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Varda BK, Levitt MA. How we select our surgical approach for cloacal reconstruction. J Pediatr Urol 2024; 20:320-322. [PMID: 38042687 DOI: 10.1016/j.jpurol.2023.11.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2023] [Revised: 11/08/2023] [Accepted: 11/13/2023] [Indexed: 12/04/2023]
Abstract
During cloacal reconstruction, we consider both common channel (CC) and urethral length when deciding between total urogenital mobilization (TUM) and a urogenital separation (UGS). Our concern about TUM in the case of a short urethra is resultant bladder neck incompetence, while conversion to UGS after completing the TUM dissection may result in urethral injury. Use of an interposition flap harvested from the ischiorectal fossa is another measure we use to prevent potential complications.
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Affiliation(s)
- Briony K Varda
- Children's National Division of Colorectal and Pelvic Reconstruction, USA; Children's National Division of Urology, USA.
| | - Marc A Levitt
- Children's National Division of Colorectal and Pelvic Reconstruction, USA
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Tyraskis A, El-Sayed J, Tiusaba L, Jacobs SE, Russell TL, Feng C, Teeple E, Ho CP, Pohl HG, Badillo AT, Levitt MA, Varda BK. Posterior Sagittal Approach Provides Optimal Exposure for Urethral Reconstruction in Children With a History of Anorectal Malformations. Urology 2024; 183:192-198. [PMID: 37805049 DOI: 10.1016/j.urology.2023.09.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2023] [Accepted: 09/27/2023] [Indexed: 10/09/2023]
Abstract
OBJECTIVE To present a unique series of children with previously repaired anorectal malformations (ARM) with subsequent urethral pathology repaired via a posterior sagittal exposure and highlight the associated technical advantages. METHODS Using a retrospective review of all procedures performed in our pediatric colorectal and pelvic reconstruction program from January 2020 through December 2022, we compiled a case series of patients with a history of ARM and prior posterior sagittal anorectoplasty (PSARP) who had urethral pathology and concurrent indication for redo-PSARP. Clinical features, operative details, and postoperative outcomes were collected. RESULTS Six male patients presented at a median age of 4.3 years, all born with an ARM of recto-urinary fistula type, of which 3 were recto-prostatic, 1 recto-bladder-neck, and 2 unknown type. In addition to redo-PSARP, 2 underwent remnant of the original fistula excision and 4 had urethral stricture repair. One required post-operative Heineke-Mikulicz anoplasty. Patients underwent cystoscopy 4-6 weeks post-reconstruction, and none showed urethral stricture requiring treatment. Post-procedurally, 5 patients were able to void urethrally and 1 required additional bladder augmentation/Mitrofanoff. CONCLUSION Redo-PSARP completely mobilizes the rectum, thereby providing excellent exposure to the posterior urethra for repair. This approach also allows the option of a rectal flap for augmented urethroplasty as well as harvest of an ischiorectal fat pad for interposition.
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Affiliation(s)
- Athanasios Tyraskis
- Division of Colorectal and Pelvic Reconstruction, Children's National Hospital, Washington DC
| | - Jana El-Sayed
- Division of Colorectal and Pelvic Reconstruction, Children's National Hospital, Washington DC
| | - Laura Tiusaba
- Division of Colorectal and Pelvic Reconstruction, Children's National Hospital, Washington DC
| | - Shimon E Jacobs
- Division of Colorectal and Pelvic Reconstruction, Children's National Hospital, Washington DC
| | - Teresa L Russell
- Division of Colorectal and Pelvic Reconstruction, Children's National Hospital, Washington DC
| | - Christina Feng
- Division of Colorectal and Pelvic Reconstruction, Children's National Hospital, Washington DC
| | - Erin Teeple
- Division of Colorectal and Pelvic Reconstruction, Children's National Hospital, Washington DC
| | - Christina P Ho
- Division of Colorectal and Pelvic Reconstruction, Children's National Hospital, Washington DC
| | - Hans G Pohl
- Division of Colorectal and Pelvic Reconstruction, Children's National Hospital, Washington DC
| | - Andrea T Badillo
- Division of Colorectal and Pelvic Reconstruction, Children's National Hospital, Washington DC
| | - Marc A Levitt
- Division of Colorectal and Pelvic Reconstruction, Children's National Hospital, Washington DC
| | - Briony K Varda
- Division of Colorectal and Pelvic Reconstruction, Children's National Hospital, Washington DC.
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Davis M, Mohan S, Russell T, Feng C, Badillo A, Levitt M, Ho CP, Pohl HG, Varda BK. A prospective cohort study of assisted bladder emptying following primary cloacal repair: The Children's National experience. J Pediatr Urol 2023; 19:371.e1-371.e11. [PMID: 37037763 DOI: 10.1016/j.jpurol.2023.03.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Revised: 02/20/2023] [Accepted: 03/11/2023] [Indexed: 04/12/2023]
Abstract
INTRODUCTION/BACKGROUND Although the combination of bladder dysfunction and upper tract anomalies puts patient with cloaca at risk for renal disease, the rarity of this condition makes it difficult to study empirically. As a high-volume center, we uniquely capture bladder function outcomes following our growing number of cloacal repairs. OBJECTIVE 1) Describe the rates of incomplete bladder emptying following primary cloacal repair (at 2-3 months after repair and last follow up), and 2) identify clinical factors associated with assisted bladder emptying. STUDY DESIGN We performed a prospective cohort study of patients undergoing primary cloaca repair by our Children's National Colorectal Center team between 2020 and 2021. The primary outcome was assisted bladder emptying at 2-3 months postoperatively and last visit. Covariables included preoperative characteristics (cloacagram measurements), ARM complexity (moderate = common channel [CC] <3-cm, severe = CC ≥ 3-cm), vesicoureteral reflux (VUR) status, sacral ratio (good ≥0.7, intermediate 0.7-0.4, poor ≤0.4), spinal cord status, means of preoperative bladder emptying, and operative details (age at repair, repair type, & concomitant laparotomy). RESULTS Eighteen participants were eligible. A majority had moderate cloaca (78%), VUR (67%), spinal cord abnormalities (89%), and good sacral ratios (56%). Preoperatively, 10 patients were diapered for urine and 8 had assisted bladder emptying. Surgical repairs were performed at a median age of 8 months (range 4-46). Nine (50%) patients underwent urogenital separation (UGS), eight (44%) total urogenital mobilization, and 1 (6%) perineal sparing posterior sagittal anorectoplasty with introitoplasty. Exploratory laparotomy was performed in 7 (39%) patients. At 2-3 months, 7 patients were voiding and 11 required assisted bladder emptying. Median length of long-term follow up was 12 months (range 5-25), and 8 patients were voiding and 10 required assisted bladder emptying. Postoperative need for assisted bladder emptying was significantly associated with assisted bladder emptying preoperatively, a shorter urethra and increasing common channel length, UGS and exploratory laparotomy. Spinal cord imaging findings were not associated. DISCUSSION Bladder emptying following cloaca repair is likely a result of congenital function and surgical effects. Indeed, increasingly cloaca complexity requiring UGS and laparotomy was associated with both pre- and post-operative assisted bladder emptying. The lack of association with spinal cord imaging may reflect a divergence between anatomy and function. CONCLUSION Approximately half of patients required assisted bladder emptying in this study. Associated factors included urethral and common channel length, the need for assisted bladder emptying preoperatively, the type of surgical approach and additional laparotomy. Being diapered with seemingly normal voiding prior to surgery did not guarantee normal bladder function postoperatively.
