Background:Urethroplasty is considered the gold standard treatment for urethral stricture. Occasionally perineal urethrostomy can be offered to patients who cannot or are unwilling to undergo complex reconstruction. In this study, we explore the factors that have influenced urologists to offer perineal urethrostomy over urethroplasty for urethral strictures on the national level. Methods:The American College of Surgeons National Surgical Quality Improvement Program database 2006-2021 was used to identify patients undergoing surgical procedures for urethral strictures using current procedural terminology (CPT) codes. The CPT codes for urethroplasty (53410) and perineal urethrostomy (53010) were used to analyze the data appropriately. Cases were excluded if they were missing any demographic data. Patient characteristics of interest were race, age, smoking status, obesity, hypertension (HTN), chronic obstructive pulmonary disease COPD, American Society of Anesthesiologists classification, use of glucocorticoids, history of cancer, and diabetes mellitus. The Chi-square and multivariate logistic regressions were used to identify significant predictors of outcomes. Significance was defined as P < 0.05. Results:In total, 2941 patients received urethroplasty, and 154 patients received perineal urethrostomy for urethral stricture. Patients with significant comorbidities such as diabetes mellitus, HTN, and COPD are significantly more likely to undergo perineal urethrostomy [Table 1]. Patients younger than 70 were more likely to undergo urethroplasty. History of cancer, congestive heart failure, race, and dialysis had no impact on the choice of repair here. Conclusion:Male patients with urethral stricture who are less healthy and had increased comorbidities such as history of diabetes, HTN, and COPD were more likely to receive perineal urethrostomy over urethroplasty, while younger patients were less likely to be offered perineal urethrostomy.

To examine the factors influencing urologists’ decision to offer slings instead of AUS for managing male stress urinary incontinence. The American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database 2006–2021 was used to identify patients undergoing surgical procedures for male urinary incontinence using current procedural terminology (CPT) codes. The Current procedural terminology (CPT) codes for AUS (53,445) and male slings (53,440) were used to analyze the data appropriately. The cases with incomplete demographic data were excluded. Patient characteristics of interest were race, age, smoking status, obesity, HTN, COPD, ASA classification, use of glucocorticoids, history of cancer, and diabetes mellitus. Chi square and multivariate logistic regressions were used to identify significant predictors of outcomes. Significance was defined as p<0.05. Among 4098 patients, 2407 underwent AUS implantation, and 1691 received a sling for male SUI. African American males were significantly more likely than Caucasian males to receive a sling (OR = 5.566, p < 0.05). The patients with comorbidities such as diabetes mellitus, hypertension, use of glucocorticoids, cancer, increased ASA, and history of DVTs are significantly more likely to undergo sling placement. COPD, congestive heart failure, and dialysis had no impact on the choice of male urinary incontinence management. Male patients who are African American or have comorbidities such as history of diabetes, hypertension, cancer, DVT, and glucocorticoid use were more likely to be offered slings for stress urinary incontinence. These findings suggest a preference among urologists to recommend slings for patients with higher surgical risk profiles.

BackgroundWe analyzed trends in age at surgery and surgical approach over time and geography.MethodsWe performed a systematic review according to PRISMA-IPD guidelines to include individual patient data. Collected data included age at surgery, location of surgery, and surgical approach. The surgical approach was independently categorized as the exploration of the brachial plexus (EBP) or nerve transfer without root exploration (NTwoRE). EBP was defined as exploring the brachial plexus in the supraclavicular fossa and applying a choice of coaptation procedures. NTwoRE included those sourcing donor nerves from, or entirely occurring outside of the plexus without exploring the root of the brachial plexus.ResultsRegression analysis of age at surgery 1985–2020 showed that age at BPBI surgery is rising (p < 0.05). Surgery was performed at a younger age in patients from Europe (7.06 ± 7.77 months) and Asia (7.58 ± 5.33 months) than those from North America (10.44 ± 5.01 months) and South America (14.71 ± 4.53 months) (p < 0.05). NTwoRE was more common in North America (37%) and least common in Europe (12%). Age at EBP was 7.2 ± 5.77 months, and age at NTwoRE was 15.85 ± 13.18 months (p < 0.05). The incidence of NTwoRE is increasing time.ConclusionsAge at NBPP surgery is increasing over time. Regional differences exist in age at NBPP surgery. Approaches to NBPP surgery that avoid exploration of BP roots are becoming more popular. Age at EBP is lower than age at NTwoRE.

