to those in the adult population. Ureteroscopic treatment can be effective in selected children with intraluminal obstruction. To our knowledge this is the largest series in the literature to document outcomes of ureteroscopy in this age group.

Purpose: Lower urinary tract reconstruction is an essential tool in the management of severely dysfunctional bladders in children. The incidence of calculi in augmented bladders has been reported in up to 50% of cases. We analyzed our experience with stone formation in this population to assess risk factors and outcomes., Material and Methods: We performed a retrospective cohort study of all patients who underwent bladder augmentation from 1988 to 2002 at our institution. Patient demographics, risk factors and management were abstracted from the medical record., Results: A total of 105 patients (58 males and 47 females) were identified. Ileum, colon and stomach were used in 37, 18 and 50 patients, respectively. Median age was 8.0 years. Median followup was 8.4 years. A total of 12 patients (11%) were found to have bladder calculi. Ten patients with ileum (27%), 1 with colon (6%) and 1 with stomach (2%) formed stones. All patients had recurrent urinary tract infections. Nine patients were successfully treated with an endoscopic procedure. Four patients (33%) formed recurrent stones despite saline bladder irrigations. One patient had multiple recurrences but is now stone-free on a daily regimen of 20% urea instillation., Conclusions: Augmentation cystoplasty carries an overall low risk of bladder calculi. Gastrocystoplasty had a significantly lower rate of stone formation than augmentation with ileum and colon. Urinary tract infection is an independent risk factor for stone formation. Endoscopic management is safe and effective in the majority of patients and it may be facilitated by a percutaneous access. Recurrent stones form in some patients despite aggressive medical management.

Purpose: Extravesical ureteroneocystostomy is an accepted technique for the surgical treatment of vesicoureteral reflux. However, many surgeons continue to use an intravesical technique when extensive ureteral tailoring is required in the case of primary megaureter. We present our experience and outcomes with these techniques., Materials and Methods: A retrospective cohort study was performed of all patients who underwent tapered ureteral reimplantation between 1990 and 2002. Patient demographics, surgical technique and outcomes were recorded. Patients with ureteral dilatation secondary to bladder or urethral pathology were excluded from study. A successful postoperative outcome was defined as improved hydronephrosis and no vesicoureteral reflux., Results: A total of 53 patients with 65 megaureters were identified. Mean patient age at surgery was 4.9 years and mean followup was 3.8 years. Primary obstructive megaureter was present in 31 renal units, while refluxing megaureter was present in 34. An excisional tapering technique was performed in all cases. An extravesical reimplantation was performed in 29 renal units and an intravesical reimplantation in 36. The success rate was 86% for intravesical and 76% for extravesical reimplantation. The success rate was 90% for obstructive megaureters and 74% for refluxing megaureters. Success rate for patients with voiding dysfunction was 93% with an intravesical approach but only 50% with an extravesical approach., Conclusions: Extensive ureteral tailoring with an extravesical ureteral reimplantation may be performed safely and effectively for primary obstructive megaureter. Patients with voiding dysfunction or preoperative vesicoureteral reflux may benefit from an intravesical ureteral reimplantation.

Purpose: The use of stomach has become controversial in pediatric lower urinary tract reconstruction. Recent series have reported a high incidence of hematuria-dysuria syndrome and metabolic abnormalities, which has prompted a significant decrease in its use at our institution during the last 5 years., Materials and Methods: We retrospectively reviewed the medical records of children who underwent urinary reconstruction with gastrocystoplasty. Patients were excluded from consideration if they had less than 5 years of followup., Results: From 1989 to 1997, 18 males and 26 females were identified. Median patient age at time of reconstruction was 4.5 years and median followup was 9.8 years. Urinary continence was present in 89% of cases, and upper tract dilatation was stable or improved in 91%. No patient had chronic metabolic alkalosis. Major surgery was required for complications of the gastrocystoplasty in 6 cases, including patch contraction and ureteral obstruction necessitating excision in 1. Two patients had severe hematuria while anuric from renal failure which was managed conservatively with bladder cycling and H2 blockers. Symptoms resolved completely after renal transplantation in both cases. Febrile urinary tract infection occurred in 20% of cases and asymptomatic bacteriuria was present in 36%., Conclusions: The use of stomach segments in pediatric urinary reconstruction can be beneficial in patients with chronic renal insufficiency, metabolic acidosis or short gut syndrome. Despite negative reports concerning serious complications of gastrocystoplasty, our long-term data confirm that it remains an important option in our reconstruction armamentarium.

