Assessing the methodological and reporting quality of clinical systematic reviews and meta-analyses in paediatric urology: can practices on contemporary highest levels of evidence be built?

INTRODUCTION

Systematic reviews and meta-analyses provide a comprehensive summary of research studies and are used to assess clinical evidence, form policy and construct guidelines. This is pertinent to childhood surgery with issues of consent and condition prevalence. The aims of this study were to evaluate the methodological and reporting quality of these reviews and to identify how these reviews might guide clinical practice amongst those conditions most commonly encountered and managed by practicing paediatric urologists.

METHODS

A systematic search of the English literature was performed to identify systematic reviews and meta-analyses focusing on clinical paediatric urology (1/1/1992-1/12/2018) to include common paediatric urological conditions managed by paediatric urology residents/fellows. To these reviews, Assessing the Methodological Quality of Systematic Reviews (AMSTAR)-2 and Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) scores were applied. Univariate linear regression and descriptive statistical methods were performed.

RESULTS

From an initial literature review of 1723 articles, 227 were included in the analysis. Inter-reviewer agreement was high amongst 3 independent reviewers (κ = 0.92). Eighty-four percent of systematic reviews and meta-analyses were published since 2009 following publication of the PRISMA guidelines. The overall impact factor was 3.38 (0.83-17.58), with adherence to AMSTAR-2 criteria 48.46% and PRISMA criteria 70.1%. From a methodological perspective, 15% of reviews were of moderate quality, 65% were of low quality and 20% reviews were of critically low quality, with none found to have good quality reporting.

CONCLUSIONS

Despite the continued increase of systematic reviews and meta-analyses in paediatric urology from which many guidelines are based, a significant number of reviews contain poor methodology and, to a lesser extent, poor reporting quality. Journals should consider having specific 'a priori' criteria based on checklists before publication of manuscripts to ensure the highest possible reporting quality.

Quality of reporting and fragility index for randomized controlled trials in the vesicoureteral reflux literature: where do we stand?

BACKGROUND/INTRODUCTION

Randomized controlled trials (RCTs) are considered the "gold standard" methodology for examining the effects of clinical interventions, yet only 1% of urology literature employs this design. The Consolidated Standards of Reporting Trials (CONSORT) statement contains a standardized checklist of 37 items to be included when reporting RCTs to ensure transparency and completeness of information [2]. Despite the robust design of RCTs, the number of events can greatly change the significance of the results, which can be represented by the fragility index (FI).

OBJECTIVE

The objective was to assess the quality of reporting of RCTs in the pediatric vesicoureteral reflux (VUR) literature using the 2010 CONSORT statement and, for studies with significant positive findings, to determine the FI as a measure of robustness of the results.

STUDY DESIGN

A comprehensive search was conducted through MEDLINE® and Embase® to identify RCTs in VUR literature from 2000 to 2016. Two reviewers independently selected articles, which were evaluated using the CONSORT checklist. An overall quality of reporting score (OQS) (%) was calculated by dividing the number of checklist items present in each study by the maximum possible score (34) and expressed as a percentage. Studies were classified as low (<40%), moderate (40-70%) and high quality (>70%) based on the modified assessing the methodological quality of systematic reviews (AMSTAR) checklist. Of the 2052 initial matches, 98% were excluded due to methodology or content, a further 28 studies were found not to meet inclusion criteria after full text review. The FI was calculated for the 7 studies that met inclusion criteria with significantly different results by manually adding events to the study groups until p>0.05.

RESULTS

Twenty-two studies met inclusion criteria. The mean OQS was 46+17% with 9 (41%) identified as low quality (score <40%), 11 (50%) as moderate (40-70%) and 2 (9%) as high quality (>70%). There was no significant difference in OQS between RCTs with a sample size > 100 (n=15) versus <100 patients (n=7) (45+17% vs. 47+17%, p=0.7). However, we noted a difference when we compared RCTs with biostatistician support (n=4) vs. those without (n=18) (59+20% vs. 43+15%, p<0.05). Seven studies reported significant positive results making calculation of FI possible. The mean FI was 5.8+5.1 indicating that most studies were fragile. There was no correlation between the OQS and FI.

DISCUSSION AND CONCLUSION

The mean OQS of VUR RCTs was suboptimal (46%), with most studies having low FI scores indicating the instability of the findings. The only variable that significantly impacted the OQS was biostatistician support. Implementation of the CONSORT checklist with a minimum of 50% inclusion as a prerequisite for submission of manuscripts may improve the quality and transparency of reporting. Calculation of the FI could provide readers with an objective measure of robustness for the published trials, allowing for appropriate interpretation of the results.