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Affiliation(s)
- Meghan Davis
- Children's National Hospital, Division of Urology, Washington D.C, USA
| | - Shruthi Mohan
- Children's National Hospital, Division of Urology, Washington D.C, USA
| | - Teresa Russell
- Children's National Hospital, Division of Urology, Washington D.C, USA; Children's National Hospital, Division of Colorectal and Pelvic Reconstruction, Washington D.C, USA
| | - Christina Feng
- Children's National Hospital, Division of Colorectal and Pelvic Reconstruction, Washington D.C, USA
| | - Andrea Badillo
- Children's National Hospital, Division of Colorectal and Pelvic Reconstruction, Washington D.C, USA
| | - Marc Levitt
- Children's National Hospital, Division of Colorectal and Pelvic Reconstruction, Washington D.C, USA
| | - Christina P Ho
- Children's National Hospital, Division of Urology, Washington D.C, USA; Children's National Hospital, Division of Colorectal and Pelvic Reconstruction, Washington D.C, USA
| | - Hans G Pohl
- Children's National Hospital, Division of Urology, Washington D.C, USA
| | - Briony K Varda
- Children's National Hospital, Division of Urology, Washington D.C, USA; Children's National Hospital, Division of Colorectal and Pelvic Reconstruction, Washington D.C, USA.
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Al-Shamaileh T, Tiusaba L, Jacobs SE, Russell TL, Bokova E, Pohl HG, Varda BK, Ho C, Feng C, Badillo A, Levitt MA. Cloacal Malformation with Associated Urethral Atresia. European J Pediatr Surg Rep 2023; 11:e1-e4. [PMID: 36760663 PMCID: PMC9904968 DOI: 10.1055/s-0043-1761206] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2020] [Accepted: 12/13/2020] [Indexed: 02/09/2023] Open
Abstract
Introduction Cloacal malformations comprise a heterogeneous group of anomalies that are considered the most complex anorectal malformations (ARMs) in females. Precise evaluation to identify the unique anatomy prior to reconstruction with collaboration between colorectal surgeons, urologists, and gynecologists is vital. Here, we present a rare anatomical variation in a patient with a cloacal malformation which affected operative and postoperative management. Case description A 6-year-old female with cloaca who underwent colostomy, vaginostomy, and vesicostomy as a newborn presented for reconstruction. Her VACTERL workup was negative except for an atretic right kidney. Her ARM index included the cloaca, a normal spine, and sacrum with a lateral sacral ratio of 0.7, predicting good potential for bowel continence. Cystoscopy through the vesicostomy showed a small bladder with normal ureteral orifices, and a closed bladder neck, with no identifiable urethra. A cloacagram showed an atretic common channel, a single small vagina, and a rectum below the pubococcygeal line. The patient underwent a posterior sagittal anorectovaginourethroplasty, vaginal patch using rectum, rectoplasty, and perineal body reconstruction. The urethra was not amenable to reconstruction, so the vesicostomy was preserved and a future Mitrofanoff was planned. Conclusion Urethral atresia is a rare and challenging finding in cloaca patients, and a vesicostomy is needed to drain urine in the newborn period. Preoperative examination under anesthesia, cystoscopy, vaginoscopy, and cloacagram are crucial to identify the precise anatomy and to plan accordingly.
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Affiliation(s)
| | - Laura Tiusaba
- Division of Colorectal and Pelvic Reconstruction, Department of Surgery, Children's National Hospital, Washington, District of Columbia, United States
| | - Shimon Eric Jacobs
- Division of Colorectal and Pelvic Reconstruction, Department of Surgery, Children's National Hospital, Washington, District of Columbia, United States
| | - Teresa Lynn Russell
- Division of Colorectal and Pelvic Reconstruction, Department of Surgery, Children's National Hospital, Washington, District of Columbia, United States
| | - Elizaveta Bokova
- Division of Colorectal and Pelvic Reconstruction, Department of Surgery, Children's National Hospital, Washington, District of Columbia, United States
| | - Hans G. Pohl
- Department of Urology, Children's National Hospital, Washington, District of Columbia, United States
| | - Briony K. Varda
- Department of Urology, Children's National Hospital, Washington, District of Columbia, United States
| | - Christina Ho
- Department of Urology, Children's National Hospital, Washington, District of Columbia, United States
| | - Christina Feng
- Division of Colorectal and Pelvic Reconstruction, Department of Surgery, Children's National Hospital, Washington, District of Columbia, United States
| | - Andrea Badillo
- Division of Colorectal and Pelvic Reconstruction, Department of Surgery, Children's National Hospital, Washington, District of Columbia, United States
| | - Marc A. Levitt
- Division of Colorectal and Pelvic Reconstruction, Department of Surgery, Children's National Hospital, Washington, District of Columbia, United States,Address for correspondence Marc A. Levitt, MD Division of Colorectal and Pelvic ReconstructionDepartment of Surgery, Children's National Hospital, Washington, District of ColumbiaUnited States
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Jacobs SE, Tiusaba L, Bokova E, Al-Shamaileh T, Russell TL, Varda BK, Feng C, Badillo AT, Levitt MA. Where Is the Vagina? A Rectal Stricture after a Presumed Cloacal Repair Turns Out to be the Mobilized Vagina and a Missed High Rectovaginal Fistula. European J Pediatr Surg Rep 2022; 10:e145-e147. [PMID: 36225532 PMCID: PMC9550519 DOI: 10.1055/s-0042-1755538] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2022] [Accepted: 07/10/2022] [Indexed: 11/03/2022] Open
Abstract
We present a case of a rare complication in a 10-month-old female referred to our institution for an anal stricture after primary cloacal repair as an infant. Multimodal imaging, careful physical exam, and endoscopic evaluation revealed her vagina had been pulled through to the location of her anal sphincter muscle complex. We describe the correction of this problem, including identification of her rectum.
