Bowel And Bladder Dysfunction Research Articles

Surgical Outcomes in Patients Exhibiting Muscular Weakness Postadolescence Due to Tight Filum Terminale.

Tight filum terminale is a neurological condition marked by various symptoms, including muscle weakness. There is a notable lack of literature addressing muscle weakness, particularly in cases emerging during adolescence and beyond. The diagnosis is challenging due to a lack of radiological abnormalities, and the literature on its treatment, especially untethering, in adults is limited. This study aims to evaluate the effectiveness of untethering in improving muscle weakness and other symptoms in postadolescent patients diagnosed with tight filum terminale. A retrospective analysis was conducted on seven postadolescent patients diagnosed with tight filum terminale and presenting muscle weakness who underwent untethering at our institution between January 2018 and August 2022. Patients were monitored for muscle strength improvement, lumbar and lower extremity pain, and bowel and bladder dysfunction (BBD) after untethering. Muscle weakness improved in all cases after untethering, with a mean duration of 9.1 weeks for the improvement. Patients unable to walk independently regained mobility in an average of 22.3 weeks. Lumbar and lower limb pain improved in all cases within an average of 8.1 weeks, while BBD improved in six of the seven cases within an average of 1.9 weeks. Our findings suggest that untethering is an effective surgical intervention for postadolescent patients diagnosed with tight filum terminale and presenting muscle weakness.

The diagnostic accuracy of neuromonitoring for detecting postoperative bowel and bladder dysfunction in spinal oncology surgery: a case series.

Postoperative bowel and bladder dysfunction (BBD) poses a significant risk following surgery of the sacral spinal segments and sacral nerve roots, particularly in neuro-oncology cases. The need for more reliable neuromonitoring techniques to enhance the safety of spine surgery is evident. We conducted a case series comprising 60 procedures involving 56 patients, spanning from September 2022 to January 2024. We assessed the diagnostic accuracy of sacral reflexes (bulbocavernosus and external urethral sphincter reflexes) and compared them with transcranial motor evoked potentials (TCMEP) incorporating anal sphincter (AS) and external urethral sphincter (EUS) recordings, as well as spontaneous electromyography (s-EMG) with AS and EUS recordings. Sacral reflexes demonstrated a specificity of 100% in predicting postoperative BBD, with a sensitivity of 73.33%. While sensitivity slightly decreased to 64.71% at the 1-month follow-up, it remained consistently high overall. TCMEP with AS/EUS recordings did not identify any instances of postoperative BBD, whereas s-EMG with AS/EUS recordings showed a sensitivity of 14.29% and a specificity of 97.14%. Sacral reflex monitoring emerges as a robust adjunct to routine neuromonitoring, offering surgeons valuable predictive insights to potentially mitigate the occurrence of postoperative BBD.

Evaluation of the results of urodynamic studies in patients with vesicoureteral reflux.

To investigate urodynamic abnormalities associated with vesicoureteral reflux (VUR) in toilet-trained children. The data of 157 children who were diagnosed with vesicoureteral reflux and referred to our hospital between 2013 and 2022 were retrospectively examined. The urodynamic parameters were analyzed and correlated with age, gender, lower urinary tract symptoms (LUTS), reflux severity, and laterality. Overall, 131 (83.4%) patients had abnormal urodynamic findings with a male-to-female ratio of 1:1.4. The most common pathological finding was detrusor overactivity (DO), identified in 101 (64.3%) patients, followed by dysfunctional voiding (DV) in 74 (50.3%) patients. Children with VUR grades II and III exhibited a greater percentage of abnormal urodynamic findings than children with grades IV and V. The prevalence of DO was higher in children younger than 10 years old with unilateral and lower-grade VURs. DV was more frequent in children older than 10 years, with bilateral VUR, and higher grade VUR. The prevalence of LUTS, bowel and bladder dysfunction (BBD), and urinary tract infection (UTI) was higher among children with abnormal urodynamic findings. Children with VUR have a high incidence of urodynamic disorders. Urodynamic dysfunction may contribute to the pathogenesis of VUR, especially in mild cases.

Complication Pattern of Sacral Primary Tumor Resection: A Study on the Risk Factors of Surgical Site Infection and Bowel or Bladder Dysfunction and Their Associations with Length of Hospital Stay.

