INTRODUCTION:Advanced practice providers (APPs) originally were integrated into healthcare out of necessity to aid primary care accessibility and have since dispersed across various surgical and nonsurgical specialties. There is a paucity of literature surrounding how APP involvement can impact divisional productivity within pediatric urology. The objective of this study is to identify the significance of APP implementation within the division of pediatric urology at a large academic pediatric institution. METHODS:Data from the Surgery Department Executive Committee annual reports from October 2011 to September 2024 was retrospectively reviewed. Descriptive analysis was completed, examining trends by provider type in productivity including clinic and surgical volume, and surgery to clinic visit ratio. RESULTS:Since fiscal year 2012, the ratio of APPs to MDs in the division of urology provider personnel has trended towards a 1-to-1 ratio with 1 APP per 1.49 MDs in 2024. Total divisional clinic volume has significantly grown since 2012, with APP clinic volume specifically increasing by over 200% from 2013 to 2024. The largest surgical volume was observed in 2024 at 3655 cases, over 225% greater than 2012. CONCLUSION:Implementation of highly autonomous APPs facilitates optimal surgeon practice, resulting in clinical and potential financial benefits within pediatric urology practices. This finding corresponds to the demand for outpatient access for non-surgical conditions, particularly bladder and bowel dysfunction, along with patients needing pediatric urologic surgery. A standardized onboarding process ensures well-trained APPs who transition seamlessly into autonomous practice. This observational study suggests that APPs improve access to care, perioperative efficiency, and productivity without requiring a significant increase in the number of surgeons.

BACKGROUND:Deploying surgeons frequently train, prepare, and bring equipment to manage adult trauma patients without sufficient planning and consideration for pediatric trauma populations. Pediatric urotrauma in this setting requires specialty care as part of the humanitarian mission. We determine the incidence of genitourinary trauma and relevant surgical procedures within the pediatric population seen in US military treatment facilities in Afghanistan and Iraq from January 2007 to January 2016. METHODS:We analyzed the prospectively maintained Department of Defense Trauma Registry between 2007 and 2016. We used diagnostic and procedural codes to identify any pediatric casualties who arrived at a military treatment facility with urological-based injuries. We compared the characteristics of pediatric patients with urologic injuries versus pediatric patients with non-urological injuries. RESULTS:The registry contained 42,790 casualties, of which 3439 (8.0 %) were pediatric by documented or estimated age. Within that, 430 (13 %) had at least one urological diagnostic or procedural code. Ages and the proportion of males to females were similar across the two groups. Explosive (48 %) and firearm (24 %) injuries were the predominant mechanisms of injury. The median injury severity score was 16 (IQR 9-22). The urological injury group was more likely to have serious injuries to the abdomen and extremities (27 %). Pelvic fractures were seen in 11 % of injuries with urotrauma. Most patients survived to hospital discharge (92 %). Massive transfusion protocols were activated in 31 % of patients with urologic wounds compared to 14 % without urologic injury. The most common procedures were surgical interventions to the bladder (70 %). Renal injuries comprised 20 % of all urological injuries; 41 % required operative intervention, with 60 % being nephrectomies. CONCLUSIONS:In combat situations, pediatric urotrauma is observed to be more frequent and often presents with more severe injuries compared to adults. Our findings highlight the need for pediatric genitourinary-specific training for deploying surgeons.

We present three new and six published infants with overlapping features of LUMBAR syndrome (lower body hemangioma, urogenital anomalies, spinal cord malformations, bony deformities, anorectal/arterial anomalies and renal anomalies) and OEIS complex (omphalocele, exstrophy, imperforate anus, and spinal defects), also known as cloacal exstrophy. OEIS is included under the recently proposed umbrella coined recurrent constellations of embryonic malformations (RCEMs). The RCEMs represent a phenotypically overlapping spectrum of rare disorders of caudal dysgenesis with unknown cause but likely shared pathogenesis. It has recently been proposed that LUMBAR be considered an RCEM. This report of infants with combined features of OEIS and LUMBAR is the first to demonstrate an overlap between LUMBAR and another RCEM, which supports LUMBAR's inclusion within the RCEM spectrum.

