Pediatric Urologic Surgery Research Articles

Comparison of 30-day emergency department bouncebacks after pediatric versus adult urologic surgery

More pediatric patients seem to present to the emergency department (ED) for non-urgent matters after urologic procedures than adult patients. Under new and expanding healthcare reform, pediatric urologists may be penalized for these visits. We compare our 30-day postoperative bounceback rates to the ED and the acuity of the concerns in these populations. All urology consults at our institution are maintained on a prospectively tracked database. We identified all patients who presented to our adult or pediatric ED between July 2013 and June 2015 within 30 days of a urologic procedure. We investigated the patient demographics including age, race, insurance, distance from the home zip code to the ED, procedures performed, chief complaint in the ED, diagnosis, and treatment required. In our pediatric group, there were 67 visits for 56 patients (19 female, 37 male, mean age 6.8 years), which represents an overall bounceback incidence of 2.7%. Of those, 19% required admission (0.60% overall readmission rate), 10% underwent a procedure (0.32% reoperative rate, 18% required catheter manipulation/placement, 13% were given a prescription (most commonly for constipation), 6% required local wound care, and 33% were reassured only). Most pediatric patients had private insurance (62.5%) and those with private insurance or who were uninsured tended to require only reassurance compared to those with Medicare/Medicaid (p=0.053). In the adult population, there were 369 visits in 310 patients (111 female, 199 male, mean age 55.4 years) for an incidence of 4.4%. Of those, 42% were admitted (2.2% overall readmission rate), 14% underwent a procedure (0.74% reoperative rate), 11% required catheter manipulation/placement, 14% were given medication (most commonly antibiotics and narcotics), 4% were given local wound care, and 12% were reassured. Most adult patients had Medicare/Medicaid (48.7%), but insurance type was not related to treatment required (p=0.382). On multivariable analysis, pediatric patients, closer proximity to the hospital, and earlier postoperative day at presentation to the ED were predictive of requiring only reassurance. Compared to adults, pediatric patients are less likely to return to the ED postoperatively (p<0.001), but they are significantly more likely to require only reassurance (p<0.001) while adults are significantly more likely to require hospital admission (p<0.001). In both groups, nearly one-third of patients required only catheter care or medication. This difference could have significant implications for new healthcare policy.

Global trends in paediatric robot-assisted urological surgery: a bibliometric and Progressive Scholarly Acceptance analysis.

The inaugural robot-assisted urological procedure in a child was performed in 2002. This study aims to catalogue the impact of this technology by utilizing bibliographic data as a surrogate measure for global diffusion activity and to appraise the quality of evidence in this field. A systematic literature search was performed to retrieve all reported cases of paediatric robot-assisted urological surgery published between 2003 and 2016. The status of scientific community acceptance was determined using a newly developed analysis model named progressive scholarly acceptance. A total of 151 publications were identified that reported 3688 procedures in 3372 patients. The most reported procedures were pyeloplasty (n=1923) and ureteral reimplantation (n=1120). There were 16 countries and 48 institutions represented in the literature. On average, the total case volume reported in the literature more than doubled each year (mean value increase 236.6% per annum). The level of evidence for original studies remains limited to case reports, case series and retrospective comparative studies. Progressive Scholarly Acceptance charts indicate that robot-assisted techniques for pyeloplasty or ureteral reimplantation are yet to be accepted by the scientific community. Global adoption trends for robotic surgery in paediatric urology have been progressive but remain low volume. Pyeloplasty and ureteral reimplantation are dominant applications. Robot-assisted techniques for these procedures are not supported by high quality evidence at present. Next-generation robots are forecast to be smaller, cheaper, more advanced and customized for paediatric patients. Ongoing critical evaluation must occur simultaneously with expected technology evolution.