Retrospective open cohort study. The current study aimed to explore the pattern of complications after primary sacral tumor resection, to investigate the possible effect of several perioperative parameters on the development of complications, and to identify which complications are associated with the length of hospital stay (LOS). Primary sacral tumor (pST) resection is associated with a high complication rate. However, the number of studies on these complications and their effect on LOS is limited. The clinical data of 140 patients with pST surgeries and 106 subsequent patients with local recurrence surgeries in four subgroups (index surgery, local recurrence surgery, malignant, and benign tumor) were prospectively collected and analyzed. The prognostic value of several perioperative factors on the development of surgical site infection (SSI), bowel and bladder dysfunction (BBD), and LOS was investigated using the logistic and linear regression models. The overall complication rates were 61.2% after index surgeries and 50.9% after local recurrence surgeries. The most frequent complications were SSI, vegetative dysfunction, urinary tract infections, and neurological deterioration. Age >55 years, malignant tumors, and red blood cell transfusion had a predictive effect on the development of SSI in the logistic model (p<0.01, R2=0.43). Bilateral S2 or S3 resection commonly caused postoperative BBD (chi-square test=62.5, degrees of freedom=4, p<0.001). In the multiple linear regression model, wound dehiscence, BBD, systemic and urinary tract infection, cerebrospinal fluid leak, and neurologic deterioration were associated with a significantly long LOS (p<0.01, R2=0.62). Surgical resection of pSTs has a high complication rate. Its common complications are SSI and BBD, both of which can have a significant influence on global therapeutic outcome. Malignant tumor diagnosis, old age, and red blood cell transfusion can remarkably increase the risk of SSI. Further, the development of BBD is significantly associated with the number of resected sacral nerve roots. By decreasing perioperative complications, LOS can decrease significantly.

Personalized Pre-clinic Nursing Telemedicine Visit: An Efficient and Efficacious Approach for Bowel and Bladder Dysfunction in Children

To evaluate the effectiveness and efficacy of a Registered Nurse (RN) led educational pre-clinic telephone call on compliance and outcomes in children with bowel and bladder dysfunction (BBD). A retrospective chart review of a prospectively applied protocol in a single academic institution was performed for children aged 4-17 presenting with BBD. All children underwent a pre-clinic RN telemedicine visit where they were educated on pathophysiology of BBD, provided personalized urotherapy and bowel recommendations and instructed to complete pre-clinic questionnaires and voiding diaries. Patients were evaluated by a provider 4weeks following RN call. Data collected included compliance with forms, bowel management and need for imaging/testing, medications, and biofeedback. Patients were considered to improve with urotherapy alone if they were discharged from urology without the need for medications and/or biofeedback. In total, 277 patients completed an RN call and 224 patients attended a provider visit between December 2020 and June 2022. Mean age was 9.4years (3:1 Female to Male ratio). During the RN call, 154 (56%) patients had bowel management initiated. Of the 224 patients seen by a provider, 69% (n=154) had symptom improvement or resolution with urotherapy alone. Thirty-eight patients (17%) enrolled in biofeedback with 7 (3%) completing all 8 sessions. Thirty-two patients (14%) required medication for daytime bladder symptoms. Our novel RN-led pre-clinic telemedicine visit demonstrates excellent compliance and patient outcomes for children with BBD and can reduce the use of unnecessary imaging, medications, and time-consuming treatments such as biofeedback.

Comorbidity of Obsessive-Compulsive Symptomatology and Bowel and Bladder Dysfunction in a Tertiary Children's Hospital: A Case Series

ObjectiveTo improve understanding of co-occurring obsessive-compulsive disorder (OCD) and bowel and bladder dysfunction (BBD) in an outpatient pediatric urology clinic setting. To provide a series of clinical care recommendations to enhance the identification and integrated medical and behavioral health treatment of these disorders. MethodsAuthors participated in a series of discussions to define the patient population and specific aims for the study. Efforts were made to select index patients of diverse background despite limited sample availability. Three patients were ultimately selected for the study. ResultsThe case studies highlight the connection between urinary issues and underlying OCD symptoms. All patients were initially seen for medical treatment of urological symptoms, then referred for psychological evaluation, and were diagnosed with and received treatment for OCD. Similarities among the cases, including experience of phantom urinary incontinence, stressors present that contributed to symptoms, and obsessive fears of incontinence that led to compulsive behavior, were discussed. Differences between the cases, including patient age, sex, and compulsive behavior demonstrated (ie, urinary frequency, excessive wiping) were also reviewed. ConclusionAccess to a behavioral health provider can enhance the identification of comorbid psychological disorders and can reduce duration of symptoms through appropriate psychological treatment. Authors provide recommendations for screening measures and reinforce importance of including basic education on psychiatric diagnoses and impact on urological symptoms in urology and pediatric fellowship training programs. Future research exploring prevalence of comorbid psychiatric conditions and efficacy of treatment interventions in a pediatric urology population would be beneficial.

