Introduction The ileovesicostomy (IV) is a surgical option for patients with refractory bladder dysfunction at-risk of upper tract deterioration who cannot catheterize or lack social support for managing an augmentation cystoplasty (AC). Long-term outcomes after IV in children are lacking in the literature. Objective We assessed the risk of long-term surgical complications in pediatric patients with IV at a single children's hospital. Study design We retrospectively reviewed the records of patients undergoing IV between 2002 and 2021 at a single children's hospital. The primary outcome was the rate of surgical complications in IV patients after initial reconstruction. Specific complications of interest included intra-abdominal, reservoir, and stomal complications, respectively. We also assessed renal outcomes, including the change in glomerular filtration rate (DGFR) and Society of Fetal Urology (DSFU) hydronephrosis from the time of surgery to last follow up. Results The study comprised 17 IV patients, with most patients having a diagnosis of spina bifida (65 %). Median follow-up was 6.4 years. The mean rate of surgical complications per patient year was 0.11 f 0.20. On survival analysis, the time to first complication for IV was 84.4 months. The incidence of intra-abdominal, reservoir, and stomal complications over the study period was 2/17(11.8 %) for each of these complication types. The mean DSFU grade from the time of surgery to last follow up was-1.24 f 1.48 and mean DGFR was-2.5 f 32.7 ml/ min. Discussion We found that IV in pediatric patients experience a low rate (0.11/year) of complications and that median time to first complication was 84 months. Additionally, IV offers adequate renal preservation. Our study is limited, though, by its retrospective nature, small sample size, heterogenous population and lack of comparison group. Conclusion Our experience demonstrates that IV has a low rate of surgical complications and preserves renal function. We believe it is a reasonable surgical option for the well selected patient with refractory bladder dysfunction at-risk of upper tract deterioration who is unable to reliably catheterize.

Introduction: There are multiple historic reports linking lower urinary tract symptoms (LUTS) in children with food allergies (FA), but contemporary studies are sparse. The objective of this study was to evaluate a potential link between FA and LUTS in the pediatric population. We hypothesized that children with FAs are more likely to have LUTS. Materials and methods: After local IRB approval, pediatric patients (6-17 years [y]) with FAs proven by positive skin prick and/or serum IgE testing were invited to participate. A control group of pediatric patients without FAs was also recruited. All families/legal guardians signed informed consent, and all children signed written assent. Each participant filled out the Vancouver Symptom Score (VSS), a validated questionnaire for dysfunctional elimination syndrome, and the Pediatric Incontinence Questionnaire (PinQ), a validated quality of life assessment for children with bladder dysfunction. Demographic and clinical information were obtained retrospectively. Results: From 2019-2020, 26 children with FAs and 57 without agreed to participate. Mean age was 9.3 y (IQR 7.9 y-13.5 y). There were no differences in gender, age, or race between the two cohorts. There were no significant differences between the two groups in mean VSS score or mean PinQ score. Four children with FAs (15%) and 15 children without (26%) had VSS score >= 11 (p = 0.339), indicating dysfunctional elimination. The median PinQ score was 0 (IQR 0-2) in both cohorts. Conclusions: This study did not identify an association between FAs and LUTS in a population of pediatric patients with laboratory proven FAs.

