Objective: Antimicrobial prophylaxis for children with vesicoureteral reflux (VUR) reduces recurrences of urinary tract infection (UTI) but requires daily antimicrobials for extended periods. We used a cost-utility model to evaluate whether the benefits of antimicrobial prophylaxis outweigh its risks and, if so, to investigate whether the benefits and risks vary according to grade of VUR. Methods: We compared the cost per quality-adjusted life-year (QALY) gained in four treatment strategies in children aged <6 years diagnosed with VUR after a first UTI, considering these treatment strategies: (1) prophylaxis for all children with VUR, (2) prophylaxis for children with Grade III or Grade IV VUR, (3) prophylaxis for children with Grade IV VUR, and (4) no prophylaxis. Costs and effectiveness were estimated over the patient's lifetime. We used $100,000/QALY gained as the threshold for considering a treatment strategy cost effective. Results: Based on current data and plausible ranges to account for data uncertainty, prophylaxis of children with Grades IV VUR costs $37,903 per QALY gained. Treating children with Grade III and IV VUR costs an additional $302,024 per QALY gained. Treating children with all grades of VUR costs an additional $339,740 per QALY gained. Conclusions: Treating children with Grades I, II, and III VUR with long-term antimicrobial prophylaxis costs substantially more than interventions typically considered economically reasonable. Prophylaxis in children with Grade IV VUR is cost effective.

OBJECTIVE: One barrier to timely access to outpatient pediatric subspecialty care is the complexity of scheduling processes. We evaluated the impact of implementing electronically transmitted referrals on subspecialty visit attendance. METHODS: Through collaboration with stakeholders, an electronically transmitted referral order system was designed, piloted, and implemented in 15 general pediatrics practices, with 24 additional practices serving as controls. We used statistical process control methods and difference-in-differences analysis to examine visits attended, appointments scheduled, appointment nonattendance, and referral volume. Electronically transmitted referrals then were expanded to all 39 practices. We surveyed referring pediatricians at all practices before and after implementation. RESULTS: From April 2015 through September 2016 there were 33,485 referral orders across all practices (7770 before the pilot, 11,776 during the pilot, 13,939 after full implementation). At pilot practices, there was a significant and sustained improvement in subspecialty visits attended within 4 weeks of referral (10.9% to 20.0%; P<.001). Relative to control practices, pilot practices experienced an 8.6% improvement (P=.001). After implementation at control practices, rates of visits attended also improved but to a smaller degree: 11.8% to 14.7% (P<.001). hi survey responses, referring pediatricians noted improved scheduling processes but had continued concerns with appointment availability and referral tracking. CONCLUSIONS: While electronically transmitted referrals improved visit attendance after pediatric subspecialty referral, the sizable percentage of children without attended visits, the muted effect at control practices, and pediatrician survey responses indicate that additional work is needed to address barriers to pediatric subspecialty care.

We performed a review of the recent literature concerning urinary tract infection (UTI) evaluation and management. In modeling options for management, one overriding conclusion became apparent: in most affected children, the presence of vesicoureteral reflux (VUR) is inconsequential since it has no bearing on optimal management or outcome. In fact, knowing that a child does not have reflux might bias the provider to withhold potentially helpful therapeutic modalities to decrease UTI morbidity, such as antibiotic prophylaxis. In this review, we will propose that evaluation for VUR is not necessary or helpful except in the small subset of children whose UTIs have proven refractory to management of their other risk factors.

This chapter contains sections titled: Introduction Surgical technique Timing of surgery Outcomes Complications Conclusion References