Robotic surgery start-up with a fellow as the console surgeon

Objective: Owing to the encouraging data on fellowship training in robotic pyeloplasty and the documented benefits of robotic pyeloplasty, the aim of this study was to test the feasibility of starting up pediatric urological robotic surgery in a center with a limited case volume.Materials and methods: The operative parameters and clinical outcome of the first 25 robotic pyeloplasties performed were compared to data on open and laparoscopic procedures from the previous 5 year period. The fellow was the only console surgeon. An experienced non-robotic pediatric urologist was supervising at the patient site.Results: The learning curve was in accordance with previously published data on fellows. The median operating time in robotic surgery was 182 min and was significantly shorter than in laparoscopic surgery (median 250 min) and the postoperative inpatient length of stay was significantly shorter after robotic surgery (median 1 day) than after both laparoscopic (median 2 days) and open surgery (median 3.5 days). For robotic cases, postoperative renography showed either stable or increased function of the hydronephrotic kidney. The only complication was in one case with ureteral orifice edema after JJ-stent removal, requiring nephrostomy for 6 weeks.Conclusions: The benefits of overall shorter postoperative hospital stay after robotic pyeloplasty and faster operating time compared to the laparoscopic procedure are clearly in accordance with data from the recent literature. The fast learning curve for robotic pyeloplasty will allow pediatric urology fellowship programs to be integrated in the start-up phase of a pediatric robotic program even though the case material is limited. Operative success rates were in accordance with the gold standard of open surgery.

MP66-14 TESTICULAR MICROLITHIASIS: A CASE-BASED, MULTINATIONAL SURVEY OF CLINICAL MANAGEMENT PRACTICES

INTRODUCTION Testicular microlithiasis (TM) is a condition characterized by calcium deposits within the testis, usually detected incidentally during ultrasonography of the scrotum. TM has been associated with the presence of, and possibly the development of, testicular malignancy. Our aim was to document international clinical management practices for TM and to analyze what factors and perception of risk influence conservative versus active management and follow-up. METHODS European Society for Paediatric Urology (ESPU) and Society for Pediatric Urology (SPU) members were invited to complete an online case-based survey of clinical management practices of TM. Eight cases had a single variable changed each time (classic versus limited TM, unilateral versus bilateral, prior cryptorchidism versus no cryptorchidism) to ascertain the provider's perception of risk. The respondents completed multiple choice questions on initial management, follow-up plan, length and interval of follow-up. Multivariate logistic regression was performed to determine factors associated with decisions on management and follow-up. RESULTS There were 265 respondents to the survey from 35 countries (Table). Median time in practice was 13 years. Factors that were significantly associated with more aggressive initial management (more than counseling on self-examination) included: not yet in independent practice, low volume TM cases per year, those practicing pediatric and adult urology, classic appearance of TM and cryptorchidism. Factors that were significantly associated with urologist follow-up and active investigation included: European practitioners, low TM case volume per year, those practicing both pediatric urology and pediatric surgery, classic TM appearance and a case history of cryptorchidism. Interval and length of follow-up was wide-ranging, with most respondents favoring annual follow-up. CONCLUSION Management of TM varies and a mix of surgeon and case factors significantly influences management strategies. This baseline understanding of the lack of systematic management suggests the need for the development of consensus guidelines and prospective study.

Management of congenital penile curvature in children

Objective The aim of this study is to assess the surgical approaches for congenital penile curvature retrospectively. Methods From April 2007 to January 2015, 109 patients with congenital penile curvature, age from 13 months to 13 years, mean 64 months, were treated in the Department of Pediatric Urology Surgery, Children′s Hospital of ZheJiang University, China. According to structural defect, the patients were categorized into 4 groups: group Ⅰ, skin tethering (50 cases, 45.9%); group Ⅱ, fascialchordee (29 cases, 26.6%); group Ⅲ, corporal disproportion (24 cases, 22.0%); and group Ⅳ, urethral tethering (6 cases, 5.5%). With the aid of intraoperative artificial erection, the curvanture was corrected by penile degloving in group Ⅰ patients ; group Ⅱ, release of dense fibrous tissue in addition; group Ⅲ, dorsal-midline-plication-based correction; and group Ⅳ, urethral transection and longitudinal-island-flap-urethroplasty-based with dorsal-midline-plication and Tunica-vaginalis-free-graft repair. Results Of the 37 hypoplastic urethra cases, urethral fistula was present in 4 patients, and six months later, urethral repair was successfully performed; and one case undergoing Duckket′s showed urethral diverticulum, and was corrected by diverticulum resection and urethra mobilization; there was no glans dehiscence and urethral stricture. Of the 26 cases with dorsal-midline-plication-based correction, residual curvature occurred in 1 child after one year; and 4 cases recurved during long-term follow-up (ranging from 1 to 9 years, mean 3.2), with a 84.6% cure rate. Conclusions Conclusions Those corresponding methods of penile curvature should be choosed based on different pathological type respectively. The findings are limited because this study was retrospective and lacked long-term follow-up data. Key words: Penis curvature; Hypospadias; Orthoplasty

