Daniel DaJusta

Diagnosing Testicular Torsion before Urological Consultation and Imaging: Validation of the TWIST Score

PURPOSEnThe TWIST (Testicular Workup for Ischemia and Suspected Torsion) score uses urological history and physical examination to assess risk of testis torsion. Parameters include testis swelling (2 points), hard testis (2), absent cremasteric reflex (1), nausea/vomiting (1) and high riding testis (1). While TWIST has been validated when scored by urologists, its diagnostic accuracy among nonurological providers is unknown. We assessed the usefulness of the TWIST score when determined by nonurological nonphysician providers, mirroring emergency room evaluation of acute scrotal pain.nnnMATERIALS AND METHODSnChildren with unilateral acute scrotum were prospectively enrolled in a National Institutes of Health clinical trial. After undergoing basic history and physical examination training, emergency medical technicians calculated TWIST score and determined Tanner stage per pictorial diagram. Clinical torsion was confirmed by surgical exploration. All data were captured into REDCap™ and ROC curves were used to evaluate the diagnostic usefulness of TWIST.nnnRESULTSnOf 128 patients (mean age 11.3 years) 44 (13.0 years) had torsion. TWIST score cutoff values of 0 and 6 derived from ROC analysis identified 31 high, 57 intermediate and 40 low risk cases (positive predictive value 93.5%, negative predictive value 100%).nnnCONCLUSIONSnTWIST score assessed by nonurologists, such as emergency medical technicians, is accurate. Low risk patients do not require ultrasound to rule out torsion. High risk patients can proceed directly to surgery, with more than 50% avoiding ultrasound. In the future emergency medical technicians and/or emergency room triage personnel may be able to calculate TWIST score to guide radiological evaluation and immediate surgical intervention at initial assessment long before urological consultation.

Segmental arterial mapping during pediatric robot-assisted laparoscopic heminephrectomy: A descriptive series

INTRODUCTIONnThe incidence of innocent moiety injury during heminephrectomy is estimated to be 4-5%. This complication can have long-term consequences for the child. Selective arterial mapping (SAM) with indocyanine green (ICG)-aided near infrared fluorescence (NIRF) imaging using the Firefly™ system on the da Vinci(®) surgical robotic console has proven to be valuable in robotic partial nephrectomy for adult renal tumors. However, there is nothing in the literature for using this technique in pediatric robot-assisted laparoscopic heminephrectomy (RALHN).nnnOBJECTIVEnTo present a descriptive series of children who had SAM RALHN using ICG-aided NIRF imaging. To determine the feasibility of using ICG-aided NIRF SAM during RALHN, and to study if real-time delineation of the selective arterial anatomy of the upper and lower moieties would be helpful or change the immediate outcomes of the surgery.nnnSTUDY DESIGNnA descriptive series of six children who received RALHN at the present institution.nnnRESULTSnSelective arterial mapping was performed safely without toxicity or vascular complications; it did not extend the operative time and did not change the complexity of the operation. As shown in the summary table below, SAM added value by increasing safety of the operation. The individual operation cost increase of using SAM was only related to the single-use vial of ICG.nnnDISCUSSIONnInadvertent injury to the innocent moiety in pediatric heminephrectomy is seldom noted intraoperatively, and many times only becomes evident postoperatively when there is acute ischemia or a chronic reduction in renal function. Although there is no replacement for good surgical technique and judgment, SAM during RALHN is a useful real-time way of alerting the surgeon to unexpected anatomy, and possible unintended or occult injury to the innocent moiety that could have devastating short-term and long-term consequences to the child, despite immediate recovery from surgery.nnnCONCLUSIONSnThis report achieved its aim of reporting the feasibility of SAM on a small descriptive series of children who had RALHN.

Spinal anesthesia for pediatric urological surgery: Reducing the theoretic neurotoxic effects of general anesthesia