Objectives: To present our experience with the use of stomach, ileum, and colon for augmentation cystoplasty to examine the incidence of, and risk factors for, spontaneous perforation. Spontaneous bladder perforation is a potentially life-threatening complication of augmentation cystoplasty with a reported incidence of up to 13%., Methods: A retrospective review of medical records from 1988 to 2001 identified 107 children (57 males and 50 females) who underwent augmentation cystoplasty at our institution. The etiology for bladder dysfunction included myelomeningocele, VATER (vertebral defects, imperforate anus, tracheoesophageal fistula, radial and renal dysplasia) syndrome, bladder and cloacal exstrophy, posterior urethral valves, and pelvic malignancy. Thirteen patients also had end-stage renal disease., Results: The median follow-up was 7.4 years. Gastrocystoplasty was performed in 50 children (47%), ileocystoplasty in 37 (35%), colocystoplasty in 18 (17%), and gastric-ileal composite neobladder in 2 (2%). Augmentation cystoplasty procedures were performed using a standard technique that included a two-layer anastomosis. Additional procedures at the time of reconstruction included Mitrofanoff neourethra in 66 patients (62%) and bladder neck repair in 44 (41%). Postoperatively, most patients started a strict incremental catheterization regimen. The overall incidence of bladder perforation was 5%, with one traumatic (1%) and four spontaneous (4%) perforations. All patients recovered uneventfully after exploratory laparotomy., Conclusions: We believe that the relatively low incidence of spontaneous bladder perforation encountered in this series may be explained by the large number of patients with gastrocystoplasty, as well as our strict adherence to a postoperative incremental catheterization program.

Purpose: During the last 10 years there has been controversy in the approach to severe hypospadias. Many pediatric urologists have elected to perform a 2-staged procedure to minimize complication rates and improve cosmesis. We continued to perform a single staged repair using the Hodgson XX or Koyanagi technique for even the most severe hypospadias. We review our results during the last 5 years in severe cases of penoscrotal hypospadias with bifid scrotum or penoscrotal transposition., Materials and Methods: The medical records of 20 consecutive children presenting to a single surgeon from 1996 to 2000 with severe penoscrotal hypospadias were reviewed. Patients underwent a 1-stage repair using an operative microscope. Cases not requiring further surgery were grouped as successful while cases requiring subsequent procedures were considered as complications., Results: After an average followup of 23 months 16 patients have not required subsequent procedures. Two patients had urethrocutaneous fistulas and 2 had a urethral diverticulum for an overall complication rate of 20%. All 4 patients were successfully treated with 1 additional procedure and have not required further intervention. Another patient with a small urethral diverticulum is being treated conservatively. All patients had satisfactory cosmetic results., Conclusions: We believe that a single staged repair can be safely and effectively performed even in patients with the most severe penoscrotal hypospadias. The Hodgson XX and Koyanagi repairs are excellent techniques with relatively low complication rates. Pediatric urologists should continue to use these techniques in their armamentarium and strive to perfect a 1-stage approach to severe hypospadias.

Purpose: The Churchill classification system grades the ectopic ureterocele based on the number of renal units in jeopardy. We apply this system to our experience to help predict response to initial surgical intervention., Materials and Methods: All cases of ectopic ureterocele diagnosed at our institution between 1990 and 2000 were retrospectively reviewed and categorized using the Churchill classification system. Initial surgical procedure and subsequent outcomes were analyzed., Results: A total of 53 patients were identified, of whom 42% had only upper pole involvement (grade I), 40% ipsilateral upper and lower pole involvement (grade II) and 19% bilateral renal involvement (grade III). Endoscopic incision was definitive in 56% of grade I, 20% of grade II and no grade III ureteroceles. An upper tract approach was definitive in 85% of grade I, 45% of grade II and no grade III ureteroceles. An initial lower tract procedure was successful in 80% of grade II and 100% of grade III ureteroceles. Overall the initial surgical procedure was definitive in 73% of grade I, 48% of grade II and 20% of grade III ureteroceles., Conclusions: Our results confirm the findings of Churchill. In this series the majority of grade I ureteroceles were successfully managed with an upper tract procedure. However, high grade ureteroceles were more likely to require a secondary operation unless an initial lower tract reconstruction was performed.

