Pediatric Urologic Procedures Research Articles

Streamlining surgical trays for common pediatric urology Procedures: A quality improvement initiative

Procedures involving the external genitalia are the most common pediatric urologic operations. Our group identified excess instrumentation for these cases to be a potential cause of operating room (OR) inefficiency at our large, freestanding pediatric hospital. This quality improvement (QI) initiative aimed to streamline surgical instrumentation for the most-performed pediatric urologic procedures at our hospital. Six Sigma DMAIC methodology (Define, Measure, Analyze, Improve, Control) guided this multidisciplinary, iterative QI effort. A stakeholder team utilized data review, direct observations, and multiple in-person discussions to create a new "Groin-Penis Tray" (GPT) to replace a larger tray for the 90 most common pediatric urologic procedures. Suture preference cards and expectations about which sutures would be opened for each case were updated. The primary outcome was estimated yearly cost-avoidance due to reduced sterile processing. Additional outcomes included: instruments opened/case, % cases with complete trays, Mayo stand set-up time, and % cases with unused sutures. Balancing measures included: total median OR time and tray weights. Baseline and post-implementation measures were characterized and compared. A QI professional, 10 pediatric urologists, 2 pediatric urology fellows, and multiple OR and sterile processing staff members participated. The Summary Figurecompares baseline and post-implementation measurements. The number of instruments opened/case decreased from 146 to 65. Annual sterile reprocessing costs decreased by >$51,000. Median Mayo stand set-up time decreased from 7.3 to 3.5min (p<0.001). The number of cases with complete trays increased from 7/20 (35%) to 11/20 (55%, p=0.34). The new GPT is 2.7kg lighter than the prior tray. Median OR time remained stable (baseline: 91min; post-implementation: 102min, p=0.44). The number of cases with suture waste decreased from 78% to 0% immediately post-implementation but increased to 40% one year later. This systematic, iterative QI process spanned the course of ∼2 years, including planning, building, and updating new trays, then assessing longer-term success via the control phase. The new GPT is used for most pediatric urologic procedures at our hospital, and benefits include sterile reprocessing cost savings and ergonomics. Our team gained valuable experience related to assessing QI project scope, determining key stakeholders and roles, and strategies for sustainability that we will apply to future initiatives. Streamlining surgical trays for common pediatric urologic procedures at a large freestanding children's hospital using established QI methodology reduced OR cost by >$51,000/year and Mayo stand set-up times without compromising balancing measures.

Office Based Pediatric Urologic Procedures: A Safe and Effective Alternative to Interventions Under Anesthesia

ObjectiveTo report on our experience performing office-based pediatric urologic procedures. We hypothesize that office-based interventions are safe and effective for children, avoiding unnecessary risk and cost associated with general anesthesia. MethodsWe retrospectively identified patients undergoing office-based interventions from 2014 to 2019, including lysis of penile or labial adhesions, division of skin bridges, meatotomy and excision of benign lesion. Success was defined as a completed attempt in the office. Failure includes any unsuccessful office attempts. Complications include 30-day ED visits/readmissions and recurrent skin bridge post division of skin bridge. ResultsWe identified 1326 interventions: 491 lyses of penile adhesions (37%), 320 division of skin bridges (24%), 128 lyses of labial adhesions (10%), 348 meatotomies (26%), and 39 excisions of benign lesions (3%) [Table 1]. There was a >95% success rate reported in every procedure with an overall complication rate of 0.6%. Excision of benign lesion had 100% success rate. ED visits within 30 days are rare (0.2%), and no patients required admission after their procedure [Table 2]. The rate of recurrence was highest following lysis of labial adhesions (13.3%). Of the 54 patients who underwent retreatment, very few required general anesthesia (n = 6). ConclusionOffice-based urologic interventions in children are well tolerated with excellent safety and efficacy. Complications and recurrence are universally low. Ultimately, 99.5% of this cohort was managed under local anesthetics, thereby avoiding the risks of anesthesia use in the pediatric population.

Assessment of skills in pediatric renal urology procedures among young pediatricians

Assessment of skills in pediatric renal urology procedures among young pediatricians

Outpatient Robotic Surgery in Pediatric Urology: Assessment of Feasibility and Short-Term Safety.

