Armando J. Lorenzo

Decisional Regret after Distal Hypospadias Repair: Single Institution Prospective Analysis of Factors Associated with Subsequent Parental Remorse or Distress

PURPOSEnHypospadias 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.nnnMATERIALS AND METHODSnWe 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.nnnRESULTSnDecisional 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 (p <0.001). 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.nnnCONCLUSIONSnTo 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.

Effect of preoperative hormonal stimulation on postoperative complication rates after proximal hypospadias repair: a systematic review.

PURPOSEnWe conducted a systematic review and meta-analysis to summarize the effect of preoperative hormonal stimulation on complication rates following proximal hypospadias repair.nnnMATERIALS AND METHODSnWe comprehensively searched the published and unpublished literature between 1990 and 2010. Eligibility criteria were applied. Title, abstract and full text screening was carried out by 2 independent authors, and discrepancies were resolved by consensus. Heterogeneity between studies was tested using Cochran chi-square Q test and quantified by calculating I(2). Quality appraisal of included studies was performed. Meta-analysis was conducted when appropriate using a random effects model.nnnRESULTSnOur search yielded 288 citations, of which 11 (622 patients) met inclusion criteria and were incorporated into the systematic review. Most series were retrospective observational studies of moderate or low methodological quality. Of the patients 45% underwent administration of preoperative hormonal stimulation, with intramuscular testosterone being the most commonly prescribed formulation. Four studies addressed postoperative complication rate stratified by preoperative hormonal stimulation use and were included in a meta-analysis. The odds ratio for a complication occurring with preoperative hormonal stimulation use was 1.67 (CI 0.96-2.91, p = 0.07, I(2) = 0%). No persistent side effects due to preoperative hormonal stimulation were reported.nnnCONCLUSIONSnTo our knowledge this is the only systematic review and meta-analysis thus far that has critically assessed the effect of preoperative hormonal stimulation on operative outcomes after hypospadias repair. The published literature is of low quality and lacks standardized reporting of important patient and surgical details. The effect of preoperative hormonal stimulation on operative outcomes after hypospadias repair remains unclear and requires further investigation.

Methodological Concerns and Quality Appraisal of Contemporary Systematic Reviews and Meta-Analyses in Pediatric Urology

PURPOSEnThe usefulness of systematic reviews and meta-analyses in influencing clinical practice depends on their quality. We sought to analyze the quality of published systematic reviews and meta-analyses in pediatric urology.nnnMATERIALS AND METHODSnWe searched PubMed (MEDLINE) and Embase for all systematic reviews and meta-analyses published in the top 5 pediatric urology journals between January 2000 and November 2009. Two reviewers independently selected articles for full text review. Scientific methodological quality was evaluated using the Assessment of Multiple Systematic Reviews 11-item tool.nnnRESULTSnOf 267 initial results 220 articles were excluded because they were surveys, case reports or narrative reviews. Full text evaluation of the remaining 47 articles further excluded 32 series of exclusively adult patients, leaving 15 for final analysis. Seven articles (47%) were published in 2009 (p <0.01). Only 1 review (7%) described a full search strategy and 3 (20%) allowed inclusion of non-English studies. In 8 reviews (53%) selection of studies was performed by 2 reviewers. Five systematic reviews (33%) described some form of quality assessment. Only 5 reviews (33%) described assessment of publication bias, while 8 (53%) checked for heterogeneity among studies. According to AMSTAR criteria, 7 systematic reviews (47%) were considered of less than fair methodological quality, 5 (33%) fair to good quality and 3 (20%) good quality.nnnCONCLUSIONSnDespite a recent increase in the number of systematic reviews and meta-analyses published in pediatric urology journals, almost half of these reviews lack good scientific quality, raising concerns about their role in influencing clinical practice. Efforts should be made to improve the methodological quality of systematic reviews and meta-analyses in the pediatric urology literature.

