Marc C. Smaldone

When is Prior Ureteral Stent Placement Necessary to Access the Upper Urinary Tract in Prepubertal Children

PURPOSEnWe studied the possibility that age, height, weight and body mass index could be used to predict the likelihood of successful ureteroscopic access to the upper urinary tract without previous stent placement in prepubertal children.nnnMATERIALS AND METHODSnWe retrospectively reviewed all ureteroscopic procedures for upper tract calculi in prepubertal children from 2003 to 2007. We compared age, height, weight and body mass index in patients who underwent successful primary flexible ureteroscopic access and in those who required initial stent placement to perform ureteroscopy.nnnRESULTSnSuccessful primary ureteroscopic access to the upper tract was achieved in 18 of 30 patients (60%). There was no difference in mean age (9.9 vs 9.5 years, p = 0.8), height (132 vs 128 cm, p = 0.6), weight (37 vs 36 kg, p = 0.86) or body mass index (19.3 vs 20.5 kg/m(2), p = 0.55) between patients with successful vs unsuccessful upper tract access. Locations that prevented access to the upper urinary tract were evenly distributed among the ureteral orifice, iliac vessels and ureteropelvic junction.nnnCONCLUSIONSnAge, height, weight and body mass index could not predict the likelihood of successful ureteroscopic access to the upper tract. Placement of a ureteral stent for passive ureteral dilation is not necessary for successful ureteroscopic access to the renal pelvis in prepubertal children. An initial attempt at ureteroscopy, with placement of a ureteral stent if upper tract access is unsuccessful, decreases the number of procedures while maintaining a low complication rate.

Computerized tomography findings in pediatric renal trauma--indications for early intervention?

PURPOSEnWe sought to determine if initial computerized tomography findings in pediatric patients suffering blunt renal trauma with urinary extravasation were predictive of the need for operative intervention.nnnMATERIALS AND METHODSnA total of 17 patients with grade IV blunt renal trauma and urinary extravasation were identified between 2000 and 2007. Each computerized tomogram was reviewed to determine location, size and number of sites of extravasation, as well as the presence of contrast material in the ipsilateral ureter. These findings were compared with subsequent ureteral stent placement, percutaneous urinoma drainage, angiographic embolization and nephrectomy.nnnRESULTSnA total of 13 male and 4 female patients (mean age 11.1 years) were identified. Eight patients (47%) required delayed intervention. Conservative treatment was unsuccessful in patients with absence of contrast material in the ipsilateral ureter and large separation of the upper and lower poles, and in 3 of 5 patients with multiple areas of extravasation and 4 of 5 patients with transfusion requirements. The diameter (9.6 vs 9.7 mm, p = 0.96) and location of extravasation were not predictive of subsequent intervention. Two of 5 patients with posterior extravasation required intervention, both for symptomatic urinoma.nnnCONCLUSIONSnEarly ureteral stent placement may be considered for pediatric patients with blunt renal trauma who demonstrate absence of contrast material in the ipsilateral ureter, since clinical indications for stent placement will likely develop. Further study may show if wide separation of the upper and lower poles, multiple areas of extravasation and transfusion requirement are factors in the decision for early intervention.

Cloacal exstrophy variant with intravesical phallus: Further description of anatomy and implications for gender reassignment

Variant presentations of cloacal exstrophy are exceedingly rare. Historically, genetic males with cloacal extrophy were re-assigned to the female gender due to phallic inadequacy. Early recognition of intravesical phallic structures in cloacal exstrophy cases may impact gender reassignment discussions and long-term gender outcomes. We report the case of a male infant with cloacal exstrophy presenting with an intravesical phallus, review and compare the presenting anatomical features of the three previously reported cases, and discuss the potential impact of these findings on gender reassignment in these complex children.

Re: Extended Urethral Mobilization in Incised Plate Urethroplasty for Severe Hypospadias: A Variation in Technique to Improve Chordee Correction: A. Bhat J Urol 2007; 178: 1031–1035

To the Editor. Abbod et al reviewed different artificial intelligence techniques, such as artificial neural networks (ANNs), Bayesian belief networks and neuro-fuzzy modeling systems (NFMs), for improved diagnosis, staging and prognosis of urological cancer. As stated, a detailed and systematic review of the literature was also performed using the MEDLINE® databases. However, we believe that the reader should be made aware of important studies on prostate cancer (PCa) diagnosis and urological imaging that were overlooked by the authors in this interesting survey. Two ANN models with the parameters prostate specific antigen (PSA), percent free PSA (%fPSA), prostate volume, status of digital rectal examination and patient age, which have been used in the clinical routine for many years, are worth mentioning in a systematic review such as this. Furthermore, both models are available for free online at www.finne.info and www.charite.de/ch/uro. Kalra et al published another ANN model named “neUROn,” which uses the input factors PSA, complexed PSA, age, digital rectal examination, ethnicity, family history and International Prostate Symptom Score, but does not include %fPSA. Other studies concerning ANN models, including potential new biomarkers, have already been reviewed. In 2006 a study using NFM based on PSA, %fPSA and age indicated a superior predictive accuracy of NFM compared to PSA and %fPSA. An interesting way to improve imaging is an ANN analysis of transrectal ultrasound images in an attempt to obtain existing subvisual information, other than the gray scale, from conventional transrectal ultrasound to enhance the ability to diagnose PCa. The authors significantly reduced the number of false-positive results in the 381 benign cases to about 1%. In the 119 patients with PCa the rate of false-negative results was 21%. We hope that these additional important studies further support the fact that artificial intelligence models can be superior to standard statistical methods as stated by Abbod et al. Artificial neural networks, or other multivariate models, are at the moment the best tool to reduce the number of unnecessary prostate biopsies. The multivariate models have the potential to overcome the dilemma of low specificity when using PSA or its derivatives to detect PCa.

WBC Associates with Readmission Following Cystectomy

Background: Radical cystectomy is associated with perioperative complication rates exceeding 50% in some series. Readmission rates are increasingly used as a surgical quality metric. White blood cell count is a crude surrogate for physiologic processes which may reflect postoperative complications leading to readmission. Objective: We assessed the association between final white blood cell count at discharge and risk of readmission following radical cystectomy. Methods: Records on 477 patients undergoing radical cystectomy from 2006–2013 were reviewed. Final white blood cell count was defined as the last documented value during index admission. Univariate analysis was performed using Fisher’s exact, Wilcoxon rank sum test, and Spearman’s coefficient tests where appropriate. Multivariable logistic regression models were used to test the associations between final white blood cell count and readmission. Results: 34% of patients were readmitted within 90 days of surgery. Amongst this cohort, a cutoff final white blood cell count of 9000/mm3 was identified, with a significantly higher proportion of patients with valuesu200a>9000/mm3 experiencing readmission than those with values≤9000/mm3 (42% vs 28%, pu200a=u200a0.004). Other perioperative variables associated with an increased readmission rate included initial hospital length of stay≤10 days, and receipt of a continent diversion. Following adjustment, final white blood cell countu200a>9000/mm3 was associated with increased risk of readmission (OR 2.09, 95% CI 1.23–3.53, pu200a=u200a0.006). Conclusions: Final white blood cell count is associated with hospital readmission following radical cystectomy. This metric may provide important guidance in discharge algorithms.