Pediatric robot-assisted extravesical ureteral reimplantation (revur) in simple and complex ureter anatomy: Report of a multicenter experience

Robot-assisted extravesical ureteral reimplantation (REVUR) is a well established approach for surgical treatment of pediatric vesicoureteral reflux (VUR). However, further evidence is needed to confirm its efficacy even in case of complex anatomy. This study aimed to further confirm the evidence that REVUR is safe and effective in both simple and complex ureter anatomy. The charts of all patients with VUR, who received REVUR in 6 different institutions over a 5-year period, were retrospectively reviewed. Patients with both simple and complex ureter anatomy were included. Patient demographics, surgical variables, and post-operative results were assessed. VUR resolution was defined as either being resolved VUR on voiding cystourethrogram (VCUG) or clinically without symptoms during the follow-up. Fifty-seven patients with median age of 6.9 years (range 4.5-12), receiving REVUR in the study period, were included. Eighteen (31.6%) patients had complex anatomy and included prior failed endoscopic injection (n=13), complete ureteral duplication (n=2), periureteral diverticulum (n=2), ectopic megaureter requiring dismembering (n=1). The median operative time was 155min for unilateral and 211.5min for bilateral repairs. The clinical+radiographic VUR resolution rate was 96.5%. Post-operative complications (Clavien 2) included urinary retention following bilateral repair (n=5, 8.7%), febrile urinary tract infection (UTI) (n=6, 10.5%) and gross hematuria (n=3, 5.2%). Comparative analysis between simple and complex cases showed that REVUR was faster in simple cases in both unilateral [p=0.002] and bilateral repair [p=0.001] and post-operative urinary retention was more frequent in simple cases [p=0.004] and in patients with pre-operative bowel and bladder dysfunction (BBD) [p=0.001] (Table). This series confirmed that the robot-assisted technique was feasible even in cases with complex anatomy using some technical refinements, that justified the longer operative times in both unilateral and bilateral cases. An interesting finding of this study was the correlation emerged between BBD and risk of post-operative urinary retention and VUR persistence. Our results also excluded any significant correlation between complex cases and risk of post-operative urinary retention. The main study limitations included the retrospective and nonrandomized design, the small number of cases and the arbitrary definition of complex anatomy. REVUR was safe and effective for management of VUR in both simple and complex ureter anatomy. Complex REVUR required slightly longer operative times, without significant differences in post-operative mordidity and success rates. Aside from complex anatomy, BBD emerged as the main risk factor associated with surgical failure and post-operative morbidity.

Bowel and Bladder Dysfunction Is Associated with Psychiatric Comorbidities and Functional Impairment in Pediatric Obsessive-Compulsive Disorder.

Objective: Neuropsychiatric disorders are common in children with bowel and bladder dysfunction (BBD), a syndrome associated with urinary frequency, urgency, holding, incontinence, and constipation. We evaluated BBD symptom severity in children and youth attending a tertiary care obsessive-compulsive disorder (OCD) clinic. Methods: Consecutive patients attending initial OCD assessments between 2016 and 2020 were invited to participate in a registry study. Diagnosis of OCD and comorbidities was established by structured clinical interview. OCD severity and impact were assessed with the Children's Yale-Brown Obsessive-Compulsive Scale (CY-BOCS) and the Child Obsessive Compulsive Impact Scale (COIS-R; self-report), respectively. BBD symptoms were quantified with the Vancouver Symptom Score (VSS), a validated self-report measure. Results: One hundred twelve participants completed the VSS (mean age 13.5 ± 3.3, range 7-20). Based on a cutoff score of 11 corresponding to pediatric urologist-diagnosed BBD, 30.4% of participants screened positive, including more females than males (39.3% vs. 21.4%; p = 0.04). Daytime urinary incontinence was present in a greater proportion of participants with OCD forbidden thoughts (34.8% vs. 8.2%, p = 0.002), major depressive disorder (MDD; 38.5% vs. 6.8%, p = 0.001), and somatization disorder (60% vs. 9%, p = 0.001) compared with those without. A regression model including CY-BOCS, COIS-R, psychiatric comorbidities, medications, age, and gender explained 52.2% of the variance in VSS; COIS-R, tic disorder, and MDD were significant predictors. Conclusion: BBD symptoms are common and associated with high OCD-related impairment and psychiatric comorbidities. Standardized assessment may facilitate identification of BBD symptoms in this population and is critical to mitigating long-term physical and mental health impacts. Further studies are required to assess the relationship between BBD and OCD treatment outcomes.