Population-based trend analysis of voiding cystourethrogram ordering practices in a single-payer healthcare system before and after the release of evaluation guidelines

INTRODUCTION

While voiding cystourethrogram (VCUG) is a widely-accepted test, it is invasive and associated with radiation exposure. Most cases of primary vesicoureteral reflux (VUR) are low-grade and unlikely to be associated with acquired renal scarring. To select patients at greatest risk, in 2011 the American Academy of Pediatrics (AAP) published guidelines for evaluation of children ages 2 - 24 months with urinary tract infections (UTIs). Similarly, in 2010 the Society for Fetal Urology (SFU) published guidelines for patients with hydronephrosis. Herein a prospectively-collected database was queried through the Institute of Clinical Evaluative Sciences (ICES), exploring trends in VCUG ordering within the Ontario Health Insurance Program (OHIP), which guarantees universal access to care.

MATERIAL AND METHODS

A dedicated ICES analyst extracted data on all patients younger than 18 years in Ontario, Canada, with billing codes for VCUG and ICD-9 codes for VUR, from 2004-2014. The baseline characteristics included patient age, gender, geographic region, specialty of ordering provider and previous diagnoses of UTI and/or antenatal hydronephrosis to determine the indication for ordering the test. Of these, patients were subsequently incurred OHIP procedure codes for endoscopic injection or ureteral reimplantation. Patients who had a VCUG in the setting of urethral trauma, posterior urethral valves, and neurogenic bladder were excluded.

RESULTS AND DISCUSSION

Trend analysis demonstrated that the total number of VCUGs ordered in the province has decreased over a decade (Figure 1), with a concurrent decrease in VUR diagnosis. On multivariate regression analysis, the decrease in VCUG ordering could not be explained by changes in population demographics or other baseline patient variables. Most VCUGs obtained per year were ordered by pediatricians or family physicians (mean 2,022+523.8), compared with urologists and nephrologists (mean 616+358.3). Interestingly, while the rate of VCUG requests decreased, the annual number of surgeries performed for VUR (endoscopic or open) did not show a significant reduction over time.

CONCLUSIONS

We present a large population-based analysis in a universal access to care system, reporting a decreasing trend in the number of cystograms and differences by primary care versus specialist providers. While it is reassuring to see practice patterns favorably impacted by guidelines, it is also encouraging to note that the number of surgeries has remained stable. This suggests that patients at risk continue to be detected and offered surgical correction. These data confirm previous institution-based assessments and affirm changes in VCUG ordering independent of variables not relevant to the healthcare system, such as the insurance status.

A meta-analysis of the incidence and fate of contralateral vesicoureteral reflux in unilateral multicystic dysplastic kidney

INTRODUCTION

Multicystic dysplastic kidney (MCDK) is the most common type of renal cystic disease. It is associated with urinary tract abnormalities in the contralateral kidney in up to 30% of cases, most commonly vesicoureteral reflux (VUR).

OBJECTIVES

The objective of this study was to describe the incidence and selected issues in management and evolution for each VUR grade in the contralateral kidney of patients with unilateral MCDK, in order to strengthen the scientific basis regarding the need for voiding cystourethrography (VCUG) screening.

METHODS

A comprehensive search of standard and gray literature was performed. Full-text screening, data abstraction, and quality appraisal were conducted in duplicates. Included studies reported a primary diagnosis of unilateral MCDK with contralateral VUR determined by VCUG. Articles had to include a distribution of VUR grade to meet the eligibility criteria.

RESULTS

From 698 retrieved articles, 37 studies enrolling 2057 patients were analyzed. Of the patients, 80% were male; 50% had left unilateral MCDK; and 87% were diagnosed prenatally. A total of 1800 patients had VCUG, of whom 303 had VUR (weighted proportion: 17%; 95% confidence interval [CI]: 14-20%). Weighted proportions of VUR were 9%, 7%, and 17% for grades I-II, III-V, and I-V, respectively. Of the patients, 99% (95% CI: 97-100%) were on continuous antibiotic prophylaxis (CAP) and 18% (95% CI: 8-37%) had urinary tract infections (UTIs), with a higher rate of UTIs (23% vs 10%) in patients with dilating (grades III-V) VUR, over a mean follow-up of 40 months. In patients with dilating VUR, reflux resolved or downgraded to grade I in 52% (95% CI: 37-67%) of patients, and 32% (95% CI: 19-49%) had surgical correction of VUR.