Abstract Disclosure: C. Nguyen: None. R. Yong: None. X. Xu: None. Y. Lin: None. S.K. Gunn: None. V. Sutton: None. N. Passoni: None. M. Axelrad: None. J. Bercaw: None. P. Georgiadis: None. P. Austin: None. M. Scheurer: None. D. Nguyen: None. L.P. Karaviti: None. Background: Congenital Adrenal Hyperplasia (CAH) is a condition characterized by a deficiency in the adrenal enzyme, 21-hydroxylase, due to mutations in the CYP21A2 gene. Therapeutic management of CAH attempts to replace deficient hormones and reduce excessive androgen levels. In all cases of classical CAH, surgical intervention is required to restore external genitalia and the urogenital sinus. The timing of the surgical intervention is critical and still remains a challenge to restore the balance and quality of life for these patients. Currently, there is no consensus or data-driven algorithms to help determine the optimal timing for surgery for those who present with different types of classical CAH. Objective: The purpose of the study is to determine whether patients who undergo early or late surgery have better clinical and quality of life outcomes and what factors underlie these differences. Method: A retrospective chart review was conducted of girls under 18 years of age diagnosed with CAH or CAH with salt loss who underwent feminizing genitoplasty surgery at Texas Children’s Hospital (TCH). We collected data including patient demographics, the patient’s age at the time of the initial consult and at the time of surgery, the class of CAH, the grade of virilization; the timing of surgery (early or delayed), the type of surgical treatment, the outcomes, complications, follow-up visits, as well as other factors that influenced the decision-making process regarding the timing of surgery. Results: Analysis of the charts identified 40 girls diagnosed with CAH at TCH between April 2012 and June 2022. The median age at diagnosis was 0.4 months. The three girls were diagnosed with the simple virilizing form of CAH and did not undergo surgery. Thirty-seven girls were diagnosed with the salt-wasting form of CAH, and 29 underwent surgery (78.3%). Of those 29 patients, 15 girls (51.5%) had surgery in the first 12 months of life, 9 (31%) had surgery between 13-24 months, 2 (6.9%) had surgery between 37-48 months, and 3 (10.3%) had surgery > 120 months. Data for Prader staging showed equal proportions of girls who underwent surgery were classified as either Prader stage III (44.8%) or IV (44.8%). No significant differences were found in clinical parameters, complications or compliance. Conclusions: This study provided valuable insights into the management of CAH patients by examining the relationship between the timing of surgery and outcomes. The results can be used to inform data-driven guidelines that will reduce the variability in the current standard of care and improve surgical outcomes for CAH patients. Presentation: 6/1/2024

PURPOSE:Urodynamic testing (UDS) is an important tool in the management of pediatric lower urinary tract conditions. There have been notable efforts to standardize pediatric UDS nomenclature and technique, but no formal guidelines exist on essential elements to include in a clinical report. We sought to identify ideal structure and elements of a pediatric UDS assessment based on expert consensus. MATERIALS AND METHODS:Pediatric urologists regularly performing UDS were queried using a Delphi process. Participants were invited representing varied geographic, experience, and societal involvement. Participants underwent 3 rounds of questionnaires between November 2022 and August 2023 focusing on report organization, elements, definitions, and automated electronic health record clinical decision support. Professional billing requirements were also considered. Consensus was defined as 80% agreeing either in favor of or against a topic. Elements without consensus were discussed in subsequent rounds. RESULTS:A diverse sample of 30 providers, representing 27 institutions across 21 US states; Washington, District of Columbia; and Canada completed the study. Participants reported interpreting an average number of 5 UDS reports per week (range 1-22). The finalized consensus report identifies 93 elements that should be included in a pediatric UDS report based on applicable study conditions and findings. CONCLUSIONS:This consensus report details the key elements and structure agreed upon by an expert panel of pediatric urologists. Further standardization of documentation should aid collaboration and research for patients undergoing UDS. Based on this information, development of a standardized UDS report template using electronic health record implementation principles is underway, which will be openly available for pediatric urologists.

