Bryce Weber

Urinary tract abnormalities in boys with recurrent urinary tract infections after hypospadias repair

To examine the development of recurrent urinary tract infections (UTIs) in boys who have undergone hypospadias repair.

Impact of penile degloving and proximal ventral dissection on curvature correction in children with proximal hypospadias

INTRODUCTION Penile degloving is an important step in orthoplasty. Although its role in correcting mild curvature in distal and midshaft hypospadias has been previously reported, its impact on ventral curvature (VC) correction in proximal defects warrants further investigation. Therefore, we sought to document the effect of degloving and proximal urethral dissection on VC correction in children with proximal hypospadias. METHODS We retrospectively reviewed the records of 137 patients who underwent proximal hypospadias repair between 1998 and 2006. VC, defined as mild (<30%), moderate (30%-45%), and severe (>45%), was recorded before penile degloving and after erection test. Percent improvement in VC and need for further treatment (beyond degloving and proximal dissection) based on preoperative degree of curvature were assessed. ANOVA test was used to compare improvement among the 3 groups. RESULTS Mean age at repair was 14 months (range: 6-24). Penile degloving associated with proximal urethral dissection when necessary was responsible for the improvement in the degree of curvature in 7 of 9 (77%) patients with mild VC, 23 of 44 (52%) with moderate and 35 of 84 (40%) with severe VC. Additionally, degloving alone was sufficient for VC correction in 7 of 9 (77%) mild cases, 14 of 44 (30%) moderate and only 2 of 84 (2%) severe cases. The difference among these 3 groups was statistically significant (p < 0.001). CONCLUSIONS Penile degloving alone can correct VC. The percentage of improvement depends on the preoperative degree of curvature, with severe VC cases showing the least improvement.

Variability of renal colic management and outcomes in two Canadian cities

BACKGROUND Some centres favour early intervention for ureteral colic while others prefer trial of spontaneous passage, and relative outcomes are poorly described. Calgary and Vancouver have similar populations and physician expertise, but differing approaches to ureteral colic. We studied 60-day hospitalization and intervention rates for patients having a first emergency department (ED) visit for ureteral colic in these diverse systems. METHODS We used administrative data and structured chart review to study all Vancouver and Calgary patients with an index visit for ureteral colic during 2014. Patient demographics, arrival characteristics and triage category were captured from ED information systems, while ED visits and admissions were captured from linked regional hospital databases. Laboratory results were obtained from electronic health records and stone characteristics were abstracted from diagnostic imaging reports. Our primary outcome was hospitalization or urological intervention from 0 to 60 days. Secondary outcomes included ED revisits, readmissions and rescue interventions. Time to event analysis was conducted and Cox Proportional Hazards modelling was performed to adjust for covariate imbalance. RESULTS We studied 3283 patients with CT-defined stones. Patient and stone characteristics were similar for the cities. Hospitalization or intervention occurred in 60.9% of Calgary patients and 31.3% of Vancouver patients (p<0.001). Calgary patients had higher index intervention rates (52.1% v. 7.5%), and experienced more ED revisits and hospital readmissions during follow-up. The data suggest that outcome events were associated with overtreatment of small stones in one city and undertreatment of large stones in the other. CONCLUSIONS An early interventional approach was associated with higher ED revisit, hospitalization and intervention rates. If these events are markers of patient disability, then a less interventional approach to small stones and earlier definitive management of large stones may reduce system utilization and improve outcomes for patients with acute ureteral colic.

Outcomes of an accelerated care pathway for pediatric blunt solid organ injuries in a public healthcare system

PURPOSE An accelerated clinical care pathway for solid organ abdominal injuries was implemented at a level one pediatric trauma center. The impact on resource utilization and demonstration of protocol safety was assessed. METHODS Data were collected retrospectively on patients admitted with blunt abdominal solid organ injuries from 2012 to 2015. Patients were subdivided into pre- and post-protocol groups. Length of hospital stay (LOS) and failure of non-operative treatment were the primary outcomes of interest. RESULTS 138 patients with solid organ injury were studied: 73 pre- (2012-2014) and 65 post-protocol (2014-2015). There were no significant differences in age, gender, injury severity score (ISS), injury grade, or mechanism (p>0.05). LOS was shorter post-protocol (mean 5.6 vs. 3.4days; median 5 .0 vs. 3.0days; p=0.0002), resulting in average savings of

MP90-16 PREDICTORS OF FAILURE OF SPONTANEOUS STONE PASSAGE AFTER EMERGENCY DEPARTMENT DISCHARGE IN PATIENTS WITH RENAL COLIC

5966 per patient. Patients in the protocol group mobilized faster (p<0.0001) and experienced fewer blood draws (p=0.02). On multivariate analysis, protocol group (p<0.001) and ISS (p<0.001) were independently associated with LOS. There were no differences between groups in the need for operation, embolization, or transfusion. CONCLUSION An accelerated care pathway is safe and effective in the management of pediatric solid organ injuries with early mobilization, less blood draws, and decreased LOS without significant morbidity and mortality. LEVEL OF EVIDENCE Therapeutic, cost effectiveness, level III.

