Neuroblastoma in a Newborn Female

Neuroblastoma is the most common solid tumor in neonates. Although often aggressive in older children, carrying high mortality rates despite multimodal therapies, neuroblastoma appears to behave differently in the neonatal population. When diagnosis is clear, the disease can often be managed with close observation alone. This is a case of neuroblastoma in a 4-day-old female managed with surgical resection. This case highlights the potential challenges of diagnosis of retroperitoneal masses on prenatal ultrasound and in newborns and the importance of utilizing available resources when making difficult decisions in management.

Critical elements of pediatric testicular germ cell tumors surgery

Children, adolescents and young adults with testicular germ cell tumors require appropriate surgical care to insure excellent outcomes. This article presents the most critical elements, and their basis in evidence, for surgery in this population. Specifically, the importance of inguinal radical orchiectomy for malignant tumors, partial orchiectomy for prepubertal tumors and normal serum tumor markers, and the appropriate use of post-chemotherapy retroperitoneal lymph node dissection in those with residual retroperitoneal masses.

Critical elements of radical nephroureterectomy for pediatric unilateral renal tumor

Children with renal masses require surgical management to provide accurate surgical staging and skilled resection of the tumor. This document includes evidence-based recommendations for pediatric surgeons regarding the resection, staging, and proper nodal basin evaluation.

Wilms Tumor

Wilms tumor (WT), or nephroblastoma, is the most common primary malignant renal tumor of childhood. It is an embryonal tumor that develops from remnants of immature kidney. There are approximately 500 new WT cases diagnosed in the United States every year. Advances in multimodal therapy including surgery, chemotherapy, and radiation therapy given according to risk stratification have allowed most patients to achieve survival rates in excess of 90%.

"Exogenous" 5 Alpha Reductase Deficiency: A Case Report

Testosterone and dihydrotestosterone are significant drivers of male external genital development, and therefore teratogens that alter these hormone profiles have been hypothesized to cause aberrations in development. Here, we present the first case report of genitalia anomalies after prenatal exposure to spironolactone and dutasteride through 8-weeks of gestation. The patient was born with abnormal male external genitalia which was surgically managed. Long-term outcomes such as gender identity, sexual function, hormonal maturation through puberty, and fertility remain unknown. These numerous considerations necessitate multi-disciplinary management with close follow-up to address sexual, psychological, and anatomic concerns.

Bilateral Wilms Tumor in CLOVES Syndrome

Wilms tumor is the most common pediatric renal mass and occurs in up to 10% of predisposition syndromes. One such syndrome is CLOVES syndrome, an extremely rare disorder within the umbrella of PIK3CA-related overgrowth spectrum disorders. This case presents the management of a bilateral Wilms tumor in a patient with CLOVES syndrome and highlights the many intricacies in caring for complex oncology patients. Particularly highlighted in this case is the delicate line in balancing the risks of treatment-related morbidity against the risks of recurrence in predisposed patients, while still abiding by established treatment guidelines.

Identifying variability in surgical practices and instrumentation for hypospadias repair across the Western Pediatric Urology Consortium (WPUC) network

BACKGROUND

Although hypospadias outcomes studies typically report a level or type of repair performed, these studies often lack applicability to each surgical practice due to technical variability that is not fully delineated. An example is the tubularized incised plate (TIP) urethroplasty procedure, for which modifications have been associated with significantly decreased complication rates in single center series. However, many studies fail to report specificity in techniques utilized, thereby limiting comparison between series.

OBJECTIVE

With the goal of developing a surgical atlas of hypospadias repair techniques, this study examined 1) current techniques used by surgeons in our network for recording operative notes and 2) operative technical details by surgeon for two common procedures, tubularized incised plate (TIP) distal and proximal hypospadias repairs across a multi-institutional surgical network.

STUDY DESIGN

A two-part study was completed. First, a survey was distributed to the network to assess surgeon volume and methods of recording hypospadias repair operative notes. Subsequently, an operative template or a representative de-identified operative note describing a TIP and/or proximal repair with urethroplasty was obtained from participating surgeons. Each was analyzed by at least two individuals for natural language that signified specified portions of the procedure. Procedural details from each note were tabulated and confirmed with each surgeon, clarifying that the recorded findings reflected their current practice techniques and instrumentation.

RESULTS

Twenty-five surgeons from 12 institutions completed the survey. The number of primary distal hypospadias repairs performed per surgeon in the past year ranged from 1-10 to >50, with 40% performing 1-20. Primary proximal hypospadias repairs performed in the past year ranged from 1-30, with 60% performing 1-10. 96% of surgeons maintain operative notes within an electronic health record. Of these, 66.7% edited a template as their primary method of note entry; 76.5% of these surgeons reported that the template captures their operative techniques very or moderately well. Operative notes or templates from 16 surgeons at 10 institutions were analyzed. In 7 proximal and 14 distal repairs, parameters for chordee correction, urethroplasty suture selection and technique, tissue utilized, and catheter selection varied widely across surgeons.

CONCLUSION

Wide variability in technical surgical details of categorically similar hypospadias repairs was demonstrated across a large surgical network. Surgeon-specific modifications of commonly described procedures are common, and further evaluation of short- and long-term outcomes accounting for these technical variations is needed to determine their relative influence.

Gonadal tumors in a contemporary cohort of patients with differences in sex development undergoing surgery - A multi-site study from the Pediatric Urologic Oncology Working Group of the societies for pediatric urology

BACKGROUND

Disturbances in gonadal development lead to increased risk of gonadal malignancy in some but not all patients with differences in sex development (DSD). However, the natural history of these tumors is poorly described, and the literature remains sparse.

OBJECTIVE

The objective of this study was to describe the incidence of germ cell neoplasia in situ (GCNIS) and germ cell tumor (GCT) in a contemporary cohort of patients with DSD undergoing surgery and to provide long-term oncologic outcomes for these patients.

STUDY DESIGN

Patients with DSD who have undergone gonadectomy or gonadal biopsy were identified at four institutions. Clinical characteristics, pathology, and treatment details were obtained retrospectively. Patients were stratified into risk categories based on DSD diagnosis. Oncologic treatment and outcomes were recorded. Descriptive statistics are reported using parametric methods.