BACKGROUNDnSpinal anesthesia (SA) is an effective technique that has been used in children for years. With growing concern with regard to the risks of general anesthesia (GA), we developed a SA program to provide an alternative option. We present our initial experience with this program.nnnOBJECTIVEnTo implement a SA program at a large tertiary care pediatric center and assess the safety and efficacy of the technique as an alternative to GA for urologic surgery.nnnSTUDY DESIGN/METHODSnWe prospectively collected data on all children undergoing SA at our institution. We recorded demographics, procedure, time required for placement of the SA, length of surgery, success of lumbar puncture, success of attaining adequate surgical anesthesia, need for supplemental systemic sedation, conversion to GA, and perioperative complications.nnnRESULTSnSA was attempted in 105 consecutive children (104 boys, 1 girl) with a mean age of 7.4xa0±xa04.3 months (range 19 days-24 months) and mean weight of 8.3xa0±xa01.7xa0kg (range 3.5-13.7). Placement of the SA was successful in 93/105 children (89%). Inability to achieve lumbar puncture (cerebrospinal fluid was not obtained) meant that SA was abandoned in seven (7%) patients and GA was administered. In five patients in whom SA was successful and surgery was begun, 5/93 (5%) required conversion to GA: two because of evisceration of intestine through large hernia defects related to coughing and abdominal irritation, two because of lack of motor blockade despite an adequate sensory block, and one because of an inability to place an intravenous catheter in the lower extremities (required per SA protocol). If necessary, an intravenous catheter can be placed in the upper extremity, but this must be weighed against the fact that the block has already been placed and is of limited duration. Overall, SA was successful (SA was placed and surgery was completed without conversion to GA) in 88/105 children (84%). No additional sedation and no systemic anesthetic agents were required in 75/88 children (85%). The average time required to place the SA was 3.8xa0±xa02.7xa0min (range 1-12). The average time for the surgical procedure was 38.3xa0±xa023.1xa0min (range 10-122). No patient required conversion to GA because of recession of block. There were no surgical complications.nnnDISCUSSION/CONCLUSIONSnSA is a safe and efficacious technique for routine pediatric urological procedures. SA should be considered for cases such as neonatal torsion or patients with significant cardiac or pulmonary comorbidities when the risks of GA are often weighed against the risks of non-intervention.

Indicators and outcomes of transfer to tertiary pediatric hospitals for patients with testicular torsion

INTRODUCTIONnTesticular torsion threatens testicular viability with increased risk of loss with delayed management. Still, healthy adolescents continue to be transferred from community hospitals to tertiary hospitals for surgical management for torsion even though adult urologists may be available. We sought to determine reasons behind patient transfer and to evaluate whether transfer to tertiary centers for testicular torsion leads to increased rates of testicular loss.nnnMATERIALS AND METHODSnA retrospective chart review was performed for patients presenting to our free-standing pediatric tertiary care facility with surgically confirmed testicular torsion during the 5-year period between January 2011 and January 2016. Data was collected regarding transfer status, patient demographics, time of presentation to our facility, duration of symptoms, patient workup, and surgical outcomes. Patients with perinatal or intermittent torsion were excluded.nnnRESULTSnOne-hundred and twenty-five patients met the inclusion criteria. Thirty-six of those were transferred from outside facilities while 89 presented directly to our hospital. A greater proportion of the transferred patients presented during nights or weekends than those presenting directly to our facility (77.8% versus 51.7%, pxa0=xa00.009). Eighty-nine patients presented with symptom duration of less than 24xa0h and had potentially viable testicles. Of those, 23 were transferred and 66 presented directly to our hospital. Differences are shown in the Table. Transferred patients had twice the rate of testicular loss as those not transferred, although the results were not significant (30.4% versus 15.2%, pxa0=xa00.129). Patients undergoing ultrasound prior to transfer had prolonged symptom duration and faced higher rates of testicular loss when compared with patients not transferred, although the latter was not significant (mean duration 8.0 versus 4.9xa0h, pxa0=xa00.025, and testicular loss 40.0% versus 15.2%, pxa0=xa00.065, respectively). Patients transferred over 30 miles had over 2.5 times the rate of testicular loss than those not transferred (42.8% versus 15.2%, pxa0=xa00.029).nnnDISCUSSIONnThis study is unique in its examination of motivations for transfer of patients presenting with testicular torsion and in its evaluation of the impact of transfer on testicular salvage rates for potentially viable testicles (those with less than 24xa0h since symptom onset).nnnCONCLUSIONnPatients are more likely to be transferred to our tertiary pediatric facility for management of testicular torsion during the night or weekend. Transferring patients for management of testicular torsion delays definitive management and threatens testicular viability, especially in those transferred greater distances. Urologists at the facility of initial patient presentation should correct testicular torsion when able.

Transscrotal Near Infrared Spectroscopy as a Diagnostic Test for Testis Torsion in Pediatric Acute Scrotum: A Prospective Comparison to Gold Standard Diagnostic Test Study