Background: The correlation between sleep apnea syndrome, irritative bladder symptoms and detrusor overactivity (DO) have been well known in adults. Recent literature demonstrated high rates of sleep disordered breathing in myelomeningocele children. We performed an exploratory analysis to examine prevalence of DO and sleep apnea in this population. Methods: A retrospective chart review was performed on children with myelomeningocele with a screening polysomnography from 2005 to 2020. Clinical variables such as demographics, Apnea-Hypopnea Index (AHI), urodynamic fi ndings and urologic use of anticholinergics, were recorded. Results: We identifi ed 26 patients; 15 were male. The median age at time of polysomnography was 1.3 years old. Most were white and non-Hispanic. Average AHI was 5.34. 6 had normal polysomnogra-phies. Of these, 2 (33%) had a urodynamic diagnosis of DO. None were placed on anticholinergics. 20 patients with abnormal polysomnographics had average AHI of 6.76. 11 (55%) had DO on urodynam-ics, and 2 were given anticholinergics. There was no association between diagnoses of sleep disordered breathing and DO (Fishers’s exact test, p=0.64). 12 patients were diagnosed with obstructive sleep apnea or combined obstructive and central sleep apnea; 8 (67%) had a diagnosis of DO. There were four patients who were treated for their sleep apnea and had corresponding pre-treatment and post-treatment

INTRODUCTION:Ureteral obstruction following pediatric kidney transplantation occurs in 5-8% of cases. We describe our experience with percutaneous antegrade ureteroplasty for the treatment of ureteral stricture in pediatric kidney transplant patients. METHODS:We retrospectively reviewed all pediatric kidney transplantation patients who presented with ureteral stricture and underwent percutaneous antegrade ureteroplasty at our institution from July 2009 to July 2021. Variables included patient demographics, timing of presentation, location and extent of stricture, ureteroplasty technique and clinical outcomes. Our primary outcome was persistent obstruction of the kidney transplant. RESULTS:Twelve patients met inclusion criteria (4.2% of all transplants). Median age at time of ureteroplasty was 11.5 years (range: 3-17.5 years). Median time from kidney transplantation to ureteroplasty was 3 months. Patency was maintained in 50% of patients. Seven patients (58.3%) required additional surgery. Four patients developed vesicoureteral reflux. Patients with persistent obstruction had a longer time from transplant to ureteroplasty compared to those who achieved patency (19.3 vs 1.3 months, p = 0.0163). Of those treated within 6 months after transplantation, two patients (25%) required surgery for persistent obstruction (p = 0.06). All patients treated >1 year after transplantation had persistent obstruction following ureteroplasty (p = 0.06). CONCLUSION:Percutaneous antegrade ureteroplasty can be considered a viable minimally invasive treatment option for pediatric patients who develop early ureteral obstruction (<6 months) following kidney transplantation. In patients who are successfully treated with ureteroplasty, 67% can develop vesicoureteral reflux into the transplant kidney. Patients who fail early percutaneous ureteroplasty or develop obstruction >1 year after transplantation are best managed with surgical intervention.