PURPOSE:Surgical resident autonomy in procedures has been eroding over time, due to multiple factors that include duty hour restrictions, focus on operating time, complication rate, and trust among supervising physicians. This study examines whether urology residents at the Veterans Affairs hospitals (VA) have experienced decreased surgical autonomy and contributing factors. METHODS:The national VA Surgical Quality Improvement Program (VASQIP) was queried for the most common urologic procedures between 2004 to 2019 with resident involvement. The most frequent surgeries were transurethral resection of prostate (TURP); transurethral resection of small, medium, or large tumor (TURBT); photo vaporization of prostate, scrotal surgery, and ureteral stent placement. The cases were stratified by resident involvement: attending as primary (AP), attending and resident (AR), resident as primary (RP). RESULTS:93,756 urology cases were selected from 2004 to 2019. The above procedures accounted for 76.5% of all urologic cases. The percentage of RP cases decreased from 44.4% of cases in 2004 to 25.1% in 2019. Reduction in RP cases was seen in all of the 7 examined urology cases. Cases with resident involvement had patients with more medical comorbidities. Mean operative times were not significantly different. The 30-day composite complications and 30-day return to operating room were greatest for AR. Postoperative morbidity and all-cause mortality were not significantly different. CONCLUSIONS:Urology resident autonomy has decreased within the VA healthcare system over the past 15 years. Mean operative times and postoperative complications are not significantly different in cases with residents as primary surgeon.

This study aimed to investigate the long-term outcomes of non-operative, operative, and minimally invasive surgery management of high-grade renal injuries (Grades III–V) in an underserved population at a high-volume trauma center. We conducted a retrospective chart review of 93 patients who sustained high-grade renal trauma and presented to University Hospital, a Level 1 trauma center, between 2017 and 2022. The patients were categorized by initial management strategy: non-operative, operative, or minimally invasive surgery (endoscopic urologic and interventional radiologic procedures). Outcome variables included length of hospital stay, complications, mortality, long-term renal function, and the need for additional procedures. We analyzed associations between management strategies and outcomes, adjusting for injury mechanism and severity. Non-operative management was the most common strategy (60

Objectives To review malpractice suits stemming from urethroplasty intervention, which is the standard of care for patients suffering from urethral strictures. Methods This retrospective study analyzed the LexisNexis and Westlaw databases between 1980 and 2024. Each database was queried with “urethroplasty” which yielded 48 cases and 20 jury verdicts/settlements in the LexisNexis database and 46 cases and 14 jury verdicts in the Westlaw database. Selected cases were reviewed variables including chief allegation, litigation location, plaintiff demand, plaintiff award, and verdict. Exclusion criteria included but were not limited to lawsuits regarding non-urologic surgery necessitating urethroplasty and litigation based on traumatic injury necessitating urethroplasty. Results After manual review of 128 cases in the LexisNexis and Westlaw databases, 12 met inclusion criteria. 5 (42%) cases sued for deformation of the genitalia after urethroplasty, 2 (17%) sued for failure of informed consent, 2 (17%) sued for erectile dysfunction, 1 (8%) sued for a post-operative venous thrombosis, 1 (8%) sued for post-operative infection, and 1 (8%) sued for failure to treat. 6 (50%) cases resulted in plaintiff awards; 3 of these were settled before a final verdict. Plaintiff awards varied from $72,500 - $810,000. Of the twelve cases, 2 (17%) occurred in California and 2 (17%) occurred in Illinois; the remaining locations were isolated. Conclusions The most common cause of litigation following urethroplasty was centered on the perceived deformation of the genitalia after urethroplasty, which underscores the significance of urologists setting realistic expectations for patients with thorough pre-operative counseling.