Purpose: A rapid test for testicular torsion in children may obviate the delay for testicular ultrasound. In this study we assessed testicular tissue percent oxygen saturation (%StO2) measured by transscrotal near infrared spectroscopy as a diagnostic test for pediatric testicular torsion. Materials and Methods: This was a prospective comparison to a gold standard diagnostic test study that evaluated near infrared spectroscopy %StO2 readings to diagnose testicular torsion. The gold standard for torsion diagnosis was standard clinical care. From 2013 to 2015 males with acute scrotum for more than 1 month and who were less than 18 years old were recruited. Near infrared spectroscopy %StO2 readings were obtained for affected and unaffected testes. Near infrared spectroscopy &Dgr;%StO2 was calculated as unaffected minus affected reading. The utility of near infrared spectroscopy &Dgr;%StO2 to diagnose testis torsion was described with ROC curves. Results: Of 154 eligible patients 121 had near infrared spectroscopy readings. Median near infrared spectroscopy &Dgr;%StO2 in the 36 patients with torsion was 2.0 (IQR −4.2 to 9.8) vs −1.7 (IQR −8.7 to 2.0) in the 85 without torsion (p=0.004). AUC for near infrared spectroscopy as a diagnostic test was 0.66 (95% CI 0.55–0.78). Near infrared spectroscopy &Dgr;%StO2 of 20 or greater had a positive predictive value of 100% and a sensitivity of 22.2%. Tanner stage 3‐5 cases without scrotal edema or with pain for 12 hours or less had an AUC of 0.91 (95% CI 0.86–1.0) and 0.80 (95% CI 0.62–0.99), respectively. Conclusions: In all children near infrared spectroscopy readings had limited utility in diagnosing torsion. However, in Tanner 3‐5 cases without scrotal edema or with pain 12 hours or less, near infrared spectroscopy discriminated well between torsion and nontorsion.

Prospective Evaluation of Predictors of Testis Atrophy After Surgery for Testis Torsion in Children

OBJECTIVEnTo prospectively correlate pain duration, red scrotal skin, ultrasound appearance of testis, and intraoperative testis color to future testis atrophy after acute testicular torsion.nnnMETHODSnPatients 2 months-18 years old with unilateral acute scrotum were consecutively enrolled in a National Institutes of Health transcutaneous near-infrared spectroscopy study, with a subgroup analysis of the true torsion group. Presence or absence of red scrotal skin, pain duration, testicular heterogeneity on preoperative ultrasound, and intraoperative testis color based on a novel visual chart 5 minutes after detorsion were recorded. All testes underwent orchiopexy regardless of appearance. Percent volume difference between normal and torsed testicles on follow-up ultrasound was compared between patients with and without risk factors.nnnRESULTSnThirty of 56 patients who had surgical detorsion underwent scrotal ultrasound at a mean of 117 days after surgery. A color of black or hemorrhagic 5 minutes after detorsion, pain duration >12 hours, and heterogeneous parenchyma on preoperative ultrasound were associated with significant testis volume loss in follow-up compared with normal testis. All patients with a black or hemorrhagic testis had >80% volume loss. Erythematous scrotal skin was not significantly associated with smaller affected testis volume in follow-up.nnnCONCLUSIONnBased on the high atrophy rate, orchiectomy can be considered for testes that are black or hemorrhagic 5 minutes after detorsion. Pain duration >12 hours and parenchymal heterogeneity on preoperative ultrasound were also associated with testis atrophy. Red scrotal skin was not a reliable predictor of atrophy and should not delay exploration.

Testicular adrenal rest tumor screening and fertility counseling among males with congenital adrenal hyperplasia

BACKGROUNDnReduced fertility is a common potential problem among males with congenital adrenal hyperplasia (CAH), with nearly half experiencing impaired sperm production. The major cause of oligo/azoospermia in CAH is testicular adrenal rest tumors (TARTs). Studies indicate that ultrasound screening for TARTs should begin during childhood, yet it remains unclear whether boys with CAH are routinely screened for TARTs and/or counseled about infertility risk and potential interventions such as fertility testing and/or preservation.nnnOBJECTIVEnThe purpose of this study was to examine TART screening and fertility counseling practices among boys with CAH.nnnSTUDY DESIGNnAn IRB-approved retrospective chart review was conducted of all males with ICD-9/10 codes for CAH (2007-2016) at a large pediatric academic center to examine: age and indication for diagnosis; age at first and last documented pediatric endocrinology and urology visit; history of ultrasound examinations; and documentation of fertility counseling.nnnRESULTSnForty-six patients were included, of whom 38 had 21-hydroxylase deficiency. Median age at diagnosis was 2 weeks (range 7 days-10 years). Median age at the most recent pediatric endocrinology clinic visit was 14 years (range 2-42 years). Twenty-nine patients were >11 years old (63% of the sample) at the time of the study and 14 of these were >18 years old (30% of the sample). Seven patients (15%) had a screening ultrasound at some point in their care, of whom three had TARTs. Fertility was mentioned in the records of six subjects (13% of the sample). Six of the subjects (13%) had any mention of fertility in their records. None of the patients had biochemical testing or semen analysis to assess gonadal function, and none were offered fertility preservation. Only one patient was seen by a pediatric urologist.nnnDISCUSSIONnDespite the limitations of a single-center retrospective design, our findings highlight that TART screening and fertility counseling remain underutilized in boys with CAH. There is a need for increased awareness and development of practice guidelines within pediatric urology and endocrinology to address this common and understudied problem.nnnCONCLUSIONnIn addition to a screening ultrasound in puberty and consideration of semen analysis after puberty, these boys may benefit from seeing a pediatric urologist independently or in an interdisciplinary program. Boys with CAH and their families should be educated about infertility risk and potential interventions, with the goal of improving reproductive outcomes in this population.

