Brian M. Rosman

Variations in Management of Mild Prenatal Hydronephrosis Among Maternal-Fetal Medicine Obstetricians, and Pediatric Urologists and Radiologists

PURPOSE There are no current guidelines for diagnosing and managing mild prenatal hydronephrosis. Variations in physician approach make it difficult to analyze outcomes and establish optimal management. We determined the variability of diagnostic approach and management regarding prenatal hydronephrosis among maternal-fetal medicine obstetricians, pediatric urologists and pediatric radiologists. MATERIALS AND METHODS Online surveys were sent to mailing lists for national societies for each specialty. Participants were surveyed regarding criteria for diagnosing mild prenatal hydronephrosis and recommendations for postnatal management, including use of antibiotic prophylaxis, followup scheduling and type of followup imaging. RESULTS A total of 308 maternal-fetal medicine obstetricians, 126 pediatric urologists and 112 pediatric radiologists responded. Pediatric urologists and radiologists were divided between Society for Fetal Urology criteria and use of anteroposterior pelvic diameter for diagnosis, while maternal-fetal medicine obstetricians preferred using the latter. For postnatal evaluation radiologists preferred using personal criteria, while urologists preferred using anteroposterior pelvic diameter or Society for Fetal Urology grading system. There was wide variation in the use of antibiotic prophylaxis among pediatric urologists. Regarding the use of voiding cystourethrography/radionuclide cystography in patients with prenatal hydronephrosis, neither urologists nor radiologists were consistent in their recommendations. Finally, there was no agreement on length of followup for mild prenatal hydronephrosis. CONCLUSIONS We observed a lack of uniformity regarding grading criteria in diagnosing hydronephrosis prenatally and postnatally among maternal-fetal medicine obstetricians, pediatric urologists and pediatric radiologists. There was also a lack of agreement on the management of mild intermittent prenatal hydronephrosis, resulting in these cases being managed inconsistently. A unified set of guidelines for diagnosis, evaluation and management of mild intermittent prenatal hydronephrosis would allow more effective evaluation of outcomes.

Development and Initial Validation of a Scoring System to Diagnose Testicular Torsion in Children

PURPOSE Testicular torsion is a surgical emergency requiring prompt intervention. Although clinical diagnosis is recommended, scrotal ultrasound is frequently ordered, delaying treatment. We created a scoring system to diagnose testicular torsion, decreasing the indication for ultrasound. MATERIALS AND METHODS We prospectively evaluated 338 patients with acute scrotum, of whom 51 had testicular torsion. Physical examination was performed by a urologist, and all patients underwent scrotal ultrasound. Univariate analysis and logistic regression were performed, and a scoring system for risk stratification of torsion was created. Retrospective validation was performed with 2 independent data sets. RESULTS The scoring system consisted of testicular swelling (2 points), hard testicle (2), absent cremasteric reflex (1), nausea/vomiting (1) and high riding testis (1). Cutoffs for low and high risk were 2 and 5 points, respectively. Ultrasound would be indicated only for the intermediate risk group. In the prospective data set 69% of patients had low, 19% intermediate and 11.5% high risk. Negative and positive predictive values were 100% for cutoffs of 2 and 5, respectively (specificity 81%, sensitivity 76%). Retrospective validation in 1 data set showed 66% of patients at low, 16% intermediate and 17% high risk. Negative and positive predictive values for cutoffs of 2 and 5 were 100% (specificity 97%, sensitivity 54%). The second retrospective data set included only torsion cases, none of which was misdiagnosed by the scoring system. CONCLUSIONS This scoring system can potentially diagnose or rule out testicular torsion in 80% of cases, with high positive and negative predictive values for selected cutoffs. Ultrasound orders would be decreased to 20% of acute scrotum cases. Prospective validation of this scoring system is necessary.

Robotic surgery in otolaryngology and head and neck surgery: a review.

Recent advancements in robotics technology have allowed more complex surgical procedures to be performed using minimally invasive approaches. In this article, we reviewed the role of robotic assistance in Otolaryngology and Head and Neck Surgery. We highlight the advantages of robot-assisted surgery and its clinical application in this field.