PURPOSE:This study aimed to analyze organ system-based causes and non-organ system-based mechanisms of death (COD, MOD) in people with myelomeningocele (MMC), comparing urological to other COD. METHODS:A retrospective review was performed of 16 institutions in Canada/United States of non-random convenience sample of people with MMC (born > = 1972) using non-parametric statistics. RESULTS:Of 293 deaths (89% shunted hydrocephalus), 12% occurred in infancy, 35% in childhood, and 53% in adulthood (documented COD: 74%). For 261 shunted individuals, leading COD were neurological (21%) and pulmonary (17%), and leading MOD were infections (34%, including shunt infections: 4%) and non-infectious shunt malfunctions (14%). For 32 unshunted individuals, leading COD were pulmonary (34%) and cardiovascular (13%), and leading MOD were infections (38%) and non-infectious pulmonary (16%). COD and MOD varied by shunt status and age (p < = 0.04), not ambulation or birthyear (p > = 0.16). Urology-related deaths (urosepsis, renal failure, hematuria, bladder perforation/cancer: 10%) were more likely in females (p = 0.01), independent of age, shunt, or ambulatory status (p > = 0.40). COD/MOD were independent of bladder augmentation (p = >0.11). Unexplained deaths while asleep (4%) were independent of age, shunt status, and epilepsy (p >= 0.47). CONCLUSION:COD varied by shunt status. Leading MOD were infectious. Urology-related deaths (10%) were independent of shunt status; 26% of COD were unknown. Life-long multidisciplinary care and accurate mortality documentation are needed.