PURPOSE:Surgical interventions in the urologic management of children with neurogenic bladder secondary to spina bifida aim to preserve upper tract function, prevent urinary tract infections, and optimize quality of life. However, since the introduction of intravesical onabotulinumtoxinA (Botox) in the management of these patients, the indications for choosing Botox over augmentation cystoplasty (AC) remain undefined. The objective of this study was to determine which factors lead patients to undergo Botox versus AC as a primary surgical treatment after failing medical management.METHODS:We retrospectively reviewed the records of pediatric patients with myelomeningocele undergoing either primary Botox or primary AC at our institution between 2013 and 2018. We recorded demographic and clinical information. We identified 10 important clinical decision-making factors: bladder trabeculation, vesicoureteral reflux, or hydronephrosis on imaging; end-filling pressure (EFP) ≥40 cm H2O, detrusor overactivity, detrusor-sphincter dyssynergia, or reduced capacity on urodynamic studies; physician-perceived bladder hostility; and patient/family desire for continence and independence. The presence of these factors was compared between patients undergoing either primary Botox or primary AC.RESULTS:We identified 14 and 50 myelomeningocele patients who underwent primary AC and primary Botox, respectively. We found no significant differences in age, sex, race, or history of reconstructive surgery (antegrade continence enema or catheterizable channel). For the 10 decision-making factors, desire for independence/continence (p = <0.001) and reduced capacity (p = 0.002) were significantly associated with AC, while trabeculation (p = 0.006), EFP ≥40 cm H2O (p = 0.029), rising slope (p = 0.019), and physician-perceived hostility (p = 0.012) were significantly more common with Botox.CONCLUSIONS:At our institution, quality of life measures prompted AC over objective urodynamic or imaging findings before attempting Botox. These findings support a shared decision-making approach when considering surgical intervention for neurogenic bladder secondary to myelomeningocele.

Objective To describe our experience with robot-assisted laparoscopic transperitoneal repair of a congenital rectourethral fistula in a pediatric patient with a urethral duplication. Methods The patient is a 2-year-old male with a past medical history of Tetralogy of Fallot presenting with a febrile urinary tract infection (UTI). He was diagnosed with urethral duplication and a rectourethral fistula by voiding cystourethrogram (VCUG). The parents were counseled on various options and agreed to proceed with a robotic repair. Results Robotic-assisted transperitoneal rectourethral fistula repair was performed. The procedure time was 229 min with an estimated blood loss (EBL) of 15 mL. His postoperative course was unremarkable. At his 2-week follow-up, the urethral catheter was removed and the patient was voiding normally and having normal bowel movements. Conclusion Congenital rectourethral fistula with urethral duplication is a rare anomaly with only a few reports in the literature. Pediatric robotic-assisted transperitoneal rectourethral fistula repair is a technically feasible approach in infants with minimal morbidity that allows for excellent visualization and avoids open repair.

INTRODUCTION AND OBJECTIVE: The aim of this study was to evaluate the efficacy and safety of vibegron with improved selectivity and metabolic stability in comparison with previously disclosed b3adrenoceptor agonists for treating antimuscarinic-resistant neurogenic bladder dysfunction in children with spina bifida. METHODS: In this retrospective study, 19 patients below 15 years of age, with antimuscarinic-resistant neurogenic bladder dysfunction due to spina bifida, underwent a video-urodynamic study before and during the prescription of vibegron. The dosage was 12.5, 25 or 50 mg once daily, based on age and body weight, for at least 12 weeks from January 2020 to July 2021, in addition to antimuscarinic therapy. The video-urodynamic study was conducted to evaluate bladder compliance, maximum cystometric bladder capacity, detrusor overactivity, detrusor leak point pressure, and vesicoureteral reflux. This was done subsequently prior to the beginning and after three months of vibegron administration. Patientreported efficacy and adverse events were measured. RESULTS: Treatment with vibegron add-on therapy drastically improved bladder compliance and maximum cystometric bladder capacity compared to treatment with antimuscarinic agents alone (6.2; IQR: 5.2e10.4 vs. 28.3; IQR: 22.7e50.7 mL/cmH2O, P < 0.0001; and 178; IQR: 135e235 vs. 450; IQR: 358e502 mL, P<0.0001, respectively). Bladder deformity in 12 patients improved after taking the drug (image 1: before taking vibegron and image 2: after taking vibegron, obtained from the same case). Moreover, vesicoureteral reflux, confirmed in four patients, disappeared post administration. All the 18 patients who were incontinent before remained dry after initiating therapy with vibegron during the daytime. None of the patients showed side effects or discontinued treatment owing to intolerance to vibegron. CONCLUSIONS: Vibegron as adjuvant treatment in children with antimuscarinic-resistant neurogenic bladder dysfunction due to spina bifida showed favorable video-urodynamic efficacy with no apparent adverse events. Vibegron helped to achieve urinary continence in the entire sample population. Vibegron is a favorable treatment option for the treatment of refractory neurogenic bladder dysfunction in children with spina bifida. Source of Funding: None

