BACKGROUND:The Anderson-Hynes dismembered pyeloplasty remains the gold-standard surgical repair of ureteropelvic junction obstruction in children. While open pyeloplasty (OP) has proven excellent long-term durability in function and drainage. Contemporary urology trainees may have more experience with minimally invasive surgery than open surgery for common urologic procedures. Increasing robotic expertise has driven adoption of minimally invasive pyeloplasty (MIP) in younger patients, potentially shifting trainee experience away from open surgery. OBJECTIVE:We report US pediatric urology fellowship trainee experience with OP and MIP over the past decade, hypothesizing that the shift toward minimally invasive approaches has reduced open surgical training. STUDY DESIGN:The Accreditation Council for Graduate Medical Education (ACGME) defines case minima for surgical specialties and annually reviews graduate case log data to assess the breadth and depth of procedural training. Deidentified ACGME case log data for all pediatric urology fellows from 2014 to 2024 were divided into three periods (2014-2017, 2017-2021, 2022-2024). Total case counts for OP (CPT 50400/50405) and MIP (CPT 50544) were recorded; ureterocalicostomy (50750) and ureteropyelostomy (50740) were excluded. The proportions of OP versus MIP cases were compared across periods using the chi-square test. RESULTS:The proportion of MIP cases increased progressively from 54.9% (2014-2017) to 58.2% (2018-2021) to 75.5% (2022-2024) (p < 0.001), rising from 48.1% in the initial year to 77.3% in the final year. DISCUSSION:The significant decline in OP cases reflects a growing limitation in open surgical experience for pediatric urology fellowship trainees, while the concomitant increase in MIP cases presents an opportunity to refine minimally invasive techniques in smaller infants. Notably, OP CPT codes 50400 and 50405 are catalogued as 'Pyeloplasty' without specifying an open approach, and the robotic modifier for case reporting was removed in 2019. As a result, underreporting or misclassification of laparoscopic cases as open cannot be excluded, particularly in the most recent study period, potentially biasing toward underestimation of the true decline in OP training experience. CONCLUSION:Over the last decade, there has been a significant trend favoring MIP over OP in US pediatric urology fellowship training, most pronounced in the most recent three-year period. This shift may jeopardize mastery of OP during fellowship. If proficiency with OP remains important in practice, training paradigms should prioritize enhancing trainee exposure to open surgical techniques.

INTRODUCTION:Most studies in pediatric urology have been limited to single-center retrospective designs with inherent limitations. Ideally, pediatric urology research would be collaborative, cross-institutional, and guided by shared priorities supported by funding mechanisms that enable rigorous study designs. OBJECTIVE:To promote collaborative research in the highest-priority areas of the field, we aimed to engage pediatric urologists to establish a shared clinical research agenda through a structured, consensus-based process. STUDY DESIGN:We employed a 3-phase approach. First, we surveyed frontline pediatric urologists in the United States to elicit research questions addressing gaps in clinical knowledge. Next, we reviewed and refined responses to inform a three-round modified Delphi prioritization with a 22-member working group. Questions meeting consensus in the final Delphi round were advanced to the final phase where an in-person 11-member workshop developed a preliminary research agenda. This agenda was subsequently finalized through electronic feedback and endorsement by the full working group. RESULTS:Eighty-eight pediatric urologists submitted 256 questions during the elicitation phase. Overlapping or redundant submissions were consolidated, resulting in 64 unique questions that advanced to prioritization. Following three Delphi rounds, this list was narrowed to 10, and the consensus workshop endorsed 6 final priorities. DISCUSSION:We describe a structured, consensus-based process to establish clinical research priorities for pediatric urology. Through three phases of elicitation, prioritization, and a consensus workshop, we engaged the pediatric urology community to identify six clinical research priorities. Next steps include targeted dissemination to major funders and professional societies to guide future research and funding priorities. The initial phase of this study focused on clinician input and was limited in stakeholder diversity due to lack of representation from allied health professionals and researchers who are not practicing urologists and other specialists in urologic disease (e.g., nephrology, infectious diseases) as well as lack of patient or family perspectives. The next phase will include further refinement of these broad priorities into actionable research questions through an iterative, multi-stakeholder process involving affected patients and families as well as interdisciplinary providers and methodological panelists. CONCLUSION:This clinician-prioritized research agenda reflects the most pressing clinical research gaps in pediatric urology in the United States, identified through broad engagement with pediatric urologists. Future work should ensure alignment of clinician-identified priorities with those of patients and caregivers. The ultimate goal is to direct collaborative, multi-institutional, and multinational efforts that strengthen the evidence base, inform clinical guidelines, and improve patient care in pediatric urology.

