Emilie K. Johnson

Patterns of Hematuria Referral to Urologists: Does a Gender Disparity Exist?

OBJECTIVESnTo examine the referral patterns of hematuria within a nonprofit healthcare organization to determine the factors that influence referral. Hematuria continues to be an important sign of urologic disease, including urothelial malignancy. An increasing awareness of gender differences in tumor stage at bladder cancer presentation has led to speculation about delayed referral and diagnosis in women. However, little is known about the referral patterns of hematuria and whether gender differences exist.nnnMETHODSnThe insurance records were examined from 926 consecutive adult health plan participants (559 men and 367 women) with newly diagnosed hematuria from 1998 to 2002. The patterns of urologic referral were evaluated. A Cox multivariate regression model was used to examine the relationship between urologic referral and the relevant variables.nnnRESULTSnOverall, 263 men (47%) and 102 women (28%) were referred for urologic evaluation of hematuria, with a median follow-up of 27 and 26 months, respectively. Referral was initiated by the primary care physician in 80% of the cohort. Increased urologic referral was associated with advancing age, repeated hematuria, provider type, and male gender. The adjusted hazard ratio of male referral was 1.65 (95% confidence interval 1.31-2.08) compared with female referral.nnnCONCLUSIONSnPrimary care physicians practicing in a managed care setting are less likely to refer women for a urologic evaluation of new or first recurrent episodes of hematuria than to refer men in all patient age categories, except for 40-49 years. This apparent gender disparity could result in unequal access of specialty evaluation and could potentially delay the diagnosis of important urologic conditions.

National Trends of Perioperative Outcomes and Costs for Open, Laparoscopic and Robotic Pediatric Pyeloplasty

PURPOSEnWe performed a population based study comparing trends in perioperative outcomes and costs for open, laparoscopic and robotic pediatric pyeloplasty. Specific billing items contributing to cost were also investigated.nnnMATERIALS AND METHODSnUsing the Perspective database (Premier, Inc., Charlotte, North Carolina), we identified 12,662 pediatric patients who underwent open, laparoscopic and robotic pyeloplasty (ICD-9 55.87) in the United States from 2003 to 2010. Univariate and multivariate statistics were used to evaluate perioperative outcomes, complications and costs for the competing surgical approaches. Propensity weighting was used to minimize selection bias. Sampling weights were used to yield a nationally representative sample.nnnRESULTSnA decrease in open pyeloplasty and an increase in minimally invasive pyeloplasty were observed. All procedures had low complication rates. Compared to open pyeloplasty, laparoscopic and robotic pyeloplasty had longer median operative times (240 minutes, p <0.0001 and 270 minutes, p <0.0001, respectively). There was no difference in median length of stay. Median total cost was lower among patients undergoing open vs robotic pyeloplasty (

Ultrasound as a Screening Test for Genitourinary Anomalies in Children With UTI

7,221 vs

Are stone protocol computed tomography scans mandatory for children with suspected urinary calculi

10,780, p <0.001). This cost difference was largely attributable to robotic supply costs.nnnCONCLUSIONSnDuring the study period open pyeloplasty made up a declining majority of cases. Use of laparoscopic pyeloplasty plateaued, while robotic pyeloplasty increased. Operative time was longer for minimally invasive pyeloplasty, while length of stay was equivalent across all procedures. A higher cost associated with robotic pyeloplasty was driven by operating room use and robotic equipment costs, which nullified low room and board cost. This study reflects an adoption period for robotic pyeloplasty. With time, perioperative outcomes and cost may improve.

Fertility Preservation for Transgender Adolescents

BACKGROUND: The 2011 American Academy of Pediatrics guidelines state that renal and bladder ultrasound (RBUS) should be performed after initial febrile urinary tract infection (UTI) in a young child, with voiding cystourethrogram (VCUG) performed only if RBUS shows abnormalities. We sought to determine test characteristics and predictive values of RBUS for VCUG findings in this setting. METHODS: We analyzed 3995 clinical encounters from January 1, 2006 to December 31, 2010 during which VCUG and RBUS were performed for history of UTI. Patients who had previous postnatal genitourinary imaging or history of prenatal hydronephrosis were excluded. Sensitivity, specificity, and predictive values of RBUS for VCUG abnormalities were determined. RESULTS: We identified 2259 patients age <60 months who had UTI as the indication for imaging. RBUS was reported as “normal” in 75%. On VCUG, any vesicoureteral reflux (VUR) was identified in 41.7%, VUR grade >II in 20.9%, and VUR grade >III in 2.8%. Sensitivity of RBUS for any abnormal findings on VCUG ranged from 5% (specificity: 97%) to 28% (specificity: 77%). Sensitivity for VUR grade >III ranged from 18% (specificity: 97%) to 55% (specificity: 77%). Among the 1203 children aged 2 to 24 months imaged after a first febrile UTI, positive predictive value of RBUS was 37% to 47% for VUR grade >II (13% to 24% for VUR grade >III); negative predictive value was 72% to 74% for VUR grade >II (95% to 96% for VUR grade >III). CONCLUSIONS: RBUS is a poor screening test for genitourinary abnormalities. RBUS and VCUG should be considered complementary as they provide important, but different, information.

