Nicholas Holmes

Plastibell complications revisited.

We suspect that the retained Plastibell® or proximal migration of the Plastibell® is more frequent than is reported. A few reported cases in the literature have noted this complication with the Plastibell® device.6,8 In the largest series to date, only three patients of 2,000 (0.015%) had problems with migrated devices.8 The exact complication rate with circumcision is not known owing to the variability in reports and definition of complication.4 It has been estimated to be from 0.067% to as high as 55%.8 Prompt recognition of the retained Plastibell® is essential, and

Comparison of Laparoendoscopic Single-Site, Conventional Laparoscopic, and Open Nephrectomy in a Pediatric Population

INTRODUCTIONnWe provide a single-institution comparison of open, conventional laparoscopic (CL) and laparoendoscopic single-site (LESS) nephrectomy in children.nnnMETHODSnWe identified all nephrectomy cases occurring at Rady Childrens Hospital from July 2007 to March 2010. Exclusion criteria included redo/bilateral operations, malignancy, transplant nephrectomy, or complex urogenital anomalies. We compared patient demographics, total operative times, estimated blood loss (EBL), length of stay (LOS), complication rates, postoperative pain score, narcotic usage, and total hospital costs.nnnRESULTSnWe identified 7 LESS, 11 CL, and 8 open nephrectomy patients who met our criteria. The mean age of patients was 8.5, 7.3, and 4.2 years for LESS, CL, and open nephrectomy, respectively (P=.217). Operative times were 192.2, 219.3, and 127.4 minutes for LESS, CL, and open nephrectomy, respectively (P=.076). EBL was 15, 13.2, and 12.5 mL, respectively, for these groups (P=.871). There were no complications in any of the groups, although 1 LESS patient required conversion to open nephrectomy for bleeding. Mean LOS was 46.8, 36.9, and 33.8 hours in the LESS, CL, and open nephrectomy groups (P=.308). Mean pain scores on postoperative day 1 were 2.3, 1.8, and 1.6 in each group, respectively (P=.518). Hospital costs were comparable between the LESS and CL groups. The mean cost for open nephrectomy was 54.4% the mean cost for CL, however (P=.001).nnnCONCLUSIONSnLESS nephrectomy in children is safe and overall comparable with CL. In our experience, no modality confers a distinct advantage except for the decreased cost associated with open surgery.

A Quality Improvement Collaborative to Improve the Discharge Process for Hospitalized Children.

OBJECTIVE: To assess the impact of a quality improvement collaborative on quality and efficiency of pediatric discharges. METHODS: This was a multicenter quality improvement collaborative including 11 tertiary-care freestanding children’s hospitals in the United States, conducted between November 1, 2011 and October 31, 2012. Sites selected interventions from a change package developed by an expert panel. Multiple plan–do–study–act cycles were conducted on patient populations selected by each site. Data on discharge-related care failures, family readiness for discharge, and 72-hour and 30-day readmissions were reported monthly by each site. Surveys of each site were also conducted to evaluate the use of various change strategies. RESULTS: Most sites addressed discharge planning, quality of discharge instructions, and providing postdischarge support by phone. There was a significant decrease in discharge-related care failures, from 34% in the first project quarter to 21% at the end of the collaborative (P < .05). There was also a significant improvement in family perception of readiness for discharge, from 85% of families reporting the highest rating to 91% (P < .05). There was no improvement in unplanned 72-hour (0.7% vs 1.1%, P = .29) and slight worsening of the 30-day readmission rate (4.5% vs 6.3%, P = .05). CONCLUSIONS: Institutions that participated in the collaborative had lower rates of discharge-related care failures and improved family readiness for discharge. There was no significant improvement in unplanned readmissions. More studies are needed to evaluate which interventions are most effective and to assess feasibility in non–children’s hospital settings.