INTRODUCTION:While an increasing number of artificial intelligence (AI) models are being developed in pediatric urology, the extent of race/ethnicity reporting among these studies is unclear. Our objective was to evaluate the inclusion and quality of race/ethnicity reporting in AI models in pediatric urology. METHODS:We conducted a secondary analysis of studies included in the AI in PEDiatric UROlogy (AI-PEDURO) collaborative living scoping review and repository. We examined racial/ethnic groups reported, their proportional representation, use of race/ethnicity as a predictor, conducting of stratified analyses by race/ethnicity, data collection methods, bias evaluation, and discussions of implications on equity. RESULTS:Of 81 studies in the AI-PEDURO repository, six (7.4%) reported race/ethnicity. Five studies included White and Black patients, representing 4824/7968 (60.5%) and 1377/7968 (17.3%) of the pooled cohort, respectively. Asian patients were included in three studies and represented 178/6861 (2.6%). Two studies reported Native Hawaiian or other Pacific Islander and Hispanic or Latino patients, representing 20/6704 (0.3%) and 1236/6704 (18.4%), respectively. One study included American Indian or Alaska Native patients, representing 69/6604 (1.0%). Mixed patients were included in three studies and represented 103/7711 (1.3%). Race/ethnicity was a predictor variable in 4/6 studies. None of these six studies conducted stratified analyses of model performance across race/ethnicity subgroups, reported race/ethnicity data collection methodologies, examined algorithmic biases, discussed implications on equity, or examined socioeconomic status or geographic residence. CONCLUSIONS:Race/ethnicity reporting is poor in most AI studies in pediatric urology. Standardized reporting may help ensure fairness and generalizability of models across diverse pediatric urology populations.

Introduction: While an increasing number of artificial intelligence (AI) models are being developed in pediatric urology, the extent of race/ethnicity reporting among these studies is unclear. Our objective was to evaluate the inclusion and quality of race/ethnicity reporting in AI models in pediatric urology. Methods: We conducted a secondary analysis of studies included in the AI in PEDiatric UROlogy (AI-PEDURO) collaborative living scoping review and repository. We examined racial/ethnic groups reported, their proportional representation, use of race/ethnicity as a predictor, conducting of stratified analyses by race/ethnicity, data collection methods, bias evaluation, and discussions of implications on equity. Results: Of 81 studies in the AI-PEDURO repository, six (7.4%) reported race/ethnicity. Five studies included White and Black patients, representing 4824/7968 (60.5%) and 1377/7968 (17.3%) of the pooled cohort, respectively. Asian patients were included in three studies and represented 178/6861 (2.6%). Two studies reported Native Hawaiian or other Pacific Islander and Hispanic or Latino patients, representing 20/6704 (0.3%) and 1236/6704 (18.4%), respectively. One study included American Indian or Alaska Native patients, representing 69/6604 (1.0%). Mixed patients were included in three studies and represented 103/7711 (1.3%). Race/ethnicity was a predictor variable in 4/6 studies. None of these six studies conducted stratified analyses of model performance across race/ethnicity subgroups, reported race/ethnicity data collection methodologies, examined algorithmic biases, discussed implications on equity, or examined socioeconomic status or geographic residence. Conclusions: Race/ethnicity reporting is poor in most AI studies in pediatric urology. Standardized reporting may help ensure fairness and generalizability of models across diverse pediatric urology populations.