Robotic reconstructive and extirpative procedures have been widely utilized for surgical management of various conditions in pediatric urology. Outpatient laparoscopic surgery has become the standard in cases of orchidopexy, inguinal hernia repair and varicocelectomy. There is a growing body of evidence that robotic surgery for more complex conditions can also be performed in an outpatient setting. The aim of the study was to assess the short-term safety and feasibility of robotic reconstructive and extirpative procedures for various pediatric urological conditions as scheduled outpatient procedures. Demographic information and perioperative data were prospectively collected in an institutional database for all pediatric patients undergoing outpatient robotic surgery from June 2012 to December 2019. Primary outcomes included rates of 30-day complications, emergency room visits and readmissions. A total of 135 pediatric patients underwent robotic procedures in an outpatient setting. The majority underwent pyeloplasty (62) or extravesical ureteral reimplantation (55). Ten patients underwent ureteroureterostomy and 8 patients underwent extirpative procedures (nephrectomy, hemi-nephrectomy). Median age at surgery was 62 months (IQR, 27-99), median weight was 20 kg (IQR, 12-30) and median body mass index was 17 (IQR, 15-18). During the 30-day followup period there were 9 complications (6.7%), of which only 1 (0.7%) was high grade (Clavien-Dindo 3). There were 9 emergency room visits (6.7%) including 5 cases of readmission (3.7%). Robotic reconstructive and extirpative procedures in pediatric urology can be safely performed as scheduled outpatient procedures in the majority of patients, obviating the need for routine inpatient care.

This Month in Pediatric Urology

You have accessJournal of UrologyThis Month in Pediatric Urology1 Feb 2022This Month in Pediatric Urology Stacy T. Tanaka Stacy T. TanakaStacy T. Tanaka More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002330AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail Safety and Efficacy of Robot-Assisted Laparoscopic Pyeloplasty Compared to Open Repair in Infants under 1 Year of Age Even as robotic pediatric urological procedures proliferated, open pyeloplasty continued to be standard of care in infants. The robotic assisted laparoscopic approach was ideal for older children, allowing for meticulous anastomotic repair of the ureteropelvic junction while decreasing recovery times and postoperative pain levels. For open infant pyeloplasty, multiple sites had already demonstrated short length of stay and pain management without opioids. Additionally, because of concerns of the decreased instrument working space in small infants, initial published studies on pediatric robotic pyeloplasty were limited to children weighing more than 10 kg. Increasingly, pediatric centers are offering a robot-assisted laparoscopic approach for these smaller infants as well. In this issue of The Journal, Rague et al (page 432) from Chicago compare outcomes from robotic assisted laparoscopic to open pyeloplasty in infants younger than 1 year of age and less than 10 kg.1 In this retrospective study, pyeloplasty was performed by robotic assisted laparoscopic approach in 83 infants and open approach in 121. Infants in the robotic group tended to be older and to weigh more. The authors did not demonstrate a significant difference in length of stay, postoperative radiographic improvement, 30-day complication rate or need for reoperative pyeloplasty. Currently, the robotic procedures required more hospital resources. The robotic procedures had longer operative times, and approximately a third of the robotic procedures had 2 attending co-surgeons. The dissemination of robotics has changed pediatric urology fellowship training much like it has changed general urology residency. The authors report that the robot-assisted laparoscopic approach has been the preferred method for correction of ureteropelvic junction obstruction in infants at their institution since 2017—so much so that no open infant pyeloplasty was performed from January to June 2020. Certainly, the needs of urology learners are ever changing, and pediatric urology educators should be vigilant. This study highlights that trainees may have limited exposure to open infant pyeloplasty in the near future unless it remains an educational priority. Reference 1. : Safety and efficacy of robot-assisted laparoscopic pyeloplasty compared to open repair in infants under 1 year of age. J Urol 2022; 207: 432. Link, Google Scholar © 2021 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 207Issue 2February 2022Page: 261-261 Advertisement Copyright & Permissions© 2021 by American Urological Association Education and Research, Inc.MetricsAuthor Information Stacy T. Tanaka More articles by this author Expand All Advertisement Advertisement Loading ...