MP44-13 A SECOND-LOOK AT REPORTED STATISTICS: CHALLENGES IN REPLICATING REPORTED P-VALUES IN PEDIATRIC UROLOGY LITERATURE

You have accessJournal of UrologyPediatric Urology II (MP44)1 Sep 2021MP44-13 A SECOND-LOOK AT REPORTED STATISTICS: CHALLENGES IN REPLICATING REPORTED P-VALUES IN PEDIATRIC UROLOGY LITERATURE Erik Drysdale, Lauren Erdman, Mandy Rickard, Marta Skreta, Jin Kyu Kim, Daniel T. Keefe, Joana Dos Santos, Michael Chua, and Armando J. Lorenzo Erik DrysdaleErik Drysdale More articles by this author , Lauren ErdmanLauren Erdman More articles by this author , Mandy RickardMandy Rickard More articles by this author , Marta SkretaMarta Skreta More articles by this author , Jin Kyu KimJin Kyu Kim More articles by this author , Daniel T. KeefeDaniel T. Keefe More articles by this author , Joana Dos SantosJoana Dos Santos More articles by this author , Michael ChuaMichael Chua More articles by this author , and Armando J. LorenzoArmando J. Lorenzo More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002065.13AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: p-values are the accepted metric for reporting statistically significant findings in science. Ensuring that p-values are robust, reproducible, and generated from the proper tests is essential for ensuring accurate scientific inference. We explored this issue by attempting to verify reported p-values from binary outcome tests and explore the reproducibility of p-value reporting in the hydronephrosis (HN) and bowel and bladder dysfunction (BBD) literature. METHODS: We analyzed 254 papers that were included in previously reported projects conducted regarding HN (n=129) and BBD (n=125). All studies reviewed had at least 2 groups being compared and reported a significant difference. We extracted group counts for the two primary groups from the sampled papers and calculated the Fisher’s exact test p-value. RESULTS: We found that 38 of the 254 (BBD=15, HN=23, 15%) papers sampled had insignificant p-values using our approach, but were reported as significant at <5%. Of these 38 papers, 16 had results that had results that could not be found significant through any attempted approach, 12 could achieve significance through a chi-square test without a Yates continuity correction, and the remaining 10 could be accounted for by differing methodologies (e.g. more than two groups or different test procedures). CONCLUSIONS: A meaningful number studies from pediatric urology appear to report p-values that are difficult to reproduce. A combination of reproducible code, sensitivity analyses, as well as arms-length reproduction attempts can help to reduce non-robust results. Source of Funding: none © 2021 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 206Issue Supplement 3September 2021Page: e797-e798 Advertisement Copyright & Permissions© 2021 by American Urological Association Education and Research, Inc.MetricsAuthor Information Erik Drysdale More articles by this author Lauren Erdman More articles by this author Mandy Rickard More articles by this author Marta Skreta More articles by this author Jin Kyu Kim More articles by this author Daniel T. Keefe More articles by this author Joana Dos Santos More articles by this author Michael Chua More articles by this author Armando J. Lorenzo More articles by this author Expand All Advertisement Loading ...

Management of paediatric recurrent urinary tract infections and challenges in special patient populations.

Urinary tract infections (UTIs) affect up to8.4% of girls and 1.7% of boys within their first six years of life. The rate of recurrence is as high as 30%, with the effects carrying long-term morbidity. Concomitant pathology such as vesicoureteric reflux (VUR) or bowel andbladder dysfunction (BBD) can posefurther diagnostic and management challenges in the primary care setting. The aim of this article is to discuss the approach to diagnosis and management of recurrence and strategies to prevent it, with additional information regarding patients with VUR and BBD. Management of recurrent UTIs requires family-centred care, with conservative, pharmacological and surgical options effective across different patient groups. In situations that exceed the capacity oflocal services, referral to paediatric subspecialties should be considered to assist in further investigation of recurrent cystitis-like symptoms.

