The Management of the Pediatric Neurogenic Bladder.

Neurogenic bladder is a heterogeneous entity that may result from a variety of conditions affecting the central or peripheral nervous systems. Regardless of etiology, the overall goals of management are primarily twofold. As a neurogenic bladder may affect the ability to store urine safely and to empty the bladder efficiently, early management is focused on optimization of bladder storage function to prevent irreversible injury to either the upper or lower urinary tracts. In older children, this goal is added to the challenge of maximizing quality of life through achievement of urinary continence and independence in bladder management that continues into the transition to adulthood. In this review, we seek to bring the reader up-to-date regarding management of the pediatric neurogenic bladder with a focus on literature published in the past year. We discuss key contributions related to fetal intervention for myelomeningocele, monitoring and medical management of the neurogenic bladder and prediction of postoperative outcomes. Put together, these studies highlight the continued need for further research to improve evidence-based medical and surgical decision-making strategies for children affected by neurogenic bladder

Congenital adrenal hyperplasia: current surgical management at academic medical centers in the United States.

PurposeControversy exists on the necessity for and timing of genitoplasty in girls with congenital adrenal hyperplasia. Our knowledge of surgical preferences is limited to retrospective series from single institutions and physician surveys, which suggest a high rate of early reconstruction. We evaluated current surgical treatment for congenital adrenal hyperplasia at academic centers.Materials and methodsWe queried the Faculty Practice Solutions Center database to identify all female patients younger than 18 years with a diagnosis of congenital adrenal hyperplasia between 2009 and 2012. Procedures were identified by CPT codes for vaginoplasty, clitoroplasty and other genital procedures. Reconstruction type, age at surgery and surgeon volume were analyzed.ResultsWe identified 2,614 females in the database with a diagnosis of congenital adrenal hyperplasia who were seen at a total of 60 institutions. Of infants younger than 12 months between 2009 and 2011 as few as 18% proceeded to surgery within a 1 to 4-year followup. Of those referred to a pediatric urologist 46% proceeded to surgery. Of patients who underwent surgery before age 2 years clitoroplasty and vaginoplasty were performed in 73% and 89%, respectively, while 68% were treated with a combined procedure. A medium or high volume surgeon was involved in 63% of cases.ConclusionsMany patients with congenital adrenal hyperplasia in the database did not proceed to early reconstructive surgery. Of those referred to surgeons, who were possibly the most virilized patients, about half proceeded to early surgery and almost all underwent vaginoplasty as a component of surgery. About two-thirds of the procedures were performed by medium or high volume surgeons, indicative of the surgical centralization of disorders of sexual development

Urinary diversion during and after pediatric pyeloplasty: a population based analysis of more than 2,000 patients.

PurposeWe evaluated the use and efficacy of intraoperative urinary diversion with ureteral stent or nephrostomy tube during pyeloplasty in children.Materials and methodsThe Faculty Practice Solutions Center® national billing database was queried to identify all pediatric pyeloplasties performed from 2009 to 2012. Patient variables, surgical approach, use of intraoperative stent/nephrostomy tube and return for postoperative stent/nephrostomy tube or second pyeloplasty were obtained.ResultsA total of 2,435 children underwent open (1,792) or laparoscopic/robotic (643) pyeloplasty, with intraoperative urinary diversion rates of 45% and 83%, respectively. Comparing patients with and without an intraoperative stent/nephrostomy tube, 5.6% and 7.4%, respectively, returned to the hospital for urinary diversion. Multivariable analysis revealed no association with surgical approach, but higher surgeon volume (p <0.01) and use of an intraoperative stent/nephrostomy tube (p <0.01) were associated with decreased odds of requiring postoperative urinary diversion. Second pyeloplasty rate was 3.8% and was not associated with surgical approach or use of intraoperative stent/nephrostomy tube.ConclusionsIntraoperative stent/nephrostomy tube use and increased surgeon volume were each independently associated with a significant but small decrease in risk of postoperative stent/nephrostomy tube placement. Use of an intraoperative stent/nephrostomy tube was not associated with rate of second (redo ipsilateral or contralateral metachronous) pyeloplasty

Meatal stenosis: a retrospective analysis of over 4000 patients.