MP34-13 A PROSPECTIVE ANALYSIS OF OPIOID USE FOLLOWING OUTPATIENT PEDIATRIC UROLOGIC SURGERY

You have accessJournal of UrologyHealth Services Research: Quality Improvement & Patient Safety II (MP34)1 Sep 2021MP34-13 A PROSPECTIVE ANALYSIS OF OPIOID USE FOLLOWING OUTPATIENT PEDIATRIC UROLOGIC SURGERY Rachael Sherrer, Ann Byrne, Fardod O'Kelly, Ruthie Su, and Walid Farhat Rachael SherrerRachael Sherrer More articles by this author , Ann ByrneAnn Byrne More articles by this author , Fardod O'KellyFardod O'Kelly More articles by this author , Ruthie SuRuthie Su More articles by this author , and Walid FarhatWalid Farhat More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002043.13AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: While opioids have a role in multimodal post-operative analgesia, there is increasing data which suggests they may not be routinely required after pediatric surgery. With this lack of consensus on opioid use after pediatric urologic procedures, we sought to examine impact of patient characteristics and surgery type on opioid usage in our outpatient urologic surgery cohort. METHODS: This prospective study was approved by the hospital’s Institutional Review Board. Opioid use data was prospectively collected over a 12-month period (January to December 2020) via routine institutional post-operative telephone calls to parents of patients undergoing outpatient urologic surgery. Patient characteristics (age, sex, race), surgery type, and opioid prescription and refill information were recorded. Those who underwent a simultaneous procedure with another specialty or were admitted to the hospital were excluded. All patients were prescribed scheduled acetaminophen and ibuprofen for 48 hours after surgery, then as needed, and up to a maximum of 5 doses of oxycodone. The count of opioid doses was modelled using negative binomial regression with robust standard errors. RESULTS: 263 patients underwent outpatient urologic surgery over the 12-month period. 182 predominantly male (99%) patients met inclusion criteria, with mean age of 5.1 years and mean 4.9 opioid doses prescribed per patient. There were 138 genital, 21 inguinal, 17 laparoscopic, and 6 cystoscopic procedures. Mean opioid use was one single dose, and 94 (52%) patients used no opioids. The mean number of excess, unused prescribed doses per patient was 4. Eleven patients used all doses prescribed, and one received a refill (5 additional doses). Table 1 outlines opioid use by surgery, age, and race. These were not independent predictors of opioid use on multivariable analysis, although there was a trend toward increased use in adolescents. CONCLUSIONS: Our findings suggest that opioids are in fact likely over-prescribed after outpatient pediatric urologic surgery, with 93% of patients not requiring all of their opioid prescription and 52% not using any opioids at all. While overall opioid requirements were low across all sub-cohorts, there was a trend toward increased use in adolescents which should be factored into education with this group. Source of Funding: None © 2021 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 206Issue Supplement 3September 2021Page: e621-e621 Advertisement Copyright & Permissions© 2021 by American Urological Association Education and Research, Inc.MetricsAuthor Information Rachael Sherrer More articles by this author Ann Byrne More articles by this author Fardod O'Kelly More articles by this author Ruthie Su More articles by this author Walid Farhat More articles by this author Expand All Advertisement Loading ...

MP44-16 ELIMINATION OF POSTOPERATIVE NARCOTICS IN INFANT ROBOTIC PYELOPLASTY USING CAUDAL ANESTHESIA AND A NON-NARCOTIC PAIN PATHWAY

You have accessJournal of UrologyPediatric Urology II (MP44)1 Sep 2021MP44-16 ELIMINATION OF POSTOPERATIVE NARCOTICS IN INFANT ROBOTIC PYELOPLASTY USING CAUDAL ANESTHESIA AND A NON-NARCOTIC PAIN PATHWAY Kristen Meier, Mit Shah, Andrew Banooni, and Zachary Liss Kristen MeierKristen Meier More articles by this author , Mit ShahMit Shah More articles by this author , Andrew BanooniAndrew Banooni More articles by this author , and Zachary LissZachary Liss More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002065.16AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Research suggests that narcotic pain medications are dramatically overprescribed. We hypothesize that narcotics are unnecessary in the majority of infants for postoperative pain control. In this series, we report our experience combining caudal blocks with a non-narcotic postoperative pathway as a means of completely eliminating postoperative narcotics following infant robotic pyeloplasty. METHODS: We reviewed 15 consecutive patients under 4 years of age who underwent robotic pyeloplasty by a single surgeon followed by a standardized postoperative non-narcotic pain pathway between May 2017 and October 2020. The standardized postoperative pathway consisted of an end-procedure caudal block followed by alternating IV acetaminophen and ketorolac. We reviewed demographics, outcomes and unscheduled healthcare encounters (office visits, ER visits or readmissions) within 30 postoperative days. RESULTS: 73.3% (11/15) patients were male and average age was 10.8 months (range 4-21 months). 60% (9/15) underwent surgery on the left. 20% (3/15) of patients received a single postoperative dose of narcotic in the PACU. No patient received additional narcotics during their hospitalization. No patient required narcotic prescriptions at discharge or anytime thereafter. Average length of stay was 1.2 days. There were no pain-related unscheduled healthcare visits or phone calls within 30 days of discharge. CONCLUSIONS: This series supports the fact that narcotics are not needed for infants following robotic pyeloplasty. Post-procedure caudal block is likely a good addition to a non-narcotic pathway. In the future, we intend to expand these findings to other pediatric urologic procedures in the hope of eliminating unnecessary narcotic use. Source of Funding: None © 2021 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 206Issue Supplement 3September 2021Page: e798-e799 Advertisement Copyright & Permissions© 2021 by American Urological Association Education and Research, Inc.MetricsAuthor Information Kristen Meier More articles by this author Mit Shah More articles by this author Andrew Banooni More articles by this author Zachary Liss More articles by this author Expand All Advertisement Loading ...

