Jonathan H. Ross

Contralateral Reflux After Unilateral Ureteral Reimplantation in Patients with a History of Resolved Contralateral Reflux

PURPOSEnWe determined the risk of contralateral reflux after unilateral ureteral reimplantation in patients with a history of resolved contralateral reflux.nnnMATERIALS AND METHODSnWe reviewed our experience with 53 children who underwent unilateral ureteral reimplantation for primary vesicoureteral reflux.nnnRESULTSnPostoperative contralateral reflux occurred in 5 of 11 children (45%) with a history of bilateral reflux that had resolved preoperatively on the contralateral side and 4 of 42 (10%) with no history of contralateral reflux.nnnCONCLUSIONSnStrong consideration should be given to performing bilateral ureteral reimplantation in children with unilateral reflux and a history of resolved contralateral reflux.

Surveillance after initial surgery for Stage I pediatric and adolescent boys with malignant testicular germ cell tumors: Report from the Children’s Oncology Group

PURPOSEnThe purpose of this study was to determine prognostic factors correlating with outcome in boys with Stage I malignant testicular germ cell tumors (MTGCT) initially managed with surveillance after surgical resection.nnnMETHODSnBetween November 2003 and July 2011, 80 boys 0-15 years with Stage I MTGCT were enrolled in Childrens Oncology Group Study AGCT0132. Those with residual or recurrent disease were treated with chemotherapy.nnnRESULTSnCharacteristics include: age (65, 0-5 years and 15, 11+years), pure YST (93.9%, 0-5 years and 0%, 11+years); and lymphovascular invasion (LVI) (50.6% present vs. 49.4% absent). At median follow-up of 4.94 years, 19 had persistent or recurrent disease, all detected by elevated AFP at a median of 87 days after study enrollment. The outcome from enrollment was 4-year EFS 74% (95% CI: 63%-83%) and 4-year OS 100%. 4-year EFS was improved with younger age (<11 years, 80% vs. 11+years, 48%, p<0.01); pure YST vs. mixed histology (81% vs. 45%, p<0.01), and lack of LVI (84% vs. 62%, p=0.03).nnnCONCLUSIONSnBoys with Stage I MTGCT have excellent overall survival when treated with surgery alone. Age greater than 10 years, mixed histology and presence of LVI are each associated with relapse and may allow identification of high risk boys at time of enrollment.

The role of testis-sparing surgery in children and adolescents with testicular tumors

Organ-sparing approaches have been applied to the treatment of a variety of urologic tumors in both the realms of adult and pediatric urology, with the goals of minimizing overtreatment of benign lesions, preserving function, and providing durable cure. The predominance of benign tumors in prepubertal patients and the reliability of both ultrasound and intraoperative frozen sections have resulted in a marked shift toward testis-sparing approaches over the last few decades. The role of testis sparing in the adolescent population is presently unclear, although there have been increasing reports of successful organ-sparing surgery for testis tumors in the adult literature. This review presents recent trends in testis-sparing approaches for both pediatric and adolescent patients, the operative technique, and some of the controversies related to testis-sparing surgery.

Management of bilateral Wilms' tumors in the daughter of Jehovah's Witnesses

Surgical treatment of the children of Jehovahs Witnesses is a challenging problem both ethically and technically. The authors recently operated on such a child who had bilateral Wilms tumors. Techniques used to minimize blood loss included erythropoietin, hemodilution, and the argon beam coagulator. A full understanding of the religious, legal, and ethical issues is essential when treating the children of Jehovahs Witnesses.

Patterns of Performance of Oncologic Surgery by North American Pediatric Urologists: A Report from the Pediatric Urologic Oncology Working Group of the Society for Pediatric Urology

Purpose: Objective data on patterns of oncology practice among pediatric urologists are lacking. We reviewed surgical case logs submitted to the American Board of Urology by those self‐reporting as pediatric urologists. We hypothesized that logs would reveal a low oncology volume (fewer than 5 cases) and identify orchiectomy as the most common oncology cases, and that less than 25% of logs would show nephrectomy for renal tumor. Materials and Methods: Case logs submitted for American Board of Urology certification, recertification or pediatric subspecialty certification were reviewed and standardized to represent 12‐month practice. Data were collected on pediatric oncologic surgeries as noted by procedure codes linked with oncologic diagnosis codes for patients up to age 30 years. Results: We identified 281 case logs meeting study criteria. A total of 364 oncology cases were logged and 131 logs (46.6%) listed at least 1 oncology case, while 150 (53.4%) contained no oncology cases. The 75th, 90th and 95th percentiles of oncology volume were represented by reporting 2, 3 and 4 cases, respectively. A total of 13 logs (4.6%) accounted for more than a third of all oncology cases (35.9%). The most frequent oncology case logged was orchiectomy, which was documented in 83 logs (29.5%). On Poisson regression surgeon variables associated with higher oncology volume included male gender (IRR 2.8, 95% CI 2.1−3.9), 2010 log year (IRR 2.4, 95% CI 1.3−4.4), 2015 log year (IRR 3.7, 95% CI 2.1−6.4) and nonpediatric subspecialty certification log (IRR 1.6, 95% CI 1.2−2.3). Conclusions: Few pediatric urologists perform a high volume of oncologic surgeries based on surgical case logs submitted to the American Board of Urology. A small cohort of pediatric urologists logged the majority of such cases.

