Kourosh Afshar

Development of a Symptom Score for Dysfunctional Elimination Syndrome

PURPOSE Dysfunctional elimination syndrome is a heterogeneous syndrome with no widely accepted diagnostic criteria. Previously developed questionnaires provide incomplete psychometric assessment. We developed a discriminative questionnaire for diagnosing dysfunctional elimination syndrome and assessed its validity and reliability. MATERIALS AND METHODS A 14-item 5-point Likert scale questionnaire was devised using literature review, expert opinions and patient input. The questionnaire was administered to 62 children 4 to 16 years old (median age 8) clinically diagnosed with dysfunctional elimination syndrome by a pediatric urologist, of whom 71% were female. It was also administered to 50 healthy controls 4 to 16 years old (median age 7), of whom 66% were female. Children with structural abnormalities were excluded from study. To assess reliability 50 participants were asked to complete the questionnaire again 1 week later. RESULTS Median total score in cases and controls was 14 of 52 (range 4 to 30) and 6 of 52 (range 1 to 13), respectively. The difference was statistically significant (p = 0.001). Discriminant function analysis showed 80% accuracy. ROC curve showed a score of 11 as the optimum threshold with an AUC of 0.903 (95% CI 0.814-0.948). Test-retest reliability was 84.5% (p = 0.001). Factor analysis showed unloading on 4 factors, corresponding to urinary incontinence, urgency, obstructive symptoms and constipation/fecal soiling. Of participants 85% classified the questionnaire as very easy or easy to complete. CONCLUSIONS This new questionnaire is valid and reliable for diagnosing dysfunctional elimination syndrome. It can be used as a clinical or research instrument.

A Prospective Randomized Trial of Povidone-Iodine Prophylactic Cleansing of the Rectum Before Transrectal Ultrasound Guided Prostate Biopsy

PURPOSE Transrectal ultrasound guided prostate biopsy can lead to urinary tract infections in 3% to 11% and sepsis in 0.1% to 5% of patients. We investigated the efficacy of rectal cleansing with povidone-iodine before transrectal ultrasound guided prostate biopsy to reduce infectious complications. MATERIALS AND METHODS Between 2009 and 2011, 865 men were prospectively randomized to rectal cleansing (421) or no cleansing (444) before transrectal ultrasound guided prostate biopsy. Patients received ciprofloxacin prophylaxis and rectal swab cultures were obtained before transrectal ultrasound guided prostate biopsy. Patients completed a telephone interview 7 days after undergoing the biopsy. The primary end point was the rate of infectious complications, a composite end point of 1 or more of 1) fever greater than 38.0C, 2) urinary tract infection or 3) sepsis (standardized definition). Chi-square significance testing was performed for differences between groups and a multivariate analysis was performed to assess risk factors for infectious complications. RESULTS Infectious complications were observed in 31 (3.5%) patients, including 11 (2.6%) treated and 20 (4.5%) control patients (p = 0.15). Sepsis was observed in 4 (1.0%) treated and 7 (1.6%) control patients (p = 0.55). On multivariate analysis resistance to ciprofloxacin in the rectal swab culture (p = 0.002) and a history of taking ciprofloxacin in the 3 months preceding transrectal ultrasound guided prostate biopsy (p = 0.009) predicted infectious complications. CONCLUSIONS Rectal cleansing with povidone-iodine before transrectal ultrasound guided prostate biopsy was safe, but the 42% relative risk reduction of infectious complications was not statistically significant. Patients who have received ciprofloxacin within 3 months of transrectal ultrasound guided prostate biopsy should be considered for alternate prophylaxis or possibly a delay of biopsy beyond 3 months.