Panurethral strictures represent the most severe form within the anterior urethral stricture spectrum, requiring more technically complex repairs and resulting in poorer outcomes compared to localized anterior urethral strictures (penile or bulbar). This abstract aims to describe the distinct characteristics of patients with panurethral strictures in a low socioeconomic status population. Patients presenting with localized anterior (penile or bulbar) or panurethral strictures at University Hospital in Newark, NJ, between 2021 and 2023 were retrospectively identified. Data were extracted from electronic medical records and analyzed statistically using IBM SPSS Software. Among the patients, 33 had localized anterior urethral strictures, and 22 had panurethral stricture disease. Hispanic and African American patients accounted for the majority of stricture cases (63.6

Introduction: Renal duodenal fistulas are a very rare connection due to chronic inflammation or infection secondary to kidney stones. Case Report: We present a female with right perinephric abscess and reno-duodenal fistula secondary to a long-standing history of kidney stones. Treatment involved drainage of the abscess, nephrostomy tube placement, intravenous antibiotics, and open nephrectomy and duodenal repair with gastrojejunostomy. Conclusion: In this report, we discuss management strategies which range from conservative treatment of antibiotics to open nephrectomy. In addition, we will discuss the urologic and gastroenterological post-operative complications in this patient.

Abstract Introduction Infertility is experienced by 15% of couples, with up to 50% of cases related to male factors. Unfortunately, infertility treatments are expensive and infrequently covered by insurance, burdening patients and deterring access to care. However, Medicaid patients are even less likely to pursue treatments. Of 92 million Medicaid enrollees, 31 million are between the ages of 18 to 44, prime age for fertility intervention. However, transparency of Medicaid coverage of fertility interventions is low. Objective In this study, we evaluated Medicaid coverage status and physician reimbursement for the most common infertility-related interventions. Methods Physician fee schedules were accessed through state Medicaid websites for the year 2023. The fee schedules were searched for current procedural terminology (CPT) codes used for male infertility interventions. The Medicaid physician fee index was accessed for each state and linear regression analysis was performed to assess if state reimbursements were attributable to a tendency for that state to reimburse more for Medicaid services. Results Of the 50 US states analyzed, 49 publish accessible physician fee schedules. Tennessee requires patient claim data to be submitted before releasing fee schedules. No states offered reimbursement for microscopic testicular extraction of sperm thus requiring alternatives for coding, or the use of out-of-pocket billing. Certain procedures were covered by every state, such as testis biopsy, while others were rarely covered, such as vasovasostomy (table 1). Reimbursement patterns for several CPTs significantly varied based on the state physician fee index, although these were typically weak correlations (table 2). Conclusions Discrepancies in state coverage and reimbursement for fertility procedures is evident. Some of the discrepancies can be explained by state fee indexes, however the absence of clear methodology behind a state’s decision to cover fertility procedures and physician reimbursement rates both contribute to overall lack of transparency within Medicaid. This lack of transparency may be partially responsible for underutilization of infertility treatments in Medicaid patients. Disclosure No.

Objectives: In the treatment of closed intertrochanteric fractures, the two most common treatment options are intramedullary medullary nail (IMN) and dynamic hip screw (DHS), yet the best treatment method remains controversial. The purpose of this study is to determine the difference in mortality and morbidity between IMN and DHS. Secondarily, this study determines which pre -operative risk factors affect rates of morbidity and mortality. Methods: American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) 2006-2016 database was used to search for patients with a closed intertrochanteric hip fracture. Bivariate analysis was performed using Pearson's Chi Square test to determine pre-operative risk factors associated with complications in fixation with IMN and DHS. Significant variables in this analysis, as well as demographic data, were analyzed via binary logistic regression. The results were recorded as odds ratio (OR) and significant differences were based on a P<0.05. Results: After adjusting for demographics and clinical covariates, patients who underwent fixation with IMN had higher 30-day mortality, reintubation, UTI, bleeding, prolonged length of stay, and non-home discharged destination rates compared to DHS. Mortality risk was increased by ascites, disseminated cancer, impaired functional status, history of congestive heart failure, and hypoalbuminemia. Bleeding risk was increased by previous percutaneous coronary (PCI) and transfusions and was decreased by impaired functional status. Myocardial infarction risk was increased by female gender. Conclusion: Our study found that IMN fixation increased risk of mortality, UTI, reintubation, bleeding, prolonged length of stay, and a non-home discharge destination compared to DHS. This study also identified patient risk factors associated with several postoperative complications. These data may better inform orthopaedic surgeons treating closed intertrochanteric fractures. Level of evidence: III