Purpose: We determined the incidence of urinary stone risk factors in pediatric patients with urolithiasis., Materials and Methods: Between 1998 and 2001, 71 children with urolithiasis at 2 pediatric institutions underwent metabolic evaluation. The 24-hour urine samples were analyzed outside central laboratory using adult and known pediatric references. Supersaturation and traditional metabolic parameters were determined and compared., Results: All patients had metabolic abnormalities. Calcium related abnormalities were present in 92% of children, calcium oxalate supersaturation was abnormal in 69%, calcium phosphate supersaturation was elevated in 70% and traditional calcium parameters were abnormal in 80%. While 11% of the patients had abnormal calcium phosphate or oxalate supersaturation with normal traditional calcium parameters, 10% had normal calcium oxalate or phosphate supersaturation with abnormal traditional calcium parameters. Low urinary volume was identified in 75% of the children., Conclusions: Metabolic abnormalities are extremely common in pediatric patients with urolithiasis. Calcium related abnormalities are the most common abnormality. Urinary supersaturation values are complementary to traditional metabolic parameters and may be more sensitive predictors of recurrent stone risk. It is important to establish pediatric reference ranges to interpret these data more accurately.

Background and Purpose: Treatment of the high intra-abdominal testis is often a challenging problem. We present our technique of and results with laparoscopically assisted testicular autotransplantation (LATA) for treatment of the high intra-abdominal testis., Patients and Methods: We reviewed the medical records of 15 patients with a high intra-abdominal testis who underwent procedures between 1993 and 1999 in which intra-abdominal dissection and testicular mobilization was performed laparoscopically. The LATA technique is described., Results: The 15 patients underwent 17 LATA procedures. Age at surgery ranged from 6 months to 13 years (mean 3.6 years; median 2.5 years). Two of these patients had undergone failed contralateral orchidopexy for an intra-abdominal testis, and two patients underwent metachronous bilateral procedures. The laparoscopic dissection and microvascular anastomoses were successful in all patients. There were no postoperative complications. The involved testis remained viable with adequate growth in 15 of 17 procedures (88%) during a median 42-month (range 7-70 months) follow-up. Successful procedures included those in the two patients with contralateral atrophic testes and the two who underwent bilateral procedures., Conclusions: The LATA demonstrated a good long-term surgical outcome and may be the technique of choice in patients with bilateral intra-abdominal testes or patients who have contralateral testis atrophy following unsuccessful orchidopexy.

Purpose: To assess outcomes after the antegrade continence enema procedure, we present our results with an ileal segment or the appendix in children with severe bowel dysfunction., Materials and Methods: A retrospective review of 45 children who had undergone the creation of a continent cecostomy for severe chronic constipation and fecal incontinence was performed., Results: The appendix was used to create the continent cecostomy in 28 patients (group 1) and ileum 17 (group 2). Of 16 patients who underwent simultaneous construction of appendiceal Mitrofanoff neourethra, including continent catheterizable stoma, the appendix was split and used for the cecostomy and neourethra in 11. Overall, acceptable continence was achieved in 39 (87%) patients and total continence 31 (69%). No significant difference was noted in the rate of continence between groups 1 and 2. Nonstomal postoperative complications occurred in 5 patients in group 1 and 3 group 2. Complications that required reoperation related to the continent cecostomy occurred in 10 patients, including stomal stenosis in 8, with 6 group 1 and 2 group 2 (p >0.05), and stricture in 2, with 1 group 1 and 1 group 2. There were 2 patients who had previously undergone colostomy for intractable constipation who were undiverted at the time of the creation of continent cecostomy. Both were continent postoperatively. There were 3 patients, including those 2 who presented with chronic severe constipation of unclear etiology, who underwent colostomy for unrecoverable colonic dys-motility, of whom 1 subsequently required total colectomy., Conclusions: The creation of a continent cecostomy for antegrade continence enema is a successful management option in children with debilitating fecal incontinence, and may enable undiversion of an existing colostomy. The appendix and ileal segment are viable options for the procedure, with no significant difference noted in continence or complication rates.