Importance Most children and adolescents with kidney and ureteral stones are treated with ureteroscopy, despite the uncertainty and equal weight of guideline recommendations for ureteroscopy or shockwave lithotripsy. Objective To compare stone clearance and patient-reported outcomes among children and adolescents after ureteroscopy or shockwave lithotripsy. Design, Setting, and Participants This nonrandomized clinical trial enrolled patients between March 16, 2020, and July 31, 2023, at 31 medical centers in the US and Canada. Patients aged 8 to 21 years with kidney stones, ureteral stones, or both were included. Follow-up was completed on October 15, 2023. Interventions Ureteroscopy or shockwave lithotripsy. Main Outcomes and Measures The primary outcome was stone clearance assessed by standardized ultrasonography 6 (+/- 2) weeks after surgery. Using inverse probability weighting and random intercepts for site, stone clearance was evaluated per kidney or ureter using logistic regression and estimated stone clearance rates were generated for each procedure. Results This study included 1142 patients (690 females [60.4%]), with a median age of 15.6 years (IQR, 12.6-17.3 years). In terms of race and ethnicity, 41 patients (3.6%) were Black, 130 (11.4%) were Hispanic, and 884 (77.4%) were White. A total of 124 urologists treated 1069 and 197 kidneys or ureters with ureteroscopy and shockwave lithotripsy (n = 953 and n = 189 patients), respectively, with a median stone size of 6.0 mm (IQR, 4.0-9.0 mm). Ureteral stents were placed at time of index surgery for 841 procedures for 767 patients (80.4%) receiving ureteroscopy and for 6 procedures for 5 patients (2.6%) receiving shockwave lithotripsy. Stone clearance occurred in 474 patients who underwent ureteroscopy (71.2% [95% CI, 63.8%-78.5%]) and in 105 patients who underwent shockwave lithotripsy (67.5% [95% CI, 61.0%-74.1%]), a difference that was not statistically significant (risk difference, 3.6% [95% CI, -6.2% to 13.5%]). Compared with shockwave lithotripsy, ureteroscopy resulted in greater pain interference (T-score difference, 5.0 [95% CI, 2.3-7.8]) and urinary symptoms (symptom score difference, 3.9 [95% CI, 1.2-6.7]) 1 week after surgery. Patients who had ureteroscopy missed more school (risk difference, 21.3% [95% CI, 9.7%-32.8%]) and caregivers missed more work (risk difference, 23.0% [95% CI, 11.0%-35.0%]) in the week after surgery. Conclusions and Relevance In this study of 1142 children and adolescents with kidney and ureteral stones, there was no clinically meaningful difference in stone clearance with ureteroscopy vs shockwave lithotripsy. Shockwave lithotripsy was associated with better patient-reported outcomes. These findings raise questions about the preference for ureteroscopy in practice.Trial RegistrationClinicalTrials.gov Identifier: NCT04285658

OBJECTIVE:To investigate practice pattern variability and drivers of imaging after febrile UTI (fUTI). METHODS:We performed a retrospective review of all children ≤6 years old presenting between 2012 and 2021 who presented in a variety of settings (outpatient, inpatient, emergency department [ED]) with diagnosis of first fUTI to a single freestanding children's hospital. Patients were excluded if no documented fever, no documented positive urine culture, or history of congenital urinary anomalies. The primary outcome was compliance with American Academy of Pediatrics guidelines regarding genitourinary (GU) imaging after the first or second fUTI. Secondary outcomes were whether patients received GU imaging and the timing of voiding cystourethrogram (VCUG). Multivariate logistic regression was performed. RESULTS:Four hundred seventy-three patients met criteria with a median age of 11 months. Overall, adherence to American Academy of Pediatrics guidelines was 41%, with no significant increase in compliance over time. Sixty-four percent (306/473) underwent renal-bladder ultrasound (RBUS) after the first fUTI. Of those with abnormal RBUS, 57.1% (44/77) underwent VCUG. Six patients had a VCUG after initial fUTI but no RBUS. Of those with a second fUTI, 36.7% (18/49) underwent VCUG. Notably, 32% received no GU imaging. On multivariate analysis, compliance was associated with younger age (OR 0.98) and inpatient treatment (OR 2.97). The receipt of any imaging was associated with younger age (OR 0.98), female patients (OR 1.78), inpatient treatment (OR 4.98), and private insurance (OR 1.72). CONCLUSION:Non-adherence to guidelines on imaging after febrile UTI remains high in the pediatric community, indicating significant potential for improvement.