Eosinophilic cystitis in the pediatric population: A case series and review of the literature

PURPOSEnEosinophilic cystitis is a rarely seen condition in the pediatric population with indistinct symptomatology and non-standardized treatment protocols. We review our experience of treating patients with this condition.nnnMATERIALS AND METHODSnWe retrospectively reviewed the records of four patients from a single institution who have been diagnosed and treated for eosinophilic cystitis. In addition, the literature was reviewed for cases of pediatric eosinophilic cystitis. Our patients were added and compared to this cohort.nnnRESULTSnOur patients included 3 females and 1 male who range in age from 5 days to 18 years (5 days, 1 month, 7 years, 18 years). Both of the infants presented with a suprapubic mass and bilateral hydroureteronephrosis. The two older patients both had dysuria while the 18 yo also complained of fatigue, flank pain, and hematuria. Only 2 of the 4 patients were found to have significant peripheral eosinophilia and only one patient had eosinophiluria. All of the patients were diagnosed via cystourethroscopy with biopsy. Treatment in each case consisted of a combination of steroids, antihistamines, and antibiotics.nnnCONCLUSIONSnThe presentation of eosinophilic cystitis is varied and diagnosis requires a high index of suspicion. Cystourethroscopy with biopsy is essential to establish the diagnosis as there is no typical appearance of the lesions or presenting signs/symptoms. Most cases of eosinophilic cystitis are responsive to medical therapy although in some cases recurrence may be noted.

Ureteroscopy in Pediatric Patients with Spinal Abnormalities

BACKGROUND AND PURPOSEnUreteroscopy (URS) is considered a safe and effective treatment modality for ureteral stones in the pediatric population. Patients with scoliosis or spinal hardware, however, may have anatomic variability that makes URS challenging because of ureteral deviation or tortuosity. We reviewed 130 ureteroscopic procedures at our institution to determine if presence of spinal hardware or severe spinal deformities was associated with increased complications or worsened treatment efficacy.nnnPATIENTS AND METHODSnA retrospective chart review was performed on 130 ureteroscopic procedures in 102 patients. Patients were divided into two groups: Those with normal spinal anatomy and those with spinal abnormalities including spinal hardware or moderate to severe scoliosis. Parameters evaluated included patient demographics, stone burden, intraoperative complications (including urinary extravasation, bleeding, or need to abort procedure), and stone-free status.nnnRESULTSnOf 130 ureteroscopic procedures between 2002 and 2010, 25 URS were performed for purposes other than stone disease (gross hematuria, filling defects, or encrusted ureteral stents). The remainder of URS (105) were performed for stone disease. Nine patients had spinal hardware or significant spinal deformities including moderate to severe scoliosis. When comparing both the intraoperative complications as well as stone-free status, there was a difference between those patients with spinal abnormalities and those without. Of 90 URS performed for stones in normal anatomy patients, the stone-free rate was 61%, compared with 35.7% in patients with spinal deformities. There were 13 total complications (Satava grade I or II): 40% in spinal deformity patients compared with 6.1% in normal anatomy patients.nnnCONCLUSIONnSpinal hardware and spinal deformities contribute to increased complications and worsened stone-free rates during pediatric URS compared with pediatric patients with normal anatomy. Our experience with URS in patients with spinal deformities suggests it may not be as safe or efficacious as in the general pediatric population but it can still be used as a primary modality.

Laparoendoscopic single-site (LESS) bilateral nephrectomy in the pretransplant pediatric population.

Marietti S, Holmes N, Chiang G. Laparoendoscopic single‐site (LESS) bilateral nephrectomy in the pretransplant pediatric population.u2028Pediatr Transplantation 2011: 15: 396–399.

Children With Spinal Abnormalities Have an Increased Health Burden From Upper Tract Urolithiasis