Purpose: Various surgical approaches have been used for treatment of vesicoureteral reflux in uncomplicated duplicated collecting systems. We retrospectively evaluated our success with extravesical common sheath detrusorrhaphy in such a setting., Materials and Methods: Between 1990 and 1997, unilateral and bilateral extravesical nondismembered detrusorrhaphy was performed in 24 and 19 patients, respectively, with 51 duplicated collecting systems, including 8 bilateral, for management of vesicoureteral reflux. Vesicoureteral reflux was present in the moieties of ipsilateral duplicated kidney in 2 patients, and bilateral reimplantation was performed in 2 who had a history of contralateral vesicoureteral reflux that resolved. Patient age ranged from 1 to 16 years (median 3.67). Followup ranged from 36 to 114 months (median 86), and included cystourethrography and renal ultrasound., Results: Vesicoureteral reflux resolved in all but 1 duplicated renal moiety, which was a success rate of 98%. In this patient the persistent reflux resolved by 16 months postoperatively on conservative treatment. There were no intraoperative complications and all patients resumed spontaneous voiding before discharge home. No postoperative obstruction of the involved kidney or de novo contralateral reflux developed in any patient., Conclusions: Common sheath ureteral reimplantation with extravesical detrusorrhaphy can be successfully used to treat vesicoureteral reflux in uncomplicated duplicated collecting systems. This approach demonstrates excellent long-term surgical outcome with minimal perioperative morbidity.

Purpose: We determined the role of magnetic resonance imaging (MRI) in symptomatic children with clinically suspected and radiologically occult dysplastic renal moieties and ectopic ureters., Materials and Methods: We reviewed clinical, imaging, cystoscopic, surgical and histological findings in 6 symptomatic children 1 to 15 years old with dysplastic renal moieties., Results: After multiple conventional imaging studies failed to delineate urinary tract anatomy MRI provided detailed multiplanar images of dysplastic renal moieties that were diagnostic and predictive of subsequent intraoperative findings. Dysplastic upper pole moieties identified in 4 children were associated with ectopic ureters inserting into the vagina, prostatic urethra, bladder neck and bladder neck ureterocele in each. A solitary kidney with contralateral blind-ending ectopic ureters inserted into the bladder base in 2 cases. Pelvic cystic structures visualized by ultrasound in 3 patients were tortuous distal ureters on MRI. MRI specifically identified ureteral insertion sites that were not evident in 3 of the 5 patients who underwent cystoscopy., Conclusions: MRI may facilitate diagnosis, guide cystoscopy and aid in preoperative planning in children with poorly functioning renal moieties and ectopic ureters.

Purpose: We present a stapling technique for constructing an antegrade continence enema (ACE) conduit that is helpful in cases of insufficient appendiceal luminal length or when a concomitant appendiceal Mitrofanoff stoma is required., Materials and Methods: In 6 patients with a mean age of 9.5 years who required an ACE procedure the cecum was tubularized in continuation with the orthotopic appendix at its base, using a stapling device to construct an ACE conduit. The tubularized segment was imbricated with permanent suture material. In 3 cases appendiceal length after tubularization was sufficient to allow splitting for the concomitant creation of an appendiceal Mitrofanoff stoma., Results: Patients have been followed an average of 16.5 months. Stomal continence was achieved in all cases as well as reliable catheterization of the appendiceal cecostomy in 6 and the Mitrofanoff conduit in 3., Conclusions: This modification of the ACE procedure with cecal tubularization in continuation with the appendix using a stapling device is an excellent approach in cases of inadequate appendiceal length. It successfully creates a catheterizable stoma with a reliable flap valve continence mechanism. The complex reconstructive procedure is simplified by eliminating the need to use tapered small intestine, while allowing the creation of a concomitant appendiceal Mitrofanoff stoma as necessary.