Cloaca reconstruction: a new algorithm which considers the role of urethral length in determining surgical planning

BACKGROUNDnCloacal malformations represent a uniquely complex challenge for surgeons. The surgical approach to date has been based on the common channel (CC) length with two patient groups considered: less than or greater than 3cm, which we believe is an oversimplification. We reviewed 19 patients, referred after surgery done elsewhere. Eight had postoperative urinary complications, 3 had constant urinary leakage and had been left after surgery with a urethra <1cm, .5 with an original 3 to 5cm common channel, who had undergone total urogenital mobilization (TUM), experienced peri-operative urethral loss needing a vesicostomy, and later, a Mitrofanoff. These patients together with a review of the cloacal and urological literature led us to design a new algorithm where urethral length is a key determinant for care.nnnMETHODSnWe prospectively collected data on 31 consecutive cloaca patients referred to our team (2014 to 2016) and managed according to this new protocol. The CC length, urethral length, surgical technique employed, and initial outcomes were recorded.nnnRESULTSnOf 31 primary cases, CC length was 1 to 3cm in 20, 3 to 5cm in 9, and greater than 5cm in 2. In the 1 to 3cm and the 3 to 5cm groups, a urethra less than 1.5cm led us to perform an urogenital separation. We only performed a TUM if the urethra was greater than 1.5cm. Using this protocol, we performed a urogenital separation in 1 of 20 in the 1 to 3cm CC group, 6 of 9 in the 3 to 5cm CC group, and 2 of 2 in the greater than 5cm CC group. Seven patients underwent separation, who with the previous approach, would have had a TUM. Thus far, no urinary leakage or urethral loss has occurred in any patient, but follow-up is less than 3years.nnnCONCLUSIONnUrethral length appears to be a vitally important component in cloacal reconstruction. A short urethra left after repair can lead to urinary leakage. A TUM done under the wrong circumstances can lead to urethral loss. We describe a new technical approach to cloacal repair which considers urethral length but recognize that long term urological outcomes will need to be carefully documented.nnnTYPE OF STUDYnClinical cohort study with no comparative group.nnnLEVEL OF EVIDENCEnLevel 4.

Non-traumatic testicular rupture following episode of epididymo-orchitis

Epididymo-orchitis is not uncommon in pediatric patients, and typically responds well to conservative treatment and antibiotics without additional sequelae. Testicular rupture is most commonly associated with testicular trauma, but has been reported in the adult population. We report the first case to our knowledge of nontraumatic, spontaneous testicular rupture in a pediatric patient being treated conservatively for epididymo-orchitis.

Intraoperative Onabotulinumtoxin-A Reduces Postoperative Narcotic and Anticholinergic Requirements After Continent Bladder Reconstruction

OBJECTIVEnTo determine if intradetrusor injection of onabotulinumtoxin-A (BTX-A) would reduce postoperative narcotic and anticholinergic requirements in children undergoing open continent bladder reconstruction.nnnMATERIALS AND METHODSnAfter institutional review board approval, we retrospectively reviewed all bladder reconstructions performed. Bladder reconstruction was defined as the following procedures in any combination: bladder neck reconstruction and sling, bladder neck closure, Mitrofanoff, Monti, or bladder augmentation. We identified 15 children who underwent reconstruction with BTX-A injection and compared these with 15 children who did not receive BTX-A. Postoperative narcotic and anticholinergic requirements were recorded as well as length of stay, time to diet, time to return of bowel function, and complications. All medications were converted to morphine mEq/kg per day or mg/kg per day to standardize for patient size and length of stay.nnnRESULTSnThirty patients who underwent open bladder reconstruction were included. Fifteen received BTX-A injection and 15 did not. The BTX-A group required significantly less narcotic medication postoperatively compared with the no-BTX-A group (0.32 vs 0.85 morphine mEq/kg per day; Pu2009=u2009.0002). The BTX-A group also required significantly less anticholinergic medication compared with the no-BTX-A group (0.22 vs 0.88u2009mg/kg per day; Pu2009=u2009.024). There was no significant difference between the groups with respect to length of stay (98.27 vs 9.287 days; Pu2009=u2009.34) or return of bowel function (5.53 vs 4.93 days; Pu2009=u2009.994). Complication rate between the groups was similar (Pu2009>.99).nnnCONCLUSIONnIntraoperative injection of BTX-A significantly reduced postoperative narcotic and anticholinergic requirements in patients who underwent open continent bladder reconstruction. This is an encouraging alternative treatment to manage postoperative pain with no associated risk of significant complications.