James M. Elmore

Incidence of Urinary Tract Infections in Children After Successful Ureteral Reimplantation Versus Endoscopic Dextranomer/Hyaluronic Acid Implantation

PURPOSE Endoscopic implantation of dextranomer/hyaluronic acid has proved to be an effective minimally invasive technique for correcting vesicoureteral reflux in children. There is some evidence suggesting that in addition to being less invasive, successful dextranomer/hyaluronic acid implantation compared to successful antireflux surgery is associated with fewer febrile and nonfebrile urinary tract infections. We review the clinical outcomes of 2 groups of children cured of reflux with open surgery and dextranomer/hyaluronic acid implantation to determine if a difference in clinical outcomes exists. MATERIALS AND METHODS We reviewed the charts of 43 patients who underwent dextranomer/hyaluronic acid implantation and 33 who underwent open surgery for vesicoureteral reflux. Data collected included age, gender, preoperative and postoperative grades of reflux, and urinalysis and urine culture results. Urinary tract infection was defined as any culture that grew more than 10(5) colonies of a single organism, with symptoms typical of cystitis (urgency, frequency, dysuria). A febrile urinary tract infection was defined as an infection accompanied by a temperature greater than 101.5F. Any hospitalizations for febrile episodes were also recorded. RESULTS The incidence of urinary tract infection after successful open surgery (38%) was significantly higher than that observed following successful dextranomer/hyaluronic acid treatment (15%, p = 0.03). Febrile urinary tract infections occurred in 24% of the children who underwent open surgery and in 5% of those who underwent dextranomer/hyaluronic acid implantation (p = 0.02). Hospital readmissions occurred only in the group undergoing open surgery. CONCLUSIONS Children successfully cured of vesicoureteral reflux with dextranomer/hyaluronic acid implantation have a lower incidence of febrile and nonfebrile urinary tract infections compared to those cured with open surgery. These findings suggest that dextranomer/hyaluronic acid implantation, when successful, may result in more favorable clinical outcomes.

Dextranomer/hyaluronic acid for vesicoureteral reflux : Success rates after initial treatment failure

PURPOSE Following Food and Drug Administration approval of Dx/HA there has been increasing interest in the endoscopic management of VUR. Currently, there are few data regarding the success rates of repeat injection. We recently published our success rates for a group of children following initial Dx/HA treatment, and herein report the success rate of a subgroup of children undergoing repeat injection. MATERIALS AND METHODS We queried our database to identify all children undergoing a second Dx/HA injection for the treatment of VUR at our institution. VUR grades as determined by VCUG before and after the second treatment were specifically noted. Success was defined as the complete absence of VUR by VCUG. RESULTS A total of 42 children (37 girls and 5 boys) with a mean age of 5 years underwent a second Dx/HA treatment for VUR after initial treatment failure. Complete followup was available for 39 patients (53 ureters). Before the second injection 14 patients had bilateral and 25 had unilateral VUR, with a mean grade of 2.2. A second Dx/HA injection resolved VUR in 35 of 39 patients (90%) and in 47 of 53 ureters (89%). A second injection resolved reflux in 7 of 8 ureters (88%) with grade I, 24 of 26 (92%) with grade II and 16 of 19 (84%) with grade III VUR. CONCLUSIONS A second Dx/HA injection for the treatment of VUR persisting after initial endoscopic treatment has a high success rate. This information is useful when counseling parents after initial treatment failure.

New Contralateral Vesicoureteral Reflux Following Dextranomer/Hyaluronic Acid Implantation: Incidence and Identification of a High Risk Group