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Affiliation(s)
- Shimon E. Jacobs
- Department of Surgery, Division of Colorectal and Pelvic Reconstruction, Children's National Hospital, Washington, District of Columbia, United States
| | - Laura Tiusaba
- Department of Surgery, Division of Colorectal and Pelvic Reconstruction, Children's National Hospital, Washington, District of Columbia, United States
| | - Elizaveta Bokova
- Department of Surgery, Division of Colorectal and Pelvic Reconstruction, Children's National Hospital, Washington, District of Columbia, United States
| | - Tamador Al-Shamaileh
- Department of General Surgery, Division of Pediatric Surgery, King Hussain Cancer Center, Amman, Jordan
| | - Teresa L. Russell
- Department of Urology, Children's National Hospital, Washington, District of Columbia, United States,Address for correspondence Marc A. Levitt, MD Department of Surgery, Division of Colorectal and Pelvic Reconstruction, Children's National HospitalWashington, DC 20010United States
| | - Briony K. Varda
- Department of Urology, Children's National Hospital, Washington, District of Columbia, United States
| | - Christina Feng
- Department of Surgery, Division of Colorectal and Pelvic Reconstruction, Children's National Hospital, Washington, District of Columbia, United States
| | - Andrea T. Badillo
- Department of Surgery, Division of Colorectal and Pelvic Reconstruction, Children's National Hospital, Washington, District of Columbia, United States
| | - Marc A. Levitt
- Department of Surgery, Division of Colorectal and Pelvic Reconstruction, Children's National Hospital, Washington, District of Columbia, United States
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Varda BK, Johnson EK. What the editors are reading: Population and health services. J Pediatr Urol 2022; 18:239-242. [PMID: 35337730 DOI: 10.1016/j.jpurol.2022.02.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2022] [Accepted: 02/16/2022] [Indexed: 11/17/2022]
Affiliation(s)
- Briony K Varda
- Division of Urology, Children's National Medical Center, Washington, DC, USA
| | - Emilie K Johnson
- Division of Urology, Ann & Robert H. Lurie Children's Hospital of Chicago and Department of Urology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.
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Krill AJ, Varda BK, Freidberg NA, Rana MS, Shalaby-Rana E, Sprague BM, Pohl HG. Predicting the likelihood of prolongation of half-time among infants with initially indeterminate drainage values: A single-institution retrospective study of 535 patients with ureteropelvic junction obstruction. J Pediatr Urol 2021; 17:512.e1-512.e7. [PMID: 34253460 DOI: 10.1016/j.jpurol.2021.05.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Revised: 05/21/2021] [Accepted: 05/24/2021] [Indexed: 11/27/2022]
Abstract
INTRODUCTION AND OBJECTIVE Prior studies have shown a broad half time (T1/2) interval on MAG3 diuresis renography (DR) that is indeterminate for obstruction. We aimed to refine and sub-divide the indeterminate range and associate it with clinically meaningful outcomes: pyeloplasty and pyeloplasty-free survival. METHODS We identified patients <1.5 years-old at presentation with unilateral, isolated moderate to severe hydronephrosis who underwent DR from 2000 to 2016. A logistic regression model was created using T1/2 to predict surgery. An indeterminate range was defined based on patients with <90% probability of pyeloplasty or resolution. This group was sub-divided into three T1/2 intervals: 5-20, 21-40, and 41-60 min. Endpoints were pyeloplasty and pyeloplasty free survival. Indications for surgery were loss of differential renal function (DRF), worsening T1/2, family preference, and/or pain. RESULTS Among 2025 patients with DR, 704 met criteria (169 were lost to follow up). Of the remaining 535, 218 had pyeloplasties and 317 did not. The Pyeloplasty group had significantly worse DRF, T1/2 at initial DR, and exited the study earlier, at a median age 1.1years vs 2.3 years (p < 0.001). For all patients with antenatally detected unilateral UPJ obstruction, the odds of undergoing pyeloplasty at any time increased by 1.8 times (p < 0.001 [95% CI: 1.04, 1.08]) per 10 unit increase in T1/2 until T1/2 = 60. However, in patients with intermediate drainage, five year surgery-free survival probability for patients with T1/2 5-20, 21-40, and 41-60 min were 79.7%, 46.7% and 33.3% respectively (χ2 = 41.2, P = <0.001). DISCUSSION Previous efforts to define indeterminate drainage resulted in ranges for T1/2 that were too broad to be clinically useful. Within our endpoint-defined indeterminate range, our data show that there are significant step offs in 5-year surgery-free survival for patients with T1/2 < 20 min, 21-40 min, and 41-60 min. Although there is a steady decrease in surgery-free survival among patients with a T1/2 of 21-40 min over the first 5 years of life, half can be managed nonoperatively. These patients likely represent the true intermediate risk group and closer follow up is justified. CONCLUSIONS Initial T1/2 on DR is predictive of future surgery. When drainage is "indeterminate" for obstruction, sub-stratification allows for more accurate prognostication.
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Affiliation(s)
- Aaron J Krill
- Division of Pediatric Urology(AJK, BKV, MSR, BMS, HGP), and the Department of Radiology (ESR) at Children's National Health System, Washington, DC, USA.
| | - Briony K Varda
- Division of Pediatric Urology(AJK, BKV, MSR, BMS, HGP), and the Department of Radiology (ESR) at Children's National Health System, Washington, DC, USA
| | - Nicholas A Freidberg
- Division of Pediatric Urology(AJK, BKV, MSR, BMS, HGP), and the Department of Radiology (ESR) at Children's National Health System, Washington, DC, USA; Division of Urology at George Washington University, Washington, DC, USA
| | - Md Sohel Rana
- Division of Pediatric Urology(AJK, BKV, MSR, BMS, HGP), and the Department of Radiology (ESR) at Children's National Health System, Washington, DC, USA
| | - Eglal Shalaby-Rana
- Division of Pediatric Urology(AJK, BKV, MSR, BMS, HGP), and the Department of Radiology (ESR) at Children's National Health System, Washington, DC, USA
| | - Bruce M Sprague
- Division of Pediatric Urology(AJK, BKV, MSR, BMS, HGP), and the Department of Radiology (ESR) at Children's National Health System, Washington, DC, USA
| | - Hans G Pohl
- Division of Pediatric Urology(AJK, BKV, MSR, BMS, HGP), and the Department of Radiology (ESR) at Children's National Health System, Washington, DC, USA
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Lee T, Varda BK, Venna A, McCarthy I, Logvinenko T, Nelson CP. Changes in Clinical Presentation and Renal Outcomes among Children with Febrile Urinary Tract Infection: 2005 vs 2015. J Urol 2021; 205:1764-1769. [PMID: 33535798 PMCID: PMC8106649 DOI: 10.1097/ju.0000000000001597] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/08/2020] [Indexed: 11/26/2022]
Abstract
PURPOSE Recent studies have demonstrated trends of decreasing voiding cystourethrogram utilization rates and delayed vesicoureteral reflux diagnosis in some children. It is possible that such delays could lead to more children sustaining repeated episodes of febrile urinary tract infection, and potential kidney injury, prior to diagnosis and treatment. MATERIALS AND METHODS Using single institutional, cross-sectional cohorts of patients in 2 time periods (2005 and 2015), we compared clinical presentation and renal outcomes among patients 13 years and younger with history of febrile urinary tract infection presenting for initial voiding cystourethrogram. Outcomes included 1) recurrent urinary tract infection, 2) presence of vesicoureteral reflux, 3) grade of vesicoureteral reflux, and 4) renal scarring. Associations between year of presentation and outcomes of recurrent urinary tract infection and vesicoureteral reflux diagnosis were evaluated using multivariable logistic regression models. For the outcome of renal scarring, a logistic regression model was fitted for propensity score matched cohorts. RESULTS Compared to children presenting in 2005, those in 2015 had 3 times the odds of recurrent urinary tract infection (OR 3.01, 95% CI 2.18-4.16, p <0.0001). Time period was not associated with the odds of vesicoureteral reflux (OR 0.98, 95% CI 0.77-1.23, p=0.85). Those in 2015 were more likely to present with vesicoureteral reflux grade >3 (OR 2.22, 95% CI 1.13-4.34, p=0.02) but not vesicoureteral reflux grade >2 (OR 1.11, 95% CI 0.74-1.67, p=0.60). Renal scarring was more common among children presenting in 2015 (OR 2.9, 95% CI 1.03-8.20, p=0.04). CONCLUSIONS Compared to 2005, children presenting in 2015 for post-urinary tract infection voiding cystourethrogram have increased likelihood of recurrent urinary tract infection and renal scarring, despite similar likelihood of vesicoureteral reflux diagnosis.