Surgical Scar Location Preference for Pediatric Kidney and Pelvic Surgery: A Crowdsourced Survey

The benefits of minimally invasive surgery in pediatric urology, such as reduced length of hospital stay and postoperative pain, are less predictable compared to findings in the adult literature. We evaluated the choices that adult patients make for themselves and their children regarding scar location. We surveyed the preference for scar location/size based on surgery for bladder and kidney procedures with additional questions assessing the impact of a hidden incision, length of hospital stay and pain. The survey was posted to Amazon® Mechanical Turk®. We analyzed a total of 954 completed surveys. Surgical history was reported in 660 surveys (69%) with scar bother reported in 357 (54.2%). For pelvic surgery the initial choice was a Pfannenstiel incision for 434 respondents (45.5%), laparoscopy port incisions for 392 (41.1%) and no preference for incision location for 126 (13.2%). When incisions were illustrated relative to undergarments, 718 respondents (75.3%) chose Pfannenstiel. For kidney surgery 567 respondents (59.4%) initially chose the dorsal lumbotomy incision, 170 (17.8%) chose a flank incision, 105 (11.0%) chose laparoscopy ports and 110 (11.5%) had no preference. Respondents were told that minimally invasive surgery might result in less pain/length of hospital stay and were asked to restate the incision choice. For pelvic surgery 232 of 434 respondents (53.5%) who had chosen Pfannenstiel and 282 of 394 (71.6%) who had chosen laparoscopy remained consistent (p <0.001). For kidney surgery 96 respondents (56.5%) who chose a flank incision, 322 (56.8%) who chose dorsal lumbotomy and 68 (64.2%) who chose laparoscopy remained consistent (p = 0.349). Agreement between the incision choice by respondent as a child and for a child was 82% (κ = 0.69) for pelvic surgery and 84.6% (κ = 0.75) for kidney surgery. The smallest incision is not always the patient preferred incision, particularly in childhood when pain, length of hospital stay and blood loss may be equivocal among approaches. Discussion of surgical treatment options should include scar length, location and relationship to undergarments.

Pediatric Laparoscopic Congenital Vesico-Vaginal Fistula Repair for Vaginal Agenesis

Abstract Introduction: The role of minimally invasive surgery in pediatric urology has markedly expanded, but has not been traditionally applied to vesico-vaginal fistulae repairs in children. The ...

Robotic surgery and anesthesia for pediatric urologic procedures.

Minimally invasive approaches to pediatric surgery have become increasingly popular over the last 15 years. With the advent of robotically controlled instruments, common pediatric urologic surgeries such as pyeloplasty and ureteral reimplantation, which were previously technically challenging, are now commonly performed laparoscopically. It is important to recognize the unique physiologic considerations with this approach and how to provide safe and effective anesthesia for these procedures. Although there are multiple studies in the surgical literature describing robot-assisted laparoscopic approaches for pediatric urologic surgery, there are few articles that describe the anesthetic considerations for this type of surgery in children. As the first pediatric hospital in the USA to obtain a surgical robot in 2001, a consistent, collaborative approach has been developed to care for infants and children undergoing robot-assisted laparoscopic surgery. Robot-assisted laparoscopic surgery is increasingly utilized for common pediatric urologic surgeries. To provide safe and effective anesthesia for this type of surgery, it is important to have a thorough understanding of the multiple physiologic derangements that occur with robot-assisted laparoscopic surgery in infants and children, the potential complications that can occur with this approach and have a consistent approach to the anesthetic management and postoperative pain control for these procedures.

Laparoendoscopic single site surgery in pediatric urology: does it require specialized tools?