Complications of the Catheterizable Channel Following Continent Urinary Diversion: Their Nature and Timing

PURPOSE We reviewed the incidence, nature and timing of complications related to the catheterizable channel following continent urinary diversion. MATERIALS AND METHODS We retrospectively reviewed the records of 67 patients who underwent continent urinary diversion at British Columbia Childrens Hospital from 2000 to 2006. Catheterizable channels included 54 Mitrofanoff appendicovesicostomies and 13 ileovesicostomies. Medical records were reviewed for predetermined complications and their timing, that is early -12 months or less, or late - more than 12 months. RESULTS At a median followup of 28 months (range 3 to 62) a total of 17 complications were identified in 14 patients (21%). Superficial cutaneous stenosis developed in 4 of 67 cases (6%) as an early and as a late complication. These cases were initially treated with operative dilation and surgical revision as necessary. Channel stricture, which developed in 4 of 67 patients (6%) as an early and as a late complication, was treated with operative revision in 2 and endoscopic resection in 2. Three patients (5%) had stomal prolapse, which was generally a late occurrence and required operative revision in all. Channel leakage developed in 6 of 67 patients, presenting as an early complication in 50%. Endoscopic injection of bulking agents was attempted in 4 of these patients and it was successful in 2. Overall 82% of complications were successfully managed by endoscopic or superficial procedures. CONCLUSIONS Complications of the catheterizable channel are a frequent and challenging problem. They appear to occur throughout the life of the channel with most developing within the first 2 years. Further followup is required to assess the performance and durability of continent catheterizable channels in children as patients progress to adulthood.

Prediction of the outcome of antenatally diagnosed hydronephrosis: a multivariable analysis.

PURPOSE The majority of cases of antenatal hydronephrosis (ANH) resolve postnatally. The purpose of this study was to determine independent predictors for resolution of ANH using a multivariable analysis model. METHODS A retrospective study was performed on 100 children (80 males and 20 females, 118 renal units) referred to a single pediatric urology clinic with the diagnosis of ANH. Patients with ultimately resolved ANH were compared to unresolved cases in a univariate analysis in terms of sex, laterality, severity of ANH using Society for Fetal Urology (SFU) grading, antero-posterior pelvic diameter (APD), parenchymal thickness, renographic differential function and development of clinical complications, followed by a Cox proportional hazard model for multivariable analysis. RESULTS Median follow up was 34 months (range 3-204). Hydronephrosis in 62 units resolved spontaneously and pyeloplasty was done in 29. The remaining 27 units had persistent uncomplicated hydronephrosis at last follow up. Multivariate analysis showed larger APD (hazard ratio 0.54; 95%CI 0.36-0.80) and SFU grade 4 (HR 0.34; 95%CI 0.13-0.90) to be associated with a significantly lower likelihood of resolution. The mean initial APD in resolved cases was 9.4mm as opposed to 29.0mm in cases requiring surgery. CONCLUSION Large initial APD has predictive value for surgical intervention. This model is helpful in counseling families about the potential outcomes of ANH.

Cranberry Juice for the Prevention of Pediatric Urinary Tract Infection: A Randomized Controlled Trial

PURPOSE Proanthocyanidins found in cranberry have been reported to have in vitro and in vivo antibacterial activity. We determined the effectiveness of cranberry juice for the prevention of urinary tract infections in children. MATERIALS AND METHODS A total of 40 children were randomized to receive daily cranberry juice with high concentrations of proanthocyanidin vs cranberry juice with no proanthocyanidin for a 1-year period. The study was powered to detect a 30% decrease in the rate of symptomatic urinary tract infection with type I and II errors of 0.05 and 0.2, respectively. Toilet trained children up to age 18 years were eligible if they had at least 2 culture documented nonfebrile urinary tract infections in the calendar year before enrollment. Patients with anatomical abnormalities (except for primary vesicoureteral reflux) were excluded from study. Subjects were followed for 12 months. The participants, clinicians, outcome assessor and statistician were all blinded to treatment allocation. RESULTS Of the children 39 girls and 1 boy were recruited. Mean and median patient age was 9.5 and 7 years, respectively (range 5 to 18). There were 20 patients with comparable baseline characteristics randomized to each group. After 12 months of followup the average incidence of urinary tract infection in the treatment group was 0.4 per patient per year and 1.15 in the placebo group (p = 0.045), representing a 65% reduction in the risk of urinary tract infection. CONCLUSIONS Cranberry juice with high concentrations of proanthocyanidin appears to be effective in the prevention of pediatric nonfebrile urinary tract infections. Further studies are required to determine the cost-effectiveness of this approach.