Purpose: The complication rate after Mathieu hypospadias repair was recently reported to be 3.6% in unstented cases. We reviewed our experience and results of the Mathieu repair performed at our institution during the last 5 years., Materials and Methods: We performed 197 primary and 5 secondary repairs in 202 patients. Reconstruction of the neourethra was done with a 2-layer anastomosis using optical magnification. Urethral stents were placed for postoperative drainage in all but 1 patient. Followup was up to 54 months., Results: There were no incidences of stent migration or symptomatic urinary tract infection while the stent was in place and all patients voided spontaneously after stent removal. Excellent cosmetic results were obtained in 201 cases. In 1 patient meatal retraction required subsequent meatoplasty with meatal advancement. In 2 patients pinpoint urethrocutaneous fistulas were successfully repaired. The total rate of reoperation was 1.5% in our series. There was no report of urethral stricture during followup., Conclusions: The well established Mathieu repair provides excellent cosmetic and functional results. The overall complication rate is minimal and compares favorably with stentless repair. A 2-layer neourethral anastomosis performed under sufficient optical magnification produces a watertight closure with minimal risk of fistula formation. Postoperative urethral stenting decreases this risk even further, while adding only minimal morbidity. We believe that in the era of newly reported techniques the well established Mathieu procedure should be the standard by which distal repair is judged.

The authors describe four patients with unusual anatomic presentation of ectopic ureteroceles and their surgical treatment. Over a 3-year period, four cases of unusual ectopic ureteroceles were encountered. A 6-month-old girl had a complex cloacal anomaly with an ectopic ureterocele within the cloaca. A 10-year-old boy had two large diverticuli within an ectopic ureterocele combined with a blind-ending ipsilateral ureter. A 3-year-old girl had an ectopic ureterocele combined with a periureteral diverticulum and a completely duplicated ipsilateral kidney. A 4-year-old girl was found to have a vaginal ectopic ureterocele. Despite thorough radiological investigation in all patients, a correct assessment of the anatomic defect was achieved only by surgical exploration or endoscopic evaluation. If preoperative radiological evaluation is equivocal, a high index of suspicion and intraoperative recognition of an unusual anatomic presentation of the ectopic ureterocele are essential for appropriate management and a successful outcome.

Purpose: Extravesical detrusorrhaphy has been successful for correcting unilateral vesicoureteral reflux, although its use in bilateral ureteral reimplantation has been questioned because of a reportedly high incidence of significant postoperative voiding dysfunction. We reviewed the incidence of voiding dysfunction after bilateral extravesical detrusorrhaphy during the last 5 years., Materials and Methods: From 1990 to 1995, 123 patients with a mean age of 5.8 years (231 refluxing renal units) underwent bilateral extravesical detrusorrhaphy. Patients requiring anticholinergic therapy or intermittent catheterization at surgery were excluded from study, although in 6 who were included voiding dysfunction had previously resolved., Results: Grades I and II vesicoureteral reflux persisted in 1 and 3 renal units, respectively, representing a 98.3% success rate. There was no postoperative upper urinary tract obstruction. Postoperatively voiding dysfunction developed in 8 patients (6.5%), including 2 with a history of voiding dysfunction. In 3 cases (2.5%) irritative voiding symptoms controlled with oxybutynin chloride resolved 2, 4 and 24 months postoperatively, respectively. In 5 patients (4%) temporary incomplete bladder emptying and/or urinary retention required outpatient Foley catheter drainage or intermittent catheterization for 2 to 21 days., Conclusions: Bilateral extravesical detrusorrhaphy is a highly successful procedure with a low incidence of significant voiding dysfunction. Should this condition develop, in our experience it is transient and of minimal morbidity. We found an increased rate of postoperative voiding dysfunction in younger patients as well as in those with a history of resolved voiding dysfunction.