ABSTRACTPurpose:To describe our experience utilizing Laparoendoscopic single site (LESS) surgery in pediatric urology.Materials and Methods:Retrospective chart review was performed on LESS urologic procedures from November 2009 through March 2013. A total of 44 patients underwent 54 procedures including: nephrectomy (23), orchiopexy (14), varicocelectomy (9), orchiectomy (2), urachal cyst excision (3), and antegrade continence enema (3) (ACE).Results:Median patient age was 6.9 years old. Estimated blood loss (EBL), ranged from less than 5cc to 47cc for a bilateral nephrectomy. Operative time varied from 56 mins for varicocelectomy to a median of 360 minutes for a bilateral nephroureterectomy. Incision length ranged between 2 and 2.5cm. In our initial experience we used a commercial port. However, as we progressed, we were able to perform the majority of our procedures via adjacent fascial punctures for instrumentation at the single incision site. One patient did require conversion to an open procedure as a result of bleeding. Three complications were noted (6.8%), with two Clavien Grade 3b complications. Two patients required additional procedures at 1-year follow-up.Conclusions:The use of LESS applies to many pediatric urologic procedures, ideally for ablative procedures or simple reconstructive efforts. The use of adjacent fascial puncture sites for instrumentation can obviate the need for a commercial port or multiple trocars.

Glove Perforation Rate in Surgery: A Randomized, Controlled Study To Evaluate the Efficacy of Double Gloving.

The risk of exposure of either the patient or the surgeon to communicable disease when the surgical glove is perforated is important. Both patients and the surgical team need to be protected from this risk. Therefore, we intended to determine the efficacy of double gloving in our center. This was a prospective cohort study, involving (randomly selected) surgeons, who wore single or double latex surgical gloves during procedures. Gloves were collected and evaluated for perforations (using air insufflation and water leak methods). A total of 1,536 gloves were collected (512 single gloves and 1,024 double gloves), with 78 of 512 gloves perforated, giving a rate of 15.2%. Perforation rate was 15.2% in single gloves, 14.4% in double gloves, 15.5% in emergency operations, and 14.3% in elective surgery. It was highest (30.8%) among registrars in training, particularly when doing any deep (16.0%) surgery. Glove perforation rate was highest (17.4%) among general surgery procedures as opposed to pediatric surgery (14.6%), urology (13.9%), neurosurgery (11.7%), and plastic surgery (10.6%), with (42.1%) index finger injury. In unused (control group) gloves, the rate of perforation was (0.8%). There was a substantial difference in the overall perforation rate between single and double glove sets (15.2% versus 14.4%) (X(2) = 1748, p < 0.0001). However, among the double set, total gloves [outer and inner set] analysis revealed a perforation rate of 27.5% (141 of 512). Of this set, the number of inner gloves that perforated as a result of a through and through puncture from outer to the inner gloves gave a rate of 1.17% (six of 512). Thus, the protection offered by double gloves was 98.83% (X(2) = 280.9, p < 0.0001) even if the outer gloves were perforated. The use of double gloves has more than 90% protection to patient and the surgeon. Therefore, wearing double gloves should be encouraged in surgery.

Pediatric outpatient surgery

The number of outpatient surgeries for routine surgical interventions continues to increase, especially in adults. For many patients, there is no doubt that interventions like arthroscopy will be performed on an outpatient basis. Regarding urologic surgeries in adults (e.g., vasectomy, hydrecelectomy), outpatient treatment is well established. For adults such a procedure represents a well-calculable situation in most cases, as the patient can quite accurately imagine the events that will follow. In terms of pediatric outpatient surgery, the scenario is sometimes quite different. Parents are more anxious and uncertain because they must decide for the well-being of their children and they often do not exactly know what will happen during the procedure. In addition, they do not have to decide for themselves but for their children. Unfortunately, parents often lack information prior to surgery. Therefore, all persons involved in the treatment of children (e.g., urologists, anesthesiologists, nurses) must be trained and educated in giving adequate and appropriate information especially for parents. The purpose of this article is to provide different starting points for an optimized preparation and care of children and parents concerning outpatient surgery in pediatric urology.