Objectives:Intertrochanteric hip fractures are a common orthopaedic injury in the United States. Complications of surgical treatment include nonunion, lag screw cutout, implant failure, post-operative pain, risk of refracture or reoperation, and infection. The purpose of this study was to compare the rate of complications of sliding hip screw fixation (SHS) compared to cephalomedullary nailing (CMN) for the treatment of closed intertrochanteric femur fractures in adult patients.Methods:PubMed, CINAHL, and Cochrane Library databases were searched for studies comparing SHS to CMN in the treatment of closed intertrochanteric femur fractures in adults. Data were compiled to observe the rate of nonunion, cutout failure, infection, refracture, perioperative blood loss, reoperation, postoperative pain, pulmonary embolism/deep venous thrombosis (DVT), length of hospital stay, and mortality.Results:Seventeen studies were included comprising 1,500 patients treated with SHS and 1,890 patients treated with CMN. Treatment of intertrochanteric femur fractures with SHS demonstrated significantly fewer refractures and reoperations. There was no significant difference in other variables between SHS and CMN treated groups.Conclusion:This meta-analysis shows that the only notable difference in outcomes is patients treated with CMN have a higher rate of refracture and reoperation. With new advances in the development of both CMNs and SHS, further studies will be required to see if these differences persist in the coming years.

PURPOSE OF REVIEW:The purpose of this review is to investigate the current use and effectiveness of active surveillance (AS) for clinical low-risk prostate cancer (PCa) in men considered to be "high-risk" based on the factors of race, genetics, healthcare access, and socioeconomic status.RECENT FINDINGS:Advances in molecular biomarkers and imaging have improved the detection, risk stratification, and treatment of PCa. Still, overdiagnosis and overtreatment of indolent disease remain a concern. AS is therefore the preferred option for clinical low-risk disease. Yet, because of the variability in PCa presentation based on the aforementioned environmental and genetic factors, the question remains: Is active surveillance a safe option for everyone? Provider hesitancy should not necessarily exclude high-risk men from participating in AS. Rather, clinicians should employ shared decision-making, sound clinical judgment, and stringent follow-up in order to effectively counsel AS candidates and optimize AS-related outcomes in "high-risk" individuals.