RESULTS

83 patients were identified. Distribution of diagnoses is summarized in the summary table. 14 (16.9%) patients underwent gonadal biopsy, and 71 (85.5%) patients underwent gonadectomy (50/71 gonadectomies were bilateral). 8/83 (9.6%) patients had GCNIS or GCT (7 GCNIS, 1 GCT). Median age at surgery was 2.95 years (y) (interquartile range [IQR] 0.6-12.2) and 14y (IQR 0.85-16.9) in patients without and with GCNIS/GCT, respectively. All 8 patients with GCNIS/GCT had high or intermediate risk DSD diagnoses (4 mixed gonadal dysgenesis, 3 Turner with Y, 1 partial gonadal dysgenesis). Of the patients with high-risk diagnoses, 8/54 (15%) had GCNIS/GCT. No patient received adjuvant therapy, no patient had a recurrence, and all patients were living with mean follow up 6.4y.

DISCUSSION

The risk of gonadal malignancy is heterogeneous in the DSD population and can vary based on DSD diagnosis as well as maturation, testicularization, and location of the gonads. The most recent consensus recommendations on gonadal management emphasize risk stratification and consideration of gonadal surveillance based on gender of rearing, but supporting literature remains sparse. In this contemporary cohort of DSD patients who underwent gonadal surgery, most patients did not have evidence of adverse pathology, all patients with malignant or premalignant pathology had a high/intermediate risk DSD diagnosis, and all patients with GCNIS/GCT were treated with surgery alone without recurrence.

CONCLUSIONS

The distribution of patients with premalignant and malignant gonadal pathology and DSD in this cohort aligns with prior literature, and oncologic outcomes were excellent. These data add valuable information to the current literature and highlight the necessity to develop appropriate screening regimens for retained gonads.

Pediatric Small Renal Masses: Can Tumor Size Predict Histology and the Potential for Nephron-sparing Surgery?

PURPOSE

The majority of children with unilateral renal masses suspicious for malignancy undergo radical nephrectomy, while nephron-sparing surgery is reserved for select cases. We investigated the impact of tumor size on the probability of histology. We hypothesized that pediatric small renal masses are more likely benign or non-Wilms tumor, thus potentially appropriate for nephron-sparing surgery.

MATERIALS AND METHODS

The SEER (Surveillance, Epidemiology, and End Results) database was analyzed for patients aged 0-18 years diagnosed with a unilateral renal mass from 2000-2016. Statistical analysis was performed to help determine a tumor size cut point to predict Wilms tumor and assess the predictive value of tumor size on Wilms tumor histology. Additionally, a retrospective review was performed of patients 0-18 years old who underwent surgery for a unilateral renal mass at a single institution from 2005-2019. Statistical analysis was performed to assess the predictive value of tumor size on final histology.

RESULTS

From the SEER analysis, 2,016 patients were included. A total of 1,672 tumors (82.9%) were Wilms tumor. Analysis revealed 4 cm to be a suitable cut point to distinguish non-Wilms tumor. Tumors ≥4 cm were more likely Wilms tumor (OR 2.67, P ≤ .001), but this was driven by the statistical significance in children 5-9 years old. From the institutional analysis, 134 patients were included. Ninety-seven tumors (72.3%) were Wilms tumor. Tumors ≥4 cm had higher odds of being Wilms tumor (OR 30.85, P = .001), malignant (OR 6.75, P = .005), and having radical nephrectomy-appropriate histology (OR 46.79, P < .001).

CONCLUSIONS

The probability that a pediatric unilateral renal mass is Wilms tumor increases with tumor size. Four centimeters is a logical cut point to start the conversation around defining pediatric small renal masses and may help predict nephron-sparing surgery-appropriate histology.

Unusual Renal Mass in a Pediatric Patient

Renal cell carcinoma (RCC) is rare in the pediatric population, comprising about 5% of renal neoplasms in children.¹ Out of all childhood cases of RCC, translocation RCCs (tRCC) is the most common.² It is well described in the literature that exposure to alkylating agents such as cyclophosphamide and/or topoisomerase II inhibitors such as doxorubicin and etoposide, is a risk factor for the development of Xp11 (or TFE3) tRCC.³ Herein is a case of tRCC development in a patient with history of exposure to topoisomerase II inhibitors and alkylating agents to treat a common childhood malignancy.

Validation of the modified Bosniak classification system to risk stratify pediatric cystic renal masses: An international, multi-site study from the pediatric urologic oncology working group of the societies for pediatric urology

BACKGROUND

Pediatric cystic renal lesions are challenging to manage as little is known about their natural course. A modified Bosniak (mBosniak) classification system has been proposed for risk stratification in pediatric patients that takes ultrasound (US) and/or computed tomogram (CT) characteristics into account. However, literature validating this system remains limited.

OBJECTIVE

To determine if the mBosniak classification system correlates with pathologic diagnoses. The hypothesis is that mBosniak classification can stratify the risk of malignancy in children with renal cysts.

STUDY DESIGN

Patients treated for cystic renal masses with available imaging and pathology between 2000 and 2019 from five institutions were identified. Clinical characteristics and pathology were obtained retrospectively. Characteristics from the most recent US, CT, and/or magnetic resonance imaging (MRI) were recorded. Reviewers assigned a mBosniak classification to each scan. mBosniak scores 1/2 were considered low-risk and 3/4 high-risk. These groups were compared with pathology (classified as benign, intermediate, malignant). Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), positive likelihood ratio (+LR), and negative likelihood ratio (-LR) were calculated to assess this categorization as a screening tool to guide surgical intervention. Agreement between imaging modalities was also explored.

RESULTS

99 patients were identified. High-risk imaging findings were correlated with malignant or intermediate pathology with a sensitivity of 88.3%, specificity of 84.6%, PPV of 89.8%, NPV of 82.5%, +LR of 5.7, and -LR of 0.14. The sensitivity for detecting malignant lesions only was 100%. There was substantial agreement between US/CT (n = 55; κ = 0.66) and moderate agreement between US/MRI (n = 20; κ = 0.52) and CT/MRI (n = 13; κ = 0.47).

DISCUSSION

The mBos classification system is a useful tool in predicting the likelihood of benign vs. intermediate or malignant pathology. The relatively high sensitivity and specificity of the system for prediction of high-risk lesions makes this classification applicable to clinical decision making. In addition, all malignant lesions were accurately identified as mBosniak 4 on imaging. This study adds substantial data to the relatively small body of literature validating the mBosniak system for risk stratifying pediatric cystic renal lesions.