Translation and cross-cultural adaptation of the Childhood Bladder and Bowel Dysfunction Questionnaire (CBBDQ)

ObjectiveTo translate and cross-culturally adapt the Childhood Bladder and Bowel Dysfunction Questionnaire (CBBDQ) for use in Brazilian Portuguese. The CBBDQ is an 18-item tool covering 10 bladder and 8 bowel symptoms that was developed for use with children of 5 to 12 years of age with bowel and bladder dysfunction (BBD). The instrument has already been validated for use in Dutch and English. MethodIn the process of translation and cultural adaptation from English to Portuguese, the CBBDQ was submitted to undergo the required steps as established by the international methodological criteria: forward translation, synthesis, back-translation, expert panel review and pre-testing. ResultsNinety-three parents of children with lower urinary tract dysfunction answered the questionnaire. The mean age of the children was 7.6±2.1 years and 54 were female. Internal consistency was excellent, with a Cronbach’s alpha of 0.91 to 0.96. Additionally, reliability was high, with an intraclass correlation coefficient of 0.94 (95%CI: 0.85-0.93; p<0.0001). ConclusionThe translation and cultural adaptation of the CBBDQ enabled a quantitative evaluation of bladder and bowel symptoms to be performed in Brazilian children. The scores achieved allow the severity of BBD to be evaluated, as well as the patient’s progress during treatment. The use of this questionnaire in clinical practice and research will allow more consistent data on BBD to be obtained.

MP71-09 COMPARISON OF FRAGILITY METRICS BETWEEN 2 COMMON PEDIATRIC UROLOGY BODIES OF LITERATURE

You have accessJournal of UrologyPediatrics: Upper Urinary Tract Disorders and Fetal Urology (MP71)1 Apr 2020MP71-09 COMPARISON OF FRAGILITY METRICS BETWEEN 2 COMMON PEDIATRIC UROLOGY BODIES OF LITERATURE Mandy Rickard, Jessica Hannick*, Daniel T Keefe, Erik Drysdale, Lauren Erdman, Joana Dos Santos, and Armando J Lorenzo Mandy RickardMandy Rickard More articles by this author , Jessica Hannick*Jessica Hannick* More articles by this author , Daniel T KeefeDaniel T Keefe More articles by this author , Erik DrysdaleErik Drysdale More articles by this author , Lauren ErdmanLauren Erdman More articles by this author , Joana Dos SantosJoana Dos Santos More articles by this author , and Armando J LorenzoArmando J Lorenzo More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000000951.09AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Fragility index (FI) is a metric recently introduced to provide an objective measure of strength of study results. One proposed reason for poor study robustness is sparse well designed randomized controlled trials (RCTs). Different topics in Pediatric Urology literature include studies with varying quality of design. In particular, bowel and bladder dysfunction (BBD) studies are more likely to be higher quality versus other topics. To assess this hypothesis, we compared measures of robustness (FI and fragility quotient [FQ]) in our BBD and hydronephrosis (HN) literature databases. METHODS: A direct comparison of FI and FQ data from previously analyzed BBD and HN literature was performed. We gathered study design data and contrasted FI and FQ data stratified by study design. Search strategy, inclusion and exclusion criteria, data extraction and analyses were identical in both groups. RESULTS: 125 BBD and 130 HN papers published between 1971 and 2019 were included. The mean h index was 16 +15, median citation count was 14 (0-252), FI was 3(0-116), and 34% of the studies were RCTs. Significantly more BBD studies (42%) were categorized as RCTs relative to HN studies 25% (p<0.01). Despite the higher proportion of RCTs in BBD papers, we noted no significant difference between FI (3 vs. 2; p=0.08) or citation counts (15 vs.14) for BBD and HN papers respectively (p=0.09) (Figure 1). CONCLUSIONS: Despite the higher number of RCTs in BBD literature, the overall robustness of findings remains similar and consistent with other Pediatric Urology topics. This finding suggests that study design alone is not a factor likely to address limitations in our literature. Source of Funding: NA © 2020 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 203Issue Supplement 4April 2020Page: e1067-e1067 Advertisement Copyright & Permissions© 2020 by American Urological Association Education and Research, Inc.MetricsAuthor Information Mandy Rickard More articles by this author Jessica Hannick* More articles by this author Daniel T Keefe More articles by this author Erik Drysdale More articles by this author Lauren Erdman More articles by this author Joana Dos Santos More articles by this author Armando J Lorenzo More articles by this author Expand All Advertisement PDF downloadLoading ...