Predicting Anatomical Urological Abnormalities in Children Who Present With Their First Urinary Tract Infection

Objectives. Classically, presence of fever ≥38.0°C is used to distinguish pyelonephritis from cystitis. We analyzed whether this is an appropriate marker to initiate further workup and whether temperature is correlated with urological abnormalities and further surgical or pharmacological intervention. Methods. Children who presented for their first workup of urinary tract infection between October 1, 2008, and September 30, 2009 were retrospectively selected from our institution. Demographics and clinical details were correlated with the diagnosis of urological abnormalities and requirement for intervention. Results. Age was the most important variable to predict urological abnormalities. The temperature value of 38.3°C maximized the balance between sensitivity (90%) and specificity (46%) for predicting the need to intervene and the presence of anatomical urological abnormalities. Conclusion. Young age (≤2 years) and temperature are the best factors to predict further intervention and urological abnormalities, with a temperature value of 38.3°C being a better predictive value than the currently used 38.0°C.

2192 DEVELOPMENT AND EVALUATION OF NEAR INFRARED FLUORESCENT IMAGING AS A SENSITIVE, NON-RADIATING ALTERNATIVE TO SCINTILLOGRAPHY FOR DIAGNOSIS OF PYELONEPHRITIS

INTRODUCTION AND OBJECTIVES: Imaging with Di-Mercaptosuccinic acid (DMSA) is the current radiographic standard for diagnosing pyelonephritis in children. This test necessitates the injection of a radioactive tracer agent and produces a low-resolution image that requires a high level of training and experience to properly interpret. Near infrared imaging is a modality that does not involve ionizing radiation and has the potential for being highly sensitive for diagnosing various urological conditions. Previous work has demonstrated that Prosense 750 FAST (Perkin Elmer), a near infrared fluorescent imaging agent that is specifically activated by inflammatory enzymes (Cathepsins), can be used to identify pyelonephritis in a swine model. The objective of this study is to determine and compare the sensitivity and specificity of Prosense imaging with that of DMSA and direct histologic evaluation. METHODS: Human pathogenic E. coli was cultured in broth and mixed with swine blood. The resultant clot was injected under ultrasound guidance into the parenchyma of a swine kidney to simulate pyelonephritis. Two to five days later, the animal was anesthetized, and imaging with DMSA followed by Prosense 750 FAST was performed. The DMSA scan was interpreted by a pediatric nuclear medicine specialist. Histological evaluation was performed on the represented sections from the infected kidney. RESULTS: Imaging with Prosense demonstrated higher sensitivity and specificity for areas of infection/inflammation than DMSA. Fluorescent areas observed in renal cortex on Prosense imaging correlated with histological findings of inflammatory cells, suggestive of an active infection. In contrast, these same areas of inflammation/ infection were not detected on the DMSA scan. Only when the infection progressed and became extensive did it become evident on DMSA imaging. CONCLUSIONS: Near infrared fluorescent imaging with Prosense 750 FAST is a sensitive and non-radiating alternative to DMSA for the detection of pyelonephritis. Its use may allow for early detection of renal infection and provides a mean of distinguishing between active and prior infection or dysplasia.

Robotic Intravesical Ureterocele Excision

Abstract Introduction: Ureterocele excision is a procedure that is typically performed in an open fashion. The robotic approach has many challenges associated with it, as well as many advantages. This video will demonstrate a robotic intravesical ureterocele excision, highlighting several novel techniques to aid the procedure, including bladder fixation to the rectus muscle and a unique approach to effective and watertight port closure, which can make a robotic approach a feasible, safe, and effective approach to ureterocele excision. Methods: A suitable patient was selected who had a large enough bladder, clinical indication for ureterocele excision, and interest in a robotic approach. The patient had congenital multicystic kidney without much function, and underwent a right nephroureterectomy previously. He had recurrent episodes of hematuria, and a ureterocele was identified via voiding cystourethrogram (VCUG). The ureterocele was a simple orthotopic stenotic ureterocele, seen on VCUG as a filling defe...