You have accessJournal of UrologyPediatrics: Urinary Tract Infections/Vesicoureteral Reflux1 Apr 2015MP54-18 THE ROLE OF PROPHYLACTIC ANTIBIOTICS AFTER LAPAROSCOPIC PYELOPLASTY WITH URETERAL STENT PLACEMENT IN CHILDREN Matthew Ferroni, Kevin Rycyna, Moira Dwyer, Francis Schneck, Michael Ost, Steven Docimo, Heidi Stephany, and Glenn Cannon Matthew FerroniMatthew Ferroni More articles by this author , Kevin RycynaKevin Rycyna More articles by this author , Moira DwyerMoira Dwyer More articles by this author , Francis SchneckFrancis Schneck More articles by this author , Michael OstMichael Ost More articles by this author , Steven DocimoSteven Docimo More articles by this author , Heidi StephanyHeidi Stephany More articles by this author , and Glenn CannonGlenn Cannon More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2015.02.2041AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Many pediatric urologists routinely prescribe prophylactic antibiotics following laparoscopic pyeloplasty with ureteral stent placement to reduce the risk of urinary tract infections while the stent is in place. We hypothesized that patients discharged without prophylactic antibiotics do not have an increased incidence of postoperative urinary tract infections compared to those discharged with antibiotics. METHODS A retrospective review of all laparoscopic pyeloplasties performed over the last five years at a single institution was conducted. Patients less than 12 months at the time of surgery were excluded. Based on surgeon preference, patients were either discharged home with or without daily prophylactic trimethoprim/sulfamathoxazole (TMP/SMX) continued until three days after ureteral stent removal. The primary outcome was incidence of culture positive urinary tract infection between the two groups, both from the time of discharge to ureteral stent removal and for one week thereafter. RESULTS Of 152 pyeloplasties (92 robotic and 60 pure laparoscpic), 123 patients were discharged on daily TMP/SMX, while 29 patients were discharged without antibiotic prophylaxis. There were no statistically significant differences in mean age (8.5 vs. 10.6 years, p=0.07), percentage of male patients (69% vs. 64%, p=0.63), or history of pre-operative urinary tract infection (3.4% vs. 11.4%, p=0.31) between the two groups. Patients receiving antibiotics had a slightly longer median stent duration (35.5 days vs. 29.5 days, p=0.03). The incidence of culture positive urinary tract infection between the time of discharge and stent removal was 3/123 (2.4%) in the antibiotic group and 1/29 (3.4%) in the group not on prophylaxis (p=0.68). At time of stent removal, peri-operative urine culture was collected 38 times and was positive in 1/18 (5.5%) patients who received prophylactic antibiotics and in 1/20 (5.0%) patients who did not (p=1.0). There were no urinary tract infections occurring within one week of stent removal in either group. CONCLUSIONS The administration of extended prophylactic antibiotics showed no significant impact on the rate of urinary tract infection following laparoscopic pyeloplasty with ureteral stent placement. Furthermore, up to 5.5% of patients may still have asymptomatic bacteriuria at stent removal despite antibiotic prophylaxis. © 2015 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 193Issue 4SApril 2015Page: e671-e672 Advertisement Copyright & Permissions© 2015 by American Urological Association Education and Research, Inc.MetricsAuthor Information Matthew Ferroni More articles by this author Kevin Rycyna More articles by this author Moira Dwyer More articles by this author Francis Schneck More articles by this author Michael Ost More articles by this author Steven Docimo More articles by this author Heidi Stephany More articles by this author Glenn Cannon More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

BACKGROUND: Little generalizable information is available on the outcomes of children diagnosed with bladder and bowel dysfunction (BBD) after a urinary tract infection (UTI). Our objectives were to describe the clinical characteristics of children with BBD and to examine the effects of BBD on patient outcomes in children with and without vesicoureteral reflux (VUR). METHODS: We combined data from 2 longitudinal studies (Randomized Intervention for Children With Vesicoureteral Reflux and Careful Urinary Tract Infection Evaluation) in which children <6 years of age with a first or second UTI were followed for 2 years. We compared outcomes for children with and without BBD, children with and without VUR, and children with VUR randomly assigned to prophylaxis or placebo. The outcomes examined were incidence of recurrent UTIs, renal scarring, surgical intervention, resolution of VUR, and treatment failure. RESULTS: BBD was present at baseline in 54% of the 181 toilet-trained children included; 94% of children with BBD reported daytime wetting, withholding maneuvers, or constipation. In children not on antimicrobial prophylaxis, 51% of those with both BBD and VUR experienced recurrent UTIs, compared with 20% of those with VUR alone, 35% with BBD alone, and 32% with neither BBD nor VUR. BBD was not associated with any of the other outcomes investigated. CONCLUSIONS: Among toilet-trained children, those with both BBD and VUR are at higher risk of developing recurrent UTIs than children with isolated VUR or children with isolated BBD and, accordingly, exhibit the greatest benefit from antimicrobial prophylaxis.

Ureteropelvic junction obstruction (UPJO), defined as the functionally significant impairment of urinary transport from the renal pelvis to the proximal ureter, is the most common cause of hydronephrosis in newborns and young children. Left untreated, this condition may cause progressive dilation of the renal collecting system, with deterioration of renal function and loss of renal unit. UPJO has a diverse presentation, as it may be a primary congenital abnormality diagnosed prenatally, or secondarily acquired, and not apparent until late adolescence or adulthood. This chapter will focus on primary UPJO with review of the current methods of diagnosis and treatment options, as well as the authors’ approach to managing this condition.