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Affiliation(s)
- Ted Lee
- Boston Children’s Hospital, Department of Urology, Boston, Massachusetts
| | - Briony K Varda
- Boston Children’s Hospital, Department of Urology, Boston, Massachusetts
- Children’s National Hospital, Division of Urology, Washington, D.C
| | - Alyssia Venna
- Boston Children’s Hospital, Department of Urology, Boston, Massachusetts
| | - Ian McCarthy
- Boston Children’s Hospital, Department of Urology, Boston, Massachusetts
| | - Tanya Logvinenko
- Boston Children’s Hospital, Department of Urology, Boston, Massachusetts
| | - Caleb P Nelson
- Boston Children’s Hospital, Department of Urology, Boston, Massachusetts
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Varda BK, Johnson EK. What the editors are reading: Population and health services. J Pediatr Urol 2021; 17:114-116. [PMID: 33531216 PMCID: PMC7816861 DOI: 10.1016/j.jpurol.2021.01.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2021] [Accepted: 01/06/2021] [Indexed: 11/30/2022]
Affiliation(s)
- Briony K Varda
- Division of Urology, Children's National Medical Center, Washington, DC, USA
| | - Emilie K Johnson
- Division of Urology, Ann & Robert H. Lurie Children's Hospital of Chicago and Department of Urology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.
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Varda BK. Commentary to 'Continence after BNR in the complete repair of bladder exstrophy (CPRE): A single institution expanded experience'. J Pediatr Urol 2020; 16:434. [PMID: 32605873 DOI: 10.1016/j.jpurol.2020.05.170] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Accepted: 05/14/2020] [Indexed: 11/15/2022]
Affiliation(s)
- Briony K Varda
- Children's National Medical Center, Washington, D.C., USA.
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Nelson CP, Varda BK. What the editors are reading: population and health services. J Pediatr Urol 2019; 15:565-567. [PMID: 31451411 DOI: 10.1016/j.jpurol.2019.07.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2019] [Accepted: 07/11/2019] [Indexed: 11/28/2022]
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Abstract
This study compares family and childbearing leave policies for resident physicians among American Board of Medical Specialty (ABMS) member organizations that set training duration requirements for US residency programs.
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Affiliation(s)
- Briony K. Varda
- Department of Urology, Boston Children’s Hospital, Boston, Massachusetts
| | - McKinley Glover
- Department of Radiology, Massachusetts General Hospital, Boston
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Varda BK, Rajender A, Yu RN, Lee RS. A contemporary single-institution retrospective cohort study comparing perioperative outcomes between robotic and open partial nephrectomy for poorly functioning renal moieties in children with duplex collecting systems. J Pediatr Urol 2018; 14:549.e1-549.e8. [PMID: 30172696 DOI: 10.1016/j.jpurol.2018.06.011] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2018] [Accepted: 06/04/2018] [Indexed: 12/28/2022]
Abstract
INTRODUCTION Studies evaluating robotic-assisted laparoscopic partial nephrectomy (RALPN) are limited to case series, amounting to a lack of studies directly comparing perioperative outcomes for RALPN to open partial nephrectomy (OPN). OBJECTIVE To compare perioperative outcomes between RALPN and OPN. METHODS A single-institution, retrospective cohort study was performed to compare perioperative outcomes (operative time (OT), length of stay (LOS), complications, readmissions, postoperative interventions, loss in size of the residual moiety, and the presence of postoperative 'contained fluid collections') for RALPN and OPN between February 2007 and July 2014. Descriptive statistics were calculated and unadjusted analyses performed, including Chi-squared/Fisher's exact for categorical variables and Wilcoxon rank sum for continuous variables. RESULTS During the study period, 43 partial nephrectomies were performed for benign disease: 27 (63%) RALPN and 16 (37%) OPN. The RALPN cohort was significantly older than the OPN cohort (3.5 vs. 0.8 years; P = 0.003). The cohorts were otherwise similar regarding race, American Society of Anesthesiologist score (ASA), affected moiety, laterality, associated anomalies, moiety function, and surgical indication. Robotic-assisted laparoscopic partial nephrectomy was associated with a significantly shorter LOS (1 vs. 3 days; P = 0.002). Operative time and complication rates were comparable. The OPN group had a longer median follow-up (2.7 years vs. 1.1; P = 0.03). No differences were observed between the cohorts for readmissions, postoperative interventions, loss in size of residual moiety, or development of 'contained fluid collections'. These outcomes are reported in the Summary Table. 'Contained fluid collections' occurred more frequently after lower pole resections (73% vs. 30%; P = 0.009). DISCUSSION This study is one of the few to directly compare RALPN to OPN, and demonstrated that RALPN has comparable (if not better) outcomes than OPN. In particular, RALPN provides the advantage of a shorter LOS. Avoiding the flank incision used in OPN may also offer reduced pain; however, this was not studied here and the literature provides weak evidence for this effect. This unadjusted analysis may have been confounded by its short median follow-up and significantly younger OPN cohort. CONCLUSION In this contemporary comparative analysis, RALPN predicted a similar median OT and safety profile to OPN while offering the advantage of a shorter LOS. Regardless of surgical cohort, there were no adverse effects on the residual renal moieties and postoperative 'contained fluid collections' occurred with notable frequency and were independently associated with lower pole pathology.
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Affiliation(s)
- B K Varda
- Department of Urology, Boston Children's Hospital, Boston, MA, USA.