You have accessJournal of UrologyCME1 May 2022PD02-06 COMPARISON OF LONG TERM ADVERSE EVENTS AND RENAL OUTCOMES BETWEEN ILEOVESICOSTOMY AND CONTINENT BLADDER AUGMENTATIONS AT A SINGLE PEDIATRIC INSTITUTION Viktor Flores, Mikhael Matthew, Heidi Chen, Benjamin Abelson, Abby S. Taylor, Stacy T. Tanaka, Cyrus M. Adams, Mark C. Adams, John C. Thomas, John C. Pope, John W. Brock, and Douglass B. Clayton Viktor FloresViktor Flores More articles by this author , Mikhael MatthewMikhael Matthew More articles by this author , Heidi ChenHeidi Chen More articles by this author , Benjamin AbelsonBenjamin Abelson More articles by this author , Abby S. TaylorAbby S. Taylor More articles by this author , Stacy T. TanakaStacy T. Tanaka More articles by this author , Cyrus M. AdamsCyrus M. Adams More articles by this author , Mark C. AdamsMark C. Adams More articles by this author , John C. ThomasJohn C. Thomas More articles by this author , John C. PopeJohn C. Pope More articles by this author , John W. BrockJohn W. Brock More articles by this author , and Douglass B. ClaytonDouglass B. Clayton More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002517.06AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Incontinent ileovesicostomy is a urinary diversion that has historically been offered as an alternative to a continent bladder augmentation (BA) in a subset of pediatric patients with poor bladder compliance and mental, physical, or social barriers to catheterization. Criticisms of ileovesicostomy include higher risk of infection and urolithiasis. We compared the incidence of specific adverse events, total adverse events rate, and renal outcomes between ileovesicostomy and BA. We hypothesize that an ileovesicostomy results in fewer adverse events due to its low-pressure reservoir while achieving similar renal outcomes. METHODS: We conducted a retrospective study of pediatric patients undergoing ileovesicostomy or BA from 2002 to 2021 at our institution. Inclusion criteria included availability of estimated glomerular filtration rate (eGFR) and renal imaging. Renal function was classified according to the stages of chronic kidney disease using eGFR, and hydronephrosis was classified according to the Society of Fetal Urology grading system. Charts were reviewed for adverse events. Chi-square test was performed for all categorical values, and Wilcoxon-test for all continuous variables. RESULTS: 15 patients with an ileovesicostomy and 56 patients with BA met study criteria. Table 1 summarizes the characteristics between both groups. Postoperative renal function did not differ between ileovesicostomy (P=0.60) or BA (P=0.80) group after surgery based on CKD stage, however SFU hydronephrosis did improve significantly for the ileovesicostomy group (P=0.03) compared to the BA group (P=0.45), with 6 out of 9 patients having resolution after surgery. Total adverse events (0.22 vs. 0.57, P=0.017) per patient year were lower in the ileovesicostomy group. Table 2 shows differences in specific adverse events. CONCLUSIONS: In our data, incontinent ileovesicostomy is a procedure that results in fewer long term adverse events compared to BA, while preserving renal function. Source of Funding: None © 2022 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 207Issue Supplement 5May 2022Page: e37 Advertisement Copyright & Permissions© 2022 by American Urological Association Education and Research, Inc.MetricsAuthor Information Viktor Flores More articles by this author Mikhael Matthew More articles by this author Heidi Chen More articles by this author Benjamin Abelson More articles by this author Abby S. Taylor More articles by this author Stacy T. Tanaka More articles by this author Cyrus M. Adams More articles by this author Mark C. Adams More articles by this author John C. Thomas More articles by this author John C. Pope More articles by this author John W. Brock More articles by this author Douglass B. Clayton More articles by this author Expand All Advertisement PDF DownloadLoading ...