CONCLUSIONS

Pediatric cystic renal lesions assigned mBosniak class 1/2 are mostly benign, whereas class 3/4 lesions are likely intermediate or malignant pathology. We observed that the mBosniak system correctly identified pathology appropriate for surgical management in 88% of cases and did not miss malignant pathologies. There is substantial agreement between CT and US scans concerning mBos classification.

White paper: Onco-fertility in pediatric patients with Wilms tumor

The survival of childhood Wilms tumor is currently around 90%, with many survivors reaching reproductive age. Chemotherapy and radiotherapy are established risk factors for gonadal damage and are used in both COG and SIOP Wilms tumor treatment protocols. The risk of infertility in Wilms tumor patients is low but increases with intensification of treatment including the use of alkylating agents, whole abdominal radiation or radiotherapy to the pelvis. Both COG and SIOP protocols aim to limit the use of gonadotoxic treatment, but unfortunately this cannot be avoided in all patients. Infertility is considered one of the most important late effects of childhood cancer treatment by patients and their families. Thus, timely discussion of gonadal damage risk and fertility preservation options is important. Additionally, irrespective of the choice for preservation, consultation with a fertility preservation (FP) team is associated with decreased patient and family regret and better quality of life. Current guidelines recommend early discussion of the impact of therapy on potential fertility. Since most patients with Wilms tumors are prepubertal, potential FP methods for this group are still considered experimental. There are no proven methods for FP for prepubertal males (testicular biopsy for cryopreservation is experimental), and there is just a single option for prepubertal females (ovarian tissue cryopreservation), posing both technical and ethical challenges. Identification of genetic markers of susceptibility to gonadotoxic therapy may help to stratify patient risk of gonadal damage and identify patients most likely to benefit from FP methods.

Recurrence rates after surgical management of labial adhesions

INTRODUCTION

Labial adhesions (LA) involves fusion of the labia minora in the midline. LA can range from involving just a small portion of the labia minora or the entire length, covering the urethra and vaginal opening. Treatment for labial adhesions includes the use of topical creams, manual lysis or surgical separation. The recurrence rate has been reported as 55%, 33% and 0% respectively. Only one study with a cohort of 9 patients examines recurrence rates after surgical release (0%).

OBJECTIVE

To verify the previous findings that surgical repair has low recurrence rate. We hypothesize the recurrence rate of LA after surgical repair to be lower than more conservative methods but that the recurrence rate is not 0%.

STUDY DESIGN

A retrospective review was performed of consecutive cases of LA that were treated surgically from August 2018 to October 2020. The surgical technique used involved opening the LA bluntly then oversewing each labia with fine absorbable suture. All patients were scheduled for clinic or telephone follow up 3 months postoperatively. Patient demographics, indication for procedure, history of prior treatment, operative time, complications, recurrence and length of follow up were recorded and are described using non-parametric methods.

RESULTS

Thirty-two female patients underwent surgical treatment of LA using the above-described technique. Median age at surgery was 3.7 y (IQR 2.7-5.3). Most patients (78.1%) had failed prior initial treatment, most commonly topical estrogen creams. Median follow up was 4.3 mos with 10 patients being lost to follow up. Only 2 patients experienced a recurrence at a median of 3.5 months.

CONCLUSIONS

This series verifies prior findings that, in the short-term, surgical repair has a lower recurrence rate than topical treatment or manual lysis. However, the recurrence rate is 9%, higher than previously reported. Further studies into longer-term follow up are underway.

Enhanced recovery after surgery and anesthetic outcomes in pediatric reconstructive urologic surgery

PURPOSE

Enhanced recovery after surgery (ERAS) is a perioperative management strategy to hasten postoperative recovery. We examined the effects of a pilot implementation of ERAS for pediatric patients on anesthetic outcomes.

METHODS

We performed a prospective case-control study utilizing an ERAS protocol in patients aged < 18 years undergoing urologic reconstruction that included a bowel anastomosis. Protocol elements included: multimodal analgesia, opioid minimization, and routine nausea/vomiting prophylaxis. ERAS patients were propensity-matched with historical controls. Outcomes of interest included maximum PACU pain score, time to first opioid, opioid-free days, and need for opioids on day of discharge.

RESULTS

A total of 13 ERAS patients and 26 historical controls were included, with median ages 9.9 years (IQR 9.1-11) and 10.4 years (IQR 8.0-12.4), respectively. ERAS increased the percentage of patients who did not receive any intraoperative or postoperative opioids (0% vs 15%, p = 0.046 for both) and reduced maximum PACU pain score (3 vs 0, p < 0.001). The use of postoperative supplemental oxygen was decreased in the ERAS group (85% vs 38%, p = 0.013).

CONCLUSIONS

The implementation of an ERAS protocol appears to decrease postoperative pain, opioid usage, and positively impact other anesthetic outcomes in children undergoing urologic reconstructive surgery utilizing a bowel anastomosis.

Lymph node yield in pediatric, adolescent and young adult Renal Cell Carcinoma - How many are enough?

PURPOSE

Pediatric, adolescent and young adult (PAYA) patients with renal cell carcinoma (RCC) have a high rate of LN involvement, yet data to guide surgical lymph node (LN) management in this group is limited. The objective is to describe a LN yield threshold to quantify the chance of missing occult LN involvement at ≤10% in PAYAs with RCC.

MATERIALS & METHODS

The National Cancer Database was queried for patients aged ≤30 y with unilateral, non-metastaticRCC from 2004 to 2013. The probability of a false negative LN sampling was determined on the cohort of patients who had at least one positive LNand ≥ 2 LNs examined. For a given LN yield, the probability that a positive LN exists but none were found was estimated using a beta-binomial model.

RESULTS

We identified 112 patients meeting study criteria. Median age was 24 y and median tumor size was 9.5 cm (IQR 5.8-14). The median number of LNs sampled was 7 (IQR 4-12) and the median number of LNs positive was 4 (IQR 2-7). To achieve ≤10% probability of a false-negativeLN sampling, the beta-binomial model estimated that 5 LNs (95% CI4-7) must be sampled.

CONCLUSIONS

The desired LN yield to reduce the risk of a false-negativeLN sampling in PAYAs with RCC to ≤10% is 5. This is in keeping with prior studies identifying a LN yield of 6-10 to achieve the same. These data may be used to standardize surgical guidelines when treating PAYAs with renal tumors.