Pupillometric assessment of dysautonomia in pediatric bowel and bladder dysfunction: a pilot study

Bowel and bladder dysfunction (BBD) refers to a heterogeneous group of voiding disorders, accounting for an estimated 40% of pediatric urology visits. Symptoms of BBD include enuresis, urgency, and urinary retention, often accompanied by constipation. The aim of this pilot study was to explore whether a pupillary response can be characterized for BBD, by examining the pupillary light reflex (PLR) before and after voiding among patients with BBD. A total of 28 patients aged from 7 to 21 years were recruited from the Wetting, Infections, and Stooling Help clinic at Children's National Medical Center. An infrared pupilometer was used to assess the PLR. Both baseline static and dynamic pupillometry assessments were obtained before and after voiding. Measurements were also taken after 5min in the supine position, followed by 5min standing to induce an orthostatic stressor. Visual inspection of the graphed data revealed a characteristic shape in 11 of 28 patients with voiding symptoms. In these 11 patients, the redilation arm of the PLR shows a 'notch,' or a brief reconstriction of the pupil before resting pupil size is reestablished (figure). This feature of the PLR has not been seen in previous and parallel studies using pupillometry to evaluate other populations. The results of this study suggest that a subset of patients with BBD may have a significant perturbation of autonomic regulation, identifiable through analysis of the PLR. To our knowledge, this 'notch' during redilation has not been previously described or seen in other patient populationsand may represent a distinctive and readily identifiable physiologic marker of disease. These results are broadly aligned with results of other studies that have examined ANS activity in patients with BBD, although further study is needed to confirm the results of this pilot study and to assess relative contributions of sympathetic and parasympathetic function in producing pupillary abnormalities. This study has several limitations, including the small sample size, the absence of data on severity and duration of symptoms, and the absence of a control group of patients without any voiding symptoms. A simple tool for diagnosing BBD and for monitoring response to treatment could significantly improve the quality of treatment for one of the most common pediatric urologic complaints. Given the heterogeneity of symptoms under the BBD umbrella, pupillometric data could guide selection of treatment options, as well as assess adequacy of response to pharmacologic therapy.

Development of a Standardized Approach for the Assessment of Bowel and Bladder Dysfunction.

Bowel and bladder dysfunction (BBD) is a common pediatric condition that describes a constellation of lower urinary tract symptoms (LUTS) associated with constipation. Many children with BBD have comorbid neuropsychiatric and psychosocial concerns that are not routinely assessed. The aim of quality improvement (QI) was to establish a comprehensive assessment for BBD by developing and evaluating (1) a standardized clinician assessment form and (2) parent-reported questionnaire. From July 2017 to April 2018, a prospective QI study was conducted in the BBD network. A standardized assessment form was developed based on literature review and expert opinions, with targeted sections for LUTS, constipation, and psychosocial history. Before clinic, families of children referred for BBD were given a questionnaire to clarify voiding, stooling, and dietary patterns. Physicians utilized the assessment form for new referrals. Afterward, both physicians and parents evaluated the assessment process anonymously. A total of 15 physicians and 45 parents responded, with 67% of patients being between 4 and 10 years old and 51% male. Physicians responded that the assessment form reminded them to ask about specific LUTS (93%), constipation (87%), and psychosocial history (87%). Parents responded positively by agreeing that they felt included in care decisions (96%) and had questions answered appropriately (100%). Only 47% found the previsit package easy to complete. In pediatric BBD consultations, a standardized assessment form can guide clinicians to efficiently gather a comprehensive history and screen for psychosocial risk factors. It can empower more pediatricians to evaluate BBD in the future.