Ninety-day perioperative complications of pediatric robotic urological surgery: A multi-institutional study

Robotic technology is the newest tool in the armamentarium for minimally invasive surgery. Individual centers have reported on both the outcomes and complications associated with this technology, but the numbers in these studies remain small, and it has been difficult to extrapolate meaningful information. The intention was to evaluate a large cohort of pediatric robotic patients through a multi-center database in order to determine the frequency and types of complications associated with robotic surgery for pediatric reconstructive and ablative procedures in the United States. After institutional review board approvals at the participating centers, data were retrospectively collected (2007-2011) by each institute and entered into a RedCap(®) database. Available demographic and complication data that were assigned Clavien grading scores were analyzed. From a cohort of 858 patients (880 RAL procedures), Grade IIIa and Grade IIIb complications were seen in 41 (4.8%); and one patient (0.1%) had a grade IVa complication. Intraoperative visceral injuries secondary to robotic instrument exchange and traction injury were seen in four (0.5%) patients, with subsequent conversion to an open procedure. Grade I and II complications were seen in 59 (6.9%) and 70 (8.2%) patients, respectively; they were all managed conservatively. A total of 14 (1.6%) were converted to an open or pure laparoscopic procedure, of which, 12 (86%) were secondary to mechanical challenges. It is believed that this study represents the largest and most comprehensive description of pediatric RAL urological complications to date. The results demonstrate a 4.7% rate of Clavien Grade IIIa and Grade IIIb complications in a total of 880 cases. While small numbers make it difficult to draw conclusions regarding the most complex reconstructive cases (bladder diverticulectomy, bladder neck revision, etc.), the data on the more commonly performed procedures, such as the RAL pyeloplasty and ureteral reimplantation, are robust and more likely represent the true complication rate for these procedures when performed by highly experienced robotic surgeons. Pediatric robotic urologic procedures are technically feasible and safe. The overall 90-day complication rate is similar to reports of laparoscopic and open surgical procedures. n (%) Life threatening (IVa): 1 (0.1%) Requiring radiologic and or surgical intervention (IIIa and IIIb): 41 (4.8%) Secondary to robotic system: 4 (0.5%) Mechanical failure leading to conversion: 14 (1.6%).

Laparoscopic Single-Site Surgery in Pediatric Urology: Where Do We Stand Today?

Since the first description of the laparoendoscopic single-site surgery (LESS) in the pediatric urology population, various authors have shared their experiences and results. We aim to provide a review of current studies of LESS and share our experience with this modality. The current literature describes the use of LESS for most surgeries performed in the pediatric urology population with similar results to open and standard laparoscopic surgery. The authors have described their experiences with transabdominal and retroperitoneal nephrectomy, nephroureterectomy, pyeloplasty, orchidopexy, varicocelectomy, and renal cyst decortication. In our experience, LESS has taken a role for extirpative surgery since we use other modalities for upper tract reconstruction. The data available has validated LESS as safe and has demonstrated similar results to standard laparoscopic surgery and open surgery with better cosmetic results.

The burden of attending a pediatric surgical clinic and family preferences toward telemedicine

Background/PurposeIndirect expenses for accessing health care may place significant fiscal strain on Canadian families. Telemedicine alternatives, using email, telephone, and video conferencing, can mitigate such financial burdens by reducing travel and related costs. Our objectives were to assess costs that families incur visiting an outpatient pediatric surgical clinic, and family attitudes toward telemedicine alternatives. MethodsA survey was offered pre-consult to all families who attended pediatric urology and general surgery outpatient clinics over a three-month period. ResultsA total of 1032 of 1574 families screened participated (66.0%). Less than half (18.5%) of participants traveled over 200km, and 32.9% spent over 4hours in transit, round-trip. The proportion of participants who spent over $50 on travel and ancillary expenses was 33.0%. In 74.0% of families, 1 or more adults missed work. The proportion of families who perceived costs as somewhat high or high was 29.1%. Perceived cost was positively correlated to distance traveled, money spent, and missed work (p<0.01). Most were comfortable with medical communication using technology; and 34.3%–42.7% would avoid an in-person clinic visit utilizing email, telephone, and video conferencing. Higher perceived cost (p<0.001) and distance traveled (p<0.01) were only weakly associated with greater willingness to substitute a clinic visit with video conferencing. ConclusionsMany families face high costs related to routine outpatient clinical visits, and there is a substantial willingness by them to access telemedicine alternatives, rather than the traditional face-to-face clinical visit.