Importance:Based on expert opinion, clinical guidelines recommend percutaneous nephrolithotomy or shockwave lithotripsy for children and adolescents with kidney stones 20 mm or larger, without mention of ureteroscopy as an alternative. Objective:To compare clinical and patient-reported outcomes for percutaneous nephrolithotomy vs ureteroscopy in children and adolescents with kidney and/or ureteral stones. Design, Setting, and Participants:This prospective cohort study was performed at 31 medical centers in the US and Canada. Participants included patients aged 8 to 21 years undergoing surgery for kidney and/or ureteral stones between March 16, 2020, and July 31, 2023. Exposures:Percutaneous nephrolithotomy vs ureteroscopy. Main Outcomes and Measures:Stone clearance assessed by ultrasonography 6 (±2) weeks postoperatively. Secondary outcomes included patient-reported outcomes 1 week after surgery. Results:The study enrolled 1039 eligible patients (median age, 15.6 [IQR, 12.5-17.3] years; 629 female [60.5%]; 40 Black [3.8%]; 128 Hispanic [12.3%]; and 792 White [76.2%]). One hundred twenty-six urologists performed percutaneous nephrolithotomy for 98 kidneys and/or ureters and ureteroscopy for 1069, including 36 undergoing percutaneous nephrolithotomy and 43 undergoing ureteroscopy for stones larger than 15 mm. Stone clearance was 67.2% (95% CI, 46.0%-88.4%) for percutaneous nephrolithotomy and 73.4% (95% CI, 69.4%-77.4%) for ureteroscopy, a difference that was not statistically significant (risk difference, -6.2%; 95% CI, -27.7% to 15.4%). For stones larger than 15 mm, stone clearance was 94.0% (95% CI, 83.3%-100%) for percutaneous nephrolithotomy and 55.0% (95% CI, 32.9%-77.1%) for ureteroscopy, a statistically significant difference (risk difference, 39.0%; 95% CI, 14.4%-63.5%). Compared with ureteroscopy, percutaneous nephrolithotomy had significantly lower pain intensity (T score difference, -5.42; 95% CI, -10.38 to -0.46), pain interference (T score difference, -5.88; 95% CI, -11.02 to -0.75), anxiety (T score difference, -5.74; 95% CI, -9.26 to -2.22), psychological stress experiences (T score difference, -7.90; 95% CI, -13.13 to -2.67), sleep disturbance (T score difference, -5.57; 95% CI, -8.56 to -2.58), and urinary symptoms (symptom score difference, -6.37; 95% CI, -11.71 to -1.03) 1 week after surgery. Conclusions and Relevance:Compared with ureteroscopy, percutaneous nephrolithotomy had similar stone clearance and better lived experiences for children and adolescents and was associated with greater stone clearance of kidney stones larger than 15 mm. A future adequately powered prospective clinical trial is needed to reaffirm these results.

