Paul J. Kokorowski

The Society for Fetal Urology consensus statement on the evaluation and management of antenatal hydronephrosis

The evaluation and management of fetuses/children with antenatal hydronephrosis (ANH) poses a significant dilemma for the practitioner. Which patients require evaluation, intervention or observation? Though the literature is quite extensive, it is plagued with bias and conflicting data, creating much confusion as to the optimal care of patients with ANH. In this article, we summarized the literature and proposed recommendations for the evaluation and management of ANH.

Evaluation of immediate endoscopic realignment as a treatment modality for traumatic urethral injuries.

BACKGROUND Traumatic urethral injuries have been traditionally managed by suprapubic drainage with a delayed repair. Advances in endoscopic techniques have facilitated early realignment and transurethral catheterization of the injured segment as a new management option. The purpose of this study was to investigate the outcomes of patients undergoing immediate endoscopic realignment (IER) compared with delayed treatment (DT). METHODS Trauma patients sustaining a traumatic urethral injury admitted to a level I trauma center were prospectively identified and followed through their course of treatment. Injury demographics and outcomes were compared for IER versus DT. The primary outcome measures were time to spontaneous voiding and urethral stricture rate. RESULTS Of 21 patients with acute urethral injuries, 14 (67%) had IER and 7 (33%) had DT (4 IER failures and 3 primary DT). The 4 IER failures represent 22% of the patients in the immediate realignment attempt group that failed and went on to delayed therapy. Mean follow-up was 7 months (range, 14 days to 1.7 years). IER and DT groups were similar with regards to age (30 +/- 16 vs. 24 +/- 6), mechanism of injury (blunt vs. penetrating), location of urethral injury (anterior vs. posterior), Glasgow Coma Scale score (13 +/- 3 vs. 12 +/- 6), ISS (14 +/- 11 vs. 20 +/- 6), and associated injuries (pelvic fractures and intra-abdominal injuries). Mean time to IER from admission was 32 +/- 80 hours (range, 1 hour-2.8 days). Patients undergoing IER had a significantly shorter time to spontaneous voiding (35 +/- 23 vs. 229 +/- 79 days, p = 0.001) and had a significantly decreased rate of stricture formation (14% vs. 100%, p < 0.0001). All DT patients required formal surgical urethroplasty whereas the 2 (14%) IER patients with strictures only required outpatient clinic dilatation. CONCLUSION Compared with the traditional DT approach, IER results in a significantly reduced time to spontaneous voiding with less risk of urethral stricture, possibly avoiding the need for surgical urethroplasty and long-term suprapubic urinary diversion.

Variations in Timing of Surgery Among Boys Who Underwent Orchidopexy for Cryptorchidism

OBJECTIVE: Current clinical guidelines recommend that orchidopexy be performed by the age of 1 in patients with congenital undescended testis. We sought to examine trends in surgical timing and to determine what factors are associated with age at surgery. METHODS: The Pediatric Health Information System (PHIS) is a national database of >40 freestanding childrens hospitals. We searched the PHIS to identify boys with cryptorchidism who underwent orchidopexy between 1999 and 2008. Patient age at orchidopexy was evaluated, and we used multivariate models to determine factors associated with timing of surgery. RESULTS: We identified 28 204 children who underwent orchidopexy at PHIS hospitals. Of these, 14 916 (53%) were white, and 17 070 (61%) had public insurance. Only 5031 patients (18%) underwent orchidopexy by the age of 1 year; only 12 165 (43%) underwent orchidopexy by the age of 2 years. These figures remained stable over time (P = .32). After adjusting for patient clustering, race (P < .001) and insurance status (P < .001) remained associated with patient age at orchidopexy; however, the treating hospital (P < .001) was the most important factor in predicting the timing of the procedure. CONCLUSIONS: Only 43% had surgery by 2 years of age, which suggests that either significant numbers of boys with congenital cryptorchidism do not undergo surgery in a timely fashion or late-onset testicular ectopy is more common than generally recognized. Factors associated with the timing of orchidopexy include patient race, insurance status, and the hospital in which surgery is performed.

In Utero Closure of Myelomeningocele Does Not Improve Lower Urinary Tract Function