PURPOSE To our knowledge the incidence of NCVUR following the endoscopic treatment of VUR with Dx/HA has not been reported previously. We evaluated the outcomes in a group of patients to determine the incidence, and to attempt to identify risk factors. MATERIALS AND METHODS A total of 126 children with primary unilateral VUR underwent unilateral Dx/HA implantation at our institutions. The incidence of NCVUR was determined by postoperative VCUG. Indications for surgery, patient age and gender, preoperative grade of VUR and volume of Dx/HA injected were assessed as possible risk factors for NCVUR. RESULTS Of the patients 96 (76.2%) were female, and mean age was 4.8 years. The principal indications for Dx/HA implantation were persistent reflux in 56 patients (44.4%) and primary therapy in 51 (40.5%). At followup VCUG 17 patients (13.5%) had NCVUR. No variable independently appeared to influence the incidence of NCVUR. Statistical analysis suggests that females younger than 5 years have an increased incidence of NCVUR (13 of 62, or 21% vs 4 of 64, or 6.3% of the remaining patients, p = 0.016). CONCLUSIONS NCVUR occurred in approximately 13% of our patients. Patients with higher preoperative VUR grade or a lower number of preoperative VCUGs and those undergoing treatment as primary therapy did not have an increased incidence. Girls younger than 5 years had the highest incidence of NCVUR, and initial bilateral injection may be a consideration for this group. Further effort directed at identifying the etiology and risk factors for NCVUR is needed.

Dynamic Hydrodistention of the Ureteral Orifice: A Novel Grading System With High Interobserver Concordance and Correlation With Vesicoureteral Reflux Grade

PURPOSE We evaluated the usefulness and interobserver concordance of a novel grading system for dynamic ureteral hydrodistention. MATERIALS AND METHODS Between May 1, 2002 and July 1, 2008 the hydrodistention grade in 697 ureters was prospectively assigned and recorded, including H0-no hydrodistention, H1-ureteral orifice open but tunnel not evident, H2-tunnel seen only and H3-extravesical ureter visualized. Specifically 489 refluxing ureters (vesicoureteral reflux group) were compared to 100 normal control ureters (normal control group). Additionally, the posttreatment hydrodistention grade in 56 ureters in which surgery for reflux failed was compared to that in 52 ureters with successful surgery. Hydrodistention grades assigned to an additional 77 ureters by 3 blinded observers were compared to assess the interobserver concordance of this system. RESULTS Vesicoureteral reflux and hydrodistention grades correlated significantly (p <0.001). Ureters with a higher reflux grade also showed a higher hydrodistention grade. The normal control group (mean +/- SEM hydrodistention grade 0.62 +/- 0.07) showed a statistically lower hydrodistention grade than the reflux groups (overall mean hydrodistention grade 2.26 +/- 0.01). Mean posttreatment hydrodistention grade in the failed reflux surgery group was statistically higher than that in the mean successful reflux surgery group (2.03 +/- 0.09 vs 1.33 +/- 0.08). By defining the degree of hydrodistention as normal (H0-H1) and abnormal (H2-H3) the concordance between observers was 95% and 96%. CONCLUSIONS The dynamic hydrodistention classification is a reliable method of evaluating the presence or absence of vesicoureteral reflux as it correlates significantly with radiographic reflux grade. It has high interobserver concordance.

The GMS hypospadias score: Assessment of inter-observer reliability and correlation with post-operative complications

OBJECTIVE An agreed upon method for describing the severity of hypospadias has not been established. Herein we assess the inter-observer reliability of the GMS hypospadias score and correlate it with the risk of a post-operative complication. METHODS A 3-component method for grading the severity of hypospadias was developed (GMS). Eighty-five consecutive patients presenting for hypospadias repair were graded independently by at least 2 surgeons using the GMS criteria. Scores were compared statistically to determine agreement between the observers. The outcomes of these patients were then reviewed to determine how the GMS score correlates to the risk of a surgical complication. RESULTS The G, M, and S scores had excellent agreement between observers. The GMS total score was exactly the same or differed by one point in 79/85 (93%) of patients. The complication rate was 5.6% for patients with a GMS score of 6 or less, but was 25.0% for patients with a GMS score greater than 6. CONCLUSIONS The GMS score provides a concise method for describing the severity of hypospadias and appears to have high inter-observer reliability. The GMS score also appears to correlate with the risk of a surgical complication.

Sutureless and scalpel-free circumcision--more rapid, less expensive and better?