PD60-06 OMISSION OF AMBULATORY NARCOTICS IS SAFE AFTER THE MAJORITY OF INPATIENT PEDIATRIC UROLOGIC SURGERIES

You have accessJournal of UrologyHealth Services Research: Practice Patterns, Quality of Life and Shared Decision Making V (PD60)1 Sep 2021PD60-06 OMISSION OF AMBULATORY NARCOTICS IS SAFE AFTER THE MAJORITY OF INPATIENT PEDIATRIC UROLOGIC SURGERIES Jeffrey Villanueva, Benjamin Pifer, Marc Colaco, Valentina Grajales, Omar Ayyash, Rajeev Chaudhry, Francis Schneck, Glenn Cannon, and Janelle Fox Jeffrey VillanuevaJeffrey Villanueva More articles by this author , Benjamin PiferBenjamin Pifer More articles by this author , Marc ColacoMarc Colaco More articles by this author , Valentina GrajalesValentina Grajales More articles by this author , Omar AyyashOmar Ayyash More articles by this author , Rajeev ChaudhryRajeev Chaudhry More articles by this author , Francis SchneckFrancis Schneck More articles by this author , Glenn CannonGlenn Cannon More articles by this author , and Janelle FoxJanelle Fox More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002097.06AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Opiate overdose has reached epidemic levels in the United States, and as such several states have implemented various strategies to curb usage. In November 2016 Pennsylvania passed Act 125 requiring written consent when prescribing opiates to a minor and limiting opiate prescriptions to a seven day course. The purpose of this study is to examine the effect of this state mandate on narcotic utilization and pain related outcomes after inpatient pediatric urologic surgeries. METHODS: A retrospective analysis was performed examining all patients who underwent inpatient pediatric urologic surgery at the Children’s Hospital of Pittsburgh between August 2015 and February 2020. Subjects were separated into pre-mandate and post-mandate cohorts (subtracting a 6 month window immediately after November 2016 to account for transition). We then assed the frequency of inpatient and ambulatory opiate utilization between cohorts as well as the use of alternative pain management approaches. Frequencies of adverse events including delayed prescriptions or emergency department visits within 30 days were also identified. RESULTS: After accounting for a 6-month transition period following policy implementation, 462 major pediatric urologic procedures were identified. The frequency of discharge opiate prescriptions decreased from 68.4% prior to the transition period to 10.7% afterward (p <0.001). Morphine milligram equivalents per prescription decreased from 75(IQR 45-150) to 45(IQR 22.5-75) (p <0.001). There was no change in the rate of delayed non-opioid analgesic prescriptions (6.6 % vs 7.4%), delayed opioid prescriptions (1.5% vs 0.3%), or emergency department visits (11.8% vs 12.6%) (p=0.809). The effect of the intervention was durable, where 1.7% of major pediatric urologic surgeries in the final 12 months of the study were discharged with an opioid. CONCLUSIONS: Omission of ambulatory narcotics is safe for most major pediatric urologic surgeries and does not require an increase in regional anesthesia utilization. Source of Funding: None © 2021 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 206Issue Supplement 3September 2021Page: e1062-e1062 Advertisement Copyright & Permissions© 2021 by American Urological Association Education and Research, Inc.MetricsAuthor Information Jeffrey Villanueva More articles by this author Benjamin Pifer More articles by this author Marc Colaco More articles by this author Valentina Grajales More articles by this author Omar Ayyash More articles by this author Rajeev Chaudhry More articles by this author Francis Schneck More articles by this author Glenn Cannon More articles by this author Janelle Fox More articles by this author Expand All Advertisement Loading ...