The literature on treatment of meatal stenosis is limited to single center series. Controversy exists regarding choice of meatotomy versus meatoplasty and need for general anesthesia. Our objective was to analyze treatment efficacy, current practice patterns and utilization of anesthesia. We hypothesized that meatoplasty would be associated with a lower re-operative rate.We used a hospital consortium database to identify children who were diagnosed with meatal stenosis between January 1, 2009 and December 31, 2012. Both univariate and multivariate analyses were completed to evaluate correlations between patient, surgeon and hospital characteristics and type of procedure. The propensity of surgeons to operate with or without general anesthesia was analyzed.We identified 4373 male patients with a diagnosis of meatal stenosis treated by 123 surgeons. Fifty-percent of boys had procedural intervention during the 4-year period. Median follow-up was 25 and 22 months after meatotomy and meatoplasty, respectively. There was a re-operative rate of 3.5% and 0.2% for office meatotomy versus meatoplasty with general anesthesia. Multivariate analysis demonstrated that being White and living in the Northeast independently increased odds of intervention. Half of the surgeons treated meatal stenosis exclusively under general anesthesia.This study is limited by an inability to determine recurrence rates. Only patients having secondary surgery at the same institution within the time period captured by the database (6 months-4 years) could be identified. As such, the true recurrence of meatal stenosis is likely higher. Although the re-operative rate is not equivalent to the recurrence rate, the two are correlated. Likewise, the surgeon's propensity to operate could be biased by their propensity to diagnosis meatal stenosis and this could affect the rates cited. In addition to the cost benefit achieved with avoidance of general anesthesia (estimated to be a 10-fold cost reduction, the 2012 Consensus Statement of the International Anesthesia Research Society has highlighted that there is increasing evidence from research studies suggesting the benefits of general anesthesia should be considered in the context of its possible harmful effects. Although this study and others have highlighted that in-office procedures are a viable alternative to meatoplasty with general anesthesia, there are multiple factors in being able to perform an office meatotomy. Arguably, the two most important are the patient's ability to cooperate and his anatomy.The large sample size, over 4000 patients, allowed us to show that the hypothesis, that meatoplasty would be associated with a lower re-operative rate (0.2%), is true. With a low re-operative rate (3.5%), office meatotomy is a reasonable choice of surgical treatment if the child can cooperate and the anatomy is appropriate. On the other hand, if general anesthesia is utilized, formal meatoplasty is associated with a lower re-operative rate

Outcomes after pediatric open, laparoscopic, and robotic pyeloplasty at academic institutions

IntroductionPatient age and hospital volume have been shown to affect perioperative outcomes after pediatric pyeloplasty. However, there are few multicenter studies that focus on outcomes at teaching hospitals, where many of the operations are performed.ObjectiveThe goal was to determine if surgical approach, age, case volume, or other factors influence perioperative outcomes in a large contemporary cohort.Study designUsing the clinical database/resource manager (CDB/RM) of the University Health-System Consortium (UHC), children who underwent open, laparoscopic, or robotic pyeloplasty from 2011 to 2014 were identified at 102 academic institutions. Surgery type, age, race, gender, insurance type, geographic region, comorbidities, surgeon volume, and hospital volume were measured. Multivariable mixed-effects logistic regression analysis was used to analyze independent variables associated with complication rates, length of stay (LOS), readmission rates, and ICU admission.ResultsA total of 2219 patients were identified. Complication rates were 2.1%, 2.2%, and 3% after open, laparoscopic, and robotic pyeloplasty, respectively. Approximately 12% of patients had underlying comorbidities. Comorbidities were associated with 3.1 times increased odds for complication (p = 0.001) and a 35% longer length of stay (p < 0.001). Age, gender, insurance type, and hospital volume had no effect on complication rates. A trend was seen towards a lower rate of complications with higher surgeon volume (p = 0.08). The mean LOS was 2.0 days in the open pyeloplasty group, 2.4 days in the laparoscopic group and 1.8 days in the robotic group. Patients who underwent robotic surgery had an estimated LOS 11% shorter than those after open surgery (p = 0.03) (Table). Patients aged 5 years and under who had robotic surgery had an estimated LOS 14% shorter than those after open surgery (p = 0.06). ICU admission and hospital readmission were not associated with any variables.DiscussionThe study is limited by the accuracy of the data submitted by the hospitals and is subject to coding error. Complication rates remain low in all three approaches, validating their safety. Patients, including younger patients, had shorter lengths of stay after robotic surgery. The statistically significant differences between approaches were small so clinically there may not be a difference.ConclusionsThis large multicenter analysis demonstrates that patient comorbidity had the greatest impact upon complication rates and length of stay. Previous work showed that the benefits of laparoscopy were limited to older children. However, this large multicenter study suggests that these benefits now extend to young children with the application of robotics