ABSTRACT Introduction Sexual health problems affect approximately 60% of male cancer survivors in the U.S. Erectile dysfunction (ED) is the most common sexual health condition men seek professional help for after cancer treatment with some studies reporting ED rates as high as 85% in these men. Inflatable penile prosthesis (IPP) implantation is a safe and highly effective form of ED treatment for patients who fail or cannot tolerate medical therapies. A 2011 study suggested that IPPs are under-utilized by urologists, as less than 1% of men with prostate cancer and ED received IPP following radical prostatectomy or external beam radiation. Objective To better characterize the utilization of IPP treatment, we examined the relationships between ED, prostate cancer treatment type and IPP implantation in a national cohort. Methods We performed a retrospective review of older SEER-Medicare patients who were diagnosed with local/regional prostate cancer between 2006 and 2011 and treated with surgery or radiation for it, with and without ED. Using ICD9/CPT/HCPCS codes we created a cohort of patients who has receipt of surgery or radiation within 3 months of cancer diagnosis as well as diagnosed ED within 5-years after undergoing treatment. Chi-square/Wilcoxon tests were used to detect significant differences between the surgical and radiation treatment groups for ED rates and use of IPP among those with ED. Results Of the 31,854 patients in our cohort, 10,475 (32.9%) received surgery and 21,152 (66.4%) received radiation only. Overall, ED was significantly more common for surgical (65.2%) than for radiation patients (33.8%, p<.001). For the subset of 14,121 patients with ED (overall IPP use=2.5%), IPP implantation was significantly more frequent for surgical patients (n=6,976, IPP use= 3.6%) than for radiation patients (n=7,145, IPP use=1.4%, p<.001). Conclusions Shockingly few (2.5%) prostate cancer patients with ED received IPP, with only 1.4% of radiation patients undergoing IPP vs. 3.6% of RALP patients. IPP under-utilization may be due to greater clinical focus on cancer treatment rather than quality-of-life issues. Discrepancies in ED rates between radiation and surgery may also be partially explained by lack of follow-up standardization and highly variable sexual dysfunction reporting, especially in the radiation literature. These findings highlight the importance of thorough counseling about all treatment options including penile prosthesis surgery for prostate cancer patients with ED. Disclosure No

You have accessJournal of UrologyCME1 May 2022MP10-03 SURGICAL AUTONOMY OF UROLOGY RESIDENTS WITHIN THE VETERANS AFFAIRS HEALTHCARE SYSTEM Janmejay Hingu, Anh Nguyen, Kunj Jain, Devashish Anjaria, Joseph Oliver, and Hossein Sadeghi-Nejad Janmejay HinguJanmejay Hingu More articles by this author , Anh NguyenAnh Nguyen More articles by this author , Kunj JainKunj Jain More articles by this author , Devashish AnjariaDevashish Anjaria More articles by this author , Joseph OliverJoseph Oliver More articles by this author , and Hossein Sadeghi-NejadHossein Sadeghi-Nejad More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002532.03AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Surgical resident autonomy in procedures has been eroding over time due to factors such as duty hour restrictions, focus on operating time, complication rates, and trust among supervising physicians. This study examines whether urology residents at the Department of Veterans Affairs hospitals (VA) have experienced decreased surgical autonomy and what factors may contribute. METHODS: The VA Surgical Quality Improvement Program (VASQIP) was queried for the most common urologic procedures between 2004 to 2019 with resident involvement. The cases were stratified by resident involvement: attending as primary (AP), attending and resident (AR), resident as primary (RP). RESULTS: 127,757 urology cases were identified from 2004 to 2019. The most frequent surgeries were transurethral resection of prostate (TURP); transurethral resection of small, medium, or large tumor (TURBT); GreenLight laser of prostate (GLL); hydrocelectomy; and ureteral stent placement. These procedures accounted for 76.5% of all cases. The percentage of RP cases decreased from 31.3% of cases to 18.6%. Reduction in RP cases was seen in all seven top urology cases, particularly in ureteral stent placement which has declined from 44% RP in 2004 to 18% in 2019. Cases with resident involvement had patients with more cardiovascular, pulmonary, and infectious comorbidities. Mean operative times in all cases were not significantly different. The 30-day composite complications and 30-day return to operating room were greatest for AR. Postoperative complications of bleeding, infection, DVT, embolism, renal failure, wound dehiscence, and 30 day all-cause mortality were not significantly different. CONCLUSIONS: Urology resident autonomy has decreased within the VA healthcare system over the past 15 years. Mean operative times and postoperative complications are not inferior in cases that involve residents as the primary surgeon. Increased focus on resident education and surgical autonomy in the operating theater is vital for training the next generation of surgeons. Source of Funding: N/A © 2022 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 207Issue Supplement 5May 2022Page: e146 Advertisement Copyright & Permissions© 2022 by American Urological Association Education and Research, Inc.MetricsAuthor Information Janmejay Hingu More articles by this author Anh Nguyen More articles by this author Kunj Jain More articles by this author Devashish Anjaria More articles by this author Joseph Oliver More articles by this author Hossein Sadeghi-Nejad More articles by this author Expand All Advertisement PDF downloadLoading ...