PURPOSE Recent data comparing prenatal to postnatal closure of myelomeningocele showed a decreased need for ventriculoperitoneal shunting and improved lower extremity motor outcomes in patients who underwent closure prenatally. A total of 11 children whose spinal defect was closed in utero were followed at our spina bifida center. We hypothesized that in utero repair of myelomeningocele improves lower urinary tract function compared to postnatal repair. MATERIALS AND METHODS Eleven patients who underwent in utero repair were matched to 22 control patients who underwent postnatal repair according to age, gender and level of spinal defect. Urological outcomes were retrospectively reviewed including urodynamic study data, need for clean intermittent catheterization, use of anticholinergic agents and prophylactic antibiotics, and surgical history. The need for ventriculoperitoneal shunting or spinal cord untethering surgery was also reviewed. RESULTS Mean followup was 7.2 years for patients who underwent in utero repair and 7.3 years for those who underwent postnatal repair. Mean patient age at compared urodynamic studies was 5.9 years for in utero repair and 6.0 years for postnatal repair. The in utero repair group was comprised of 5 lumbar and 6 sacral level defects with equal matching (1:2) in the postnatal repair cohort. There were no differences between the groups in terms of need for clean intermittent catheterization, incontinence between catheterizations or anticholinergic/antibiotic use. Urodynamic parameters including bladder capacity, detrusor pressure at capacity, detrusor overactivity and the presence of detrusor sphincter dyssynergia were not significantly different between the groups. There was no difference in the rate of ventriculoperitoneal shunting (p = 0.14) or untethering surgery (p = 0.99). CONCLUSIONS While in utero closure of myelomeningocele has been shown to decrease rates of ventriculoperitoneal shunting and improve motor function, it is not associated with any significant improvement in lower urinary tract function compared to repair after birth.

Use of the Ureteral Access Sheath During Ureteroscopy in Children

PURPOSE The use of ureteral access sheaths during ureteroscopy is common but there are sparse data on the safety and outcomes of ureteral access sheath use in children. We compared the outcomes of ureteroscopy with vs without a ureteral access sheath in children. MATERIALS AND METHODS We retrospectively reviewed all ureteroscopy procedures for urolithiasis in patients younger than 21 years at our hospital from 1999 to 2009. The primary outcome was intraoperative complications. Secondary outcomes were postoperative hydronephrosis, emergency room visit/hospital readmission within 90 days, stone-free status and need for re-treatment. We analyzed associations of a ureteral access sheath with outcomes. RESULTS A total of 34 boys and 62 girls with a mean age of 13 years underwent ureteroscopy. A ureteral access sheath was used in 40 of the 96 patients (42%). The mean stone burden was 9.6 mm. Median followup was 11 months (range 0.2 to 110). Intraoperative complication occurred in 7 cases, including perforation/extravasation in 4, a submucosal wire in 2 and stent migration in 1. Intraoperative complications were more common when a sheath was used (15% vs 2%, adjusted OR 8.2, 95% CI 1.3-50.9, p = 0.02). Postoperative hydronephrosis was observed in 7 of 73 cases (10%) but it was not significantly more common when a sheath was used. No ureteral stricture was identified. Sheath use was not associated with postoperative telephone calls, emergency room visits or rehospitalization. Although the stone-free rate tended to be higher in cases without a sheath (78% vs 59%, p = 0.09), this association was not significant in a multivariate model (p = 0.6). CONCLUSIONS Although intraoperative complications occur more commonly during ureteroscopy with a ureteral access sheath, no increase in longer term adverse effects were observed. Future prospective studies of ureteral access sheath use in children with longer followup are warranted.

Screening for Malignancy After Augmentation Cystoplasty in Children With Spina Bifida: A Decision Analysis

PURPOSE Augmentation cystoplasty is the mainstay of surgical treatment for medically refractory neurogenic bladder in patients with spina bifida. Concerns regarding an increased risk of malignancy have prompted many centers to consider routine postoperative screening. We examine the potential cost-effectiveness of such screening. MATERIALS AND METHODS A Markov model was used to compare 2 screening strategies among patients with spina bifida after cystoplasty, namely annual screening cystoscopy and cytology and usual care. Model parameters were informed via a systematic review of post-augmentation malignancy and cost estimates from published reports or government sources. RESULTS In a hypothetical cohort the individual increase in life expectancy for the entire cohort was 2.3 months with an average lifetime cost of

Timeliness of surgical care in children with special health care needs: delayed palate repair for publicly insured and minority children with cleft palate

55,200 per capita, for an incremental cost-effectiveness ratio of

Prospective Measurement of Patient Exposure to Radiation During Pediatric Ureteroscopy

273,718 per life-year gained. One-way and two-way sensitivity analyses suggest the screening strategy could be cost effective if the annual rate of cancer development were more than 0.26% (12.8% lifetime risk) or there were a greater than 50% increase in screening effectiveness and cancer risk after augmentation. After adjusting for multiple levels of uncertainty the screening strategy had only an 11% chance of being cost effective at a

Prospective Systematic Intervention to Reduce Patient Exposure to Radiation During Pediatric Ureteroscopy

100,000 per life-year threshold or a less than 3% chance of being cost effective at

Costs and Consequences of Universal Sibling Screening for Vesicoureteral Reflux: Decision Analysis

100,000 per quality adjusted life-year. CONCLUSIONS Annual screening for malignancy among patients with spina bifida with cystoplasty using cystoscopy and cytology is unlikely to be cost effective at commonly accepted willingness to pay thresholds. This conclusion is sensitive to a higher than expected risk of malignancy and to highly optimistic estimates of screening effectiveness.