Unilateral open extravesical ureteral reimplanation with contralateral dextronomer/hyaluronic acid injection performed as an outpatient therapy

Historically, patients with unilateral high-grade vesicoureteral reflux (VUR) and contralateral low-grade or resolved VUR have been treated with bilateral intravesical ureteral reimplantation, which requires postoperative admission. If the high-grade VUR side is treated alone, then the contralateral side is at risk of developing recurrent or worsening VUR. Bilateral subureteric injection of dextronomer/hyaluronic acid (DHA) is another option that can be performed as an outpatient therapy, but a single injection is less effective for high-grade VUR. The safety and efficacy of an outpatient combination of open extravesical ureteral reimplantation (EVUR) and contralateral DHA injection were investigated. A retrospective review of children who had concomitant EVUR and subureteric injection of DHA between January 2005 and December 2015 was performed. Exclusion criteria were diagnosis other than VUR, repeat procedures, and patients with no follow-up. Patient characteristics, postsurgical complications, and follow-up imaging were evaluated. Febrile urinary tract infection (fUTI) was defined as ≥50,000Colony Forming Units (CFU) of an organism from clean-catch or catheterized urine and temperature ≥101.5F. Clinical success is defined as no fUTI for 1 year after the initial operation. Univariate analyses were used to identify risk factors for treatment failure. A total of 117 patients met inclusion criteria. Mean age at surgery was 6.0 years, and 85% were female. The mean pre-operative grade of VUR was 3.3 on the EVUR side and 0.6 on the contralateral side (42% resolved before treatment). Median follow-up was 12.2 months (interquartile range, 3.1-25.4). Sixteen patients (14%) had documented fUTI within 1 year, with a clinical success rate of 86%. Of these, five had a postoperative imaging showing resolution of VUR, increasing overall success to 91%. Postoperative fUTI was more common in patients with pre-operative bowel and bladder dysfunction (BBD) (P=0.003), but this was not associated with a higher reoperation rate (P=0.168). There were 11 total complications, with three grade 3 complications. This study is the first to report safety and outcomes of EVUR and contralateral DHA injection for patients with high-grade VUR with contralateral low-grade or resolved VUR. It was shown that it is an effective and safe treatment that can be performed as an outpatient therapy. Limitations to this study include the retrospective designand the clinical definition of success that is used in a cohort of patients from across the mountain west region without routine postoperative voiding cystourethrogram. Extravesical ureteral reimplantation and contralateral DHA injection can safely be performed as an outpatient therapy and are effective in the treatment of higher grade VUR with contralateral low-grade or resolved VUR. Treatment failure is more likely in patients with BBD.

Prolonged urinary retention can and does occur after any type of ureteral reimplantantion.

Transient urinary retention has been recognized as a complication of bilateral ureteroneocystostomy (UNC), when performed extravesically. The objective of this study was to review a collective surgeons' experiences of unilateral extra- and unilateral and/or bilateral intra-vesical ureteral reimplanation, where urinary retention greater than 6weeks, or what we have termed, "prolonged urinary retention" (PUR), occurred. We retrospectively reviewed charts to identify PUR after any open or robotic reimplant, other than bilateral extravesical, between 1998 and 2015 as reported by five surgeons. During the review period, ten cases were documented where PUR was encountered. Bilateral Cohen reimplants (5), unilateral extravesical open reimplant with ureteral tapering (3), unilateral Cohen reimplant (1) and unilateral extravesical robotic reimplant with tapering (1) were associated with PUR. Younger males predominated (70%). The mean age at operation of the patients was 3.1years. Eventually 7/10 patients were able to void normally, with periods ranging from 6weeks to 8years. The remaining three patients are still unable to void more than 5years after UNC. A majority of the samples (6/10) were suspected to have bowel and bladder dysfunction (BBD), but neurologically all were normal. PUR can occur as a potential complication following any type of UNC and is associated with the risk of significant morbidity, including permanent urinary retention. Patients and caregivers should be counseled accordingly.

Urinary tract infection and vesicoureteric reflux

Urinary tract infection (UTI) is one of the common causes of hospital visit in infants and children. Vesicoureteral reflux (VUR) predisposes to UTI and renal scarring. VUR is usually diagnosed after an episode of UTI. VUR is the most common underlying etiology responsible for febrile UTIs or pyelonephritis in children. Along with the morbidity of pyelonephritis, long-term sequelae of recurrent renal infections include renal scarring, proteinuria, and hypertension. Treatment is directed toward the prevention of recurrent infection through the use of continuous antibiotic prophylaxis during a period of observation for spontaneous resolution or by surgical correction. In children, bowel and bladder dysfunction (BBD) plays a significant role in the occurrence of UTI and the rate of VUR resolution. Effective treatment of BBD leads to higher rates of spontaneous resolution and decreased risk of UTI.