LEVEL OF EVIDENCE

II.

Gonadal malignancy in patients with differences of sex development

Differences of sexual development (DSD) are known to be associated with an elevated risk of malignant and pre-malignant tumors. However, given the rarity of DSD and tumors in patients with DSD, more robust, large scale, prospective literature is required to truly determine the extent of this association, long-term outcomes and the nuances associated with the wide variety of DSD diagnoses. In addition, the spectrum of diagnoses and nomenclature has been ever-changing, limiting assessment of long-term patient outcomes. This review aims to provide an overview of the pathogenesis of DSD conditions, potential malignancies associated with the diagnoses, the available screening for malignancy, and the most recent data on stratification for each DSD diagnosis and association with malignancy.

Oncologic outcomes of pre-malignant and invasive germ cell tumors in patients with differences in sex development - A systematic review

OBJECTIVE

To describe the rates of GCNIS-free and GCT-free pathology based on age at gonadal surgery and to describe long-term oncologic outcomes in patients with DSD who have GCNIS or GCT at the time of gonadal surgery.

STUDY DESIGN

A systematic review was conducted using MEDLINE to identify patients with DSD who underwent gonadal surgery. DSD diagnoses were stratified based on malignancy risk. GCNIS/GCT and GCT-free survival by age of gonadal surgery, RFS and OS were calculated using the Kaplan-Meier method, with groups compared using log-rank testing.

RESULTS

386 articles from 1951 to 2017 were included (2037 patients). Median age at gonadal surgery was 17 years (y) (IQR 11-20), median follow-up was 60 months (m) (IQR 30-68.1). GCNIS/GCT- and GCT-free survival at the time of gonadal surgery was lowest for those in the high/intermediate risk group (p < 0.001) but decreased sharply around age 15y, regardless of risk category. 5y RFS and OS was similar for those with no GCNIS/GCT and GCNIS and was worse for those with GCT (p < 0.001).

DISCUSSION

When patients undergo gonadal surgery, regardless of indication (i.e. prophylactic vs. tumor), it appears that GCTs are more commonly found when surgery is done around age 15 y or older, despite risk category. This is similar to ovarian and testicular GCTs. Patients with GCNIS can be reassured that long-term oncologic outcomes are excellent. While RFS and OS for GCTs are not as good as for ovarian and testicular GCTs (95%), they are still >80%. This similar trend was found in a COG review of 9 patients with DSD and ovarian GCT. There were several limitations to this study. This is a retrospective analysis that included aa wide time frame of publications. The indication for surgical intervention was not addressed in the majority of publications. Thus these data provide pathologic outcomes based on age at gonadal surgery rather than the age at which GCNIS/GCT develops over a lifetime, if at all.

CONCLUSIONS

The risk of GCNIS or GCT at the time of gonadal surgery appears to increase with age, accelerating between 15 and 20y regardless of risk category. 5y RFS and OS for those with GCNIS is equivalent to those without GCNIS/GCT but is worse for those with GCT. These data may be used when counseling families on timing of gonadal surgery and quantification of outcomes should GCNIS or malignancy be identified.

Surgical management of pediatric renal masses: surgeon subspecialty practice patterns

INTRODUCTION

Management of pediatric renal masses has lagged behind adult paradigms adopting minimally invasive surgery (MIS) and nephron-sparing surgery (NSS). This study investigated national practice patterns between pediatric urologists (PU) and pediatric surgeons (PS) in pediatric renal malignancy.

MATERIALS AND METHODS

The Pediatric National Surgical Quality Improvement Program database was queried for CPT codes for radical/partial nephrectomy from 2012-2017 performed for renal malignancy. Patients were grouped by specialty and operative approach.

RESULTS

PU managed 175 (17%) patients while PS managed 811 (77%). PU were more likely to use MIS (14% versus 5%, p < 0.001) and NSS (33% versus 13%, p < 0.001) compared to PS. PS more commonly performed lymph node (LN) sampling/tumor thrombectomy, especially in MIS cases (67% versus 35%, p = 0.008). PS operated on younger patients with higher ASA class compared to PU, but had higher transfusion rates and longer length of stay. Central venous access surgery was more commonly performed on patients operated on by PS, while PU performed more cystoscopy/retrograde pyelography. Patients who underwent NSS compared to radical nephrectomy were less likely to undergo LN sampling, while LN sampling did not differ between open and MIS groups.

CONCLUSIONS

PU were likely to perform MIS and NSS than PS for pediatric renal masses in this national database. This likely results from inherent training differences between PS and PU and reflects emerging data on safety and efficacy of these advanced surgical techniques. Further investigation into the impact on oncologic and clinical outcomes by surgical specialty and operative approach is necessary.

A decision tree to guide long term venous access placement in children and adolescents undergoing surgery for renal tumors

BACKGROUND/PURPOSE

While many children with renal tumors require long term venous access (VA) for adjuvant chemotherapy, certainly not all do. This study develops and tests a VA decision tree (DT) to direct the placement of VA in patients with renal tumors.

METHODS

Utilizing data readily available at surgery a VADT was developed. The VADT was tested retrospectively by 2 independent reviewers on a historic cohort. The ability of the VADT to appropriately select which patients would benefit from VA placement was tested.

RESULTS

160 patients underwent renal tumor surgery between 2005 and 2018. 70 (43.8%) patients met study criteria with median age of 45.1 months (range 1.1-224); 73% required VA. Using the VADT, VA placement was "needed" in 67.1% of patients and "deferred" in 32.9%. Interrater reliability was very high (kappa = 0.97, 95% CI 0.91-1, p < 0.001). The sensitivity and specificity of the VADT to correctly decide on VA placement were 0.92 (0.8-0.98) and 1 (0.79-1). Using the VADT, no patient would have undergone unnecessary VA placement. In reality, 4.3% of patients had an unnecessary VA placed which required a subsequent removal.

CONCLUSIONS

These preliminary data support the continued study of this VADT to guide intraoperative decisions regarding VA placement in patients with renal tumors.

LEVEL OF EVIDENCE

III - Study of diagnostic test.

Factors affecting lymph node sampling patterns and the impact on survival of lymph node density in patients with Wilms tumor: a Surveillance, Epidemiology, and End Result (SEER) database review

BACKGROUND

Lymph node (LN) involvement is an important prognostic indicator for patients with Wilms tumor (WT), and there have been previous reports of utilizing LN density (LND = positive LN/LNs examined) as an advanced metric to risk-stratify patients with WT.