| | - A Rajender
- Department of Urology, Boston Medical Center, Boston, MA, USA
| | - R N Yu
- Department of Urology, Boston Children's Hospital, Boston, MA, USA
| | - R S Lee
- Department of Urology, Boston Children's Hospital, Boston, MA, USA
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Varda BK, Finkelstein JB, Wang HH, Logvinenko T, Nelson CP. The association between continuous antibiotic prophylaxis and UTI from birth until initial postnatal imaging evaluation among newborns with antenatal hydronephrosis. J Pediatr Urol 2018; 14:539.e1-539.e6. [PMID: 29891187 PMCID: PMC6265114 DOI: 10.1016/j.jpurol.2018.04.022] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2017] [Accepted: 04/15/2018] [Indexed: 10/16/2022]
Abstract
INTRODUCTION There is a lack of consensus regarding the use of continuous antibiotic prophylaxis (CAP) during the interval between birth and initial postnatal imaging in infants with a history of antenatal urinary tract dilation (AUTD). OBJECTIVE To determine the incidence of urinary tract infection (UTI), and the association between CAP use and UTI during the interval between birth and the first postnatal renal ultrasound (RUS) in infants with AUTD. STUDY DESIGN A single-institution, retrospective cohort study of newborns with a history of AUTD. Infants undergoing RUS within 3 months of birth for an indication of 'hydronephrosis' between 2012 and 2014 were identified. A random sample of 500 infants was selected; six were excluded for concomitant congenital anomalies. Baseline patient (sex, race, insurance) and clinical characteristics (circumcision status, UTD risk score, receipt of CAP, UTI prior to RUS, age at UTI, and age at RUS) were collected via retrospective chart review. Descriptive statistics were calculated. To adjust for receipt of CAP, propensity score adjusted univariate logistic regression for UTI based on CAP status was performed. RESULTS Among the 494 infants with AUTD, 157 (32%) received CAP. Infants with normal/low-risk UTD scores were less likely to receive CAP than those with medium/high-risk UTD (23% vs 77%; P < 0.001). There was no difference in CAP based on sex, insurance, or circumcision status (among 260/365 males with known circumcision status). Overall, seven infants (1.4%) developed UTI prior to imaging: six (1.8%) without CAP vs one (0.64%) with CAP (P = 0.44). The median age at UTI was 59 days (range 2-84); among those with UTI, initial imaging occurred significantly later (66 vs 28 days; P = 0.001). The propensity score adjusted odds of developing UTI with CAP (vs without) was 0.93 (95% CI 0.10-8.32; P = 0.95). The Summary Figure describes the infants with UTI. CONCLUSION The incidence of UTI prior to initial neonatal imaging in newborns with AUTD was low. Use of CAP was not associated with UTI incidence after adjusting for UTD severity. Routine use of CAP in newborns with AUTD prior to initial imaging may be of limited benefit in most patients.
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Affiliation(s)
- B K Varda
- Department of Urology, Boston Children's Hospital, Boston, MA, USA.
| | - J B Finkelstein
- Department of Urology, Boston Children's Hospital, Boston, MA, USA
| | - H-H Wang
- Department of Urology, Boston Children's Hospital, Boston, MA, USA
| | - T Logvinenko
- Department of Urology, Boston Children's Hospital, Boston, MA, USA
| | - C P Nelson
- Department of Urology, Boston Children's Hospital, Boston, MA, USA
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T Rague J, Varda BK, Wagner AA, Lee RS. Delayed Return of Ejaculatory Function in Adolescent Males Treated With Retroperitoneal Lymph Node Dissection and Adjuvant Therapy for Paratesticular Rhabdomyosarcoma. Urology 2018; 124:254-256. [PMID: 30366047 DOI: 10.1016/j.urology.2018.10.030] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2018] [Revised: 10/08/2018] [Accepted: 10/15/2018] [Indexed: 10/28/2022]
Abstract
Due to the rarity of the disease, adverse events related to ejaculatory function following the management of paratesticular rhabdomyosarcoma with multimodal therapy in adolescents are rarely discussed. Two patients, age 14 and 15 at time of diagnosis were treated with multimodal therapy with nerve-sparing retroperitoneal lymph node dissection, chemotherapy, and radiotherapy. Each developed ejaculatory dysfunction during the treatment period, which resolved 1 year after completion of all therapies. We sought to assess the role of each component of multimodal therapy on the observed side effect and the potential for delayed recovery of function after cessation of all therapies.
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Affiliation(s)
- James T Rague
- Department of Urology, Boston Medical Center, Boston, MA
| | - Briony K Varda
- Department of Urology, Boston Children's Hospital, Boston, MA
| | - Andrew A Wagner
- Division of Urology, Beth Israel Deaconess Medical Center, Boston, MA; Department of Surgery, Harvard Medical School, Boston, MA
| | - Richard S Lee
- Department of Urology, Boston Children's Hospital, Boston, MA; Department of Surgery, Harvard Medical School, Boston, MA.
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Varda BK, Wang Y, Chung BI, Lee RS, Kurtz MP, Nelson CP, Chang SL. Has the robot caught up? National trends in utilization, perioperative outcomes, and cost for open, laparoscopic, and robotic pediatric pyeloplasty in the United States from 2003 to 2015. J Pediatr Urol 2018; 14. [PMID: 29530407 PMCID: PMC6105565 DOI: 10.1016/j.jpurol.2017.12.010] [Citation(s) in RCA: 67] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
INTRODUCTION Since 2010, there have been few new data comparing perioperative outcomes and cost between open (OP) and robotic pyeloplasty (RP). In a post-adoption era, the value of RP may be converging with that of OP. OBJECTIVE To 1) characterize national trends in pyeloplasty utilization through 2015, 2) compare adjusted outcomes and median costs between OP and RP, and 3) determine the primary cost drivers for each procedure. STUDY DESIGN We performed a retrospective cohort study using the Premier database, which provides a nationally representative sample of U.S. hospitalizations between 2003 and 2015. ICD9 codes and itemized billing were used to abstract our cohorts. Trends in utilization and cost were calculated and then stratified by age. We used propensity scores to weight our cohorts and then applied regression models to measure differences in the probability of prolonged operative time (pOT), prolonged length of stay (pLOS), complications, and cost. RESULTS During the study period 11,899 pyeloplasties were performed: 75% open, 10% laparoscopic, and 15% robotic. The total number of pyeloplasty cases decreased by 7% annually; OP decreased by a rate of 10% while RP grew by 29% annually. In 2015, RP accounted for 40% of cases. The largest growth in RPs was among children and adolescents. The average annual rate of change in cost for RP and OP was near stagnant: -0.5% for open and -0.2% for robotic. The summary table provides results from our regression analyses. RP conferred an increased likelihood of pOT, but a reduced likelihood of pLOS. The odds of complications were equivalent. RP was associated with a significantly higher median cost, but the absolute difference per case was $1060. DISCUSSION Despite advantages in room and board costs for RP, we found that the cost of equipment and OR time continue to make it more expensive. Although the absolute difference may be nominal, we likely underestimate the true cost because we did not capture amortization, hidden or down-stream costs. In addition, we did not measure patient satisfaction and pain control, which may provide the non-monetary data needed for comparative value. CONCLUSION Despite an overall decline in pyeloplasties, RP utilization continues to increase. There has been little change in cost over time, and RP remains more expensive because of equipment and OR costs. The robotic approach confers a reduced likelihood of pLOS, but an increased likelihood of pOT. Complication rates are low and similar in each cohort.