Urgent surgery for COVID-19\u2013positive pediatric patient

BackgroundWe present a case of COVID-19–positive pediatric patient for urgent urological surgery by spinal anesthesia to avoid aerosolizing procedure.Case presentationA 12-year-old, COVID-19–positive boy presented for urgent wound incision and drainage at the circumcision site. Our anesthetic plan consisted of spinal anesthesia with sedation. He was transported from the COVID-19 isolation floor to the negative pressure operating room. He was placed in lateral decubitus position and oxygen was delivered through facemask. Under sedation, spinal anesthesia was achieved at first attempt. The patient maintained spontaneous ventilation without airway intervention. Patient was recovered in the operation room then transported back to the floor.ConclusionSpinal anesthesia is a safe alternative to general endotracheal anesthesia for many pediatric urology procedures. Effective team communication and preparation are keys when caring COVID-19–positive patient in perioperative setting to avoid minimize the risk to healthcare providers.

Does port type or wound closure technique influence cosmetic outcomes in laparoscopic pediatric urology procedures?

Does port type or wound closure technique influence cosmetic outcomes in laparoscopic pediatric urology procedures?

Endourology Methods in Pediatric Population for Kidney Stones Located in Lower Calyx: FlexURS vs. Micro PCNL (MicroPERC®).

Kidney stone disease in children is always a therapeutic challenge. It is a multifactorial condition and it should be approached, diagnosed and treated as such. One of the biggest challenges is kidney stones located in the lower renal calyx. There are currently three main surgical techniques to treat this condition: ESWL—Extracorporeal Shock Wave Lithotripsy, RIRS—Retrograde IntraRenal Surgery, and PCNL—PerCutaneous Nephro-Lithotripsy. In pediatric population, the most frequently used method is ESWL, and in the event of failure, endoscopic procedures are the second-best choice. In this article, a sample of 53 children admitted to a tertiary medical center was examined. Thirty-eight of those children underwent flexible URS, while the remaining 15—micro PCNL. The average size of the deposit in the former group was 12.2 mm, against 13.5 mm in the latter. The full Stone Free Rate (SFR) was achieved in RIRS at 84.21 and 86.7% in percutaneous nephrolithotripsy. Flexible ureterorenoscopy and MicroPERC are two comparably effective methods for treating lower calyx stones of any size. However, according to our data, flexible ureterorenoscopy carries a lower risk of complications and inpatient care (with the mean of 3 days). The learning curve for these procedures in pediatric urology is long and relies on a limited number of patients. The number of pediatric patients qualifying for these procedures is restricted also due to the high efficacy of extracorporeal shock wave lithotripsy in pediatric population. Radiation exposure is an important factor in every endoscopy procedure and should never exceed the limits set in the ALARA protocol. ESWL remains to this day the treatment of choice for stone disease in children and can be performed under ultrasound control. For many parents, it is a first-choice treatment preference for their child due to its greater apparent safety, although data on this remains insufficient. Prospective, randomized, multicenter trials are definitely needed.

The impact of patient age and procedure type on postoperative opioid use following ambulatory pediatric urologic procedures.

The aim of this study is to determine whether patient age and procedure type are associated with duration of opioid use in pediatric patients undergoing ambulatory urologic procedures. We retrospectively reviewed pediatric patients who underwent outpatient urologic procedures from 2013 to 2017. At postoperative visits, parents reported the number of days their child took opioid pain medication. Factors associated with duration of opioid use were evaluated using negative binomial regression models. 805 patients were included: 320 infants (39.8%), 430 children (53.4%), and 55 adolescents (6.8%). Overall mean length of opioid use was 1.7 (± 2.6) days. On average, infants used opioids for the shortest duration: 1.5 (± 2.3) days, followed by children: 1.7 (± 2.5) days, and adolescents: 3.1 (± 4.6) days. In adjusted models, adolescents used opioids for 85.2% longer (95% CI 13.1-161.8%; p < 0.001) than children and infants used opioids for 19.4% shorter duration (95% CI 0.4-34.7%; p = 0.05) than children. Each 1-year increase in age was associated with 6.1% increased duration of opioid use (95% CI 3.9-8.5%; p < 0.0001). Patients who underwent circumcision, hypospadias repair, and penile reconstruction took opioids for 75.9% (95% CI 42.6-117.1%; p < 0.001), 144.2% (95% CI 76.4-238.0%; p < 0.001), and 126.7% (95% CI 48.8-245.3%; p < 0.001) longer respectively than patients who underwent inguinal procedures. Increasing age, circumcision, hypospadias repair, and penile reconstruction are associated with increased duration of opioid use.

EDITORIAL COMMENT

As a specialty caring for infectious diseases, urologists are sensitive to the importance of antibiotic stewardship. The benefits of reducing antibiotics are clear. Responsible prescribing minimizes the development and ultimate spread of pathogens with antibiotic resistance.1 Further, potential medication adverse events and battles between the parent and child can be avoided. Among pediatric urologic procedures, there are not set guidelines for antimicrobial therapy, and prescribing patterns are all over the map.

