Luis Guerra

Reliability Assessment of Society for Fetal Urology Ultrasound Grading System for Hydronephrosis

PURPOSEnThe Society for Fetal Urology introduced a subjective grading system for classifying hydronephrosis that has important implications in patient diagnosis, treatment and outcome. The grading system is frequently used to standardize the severity of hydronephrosis, and compare results among patients and centers. Despite widespread use to our knowledge no groups have investigated the reliability of the grading system since its introduction. We assessed the intrarater and interrater reliability of the Society for Fetal Urology grading system for hydronephrosis and examined levels of agreement by the degree of hydronephrosis (grades 0 to 4) and level of experience (staff vs trainee).nnnMATERIALS AND METHODSnA series of 50 pediatric renal ultrasound images from patients with a diagnosis of hydronephrosis were assessed by 4 staff individuals and 4 trainees using the Society for Fetal Urology grading system. Ultrasound images included the kidneys, ureters and bladder to be consistent with practice. After 7 to 14 days each rater repeated the assessment. The nonweighted Cohen kappa statistic was used to estimate intrarater and interrater reliability by Society for Fetal Urology grade and training level.nnnRESULTSnStaff and trainee raters independently assigned Society for Fetal Urology grades to 50 patients (99 renal units). The average number of images per ultrasound was 41, including the right and left kidneys. Overall interrater agreement for staff individuals was substantial for grade 0, moderate for grades 1, 2 and 4, and only slight to fair for grade 3. Intrarater agreement was substantial to almost perfect for staff agreement (range 69% to 94%, kappa 0.56 to 0.89) and trainees (range 63% to 90%, kappa 0.48 to 0.85).nnnCONCLUSIONSnOur study suggests that the Society for Fetal Urology grading system has good intrarater but modest interrater reliability. Individual rater interpretations of the grading system may explain the modest interrater agreement. Proposed modifications to the Society for Fetal Urology classification system, such as distinguishing between diffuse and segmental cortical thinning, may improve reliability.

Effectiveness of biofeedback for dysfunctional elimination syndrome in pediatrics: A systematic review

PURPOSEnDysfunctional elimination syndrome is associated with an inability to effectively empty the bladder and may present with UTI, incontinence, intestinal constipation or other voiding symptoms. Biofeedback has emerged as one potentially effective and non-invasive treatment. We sought to analyze if biofeedback is an effective method to treat children less than 18 years of age.nnnMETHODSnA literature search was conducted in MEDLINE, EMBASE, CINAHL, Cochrane Database, AUA, CUA, AAP and ESPU abstracts. Copies of all relevant articles were retrieved for quality assessment and data abstraction by two independent reviewers. Primary outcomes were UTIs and daytime incontinence.nnnRESULTSn27 studies were included (1 RCT and 26 case-series). The pooled estimate showed 83% (95% CI: 79%-86%) and 80% (95% CI: 76%-85%) improvement in UTI and daytime incontinence respectively. I(2) statistic showed Low (7%) and High (77%) heterogeneity across studies results for UTI and daytime incontinence. The only included RCT favored biofeedback over standard therapy (RR 1.4, 95% CI: 0.98-2.00) but this was not statistically significant. On analysis of all included studies there was also improvement in constipation (18%-100%), frequency (67%-100%), urgency (71%-88%) and VUR (21%-100%). PVR improvement ranged from 26 ml to 99 ml and Q(max) improvement was from 3.1 ml/s-4.7 ml/s.nnnCONCLUSIONnBased on this review, biofeedback is an effective, non-invasive method of treating dysfunctional elimination syndrome, and approximately 80% of children benefited from this treatment. However, most reports were of low level of evidence and studies of more solid design such as RCT should be conducted.

Analysis of the Clinical Significance and Cost Associated With the Routine Pathological Analysis of Pediatric Inguinal Hernia Sacs

PURPOSEnPediatric inguinal and scrotal surgeries for inguinal hernia, cryptorchidism and hydrocele are common and usually involve the excision of a hernia sac. Groups at many centers send hernia sacs for pathological analysis to identify occult disease as well as structures that may have been erroneously resected. We hypothesized that, since the incidence of significant findings is low and the associated health care costs are significant, the routine pathological analysis of inguinal hernia sacs is unnecessary.nnnMATERIALS AND METHODSnAfter receiving institutional review board approval we retrospectively reviewed pathology reports at our institution of patients who underwent surgery with an inguinal hernia sac sent for pathological analysis from January 2000 to September 2009. The primary outcome was to determine the incidence of clinically significant structures in hernia sac specimens. The secondary outcome was to evaluate the costs associated with analyzing these specimens.nnnRESULTSnA total of 2,287 boys and 441 girls underwent some form of inguinal or scrotal surgery during the study. In the 2,287 boys a total of 2,657 hernia sac specimens were analyzed, of which 2 (0.08%) contained clusters of epididymal-like tubules. Most unexpected findings were likely clinically insignificant, including mesothelial proliferation in 5.6% of cases, genital duct remnants in 0.8%, lipoma in 0.23% and adrenocortical rests in 0.04%. The average cost of analyzing hernia sac specimens at our institution was approximately

Benign penile skin anomalies in children: a primer for pediatricians

7,100 Canadian annually.nnnCONCLUSIONSnRoutine analysis of inguinal hernia sacs is unnecessary and costly, and should be reserved for cases in which resection of important structures such as the vas deferens is suspected.