Early Postoperative Ultrasound After Open Pyeloplasty in Children with Prenatal Hydronephrosis Helps Identify Low Risk of Recurrent Obstruction

PURPOSEnPrediction of successful pyeloplasty can be challenging, particularly in asymptomatic children treated for worsening prenatally diagnosed hydronephrosis. We evaluated early noninvasive objective predictors of success in this population.nnnMATERIALS AND METHODSnWe reviewed patients who underwent pyeloplasty for asymptomatic, prenatally detected, worsening hydronephrosis treated between 2000 and 2010 with followup greater than 1 year. For all patients renal pelvis anteroposterior diameter in a mid transverse view and Society for Fetal Urology hydronephrosis grade were evaluated preoperatively and 3 to 4 months postoperatively. Aside from subjective evaluation based on change in hydronephrosis grade, we estimated the percentage of improvement in anteroposterior diameter (preoperative diameter--postoperative diameter/preoperative diameter). Repeat intervention after pyeloplasty arbitrarily defined failure. Patients were categorized into 3 groups, ie no failure on followup ultrasound (group 1), no failure with postoperative nuclear scan to document success (group 2) and failed pyeloplasty (group 3). ROC curves were plotted to correlate 4 variables with failure, namely preoperative anteroposterior diameter, postoperative anteroposterior diameter, percent improvement in anteroposterior diameter and subjective change in grade.nnnRESULTSnOf 229 patients 192 (84%) who met inclusion criteria had ultrasound at 3 to 4 months postoperatively available. Mean age at surgery was 19 months and mean ± SD followup was 49.9 ± 27.7 months. Percent improvement in anteroposterior diameter and postoperative anteroposterior diameter measure were the most reliable variables to predict failure (AUC 0.88 and 0.86, respectively, p <0.0001), whereas preoperative anteroposterior diameter and subjective changes in grade were not good predictors (AUC 0.52, p >0.05). A percent improvement in anteroposterior diameter of 38% or greater or postoperative anteroposterior diameter of 11.5 mm or less was associated with success, with sensitivity of 100% and specificity of 61% and 55%, respectively.nnnCONCLUSIONSnPercent improvement in anteroposterior diameter and postoperative pelvic anteroposterior diameter measure can provide objective guidance as to which patients need closer monitoring during followup, and can help select children at low risk for repeat intervention after pyeloplasty.

Is Statistical Significance Sufficient? Importance of Interaction and Confounding in Hypospadias Analysis

PURPOSEnWe hypothesized that a stratified analysis, where measures of association between dartos flap coverage and fistula formation were adjusted by segregation into 2 strata according to stent insertion, would help better define the dartos flap-urethrocutaneous fistula association.nnnMATERIALS AND METHODSnWe retrospectively reviewed 153 consecutive boys with distal hypospadias who underwent tubularized incised plate repair by a single pediatric urologist between 2000 and 2005. Fistula rate was analyzed separately according to patient age, stenting and dartos flap coverage using univariate and multivariable analyses, and checking for effect modification/interaction.nnnRESULTSnMean±SD age at surgery was 16.5±12.8 months and followup was 17.0±11.6 months. Nonstented tubularized incised plate repair was performed in 88 patients (58%) and dartos flap coverage in 118 (77%). Urethrocutaneous fistula developed in 19 patients (12%). Nonstented repair (p=0.003) and absence of dartos flap coverage (p<0.001) were significantly associated with higher fistula rates. In children without stent a significant increase in fistula rate was observed when dartos flap coverage was not used (9% vs 37%, p=0.002; OR 0.16, 95% CI 0.05-0.51). In boys who underwent stent placement the fistula rate also increased in the absence of dartos flaps, from 2% to 25% (p=0.12; OR 0.05, 95% CI 0.002-1.0).nnnCONCLUSIONSnDartos flap coverage emerges as an important, clinically identifiable and modifiable risk factor associated with fistula reduction following tubularized incised plate repair for distal hypospadias after adjusting for placement of a urethral stent. Furthermore, stenting is an effect modifier in the association between dartos flap coverage and urethrocutaneous fistula.