CONCLUSIONS

Among patients with unilateral MCDK, 17% have VUR in the contralateral kidney, 41% of which is dilating VUR. Of the cases with dilating VUR, half will resolve or downgrade to grade I during follow-up; 23% will develop a UTI despite CAP; and one-third will undergo ureteral re-implantation. While many physicians may thus choose to forego routine VCUG screening of the single functional kidney, shared decision-making with the patient's caregivers is currently recommended, where the risks and benefits of the different approaches can be discussed. The data from this analysis can help inform the discussions.

Open ureteroureterostomy for repair of upper-pole ectopic ureters in children with duplex systems: is stenting really necessary?

BACKGROUND

Ectopic upper-pole (UP) ureters in duplex kidneys can be managed surgically by ipsilateral distal ureteroureterostomy (U-U) with or without ureteric stenting. Evidence to support routine stenting during this procedure is lacking.

OBJECTIVE

The authors present their outcomes of children with ectopic UP ureters who underwent ipsilateral distal U-U. They also compared outcomes of those who underwent routine ureteric stenting to those who did not.

STUDY DESIGN

Between 2009 and 2015, the authors performed a prospective analysis on consecutive patients with duplex collecting systems who underwent distal U-U via an inguinal incision for ectopic UP ureters by one of two pediatric urologists. The demographic information, operative factors, and any postoperative complications on follow-up were recorded.

RESULTS

The study included 47 patients (28 female) who underwent distal U-U with a mean age of 9.8 months. There were 30 patients who were routinely stented, and 17 who were not based on the routine practices of the operating surgeons without any selection bias. The mean operative time was 90 min, and the mean hospital stay was 0.9 days. No major complications were observed in this series, with 96% of patients showing resolution of hydronephrosis. There were no statistical differences between the stented and stentless U-U groups in terms of operative time, hospital stay, hydronephrosis resolution, time to resolution of hydronephrosis, and major complications. Only stented patients were found to have minor complications (2-urinary tract infection, 2-dysuria, and 2-stent displacement). All patients who underwent routine stent placement required a secondary planned procedure under general anesthesia for the cystoscopic removal of stent.

CONCLUSION

Stenting was associated with a higher number of minor complications compared to the stentless group and thus, may not be routinely necessary when performing distal U-U for management of UP ectopic ureters associated with duplicated collecting systems.

The impact of a bladder training video versus standard urotherapy on quality of life of children with bladder and bowel dysfunction: A randomized controlled trial

INTRODUCTION

Bladder and bowel dysfunction (BBD) can negatively impact the quality of life (QoL) of children. Urotherapy is an accepted treatment option for BBD; however, literature that examines the impact of management options on QoL in this population is scarce.

OBJECTIVE

To determine whether a bladder training video (BTV) is non-inferior to standard urotherapy (SU) in improving QoL in children with BBD.

METHODS

Children aged 5-10 years and who scored ≥11 on the Vancouver Non-Neurogenic Lower Urinary Tract Dysfunction/Dysfunctional Elimination Syndrome Questionnaire (NLUTD/DES) were recruited from a pediatric tertiary care center. Children were excluded with known vesicoureteral reflux; spinal dysraphism; learning disabilities; recent urotherapy; and primary nocturnal enuresis. Quality of life was evaluated using the Pediatric Incontinence Quality-of-Life questionnaire (PinQ). Questionnaires were administered at the baseline and 3-month follow-up clinic visits. Following centralized electronic blocked randomization schemes to guarantee allocation concealment, patients were assigned to receive SU or BTV during their regular clinic visits. An intention-to-treat protocol was followed. Between-group baseline and follow-up QoL scores were compared using paired and unpaired t-tests, and linear regression analysis.

RESULTS

Of the 539 BBD patients who were screened, 173 (32%) were eligible, and 150 (87%) were randomized. Of these, 143 (96%) completed the study, five (3%) were lost to follow-up, and two (1%) withdrew. In total, 140/143 (97%) completed the QoL questionnaire at baseline and follow-up. Mean follow-up time was 3.5 ± 1.1 months for BTV patients and 3.7 ± 1.6 months for SU. At baseline, BTV and SU patients had a mean QoL score of 26.6 ± 13 and 23.8 ± 12, respectively (P = 0.17). Between-group mean change in PinQ scores from baseline was not statistically significant (BTV: 6.25 ± 12.5 vs SU: 3.75 ± 12.2; P = 0.23; Summary Fig.). Significant predictors of positive change in QoL were: higher symptomatology score, with a correlation coefficient of 0.5 (95% CI: 0.2-0.9; P = 0.003), and worse baseline QoL score, with a correlation coefficient of 0.5 (95% CI: 0.4-0.7; P < 0.001). Overall, most patients had improved symptomatology and QoL scores.