OBJECTIVEnTo examine the epidemiology and health care burden of upper tract urolithiasis in children with spinal abnormalities using a large, national database. Children with spinal dysraphism are predisposed to urolithiasis for many reasons, including immobility, bacteriuria, and urinary stasis. No large epidemiologic studies exist regarding stones in this specific group. Isolated spinal curvature may lead to hypercalciuria from immobility; however, urolithiasis rates are unknown.nnnMETHODSnWe extracted data from the Pediatric Health Information Systems database over an 8-year period. Hospitals reporting inpatient visits, emergency room visits, and ambulatory surgery visits were included. Using International Classification of Diseases, Ninth Revision codes and Current Procedural Terminology codes, we identified children with upper tract urolithiasis, spinal dysraphism, and spinal curvature. Data regarding demographics, prevalence, surgical procedures, costs related to stone procedures were extracted.nnnRESULTSnA total of 11,987 patients had urolithiasis. Prevalence of stones in patients with normal spines was 0.24% compared with 1.40% and 4.03% among children with spinal curvature and spinal dysraphism, respectively (P<.001). Children with spinal curvature and spinal dysraphism were more likely to have multiple procedures for stones than those without spinal abnormalities (25% vs 25.7% vs 13.1%, P<.001). Costs per patient were significantly higher for children with spinal abnormalities compared with those with normal spines.nnnCONCLUSIONnChildren with spinal curvature and spinal dysraphism have a much greater rate of upper tract urolithiasis, resulting in more procedures and related costs. Urolithiasis represents a significant, chronic health burden for children with spinal abnormalities. Screening and preventive care may reduce the impact of urolithiasis in these patients.

Adolescent Xanthogranulomatous Pyelonephritis Mimicking Renal Cell Carcinoma on Urine Cytology: An Atypical Presentation

Xanthogranulomatous pyelonephritis (XGP) is a chronic renal inflammatory lesion that is rarely diagnosed in children. We present a case of a 16-year-old boy presenting with gross hematuria and a lack of laboratory and radiographic findings for XGP who was suspected of having renal cell carcinoma on urine cytology. Left radical nephrectomy was performed, confirming the diagnosis of XGP. The cytologic mimicking of renal cell carcinoma by XGP emphasizes that physicians should consider XGP in the differential diagnosis. The inability of urine cytopathology to distinguish XGP from renal cell carcinoma suggests a need for the development of new pathology techniques.

Genitourinary rhabdomyosarcoma: Unusual diagnosis presenting within hours of delivery

Genitourinary rhabdomyosarcoma of the newborn is extremely rare. We present a case report of a newborn delivered with a palpable abdominal mass revealing rhabdomyosarcoma on biopsy. Prenatal care was normal. The child was treated with multimodal therapy including extensive chemotherapy, surgical excision, and radiation therapy. Surgical excision included cystoprostatectomy, ureterostomy, abdominoperineal resection and colostomy placement. He continued to progress and eventually succumbed to his disease.

Salvage Ureteral Reimplantation After Failure of Dextranomer/Hyaluronic Acid Injection

PURPOSEnUreteroneocystostomy after dextranomer/hyaluronic acid injection is reportedly associated with significantly more morbidity, and increased operative time, length of stay and postoperative obstruction. To evaluate our experience, we reviewed results of patients who underwent salvage ureteral reimplantation following failed dextranomer/hyaluronic acid injection.nnnMATERIALS AND METHODSnWe retrospectively reviewed charts of patients at a single institution who underwent intravesical ureteral reimplantation as salvage treatment following failed dextranomer/hyaluronic acid injection. Data points such as operative time, blood loss and length of stay were compared to those of controls undergoing de novo reimplantation by the same surgeons. Statistical analysis was performed using Students t test and chi-square test.nnnRESULTSnWe identified 18 patients who underwent salvage reimplant. We compared data to an equal number of controls. Mean age (4.28 years in patients vs 3.34 years in controls, p = 0.62) and mean reflux grade at reimplant (3.15 vs 3.40, p = 0.97) were comparable between the groups. Operative time (128 vs 141.9 minutes, p = 0.14), blood loss (12.9 vs 11.9 ml, p = 0.71) and length of hospital stay (1.68 vs 1.3 days, p = 0.25) were not significantly different. No statistically significant differences were found regarding any of the compared variables.nnnCONCLUSIONSnUreteral reimplantation after dextranomer/hyaluronic acid injection is no more difficult than primary ureteral reimplantation regarding operative time, blood loss and length of hospital stay. These results support dextranomer/hyaluronic acid as initial operative treatment of vesicoureteral reflux when deemed appropriate and may further shift the paradigm of treatment away from prolonged medical management.