OBJECTIVE

The purpose of this study was to describe patient characteristics that affect LN yield and assess the effect of LND on the overall survival (OS) in patients with WT, with the expectation that patients with LNDs above a critical cut-point would demonstrate lower OS.

STUDY DESIGN

The Surveillance, Epidemiology, and End Result (SEER) database was queried for all patients diagnosed with unilateral WT from 2004 to 2015. Patient and disease characteristics were collected, and Poisson regression was used to identify characteristics correlated with LN yield. LND was calculated for LN-positive patients, and multivariable survival analysis was performed, including patient demographics and LND as variables.

RESULTS

1489 patients with unilateral WT were identified for analysis, 231 (15.51%) of whom were LN-positive. Median patient age at diagnosis was three years (IQR 1-5). On Poisson regression, the year of diagnosis, patient age, tumor size and laterality, and stage were found to impact LN yield. For patients with positive LNs, five-year OS of patients with LNDs above 0.4 was worse than those below 0.4 (76.1% vs 89.6%, p = 0.041). On multivariable analysis, tumor size and LND remained significant predictors of OS.

DISCUSSION

Administrative databases such as SEER provide an excellent resource for studying conditions where large patient numbers for analysis are difficult to obtain. Unfortunately, the SEER database is unable to account for every factor that could affect LN sampling patterns. Additionally, favorable vs unfavorable histology is not available in SEER, and SEER utilizes its own staging system, which makes comparison to Children's Oncology Group staging difficult. Despite these limitations, the findings of this study are similar to those previously published using administrative databases analyzing LN sampling patterns and the effect of LND on OS in WT.

CONCLUSIONS

Analysis of the SEER database confirms that there are several patient- and disease-specific factors that affect the number of LNs sampled during nephrectomy for WT, and that LND may be a predictor of OS. These findings highlight the need for standardization of LN sampling patterns for pediatric renal tumors and support the investigation of LND in future studies to further risk-stratify WT patients to tailor therapy intensity.

Extirpative renal surgery volume in training: different roads to the (same?) destination

PURPOSE

To describe the overall extirpative renal surgery (ERS) training volume reported by PU and PS.

METHODS

Case log data from the Accreditation Council for Graduate Medical Education (ACGME) was examined from 2013-2016 for surgery residents (S_res), urology residents (U_res), pediatric surgery fellows (PS_fel) and pediatric urology fellows (PU_fel). Case log information for all levels of participation over all case categories that could potentially offer ERS volume were recorded. Volume was estimated using the mean number of included cases during residency and fellowship and the sum was used to estimate total training volume. Volume between groups was compared using the student's t test.

RESULTS

Case logs were included for 4447 residents (4259 S_res, 840 U_res) and fellows (188 PS_fel, 71 PU_fel). Mean PU volume was 113.1, which was higher than the mean PS volume of 10.3 (p < 0.001). For PU, more ERS were performed during residency than fellowship (p < 0.001). For PS the opposite was true (p < 0.001). When examining fellow training only, PU_fel performed more ERS than PS_fel (11.7 vs. 7.0 p < 0.001).

CONCLUSION

While previous publications note similar short-term outcomes for ERS for malignancy for PU and PS, ERS case volume during training is significantly different. Review of recent ACGME data indicate that PU have more overall experience with ERS, with most gained during residency. Additionally, PU_fel performed significantly more ERS than PS_fel. Further study into how these training differences affect long-term outcomes is necessary.

The impact of age at orchiopexy on testicular cancer outcomes

PURPOSE

To estimate how many boys with UDT must undergo orchiopexy to prevent one case of TC, one death from TC and one exposure to TC treatment beyond radical orchiectomy as compared to being treated at an older age.

METHODS

This retrospective study utilized data from a 2007 Swedish study of males who underwent orchiopexy for UDT (Pettersson et al.). TC incidence for boys undergoing orchiopexy for UDT was assessed based on the age at orchiopexy (0-6 years, 7-9 years, 10-12 years, 13-15 years). The incidence of TC in each age cohort was calculated and used to determine the number needed to treat (NNT) for each age group using assumptions based on published TC outcomes.

RESULTS

For an index patient ≤ 6 years, 372 boys need to undergo orchiopexy to prevent a single case of TC, 1488 boys to prevent exposure to TC therapy beyond radical orchiectomy, and 5315 boys to prevent a single TC-related death compared to treatment at an older age.

CONCLUSION

While there is evidence supporting benefits of early orchiopexy, the NNT to affect TC outcomes is very high. Even those with delayed orchiopexies have low risk for TC poor outcomes. This information can be used when counseling patients and families faced with UDT about the risks related to TC, especially with comorbidities.

Open Radical Nephrectomy for Suspected Renal Malignancy-Tips and Tricks

OBJECTIVE

To present the surgical approach to a cystic renal mass suspicious for malignancy in a 22-month-old female.

MATERIALS

The patient was a healthy female was found to have an abdominal mass by her parents. Her mother underwent a nephrectomy as a child for unknown pathology. Physical examination was otherwise unremarkable and laboratory workup was normal. Imaging workup revealed a large cystic renal mass suspicious for malignancy. Surgical resection was planned.

RESULTS

A nonsyndromic 22-month-old female underwent open radical nephrectomy on the left with regional lymph node dissection. A transverse abdominal incision was used, followed by medial reflection of the colon and complete renal mobilization. The distal ureter and renal vasculature were identified and controlled and the kidney removed. A retractor was then assembled and regional lymph node dissection performed. Final pathology was cystic nephroma with 10 benign lymph nodes. The patient recovered well and was discharged home 3 days after surgery.

CONCLUSION

Open radical nephrectomy is an important part of protocol management for patients with renal masses suspicious for malignancy.

Partial Nephrectomy for Multifocal, Unilateral Wilms Tumor in a Patient with Hemihypertrophy

OBJECTIVE

To present the surgical approach to a multifocal Wilms tumor found on screening ultrasound in an asymptomatic 2-year-old female.

MATERIALS

A 2-year-old female with hemihypertrophy underwent screening imaging every 3 months with renal ultrasound. A solitary, incidental renal mass was detected. Physical exam was unremarkable except for left leg hemihypertrophy. Laboratory workup was largely normal other than an elevated lactate dehydrogenase. Staging imaging revealed multiple masses on the right kidney and a normal left kidney. There were no distant metastases. The most likely diagnosis was Wilms tumor. After receiving chemotherapy for 6 weeks, imaging revealed an excellent response to chemotherapy and surgery was performed.