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Affiliation(s)
- Briony K Varda
- Department of Urology, Boston Children's Hospital, Harvard Medical School, MA, USA.
| | - Ye Wang
- Division of Urologic Surgery, Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, MA, USA
| | | | - Richard S Lee
- Department of Urology, Boston Children's Hospital, Harvard Medical School, MA, USA
| | - Michael P Kurtz
- Department of Urology, Boston Children's Hospital, Harvard Medical School, MA, USA
| | - Caleb P Nelson
- Department of Urology, Boston Children's Hospital, Harvard Medical School, MA, USA
| | - Steven L Chang
- Division of Urologic Surgery, Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, MA, USA
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Varda BK, Cho P, Wagner AA, Lee RS. Collaborating with our adult colleagues: A case series of robotic surgery for suspicious and cancerous lesions in children and young adults performed in a free-standing children's hospital. J Pediatr Urol 2018; 14:182.e1-182.e8. [PMID: 29503221 PMCID: PMC5970046 DOI: 10.1016/j.jpurol.2018.01.003] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2017] [Accepted: 01/03/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND In adult urologic oncology the use of robotics has become commonplace; in pediatric urology it is rare. Herein, we describe a collaboration between an adult and a pediatric urologist performing robotic surgery for children and young adults with suspicious or cancerous genitourinary (GU) lesions. OBJECTIVES To evaluate clinical and oncologic outcomes in children and young adults undergoing robotic surgery for suspicious or cancerous lesions of the GU tract; to describe our collaborative model between an adult and pediatric surgeon at a free-standing children's hospital. DESIGN We retrospectively reviewed all robotic cases performed at our institution from 2014 to 2016 for patients with a GU malignancy or a suspicious mass. The surgeries were performed by a pediatric urologist with robotic experience and a fellowship-trained MIS adult urologist specializing in oncology. Perioperative and oncologic outcomes were recorded. RESULTS A total of eight robotic cases were performed: four partial nephrectomies (PN) with retroperitoneal lymph node dissection (LND) (OT 269-338 min, EBL 5-300 mL, LOS 3-6 days), one adrenalectomy with LND (6.4 cm mass; OT 172 min, EBL 5 mL, LOS 3 days), one nephrectomy with pericaval LND (9.8 cm mass; 234 min, EBL 25 mL, LOS 3 days), and two retroperitoneal LNDs (OT 572 and 508 min, EBL 250 and 100, LOS 3 and 4 days). Patient weights ranged from 14 to 79 kg (mean 53.4 kg). There were no major complications (Clavien 3-5). Pathology results for PN included papillary RCC (AJCC pT1aNx) and two cases of segmental cystic renal dysplasia with nephrogenic rests. Bilateral template RPLNDs yielded paratesticular rhabdomyosarcoma (43 nodes; COG low risk group II stage I) and mixed non-seminomatous germ cell tumor (74 nodes; COG stage III). The nephrectomy yielded an undifferentiated sarcoma, low grade; the adrenalectomy favorable-type ganglioneuroma. DISCUSSION In pediatrics, urologic oncology cases are often managed with open surgery. Our series demonstrates the feasibility of using the robotic approach in carefully selected cases. In doing so, the patient benefits from a minimally invasive surgery, while the surgeon benefits from robotic surgical dexterity. We seamlessly advanced these new techniques through a step-wise collaboration between an adult urologist who routinely performs robotic oncology procedures and a pediatric urologist experienced in robotics for benign conditions. CONCLUSION In this small series, we safely and effectively adapted adult robotic techniques for genitourinary oncology cases in children and young adults.
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Affiliation(s)
- Briony K Varda
- Boston Children's Hospital, Department of Urology, Harvard Medical School, Boston, MA, USA.
| | - Patricia Cho
- Boston Children's Hospital, Department of Urology, Harvard Medical School, Boston, MA, USA
| | - Andrew A Wagner
- Beth Israel Deaconess Medical Center, Department of Urology, Harvard Medical School, Boston, MA, USA
| | - Richard S Lee
- Boston Children's Hospital, Department of Urology, Harvard Medical School, Boston, MA, USA
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Finkelstein JB, Kurtz MP, Campbell J, Varda BK, Grant R, Nelson CP, Estrada, Jr. CR. LBA2 THE USE OF TELEMEDICINE FOR THE POSTOPERATIVE UROLOGIC CARE OF CHILDREN: RESULTS OF A PILOT PROGRAM. J Urol 2018. [DOI: 10.1016/j.juro.2018.03.081] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Varda BK, Logvinenko T, Bauer S, Cilento B, Yu RN, Nelson CP. Minor procedure, major impact: Patient-reported outcomes following urethral meatotomy. J Pediatr Urol 2018; 14:165.e1-165.e5. [PMID: 29221617 PMCID: PMC5957770 DOI: 10.1016/j.jpurol.2017.10.012] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2017] [Accepted: 10/30/2017] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Urethral meatotomy as treatment for meatal stenosis is a common pediatric urology procedure; however, little is known about the patient experience following this procedure. OBJECTIVE We aim to evaluate clinical factors associated with patient-reported symptom improvement after urethral meatotomy. STUDY DESIGN The families of boys undergoing urethral meatotomy between 2/2013 and 8/2016 received a survey by mail 6 weeks after surgery. Families were queried on changes in symptoms using a Likert-type scale (5 = much improved, 4 = somewhat improved, 3 = no change, 2 = somewhat worse, and 1 = much worse). Patient and procedure characteristics of the respondents were obtained via chart review. These included surgical indication(s) (abnormal stream, dysuria, or storage symptoms), postoperative complications, reoperation, and unplanned postoperative communications. Patients who had procedures other than simple urethral meatotomy were excluded. Descriptive statistics were compiled, and generalized estimating equations used to determine the associations of patient and procedure characteristics with symptom improvement. RESULTS We sent 629 surveys and received 194 responses (30.4%). Twelve respondents were excluded for complex procedures or miscoding. The majority of respondents were privately insured (74%) and were between 5 and 12 years old (45%) or 1 and 4 years old (42%). The most frequent surgical indication was abnormal stream (72%) followed by pain (21%) and storage symptoms (15.5%). Nine respondents had minor complications (4.9%). Four patients had restenosis requiring repeat urethral meatotomy. After surgery, a majority (79%) were "much improved," 16% were "somewhat improved," 3% had "no change," and 1% were "somewhat worse." No family reported "much worse." Those patients who had "abnormal stream" as a surgical indication were significantly more likely to report "much improved" (OR 1.83, p = 0.014) than those without. Patient-reported improvement was not associated with suture use, patient age, insurance, surgeon, or location of the procedure (Table). DISCUSSION Little has been written about patient-reported outcomes following urethral meatotomy. Our study affirms that the majority of boys improve following this procedure. However, improvement is significantly more likely if the child has a preoperative indication of an abnormal stream, such as deflection or spraying. Boys with symptoms of dysuria, frequency, or incontinence may be experiencing sequelae of meatal stenosis that simply take longer to improve. Alternatively, the meatal stenosis may be incidental to the primary symptoms. CONCLUSIONS A majority of families report substantial symptomatic improvement after urethral meatotomy. However, boys undergoing urethral meatotomy for reasons other than a urinary stream abnormality are less likely to experience improvement.