Purpose: The prevalence of erectile dysfunction (ED) and the utilization of inflatable penile prosthesis (IPP) among prostate cancer patients are understudied. The aim of the study was to examine the relationships between ED, prostate cancer treatment type and IPP implantation in a national cohort. Materials and Methods: We identified a retrospective cohort of Surveillance, Epidemiology, and End Results (SEER)-Medicare patients diagnosed with locoregional prostate cancer between 2006 and 2011 and treated with surgery or radiation. Chi-square tests were used to detect significant differences in ED rates as well as use of IPP among the subset with ED. Multivariable logistic regression was used to examine factors associated with the use of IPP. Results: Among 31,233 patients in our cohort, 10,334 (33.1%) received prostatectomy and 20,899 (66.9%) received radiation. ED within 5 years was significantly more common in the prostatectomy group relative to those the radiation group (65.3% vs. 33.8%, p<0.001). In the subset of 13,812 patients with ED, the radiation group had greater median time to ED diagnosis compared to the prostatectomy group (346 vs. 133 days, p<0.001). IPP implantation was more frequent for prostatectomy patients than for radiation patients (3.6% vs. 1.4%, p<0.001). Cancer treatment type, race, and marital status were significantly associated with IPP utilization. Conclusions: ED is highly prevalent among prostate cancer patients, and IPP implantation is be underutilized. ED rates, time to ED diagnosis and utilization of IPP differed significantly by prostate cancer treatment type.

You have accessJournal of UrologyCME1 May 2022MP10-02 UROLOGY RESIDENT AUTONOMY COMPARED TO GENERAL SURGERY RESIDENT AUTONOMY Kunj Jain, Janmejay Hingu, Anh Nguyen, Devashish Anjaria, Joseph B. Oliver, and Hossein Sadeghi-Nejad Kunj JainKunj Jain More articles by this author , Janmejay HinguJanmejay Hingu More articles by this author , Anh NguyenAnh Nguyen More articles by this author , Devashish AnjariaDevashish Anjaria More articles by this author , Joseph B. OliverJoseph B. Oliver More articles by this author , and Hossein Sadeghi-NejadHossein Sadeghi-Nejad More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002532.02AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Urology and general surgery resident autonomy in the operating room has been declining in recent years. This may be due to perceptions of poorer outcomes, complications, and operating time. Residents and faculty have expressed decreased preparedness as independent surgeons due to inadequate autonomy during residency. We sought to compare resident involvement for general surgery and urology residents and evaluated the associated outcomes. METHODS: This study is a retrospective study from the Veterans Affairs Surgical Quality Improvement Program (VASQIP) database. All operative cases from July 1, 2004 to September 30, 2019 in the VASQIP database were included in the study. Patients who underwent a urologic surgical procedure were identified based on the code of the surgeon’s specialty and stratified based on CPT codes. The cases were coded based on the level of supervision by an attending physician: AP- attending as primary surgeon, RP- resident as primary surgeon, AR- attending and resident as primary surgeons. Logistic regression and ANOVA analysis was performed. RESULTS: The VASQIP database included 127,757 patients who underwent urologic surgery over the 15 year time frame. There was decline in resident primary surgeon (RP) cases from 31.3% in 2004 to 18.6% in 2019 with an increase in total cases (p <0.01). The number of urology RP cases is higher compared to general surgery/vascular surgery RP cases which decreased from 15% to 5% in the same period. Urology and general surgery AR cases had increased operating times, but RP surgeries did not have significantly increased operating times when compared to AP surgeries. There was no increase in mortality with RP or AR urology cases. However, the 30-day return to OR was significantly increased compared to AP cases. There was no difference in mortality between RP or AP general surgery cases, but AP general surgery cases had an increased rate of complications. CONCLUSIONS: Residents in urology and general surgery have had a major decline in resident autonomy between 2004 and 2019. Although urology has had better autonomy maintenance compared to general surgery, both specialties have seen a decline that is not warranted based on operating time, complications, and patient outcomes. There is a need for increased efforts to expand resident autonomy to create prepared and independent future surgeons. Source of Funding: N/A © 2022 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 207Issue Supplement 5May 2022Page: e146 Advertisement Copyright & Permissions© 2022 by American Urological Association Education and Research, Inc.MetricsAuthor Information Kunj Jain More articles by this author Janmejay Hingu More articles by this author Anh Nguyen More articles by this author Devashish Anjaria More articles by this author Joseph B. Oliver More articles by this author Hossein Sadeghi-Nejad More articles by this author Expand All Advertisement PDF downloadLoading ...