You have accessJournal of UrologyPediatrics: Testis, Varicocele & Stones1 Apr 2014MP26-12 RADIATION EXPOSURE IN PEDIATRIC PATIENTS UNDERGOING EVALUATION AND MANAGEMENT OF NEPHROLITHIASIS Benjamin Ristau, Daniel Casella, Omaya Banihani, Janelle Fox, Glenn Cannon, Francis Schneck, Steven Docimo, and Michael Ost Benjamin RistauBenjamin Ristau More articles by this author , Daniel CasellaDaniel Casella More articles by this author , Omaya BanihaniOmaya Banihani More articles by this author , Janelle FoxJanelle Fox More articles by this author , Glenn CannonGlenn Cannon More articles by this author , Francis SchneckFrancis Schneck More articles by this author , Steven DocimoSteven Docimo More articles by this author , and Michael OstMichael Ost More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2014.02.900AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES The incidence of pediatric nephrolithiasis is increasing. Some radiation exposure in children is a necessary consequence. Higher levels of radiation exposure are associated with increasing risk of solid and hematologic malignancies. Thus, it is important for pediatric institutions to assess historical use of radiation in patients with stone disease and develop protocols to minimize future exposure. METHODS We retrospectively identified 151 stone procedures performed on pediatric patients between 2005 and 2012. Procedures were classified as primary ureteroscopy (URS), stent placement prior to ureteroscopy (SURS), percutaneous nephrolithotomy (PCNL) and bilateral ureteroscopy (BLURS). Patient demographic information, stone size, stone location, number of radiographic images, and fluoroscopy times were analyzed. RESULTS 151 stone procedures were included in the final analysis (92 URS, 38 SURS, 8 BLURS and 13 PCNL). Mean patient age at time of stone treatment was 15.94 ±4.1 years. Median fluoroscopy times (IQR) were 109.95 (20.2-199.7), 150.8 (64.06-237.56), 179.6 (124.6-234.6) and 704.69 (299.69-1109.69) seconds for URS, SURS, BLURS and PCNL respectively (Figure 1). There was a weak association between stone and size and fluoroscopy time (r=0.33). PCNL was associated with a significantly higher fluoroscopy time when compared to ureteroscopic procedures (125.24 vs 704.69, P<0.001). Fluoroscopy results in an effective dose of 0.024±0.0019mSv/sec, which translates to an average effective dose 3mSv for ureteroscopic procedures and 16.91mSv for PCNL. Additionally, patients in our cohort underwent an average of 2.9±4.7 CT scans and 7.16±12.7 abdominal x-rays throughout the 7-year study period. No new malignancies were identified during the limited follow-up period. CONCLUSIONS Radiation exposure in pediatric stone patients from diagnostic studies and interventional fluoroscopy is not trivial. Given the recommended maximum effective dose of 5mSv/year for patients under 18; urologists should closely monitor the amount of fluoroscopy used, and consider the potential for radiation exposure when choosing the operative approach. Prospective studies are currently underway to elucidate precise dose measurements and localize sites of radiation exposure in children during stone treatment. © 2014FiguresReferencesRelatedDetails Volume 191Issue 4SApril 2014Page: e255-e256 Advertisement Copyright & Permissions© 2014MetricsAuthor Information Benjamin Ristau More articles by this author Daniel Casella More articles by this author Omaya Banihani More articles by this author Janelle Fox More articles by this author Glenn Cannon More articles by this author Francis Schneck More articles by this author Steven Docimo More articles by this author Michael Ost More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Purpose: Laparoscopic pyeloplasty and open pyeloplasty have comparable efficacy for ureteropelvic junction obstruction in pediatric patients. The role of laparoscopic pyeloplasty in infants is less well defined. We present our updated experience with laparoscopic pyeloplasty in children younger than 1 year.Materials and Methods: We retrospectively reviewed the records of all 29 infants treated with transperitoneal laparoscopic pyeloplasty for symptomatic and/or radiographic ureteropelvic junction obstruction from May 2005 to February 2012. Patients were followed with renal ultrasound at regular intervals. Treatment failure was defined as the inability to complete the intended procedure, persistent radiographic evidence of obstruction and/or the need for definitive adjunctive procedures.Results: Transperitoneal laparoscopic pyeloplasty was performed in 29 infants 2 to 11 months old (mean age 6.0 months) weighing 4.1 to 10.9 kg (mean +/- SD 7.9 +/- 1.6). Followup was available in all except 5 patients (median 13.9 months, IQR 7.7-23.8). Mean operative time was 245 +/- 44 minutes. All cases were completed laparoscopically. Three postoperative complications were reported, including ileus, superficial wound infection and pyelonephritis. Two patients had persistent symptomatic and/or radiographic evidence of obstruction, and required reoperative pyeloplasty. The overall success rate was 92%.Conclusions: Laparoscopic pyeloplasty in infants remains a technically challenging procedure limited to select centers. Our early experience revealed a success rate comparable to that of other treatment modalities with minimal morbidity.