PURPOSE We previously reported our success with sutureless circumcision using 2-octyl cyanoacrylate in 267 patients. We have since modified our technique by making incisions with electrocautery. We report our results with this novel technique. We also performed a cost analysis. MATERIALS AND METHODS We compiled data on all patients 6 months to 12 years old who underwent primary circumcision and circumcision revision in a 39-month period, as done by 3 surgeons. Study exclusion criteria were complexity beyond phimosis and Gomco clamp use. The technique included 1) a circumferential inner incision using electrocautery on cutting current, 2) a circumferential outer incision using electrocautery, 3) foreskin removal, 4) hemostasis with electrocautery, 5) skin edge approximation with 2-octyl cyanoacrylate or 6-zero suture and 6) antibiotic ointment application. We also determined the cost of all procedures based on anesthesia and operating room facility fees, and material costs. RESULTS Between July 1, 2006 and October 1, 2009 we performed 493 primary circumcisions and 248 revisions using 2-octyl cyanoacrylate, and 152 primary circumcisions and 115 revisions using 6-zero sutures. Mean operative time for primary circumcision and revision using 2-octyl cyanoacrylate was 8 minutes (range 6 to 18), and for sutured primary circumcision and revision it was 27 minutes (range 18 to 48). At a mean 18-month followup (range 1 to 39) 3 patients treated with 2-octyl cyanoacrylate and 2 treated with sutures were rehospitalized for bleeding. When done with electrocautery, the cost of the 2-octyl cyanoacrylate technique was

Further analysis of the Glans-Urethral Meatus-Shaft (GMS) hypospadias score: Correlation with postoperative complications

743.55 less than the sutured technique as long as the 2-octyl cyanoacrylate procedures required less than 15 minutes and the sutured procedures required more than 15 minutes. CONCLUSIONS Combined electrocautery and 2-octyl cyanoacrylate for circumcision is a safe, efficient, financially beneficial, cosmetically appealing alternative to traditional circumcision done with scalpel and sutures.

Emergency room visits and readmissions after pediatric urologic surgery.

INTRODUCTION AND OBJECTIVE The Glans-Urethral Meatus-Shaft (GMS) score is a concise and reproducible way to describe hypospadias severity. We classified boys undergoing primary hypospadias repair to determine the correlation between GMS score and postoperative complications. STUDY DESIGN Between February 2011 and August 2013, patients undergoing primary hypospadias repair were prospectively scored using the GMS classification. GMS scoring included a 1-4 scale for each component: G - glans size/urethral plate quality, M - meatal location, and S - degree of shaft curvature, with more unfavorable characteristics assigned higher scores [Figure]. Demographics, repair type, and complications (urethrocutaneous fistula, meatal stenosis, glans dehiscence, phimosis, recurrent chordee and stricture) were assessed. Total and individual component scores were tested in uni- and multivariate analysis. RESULTS Two-hundred and sixty-two boys (mean age 12.3 ± 13.7 months) undergoing primary hypospadias repair had a GMS score assigned. Mean GMS score was 7 ± 2.5 (G 2.1 ± 0.9, M 2.4 ± 1, S 2.4 ± 1). Mean clinical follow-up was 17.7 ± 9.3 months. Thirty-seven children (14.1%) had 45 complications. A significant relationship between the total GMS score and presence of any complication (p < 0.001) was observed; for every unit increase in GMS score the odds of any postoperative complication increased 1.44 times (95% CI, 1.24-1.68). Urethrocutaneuous fistula was the most common complication, occurring in 21 of 239 (8.8%) of single-stage repairs. Patients with mild hypospadias (GMS 3-6) had a 2.4% fistula rate vs. 11.1% for moderate (GMS 7-9) and 22.6% for severe (GMS 10-12) hypospadias (p < 0.001). Degree of chordee was an independent predictor of fistula on multivariate analysis; S4 (>60° ventral curvature) patients were 27 times more likely to develop a fistula than S1 (no curvature) boys (95% CI, 3.2-229). DISCUSSION The GMS score is based on anatomic features (i.e. glans size/urethral plate quality, location of meatus, and degree of chordee) felt to most likely impact functional and cosmetic outcomes following hypospadias repair. We demonstrated a statistically significant increase in the likelihood of any postoperative complication with every unit increase in total GMS score. The concept that factors aside from meatal location affect hypospadias repair and outcomes is not novel, and degree of ventral curvature and urethral plate quality are often cited as important factors. In our series, boys with greater than 60° of ventral curvature undergoing a single-stage repair were 27 times more likely to develop a fistula than those without chordee on multivariate analysis, making severe curvature an independent predictor of urethrocutaneous fistula formation. That meatal location did not retain significance on multivariate analysis highlights the importance of considering the entire hypospadias complex when determining severity, rather than just evaluating the position of the meatus. Our study has several limitations that warrant consideration. While GMS scores were assigned prospectively, the data was collected retrospectively, subjecting it to flaws inherent with such study design. Furthermore, type of repair is influenced by surgeon preference and subjective assessment of hypospadias characteristics not incorporated in our scoring system (i.e. tissue quality, urethral hypoplasia, penoscrotal transposition). Despite these limitations, our study demonstrates a strong correlation between the GMS classification and surgical complications, furthering supporting its potential as a tool to standardize hypospadias severity and gauge postoperative complications. CONCLUSION The Glans-Urethral Meatus-Shaft (GMS) classification provides a means by which hypospadias severity and reporting can be standardized, which may improve inter-study comparison of reconstructive outcomes. There is a strong correlation between complication risk and total GMS score. Degree of chordee (S score) is independently predictive of fistula rate.