A Society for Pediatric Urology Workforce Survey on the Current Perceptions of Oncology Care by Pediatric Urologists: A Report from the Pediatric Urologic Oncology Working Group of the Society for Pediatric Urology

Purpose: Data are lacking on the current perception of oncology care among pediatric urologists. Thus, we developed, pilot tested and administered a survey on this topic to SPU (Society for Pediatric Urology) members. Materials and Methods: Approval for this proposal was granted by SPU leadership prior to developing or distributing the survey instrument. The survey was developed and pilot tested by the PUOWG (Pediatric Urologic Oncology Working Group). Response data were collected and descriptive statistics were used for analysis. Logistic regression analysis was performed to correlate surgeon reported factors with higher volumes of reported oncology surgery. Results: A total of 426 surveys were distributed via email to SPU members and 212 individual surveys (49.8%) were returned with the background/introduction section completed. Of these surveys 200 (94.3%) were completed by practicing pediatric urologists. Overall, 155 respondents (77.5%) reported performing 5 or fewer oncology related surgeries per year and 74.9% reported that less than 25% of renal tumor surgery at their institution was performed through the pediatric urology service. On multivariate analysis the self‐reported factors significantly associated with increased oncology surgical volume (more than 5 cases per year) were greater than 50% attendance at institutional tumor board meetings (OR 4.8, 95% CI 1.4–16.9) and practicing at a hospital with a higher volume of renal tumor surgery (OR 2.6, 95% CI 1.2–5.8). Conclusions: Few surveyed pediatric urologists reported performing a high volume of oncology surgery. Respondents expressed interest in ways to increase pediatric urology involvement in oncology care, including opportunities for increased education. Self‐reported factors that correlated with higher volume were regular attendance at the institutional pediatric tumor board and practice at a higher volume institution.

A Curious Case of Ureteral Obstruction in a 15-Year-Old Female.

A 15-year-old Caucasian female presented to pediatric rheumatology clinic for evaluation of an intermittent, nonpruritic, painful rash of 2 months duration over her shins and knees. She endorsed fatigue, weight loss, xerostomia, irregular menses, abdominal pain, shoulder and back stiffness, and left calf myalgias. Skin examination was notable for blanching erythematous macules on the bilateral lower extremities. Vital signs and the rest of her examination were unremarkable. Laboratory evaluation revealed a normal complete blood count and differential, comprehensive metabolic panel, coagulation panel, and von Willebrand antigen. Antinuclear antibody, anti-neutrophil cytoplasmic antibody, and cryoglobulin were negative; total complement and urinalysis were normal. Her erythrocyte sedimentation rate was 43 mm/h (0-13), and C-reactive protein was 1.63 mg/dL (<0.8). Radiographic examination and vascular ultrasound of her lower extremities were unremarkable. Biopsy of her rash revealed a perivascular lymphocytic infiltrate. The patient was lost to follow-up and returned 19 months later at which time she reported a 2-month history of back pain. She also developed chest, shoulder, arm, and bilateral lower extremity pain with a different leg rash. She reported a 2.7 kg weight loss, daily emesis, fatigue, and hypertension at her pediatrician’s office 2 weeks previously. Manual blood pressure reading was 155/95 mm Hg (>99th percentile for age and height). Weight was 57.6 kg, approximately the 50th percentile. Skin exam was notable for blood-filled, bullous, necrotic lesions on the lower extremities and plantar surfaces with telangiectasias on her thighs (Figure 1). Given her hypertension, she was admitted to the hospital for evaluation.

Evaluation of an Electronic Platform for Problem Based Learning for Subspecialty Fellows

Introduction: Increasing demands on the time of trainees may warrant new self‐directed, concise methods of problem based learning. To address these issues in urological oncology CBULP was designed to provide a concise electronic format that could be readily accessed when the fellow was rested and ready to learn. We evaluated the perceived usefulness of this program. Methods: Subspecialists from 2 academic urology programs and an educational professional wrote 42 clinical scenarios about various renal and adrenal malignancies, and generated concise learning points. These cases were mailed to various urological oncology fellowships in the United States and Canada. An 18‐question survey was delivered electronically 8 weeks later. Responses were recorded anonymously via survey software. Results: Of 36 fellows 30 (83%) responded. Of the respondents 74% completed at least 5 cases and the majority completed more than 10. Of the respondents 93% thought that the cases had the appropriate amount of detail and covered core concepts related to renal/adrenal tumors. No respondent required more than 20 minutes to finish any case. Of the respondents 93% and 100% indicated that the cases effectively illustrated the basic principles of the disease process, and the fundamentals of evaluation and management, respectively. Overall 97% of respondents thought that CBULP could be an effective learning resource for fellows. Conclusions: An electronic case based method of learning appears to be a useful tool for subspecialty fellows. It may be a worthwhile self‐directed supplement to traditional educational resources.