Purpose: We investigated longer term urological outcomes in patients enrolled in the Management of Myelomeningocele Study (MOMS). Materials and Methods: Women who participated in the original trial were asked for consent for followup for their child at age 6 years or older in a single comprehensive study visit to a MOMS center. Participating children underwent urological and radiologic procedures to provide objective evidence of current bladder functioning. Primary urological outcome was defined as any among need for clean intermittent catheterization, vesicostomy, urethral dilatation or augmentation cystoplasty. Results: A total of 156 children were evaluated, with a mean age of 7.4 years. Overall 62% vs 87% in the prenatal and postnatal surgery groups, respectively, were placed on clean intermittent catheterization (RR 0.71, 95% CI 0.58-0.86, p < 0.001). Voiding status was significantly different between the groups (p < 0.001) as 24% in the prenatal group vs 4% in the postnatal group (RR 5.8, 95% CI 1.8-18.7) were reported to be voiding volitionally. Augmentation cystoplasty, vesicostomy and urethral dilation did not differ between the 2 groups. Aside from a larger post-void residual urodynamic catheterization volume, there were no other statistical differences in videourodynamic data or findings on renal/bladder ultrasound. Conclusions: Prenatal closure of myelomeningocele resulted in less reported clean intermittent catheterization at school age and the mechanism for this is unclear. Although most children are in diapers or on clean intermittent catheterization, parental reports showed children who underwent prenatal closure may be more likely to void volitionally than the postnatal group. Despite these findings, urological outcomes alone should not be the sole impetus to perform in utero closure in children with spina bifida.

Purpose: We assessed the impact of a 2-phase Plan-Do-Study-Act cycle to decrease opioid prescriptions following pediatric urological surgery. Materials and Methods: Parents of children undergoing outpatient urological procedures were given questionnaires to assess opioid dosing and pain scores using the Parents' Postoperative Pain Measure scale. Age, procedure and opioid prescription data were recorded, as well as volume of medication administered. During the first phase of data collection children received an opioid prescription for 10 doses. In the second phase opioid prescriptions were reduced by 50%. Nonparametric tests and Fisher exact test were used for analysis. Results: Of 250 eligible children 98 (39%) with a median age of 3.0 years (IQR 7.0) participated. In the 81 patients prescribed opioids a median of 2 doses (IQR 3.6) were used in the preintervention and postintervention groups (p = 0.68). Using nonparametric statistical testing, no significant differences were found between pain scores in the 5-dose group (31 patients) and the 10-dose group (24 patients; p = 0.05 for day 1, p = 0.07 for day 2, p = 0.06 for day 3). There was no association between age and percent opioid used (p = 0.83). There were no significant differences in median pain scores or median doses among procedure types. Conclusions: In outpatient pediatric surgical practice opioid prescriptions can be decreased without increasing pain scores. Physician prescribing practices may contribute more to opioid consumption than actual pain patterns.

Blockchain records track information about financial payments, movements of products through supply chains, identity verification information, and many other assets. Analytics on this data can provide provenance histories, predictive planning, fraud identification, and regulatory compliance. In this paper, we describe analytics engines connected to blockchains to provide easy-to-use configurable dashboards, predictive models, provenance histories, and compliance checking. We also describe how blockchain data can be combined with external data sources for secure and private analytics, enable artificial intelligence (AI) model creation over geographically dispersed data, and create a history of model creation enabling provenance and lineage tracking for trusted AI.