CONCLUSION

Significant and similar QoL changes from baseline to follow-up were observed in both the BTV and SU groups, suggesting that BTV was non-inferior to SU in improving QoL in children with BBD. Quality of life assessment should be considered when evaluating interventions for BBD, as it appears to be an important clinical outcome with which to determine urotherapy success.

Percent improvement in renal pelvis antero-posterior diameter (PI-APD): Prospective validation and further exploration of cut-off values that predict success after pediatric pyeloplasty supporting safe monitoring with ultrasound alone

INTRODUCTION

Renograms are frequently obtained post-pyeloplasty in patients with residual hydronephrosis to confirm adequate drainage. Recent evidence suggests that percent improvement in antero-posterior diameter (PI-APD) ≥38 is predictive of success. We sought to further explore PI-APD ranges that would allow identification of patients who would benefit from ultrasound (US) monitoring alone vs. post-operative renal scan, and those more likely to develop recurrent ureteropelvic junction obstruction (rUPJO).

METHODS

A single-center prospectively-collected pyeloplasty database (2008-2015) was queried (n = 151). Only patients with both pre- and post-operative APD measurements were included (n = 138). PI-APD was divided into 3 categories: <20%; 20-39%; ≥40%. The following variables were collected post-operatively: patients monitored with US alone, renogram and US, rUPJO and minimal or resolved hydronephrosis (SFU ≤2; UTD ≤1; APD ≤15 mm).

RESULTS

Mean age at first and last follow-up were 4.8 (median 4.0; range 0-60) months and 26.6 (median 20.5; range 1-77) months, respectively. Of 138 patients, 84 (61%) had US alone, 54 (39%) had a renogram and US post-operatively, and 6 (4%) developed rUPJO. Of 84 patients who had US alone, 71 (84%; p < 0.01) demonstrated ≥40% PI-APD. Of 54 patients with renogram and US 46 (85%; p < 0.01) had ≥40 PI-APD. Of the 6 patients who developed rUPJO, all were in the <20 PI-APD group (100%; p < 0.01). Resolution of hydronephrosis according to SFU, UTD and APD occurred in 96/138 (70%), 89/138 (64%) and 113/138 (82%) patients respectively. Of these, 87 (91%), 81 (91%), and 108 (95%) occurred in >40% PI-APD group.

CONCLUSION

≥40% PI-APD at the first post-operative visit strongly predicts pyeloplasty success, as up to 82% of these patients showed resolved hydronephrosis and 61% underwent non-invasive monitoring by US alone. Our data suggests that up to 85% of renograms may have been unnecessary. Finally, <20% PI-APD permitted identification of all rUPJO cases. Stratification of patients based in PI-APD is a promising strategy for further minimizing radiation exposure while safely detecting children at risk for rUPJO.

Economic analysis of continuous antibiotic prophylaxis for prevention of urinary tract infections in infants with high-grade hydronephrosis

BACKGROUND

For infants with hydronephrosis, continuous antibiotic prophylaxis (CAP) may reduce urinary tract infections (UTIs); however, its value remains controversial. Recent studies have suggested that neonates with severe obstructive hydronephrosis are at an increased risk of UTIs, and support the use of CAP. Other studies have demonstrated the negligible risk for UTIs in the setting of suspected ureteropelvic junction obstruction and have highlighted the limited role of CAP in hydronephrosis. Furthermore, economic studies in this patient population have been sparse.

OBJECTIVE

This study aimed to evaluate whether the use of CAP is an efficient expenditure for preventing UTIs in children with high-grade hydronephrosis within the first 2 years of life.

STUDY DESIGN

A decision model was used to estimate expected costs, clinical outcomes and quality-adjusted life years (QALYs) of CAP versus no CAP (Fig. 1). Cost data were collected from provincial databases and converted to 2013 Canadian dollars (CAD). Estimates of risks and health utility values were extracted from published literature. The analysis was performed over a time horizon of 2 years. One-way and probabilistic sensitivity analyses were carried out to assess uncertainty and robustness.

RESULTS

Overall, CAP use was less costly and provided a minimal increase in health utility when compared to no CAP (Table). The mean cost over two years for CAP and no CAP was CAD$1571.19 and CAD$1956.44, respectively. The use of CAP reduced outpatient-managed UTIs by 0.21 infections and UTIs requiring hospitalization by 0.04 infections over 2 years. Cost-utility analysis revealed an increase of 0.0001 QALYs/year when using CAP. The CAP arm exhibited strong dominance over no CAP in all sensitivity analyses and across all willingness-to-pay thresholds.

