Jonathan C. Routh

Epidemiological Trends in Pediatric Urolithiasis at United States Freestanding Pediatric Hospitals

PURPOSE Anecdotal and lay press reports suggest that the incidence of pediatric urolithiasis is increasing but reliable data are lacking. The objective of this study was to examine trends in the epidemiology of urolithiasis at pediatric hospitals nationwide. MATERIALS AND METHODS The Pediatric Health Information System database is a national database covering 42 freestanding United States pediatric hospitals that captures inpatient admissions, and emergency department and outpatient surgery visits. We searched the Pediatric Health Information System database to identify children (18 years old or younger) treated for urolithiasis between 1999 and 2008. Patients with urolithiasis were measured as a proportion of the total number of patients seen per hospital annually. Trends were verified by comparing results to 2 other common pediatric diagnoses-appendicitis and viral bronchiolitis. RESULTS We identified 7,921 children diagnosed with urolithiasis during the study period. The total number of children with urolithiasis seen in Pediatric Health Information System hospitals increased from 125 in 1999 to 1,389 in 2008. Mean number of stone cases per hospital per year increased from 13.9 to 32.6. Compared to total hospital patients, the proportion of patients with pediatric urolithiasis increased from 18.4 per 100,000 in 1999 to 57.0 per 100,000 in 2008, an adjusted annual increase of 10.6% (p <0.0001). Urolithiasis also increased compared to appendicitis (p <0.0001) and bronchiolitis (p <0.0001). CONCLUSIONS Even after correcting for increases in total patient volume at Pediatric Health Information System hospitals, there has been a significant increase in the number of children diagnosed with and treated for urolithiasis at these hospitals in the last decade.

Adenocarcinoma of the prostate: epidemiological trends, screening, diagnosis, and surgical management of localized disease.

Prostate cancer is a leading cause of mortality and morbidity worldwide. Despite years of study and effort, certain key questions remain unanswered, including how prostate cancer is best detected and diagnosed, how it is best treated, and how best to minimize the complications of treatment. The aim of this article is to briefly address these topics to shed light on the current best practices in prostate cancer screening, diagnosis, and surgical treatment of localized disease. We examine current trends in prostate cancer epidemiology and screening, including genetic and dietary risk factors and the newer prostate-specific antigen-derived screening modalities. Methods of diagnosis, including an overview of prostate biopsy technique and indications, and a brief review of relevant pathologic findings are provided. An in-depth analysis of traditional prostate cancer surgical management highlights the relevant advantages and disadvantages of radical retropubic and perineal prostatectomy. Complications of surgery, prognostic factors, and the many risk prediction models currently available are discussed. In all, this article aims to give the reader a broad overview of the basic elements of prostate cancer diagnosis and surgical treatment in the modem era.

Nonoperative Management of Nonvascular Grade IV Blunt Renal Trauma in Children: Meta-analysis and Systematic Review

OBJECTIVES To evaluate nonoperative management of grade IV blunt renal trauma in pediatric patients by performing a systematic review and meta-analysis of published studies. METHODS MEDLINE, EMBASE, Cochrane, and Scopus databases were searched between January 1992 and June 2008 for studies of pediatric renal trauma management. Inclusion criteria were patient age <or= 18 years and use of the American Association for the Surgery of Trauma renal injury scale. RESULTS A total of 95 children with grade IV injuries were identified. No intervention was required in 72% (68/95). Hemodynamic instability necessitated surgical exploration in 11% of patients (11/95). Of these, 46% (5/11) required a partial nephrectomy, 27% (3/11) underwent nephrectomy, and 27% (3/11) were salvaged. Angiographic infarction was not used for patients with delayed or persistent hemorrhage. Symptomatic urinoma developed in 17% (16/95). Of these patients, 81% (13/16) were successfully managed by percutaneous drainage or ureteral stent placement, and open intervention to manage complications became necessary in the remaining 19% (3/16). Partial renal preservation was possible in 95% of patients (90/95). CONCLUSIONS Nonoperative management of children with grade IV blunt renal injuries is highly successful, with at least partial renal preservation possible in 95% (90/95) of patients.