You have accessJournal of UrologyPediatrics: Urinary Tract Infection/Vesicoureteral Reflux1 Apr 2013647 MODELS OF CARE FOR VESICOURETERAL REFLUX WITH AND WITHOUT AN END POINT OF REFLUX RESOLUTION: A COMPUTER COST ANALYSIS Gaayana Raju, Andrew Marks, Ronald Benoit, and Steven Docimo Gaayana RajuGaayana Raju Pittsburgh, PA More articles by this author , Andrew MarksAndrew Marks Madera, CA More articles by this author , Ronald BenoitRonald Benoit Pittsburgh, PA More articles by this author , and Steven DocimoSteven Docimo Pittsburgh, PA More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2013.02.200AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES The purpose of this study was to assess the impact of different management pathways on the cost of managing vesicoureteral reflux (VUR) in girls. METHODS Using standard cost accounting methods, computer modeling was used to compare eight management pathways for VUR in a population of girls presenting with pyelonephritis and VUR. The model was populated with contemporary real costs from the perspective of a Health System. We examined treatment strategies ranging from up front VUR correction to observation, and with five-year endpoints either requiring reflux resolution or years free of pyelonephritis on observation regardless of reflux status. In models including dextranomer/hyaluronic acid injection, we estimated success rates needed for cost equivalence, rather than making assumptions about success rates. We scored each pathway for number of noxious events. RESULTS The most cost efficient treatment pathways are those not requiring resolution of reflux as an endpoint. Generally, models that employed dextronamer/hyaluronic acid injection were less cost effective than traditional management or those employing open surgery for VUR correction, due mostly to cost of the implant material. Noxious events were greatest in models that required multiple studies and/or dextranomer/hyaluronic acid injection. The average per patient number of anesthetics was greatest in those models that required upfront VUR correction. CONCLUSIONS Models that do not insist on reflux resolution are less costly than traditional management. The cost effectiveness of dextranomer/hyaluronic acid injection is limited by high material costs. Cost is one consideraton in the management of patients with VUR; the strategies studied require further clinical validation. Per Patient Cost Of Treating Reflux Based On Grade And Laterality For Each Individual Model model grade I grade II grade III grade IV grade V unilateral bilateral unilateral bilateral unilateral bilateral unilateral bilateral unilateral bilateral 1 $3,125.90 $3,720.41 $4,387.66 $5,003.38 $7,578.32 $8,540.00 $9,414.97 $9,947.05 $10,872.37 $11,491.76 2 $3,159.75 $4,011.06 $4,209.39 $5,222.23 $7,563.57 $9,571.13 $9,783.15 $11,738.54 $11,211.16 $15,269.18 3 $3,280.03 $4,123.30 $4,168.61 $5,202.56 $7,477.57 $9,515.26 $9,637.72 $11,699.32 $13,767.72 $15,727.01 4 $9,495.80 $9.495.78 $9,495.72 $9,495.73 $9,495.73 $9,495.73 $9,495.75 $9,495.74 $9,496.19 $9,495.78 5 $6,446.92 $8,346.35 $6,446.84 $8,346.30 $8,346.30 $10,245.75 $9,295.94 11,195.38 $9,296.37 $13,094.86 6 $6,214.12 $8,188.21 $6,234.49 $8,212.71 $8,259.14 $10,248.06 $9,230.12 $11,400.28 $9,359.13 $13,632.37 7 $2,416.74 $2,659.01 $3,062.93 $3,453.53 $4,942.05 $5,863.33 $6,580.19 $7,154.59 $8,071.49 $8,526.97 8 $2,398.87 $2,639.55 $2,961.85 $3,397.60 $4,846.05 $6,288.52 $6,757.94 $8,199.88 $8,355.09 $11,090.06 © 2013 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 189Issue 4SApril 2013Page: e264-e265 Advertisement Copyright & Permissions© 2013 by American Urological Association Education and Research, Inc.Metrics Author Information Gaayana Raju Pittsburgh, PA More articles by this author Andrew Marks Madera, CA More articles by this author Ronald Benoit Pittsburgh, PA More articles by this author Steven Docimo Pittsburgh, PA More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Computerized physician order entry (CPOE) systems can create unintended consequences. These include medication errors and adverse drug events. We look at a less understood error; patient misidentification. First, two email surveys were used to establish potential risk factors for this error. Next, an automated detection trigger was designed and validated with inpatient medication orders at a large pediatric hospital. The incidence was 0.064% per medication ordered. Finally, a case-control study identified the following as significant risk factors on multivariate analysis: patient age, last name spelling, bed proximity, medical service, time/date of order, and ordering intensity. These results can be used to improve patient safety by increasing awareness of high risk situations and guiding future research.