Practice patterns and outcomes of pediatric partial nephrectomy in the United States: Comparison between pediatric urology and general pediatric surgery

In the United States, both pediatric urologists (PUROs) and general pediatric surgeons (GPSs) perform nephrectomies in children, with PUROs performing more nephrectomies overall, most commonly for benign causes. GPSs perform more nephrectomies for malignant causes. We questioned whether the same trends persisted for partial nephrectomy. We hypothesized that PUROs performed more partial nephrectomies for all causes, including malignancy. Our primary aim was to characterize the number of partial nephrectomies performed by PUROs and GPSs. We also compared short-term outcomes between subspecialties. We analyzed the Pediatric Health Information System (PHIS), a database encompassing data from 44 children's hospitals. Patients were ≤18 years old and had a partial nephrectomy (ICD-9 procedure code 554) carried out by PUROs or GPSs between 1 January, 2004 and June 30, 2013. Queried data points included surgeon subspecialty, age, gender, 3M™ All Patient Refined Diagnosis Related Groups (3M™ APR DRG) code, severity level, mortality risk, length of stay (LOS), and medical/surgical complication flags. Data points were compared in patients on whom PUROs and GPSs had operated. Statistical analysis included the Student t test, chi-square test, analysis of covariance, and logistic regression. Results are presented in the table. While PUROs performed the majority of partial nephrectomies, GPSs operated more commonly for malignancy. For surgeries performed for non-malignant indications, PURO patients had a shorter LOS and lower complication rate after controlling for statistically identified covariates. There was no difference in LOS or complication rate for patients with malignancy. A Pediatric Health Information System study of pediatric nephrectomy demonstrated PUROs performed more nephrectomies overall, but GPSs performed more surgeries for malignancy. The difference was less dramatic for partial nephrectomies (63% GPS, 37% PURO) than for radical nephrectomies (90% GPS, 10% PURO). PUROs performed more partial nephrectomies for benign indications (94% PURO, 6% GPS) at an even greater rate than nephrectomies (88% PURO, 12% GPS). As a national database study, there are a number of inherent limitations: applicability of results to non-participating hospitals, possibility of inaccurate data entry/coding, and lack of data points that would be relevant to the study. While most partial nephrectomies in the United States are performed by PUROs, GPSs perform the majority of surgeries for malignancy. There is no difference in LOS or complication rate undergoing nephron-sparing surgery for malignant disease; however, PUROs had a shorter LOS and lower complication rate when operating for benign diseases.

This Month in Pediatric Urology

No AccessJournal of UrologyThis Month in Pediatric Urology1 Aug 2015This Month in Pediatric Urology Michael L. Ritchey Michael L. RitcheyMichael L. Ritchey More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2015.05.005AboutFull TextPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail "This Month in Pediatric Urology." The Journal of Urology, 194(2), p. 275 References 1 : Hospital surgical volume and associated postoperative complications of pediatric urological surgery in the United States. J Urol2015; 194: 506. Link, Google Scholar 2 : Complications following staged hypospadias repair using transposed preputial skin flaps. J Urol2015; 194: 512. Link, Google Scholar © 2015 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 194Issue 2August 2015Page: 275 Advertisement Copyright & Permissions© 2015 by American Urological Association Education and Research, Inc.MetricsAuthor Information Michael L. Ritchey More articles by this author Expand All Advertisement PDF downloadLoading ...