Throughout much of the past decade, there has been controversy as to the impact of a caudal block on the development of complications following hypospadias surgery in children. Collectively, the data sparking this debate allows us to examine some of the critical aspects of study design and statistical analysis and unpack how we arrived at these conclusions. In 2012, Kundra et al. published their prospective cohort which included 53 patients undergoing hypospadias repair with a primary aim of investigating the quality of postoperative analgesia.1 This study was designed to compare the quality and duration of analgesia between caudal and penile blocks following hypospadias repair. The power analysis for this study was performed post hoc and done solely for the primary aim, the difference in opioid consumption. Ironically, when published, the papers' title suggested this study to be one on surgical outcomes based on the type of block used (e.g., penile vs. caudal block).1 The authors reported an incidence of 19.2% with respect to postoperative urethrocutaneous fistula all of which occurred in patients having received a caudal block.1 This outcome was reported despite only having devoted a single sentence detailing the methodology used in evaluating for complications. Moreover, there was a complete lack of justification for the sample size used to assess the strength of association between caudal and penile blocks (e.g., how often does the outcome of interest, in this case a complication occur and how confident can we be that this outcome did not happen due to chance or due to some other factor such as meatal location or surgical skill, etc.). This first study suggesting causation between caudal block and the development of urethrocutaneous fistula following hypospadias surgery invites a multitude of questions. The authors reported incidence of complications at 19.2% is significantly higher when compared to rates reported in other larger cohorts.1 In our recently published study which included 983 patients, we identified the rate of complications in distal hypospadias to be 5.5%.2 Similarly, Braga et al. and Kim et al. report distal complication rates of 4.7% and 6.4%, respectively.3, 4 However, based on the description provided in their discussion, Kundra et al. may have included mid-shaft hypospadias within the distal category.1 Despite this, their reported incidence of complications at 19.2%, exponentially greater than the <10% reported in other much larger series (and mostly between 5% and 7% for distal hypospadias). The most significant issue with the study by Kundra et al. with respect to their reporting of complications lies with their sample size.1 For example, if we consider the incidence of complications to be 7% for penile blocks and contrasted this with the authors 19.2% complication rate for those with caudal blocks, performing a study to investigate the association between block and complications would require 238 patients (119 per group for both caudal and penile blocks). Given the small cohort in the Kundra et al. study, (26 and 27 patients with caudal and penile blocks respectively), the likelihood of not experiencing a complication simply by random chance alone (given a 7% rate of occurrence) is extraordinarily high. Not reported by the Kundra study was the relative risk (RR) of a complication when a caudal block is performed nor the strength of the association (which should be reported with most statistical analyses).5 In performing our meta-analysis on this subject, we calculated the RR and 95% confidence interval (CI) for the Kundra study to be RR 11.41; 95%CI (0.66, 196.5), relating a statistically insignificant association between block type and complication likely attributable to the very small sample size in this study (Figure 1).5 Following this initial paper suggesting a causal relationship between caudal block and complications, Taicher et al. published their institutional data on the association of block type (penile or caudal) and the association with complications following hypospadias surgery.6 They identified 395 patients undergoing hypospadias correction with 326 having distal meatal location and 69 with proximal meatal location. They identified 22 patients (5.6%) to have complications including 9 (2.8%) with distal hypospadias and 13 (18.8%) with proximal hypospadias.6 Their study demonstrates the strongest predictor of complications to be meatal location as proximal. Regarding block type, they report an adjusted odds ratio of 13.4 with a 95% CI of 1.8–101.8 in favor of penile block.6 While this finding would be considered alarming, as noted by Polaner et al., associations of this magnitude are seldom observed in medicine.7 Tellingly, the extreme width of the CI suggests the imprecise nature of the association.7 Considering the overall reduced frequency of complications in distal hypospadias surgery, when compared with proximal hypospadias, once again begs the question of sufficient sample size. In our recently published meta-analysis, after separating the complication rate by meatal location (proximal or distal), we identified the RR to be 15.24 (0.89, 259.69) for distal and RR 4.90 (95% CI: 0.68, 35.21) for proximal meatus defects for patients within the Taicher et al study.6 Overall, there have been several retrospective studies attempting to elucidate an association between caudal blocks and urethrocutaneous fistula following hypospadias correction.1-4, 6, 8-12 In 2019, Tanseco et al. published a meta-analysis summarizing the available data from the nine applicable studies at that time.13 While collectively, they identified an association between caudal block and postoperative complication, subgroup analysis (separating distal and proximal hypospadias) revealed that the severity of the hypospadias (proximal meatal location) may be an important determinant in development of postoperative fistula. In 2021, we published our institutional results including 983 patients representing the outcomes of 14 surgeons.2 Our cohort included 812 patients with distal hypospadias and 171 with proximal and a complication rate of 5.5% and 24%, respectively.2 Multivariable logistic regression showed that proximal hypospadias (OR 3.85, 95% CI 2.32–6.39, p < .001), increased surgical duration (OR 1.02, 95% CI 1.01–1.02, p < .001), and increased age at procedure (OR 1.13, 95% CI 1.05–1.22, p < .001) were significantly associated with postoperative complications.2 However, caudal block was not found to be associated with an increased rate of complications (OR 0.67, 95% CI 0.41–1.09, p .98).2 Similarly, a subset analysis of patients with distal hypospadias (n = 812) did not identify an association between caudal block and postoperative complications of urethrocutaneous fistula or glans dehiscence (OR 1.24, 95% CI 0.57–2.71, p .59).2 With the addition of our cohort and the data from Ngoo et al, we revisited this topic conducting a meta-analysis expanding the total sample to include the addition of 1171 patients representing a weight of 47% of the updated analysis.5, 10 In this meta-analysis, 10 studies were analyzed representing the outcomes from 3201 patients amongst 33 surgeons.5 No association between caudal block and risk of complications was identified (OR 1.11, 95% CI 0.88–1.41, p = .38).5 There was no significant association with development of urethrocutaneous fistulae or glans dehiscence based on meatal location (proximal vs. distal) following primary hypospadias correction with caudal blocks in comparison to the reference group of penile blocks for distal, (RR 1.46, 95% CI (0.98, 2.17); p = .065) and proximal (RR 0.95, 95% CI (0.58, 1.54); p = .823) meatal locations (Figure 2).5 An initial hypothesis presented by Kundra et al was that caudal block resulted in penile vasodilation, altering the tissues planes, and resulting in complications.1 While interesting, neuraxial anesthesia generally does not result in a sympathectomy in young children.14 This was confirmed during a recent ultrasound study which did not identify an association between penile arterial or venous blood flows following a caudal block in children undergoing circumcision.15 Previous studies have reported either combined outcomes for the proximal and distal meatus hypospadias groups and or included “other” complications (e.g., meatal stenosis, hematoma formation or infection). The studies reporting positive association between caudal block and complications reflect the results of a single surgeon and or a small sample size or number of complications as evidenced by their wide CIs. Collectively, the previous eight available studies included the outcomes from 11 surgeons and thus, may not be representative. Therefore, this recent meta-analysis highlights the importance of large sample size studies in addressing questions with numerous confounding variables and variable frequency in the occurrence of the outcome. While this data, sans the study from Kundra, is retrospective, the current sample size using the pooled data is sufficient to address the association between caudal block and postsurgical complications following hypospadias surgery, specifically urethrocutaneous fistula. At this point, in the absence of a very large sample series or the provision of data from a prospective and multicenter study, there is no compelling evidence that caudal block increases the incidence of complication following hypospadias repair. Yet perhaps the most critical learning point highlights the need for attention to study design and underlines the importance of a power analysis to ensure that all aims suggested in a study can be properly interpreted and their findings supported by the data. Adam C. Adler drafted manuscript. Paul F. Austin helped with manuscript preparation. The authors have approved the final manuscript. Dr. Paul F. Austin is a consultant to Allergan and Urovant. Dr. Adam C. Adler has no conflicts of interest to report. There is no data related to this manuscript.