Percent improvement in renal pelvis antero-posterior diameter (PI-APD): Prospective validation and further exploration of cut-off values that predict success after pediatric pyeloplasty supporting safe monitoring with ultrasound alone

INTRODUCTIONnRenograms are frequently obtained post-pyeloplasty in patients with residual hydronephrosis to confirm adequate drainage. Recent evidence suggests that percent improvement in antero-posterior diameter (PI-APD) ≥38 is predictive of success. We sought to further explore PI-APD ranges that would allow identification of patients who would benefit from ultrasound (US) monitoring alone vs. post-operative renal scan, and those more likely to develop recurrent ureteropelvic junction obstruction (rUPJO).nnnMETHODSnA single-center prospectively-collected pyeloplasty database (2008-2015) was queried (n = 151). Only patients with both pre- and post-operative APD measurements were included (n = 138). PI-APD was divided into 3 categories: <20%; 20-39%; ≥40%. The following variables were collected post-operatively: patients monitored with US alone, renogram and US, rUPJO and minimal or resolved hydronephrosis (SFUxa0≤2; UTD ≤1; APD ≤15 mm).nnnRESULTSnMean age at first and last follow-up were 4.8 (median 4.0; range 0-60) months and 26.6 (median 20.5; range 1-77) months, respectively. Of 138 patients, 84 (61%) had US alone, 54 (39%) had a renogram and US post-operatively, and 6 (4%) developed rUPJO. Of 84 patients who had US alone, 71 (84%; p < 0.01) demonstrated ≥40% PI-APD. Of 54 patients with renogram and US 46 (85%; p < 0.01) had ≥40 PI-APD. Of the 6 patients who developed rUPJO, all were in the <20 PI-APD group (100%; p < 0.01). Resolution of hydronephrosis according to SFU, UTD and APD occurred in 96/138 (70%), 89/138 (64%) and 113/138 (82%) patients respectively. Of these, 87 (91%), 81 (91%), and 108 (95%) occurred in >40% PI-APD group.nnnCONCLUSIONn≥40% PI-APD at the first post-operative visit strongly predicts pyeloplasty success, as up to 82% of these patients showed resolved hydronephrosis and 61% underwent non-invasive monitoring by US alone. Our data suggests that up to 85% of renograms may have been unnecessary. Finally, <20% PI-APD permitted identification of all rUPJO cases. Stratification of patients based in PI-APD is a promising strategy for further minimizing radiation exposure while safely detecting children at risk for rUPJO.

Six of one, half a dozen of the other: A measure of multidisciplinary inter/intra-rater reliability of the society for fetal urology and urinary tract dilation grading systems for hydronephrosis

INTRODUCTIONnThe urinary tract dilation (UTD) classification system was introduced to standardize terminology in the reporting of hydronephrosis (HN), and bridge a gap between pre- and postnatal classification such as the Society for Fetal Urology (SFU) grading system. Herein we compare the intra/inter-rater reliability of both grading systems.nnnMATERIALS AND METHODSnSFU (I-IV) and UTD (I-III) grades were independently assigned by 13 raters (9 pediatric urology staff, 2 nephrologists, 2 radiologists), twice, 3 weeks apart, to 50 sagittal postnatal ultrasonographic views of hydronephrotic kidneys. Data regarding ureteral measurements and bladder abnormalities were included to allow proper UTD categorization. Ten images were repeated to assess intra-rater reliability. Krippendorffs alpha coefficient was used to measure overall and by grade intra/inter-rater reliability. Reliability between specialties and training levels were also analyzed.nnnRESULTSnOverall inter-rater reliability was slightly higher for SFU (αxa0=xa00.842, 95% CI 0.812-0.879, in session 1; and αxa0=xa00.808, 95% CI 0.775-0.839, in session 2) than for UTD (αxa0=xa00.774, 95% CI 0.715-0.827, in session 1; and αxa0=xa00.679, 95% CI 0.605-0.750, in session 2). Reliability for intermediate grades (SFU II/III and UTD 2) of HN was poor regardless of the system. Reliabilities for SFU and UTD classifications among Urology, Nephrology, and Radiology, as well as between training levels were not significantly different.nnnDISCUSSIONnDespite the introduction of HN grading systems to standardize the interpretation and reporting of renal ultrasound in infants with HN, none have been proven superior in allowing clinicians to distinguish between moderate grades. While this study demonstrated high reliability in distinguishing between mild (SFU I/II and UTD 1) and severe (SFU IV and UTD 3) grades of HN, the overall reliability between specialties was poor. This is in keeping with a previous report of modest inter-rater reliability of the SFU system. This drawback is likely explained by the subjective interpretation required to assign grades, which can be impacted by experience, image quality, and scanning technique. As shown in the figure, which demonstrates SFU II (a) and SFU III (b), as assigned by a radiologist, it is possible to make an argument that either of these images can be classified into both categories that were observed during the grading sessions of this study.nnnCONCLUSIONnAlthough both systems have acceptable reliability, the SFU grading system showed higher overall intra/inter-rater reliability regardless of rater specialty than the UTD classification. Inter-rater reliability for SFU grades II/III and UTD 2 was low, highlighting the limitations of both classifications in regards to properly segregating moderate HN grades.