Single Center Experience With Endoscopic Management of Vesicoureteral Reflux in Children

PURPOSE Dx/HA copolymer was approved by the Food and Drug Administration in 2001 for the treatment of VUR in children. Published results have varied widely, prompting us to report our single center experience with 300 consecutive patients. MATERIALS AND METHODS All patients undergoing Dx/HA injection (300 children, median age 5.4 years) at our institution were eligible for this study. We examined several parameters to determine which variables influence the success of Dx/HA injection, including preoperative reflux grade, bladder diverticula, neurogenic bladder, ureteral duplication, perioperative urinary tract infection, dysfunctional voiding, laterality of reflux and amount of Dx/HA injected. RESULTS A total of 225 patients (75%) underwent postoperative studies, and, thus, were eligible for study inclusion. Reflux was cured in 144 patients (64%) and improved in 44 (20%). A total of 20 patients had ureteral duplication anomalies. Cure rates in this subgroup were significantly decreased compared to nonduplicated cases (40% vs 66%). Injection in low grade (I to II) reflux was significantly more successful than in high grade (III to IV) reflux (72% vs 54%). A total of 10 patients (8.3%) with unilateral reflux had development of de novo contralateral reflux. Of the patients who failed initial injection 10 (4%) underwent repeat injection, of whom 5 (50%) were cured after the second injection. Two patients (0.9%) had development of temporary ureteral obstruction. CONCLUSIONS We report a large short-term single center experience with endoscopically injected Dx/HA. Although our cure rate of 64% was less than published rates for open surgery, the minimal morbidity and low complication rate of endoscopic treatment make it an attractive first line therapy for patients with VUR. Longer followup is required to better evaluate this technique.

Trends in Imaging and Surgical Management of Pediatric Urolithiasis at American Pediatric Hospitals

PURPOSE Little is known of current practice patterns for pediatric urolithiasis. We examined recent trends in imaging and surgical management. MATERIALS AND METHODS The Pediatric Health Information System database is a national database collected at American pediatric hospitals. We searched the database from 1999 to 2008 to identify children diagnosed with urolithiasis. Inpatient hospital admissions, and emergency department and outpatient medical/surgical short stay visits were included. We examined imaging and surgical management trends during the study period using bivariate and multivariate logistic regression models. RESULTS We identified 7,921 children diagnosed with urolithiasis during the study period, of whom 1,712 (22%) underwent stone related surgery and 6,318 (80%) underwent stone related diagnostic imaging. The surgery rate remained stable during the study period (p = 0.15), as did the overall imaging rate (p = 0.2). However, computerized tomography use increased (26% to 45%) and plain x-ray of kidneys, ureters and bladder plus excretory urogram use decreased (59% to 38%) during the study period (each p <0.0001). Surgery was associated with older patient age, female gender, white race and private insurance. Computerized tomography use was associated with older patient age, nonwhite race and public insurance. After adjusting for other factors, including hospital region, the treating hospital was most important for predicting surgery or computerized tomography (each p <0.0001). CONCLUSIONS Surgery and imaging for pediatric urolithiasis remained stable at pediatric hospitals in the last decade, although computerized tomography use has increased. The hospital where a patient receives treatment is the single most important feature driving computerized tomography and surgery use. Patient age, race and insurance status have a smaller but significant role.

Variations in Timing of Surgery Among Boys Who Underwent Orchidopexy for Cryptorchidism

OBJECTIVE: Current clinical guidelines recommend that orchidopexy be performed by the age of 1 in patients with congenital undescended testis. We sought to examine trends in surgical timing and to determine what factors are associated with age at surgery. METHODS: The Pediatric Health Information System (PHIS) is a national database of >40 freestanding childrens hospitals. We searched the PHIS to identify boys with cryptorchidism who underwent orchidopexy between 1999 and 2008. Patient age at orchidopexy was evaluated, and we used multivariate models to determine factors associated with timing of surgery. RESULTS: We identified 28 204 children who underwent orchidopexy at PHIS hospitals. Of these, 14 916 (53%) were white, and 17 070 (61%) had public insurance. Only 5031 patients (18%) underwent orchidopexy by the age of 1 year; only 12 165 (43%) underwent orchidopexy by the age of 2 years. These figures remained stable over time (P = .32). After adjusting for patient clustering, race (P < .001) and insurance status (P < .001) remained associated with patient age at orchidopexy; however, the treating hospital (P < .001) was the most important factor in predicting the timing of the procedure. CONCLUSIONS: Only 43% had surgery by 2 years of age, which suggests that either significant numbers of boys with congenital cryptorchidism do not undergo surgery in a timely fashion or late-onset testicular ectopy is more common than generally recognized. Factors associated with the timing of orchidopexy include patient race, insurance status, and the hospital in which surgery is performed.