BACKGROUNDDebate over the optimal age at time of surgery for treatment of brachial plexus birth injury (BPBI) remains controversial, and there exists geographical varia- tion in surgical preference for age at time of surgery. The objective of this review was to analyze trends in age and geography in brachial plexus microsurgery for treatment of brachial plexus birth injury (BPBI) over time.METHODSReview of the literature in this study was con- ducted according to the Preferred Reporting Items for Sys- tematic Reviews and Meta-Analysis (PRISMA) guidelines. PubMed, Cochrane, Web of Science, and the Cumulative Index to Nursing and Allied Health Literature (CINAHL) databases were searched.RESULTSPediatric patients undergoing brachial plexus microsurgery described in published reports before 2011 had a mean of 7.15 ± 6.56 months of age, while pediatric patients undergoing brachial plexus microsurgery surgery described in published reports after 2011 had a mean of 11.23 ± 9.76 months of age (p < 0.05). The mean age at surgery was lower in publications from Asian countries (6.29 months) than in publications from North America (11.34 months; p < 0.05).CONCLUSIONSAge at time of microsurgery for treatment of BPBI is increasing, with mean age at surgeries occurring in and after 2011 being 4 months higher than thos occuring before 2011. The mean age at surgery was about 5 months higher in North American publications than in Asian pub- lications.

BACKGROUND:Neonatal brachial plexus palsy (NBPP) is a serious complication of high-risk deliveries with controversy surrounding timing of corrective nerve surgery. This review systematically examines the existing literature and investigates correlations between age at time of upper trunk brachial plexus microsurgery and surgical outcomes. METHODS:A systematic screening of PubMed, Cochrane, Web of Science, and CINAHL databases using PRISMA-IPD guidelines was conducted in January 2020 to include full-text English papers with microsurgery in upper trunk palsy, pediatric patients. Spearman rank correlation analysis and two-tailed t-tests were performed using individual patient data to determine the relationship between mean age at time of surgery and outcome as determined by the Mallet, Medical Research Council (MRC), or Active Movement Scale (AMS) subscores. RESULTS:Two thousand nine hundred thirty six papers were screened to finalize 25 papers containing individual patient data (n = 256) with low to moderate risk of bias, as assessed by the ROBINS-I assessment tool. Mallet subscore for hand-to-mouth and shoulder abduction, AMS subscore for elbow flexion and external rotation, and MRC subscore for elbow flexion were analyzed alongside the respective age of patients at surgery. Spearman rank correlation analysis revealed a significant negative correlation (ρ = -0.30, p < .01, n = 89) between increasing age (5.50 ± 2.09 months) and Mallet subscore for hand-to-mouth (3.43 ± 0.83). T-tests revealed a significant decrease in Mallet hand-to-mouth subscores after 6 months (p < .05) and 9 months (p < .05) of age. No significant effects were observed for Mallet shoulder abduction, MRC elbow flexion, or AMS elbow flexion and external rotation. CONCLUSION:The cumulative evidence suggests a significant negative correlation between age at microsurgery and Mallet subscores for hand-to-mouth. However, a similar correlation with age at surgery was not observed for Mallet shoulder abduction, MRC elbow flexion, AMS external rotation, and AMS elbow flexion subscores.