Purpose: OnabotulinumtoxinA is an approved treatment for neurogenic detrusor overactivity in adults inadequately managed with anticholinergics, and more recently was approved in children on the basis of a phase 3, 48-week, single-treatment study (NCT01852045). Given the paucity of long-term pediatric data, we report on the continued safety in these patients after repeated onabotulinumtoxinA treatment. Materials and Methods: This was a multicenter, double-blind, repeat-treatment extension study (NCT01852058) in patients who entered from the preceding single-treatment study. Data were integrated across both studies. All patients (5-17 years) used clean intermittent catheterization and could receive dose escalations based on response to preceding treatment (50 U, 100 U, or 200 U onabotulinumtoxinA [not to exceed 6 U/kg]). Results: Overall, 95, 90, 55, and 11 patients received 1, 2, 3, and 4 treatments with onabotulinumtoxinA, respectively, and median (quartiles) duration of follow-up was 82 (65, 94) weeks. The safety profile was similar across doses and after repeat treatments. The most common treatment-emergent adverse event during cycles 1, 2, and 3 was urinary tract infection (31%, 34%, 22%). Three serious treatment-emergent adverse events related to study treatment (3/95; 3.2%) were reported during the study, which were all cases of urinary tract infection. Annualized urinary tract infection rates post-treatment were similar to pre-screening rates. There were no cases of autonomic dysreflexia, neutralizing antibodies, and treatment-emergent adverse events related to distant spread of toxin. Conclusions: OnabotulinumtoxinA continued to be well tolerated after repeated treatments in pediatric neurogenic detrusor overactivity patients with similar safety profiles across dose groups. Treatment-emergent adverse events were primarily urological with no new safety concerns.