Vesicoureteral Reflux: Current Trends in Diagnosis, Screening, and Treatment

CONTEXT Vesicoureteral reflux (VUR) is present in approximately 1% of children in North America and Europe and is associated with an increased risk of pyelonephritis and renal scarring. Despite its prevalence and potential morbidity, however, many aspects of VUR management are controversial. OBJECTIVE Review the evidence surrounding current controversies in VUR diagnosis, screening, and treatment. EVIDENCE ACQUISITION A systematic review was performed of Medline, Embase, Prospero, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, clinicaltrials.gov, and the most recent guidelines of relevant medical specialty organizations. EVIDENCE SYNTHESIS We objectively assessed and summarized the published data, focusing on recent areas of controversy relating to VUR screening, diagnosis, and treatment. CONCLUSIONS The evidence base for many current management patterns in VUR is limited. Areas that could significantly benefit from additional future research include improved identification of children who are at risk for VUR-related renal morbidity, improved stratification tools for determining which children would benefit most from which VUR treatment option, and improved reporting of long-term outcomes of VUR treatments.

B7-H1 expression in Wilms tumor: correlation with tumor biology and disease recurrence.

PURPOSE Despite tremendous gains in improving prognosis, 10% of patients with Wilms tumor will ultimately experience disease recurrence. The identification of novel prognostic markers and tumor associated targets for patients at risk could enable clinicians to treat recurrences more aggressively and, thus, optimize outcomes. We have previously shown that tumor expression of the T cell coregulatory ligand B7-H1 portends a poor prognosis for adults with renal cell carcinoma and represents a promising target to improve therapy. We hypothesize that this finding may be true for Wilms tumor. MATERIALS AND METHODS We identified 81 patients with Wilms tumor treated at 1 institution between 1968 and 2004. Histopathological features, including Wilms tumor B7-H1 expression, were correlated with clinical observations and outcome. RESULTS Tumor recurrences were noted in 22% of patients with Wilms tumor and 14% died. B7-H1 was expressed in 11 tumors (14%) and was more likely to occur in anaplastic Wilms tumor (p = 0.03). Tumor B7-H1 expression was associated with a 2.7-fold increased risk of recurrence, although this difference did not achieve statistical significance (p = 0.06). However, in favorable histology tumors B7-H1 expression was associated with a 3.7-fold increased risk of recurrence (p = 0.03). CONCLUSIONS B7-H1 is expressed by Wilms tumor, correlates with tumor biology and is associated with an increased risk of recurrence in patients with favorable histology tumors. B7-H1 may prove useful in identifying high risk patients who could benefit from more aggressive initial treatment regimens, and may represent a promising therapeutic target. Multi-institutional studies to elucidate the role of B7-H1 in the treatment of Wilms tumor are warranted.

Management Strategies for Mayer-Rokitansky-Kuster-Hauser Related Vaginal Agenesis: A Cost-Effectiveness Analysis

PURPOSE The optimal method for neovagina creation in patients with vaginal agenesis is controversial. Progressive perineal dilation is a minimally invasive method with high success rates. However, the economic merits of progressive perineal dilation compared to surgical vaginoplasty are unknown. MATERIALS AND METHODS We performed a Markov based cost-effectiveness analysis of 3 management strategies for vaginal agenesis-progressive perineal dilation with and without subsequent vaginoplasty, and up-front vaginoplasty. Cost data were drawn from the Pediatric Health Information System database (2004 to 2009) for inpatient procedures and from governmental cost data (2009) for outpatient procedures and clinical followup. Other model parameters were derived from a systematic literature review and comparison with other congenital and acquired pediatric and/or adolescent gynecologic conditions. Bounded and probabilistic sensitivity analyses were used to assess model stability. RESULTS Including all procedures, equipment and physician visits, progressive perineal dilation had a mean cost of

Regional variations in small intestinal submucosa evoke differences in inflammation with subsequent impact on tissue regeneration in the rat bladder augmentation model.

796, while vaginoplasty cost