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Kurtz MP, Leow JJ, Varda BK, Logvinenko T, Yu RN, Nelson CP, Chung BI, Chang SL. Robotic versus open pediatric ureteral reimplantation: Costs and complications from a nationwide sample. J Pediatr Urol 2016; 12:408.e1-408.e6. [PMID: 27593917 DOI: 10.1016/j.jpurol.2016.06.016] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2016] [Accepted: 06/06/2016] [Indexed: 02/08/2023]
Abstract
INTRODUCTION We sought to compare complications and direct costs for open ureteral reimplantation (OUR) versus robot-assisted laparoscopic ureteral reimplantation (RALUR) in a sample of hospitals performing both procedures. Anecdotal reports suggest that use of RALUR is increasing, but little is known of the outcomes and costs nationwide. OBJECTIVE The aim was to determine the costs and 90-day complications (of any Clavien grade) in a nationwide cohort of pediatric patients undergoing OUR or RALUR. METHODS Using the Premier Hospital Database we identified pediatric patients (age < 21 years) who underwent ureteral reimplantation from 2003 to 2013. We compared 90-day complication rates and cost data for RALUR versus OUR using descriptive statistics and hierarchical models. RESULTS We identified 17 hospitals in which both RALUR and OURs were performed, resulting in a cohort of 1494 OUR and 108 RALUR cases. The median operative time was 232 min for RALUR vs. 180 min for OUR (p = 0.0041). Incidence of any 90-day complications was higher in the RALUR group: 13.0% of RALUR vs. 4.5% of OUR (OR = 3.17, 95% CI: 1.46-6.91, p = 0.0037). The difference remained significant in a multivariate model accounting for clustering among hospitals and surgeons (OR, 3.14; 95% CI, 1.46-6.75; p = 0.0033) (Figure). The median hospital cost for OUR was $7273 versus $9128 for RALUR (p = 0.0499), and the difference persisted in multivariate analysis (p = 0.0043). Fifty-one percent (55/108) of the RALUR cases occurred in 2012-2013. DISCUSSION We present the first nationwide sample comparing RALUR and OUR in the pediatric population. There is currently wide variation in the probability of complication reported in the literature. Some variability may be due to differential uptake and experience among centers as they integrate a new procedure into their practice, while some may be due to reporting bias. A strength of the current study is that cost and 90-day postoperative complication data are collected at participating hospitals irrespective of outcomes, providing some immunity from the reporting bias to which individual center surgical series' may be susceptible. CONCLUSIONS Compared with OUR, RALUR was associated with a significantly higher rate of complications as well as higher direct costs even when adjusted for demographic and regional factors. These findings suggest that RALUR should be implemented with caution, particularly at sites with limited robotic experience, and that outcomes for these procedures should be carefully and systematically tracked.
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Affiliation(s)
- Michael P Kurtz
- Boston Children's Hospital, Harvard Medical School, Boston, MA, USA.
| | - Jeffrey J Leow
- Division of Urology, Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Briony K Varda
- Division of Urology, Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Tanya Logvinenko
- Boston Children's Hospital, Harvard Medical School, Boston, MA, USA; Center for Clinical Research, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Richard N Yu
- Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Caleb P Nelson
- Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | | | - Steven L Chang
- Division of Urology, Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
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Varda BK, Johnson EK, Johnson KL, Rosoklija I, Baum MA, Nelson CP. Imaging and surgical utilization for pediatric cystinuria patients: A single-institution cohort study. J Pediatr Urol 2016; 12:106.e1-7. [PMID: 26597229 DOI: 10.1016/j.jpurol.2015.08.019] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2014] [Accepted: 08/31/2015] [Indexed: 12/22/2022]
Abstract
OBJECTIVE Although cystinuria is rare, its clinical manifestations are life-long. Little is known about healthcare utilization in this population. STUDY DESIGN Through billing records and chart review, we identified pediatric patients with cystinuria treated at our institution. Variables included demographics, gender, race, comorbidities, location of presentation, presenting symptoms, initial laboratory data, and stone characteristics. Outcomes included the number and type of imaging tests and procedures performed. Descriptive statistics were performed. Median annual frequencies of procedures and imaging were calculated. RESULTS Twenty-three patients who presented between 1995 and 2011 were identified. The median age at presentation was 12 years, 48% of our patients were male, and 91% were Caucasian. Median follow-up was 4.6 years. Over half were diagnosed in clinic (13/23), while 30% (7/23) presented to the ED. Pain was the most common presenting symptom (13/23), followed by nausea/vomiting (6/23), gross hematuria (5/23), and fevers (5/23). Only one patient presented with acute renal failure. Five patients were discovered by sibling screening. The median number of stones at presentation was two and median size of the largest stone was 9 mm, with three staghorn calculi. During follow-up, a total of 110 stone procedures were performed in 15 patients. Five patients underwent 13 PCNLs, 11 patients underwent 44 ureteroscopy procedures, and nine underwent open or robotic surgery, including one nephrectomy. Among patients identified by sibling screening, most (4/5) were managed with medical therapy alone. A total of 390 imaging procedures were performed. Radiation-associated imaging comprised half of all imaging tests. DISCUSSION The high rates of imaging and surgical utilization among pediatric cystinuria patients reflect the morbidity of this condition and the need for preventative management. By practicing the ALARA principle during urologic procedures, urologists can reduce radiation exposure. Multiple procedures are often required to render patients stone-free. URS/LL and PCNL are likely to be more effective than ESWL. In complex cases, robotic-assist lithotomy provides the advantage of a minimally invasive approach. Both sibling screening and transitional care represent long-term strategies with the potential to reduce life-long morbidity. The limitations of this study include its small sample size, retrospective nature, and single-center experience. CONCLUSIONS Our study demonstrates that the clinical impact of disease among pediatric patients presenting with cystinuria at our institution is considerable, with most requiring surgery. Our population also generates heavy utilization of diagnostic imaging. Given the lifelong nature of this disease, research on improved preventive therapies is urgently needed.
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Affiliation(s)
- Briony K Varda
- Harvard Medical School, Brigham and Women's Hospital, Division of Urology, Boston, MA, USA.
| | - Emilie K Johnson
- Harvard Medical School, Boston Children's Hospital, Department of Urology, Boston, MA, USA
| | - Kathryn L Johnson
- Harvard Medical School, Boston Children's Hospital, Department of Urology, Boston, MA, USA
| | - Ilina Rosoklija
- Harvard Medical School, Boston Children's Hospital, Department of Urology, Boston, MA, USA
| | - Michelle A Baum
- Harvard Medical School, Boston Children's Hospital, Division of Nephrology, Boston, MA, USA
| | - Caleb P Nelson
- Harvard Medical School, Boston Children's Hospital, Department of Urology, Boston, MA, USA
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Varda BK, McNabb-Baltar J, Sood A, Ghani KR, Kibel AS, Letendre J, Menon M, Sammon JD, Schmid M, Sun M, Trinh QD, Bhojani N. Urolithiasis and urinary tract infection among patients with inflammatory bowel disease: a review of US emergency department visits between 2006 and 2009. Urology 2015; 85:764-70. [PMID: 25669736 DOI: 10.1016/j.urology.2014.12.011] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2014] [Revised: 11/29/2014] [Accepted: 12/03/2014] [Indexed: 02/06/2023]
Abstract
OBJECTIVE To compare patients with inflammatory bowel disease (IBD) to a general population of urinary stone formers who present to US emergency departments with infected urolithiasis. Patients with IBD are at risk for both infection and stone formation, however studies investigating emergent urolithiasis presentations for this population are limited. METHODS Using the Nationwide Emergency Department Sample (2006-2009) we identified all patients presenting to the US emergency departments with a diagnosis of upper tract urolithiasis. We then described a subgroup with the concomitant diagnosis of IBD. We compared rates of urinary tract infection (UTI), sepsis, organ failure, admission, and mortality between the 2 groups. Using multivariate analysis, we determined whether or not IBD was a predictor of UTI, sepsis, and hospitalization. RESULTS Overall, 14,352 patients had concomitant IBD and urolithiasis. IBD patients with urolithiasis presented with infections (10.4% vs 9.1%; P <.001), sepsis (0.6% vs 0.2%; P <.001), and end-organ failure (6.3% vs 1.6%; P <.001) more frequently than non-IBD patients. They were also more likely to have characteristics independently associated with infection and sepsis, such as older age and female gender. In adjusted analyses, IBD was an independent predictor of infection (odds ratio [OR] = 1.3 [1.14-1.46]; P <.0001), sepsis (OR = 1.8 [1.09-2.92]; P <.0001), and admission (OR = 3.3 [3.04-3.64]; P <.0001). CONCLUSION IBD patients with urinary calculi have greater odds of UTI, renal failure, and sepsis compared to the general stone-forming population. The increased occurrence and severity of infected urolithiasis in this select group of patients warrants screening for stone disease, improved outpatient medical management, and early elective surgery for detected stones.