Detecting user input based on multiple gestures is provided. One or more interactions are received from a user via a user interface. An inferred interaction is determined based, at least in part, on a geometric operation, wherein the geometric operation is based on the one or more interactions. The inferred interaction is presented via the user interface. Whether a confirmation has been received for the inferred interaction is determined.

You have accessJournal of UrologyPediatrics: Dysfunctional Voiding & Enuresis1 Apr 2018MP56-18 COMPARISON OF UROFLOWMETRY WITH AND WITHOUT URETHRAL CATHETERIZATION Caroline L. Kang, Abby S. Taylor, Douglass B. Clayton, John C. Thomas, John C. Pope, Mark C. Adams, John W. Brock, and Stacy T. Tanaka Caroline L. KangCaroline L. Kang More articles by this author , Abby S. TaylorAbby S. Taylor More articles by this author , Douglass B. ClaytonDouglass B. Clayton More articles by this author , John C. ThomasJohn C. Thomas More articles by this author , John C. PopeJohn C. Pope More articles by this author , Mark C. AdamsMark C. Adams More articles by this author , John W. BrockJohn W. Brock More articles by this author , and Stacy T. TanakaStacy T. Tanaka More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2018.02.1809AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Uroflowmetry is an important, first-line, non-invasive test for children with suspected lower urinary tract dysfunction. However, children often produce inadequate voided volumes. Urodynamic studies can be useful in evaluating bladder function but requires urethral catheterization. We sought to compare uroflowmetry during non-instrumented versus urodynamic studies to determine whether urethral catheterization affects study parameters. Our hypothesis is that results from uroflowmetry immediately after urethral catheterization (UDS-IF) will not agree with results from non-instrumented uroflowmetry (NIF). METHODS A retrospective review was performed of patients undergoing pelvic muscle rehabilitation at a tertiary referral center from April 2015 to June 2017. We identified individuals less than 18 years of age who had undergone both NIF and UDS-IF within a three-month timeframe. Patients with neurogenic bladder dysfunction were excluded. We collected demographic data including age, sex, and race. We calculated estimated bladder capacity by age. We compared maximum urine flow rate (Qmax), voided volume, flow curve pattern, and pelvic floor patch electrode EMG pattern between UDS-IF and NIF for each patient. Flow curve patterns were characterized as tower, staccato, interrupted, bell, or plateau. Pelvic EMG pattern was characterized as active or not active. RESULTS A total of 71 children met our inclusion criteria and underwent both UDS-IF and NIF. Only 25% of flow studies during NIF were adequate based on voided volume of 50% estimated bladder capacity; in contrast, 92% of flow studies during UDS-IF were adequate. When limited to studies with adequate voided volumes, flow patterns were the same in 54% of patients and maximum flow rate did not vary significantly (mean Qmax UDS-IF 28.5 ml/s, mean Qmax NIF 24.7 ml/s, p = 0.5). When comparing all studies, flow patterns were similar in 28% of patients and maximum flow rate was significantly higher in UDS-IF compared with NIF (mean UDS-IF Qmax 27.4 ml/s, mean NIF Qmax 15.2 ml/s, p < 0.0001). Pelvic floor EMG patterns were the same > 75% of the time regardless of whether the studies were adequate based on voided volume. CONCLUSIONS The majority of children have inadequate voided volumes on non-instrumented uroflowmetry and their maximum flow rates were significantly lower than that obtained during urodynamic testing. Flow patterns matched between UDS-IF and NIF more often if voided volumes were adequate. Lastly, pelvic floor EMG patterns were not affected by urethral catheterization or amount voided. © 2018FiguresReferencesRelatedDetails Volume 199Issue 4SApril 2018Page: e762-e763 Advertisement Copyright & Permissions© 2018MetricsAuthor Information Caroline L. Kang More articles by this author Abby S. Taylor More articles by this author Douglass B. Clayton More articles by this author John C. Thomas More articles by this author John C. Pope More articles by this author Mark C. Adams More articles by this author John W. Brock More articles by this author Stacy T. Tanaka More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