Opioid prescribing is excessive and variable after pediatric ambulatory urologic surgery

Acute pain after surgery is one of the most frequent indications for opioid prescribing in children. Opioids are often not stored or disposed of safely after their use, placing children and others in the home at risk for accidental ingestion or intentional misuse. We currently lack evidence-based guidelines for post-operative pain management after common ambulatory pediatric urologic procedures. Thus, each surgeon must decide if and how much opioid to prescribe based on his/her own assumptions of perceived post-operative pain. As part of an effort to establish opioid prescribing guidelines across two academic centers, the objectives of this study were to evaluate current variability in pediatric urologists' opioid prescribing factors and identify patients at greatest risk of being prescribed high doses of opioids after common ambulatory pediatric urologic procedures. We retrospectively evaluated post-operative opioid prescribing patterns after common ambulatory pediatric urology procedures (circumcision, orchiopexy, and hernia/hydrocele) at two major children's hospitals. Specifically, we evaluated if and how much opioid was prescribed for all children (18 years or younger) between 2016 and 2017. Bivariate analysis was performed using Kruskal-Wallis Test and Wilcoxon Rank Sum. Multivariable logistic regression was performed to determine patient, surgeon, and procedural factors that predicted the prescription of a high dose of opioids (greater than the median number of doses prescribed for that procedure). Over the two-year period, 811 circumcisions and 883 inguinal surgeries (inguinal orchiopexy and hernia/hydrocele) were performed. 94% of patients undergoing circumcision and 97% of those undergoing inguinal surgery were prescribed opioid analgesia. The median number of doses prescribed for circumcision was 20; for inguinal surgeries, 23.75% of patients received 15 opioid doses or more. Patients ages 0-2 years, who represented the largest age group (41% of all patients), received significantly more opioid doses than all other age groups, followed by those >10 years (p<0.01). There was significant variation in opioid prescribing patterns by provider (p<0.01) (Figure1) On multivariable logistic regression, younger age, pill form, and earlier year were all associated with a greater number of opioid doses prescribed for all surgeries. Across two institutions without a formal post-operative opioid prescribing policy for ambulatory pediatric urologic procedures, we observed considerable variability in provider prescribing patterns, with nearly all patients receiving an opioid, and those 0-2 years receiving the highest number of doses. This highlights the need for evidence-based guidelines for post-operative pain management after ambulatory pediatric urologic surgeries.

Trends in robotic surgery utilization across tertiary children's hospitals in the United States.

A growing number of tertiary children's hospitals are utilizing robotic surgical technology. We sought to characterize national trends in pediatric surgical robotic case utilization and related drivers. Pediatric urology and pediatric surgery (abdominal and thoracic) procedures, performed from January 2010 to December 2019 across 19 U.S. tertiary care children's hospitals, were identified using the Pediatric Health Information System (PHIS). Trends in robot utilization were evaluated by surgical subspecialty, procedure type, and number of individual operating surgeons. Increases were noted in the overall numbers of pediatric surgery (1.3% per quarter, p = 0.005) and urology robotic procedures (2.0% per quarter, p < 0.001), as well as the numbers of pediatric surgeons (7.5% per year, p < 0.001) and pediatric urologists (7.8% per year, p < 0.001) operating robotically. Biliary system and spleen surgery were the most common robotic pediatric surgery procedures (45.5%) and had stable utilization over time (- 0.8% per quarter, 95% CI - 2.3-0.8). Robotic foregut surgery showed the most rapid growth in utilization (2.1% per quarter, 95% CI 0.7-3.6, p = 0.004) in pediatric surgery, while mediastinal/thoracic surgery demonstrated a decrease in utilization (- 4.6%, 95% CI - 7.9-1.2, p = 0.008). Renal pelvis/ureter surgery was the most common robotic urologic procedure (55.8%) and also demonstrated the fastest growth utilization (2.2% per quarter, 95% CI 1.5-2.9, p < 0.001) in urology. Utilization of robotic-assisted surgery in pediatric surgery and pediatric urology has increased both in case volume and the number of operating surgeons, with foregut and renal pelvis/ureter surgery responsible for the areas of greatest growth.