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Affiliation(s)
- Briony K Varda
- Division of Urologic Surgery, the Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, MA.
| | - Julia McNabb-Baltar
- Division of Gastroenterology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Akshay Sood
- Division of Urologic Surgery, the Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, MA; Center for Outcomes Research, Analytics and Evaluation, Vattikuti Urology Institute, Henry Ford Health System, Detroit, MI
| | | | - Adam S Kibel
- Division of Urologic Surgery, the Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Julien Letendre
- Division of Urology, Université de Montréal, Montreal, Canada
| | - Mani Menon
- Center for Outcomes Research, Analytics and Evaluation, Vattikuti Urology Institute, Henry Ford Health System, Detroit, MI
| | - Jesse D Sammon
- Center for Outcomes Research, Analytics and Evaluation, Vattikuti Urology Institute, Henry Ford Health System, Detroit, MI
| | - Marianne Schmid
- Division of Urologic Surgery, the Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Maxine Sun
- Division of Urology, Université de Montréal, Montreal, Canada
| | - Quoc-Dien Trinh
- Division of Urologic Surgery, the Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Naeem Bhojani
- Division of Urology, Université de Montréal, Montreal, Canada
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Varda BK, Schmid M, Trinh QD. Predicting other-cause mortality: the minimalistic approach. Eur Urol 2014; 66:1010-1. [PMID: 25145550 DOI: 10.1016/j.eururo.2014.08.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2014] [Accepted: 08/04/2014] [Indexed: 11/15/2022]
Affiliation(s)
- Briony K Varda
- Division of Urologic Oncology and Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Marianne Schmid
- Division of Urologic Oncology and Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Quoc-Dien Trinh
- Division of Urologic Oncology and Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
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Varda BK, Cheng PJ, Cendron M, Chang SL. MP16-20 CIRCUMCISION STATUS AND HIV, HSV, AND HPV: A CONTEMPORARY ANALYSIS OF U.S. MEN USING THE NATIONAL HEALTH AND NUTRITION SURVEY (NHANES). J Urol 2014. [DOI: 10.1016/j.juro.2014.02.593] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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25
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Varda BK, Johnson EK, Clark C, Chung BI, Nelson CP, Chang SL. National trends of perioperative outcomes and costs for open, laparoscopic and robotic pediatric pyeloplasty. J Urol 2013; 191:1090-5. [PMID: 24513164 DOI: 10.1016/j.juro.2013.10.077] [Citation(s) in RCA: 74] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/10/2013] [Indexed: 02/01/2023]
Abstract
PURPOSE We performed a population based study comparing trends in perioperative outcomes and costs for open, laparoscopic and robotic pediatric pyeloplasty. Specific billing items contributing to cost were also investigated. MATERIALS AND METHODS Using the Perspective database (Premier, Inc., Charlotte, North Carolina), we identified 12,662 pediatric patients who underwent open, laparoscopic and robotic pyeloplasty (ICD-9 55.87) in the United States from 2003 to 2010. Univariate and multivariate statistics were used to evaluate perioperative outcomes, complications and costs for the competing surgical approaches. Propensity weighting was used to minimize selection bias. Sampling weights were used to yield a nationally representative sample. RESULTS A decrease in open pyeloplasty and an increase in minimally invasive pyeloplasty were observed. All procedures had low complication rates. Compared to open pyeloplasty, laparoscopic and robotic pyeloplasty had longer median operative times (240 minutes, p <0.0001 and 270 minutes, p <0.0001, respectively). There was no difference in median length of stay. Median total cost was lower among patients undergoing open vs robotic pyeloplasty ($7,221 vs $10,780, p <0.001). This cost difference was largely attributable to robotic supply costs. CONCLUSIONS During the study period open pyeloplasty made up a declining majority of cases. Use of laparoscopic pyeloplasty plateaued, while robotic pyeloplasty increased. Operative time was longer for minimally invasive pyeloplasty, while length of stay was equivalent across all procedures. A higher cost associated with robotic pyeloplasty was driven by operating room use and robotic equipment costs, which nullified low room and board cost. This study reflects an adoption period for robotic pyeloplasty. With time, perioperative outcomes and cost may improve.
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Affiliation(s)
- Briony K Varda
- Division of Urologic Surgery, and Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts; Department of Urology, Boston Children's Hospital, Boston, Massachusetts.
| | - Emilie K Johnson
- Department of Urology, Boston Children's Hospital, Boston, Massachusetts
| | - Curtis Clark
- Pediatric and Adolescent Urology, Inc., Akron, Ohio
| | - Benjamin I Chung
- Department of Urology, School of Medicine, Stanford University, Stanford, California
| | - Caleb P Nelson
- Department of Urology, Boston Children's Hospital, Boston, Massachusetts
| | - Steven L Chang
- Division of Urologic Surgery, and Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
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26
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St. Aubin M, Willihnganz-Lawson K, Varda BK, Fine M, Adejoro O, Prosen T, Lewis JM, Shukla AR. Society for Fetal Urology Recommendations for Postnatal Evaluation of Prenatal Hydronephrosis—Will Fewer Voiding Cystourethrograms Lead to More Urinary Tract Infections? J Urol 2013; 190:1456-61. [DOI: 10.1016/j.juro.2013.03.038] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/12/2013] [Indexed: 11/25/2022]
Affiliation(s)
- Melissa St. Aubin
- Amplatz Children's Hospital, University of Minnesota, Minneapolis, Minnesota
- Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Katie Willihnganz-Lawson
- Amplatz Children's Hospital, University of Minnesota, Minneapolis, Minnesota
- Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Briony K. Varda
- Amplatz Children's Hospital, University of Minnesota, Minneapolis, Minnesota
- Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Matthew Fine
- Amplatz Children's Hospital, University of Minnesota, Minneapolis, Minnesota
- Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Oluwakayode Adejoro
- Amplatz Children's Hospital, University of Minnesota, Minneapolis, Minnesota
- Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Tracy Prosen
- Amplatz Children's Hospital, University of Minnesota, Minneapolis, Minnesota
- Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Jane M. Lewis
- Amplatz Children's Hospital, University of Minnesota, Minneapolis, Minnesota
- Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Aseem R. Shukla
- Amplatz Children's Hospital, University of Minnesota, Minneapolis, Minnesota
- Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
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