Introduction:The ability to perform flexible ureteroscopy in children may be limited because of a smaller pediatric ureterovesical junction and ureteral diameter. Tamsulosin has been shown to improve success rates of ureteral instrumentation in adults. To date, the efficacy of this medication to facilitate pediatric ureteral access remains unclear.Methods:We conducted a multi-institutional retrospective review of patients aged 0 to 17 years who underwent ureteroscopy for the treatment of nephrolithiasis from 2013 to 2022. Patients were excluded if they had undergone ureteroscopy or ureteral stent placement within the prior year, underwent semirigid ureteroscopy, or had a known genitourinary abnormality. Study groups included patients prescribed 0.4 mg tamsulosin daily for at least 1 week preoperatively and patients who did not receive tamsulosin.Results:There were 382 patients included, with 126 in the tamsulosin group and 256 in the no-tamsulosin group. Although there were no differences in sex, race, and stone characteristics between the 2 groups, the tamsulosin group was significantly older and had a larger BMI. One week of preoperative tamsulosin was associated with a significantly increased success of flexible ureteroscopic access on first attempt ureteroscopy, with a 24% failure in the no-tamsulosin group vs a 13% failure in the tamsulosin group (P = .010).Conclusions:Our results expand on prior research and suggest that at least 1 week of preoperative tamsulosin facilitates flexible ureteroscopic access in the pediatric population. These results have significant clinical implications, with the potential to reduce multiple procedures and spare children from repeat anesthetic exposures.

IntroductionCircumcision is a common procedure that can evoke caregiver anxiety in the postoperative period due to unfamiliarity with the healing process. To mitigate unnecessary healthcare utilization such as phone calls and unanticipated clinic or emergency department (ED) visits, photographic atlases have been developed to better prepare caregivers for the recovery process. The objective of our study is to further investigate the efficacy of a photographic atlas in its ability to decrease postoperative healthcare utilization using an increased sample size and extended study period compared to previous studies. Materials and methodsIn this study, we compared a prospective intervention cohort of patients undergoing circumcision at our institution who received a photographic atlas during postoperative teaching to a retrospective cohort of patients who had not received it. Our primary outcome was unanticipated healthcare utilization, defined as postoperative telephone calls and unanticipated presentations to the urology clinic or ED.ResultsThe retrospective no-atlas cohort included 105 pa-tients, and the prospective intervention atlas cohort included 80 patients. Both groups were similar with respect to age (p = 0.47) and other demographics.There was no statistically significant difference in healthcare utilization between the no-atlas and atlas cohort. Specifically, we identified no differ-ence in the number of phone calls to clinic staff (12 [11.4%] vs. 11 [13.8%], p = 0.64) or unanticipated postoperative clinic or ED visits (2 [1.9%] vs. 4 [5.0%], p = 0.41). DiscussionThe use of a photographic atlas as part of caregiver support for circumcision patients did not demon-strate a statistically significant reduction in either postoperative phone calls or clinic/ED visits. The decrease in absolute number of caregiver phone calls was minimal (12-11), with a small increase in follow-up presentations (2-4). The lack of signifi-cant change may be due to the already infrequent occurrence of these events following circumcision, as demonstrated by the no-atlas cohort. Other po-tential advantages of the atlas, such as improved caregiver confidence and satisfaction, may have been present, but were not measured in this study.ConclusionsAdding to the mixed results of previous studies, these findings do not support that photographic atlases decrease unanticipated healthcare utiliza-tion in children undergoing a circumcision. However, utilization was found to be low. Additionally, further studies are needed to determine other significant benefits of this form of education, such as improved caregiver confidence and satisfaction.

Five-alpha reductase type 2 deficiency (5αRD2) is a rare cause of atypical genitalia in newborns. There are no definitive guidelines regarding management of children with this disorder. While many children are raised as female given the under-virilized appearance of their external genitalia at birth, these patients are historically counseled to undergo male puberty, resulting in a change in gender identity from female to male in more than half of post-pubertal patients. Here we report the first case of a patient with 5αRD2who identified as female from a very early age, strongly desired gender-affirming surgery, and elected to initiate puberty-blocking therapy prior to the onset of male puberty.

INTRODUCTION:Flexible ureteroscopes are not tailored for pediatric ureteral size and may not pass at first attempt into the pediatric ureter. Administration of tamsulosin preoperatively in adults has been shown to facilitate ureteral access sheath placement. Several studies have shown tamsulosin to be safe and effective when utilized for medical expulsive therapy in pediatric patients, but its utility for preoperative ureteral dilation has not been studied to date. OBJECTIVE:We hypothesized that preoperative tamsulosin reduces failed ureteroscopic access in children. MATERIALS AND METHODS:We conducted a retrospective review of patients aged 0-18 years undergoing flexible ureteroscopy (URS) from 2014 to 2019 at a single institution. Patients were divided into those taking 0.4 mg of tamsulosin daily for at least 1 week prior to surgery and those not taking tamsulosin. The primary outcome was failure to pass a 7.95 Fr flexible ureteroscope on initial attempt, requiring stent placement and staged management. Patients undergoing URS or stent placement within the prior year, requiring semi-rigid URS, or with genitourinary anomalies were excluded. RESULTS AND DISCUSSION:A total of 49 patients met inclusion criteria. The tamsulosin group (n = 13) and non-tamsulosin group (n = 36) were similar with respect to demographic data. The percentage of prepubertal patients was 53% vs 33% (p = 0.19). The tamsulosin group had lower failed URS (38% vs 61%, p = 0.20). When stratified by age, both prepubertal and postpubertal patients in the tamsulosin group had lower failed URS (43% vs 67%, p = 0.67 and 33% vs 58%, p = 0.38). These clinically significant results suggest initial passage of a flexible ureteroscope is more successful in pediatric patients on preoperative tamsulosin. This study was largely limited by its low power and flaws inherent to its retrospective design. CONCLUSION:Our results have implications for prescribing tamsulosin preoperatively to reduce multiple procedures and anesthetics in children. Adequately powered prospective trials are warranted to confirm preoperative tamsulosin reduces failed first-attempt flexible URS in children.