The effects of primary and recurrent pediatric urological surgeries on parental anxiety levels

Invasive diagnostic and therapeutic procedures in pediatric urology may generally cause distress and pain in children. As a result, it may have a negative effect on adult and child behaviors. The anxiety, depression levels or distress and fear status caused by recurrent diseases or repetitive medical interventions in adult patients or the parents of pediatric patients have been investigated previously. To the best of our knowledge, we have not found a study evaluating the effects of primary or recurrent pediatric urological operations on parental anxiety. Our main aim was to compare the effects of primary and repetitive pediatric urological surgeries on the anxiety levels of both mothers and fathers. We also aimed to investigate the effects of other factors related to parents and children on parental anxiety. A total of 163 patients under 14 years old who had undergone primary or recurrent pediatric urological operations and also their parents were included in a prospective, cross-sectional study. Demographic and clinical data of the patients and their parents were recorded. Before the surgeries, the Children's Fear Scale was applied to all patients over 3 years old and the State-Trait Anxiety Inventory was applied to all parents. The participants were divided into two main groups: primary surgery group (n:84) and recurrent surgery group (n:79). A subgroup analysis was performed according to surgery type (day surgery, minor surgery and major surgery). We found that repetitive surgeries, higher fear scores of children, parents' being younger, having low education level, not having enough information about the surgeries and presence of someone in the immediate vicinity who previously experienced the same surgery increased parental anxiety levels. Day surgeries did not affect fathers' state anxiety levels as much as minor and major surgeries, whereas mothers' state anxiety levels were higher than fathers' regardless of the surgery type. Children's fear level was not affected by child age, gender, surgery type or previous history of surgery. The majority of studies in the literature show no significant difference in terms of pain and fear levels in pediatric patients undergoing repeated diagnostic interventions but there are contradictory results about parental anxiety levels. There is also a lack of studies on the effects of recurrent surgeries. According to our findings, repetitive surgeries and presence of someone who previously experienced the same surgery are the most significant predictive factors increasing parental anxiety levels.

The pudendal nerve block for ambulatory urology: What's old is new again. A quality improvement project

Caudal epidural analgesia (CEA) is a common analgesic technique performed for pediatric penile surgeries; however, it has associated morbidity. The pudendal nerve block (PNB) has been described as an effective analgesic alternative to CEA. In this quality improvement study, we aim to assess the efficacy of PNB as compared to CEA within our ambulatory surgery center (ASC). We demonstrate our initial experience employing PNB for ambulatory pediatric urology procedures. Using retrospective, non-randomized, time-series, observational data, a comparative effectiveness study of CEA and PNB was performed. Patients less than three years old, who underwent circumcision, hypospadias repair, congenital chordee repair, correction of penile angulation/torsion, and buried penis repair with or without scrotoplasty, between January 1, 2015-September 9, 2019 with either CEA or PNB in an ASC at a single institution were included. Standard protocols for local and postoperative analgesia were used. Outcome measures were post anesthesia care unit (PACU) pain scores, morphine rescue rates, and PACU length of stay (LOS). These were analyzed using statistical process control (SPC) charts; standard SPC rules were used to detect special cause variation. A total of 999 patients were identified; 746 (74.7%), 172 (17.2%) and 81 (8.1%) received CEA, ultrasound guided PNB (US-PNB) and landmark directed PNB (LD-PNB), respectively. Demographic data was comparable between the three cohorts. There was no special cause variation in the outcome measures between the CEA, US-PNB and LD-PNB cohorts for maximum pain score, morphine rescue rates and PACU LOS. Pain outcomes and PACU LOS were similar between the CEA, US-PNB and LD-PNB cohorts, suggesting equivalent postoperative pain control between these techniques within our cohort. Previous published data has reported lower postoperative pain scores with PNB as compared to CEA for patients undergoing circumcision and hypospadias repair. PNB is non-inferior to CEA for analgesia for pediatric penile surgery, with LD-PNB being as effective as US-PNB. Given the simplicity and documented lower risk profile, PNB may be preferred to CEA for ambulatory pediatric urology procedures.