MP54-08 INCIDENCE AND RISK FACTORS FOR POSITIVE URINE CULTURE AT THE TIME OF PEDIATRIC UROLOGIC SURGERY

You have accessJournal of UrologyPediatrics: Urinary Tract Infections/Vesicoureteral Reflux1 Apr 2015MP54-08 INCIDENCE AND RISK FACTORS FOR POSITIVE URINE CULTURE AT THE TIME OF PEDIATRIC UROLOGIC SURGERY Michael A Maccini, David Chalmers, and Jeffrey B. Campbell Michael A MacciniMichael A Maccini More articles by this author , David ChalmersDavid Chalmers More articles by this author , and Jeffrey B. CampbellJeffrey B. Campbell More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2015.02.2031AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Urinary tract infections (UTI) are common in pediatric urology populations. Unrecognized bacteriuria at the time of urologic surgery may put patients at risk for complications. Many providers obtain preoperative and/or intraoperative urine cultures when performing surgery on the urinary tract, but there are no data in the literature documenting the overall rate of positive urine culture at the time of pediatric urologic surgery. We hypothesized that there are risk factors associated with an increased likelihood of positive urine culture at the time of pediatric urologic surgery. METHODS We identified all patients less than 18 years of age undergoing endoscopic urologic procedure or surgery on the collecting system from 01/01/08 through 12/31/13 with a single pediatric urologist (JBC) who routinely sends intraoperative urine cultures. We performed a retrospective chart review, collecting demographic information, intraoperative urine culture results (defined as positive if >100,000 or 10-100,000 CFU of a single pathogenic organism), circumcision status, and suspected risk factors from problem/diagnosis lists (hydronephrosis, vesicoureteral reflux, UPJ obstruction, urolithiasis, neurogenic bladder, posterior urethral valves, ureterocele, and constipation). We also examined all prior urine culture results in our electronic medical record. We then analyzed each item for relative risk of positive urine culture at the time of surgery. RESULTS A total of 838 procedure records (470 unique patients) were reviewed. 717 had associated intraoperative urine culture results (85.6%) and were further analyzed. Overall, 97 (13.5%) cultures were positive. Factors associated with increased relative risk included neurogenic bladder (p<0.0001), prior UTI (p<0.0001), constipation (p<0.0001), female gender, (p=0.001), and urolithiasis (p<0.05). The absence of any of the selected diagnoses was associated with a reduced risk of positive culture (p<0.05). CONCLUSIONS Patients with neurogenic bladder, prior UTI, constipation, female gender, and urolithiasis have an increased likelihood of bacteriuria at the time of pediatric urologic surgery. This information may be helpful in tailoring the acquisition of preoperative and/or intraoperative urine cultures, which may result in significant cost savings. © 2015 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 193Issue 4SApril 2015Page: e667-e668 Advertisement Copyright & Permissions© 2015 by American Urological Association Education and Research, Inc.MetricsAuthor Information Michael A Maccini More articles by this author David Chalmers More articles by this author Jeffrey B. Campbell More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

MP54-09 ANTIMICROBIAL EXPOSURE AND UROPATHOGEN RESISTANCE: AN ANALYSIS OF INDIVIDUAL PATIENT DATA FROM RCTS ON ANTIBIOTIC PROPHYLAXIS AND THE PREVENTION OF UTI

bacteriuria at the time of urologic surgery may put patients at risk for complications. Many providers obtain preoperative and/or intraoperative urine cultures when performing surgery on the urinary tract, but there are no data in the literature documenting the overall rate of positive urine culture at the time of pediatric urologic surgery. We hypothesized that there are risk factors associated with an increased likelihood of positive urine culture at the time of pediatric urologic surgery. METHODS: We identified all patients less than 18 years of age undergoing endoscopic urologic procedure or surgery on the collecting system from 01/01/08 through 12/31/13 with a single pediatric urologist (JBC) who routinely sends intraoperative urine cultures. We performed a retrospective chart review, collecting demographic information, intraoperative urine culture results (defined as positive if >100,000 or 10100,000 CFU of a single pathogenic organism), circumcision status, and suspected risk factors from problem/diagnosis lists (hydronephrosis, vesicoureteral reflux, UPJ obstruction, urolithiasis, neurogenic bladder, posterior urethral valves, ureterocele, and constipation). We also examined all prior urine culture results in our electronic medical record. We then analyzed each item for relative risk of positive urine culture at the time of surgery. RESULTS: A total of 838 procedure records (470 unique patients) were reviewed. 717 had associated intraoperative urine culture results (85.6%) and were further analyzed. Overall, 97 (13.5%) cultures were positive. Factors associated with increased relative risk included neurogenic bladder (p<0.0001), prior UTI (p<0.0001), constipation (p<0.0001), female gender, (p1⁄40.001), and urolithiasis (p<0.05). The absence of any of the selected diagnoses was associated with a reduced risk of positive culture (p<0.05). CONCLUSIONS: Patients with neurogenic bladder, prior UTI, constipation, female gender, and urolithiasis have an increased likelihood of bacteriuria at the time of pediatric urologic surgery. This information may be helpful in tailoring the acquisition of preoperative and/or intraoperative urine cultures, which may result in significant cost savings.