Health related quality of life in patients with spina bifida: a prospective assessment before and after lower urinary tract reconstruction.

PURPOSE In a previous retrospective cohort study we challenged the assumption that lower urinary tract reconstruction improves health related quality of life in spina bifida cases. We readdressed this issue prospectively in a new series of patients. MATERIALS AND METHODS A total of 31 consecutive incontinent patients with spina bifida undergoing reconstruction with a continent stoma with or without augmentation, with or without bladder neck reconstruction and with or without cecostomy were assessed preoperatively and 6 months postoperatively with the Parkin disease specific health related quality of life score. The instrument stratifies patients by ages 12 years or younger and 13 years or older. An additional 4-item questionnaire was used to score bladder and bowel continence. RESULTS There was no significant change in health related quality of life following surgery in either age group. The median score changed from 167 to 174 in patients 12 years old or younger (p = 0.74) and from 199 to 193 in patients 13 years old or older (p = 0.42) despite a significant improvement in scores on all continence questions (p <0.05). In patients 12 years old or younger there was significant improvement in 3 items in the domains of independence and emotional expression (p <0.05). In adolescents 4 items changed significantly, and all were related to the independence and emotional domains (p <0.05). CONCLUSIONS Despite improvement in some question items we did not note an improvement in overall quality of life following reconstruction. Correcting only 1 system in a profound multisystem disability may be insufficient to improve health related quality of life or perhaps only caregiver quality of life is improved. The impact of lower urinary tract reconstruction on quality of life in patients with spina bifida requires further assessment before improvements are assumed.

Randomized Controlled Trials in Pediatric Urology: Room for Improvement

PURPOSE The primary purpose of this study was to ascertain what proportion of the body of published literature in pediatric urology is represented by randomized controlled trials. The secondary purpose was to assess the quality of these trials. MATERIALS AND METHODS Using a predefined strategy, we conducted systematic computerized searches of the MEDLINE (years 1966 to 2004) and EMBASE (1980 to 2004) databases to identify all English language randomized controlled trials related to pediatric urology. Full text versions of identified studies were reviewed in blinded fashion for key demographic, methodological and statistical characteristics. Trial quality was assessed with the previously validated Jadad tool. RESULTS The 77 identified randomized controlled trials represented only 0.4% to 0.9% of the indexed pediatric urology literature. The origins of these trials were Europe (40%), North America (26%) and a variety of other geographic centers (34%). A primarily surgical focus was present in 43% of the studies. Trials with negative results represented only 19% of the total randomized controlled trials. Generally, the trials were of low to fair quality (median Jadad score 3), with substandard methodological reporting and planning. There was not a significant trend toward improved quality in recent years. Trials from North America and Europe had higher quality (p = 0.007), as did those reporting negative results (p = 0.0001). CONCLUSIONS Randomized controlled trials in pediatric urology constitute only a small proportion of the body of published literature in the field. High quality studies are uncommon. Efforts should be made to increase the number of well designed, randomized controlled trials in pediatric urology.

Bladder neck closure in conjunction with enterocystoplasty and Mitrofanoff diversion for complex incontinence: closing the door for good.