Assessing quality of life of patients with hypospadias: A systematic review of validated patient-reported outcome instruments

BackgroundAbnormalities involving the skin coverage of the penis are difficult to define, but they can significantly alter penile appearance, and be a cause of parental concern.Data sourcesThe present review was based on a nonsystematic search of the English language medical literature using a combination of key words including penile skin anomalies and the specific names of the different conditions.ResultsConditions were addressed in the following order, those mainly affecting the prepuce (phimosis, balanitis xerotica obliterans, balanitis, paraphimosis), those which alter penile configuration (inconspicuous penis and penile torsion), and lastly focal lesions (cysts, nevi and vascular lesions). Most of these anomalies are congenital, have no or minimal influence on urinary function, and can be detected on clinical examination. Spontaneous improvement is possible. In the majority of cases undergoing surgery, the potential psychological implications of genital malformation on patient development are the main reason for treatment, and the age generally recommended for surgery is after 12 months of age.ConclusionThis review provides the pediatrician with a handy tool to identify the most common penile skin anomalies, counsel parents adequately, make sensible and evidence based choices for management, and recognize complications or untoward outcomes in patients undergoing surgery.

Laparoscopic manoeuvre for orchidopexy in high intra-abdominal testes when cremasteric artery is present.

BACKGROUNDnPatient-reported outcomes have the potential to provide invaluable information for evaluation of hypospadias patients, aid in decision-making, performance assessment, and improvement in quality of care. To appropriately measure patient-relevant outcomes, well-developed and validated patient-reported outcome (PRO) instruments are essential.nnnOBJECTIVEnTo identify and evaluate existing PRO instruments designed to measure quality of life and/or satisfaction of individuals with hypospadias that have been developed and validated in a hypospadias population.nnnMETHODSnA systematic search of MEDLINE, EMBASE, PsycINFO, CINAHL and Health and Psychosocial Instruments was conducted in April 2016. Two reviewers independently assessed studies and identified PRO instruments for inclusion. Data were extracted on study characteristics, instrument development and validation, and content domains.nnnRESULTSnA total of 32 studies were included that used or described five PRO instruments: Hypospadias Objective Scoring Evaluation (HOSE), Pediatric Penile Perception Score (PPPS), Penile Perception Score (PPS), Genital Perception Scale (GPS) for adults, and GPS for children/adolescents. Instrument development and validation was limited. The majority of identified instruments focused on postoperative cosmetic satisfaction, with only one instrument considering urinary function, and no instruments evaluating sexual function and psychosocial sequelae.nnnCONCLUSIONSnWhile many hypospadias studies have acknowledged the necessity of a patient-reported element, few have used validated PRO instruments developed in a hypospadias population. Existing instruments to measure patient-reported outcomes in hypospadias require improvement in both the breadth of content and in their development and validation methodology.

Active surveillance for antenatally detected ureteroceles: Predictors of success

OBJECTIVEnWe report a case of high intra-abdominal testes (HIT) associated with the presence of the cremasteric artery (CA). The aim was to correlate the normal anatomy of the CA with the clinical finding in our patient and discuss its surgical implication.nnnMETHODSnLeft primary laparoscopic testicular descent by the Prentiss manoeuvre was performed in a 2 year-old boy with bilateral HIT. Cadaveric dissection was carried out focusing on the anatomical origin of the CA. Data obtained from cadavers and the clinical findings were analyzed.nnnRESULTSnDuring laparoscopic orchiopexy a left HIT was found in the presence of the CA. Primary tension-free orchiopexy was achieved preserving the CA. Our cadaver study revealed that the CA arose more frequently (68%) from the medial aspect of the inferior epigastric artery.nnnCONCLUSIONnIn the presence of HIT, surgeons should be aware of the CA as part of the testicular collateral circulation. Acquaintance with the normal anatomy of the CA is important to determine the most appropriate laparoscopic manoeuvre in orchiopexy when this artery is present. We believe that the Prentiss manoeuvre avoids compression and strangulation of the CA around the epigastric vessels while allowing testicular placement in the scrotum.