Laparo-endoscopic single site surgery in pediatrics: Feasibility and surgical outcomes from a preliminary prospective Canadian experience.

Laparo-endoscopic single-site surgery (LESS) is becoming an alternative to standard laparoscopic surgery. Proposed advantages include enhanced cosmesis and faster recovery. We assessed the early post-operative surgical outcomes of LESS surgery utilizing different instruments in the pediatric urological population in Canada. We prospectively captured data on all patients undergoing LESS at our institution between February 2011 and August 2012. This included patient age, operative time, length of stay, complications and short-term surgical outcomes. Different instruments/devices were used to perform the procedures. Access was achieved through a transumbilical incision. A total of 16 LESS procedures were performed, including seven pyeloplasties, four unilateral and one bilateral varicocelectomies, two simple nephrectomies, one renal cyst decortication and one pyelolithotomy. There was no statistical difference in the operative times, hospital length of stay and cost (pyeloplasty only) in patients undergoing pyeloplasty and varicocelectomy using the LESS technique when compared to an age matched cohort of patients managed with the traditional laparoscopic approach. One pyeloplasty in the LESS group required conversion to open due to a small intra-renal pelvis. There were no immediate or short term post-operative complications; however, one patient experienced a decrease in renal function status post LESS pyeloplasty. Since all procedures were performed by a vastly experienced surgeon at a tertiary center, the generalizability of the results cannot be assessed. There are only a few series that have assessed the role of LESS in pediatric urological surgery. Although our experience is limited by a heterogeneous group of patients with a short follow-up period, the present cohort demonstrates the safety and feasibility of LESS. Further evaluation with randomized studies is required to better assess the role of LESS in pediatric urology.

Hospital Surgical Volume and Associated Postoperative Complications of Pediatric Urological Surgery in the United States

Hospital and provider surgical volume have been increasingly linked to surgical outcomes. However, this topic has rarely been addressed in children. We investigated whether hospital surgical volume impacts complication rates in pediatric urology. We retrospectively reviewed the Nationwide Inpatient Sample (1998 to 2011) for pediatric (18 years or younger) hospitalizations for urological procedures. We used ICD-9-CM codes to identify elective urological interventions and NSQIP® postoperative in hospital complications. Annual hospital surgical volume was calculated and dichotomized as high volume (90th percentile or above) or non-high volume (below 90th percentile). We identified 158,805 urological admissions (114,634 high volume and 44,171 non-high volume hospitals). Of the hospitals 75% recorded fewer than 5 major pediatric urology cases performed yearly. High volume hospitals showed treatment of significantly younger patients (mean 5.4 vs 9.6 years, p < 0.001) and were more likely to be teaching hospitals (93% vs 71%, p < 0.001). The overall rate of NSQIP identified postoperative complications was higher at non-high volume vs high volume hospitals (11.6% vs 9.3%, p = 0.003). After adjusting for confounding effects patients treated at non-high volume hospitals remained more likely to suffer multiple NSQIP tracked postoperative complications, including acute renal failure (OR 1.4, p = 0.04), urinary tract infection (OR 1.3, p = 0.01), postoperative respiratory complications (OR 1.5, p = 0.01), systemic sepsis (OR 2.0, p ≤ 0.001), postoperative bleeding (OR 2.5, p < 0.001) and in hospital death (OR 2.2, p = 0.007). Urological procedures performed in children at non-high volume hospitals were associated with an increased risk of in hospital, NSQIP identified postoperative complications, including a small but significant increase in postoperative mortality, mostly following nephrectomy and percutaneous nephrolithotomy.