Urinary tract infection in the setting of vesicoureteral reflux.

Vesicoureteral reflux (VUR) is the most common underlying etiology responsible for febrile urinary tract infections (UTIs) or pyelonephritis in children. Along with the morbidity of pyelonephritis, long-term sequelae of recurrent renal infections include renal scarring, proteinuria, and hypertension. Treatment is directed toward the prevention of recurrent infection through use of continuous antibiotic prophylaxis during a period of observation for spontaneous resolution or by surgical correction. In children, bowel and bladder dysfunction (BBD) plays a significant role in the occurrence of UTI and the rate of VUR resolution. Effective treatment of BBD leads to higher rates of spontaneous resolution and decreased risk of UTI.

Contemporary Management of Vesicoureteral Reflux.

The past 30 years have seen broad changes in the diagnosis and management of vesicoureteral reflux (VUR). Recently, a clinical debate has generated an open discussion in academic circles. New evidence has shifted treatment patterns away from widespread surgical management and recently brought into question some pharmacologic treatments. VUR is usually not hazardous by itself but is a significant risk factor for urinary tract infection (UTI) and less commonly, renal scarring and insufficiency. Given the costs and morbidity of UTI as well as the potential for significant renal injury, our approach remains conservative. Careful follow-up, parental education about pathophysiology and management of VUR and UTI, and management of bowel and bladder dysfunction (BBD) when present, are the foundation of treatment. Additionally, though we recognize the limitation of continuous antibiotic prophylaxis (CAP), we believe the benefits outweigh the risks and costs for many patients. Careful observation can be considered in patients with a single medical home, parental understanding of what UTI signs and symptoms are, low grade VUR, no history of complicated UTIs and close follow-up. Surgical management remains a relevant option for select patients who fail conservative measures with breakthrough UTIs or failure to resolve. Minimally invasive surgical options are available with acceptable outcomes though open ureteroneocystostomy still carries the highest success rate.

Can a simple question predict prolonged uroflow lag times in children?

It is our experience that some children with bowel and bladder dysfunction (BBD) who have bladder neck dysfunction had a tendency to complain of dizziness when we subjected the patients with dizziness to tilt-table testing to confirm the diagnosis of autonomic dysfunction. From these findings we postulated that patients who complain of dizziness are likely to have prolonged lag times that are a proxy for bladder neck dysfunction (BND). This was an Institute Review Board-approved study in which we enrolled new patients in a sequential fashion who were referred to our outpatient urology offices for evaluation of BBD over a 3-month period. All patients were asked if they frequently experienced dizziness when they rapidly stood from a sitting or lying down position or when they raised their head rapidly. An analysis of the following parameters was undertaken: prevalence of dizziness, bladder neck dysfunction, and comorbid psychiatric problems. Uroflowmetry findings were analyzed as well. Tilt-table group: In the tilt-table group the median age of the patients was 14.5 (4.5-18) years for the five males and five females who were tested. All males and four out of five females experienced a blood pressure drops of 20mmHg or more on table tilting and three experienced syncope. All patients had prolonged lag times, with an average lag time of 16.5s. All these patients were able to tolerate alpha-blockers once they were adequately hydrated and salt loaded. Alpha-blocker dosing was increased gradually. In the questionnaire group, 212 patients were initially enrolled: 125 girls and 87 boys. Eleven of 12 males and eleven of 16 females had prolonged lag times when dizziness was present. Sensitivity was 92% and 69%, specificity was 80% and 91% respectively for male and females. Analysis of the psychiatric history revealed a statistically significant association with dizziness and neuropsychiatric problems in the patients and family members. We have been able to show a high degree of sensitivity in male patients and a high degree of specificity in female patients that a simple question, "Do you get dizzy on rising in the morning or with rapid standing?", is a reliable marker for BND in children. We have also seen that there is an association between dizziness and psychiatric problems in patients and in family members. It appears from our results and the available literature that autonomic dysfunction is commonly associated with BND and dizziness can be a simple proxy question to identify this problem.