Use of ultrasound for the palpable undescended testis: a wasteful practice

INTRODUCTIONnHistorically, ureteroceles were surgically treated, as patients were diagnosed after developing symptoms. However, with the advance of fetal medicine, antenatal detection has provided an opportunity to look at the natural history of ureteroceles.nnnOBJECTIVESnWith data derived from a retrospective chart review of patients with ureteroceles that were detected antenatally, the current study aimed to determine which group of children would be at risk for failure on active surveillance. It was hypothesized that single system ureteroceles (SSU) and male patients with duplex system ureteroceles (DSU) would be ideal for observation.nnnMETHODSnOutcomes were assessed by descriptive statistics. Kaplan-Meier curves were utilized to estimate median duration on active surveillance in both single and duplex cohorts. Breakthrough febrile urinary tract infection (fUTI) and surgery were determined by Cox regression in the duplex system cohort. Surgery was considered surveillance failure.nnnRESULTSnA total of 102 patients (64 females/38 males) met the criteria: 78 (76.5%) had DSU and 24 (23.5%) SSU. The overall median observation was 1.2 years (range 0.7-3.1). Follow-up ranged from 0.3 to 11.7 years for SSU, and from 0.02 to 17.3 years for DSU. The predictors of failure of active surveillance (AS) in DSU (surgical intervention) were male gender (HR 1.8, 1.0-3.3, Pxa0=xa00.037), or fUTI (HR 3.1, 1.7-5.8, Pxa0=xa00.002). Predictors of fUTI were contralateral hydroureter or ipsilateral hydronephrosis ± hydroureter (OR 9.5, 1.2-71.7, Pxa0=xa00.028). Interestingly, vesicoureteral reflux (VUR) was not a predictor of fUTI. The SSU patients were ideal for AS, while in DSU, surveillance was successful in 30% of patients who were primarily females without contralateral hydroureter or ipsilateral hydronephrosisxa0±xa0hydroureter. However, in contradiction to the hypothesis, males were at higher risk for surgical intervention in the DSU cohort.nnnCONCLUSIONnActive surveillance is an option for patients with antenatally detected ureteroceles, but careful long term follow up is mandatory. Parents should be advised that surgical intervention may still be necessary, particularly in males with DSU.

Selective use of laparoscopy in nonpalpable undescended testes.

BackgroundnMany primary care physicians order an ultrasound (US) before referral to specialist care for suspected undescended testis; however, the value of this practice is questionable.nnnObjectivenTo determine the proportion of boys referred for suspected undescended testis who had accompanying US, the cost of this practice and the accuracy of US for testis localization when compared with physical examination by a pediatric urologist.nnnMethodsnThis was a retrospective chart review at a pediatric urology service, including all patients referred for suspected undescended testis from 2008 to 2012. We determined the cost of US ordered, and calculated Cohens kappa, sensitivity and specificity, and positive and negative predictive value.nnnResultsnWe identified 894 eligible patients; 32% (289/894) were accompanied by US. In 77% (223/289), the urologist was able to palpate the testis: 51% (147/289) had a normal/retractile testis and 26% (76/289) had a palpable undescended testis. At a cost of 71.10 CAD per US, 20 547.90 CAD was expended on this practice. Of the 223 patients with palpable testes, we were able to gather detailed US and physical examination results for 214 patients. Cohens kappa was 0.06 (95% CI -0.005, 0.11; P = 0.10). US had 92.8% sensitivity (95% CI 84.1, 96.9%) and 15.2% specificity (95% CI 10.2, 21.9%) to detect an undescended testis. The positive predictive value was 34.2% (95% CI 27.8, 41.3%), while the negative predictive value was 81.5% (95% CI 63.3, 91.8%).nnnConclusionsnReferral of patients for suspected undescended testis should not be accompanied by an US study as US is not useful in these cases.

Editorial comment to efficacy of endoscopic subureteral injection for vesicoureteral reflux in adults with decreased bladder compliance.

Introduction: Approximately, 20% of undescended testes (UDT) are nonpalpable. Surgical management of the nonpalpable testis comprises laparoscopy. The aim of this study was to determine if ultrasonography can be used as a preoperative tool to localize the nonpalpable inguinal testis, eliminating the need for laparoscopy. Methods: We identified 46 patients diagnosed with nonpalpable UDT between 2007 and 2012 who underwent an inguino-scrotal ultrasound preoperatively. We analyzed correlations between radiological and surgical findings. Results: A total of 46 patients (53 UDT), median age 14 months (quartile 1st: 7; 3rd: 80) were included. Ultrasound localized the testis as intracanalicular in 24/53 (45.2%), intraabdominal in 10/53 (18.8%), scrotal in 1/53 (1.8%), and could not localize 18/53 (33.9%) testes. In 35/53 (66%) testes, the ultrasound location correlated with the surgical findings (P < 0.001). Ultrasound detection showed 96% sensitivity and 56% specificity for intracanalicular testes. Conclusion: The use of preoperative ultrasound in this series was helpful in identifying the location of nonpalpable testes in children. In particular, the ultrasound finding of an intracanalicular testis may preclude the need for laparoscopy.