The modern peer review process relies on review by independent experts; however, it is threatened by time constraints and increasing review demands placed on a limited number of involved individuals. To expand the pool of reviewers in paediatric urology, a joint effort was undertaken by the Journal of Urology and Journal of Paediatric Urology via a mentorship program occurring at the 2022 Paediatric Urology Fall Congress. The objective was to increase participants' knowledge and comfort with the review process. Our experience could serve as a pilot for other academic groups looking to expand their peer review pool. Overall, 39 individuals attended the program. An increase in comfort with performing a journal review was noted by 14/23 respondents (61%), with an average increase of 1.2 points on a 10-point Likert scale. The average rating of satisfaction with the journal review program on a 10-point scale was 9.7, with 77% (23/30) rating the program 10/10. When asked for specific elements of the program that participants particularly liked, the most common responses were networking with senior mentors in a small group setting and the panel discussion led by editors describing specifics of what they are looking for in a review. Previous programs with goals similar to ours have required more long-term commitment from both mentors and mentees in developing their skills as peer reviewers. Our program benefited from a short-term commitment at a large national conference. Long term results will need to be collected moving forward. However, initial feedback was positive and participants describe increased comfort and knowledge in the review process. Our program evaluation was limited by lack of validated surveys and a lack of longitudinal data on future completion of reviews. This pilot program inspired enthusiasm and increased interest in the peer review process among young paediatric urologists. This program could serve as a model for improving recruitment of peer reviewers and could impact reviewer quality.

INTRODUCTION:Timely diagnosis and management of acute testicular torsion (ATT) is a benchmark for quality of care. We sought to evaluate whether patient sociodemographic factors and transfer status had an impact on hospital throughput and orchiectomy in ATT patients. METHODS:From 1/1/2022 to 9/9/2023, patients were identified by CPT code for operations to treat ATT and confirmed by chart review. Patient demographics were noted, and socioeconomic status (SES) was estimated using a distress score produced via the Distressed Communities Index (DCI), a multidimensional measure of social context. We denoted patients who were transferred to our urban tertiary care children's hospital and tracked emergency department (ED) registration time, time of arrival in the operating room (OR), and whether a repeat scrotal ultrasound (SUS) was performed for transfer patients. Based on a quality improvement measurement framework, the time between ED and OR (i.e., hospital throughput) served as our process measure, and orchiectomy rate was our outcome measure. RESULTS:100 patients were diagnosed with ATT at a median age of 14 years (IQR 12-15). Median time from ED to OR was 110 min (IQR 79-144). Sixty-one patients were transferred to our institution, and this cohort reflected a higher proportion of White, non-Hispanic patients (p = 0.04) with a lower median distress score (14.4 vs 36.8, p = 0.03). Obtaining a repeat SUS in 25 transfer patients (41 %) prolonged the time to OR by a median of 20 min (p < 0.01). Regardless of repeat SUS, transfer patients had faster hospital throughput than those patients who presented primarily to our institution (p < 0.01). Overall, the orchiectomy rate was 18 %, and this outcome was associated with younger patient age (p < 0.01) and longer reported duration of symptoms (p < 0.01). DISCUSSION:Transfer patients had a higher SES and experienced faster hospital throughput than patients presenting primarily to our institution. Repeating SUS in transfer patients added modestly to the time to OR but did not impact the likelihood of orchiectomy. In fact, neither transfer status nor sociodemographic factors, other than patient age, were associated with orchiectomy. Further research is needed to identify factors that affect testicular viability and what efforts might improve surgical outcomes. CONCLUSIONS:Patients with ATT transferred to our institution after presenting to a local hospital experienced prompt management with quicker time from ED to OR, though this did not impact their surgical outcome. Only younger patient age and longer reported duration of symptoms increased the likelihood of orchiectomy.