De novo testicular tissue generation from non-testicular cell lines, biologic and synthetic scaffolds: Current findings and future translational applications.

In recent decades, reproductive science has revolutionized the options for biological parenthood for the 20-50% of infertility cases affected by male factors. However, current solutions exclude those who are infertile due to absent testicular tissue. This includes anorchic 46, XY individuals due to trauma or congenital factors and transgender men with a 46, XX genotype. There is a clinical need for methods to restore testicular function independent of pre-existing testicular tissue. This mini-review analyzes studies that have applied non-testicular cell lines to generate germline and non-germline testicular parenchymal components. While only 46, XY cell lines have been evaluated in this context to date, the potential for future application of cell lines from 46, XX individuals is also included. Additionally, the role of varied culture methods, media supplementation, and biologic and synthetic scaffolds to further support testicular parenchyma generation are critiqued. De novo testicular tissue generation in this manner will require a focus on both cellular and environmental aspects of tissue engineering. Put together, these studies highlight the future potential for expanded clinical, reproductive, and endocrine management options for individuals who are currently excluded from aspects of biologic reproduction most consistent with their gender identity and reproductive preferences

Meatal stenosis: a retrospective analysis of over 4000 patients.

The literature on treatment of meatal stenosis is limited to single center series. Controversy exists regarding choice of meatotomy versus meatoplasty and need for general anesthesia. Our objective was to analyze treatment efficacy, current practice patterns and utilization of anesthesia. We hypothesized that meatoplasty would be associated with a lower re-operative rate.We used a hospital consortium database to identify children who were diagnosed with meatal stenosis between January 1, 2009 and December 31, 2012. Both univariate and multivariate analyses were completed to evaluate correlations between patient, surgeon and hospital characteristics and type of procedure. The propensity of surgeons to operate with or without general anesthesia was analyzed.We identified 4373 male patients with a diagnosis of meatal stenosis treated by 123 surgeons. Fifty-percent of boys had procedural intervention during the 4-year period. Median follow-up was 25 and 22 months after meatotomy and meatoplasty, respectively. There was a re-operative rate of 3.5% and 0.2% for office meatotomy versus meatoplasty with general anesthesia. Multivariate analysis demonstrated that being White and living in the Northeast independently increased odds of intervention. Half of the surgeons treated meatal stenosis exclusively under general anesthesia.This study is limited by an inability to determine recurrence rates. Only patients having secondary surgery at the same institution within the time period captured by the database (6 months-4 years) could be identified. As such, the true recurrence of meatal stenosis is likely higher. Although the re-operative rate is not equivalent to the recurrence rate, the two are correlated. Likewise, the surgeon's propensity to operate could be biased by their propensity to diagnosis meatal stenosis and this could affect the rates cited. In addition to the cost benefit achieved with avoidance of general anesthesia (estimated to be a 10-fold cost reduction, the 2012 Consensus Statement of the International Anesthesia Research Society has highlighted that there is increasing evidence from research studies suggesting the benefits of general anesthesia should be considered in the context of its possible harmful effects. Although this study and others have highlighted that in-office procedures are a viable alternative to meatoplasty with general anesthesia, there are multiple factors in being able to perform an office meatotomy. Arguably, the two most important are the patient's ability to cooperate and his anatomy.The large sample size, over 4000 patients, allowed us to show that the hypothesis, that meatoplasty would be associated with a lower re-operative rate (0.2%), is true. With a low re-operative rate (3.5%), office meatotomy is a reasonable choice of surgical treatment if the child can cooperate and the anatomy is appropriate. On the other hand, if general anesthesia is utilized, formal meatoplasty is associated with a lower re-operative rate