IntroductionPelvic Floor Biofeedback Therapy (PFBT) can be an effective treatment for pediatric lower urinary tract symptoms (LUTS). Due to differing perceptions of efficacy and practice patterns, we sought to further evaluate PFBT in our practice. We hypothesized that PFBT results in quiescence of EMG activity during voiding and improves questionnaire scores in patients with LUTS.MethodsWe retrospectively reviewed all patients undergoing PFBT and refined the analysis to females ≥6 years old with ≥2 sessions with completed voiding questionnaires pre‐ and post‐treatment, active EMG during voiding, with non‐neurogenic urinary tract complaints refractory to standard urotherapy. Validated Bladder Bowel Dysfunction (BBD) questionnaires were collected at each visit. Quiescence of EMG activity and changes in BBD score were the primary outcomes.Results229 patients underwent ≥1 PFBT session, of which 64 females ≥6 years of age with ≥2 PFBT sessions and completed pre and post PFBT voiding questionnaires were identified. In this group, mean age at PFBT start was 10.1 (6.2‐17.0). Patients completed 3.1 sessions (2‐6). No difference was seen in post‐void residual (PVR) between first and last session (23.8 vs 22.6 mL, P = 0.55). Median questionnaire score decreased from 18 (4‐42) before to 13 (2‐28) following PFBT (P < 0.0001). Responders, characterized by silencing of the EMG after PFBT, occurred in 31% (20/64). Non‐responders were younger (P = 0.007) with higher pre‐PFBT questionnaire scores.ConclusionThe use of PFBT appears to result in a significant reduction in symptom scores, though quiescence of EMG was observed following therapy in less than 1/3 of patients.

Purpose The purpose of this paper is to help bridge the digital divide that arises from people having such different viewpoints that little communication is possible, even though all have access to the internet and speak the same language. Design/methodology/approach The method is to catalog the best practices in collaboration and cooperation in the form of a pattern language. After describing pattern languages, some examples are given. Findings People have been trying to cooperate in many cultures over many centuries, and there are many the best practices that can be useful to find a common ground. Research limitations/implications The patterns suggested do not easily allow empirical and objective A/B testing. Practical implications Any pattern or guideline will be applied by most people in most contexts. There will always be practical limitations in the appropriate scope of application. Social implications A more widespread use of the patterns should help heal the divisiveness in society. Originality/value While pattern languages have been used in many fields, this is the first attempt to do so in fostering civil engagement.