Purpose: The development of contralateral vesicoureteral reflux following different types of unilateral antireflux surgery has been reported to be as high as 22%. We review our recent experience with unilateral extravesical detrusorrhaphy in regard to the incidence of postoperative contralateral vesicoureteral reflux., Materials and Methods: Between 1990 and 1995, 72 children underwent unilateral extravesical detrusorrhaphy. Of 73 refluxing renal moieties (1 patient had reflux in both moieties of a completely duplicated kidney) reflux grade was II in 35 (48%), III in 25 (34%), IV in 11 (15%) and V in 2 (3%). Common sheath reimplantation for complete ipsilateral duplication was performed in 16 patients., Results: One patient had grade I postoperative ipsilateral vesicoureteral reflux resulting in a success rate of 98.6%. In 4 patients (5.6%) contralateral vesicoureteral reflux developed, and was grade II in 3 and grade I in 1. In all patients contralateral reflux resolved at 16, 17, 18 and 31 months of followup. No additional surgery was required in any patient. There was no association between the incidence of contralateral vesicoureteral reflux, and patient age, gender, preoperative ipsilateral reflux grade and presence of ipsilateral duplication., Conclusions: Unilateral extravesical detrusorrhaphy is a highly successful procedure with a low incidence of postoperative contralateral vesicoureteral reflux. Should reflux develop, it is of low grade with a significant rate of spontaneous resolution.

Purpose: In large series of adults microsurgical varicocelectomy has been associated with extremely high success rates, combined with minimal incidence of postoperative hydrocele. We report our initial experience of inguinal varicocelectomy using an intraoperative microscope in adolescents., Materials and Methods: From 1994 to 1996, 32 adolescents (mean age 15.3 years) underwent inguinal microsurgical varicocelectomy. An operative microscope and Doppler probe were used during spermatic cord dissection to identify and preserve the testicular artery and lymphatics., Results: All patients were available for followup, which ranged from 2 to 35 months (mean 20). There were no intraoperative complications. A temporary reactive hydrocele, which subsequently completely resolved, was observed in 1 patient. There were no palpable recurrent varicoceles., Conclusions: The operative microscope permits reliable identification of the testicular artery and lymphatics, as well as venous channels in adolescents. As a result, the postoperative development of hydrocele or recurrence of the varicocele may be prevented.

Purpose: Conservative management of children who have unequivocal multicystic dysplastic kidney with a stable or regressive pattern of disease during close followup is well established. However, a clear diagnosis may prove difficult. We report 3 cases in which the diagnosis was particularly difficult to increase awareness of the importance of applying strict criteria for the diagnosis of multicystic dysplastic kidney., Materials and Methods: Three children in whom a diagnosis of multicystic dysplastic kidney was suspected underwent surgical exploration. One patient who did not comply with followup presented with a large retroperitoneal mass suspicious for neuroblastoma 8 months later. In another patient a growing renal cystic mass was suspicious for a multilocular cyst at 3 months of followup. At 2 months of followup a cystic nephroma was suspected in the remaining patient., Results: All patients underwent surgical exploration. The patient with suspected neuroblastoma had extensive stage 3 Wilms tumor. In the child with a suspected multilocular cyst segmental multicystic dysplastic kidney of the lower pole of an ipsilateral duplicated system was found. In the patient in whom cystic nephroma was suspected mesoblastic nephroma was confirmed by the National Wilms Tumor Study Pathology Center., Conclusions: An unequivocal diagnosis of multicystic dysplastic kidney should be made early in life. The urologist should have an active role in making the initial radiological diagnosis and close followup with renal ultrasound every 3 to 4 months is essential during year 1 of life. Surgical exploration is indicated if the diagnosis becomes equivocal at any point or should concerns exist regarding compliance with followup.