Comparison of Ultrasound and Magnetic Resonance Urography for Evaluation of Contralateral Kidney in Patients With Multicystic Dysplastic Kidney Disease

OBJECTIVE Reducing readmissions has become a focal point to increase quality of care while reducing costs. We report all-cause unplanned return visits following urologic surgery in children at our institution. MATERIALS AND METHODS Children undergoing urology procedures with returns within 30 days of surgery were identified. Patient demographics, insurance status, type of surgery, and reason for return were assessed. RESULTS Four thousand and ninety-seven pediatric urology surgeries were performed at our institution during 2012, with 106 documented unplanned returns (2.59%). Mean time from discharge to return was 5.9 ± 4.9 days (range, 0.3-24.8 days). Returns were classified by chief complaint, including pain (32), infection (30), volume status (14), bleeding (11), catheter concern (8), and other (11). Circumcision, hypospadias repair, and inguinal/scrotal procedures led to the majority of return visits, accounting for 21.7%, 20.7%, and 18.9% of returns, respectively. Twenty-two returns (20.75%) resulted in hospital readmission and five (4.72%) required a secondary procedure. Overall readmission rate was 0.54%, with a reoperation rate of 0.12%. CONCLUSIONS The rate of unplanned postoperative returns in the pediatric population undergoing urologic surgery is low, further strengthening the argument that readmission rates in children are not necessarily a productive focal point for financial savings or quality control.

Selective endoscopic treatment of the non-refluxing contralateral ureter prevents new contralateral vesicoureteral reflux

PURPOSE The contralateral kidney is abnormal in up to 25% of patients with multicystic dysplastic kidney. Traditionally, anatomical and functional evaluation of the contralateral kidney has been performed with ultrasound and dimercapto-succinic acid renal scintigraphy, as indicated. Recently magnetic resonance urography has been used to evaluate renal anatomy and function in other urological abnormalities. We compared the results of magnetic resonance urography and ultrasound for evaluating the contralateral kidney in patients with multicystic dysplastic kidney and we describe the range of findings detected. MATERIALS AND METHODS Patients with multicystic dysplastic kidney who underwent magnetic resonance urography were identified. Anatomical findings on magnetic resonance urography were analyzed and compared to those on renal ultrasound. Additional functional information derived from magnetic resonance urography was also recorded. RESULTS We retrospectively identified 58 patients with a unilateral multicystic dysplastic kidney who had undergone magnetic resonance urography, of whom 54 also underwent ultrasound. Of the patients 19 (32.8%) had a contralateral abnormality. A discrepancy between magnetic resonance urography and ultrasound was seen in 9 patients (16.7%). Of these patients only 1 had a completely normal contralateral kidney by ultrasound on retrospective review. The incidence and range of parenchymal abnormalities was wider than previously reported. CONCLUSIONS Contralateral abnormalities in children with multicystic dysplastic kidney are common and more definitively evaluated with magnetic resonance urography vs ultrasound. Renal ultrasound remains the most appropriate modality for the initial evaluation of children with multicystic dysplastic kidney, and magnetic resonance urography is recommended when a functional study is required either to confirm the diagnosis of multicystic dysplastic kidney or to evaluate suspected abnormalities of the contralateral kidney.