Variant presentations of cloacal exstrophy are exceedingly rare. Historically, genetic males with cloacal extrophy were re-assigned to the female gender due to phallic inadequacy. Early recognition of intravesical phallic structures in cloacal exstrophy cases may impact gender reassignment discussions and long-term gender outcomes. We report the case of a male infant with cloacal exstrophy presenting with an intravesical phallus, review and compare the presenting anatomical features of the three previously reported cases, and discuss the potential impact of these findings on gender reassignment in these complex children.

Laparoscopy has been utilized in pediatric urology for over 30 years, dating back to Cortesi, who first described using the modality for the evaluation of non-palpable testes [1]. Nevertheless, acceptance of pediatric urologic laparoscopy has generally lagged behind when compared to its adult counterpart, in large part due to the nature of the practice of pediatric urology [2]. Fortunately, there has been a shift in the paradigm. Pediatric laparoscopy has recently benefited from improvement in equipment and technology, as well as an increase in experienced laparoscopic surgeons entering the field. The techniques that were developed in adults have been refined for the pediatric population, allowing for the expansion of the technique from diagnostic procedures to complex reconstructive surgeries.

Purpose: Undescended testicle after groin surgery is a condition traditionally approached through an inguinal incision with en bloc mobilization of the spermatic cord and external oblique fascia, and extensive dissection of the proximal spermatic vessels. We report on a single surgeon series of orchiopexies after prior inguinal surgery approached through a single scrotal incision.Materials and Methods: From November 2001 to February 2007, 24 patients with a mean age of 6.4 years (range 1.3 to 16.2) presented with 27 undescended testicles. All patients had undergone previous groin surgery including 13 inguinal hernia repairs, 3 orchiopexies and 3 hernia repairs with orchiopexy. Of the 27 testicles 24 (21 patients) were successfully approached through a single scrotal incision (89%). If the scrotum could not be manipulated over or near the relatively fixed testicle, an inguinal incision was made (11%). Charts were retrospectively reviewed for technique and operative outcomes.Results: A mean followup of 12 months was available for 20 of 21 patients. A patent processus vaginalis was found in 3 (12.5%) patients and hernia repair was performed through the scrotal incision in these patients. There were no intraoperative complications. In 1 (4.2%) patient the testicular position was unacceptable and subsequently successful repeat scrotal orchiopexy was performed. At last followup all testes were in a satisfactory scrotal position without hydrocele, hernia or testicular atrophy.Conclusions: The majority of orchiopexies after prior inguinal surgery can be approached through a single scrotal incision. Retrograde serial dissection of adhesions to the distal cord usually reveals adequate vessel length, thus avoiding extensive inguinal and/or retroperitoneal dissection.

PURPOSE:To examine our experience of laparoscopic pyeloplasty for the treatment of ureteropelvic junction obstruction (UPJO) in the pediatric population.METHODS:From November 2001 to June 2009, 112 patients underwent transperitoneal laparoscopic pyeloplasty for the treatment of symptomatic or radiographic UPJO. Data were collected retrospectively. Patients were followed at regular intervals with imaging and symptom assessment. Failure was defined as inability to complete the intended procedure, persistent flank pain, radiographic evidence of obstruction, or the need for definitive adjunctive procedures.RESULTS:Mean patient age was 9.4 years (0.2-20.5 years), and follow-up was available on all 112 patients with a mean duration of 15.3 months (0.6-84.5 months). There was one open conversion in the series. Mean operative time was 254 minutes (102-525 minutes). There was one minor intraoperative complication reported (0.8%). There were 12 (10.8%) postoperative complications; most were relatively minor with complete resolution and without long-term sequelae. Postoperative ultrasonography has been performed in 102 patients, with 99 (97%) patients demonstrating improvement of the UPJO. Three patients (3%) continued to have symptomatic and/or radiographic evidence of obstruction that necessitated the need for adjunctive procedures, which included laser endopyelotomy in 2 patients, and a re-do open pyeloplasty in 1 patient. Of those cases that were completed laparoscopicaly, the overall success rate was 97.2%.CONCLUSIONS:Laparoscopic pyeloplasty for UPJO in the pediatric population is technically challenging; however, with experience, one can expect excellent success rates comparable to open pyeloplasty, with minor complications with reasonable operative times.