You have accessJournal of UrologyGeneral & Epidemiological Trends & Socioeconomics: Practice Patterns, Quality of Life and Shared Decision Making IV1 Apr 2017MP76-15 SURGICAL OUTCOMES CENTER FOR KIDS: A RESEARCH MODEL FOR PEDIATRIC UROLOGY Chelsea Lauderdale, Madison Shultz, Douglass Clayton, Stacy Tanaka, John Thomas, John Pope, Mark Adams, John Brock, and Chevis Shannon Chelsea LauderdaleChelsea Lauderdale More articles by this author , Madison ShultzMadison Shultz More articles by this author , Douglass ClaytonDouglass Clayton More articles by this author , Stacy TanakaStacy Tanaka More articles by this author , John ThomasJohn Thomas More articles by this author , John PopeJohn Pope More articles by this author , Mark AdamsMark Adams More articles by this author , John BrockJohn Brock More articles by this author , and Chevis ShannonChevis Shannon More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2017.02.2143AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Surgical Outcomes Center for Kids (SOCKs) was born out of a need to make research infrastructure available to pediatric surgeon scientists with an interest in improving clinical care using evidenced-based medicine and evaluating patient-centered outcomes. Evolution and impact of our multi-disciplinary, trans-institutional, and multi-institutional research center on our Pediatric Urology Department is described here. METHODS The overarching goal of SOCKs is to assess surgical and patient-centered outcomes that can inform future clinical decision making, identifying standards of excellence that can potentially improve resource utilization for the healthcare system. This research infrastructure gives academically-minded clinicians the ability to maintain their level of clinical productivity while establishing an active research agenda. Through internal and external funding, SOCKs supports personnel, referred to as research extenders, used to facilitate clinical research for our surgeon-scientists. These individuals oversee all aspects of the research process from hypothesis generation, data analysis and dissemination of results, allowing the busy clinician to successfully produce relevant works that can be disseminated through national podium talks and peer-reviewed publications. RESULTS Still in infancy, pediatric urologic research has grown from 3 to 16 studies, supporting 4 research fellows, resulting in 15 abstracts (many in manuscript development), and a national clinical research award. Our center has allowed for seamless integration of research into the day-to-day clinical world without disruption. We have seen a multitude of successes since inception including 1) capturing quality of life data to better inform treatment decision making, 2) understanding the variation in interpretation of urodynamics across institutions, 3) initiating prospective patient registries allowing for better evaluation of clinical outcomes, 4) utilizing implementation science methodology to better understand the value of biofeedback therapy, and 5) reducing resource utilization through the development of multi-disciplinary imaging protocols. CONCLUSIONS The SOCKs model was created in response to the needs of our surgeon scientists to be more academically successful. This program has created a collaborative, accessible research environment without compromising clinical productivity. Additionally, this model has proven value-added to the healthcare system and has showcased the potential to positively impact on patients. © 2017FiguresReferencesRelatedDetails Volume 197Issue 4SApril 2017Page: e1019 Advertisement Copyright & Permissions© 2017MetricsAuthor Information Chelsea Lauderdale More articles by this author Madison Shultz More articles by this author Douglass Clayton More articles by this author Stacy Tanaka More articles by this author John Thomas More articles by this author John Pope More articles by this author Mark Adams More articles by this author John Brock More articles by this author Chevis Shannon More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Purpose: Urodynamic studies are crucial to neuropathic bladder management and they often determine surgical intervention. However, current evidence indicates that interpretations show poor agreement across physicians. We sought to determine the interrater reliability of urodynamic interpretation in our practice. We hypothesized that there would be strong correlation among pediatric urologists of similar training in a single academic practice.Materials and Methods: We retrospectively identified patients with neuropathic bladder who underwent urodynamics at our institution between 2014 and 2015. An anonymous electronic survey (phase I) was developed with 20 clinical scenarios, each containing a brief history, a single urodynamic tracing and an accompanying fluoroscopic image. Faculty members assessed each tracing by an online instrument developed using urodynamic reports and published literature. The primary outcome was statistical correlation across raters as measured by the Spearman correlation coefficient. In a followup study (phase II) we investigated the sources of variability in urodynamic interpretations.Results: Six faculty members completed the study with a response rate of 100%. In comparing urodynamic interpretation across raters, the faculty demonstrated a weak to strong correlation (rs 0.39-0.61, p < 0.001). A strong correlation was found for fluoroscopic and clinical decision making variables, while electromyography synergy and detrusor overactivity demonstrated weaker correlation across physicians.Conclusions: Faculty interpretations of urodynamic tracings showed only moderate agreement despite a close working relationship and similar training at a single institution. Variability in interpretation can strongly impact patient treatment. Therefore, further work is needed to standardize the reporting and interpretation of urodynamic studies to optimize patient care.