PURPOSE Bladder neck closure is an irreversible procedure requiring compliance with catheterization of a cutaneous stoma and historically has been reserved for the definitive treatment of intractable incontinence after prior failed procedures. We assessed long-term outcomes of our patients undergoing bladder neck closure including continence status, additional surgical interventions, postoperative complications, conception and sexual function, and satisfaction with bladder neck closure. MATERIALS AND METHODS We performed a retrospective review of all patients who underwent bladder neck closure between 1990 and 2010 at our institution. RESULTS A total of 28 consecutive patients (exstrophy 15 and neurogenic bladder 13 [myelomeningocele 4, cloacal anomaly 4, spinal cord injury 2, VACTERL (Vertebral Anorectal Cardiac Tracheo-Esophageal Radial Renal Limb) 1, sacral agenesis 1 and urogenital sinus 1]) were identified. Of these patients 19 (68%) had undergone 20 unsuccessful bladder neck procedures before bladder neck closure. Bladder neck closure was initially successful in 27 of the 28 (96.4%) patients. One patient required subsequent closure of a postoperative vesicovaginal fistula. Median time from bladder neck closure was 69 months (range 16 to 250). In 11 patients 16 additional procedures were required, including stomal injection of bulking agents (2), stomal revision for stenosis (2) or prolapse (1), percutaneous nephrolithotripsy for stone (1), open cystolithotomy (2), extracorporeal shock wave lithotripsy for upper tract stones (4), repair of augment rupture (3) and open retrograde ureteral stenting for stone (1). The total surgical re-intervention rate was 39.3% (11 of 28). There were no observed cases of progressive or de novo hydronephrosis. CONCLUSIONS Bladder neck closure in conjunction with enterocystoplasty and Mitrofanoff diversion is an effective means of achieving continence in complex cases as a primary or secondary therapy. Long-term urological followup into adulthood is essential.

Biofeedback for Nonneuropathic Daytime Voiding Disorders in Children: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

PURPOSE Biofeedback has been used to treat children with symptoms of bladder dysfunction not responding to standard therapy alone. However, evidence of the effectiveness of biofeedback is scarce and is based on small studies. We conducted a systematic review of the literature to assess the effects of biofeedback as adjunctive therapy for symptoms of nonneuropathic voiding disorders in children up to age 18 years. MATERIALS AND METHODS We searched MEDLINE(®), Embase(®) and CENTRAL on the OvidSP(®) platform as well as conference proceedings for randomized trials presented at scientific conventions, symposia and workshops through August 13, 2013. Hand searches and review of reference lists of retrieved articles were also performed. RESULTS Five eligible studies were included in the systematic review, of which 4 (382 participants) were pooled in the meta-analysis based on available outcomes data. The overall proportion of cases with resolved incontinence at month 6 was similar in the biofeedback and control groups (OR 1.37 [95% CI 0.64 to 2.93], RD 0.07 [-0.09, 0.23]). There was also no significant difference in mean maximum urinary flow rate (mean difference 0.50 ml, range -0.56 to 1.55) or likelihood of urinary tract infection (OR 1.30 [95% CI 0.65 to 2.58]). CONCLUSIONS Current evidence does not support the effectiveness of biofeedback in the management of children with nonneuropathic voiding disorders. More high quality, randomized controlled trials are needed to better evaluate the effect of biofeedback.

Surgical Case Volume in Canadian Urology Residency: A Comparison of Trends in Open and Minimally Invasive Surgical Experience

BACKGROUND AND PURPOSE The application of minimally invasive surgery (MIS) has become increasingly common in urology training programs and clinical practice. Our objective was to review surgical case data from all 12 Canadian residency programs to identify trends in resident exposure to MIS and open procedures. MATERIALS AND METHODS Every year, beginning in 2003, an average of 41 postgraduate year 3 to 5 residents reported surgical case data to a secure internet relational database. Data were anonymized and extracted for the period 2003 to 2009 by measuring a set of 11 predefined index cases that could be performed in both an open and MIS fashion. RESULTS 16,687 index cases were recorded by a total of 198 residents. As a proportion, there was a significant increase in MIS from 12% in 2003 to 2004 to 32% in 2008 to 2009 (P=0.01). A significant decrease in the proportion of index cases performed with an open approach was also observed from 88% in 2003 to 2004 to 68% in 2008 to 2009 (P=0.01). The majority of these shifts were secondary to the increased application of MIS for nephrectomies of all type (29%-45%), nephroureterectomy (27%-76%), adrenalectomy (15%-71%), and pyeloplasty (17%-54%) (P<0.0001 for all). While there was a significant increase in MIS experience with radical prostatectomy (2%-18%, P<0.0001), the majority of these were still taught in an open fashion during the study period. CONCLUSION MIS constitutes an increasingly significant component of surgical volume in Canadian urology residencies with a reciprocal decrease in exposure to open surgery. These trends necessitate ongoing evaluation to maintain the integrity of postgraduate urologic training.