MP75-20 EVALUATION OF THE TREATMENT OF DISTAL URETRAL STONES CAUSING RENAL COLIC IN A HIGH INTERVENTION SETTING

on stone activity is not well studied. Our goal was to determine if SI CaOx correlates with stone activity in calcium oxalate (CaOx) stone formers. METHODS: We reviewed the charts of 604 patients from our stone clinic between 2005 and 2016 and identified CaOx stone formers who had a baseline 24-hour urine collection and at last one follow-up urine collection after the initiation of drug and/or dietary therapy. Patient demographics, imaging studies, serum chemistries, and 24-hour urine studies were recorded in a timeline for each patient. SI was calculated using JESS for each 24-hour urine study. Stone recurrence (SR) was defined as stone growth or new stone formation and no recurrence (NR) indicated no new stone formation. Absolute SI values were compared between times of SR and times of NR, and change in SI from baseline to time of SR were correlated with SI. Statistical analysis was performed with SAS, and significance was set at p<0.05. RESULTS: In total, 255 patients with 358 events were included in the analysis. Mean patient age was 51 13 SD years, with a male:female ratio of 1.3. Comparing NR (98 patients with 97 events) to SR (157 patients with 113) demonstrated no significant difference in mean SI CaOx values (5.6 2.8 versus 5.6 2.9, p1⁄40.6). In addition, in patients who experienced SR (n1⁄4157) no significant difference was seen comparing mean SI CaOx values during NR (n1⁄4148) or SR (n1⁄4113) events (5.9 2.8 versus 5.6 2.9, respectively, p1⁄40.08). For all patients with SR, 65 were identified who experienced both changes from SR to NR (median DSI CaOx 0.20, IQR -1.46-1.21) and NR to SR (median DSI CaOx 0.52, IQR -1.55-1.47). No significant difference was seen (p1⁄40.84). CONCLUSIONS: At first evaluation, neither absolute nor change in SI correlates with stone recurrence and may not be a reliable way to follow effectiveness of medical therapy.

Incidence of bleeding in children undergoing circumcision with ketorolac administration

INTRODUCTION AND OBJECTIVES: Imaging after ureteroscopy (URS) and shockwave lithotripsy (SWL) is suggested by the American Urologic Association to ensure stone fragment clearance, resolution of hydronephrosis, and rule out ureteral stricture formation. To our knowledge, no prior studies have examined large-scale national imaging patterns after procedural intervention for nephrolithiasis. We sought to characterize imaging utilization patterns after URS and SWL. METHODS: Using Marketscan, a private employer-based insurance database, we identified patients 17-64 years old undergoing URS or SWL between 2007-2014. A minimum of 12 months of enrollment was required and patients were excluded if they received more than 1 lithotripsy procedure of any type within 90 days. Imaging modalities identified by CPT and ICD-9 codes included computed tomography (CT), renal ultrasound (US), abdominal X-ray (KUB), and intravenous pyelogram (IVP), and were tracked postoperatively. Utilization patterns by demographic factors were assessed using chisquared test. RESULTS: A total of 100,710 patients met inclusion criteria following URS, with 39% having no post-operative imaging within 12 months. Only 45% underwent imaging within 3 months of URS, most commonly KUB (28%). At 3, 6, and 12 months, only 26%, 33%, and 42%, respectively, of URS patients had any anatomic imaging (US, CT, or IVP). A total of 109,237 patients met inclusion criteria following SWL, with 16% having no postoperative imaging within 12 months. 78% underwent imaging within 3 months; most commonly KUB (69%). By 3, 6, and 12 months, 19%, 26%, and 36%, respectively, of SWL patients had any anatomic imaging. KUB was the most common imaging modality after either intervention type (38% of URS, 74% of SWL) within 12 months, followed by CT (25% of URS, 24% of SWL), then US (23% of URS, 17% of SWL). Over the 7 year study interval US increased by 10% after URS and 6% after SWL, while CT use decreased by 4%. Older age and female sex were independently associated with higher rates of imaging (p<0.001). US use was 13% higher in the Northeast, and more likely to be utilized in patients in metropolitan statistical areas or enrolled in health maintenance organizations. CONCLUSIONS: Despite recommendations for routine imaging after stone procedures, a large proportion of insured patients received none, especially following URS. The majority of URS and SWL patients did not receive any postoperative anatomic imaging, which may raise the risk of undiagnosed ureteral strictures, silent obstruction, and renal function loss. Although RUS use is slowly increasing, it remains underutilized compared to CT.

Hsp90 Phosphorylation Is Linked to Its Chaperoning Function ASSEMBLY OF THE REOVIRUS CELL ATTACHMENT PROTEIN

INTRODUCTION Circumcision is the most common surgical procedure performed by pediatric urologists. Ketorolac has been shown to have an efficacy similar to morphine in multimodal analgesic regimens without the commonly associated adverse effects. Concerns with perioperative bleeding limit the use of ketorolac as an adjunct for pain control in surgical patients. As such, we sought to evaluate our institutional outcomes with respect to ketorolac and postoperative bleeding. METHODS We retrospectively reviewed all pediatric patients undergoing circumcision from January 1, 2014 to December 31, 2015 at the Alberta Childrens Hospital. Demographics, perioperative analgesic regimens, and return to emergency department or clinic for bleeding were gathered through chart review. RESULTS A total of 475 patients undergoing circumcisions were studied, including 150 (32%) who received perioperative ketorolac and 325 (68%) who received standard analgesia. Patients receiving ketorolac were more likely to return to the emergency department or clinic for bleeding (ketorolac group 19/150 [13%], non-ketorolac group 16/325 [5.0%]; p=0.005). Patients receiving ketorolac were more likely to have postoperative sanguineous drainage (ketorolac group 96/150 [64%], non-ketorolac group 150/325 [46%]; p<0.001). There was no significant difference in the number of patients requiring postoperative admission or further medical intervention. CONCLUSIONS Although a promising analgesic, ketorolac requires additional investigation for safe usage in circumcisions due to possible increased risk of bleeding.