RESULTS

The patient underwent open partial nephrectomy of the 3 tumors on the right. Prior to beginning, cystoscopy and ureteral stent placement was performed as it was felt the collecting system would likely be entered during resection. The renal hilum was not clamped throughout this resection and manual parenchymal compression was used to minimize global ischemia. Retroperitoneal lymph node dissection was also performed. The patient recovered well and was discharged home 5 days after surgery. Her stent was removed at home without complications. Final pathology revealed nephrogenic rests with all 7 lymph nodes were negative for malignancy.

CONCLUSION

Management of multifocal, unilateral Wilms tumor with open partial nephrectomy after neoadjuvant chemotherapy is an important part of protocol management for patients with Wilms tumor with predisposition syndromes.

Appropriateness for testis-sparing surgery based on the testicular tumor size in a pediatric and adolescent population

INTRODUCTION

In children, most small testicular tumors are benign, and testicular-sparing surgery (TSS) is a viable treatment option.

OBJECTIVE

The objective of this study is to assess for correlation between the tumor size and final pathologic diagnoses appropriate for TSS for pediatric and adolescent patients with an intratesticular mass and negative serum tumor markers (STMs).

MATERIALS AND METHODS

A retrospective review of 24 patients (aged 0-18 years) who underwent radical or partial orchiectomy between 2003 and 2015. Patients with unifocal, unilateral intratesticular tumors and negative STMs were included. Tumors with benign and non-germ cell histology were considered appropriate for TSS, and active germ cell tumor elements on final histology were categorized as inappropriate for TSS. Baseline characteristics, tumor size, and frozen section results were evaluated for association, for the entire cohort and then for a subset of pubertal and postpubertal patients (defined as ≥10 years old).

RESULTS

Patients with testicular tumor pathology inappropriate for TSS were significantly older (median age 17.1 years, P = 0.03). A 2-cm size cutoff did not accurately predict pathology for the entire cohort, or for just pubertal and postpubertal patients (P = 0.132, P = 0.154, respectively). Frozen section and final pathology demonstrated good agreement (κ = 0.826, P < 0.001) as did pre-operative and final pathologic size measurement (κ = 0.703, P < 0.001). Frozen section analysis did not miss a TSS inappropriate pathology.

DISCUSSION

The present data refute the finding in adults that a 2-cm cutoff accurately predicts pathology in pediatric patients with an intratesticular mass and normal STMs. These data suggest that TSS should still be offered, regardless of the tumor size alone, but frozen section appears to more accurately predict pathology than the tumor size, and its use should, thus, be emphasized. There are several limitations of this study to mention. First, this is a retrospective review of a small cohort of patients with a rare clinical scenario, which necessitated the combination of pediatric and adolescent patients. The study did not evaluate oncologic outcomes.

CONCLUSIONS

In children with an intratesticular tumor and normal STMs, a tumor size cutoff of 2 cm does not appear to accurately predict the final pathology. However, the data presented support the continued use intra-operative frozen section analysis in both children and adolescents undergoing TSS.

Inpatient interventions that may preclude outpatient open pyeloplasty in infants

Objective:

In the majority of published series, children undergoing open pyeloplasty are admitted for at least one night. We hypothesized that it would be possible in the majority of infants to perform open pyeloplasty as an outpatient procedure.

Materials and Methods:

All patients who underwent open pyeloplasty by a single surgeon between 2008 and 2016 were retrospectively reviewed. Demographic data (age at surgery, gender, pre- and postoperative imaging studies, laterality, type of local anesthesia), operative time, duration of hospital stay, need for narcotic analgesics, complications, readmission within 1-month after surgery and need for additional procedures were abstracted.

Results:

A total of 18 infants underwent open pyeloplasty by single surgeon. Mean age at time of surgery was 19 months (range 3-23 months). There were 8 girls and 10 boys. In addition to general anesthesia, all of the patients received regional anesthesia (caudal block 8, epidural block 8, subcutaneous nerve block 2). Median operative time was 135 minutes (range 81-166). Median hospital stay was 1 day (range 1 to 2). Two patients required iv narcotics for pain management. None of the patients required parenteral administration of other medications during the short hospitalization. No patients required any additional procedures or hospital readmissions within 1 month from surgery.

Conclusions:

In appropriately selected patients, outpatient pyeloplasty appears to be feasible with an oral postoperative analgesia plan to be administered at home.

Development of a postoperative care pathway for children with renal tumors

PURPOSE

To identify the factors associated with a shorter postoperative stay, as an initial step to develop a care pathway for children undergoing extirpative kidney surgery.

STUDY DESIGN

This study retrospectively reviewed patients managed with upfront open radical nephrectomy for renal tumors between 2005 and 2016 at a pediatric tertiary care facility. Univariate and multivariate logistic regression were performed to identify factors associated with early discharge (by postoperative day 4).

RESULTS

A total of 84 patients met inclusion criteria. Median age was 28.1 months (range 1.8-193.1). Thirty-four (40.5%) patients had a nasogastric tube postoperatively. The patients were advanced to a clear liquid diet on a median postoperative day 2 (range 0-7) and regular diet on a median postoperative day 3 (range 1-8). Median time from surgery to discharge was 5 days (range 2-12), with 38 (45.2%) discharged early. Univariate and multivariate logistic regression analyses showed that earlier resumption of regular diet (OR 0.523, P = 0.028) was positively associated with early discharge. Other analyzed factors were not significant (see Table).

DISCUSSION

Timely initiation of adjuvant therapy is a specific requirement of Children's Oncology Group (COG) protocols. Chemotherapy and radiation therapy are ideally initiated simultaneously, as early as possible, within 2 weeks of surgery. Thus, factors that can facilitate early discharge from the hospital can maximize protocol adherence with respect to timing of adjuvant therapy initiation and optimize patient outcome. This study shed light on several postoperative factors and how these relate to postoperative stay and recovery. Specifically, tumor size, pre-operative bowel preparation, extent of lymph node sampling, stage, operative time, estimated blood loss, surgical service, postoperative nasogastric tube use, transfusion, and chemotherapy prior to discharge were not associated with discharge timing. Early re-feeding was associated with early discharge. Thus, it seems reasonable that, when developing a postoperative care pathway for these patients, these factors be considered and specifically encourage early re-feeding. In pediatrics, data on early recovery after surgery protocols are limited, and high-quality studies are unavailable. Within pediatric urology, early recovery after surgery protocols in children undergoing major urologic reconstruction have been shown to reduce hospital stay and can decrease complication rates. It seems reasonable that a similar pathway can be applied to children undergoing radical nephrectomy for suspected malignancy.