PURPOSE:Sacral neuromodulation has been demonstrated to improve refractory bowel bladder dysfunction in children. The purpose of the current study was to determine whether results are durable in children after longer followup, whether children with a lower body mass index are at risk for device failure and whether pretreatment urodynamic evaluation can predict posttreatment outcome.MATERIALS AND METHODS:Pediatric patients with refractory bowel bladder dysfunction were enrolled following informed consent and followed prospectively. All patients underwent preoperative videourodynamic evaluation and a 2-stage implantation procedure. Validated questionnaires were used to assess symptom severity and quality of life. Complications were analyzed with regard to treatment required and patient body mass index.RESULTS:During 45 months 30 patients were enrolled. Median age was 8.3 years at enrollment. Median followup was 14.8 months. Patients had significant improvement in quality of life and symptom scores, which persisted at the most recent followup. Patients who had uninhibited detrusor contractions on preoperative urodynamic assessment had significantly greater improvement in symptoms. Of the patients 23% had a complication requiring reoperation, most commonly neurostimulator lead breakage in those with a significantly lower body mass index.CONCLUSIONS:Sacral neuromodulation significantly improves quality of life and symptom severity in children with refractory bowel bladder dysfunction. Children gain greater benefit if they show uninhibited bladder contractions on preoperative urodynamic evaluation. Children have a high rate of lead breakage requiring operative revision, which was seen after minor trauma in those with a lower body mass index.

PURPOSE:We previously reported catheterizable channel associated outcomes and concluded that the incidence of postoperative complications was greatest in the first 2 years after surgery. At that time our followup was short. In this series we sought to determine whether complications continued to accumulate with longer followup in an updated cohort of patients. MATERIALS AND METHODS:We comprehensively reviewed the outcomes in 81 consecutive patients who underwent construction of a MACE (Malone antegrade continence enema) and/or a Mitrofanoff channel in association with complex genitourinary reconstruction. Mean followup was 80.1 months. Outcomes of these 119 stomas were classified by Clavien-Dindo grade and time to complication. RESULTS:The 48 unique, channel related events (40.3%) necessitated a total of 70 interventions with a mean 24.2 months to the first event. Difficult catheterization was the most common event, occurring in 20.1% of channels an average of 29.9 months after surgery. Stomal stenosis was also common, developing in 12.6% of channels at an average of 19.9 months after surgery. Unique complications clustered in the first 2 years, after which there was a statistically significant decline (p = 0.0013). High grade complications similarly clustered (p <0.0001). Channel composition was significantly associated with rates of difficult catheterization events. CONCLUSIONS:Compared to our previous cohort of patients with similar volume but shorter followup, our assumption that channel associated complications cluster postoperatively and then decrease significantly was correct. Our current and more detailed series demonstrates that the rate of postoperative complications decreases with time. However, with longer followup patients continue to experience lower grade events requiring fewer interventions.

We propose a "maturity model" for Human Computer Interaction for Development (HCI4D). We focus on the last phase, transmutation, in which cultural diversity allows humanity to find, formulate and solve otherwise insoluble issues. Further, the diversity of existing cultures provides frameworks for a space of cultures allowing new representations.

Purpose: Literature pertaining to surgical disclosure to the pediatric patient is lacking. We hypothesized parents would find it difficult to disclose urologic surgery to a child.Materials and Methods: Parents of patients <5 years old undergoing urologic surgery were contacted for telephone survey. Parents were asked about future plans of surgical disclosure, comfort with disclosure, and any support received.Results: 98 parents consented to study participation. 87% of surgeries were on the genitalia with 62% being minor genitalia surgery (i.e. circumcision). 70% of parents would tell their child about minor genital surgery while 84% would tell about major genital surgery (p=0.07). 4 of 20 parents of children undergoing hypospadias repair (major genital surgery) did not plan to tell their child about surgery. All parents of children undergoing non-genital surgery would tell. Of all parents planning to tell their children about surgery, only 14% were nervous. 34% of parents would find guidance in talking to their child helpful despite the majority (90%) stating no guidance had ever been provided.Conclusions: Parents seem comfortable discussing urologic surgeries with a child but about 1/3 would appreciate further counseling. 20% of parents of children undergoing hypospadias repair hope to avoid telling their child.