Study Objective: Infants with genital development considered atypical for assigned female sex may undergo feminizing genitoplasty (cli-toroplasty and/or vaginoplasty) in early life. We sought to identify factors associated with parent/caregiver decisions regarding genitoplasty for their children with genital virilization.Design: Longitudinal, observational studySetting: Twelve pediatric centers in the United States with multidisciplinary differences/disorders of sex development clinics, 2015-2020Participants: Children under 2 years old with genital appearance atypical for female sex of rearing and their parents/caregivers Interventions/Outcome Measures: Data on the child's diagnosis and anatomic characteristics before surgery were extracted from the med-ical record. Parents/caregivers completed questionnaires on psychosocial distress, experience of uncertainty, cosmetic appearance of their child's genitalia, and demographic characteristics. Urologists rated cosmetic appearance. For 58 patients from the study cohort with gen-ital virilization being raised as girls or gender-neutral, we compared these data across 3 groups based on the child's subsequent surgical intervention: (i) no surgery ( n = 5), (ii) vaginoplasty without clitoroplasty (V-only) ( n = 15), and (iii) vaginoplasty and clitoroplasty (V + C) ( n = 38).Results: Fathers' and urologists' ratings of genital appearance were more favorable in the no-surgery group than in the V-only and V + C groups. Clitorophallic length was greater in the V + C group compared with the V-only group, with substantial overlap between groups. Mothers' depressive and anxious symptoms were lower in the no-surgery group compared with the V-only and V + C groups.Conclusions: Surgical decisions were associated with fathers' and urologists' ratings of genital appearance, the child's anatomic charac-teristics, and mothers' depressive and anxious symptoms. Further research on surgical decision-making is needed to inform counseling practices.

ABSTRACT: Objective: The impact of parent-reported stigma due to their child's disorder/difference of sex development (DSD) on parent psychosocial adjustment is poorly understood. In other pediatric populations, perceived interference of medical conditions into daily activities (i.e., illness intrusiveness) mediates the relationship of stigma to adjustment. This study assessed relationships between parent-focused and child-focused stigma → illness intrusiveness → depressive and anxious symptoms. Exploratory analyses sought to identify patient characteristics associated with stigma. Method: Caregivers (59 women and 43 men) of 63 children diagnosed with a DSD up to age 4 years completed measures of demographics, parent-focused and child-focused stigma, illness intrusiveness, and depressive and anxious symptoms. Results: Increased parent-focused and child-focused stigma were associated with increased illness intrusiveness, which, in turn, was associated with increased depressive and anxious symptoms for parents nested within dyads. Among children with DSD family histories, parents reported greater child-focused stigma. Conclusion: Parents who experience DSD-related stigma report greater interference of their child's DSD into their daily activities, which is associated with poorer psychosocial adjustment. Findings support developing clinical interventions related to parents' perceptions of stigma and illness intrusiveness to improve parent adjustment.

To examine the association between type of analgesic block and incidence of complications following primary hypospadias correction. Data sources included MEDLINE, Embase, Web of Science and the Cochrane Library, inception-01/2021. Randomized clinical trials, cohort and case control studies reporting original data for patients <18 years of age undergoing primary hypospadias correction with either a penile or caudal block for which outcomes (urethrocutaneous fistula or glans dehiscence) were reported. Two researchers independently extracted data and assessed quality for inclusion. The primary outcome was the incidence of complication within six-months postoperatively based on block performed. Ten studies (3201 patients; range: 54-983) were included. Six studies (cumulative weight 28.6%) favored penile block while 4 studies (cumulative weight 71.4%) favored caudal block. Compared to the reference group of penile blocks, caudal blocks had no significant association with development of complications following primary hypospadias correction (relative risk 1.11, 95% CI (0.88, 1.41); P = .38). When adjusting for meatal location (distal vs proximal) there was no significant association with development of fistulae or glanular dehiscence following primary hypospadias correction with caudal blocks in comparison to the reference group, penile blocks for distal, (relative risk 1.46, 95%CI (0.98, 2.17); P = .065) and proximal (relative risk 0.95, 95% CI (0.58, 1.54); P = .823). The type of analgesic block is not associated with the risk of developing complications following primary hypospadias correction in children. Caudal block should be considered for these urological interventions.