Relative value units do not adequately account for operative time in pediatric urology

BackgroundRelative value units (RVUs) are the measure of value used in United States Medicare and Medicaid reimbursement. The Relative Update Committee (RUC) determines physician work RVU (wRVUs) based on operative time, technical skill and effort, mental effort and judgment, and stress. The primary aim of this study was to assess whether operative time is adequately accounted for in the wRVU system in pediatric urology. MethodsThe American College of Surgeons National Surgical Quality Improvement Program Pediatric Participant User File (ACS-NSQIPP-PUF) was reviewed from 2012 to 2017. Most common single pediatric urology current procedural terminology (CPT) codes were included. The primary variable was wRVU per hour of operative time (wRVU/h). Linear regression analysis was used to assess the relative influence that operative time had on wRVU/h. Results25,432 cases were included in the final study population from 45 unique CPT codes. The median operative time was 79 min, and the median RVU/h was 12.2. Procedures with operative time less than 79 min had higher wRVU/h compared with procedures longer than 79 min (14.5 vs 10.5, p < 0.001). Procedures with higher than average incidence of any complications had a lower wRVU/h (9.0 vs. 14.6 p < 0.001). Linear regression analysis revealed that each additional hour of operative time was expected to decrease wRVU/h by 4.2 (−0.70 per 10 min, 95% CI: −0.71 to −0.69, p < 0.001; R2 = 0.39). ConclusionThis analysis of contemporary large pediatric population national-level data suggests that the wRVU system significantly favors shorter and less complex procedures in Pediatric Urology. Pediatric urologists performing longer and more complex procedures are not adequately compensated for the increase in complexity. Evidence level IIIRetrospective comparative study.

The role of preoperative instructions in parents' understanding of preoperative fasting for outpatient pediatric urology procedures.

To assess the impact of modifications in preoperative instructions on parental understanding of preoperative fasting guidelines. A prospective postoperative parental survey was conducted to assess parental understanding of preoperative fasting requirements in patients undergoing surgery before and after institution of instructions that included visual aids. Data regarding demographics, procedure type, and time to surgery from preoperative visit were also captured. Survey data were compared between pre- and post-intervention groups using Chi-squared tests for categorical variables and Wilcoxon rank sum test for continuous variables. 173 parents in the pre-intervention group and 162 parents in the post-intervention group were included in the analysis. Parent identification of aspiration risk as the reason for fasting almost doubled after intervention (72.2% vs. 38.2%). There was some evidence of demographic differences between groups; however, in an adjusted model, there was strong evidence (p < 0.001) that parents in the post-intervention group were more likely to identify aspiration as the reason for preoperative fasting (OR 4.73; 95% CI 2.93-7.63). Addition of visual aids in preoperative instructions was associated with improvement in parents' understanding of the rationale behind preoperative fasting instructions. Further studies are needed to determine whether improved understanding is associated with improved adherence.

Inclusion of surgical antibiotic regimens in pediatric urology publications: A systematic review

Perioperative antibiotics prevent infections after surgery. Guidelines for antibiotic use allow the surgeon to balance the risks of adverse events and drug resistance with the benefit of reduced infection rates. However, due to a lack of evidence-based guidelines within pediatric urology, antibiotic practices vary widely. We performed a systematic literature review to investigate when and how authors report their antibiotic usage and infectious outcomes. Our aim was to analyze the available data on perioperative antibiotics and infection rates within pediatric urology. This systematic review was conducted in line with the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. A search strategy was devised to identify reports of pediatric urology surgery and use of antibiotics or infectious outcomes. Embase and Medline were queried with no year restrictions with subject heading terms to identify publications on common pediatric urology surgeries. The procedures studied were hypospadias repair, pyeloplasty, orchidopexy, ureteral reimplant, and circumcision. Two independent reviewers screened all titles and abstracts, followed by relevant full texts, for eligibility. Articles were included if the procedure was performed on the majority of study patients, the procedure was performed by urologic surgeons, and the population studied was a pediatric population defined as 0-18 years of age. Case reports, meta-analyses, and editorials were excluded. Data was extracted by one independent reviewer into a preformatted database. Collected data included journal type, date of publication, patient demographics, preoperative and postoperative antibiotic details including regimens, and infection outcomes. The primary outcome was reporting of antibiotic use preoperatively or postoperatively. Secondary outcomes included: reporting of infection, antibiotic class and dosage. Since all studies were diverse, only qualitative analysis was conducted. We identified 1483 publications with 297 meeting inclusion criteria. Of these, 9% reported their use of preoperative antibiotics, and 34% reported their use of postoperative antibiotics. Only 6% of studies reported the specific antibiotic class, 15% reported duration, and 1% reported dosage and frequency. Infection outcomes were reported in 58% of studies. Only 57% of studies that reported on infection outcomes described their antibiotics practices. Surgical antibiotic regimens and infection outcomes are infrequently included in pediatric urology studies, limiting the data available for development of evidence-based guidelines. Routine incorporation of antibiotic regimens, infection outcomes and adverse events in the pediatric urology literature will increase our ability to identify indications for antibiotics. Reporting of perioperative antibiotic outcomes in pediatric urology procedures will allow the eventual development of strong evidence-based guidelines.