CONCLUSIONS

For children with renal tumors who underwent radical nephrectomy, early re-feeding was associated with a shorter time to discharge. Use of bowel preparation and nasogastric tube did not appear to shorten time to discharge. These data are important for developing postoperative care pathways for these patients.

Current state of renal tumor surgery among pediatric surgeons and pediatric urologists: A survey of American Pediatric Surgical Association (APSA) and Society for Pediatric Urology (SPU) members

INTRODUCTION

Anecdotally, renal tumor (RT) surgery makes up a limited portion of the practice for most pediatric urologists and pediatric surgeons. Data are lacking on the current perceptions of RT surgery, both volume of surgery and issues related to surgical practice, among pediatric surgeons (PS) and pediatric urologists (PU).

OBJECTIVES

To describe practice patterns of pediatric renal tumor (RT) surgery and identify factors related to higher reported volumes of RT surgery.

STUDY DESIGN

The survey was developed and pilot-tested by the Children's Oncology Group (COG) RT surgery committee. The survey was distributed to APSA and SPU members. Logistic regression was performed to correlate surgeon-reported factors with higher reported volumes of RT surgery.

RESULTS

The survey was sent to 1,282 APSA and 426 SPU members, 367 (21.5%) surveys were completed from eligible responders, 244 (65.2%) and 123 (32.9%) from APSA and SPU invitations, respectively. Overall, 33.9% reported being part of a practice group in which RT surgical care is sub-specialized. A majority (50.7%) of respondents reported personally performing one to two RT surgeries annually, and 16.7% reported performing none. Multivariate logistic regression identified the following significant factors associated with increased individual RT surgical volume: group sub-specialization, COG/SIOP membership, regular tumor board attendance, and annual institutional volume >10 RT surgeries (Table). Accurate responses on the need for lymph node (LN) sampling in RT surgery were reported by 89.9%. Overall, 15.8% and 24.5% of respondents failed to correctly correlate local stage III disease in Wilms tumor (WT) with open or percutaneous biopsy, respectively (p < 0.001).

DISCUSSION

While we found that reported RT surgery volume is low among both pediatric urologists and surgeons, we did identify surgeon-specific factors which correlated with higher RT surgical volume. Interested pediatric urologists and surgeons may use these data to tailor their practice if their goal is to increase RT surgery volume. Additionally, based on less than ideal rates of correct responses to nuance in the staging and treatment of WT, there are clear opportunities to increase education in this content area. However, the study is limited by use of a non-validated survey instrument and the relatively low response rates.

CONCLUSION

Reported individual RT surgery volume is low. Factors associated with increased volume include sub-specialty practice, tumor board involvement, and higher institutional volume. Responses on LN sampling and biopsy in WT demonstrate opportunities for educational initiatives.

Patterns of lymph node sampling and the impact of lymph node density in favorable histology Wilms tumor: An analysis of the national cancer database

INTRODUCTION

There is controversy about the role of lymph node (LN) sampling or dissection in the management of favorable histology (FH) Wilms tumor (WT), specifically how it performed and how it may impact survival.

OBJECTIVE

The objective of this study was to analyze factors affecting LN sampling patterns and the impact of LN yield and density (number of positive LNs/LNs examined) on overall survival (OS) in patients with advanced-stage favorable histology Wilms tumor (FHWT).

METHODS

The National Cancer Database (NCDB) was queried for patients with FHWT during 2004-2013. Demographic, clinical and OS data were abstracted for those who underwent surgical resection. Poisson regression was performed to analyze how factors influenced LN yield. Patients with positive LNs had LN density calculated and were further analyzed.

RESULTS

A total of 2340 patients met criteria, with a median age at diagnosis of 3 years (range 0-78 years). The median number of LNs examined was three (range 0-87). Lymph node yield was affected by age, race, insurance, tumor size, laterality, advanced stage, LN positivity, and institutional volume. A total of 390 (16.6%) patients had LN-positive disease. Median LN density for these LN-positive patients was 0.38 (range 0.02-1) (Summary Figure). Estimated 5-year OS was significantly improved for those with LN density ≤0.38 vs. >0.38 (94% vs. 84.6%, P = 0.012). In this population, on multivariate analysis, age and LN density were significant predictors of OS.

DISCUSSION

It is difficult to compile large numbers of cases in rare diseases like WT, and fortunately a large administrative database such as the NCDB can serve as a great resource. However, administrative data come with inherent limitations such as missing data and inability to account for a variety of factors that may influence LN yield and/or OS (specimen designation, pathologist experience, surgeon experience/volume, institutional Children's Oncology Group (COG) association, etc.). In this specific disease, the American Joint Committee on Cancer staging (captured by the NCDB) is different than the COG WT staging system that is used clinically, and the NCDB does not capture oncologic outcomes beyond OS.

CONCLUSIONS

In a review of the NCDB, various factors associated with LN yield and observed LN density were identified to be significantly associated with OS in patients with LN-positive FHWT. This reinforces the need for adequate LN sampling at the time of WT surgery, to maximize surgical disease control. It was proposed that LN density as a metric may allow for improved risk-stratification, and possibly allow for therapeutic reduction in a sub-set of patients with low LN density.

Metastatic Pheochromocytoma in an Asymptomatic 12-Year-Old With von Hippel-Lindau Disease

Pheochromocytoma is a rare chromaffin cell tumor that may be associated with a genetic predisposition, such as von Hippel-Lindau (VHL) disease. VHL is an autosomal dominant disorder that is characterized by a predisposition to multiple tumors, including retinal and central nervous system hemangioblastomas, renal cell carcinoma, and pheochromocytomas. The classic presentation of pheochromocytoma is episodic hypertension, headaches, palpitations, and diaphoresis. In the pediatric population, 40% of pheochromocytomas have a hereditary basis. We present a case of metastatic pheochromocytoma in a child with VHL and discuss the relevant current medical literature.