OBJECTIVE To characterize penile arterial and venous blood flow in association with caudal block. METHODS A prospective observational study was conducted in children undergoing primary circumcision at Texas Children's Hospital between September 10, 2020 and November 23, 2021. The penile artery and venous flow velocity were assessed using Doppler ultrasound pre and post caudal block under state-state anesthetic depth. RESULTS Ten healthy patients were included in the study with a mean age and weight of 1.3 years and 10.7 kg, respectively. There was no significant difference in mean penile arterial blood flow velocity 0.18 m/s, (95% confidence interval: -1.55 to 1.92; P = .81) or mean dorsal penile vein flow velocity 0.11 m/s (95% confidence interval: -1.12 to 1.33; P = .84) prior to and following caudal block in our pediatric cohort. there was no correlation in the direction of change between the arterial flow and venous flow from before and after caudal block (R-2 = 0.03). CONCLUSION We did not identify an association between penile arterial or venous blood flow and performance of a caudal block in children undergoing circumcision. (C) 2022 Elsevier Inc.

Purpose: The purpose of this study is to evaluate the relationship of social continence with patient cen-tered outcomes, such as quality of life, in children with sarococcygeal teratoma (SCT). We hypothesize there is a correlation between social continence and patient-centered outcomes. Methods: A chart review and three surveys (Pediatric Quality of Life InventoryTM (PedsQL (TM)), Baylor Continence Scale (BCS), and Impact on Family (IOF)) were performed for SCT patients who underwent resection at our institution from 2013 to 2018. PedsQLT (TM) assesses quality of life, BCS evaluates global continence, and the IOF scale measures the impact of a child's illness on the family. Pearson correlation was used to examine the relationship between BCS, PedsQL (TM), and IOF. Results: Eighteen patients were identified with 72% (13/18) participating in the surveys with a median age at time of survey of 4.7 years (range 2.8-7.9). Patients with Altman IV were diagnosed postnatally and had smaller tumors. At the time of survey administration, a majority of children were toilet trained (54%, 7/13). Parents reported urinary incontinence (46%, 6/13) more frequently than bowel incontinence (15%, 2/13). Altman III/IV trended towards worse PedsQL (TM), BCS, and IOF surveys; however, it was not signifi-cant. The BCS correlated with the Total PedsQL (TM) (rho =-0.56, p = 0.048) and IOF (rho = 0.68, p = 0.011). Conclusion: Children with SCT have a correlation between social continence, quality of life, and the im-pact on family. This study suggests interventions to screen and improve continence in children with SCT could also improve patient centered metrics. Study Design: Cross-sectional study (C) 2022 Elsevier Inc. All rights reserved.

Bladder outlet obstruction (BOO) induces bladder dysfunction and altered bladder architecture. Irrespective of the release of the obstruction, persistent bladder dysfunction severely affects the quality of life. A better understanding of the repair process offers an opportunity to enhance postintervention management. We subsequently evaluated the postobstructive repair process in mice subjected to 24 h BOO followed by release. Male and female mice bladders were obstructed for 24 h by placing a clip around the bladder neck. After the release of obstruction, the mice were studied for 3, 7, and 14 days to observe the bladder repair process over time. Voiding frequency and volume were recorded using the voiding spot assay, and the transcutaneous glomerular filtration rate (tGFR) was measured. Fibrogenesis and associated gene expressions and altered protein levels were evaluated in the bladder using histology, quantatative polymerase chain reaction (qPCR), and Western blot analyses. Bladder wall thickness was increased in both genders over time but occurred later in female mice. Moreover, collagen deposition in the smooth muscle layer increased over time in both genders. Male mice showed a decreased average voided volume at 3 days post release, while female mice showed no significant change during the time course. Fibrosis-related molecular events, including upregulation of fibronectin (FN) protein and Collagen-3 (Col-3) mRNA expression, were transient and normalized again at 14 days in both genders. Transforming growth factor-β (TGF-β) and bone morphogenic protein (BMP)-7 mRNA expressions were upregulated at 14 days post release in both genders. Transcutaneous GFR remained normal during the time course. Release of 24 h BOO initiated a bladder remodeling process. The animal model enables a wide range of experiments to study bladder remodeling, and gender differences offer potential targets for understanding bladder fibrosis and adaptation with BOO.