Patency of the “Third Inguinal Ring” in Children with Unilateral Cryptorchidism: Fact or Fiction?

BACKGROUNDnThe entrance to the scrotum, or the so-called third inguinal ring (3rd IGR), was thought to be an important finding and etiological factor for cryptorchidism at the beginning of the 20th century. Historical reports of its association with undescended testis suggest that it was considered by many to be a true anatomical entity. As the understanding of testicular descent has changed, the description of this anatomical passage has vanished from textbooks and publications. In order to evaluate the findings that led to its original report, we sought to assess the patency of the expected testicular path of descent into the scrotum in children with unilateral cryptorchidism.nnnMETHODSnTwo hundred consecutive children who underwent unilateral orchidopexy were prospectively evaluated at the time of surgery to determine the anatomical patency of the area thought to represent the 3rd IGR. We also evaluated its association with the patients age at surgery, the affected side, position of the undescended testis, macroscopic epididymal anomalies (MEA), and the patency of the processus vaginalis (PV).nnnRESULTSnThe mean age at surgery was 5.2 +/- 3.0 years, ranging from 1 to 13 years. The 3rd IGR was closed in 118 boys (59.0 %) and open in 82 (41.0 %). A closed 3rd IGR was found significantly more frequently in patients with intra-abdominal testes (p < 0.01). No significant association was observed between patency of the 3rd IGR and other evaluated factors.nnnCONCLUSIONnOur results suggest that the so-called 3rd IGR may represent the passage point of the testicle into the scrotum, which was not patent during the intraoperative examination in (2/3) of children with unilateral cryptorchidism. This observation by surgeons at the beginning of the 20th century may represent an anatomical curiosity rather than an important factor in the pathogenesis of cryptorchidism.

The impact of a bladder training video versus standard urotherapy on quality of life of children with bladder and bowel dysfunction: A randomized controlled trial