Current Treatment of Pediatric Bladder and Prostate Rhabdomyosarcoma

PURPOSE OF REVIEW

Rhabdomyosarcoma (RMS) is the most common sarcoma diagnosed in the first 20 years of life; bladder/prostate (BP) RMS accounts for 5% of all cases. Through efforts from multiple cooperative study groups, survival has improved significantly. This article aims to review the complex RMS classification system and treatment of BP RMS, with a focus on developing aspects of treatment.

RECENT FINDINGS

Recent advancements in technology are responsible for most of the progress in RMS treatment. PET-CT scanning has been shown to be superior to conventional metastatic workup. The use of proton beam therapy and brachytherapy to reduce the side effects of radiation is also showing promise. All cooperative oncology groups agree on surgical biopsy for diagnosis and staging of BP RMS. Patients are then grouped and risk classified before receiving chemotherapy. Regardless of local control strategy, oncologic outcomes appear to be similar for BP RMS. Alternative treatment strategies, which remain unproven, include brachytherapy and proton therapy.

Factors Affecting the Completion of Genitourinary Physical Examinations Prior to Urologic Consultation

BACKGROUND

Proper instruction during medical training regarding performing adequate physical examinations prior to urologic consultations greatly improves patient care. We evaluated the frequency of genitourinary (GU) physical examinations performed prior to urologic consultation to determine the influence of factors affecting the completion of these examinations.

METHODS

Between January 2013 and December 2014, 1,596 consultations were requested by primary providers and completed by the urology department at a major tertiary care teaching institution. We reviewed patient medical records retrospectively and recorded the number of GU examinations performed prior to consultation. Patient demographics were evaluated for trends in the rates of examination. A total of 9 available urology residents saw at least one consult each.

RESULTS

We identified a total of 1,596 urologic consultations during the study period, of which 233 of 407 (57.2%) (51 female and 182 male patients) received GU examinations prior to the urologic consult in the emergency department (ED) and 394 of 1,189 (33.1%) (118 female and 276 male patients) received GU examinations by the inpatient care team. Staff in the ED were 3.11 times more likely to perform a GU examination on a male patient than a female patient, and the inpatient teams were 1.48 times more likely to perform a GU examination on a male patient than a female patient. The likelihood of examination by either team was low in patients aged ≥65 years.

CONCLUSION

Prior to urologic consultation, GU examinations are inconsistently performed. This variability may affect patient care and could be the subject of a future study.

Incidental Discovery of Adenocarcinoma of an Augmented Bladder in a Patient With Myelomenigocele Undergoing Cystolithotomy

Bladder malignancy in patients with congenital bladder anomalies who have undergone bladder augmentation is a rare but well-recognized condition. These patients present with locally advanced or metastatic disease and have poor survival. We report a case of a patient with myelomeningocele who was incidentally found to have a high-grade intestinal type adenocarcinoma of her bladder augment at the time of cystolithotomy. This case highlights the need to continue to follow patients with congenital bladder anomalies and highlights the lack of adequate screening methods available.

Long-term outcomes of cutaneous vesicostomy in patients with neuropathic bladder caused by spina bifida

OBJECTIVE

To evaluate the outcomes of patients who underwent cutaneous vesicostomy for management of neuropathic bladder secondary to spina bifida. We hypothesize that vesicostomy, in select patients, is beneficial to prevent upper urinary tract deterioration (UTD), reduce febrile urinary tract infections (UTIs), and preserve renal function.

STUDY DESIGN

We performed a retrospective chart review on patients with spina bifida who underwent cutaneous vesicostomy at our institution between 2000 and 2016. Demographic information, indication for vesicostomy, pre and postoperative laboratory/radiologic studies, incidence of febrile UTIs, and urodynamic findings were abstracted.

RESULTS

A total of 14 patients (eight females and six males) were identified. The indication for vesicostomy was UTD in four, recurrent febrile UTIs in five, parental request in two, both UTD and recurrent febrile UTIs in two, and both UTI and parental request in one patient. Seven patients had a median of three (range one to five) febrile UTI prior to surgery for cutaneous vesicostomy. Median creatinine level before surgery was 0.26 mg/dL (range 0.16-0.97). Either unilateral or bilateral ≥SFU Grade 2 hydronephrosis was present in six patients. Median age at vesicostomy creation was 26.5 months (range 4-96). Mean functional bladder capacity assessed during preoperative urodynamic studies was 107 mL (range 20-279), and detrusor sphincter dysynergia was present in all patients. High-grade vesicoureteral reflux (grade ≥3) was present in three patients, all with UTD. Mean follow-up after vesicostomy was 62.4 ± 39.3 months. After vesicostomy, only two of the seven patients with history of febrile UTIs experienced an additional febrile UTI. The median serum creatinine level was 0.36 mg/dL (range 0.2-0.58) at last follow-up. Moreover, 11/14 patients had no hydronephrosis and just two patients had unilateral SFU grade 1 hydronephrosis (Table).

DISCUSSION

Worsening UTD, recurrent febrile UTIs, and high-pressure bladder despite maximal medical therapy are several reasons to consider more aggressive management of neuropathic bladders. In young patients, vesicostomy is able to protect the upper urinary tract, decrease rates of febrile UTI, and delay the need for bladder augmentation.

CONCLUSION

Vesicostomy is a safe method for temporary diversion of the lower urinary tract in patients with spina bifida who are refractory to conservative and minimally invasive treatments.

An uncommonly encountered perirenal mass: Robotic resection of renal vein leiomyosarcoma

Primary leiomyosarcoma (LMS) of the renal vein is a rare tumour and poorly described in the literature. Surgical resection, using open and laparoscopic approaches, is the mainstay of treatment. In this report, we describe a patient with left renal vein LMS, report the first robotic laparoscopic resection for this tumor, and review the typical presentation, imaging, pathology and treatment for this rare clinical entity.

Peyronie’s Disease

Peyronie’s disease (PD), more commonly known as penile curvature, is caused by plaque formation in the connective tissue of the penis. PD affects 0.3% to 8.9% of men, most commonly between ages 40 and 60 years and can cause significant psychological distress, regardless of severity. There is a rich history behind the initial reports of PD, initial beliefs about pathogenesis, and initial treatment. This article aims to discuss the history of PD as well as the evolution of causes and treatments throughout time up to present-day theories of pathogenesis and treatment.