Clinical, Pathologic, and Functional Outcomes After Nephron-Sparing Surgery in Patients with a Solitary Kidney: A Multicenter Experience

megalourethra and all cases had normal karyotype. Of seven liveborn babies, one died neonatally of pulmonary hypoplasia. All six infants alive at the time of writing had a dysfunctional urethra and three suffered from impaired or end-stage renal disease. Associated anomalies were found in half of the cases. Conclusion: Congenital megalourethra is caused by abnormal development or hypoplasia of the penile erectile tissue, secondary to distal urethral obstruction. When the amniotic fluid volume is normal, survival is possible. However, all liveborn infants have voiding and renal dysfunction and sexual dysfunction is expected. Megalourethra should be considered in all male fetuses presenting prenatally with megacystis and detailed fetal ultrasonography should look for an elongated and/or distended phallic structure as well as any associated anomalies.

Values and Pitfalls of the Use of Administrative Databases for Outcomes Assessment

PURPOSEnTo describe fertility preservation (FP) utilization by transgender adolescents within a pediatric gender clinic between July 2013 and Julyxa02016.nnnMETHODSnA retrospective chart review was conducted to abstract demographic and clinical information among adolescents initiating gender-affirming hormones, including patient age at initial FP consultation, birth-assigned sex, race/ethnicity, and outcome of FP consultation.nnnRESULTSnIn our sample of 105 transgender adolescents, a total of 13 (seven transgender men and six transgender women) between the age of 14.2 and 20.6xa0years were seen in formal consultation for FP before initiating hormones. Of these adolescents, four completed sperm cryopreservation and one completed oocyte cryopreservation.nnnCONCLUSIONSnRates of FP utilization among transgender youth were low, which is consistent with a recently published report of FP utilization among transgender youth at another pediatric institution. Identified barriers to FP in our sample included cost, invasiveness of procedures, and desire not to delay medical transition.

The Impact of Urethroplasty on Voiding Symptoms and Sexual Function

BACKGROUND AND PURPOSEnSurgical management of a renal neoplasm in a solitary kidney is a balance between oncologic control and preservation of renal function. We analyzed patients with a renal mass in a solitary kidney undergoing nephron-sparing procedures to determine perioperative, oncologic, and renal functional outcomes.nnnPATIENTS AND METHODSnA multicenter study was performed from 12 institutions. All patients with a functional or anatomic solitary kidney who underwent nephron-sparing surgery for one or more renal masses were included. Tumor size, complications, and recurrence rates were recorded. Renal function was assessed with serum creatinine level and estimated glomerular filtration rate.nnnRESULTSnNinety-eight patients underwent 105 ablations, and 100 patients underwent partial nephrectomy (PN). Preoperative estimated glomerular filtration rate (eGFR) was similar between the groups. Tumors managed with PN were significantly larger than those managed with ablation (P<0.001). Ablations were associated with a lower overall complication rate (9.5% vs 24%, P=0.01) and higher local recurrence rate (6.7% vs 3%, P=0.04). Eighty-four patients had a preoperative eGFR ≥60u2009mL/min/1.73u2009m(2). Among these patients, 19 (23%) fell below this threshold after 3 months and 15 (18%) at 12 months. Postoperatively, there was no significant difference in eGFR between the groups.nnnCONCLUSIONSnExtirpation and ablation are both reasonable options for treatment. Ablation is more minimally invasive, albeit with higher recurrence rates compared with PN. Postoperative renal function is similar in both groups and is not affected by surgical approach.

Nationwide emergency department imaging practices for pediatric urolithiasis: Room for improvement

In this issue of The Journal Lee et al (page 000) examine rates of reoperation and predictors of complications in patients with hypospadias.1 This article represents an interesting example of the use of administrative data to address a clinical question. We discuss the uses and limitations of administrative databases. n nAdministrative data (also known as claims data or secondary data) are data collected for nonresearch purposes (often for billing) that can be analyzed retrospectively for research. Examples include Medicare claims, the Nationwide Inpatient Sample, proprietary insurance claims databases and the Pediatric Health Information System Database. When used for research, such data sets typically contain limited, de-identified information regarding hospitals, clinicians and patients (including demographics and clinical information via ICD and/or CPT diagnosis and procedure codes) as these pertain to specific clinical encounters.

Prevalence and correlates of vitamin and supplement usage among men with a family history of prostate cancer

OBJECTIVEnTo determine the effect of urethroplasty for urethral stricture disease on both voiding symptoms and sexual function through the use of validated patient questionnaires.nnnMETHODSnPre- and post-operative scores for the American Urological Association Symptom Index (AUASI), Incontinence Symptom Index (ISI), and Sexual Health Inventory for Men (SHIM) were obtained and compared for adult male patients undergoing urethroplasty. Score differences were then stratified by age. Relevant clinical and demographic characteristics were also examined.nnnRESULTSnOver the 15-year study period, 183 patients underwent 222 urethroplasties. Median age at the time of surgery was 45 years. Urethroplasties were performed for 207 anterior and 15 posterior urethral strictures. The most common approaches were primary anastomotic (36.5%), staged (23.9%), and buccal graft augmented (21.6%). Overall, 63% of men had a clinically meaningful (≥4 point) improvement in AUASI total score and 69% had improvement in their quality of life (QOL) score after urethroplasty. In aggregate, AUASI total scores improved by 7 points (P<.001), and QOL scores improved by 2 points (P<.001). There was no significant difference in ISI or SHIM scores before and after urethroplasty. AUASI total scores improved more dramatically in younger patients. Half of patients with improved AUASI QOL scores did not have a corollary improvement in their total score.nnnCONCLUSIONSnAs measured by validated questionnaires, patients of all ages can expect a meaningful improvement in bothersome voiding symptoms after urethroplasty for urethral stricture disease, with minimal impact on continence or erectile function.