INTRODUCTIONnBladder and bowel dysfunction (BBD) can negatively impact the quality of life (QoL) of children. Urotherapy is an accepted treatment option for BBD; however, literature that examines the impact of management options on QoL in this population is scarce.nnnOBJECTIVEnTo determine whether a bladder training video (BTV) is non-inferior to standard urotherapy (SU) in improving QoL in children with BBD.nnnMETHODSnChildren aged 5-10 years and who scored ≥11 on the Vancouver Non-Neurogenic Lower Urinary Tract Dysfunction/Dysfunctional Elimination Syndrome Questionnaire (NLUTD/DES) were recruited from a pediatric tertiary care center. Children were excluded with known vesicoureteral reflux; spinal dysraphism; learning disabilities; recent urotherapy; and primary nocturnal enuresis. Quality of life was evaluated using the Pediatric Incontinence Quality-of-Life questionnaire (PinQ). Questionnaires were administered at the baseline and 3-month follow-up clinic visits. Following centralized electronic blocked randomization schemes to guarantee allocation concealment, patients were assigned to receive SU or BTV during their regular clinic visits. An intention-to-treat protocol was followed. Between-group baseline and follow-up QoL scores were compared using paired and unpaired t-tests, and linear regression analysis.nnnRESULTSnOf the 539 BBD patients who were screened, 173 (32%) were eligible, and 150 (87%) were randomized. Of these, 143 (96%) completed the study, five (3%) were lost to follow-up, and two (1%) withdrew. In total, 140/143 (97%) completed the QoL questionnaire at baseline and follow-up. Mean follow-up time was 3.5xa0±xa01.1 months for BTV patients and 3.7xa0±xa01.6 months for SU. At baseline, BTV and SU patients had a mean QoL score of 26.6xa0±xa013 and 23.8xa0±xa012, respectively (Pxa0=xa00.17). Between-group mean change in PinQ scores from baseline was not statistically significant (BTV: 6.25xa0±xa012.5 vs SU: 3.75xa0±xa012.2; Pxa0=xa00.23; Summary Fig.). Significant predictors of positive change in QoL were: higher symptomatology score, with a correlation coefficient of 0.5 (95% CI: 0.2-0.9; Pxa0=xa00.003), and worse baseline QoL score, with a correlation coefficient of 0.5 (95% CI: 0.4-0.7; Pxa0<xa00.001). Overall, most patients had improved symptomatology and QoL scores.nnnCONCLUSIONnSignificant and similar QoL changes from baseline to follow-up were observed in both the BTV and SU groups, suggesting that BTV was non-inferior to SU in improving QoL in children with BBD. Quality of life assessment should be considered when evaluating interventions for BBD, as it appears to be an important clinical outcome with which to determine urotherapy success.

Stent-related complications after hypospadias repair: a prospective trial comparing Silastic tubing and Koyle urethral stents

INTRODUCTIONnThere is a paucity of data comparing urethral stents after hypospadias repair. The aim of this study is to compare Silastic tubing vsxa0Koyle stents (Cook Medical), addressing outcomes related to stent-related complications, added visits to healthcare providers in the early postoperative period, and postoperative complications at clinic follow-up.nnnMATERIALS AND METHODSnFollowing an alternate week allocation, 150 patients were prospectively assigned to have Silastic tubes (nxa0=xa076) and Koyle stents (nxa0=xa074) after hypospadias repair. Exclusion criteria included fistula repairs, drainage via alternative catheter, or stentless repairs. Silastic tubes were secured with 5-0 Prolene and removed during a planned clinic visit. Koyle stents were secured with 7-0 PDS and left to fall out spontaneously. Questionnaires capturing postoperative outcomes were completed.nnnRESULTS AND DISCUSSIONnMedian age was 13 and 11 months in the Silastic and Koyle stent groups, respectively (Pxa0=xa00.48). There was no statistically significant difference in hypospadias location. Blockage/kinking of stents occurred in 8% (nxa0=xa06) of the Silastic and 9% (nxa0=xa07) Koyle stent groups, Pxa0=xa00.78. Although follow-up was short, there was no difference in fistula rate among the Silastic (21%, nxa0=xa014) versus Koyle stent group (17%, nxa0=xa011), Pxa0=xa00.66. There was a twofold higher rate of emergency department (ED) visits in the Silastic (32%, nxa0=xa024) versus Koyle stent group (16%, nxa0=xa012), Pxa0=xa00.03. Half of ED visits in the Silastic group were related to stents falling out before planned removal. The authors propose that Silastic stents falling out before the removal date may have led to increased parental anxiety and thusxa0a visit to the ED. With improved parental education, the authors propose that many of these visits may have been preventable.nnnCONCLUSIONSnThere were no significant differences in stent-related complications or fistula rate between the Silastic and Koyle stent groups. Although there were a twofold higher number of visits to the ED in the Silastic stent group, the authors propose that this was due to parental education rather than the stent itself.