Purpose: We evaluated the antegrade continence enema for managing the most severely compromised fecal continence mechanisms and the efficacy of nonappendiceal conduits in children when appendix is unavailable., Materials and Methods: Ten patients 3 to 25 years old underwent continent cecostomy for the purpose of the antegrade continence enema. Diagnoses included the VATER association in 4 cases, myelomeningocele in 3, cloacal anomaly in 2 and isolated imperforate anus in 1. Eight patients received a tubularized ileal conduit, 2 received an appendiceal conduit and 2 underwent concomitant fecal undiversion., Results: Followup ranged from 4 to 28 months (mean 17.6). All patients have achieved excellent fecal continence and no significant stomal soilage or difficulty with catheterization has been noted. Patients reported a high degree of satisfaction., Conclusions: Continent cecostomy for the antegrade continence enema is highly effective even in the presence of severe structural anorectal disease. The tapered ileal conduit is an excellent alternative to the appendiceal conduit.

Purpose: We describe a useful technique for overcoming difficult pediatric urethral intubation problems., Materials and Methods: An 8F pediatric urethroscope is passed through a peel away sheath, advanced through the urethra into the bladder and removed. An 8F urethral catheter is passed, the balloon is inflated and the peel away sheath is removed., Results: This procedure has been performed in 6 children with difficult urethral problems without complication and with universal success., Conclusions: The peel away sheath technique offers a more reliable and less traumatic mechanism for difficult infant urethral intubation.

Purpose: We compared outcomes following single or 2-stage repair of infected urachal cysts in the pediatric population., Materials and Methods: We reviewed the records of 17 patients 1 day to 14 years old (median age 22 months) with a urachal cyst. Immediate cyst excision was performed in 6 patients without infection, while those with an abscess underwent single or 2-stage repair., Results: Median postoperative hospital stay for the urachal abscess group was 14 and 11.5 days for single and 2-stage procedures, respectively. After immediate excision postoperative complications developed in each case, although none occurred with a 2-stage approach., Conclusions: In the absence of infection, urachal cyst excision affords the most benign postoperative course. However, when infection is present, perioperative drainage with subsequent total excision, including a cuff of bladder, may offer the most effective surgical option.

Ureteroscopic management of ureteral obstruction in children presents a challenge to the urologist because of the use of relatively large instruments in smaller anatomy. The authors present our initial experience and describe the technique and equipment found to be most useful. Eleven ureteroscopic procedures were performed in ten patients, either for stone extraction or diagnostic evaluation of ureteral obstruction. Six of seven patients with ureteral stones became stone free, and the stone load was reduced to 25% in the remaining patient. Diagnostic ureteroscopy for ureteral obstruction was successfully performed in four patients. There were no intraoperative ureteral injuries and no postoperative complications. Pediatric ureteroscopy appears to be safe and effective for the diagnosis and treatment of distal ureteral obstruction. Further studies and longer follow-up are necessary to determine whether this technique will prove as successful in children as it has been in the adult population.

Objective: The prognosis in patients with posterior urethral valves (PUV) is related to the degree of renal insufficiency. Urinary ascites or urinoma, congenital bladder diverticula, or severe unilateral vesicoureteral reflux has been associated with protected renal function. We present clinical and imaging findings in eight patients with PUV and unilateral reflux who have preserved renal function. Initial and follow-up sonography, voiding cystourethrography, and nuclear imaging were reviewed and compared with long-term serum creatinine levels., Conclusion: All eight patients had normal renal function on long-term follow-up, suggesting that unilateral reflux, which occurs in as many as 35% of boys with PUV, is associated with protected renal function. Although early nephrectomy of the refluxing unit has been advocated for patients with PUV and unilateral reflux into a dysplastic kidney (the vesicoureteral reflux and renal dysplasia syndrome), we found that significant renal function may be present in the refluxing kidney and that function may even increase with time. Most of these patients did well without nephrectomy. Therefore, a sufficient interval should elapse before nephrectomy is considered in these patients.

Purpose: The intra-abdominal testis continues to present a considerable urological challenge and the approach to its management continues to evolve. We report our initial experience with laparoscopically assisted testicular autotransplantation., Materials and Methods: An intra-abdominal testicle was identified laparoscopically in 5 patients who subsequently underwent testicular autotransplantation., Results: The success rate was 100% and median operative time was 5 hours. All patients were discharged home the day after surgery with no complications and a good result., Conclusions: Because of success with this technique, this procedure offers significant advantages (decreased hospital stay and lower morbidity) than an open or 2-stage Fowler-Stephens approach.