INTRODUCTION:We tested whether a commercially available, wearable bladder ultrasound device (DFreeⓇ, Triple W Japan Inc.) could accurately estimate bladder volume in children with urologic conditions by comparing sensor readings to instilled volume during cystometrography (CMG). MATERIALS AND METHODS:We prospectively enrolled 40 children (6 months to 18 years old). The device was taped to the suprapubic region and volume measurements obtained during CMG. Primary outcome was device accuracy, defined as device indicating ≥ 8 (0-10 scale) when the instilled volume was ≥ 80% of CMG-determined capacity. Mixed effects linear regression modeled the relationship between sensor indication and instilled volume after adjusting for clinical variables. RESULTS:Median age was 7.2 years, 20 (50%) were male, 27 (67.5%) were on clean intermittent catheterization, 30 (75%) had spina bifida. The sensor accurately measured capacity in 46.2% of patients with a sensitivity of 0.70, specificity of 0.13, positive predictive value of 0.53, and negative predictive value of 0.22. Device readings were statistically associated with instilled volume; single-digit (10%) increase in sensor reading was associated with an average increase of 10% (95% CI: 9% to 12%, p < 0.001) in bladder volume. CONCLUSION:A commercially available, wearable ultrasound bladder sensor accurately measured bladder capacity in 46.2% of children undergoing UDS. Our findings caution clinicians in recommending these types of direct-to-consumer devices. Repeated measures testing is needed to determine if the accurate device indicators observed in a minority of patients herein, are reproducible. TRIAL REGISTRATION:Our study did not need to be registered per the International Committee of Medical Journal Editors Uniform Requirements.

Most children and adolescents with kidney and ureteral stones are treated with ureteroscopy, despite the uncertainty and equal weight of guideline recommendations for ureteroscopy or shockwave lithotripsy. To compare stone clearance and patient-reported outcomes among children and adolescents after ureteroscopy or shockwave lithotripsy. This nonrandomized clinical trial enrolled patients between March 16, 2020, and July 31, 2023, at 31 medical centers in the US and Canada. Patients aged 8 to 21 years with kidney stones, ureteral stones, or both were included. Follow-up was completed on October 15, 2023. Ureteroscopy or shockwave lithotripsy. The primary outcome was stone clearance assessed by standardized ultrasonography 6 (±2) weeks after surgery. Using inverse probability weighting and random intercepts for site, stone clearance was evaluated per kidney or ureter using logistic regression and estimated stone clearance rates were generated for each procedure. This study included 1142 patients (690 females [60.4%]), with a median age of 15.6 years (IQR, 12.6-17.3 years). In terms of race and ethnicity, 41 patients (3.6%) were Black, 130 (11.4%) were Hispanic, and 884 (77.4%) were White. A total of 124 urologists treated 1069 and 197 kidneys or ureters with ureteroscopy and shockwave lithotripsy (n = 953 and n = 189 patients), respectively, with a median stone size of 6.0 mm (IQR, 4.0-9.0 mm). Ureteral stents were placed at time of index surgery for 841 procedures for 767 patients (80.4%) receiving ureteroscopy and for 6 procedures for 5 patients (2.6%) receiving shockwave lithotripsy. Stone clearance occurred in 474 patients who underwent ureteroscopy (71.2% [95% CI, 63.8%-78.5%]) and in 105 patients who underwent shockwave lithotripsy (67.5% [95% CI, 61.0%-74.1%]), a difference that was not statistically significant (risk difference, 3.6% [95% CI, −6.2% to 13.5%]). Compared with shockwave lithotripsy, ureteroscopy resulted in greater pain interference (T-score difference, 5.0 [95% CI, 2.3-7.8]) and urinary symptoms (symptom score difference, 3.9 [95% CI, 1.2-6.7]) 1 week after surgery. Patients who had ureteroscopy missed more school (risk difference, 21.3% [95% CI, 9.7%-32.8%]) and caregivers missed more work (risk difference, 23.0% [95% CI, 11.0%-35.0%]) in the week after surgery. In this study of 1142 children and adolescents with kidney and ureteral stones, there was no clinically meaningful difference in stone clearance with ureteroscopy vs shockwave lithotripsy. Shockwave lithotripsy was associated with better patient-reported outcomes. These findings raise questions about the preference for ureteroscopy in practice. ClinicalTrials.gov Identifier: NCT04285658