DISCUSSION

The use of CAP exhibited strong dominance in the economic evaluation, despite a small gain of 0.0001 QALYs/year. Whether this slight gain is clinically significant remains to be determined. However, small QALY gains have been reported in other pediatric economic evaluations. Strengths of this study included the use of data from a recent systematic review and meta-analysis, in addition to a comprehensive probabilistic sensitivity analysis. Limitations of this study included the use of estimates for UTI probabilities in the second year of life and health utility values, given that they were lacking in the literature. Spontaneous resolution of hydronephrosis and surgical management were also not implemented in this model.

CONCLUSION

To prevent UTIs within the first 2 years of life in infants with high-grade hydronephrosis, this probabilistic model has shown that CAP use is a prudent expenditure of healthcare resources when compared to no CAP.

Congenital adrenal hyperplasia: a critical appraisal of the evolution of feminizing genitoplasty and the controversies surrounding gender reassignment

Although congenital adrenal hyperplasia (CAH) is the most common cause of genital ambiguity, its surgical treatment remains controversial and often times difficult, especially in cases of high urethro-vaginal confluence. Many aspects are still uncertain, such as the timing of feminizing genitoplasty and type of surgical technique. The objective of this study is to provide a thorough review of the surgical management of children with CAH, discussing the evolution of feminizing genitoplasty and its different techniques, and also to critically appraise the available literature on the timing of surgical intervention and gender reassignment. Prospective long-term studies evaluating the results of modern feminizing genitoplasty techniques are needed as current evidence is based on outdated operations that are no longer used. To date, there have been no studies comparing early and delayed feminizing genitoplasty with regard to psychological outcomes. All families should be counseled regarding the controversies and treatment options, including the watchful waiting approach.

Patency of the "third inguinal ring" in children with unilateral cryptorchidism: fact or fiction?

BACKGROUND

The entrance to the scrotum, or the so-called "third inguinal ring" (3rd IGR), was thought to be an important finding and etiological factor for cryptorchidism at the beginning of the 20th century. Historical reports of its association with undescended testis suggest that it was considered by many to be a true anatomical entity. As the understanding of testicular descent has changed, the description of this anatomical passage has vanished from textbooks and publications. In order to evaluate the findings that led to its original report, we sought to assess the patency of the expected testicular path of descent into the scrotum in children with unilateral cryptorchidism.

METHODS

Two hundred consecutive children who underwent unilateral orchidopexy were prospectively evaluated at the time of surgery to determine the anatomical patency of the area thought to represent the 3rd IGR. We also evaluated its association with the patient's age at surgery, the affected side, position of the undescended testis, macroscopic epididymal anomalies (MEA), and the patency of the processus vaginalis (PV).

RESULTS

The mean age at surgery was 5.2 +/- 3.0 years, ranging from 1 to 13 years. The 3rd IGR was closed in 118 boys (59.0 %) and open in 82 (41.0 %). A closed 3rd IGR was found significantly more frequently in patients with intra-abdominal testes (p < 0.01). No significant association was observed between patency of the 3rd IGR and other evaluated factors.

CONCLUSION

Our results suggest that the so-called 3rd IGR may represent the passage point of the testicle into the scrotum, which was not patent during the intraoperative examination in (2/3) of children with unilateral cryptorchidism. This observation by surgeons at the beginning of the 20th century may represent an anatomical curiosity rather than an important factor in the pathogenesis of cryptorchidism.

Biliary ascariasis after Roux-en-Y hepaticojejunostomy

The authors report on a 6-year-old girl with biliary ascariasis after surgical treatment of a choledochal cyst and biliary-digestive tract reconstruction by Roux-en-Y hepaticojejunostomy. A precise diagnosis can be obtained by ultrasonography. Surgical treatment is required when clinical and endoscopic treatments fail. In countries in which this disease is endemic, biliary ascariasis should be considered in the differential diagnosis of cholangitis after surgery for hepaticojejunostomy.

Laparoscopic diagnosis and treatment of splenogonadal fusion associated with intra-abdominal cryptorchidism in a child

The authors describe the surgical findings and laparoscopic treatment in a child with splenogonadal fusion associated with intra-abdominal cryptorchidism. Laparoscopy was shown to be an excellent method for the diagnosis and treatment of this condition. No reports of similar cases using the technique were found in the literature.