Increase in robot assisted operating room efficiency: A quality improvement study

INTRODUCTION

Pyeloplasties are time-sensitive, and the most common robot assisted intervention performed in pediatric urology. Early intervention is intended to avoid permanent loss of renal function with negative long-term effects if surgery is delayed when indicated. A need to increase capacity has become a premium value in patient care.

OBJECTIVE

Our aim was to reduce operative time, providing value by reducing total robotic console time in robot assisted pyeloplasty (RP) cases. We hypothesized that process improvement and supply management during RP leads to a significant reduction in operative time.

METHODS

Intraoperative surgical workflow was reviewed and routine tasks performed during the various sections were selected with the goal of reducing Operating room inactivity. We focused on robotic arm activity, and total operative time to assess our outcomes. Our intervention was to standardize an OR staff task list, a priori supply inventory procurement for each anticipated major step in the case, confirmed prior to each major step. Baseline RP duration data for a single Pediatric Urologist were identified and recorded before any interventions. A clinical standard work (CSW) was developed based on optimization of equipment/supplies for the RP procedure, compartmentalized into the 8 key steps for RP. These major steps included: patient positioning, docking, retroperitoneal and ureteral dissection, hitch stitch, pyelotomy, stent placement, and anastomosis. Balancing measures included percentage trainee console use, preparatory time, and OR block start/end time. Baseline data for RP cases performed between 11/2020 and 2/2022 were automatically extracted from charts and analyzed using AdaptX (Seattle, WA). Post-intervention was between 3/2022 to 3/2023. Mann-WhitneyU was used for continuous variables for non-parametric distribution.

RESULTS

37 patients underwent RP during the study period. 15 cases were performed prior to intervention and 22 post intervention Total console time prior to intervention was 152 vs 109 min after intervention (p = 0.0002). Dual instrument inactivity was reduced from 13.1 % to 7.1 % (p < 0.0001). Dual consoles were used in 40 % vs ∼69 % pre-vs post-intervention, respectively (p = 0.5000). No difference in patient age distribution between groups was seen (p = 0.1498). Trainee operative time did not differ statistically pre- and post-intervention (63.0 vs 48.6 %, p = 0.0871).

CONCLUSIONS

Decreasing surgical lapses and standardizing intraoperative tasks can result in more efficient case completion, potentially increasing OR capacity.

Putting the coach in the game: Current and future state of surgical coaching in pediatric urology

BACKGROUND

Surgical coaching has been proposed as a mechanism to fill gaps in proficiency and encourage continued growth following formal surgical training. Coaching benefits have been demonstrated in other surgical fields; however, have not been evaluated within pediatric urology. The aims of this study were to survey members of The Societies for Pediatric Urology (SPU) to assess the current understanding and utilization of surgical coaching while gauging interest, potential barriers and personal goals for participation in a coaching program.

METHODS

Following IRB approval, members of the SPU were invited to electronically complete an anonymous survey which assessed 4 domains: 1) understanding of surgical coaching principles, 2) current utilization, 3) interest and potential barriers to participation, and 4) personal surgical goals. To evaluate understanding, questions with predefined correct answers on the key principles of coaching were posed either in multiple choice or True/False format to the SPU membership.

RESULTS

Of the 674 pediatric urologists invited, 146 completed the survey (22%). Of those, 46% correctly responded the definition of surgical coaching. Coaching utilization was reported in 27% of respondents currently or having previously participated in a surgical coaching program. Despite current participation rates, only 6 surgeons (4%) have completed training in surgical coaching, despite 79% expressing interest to participate in a surgical coaching program. The most influential barrier to participating in a coaching program was time commitment. Respondents largely prioritized technical and cognitive skill improvement as their primary goals for coaching (see figure below).

CONCLUSIONS

While interest in surgical coaching is high among pediatric urologists, the principles of surgical coaching were not universally understood. Furthermore, formal coach training is markedly deficient, representing a gap in our profession and an opportunity for significant avenues for improvement, especially for technical and cognitive skills. Development of a coaching model based on these results would best suit the needs of pediatric urologists providing that the time commitment barrier for these endeavors can be mitigated and/or reconciled.

Standardization and Implementation of a Surgical Coaching Model for Pediatric Urology

To bridge gaps in proficiency and encourage life-long learning following training, coaching models have been utilized in multiple surgical fields; however, not within pediatric urology. In this review of our methodology, we describe the development of a coaching model at a single institution. In our initial experience, the perceived most beneficial aspect of the program was the goal setting process with logistics around debriefs being the most challenging. With our proposed coaching study, we aim to develop a model based upon prior coaching frameworks,1,2 that is feasible and universally adaptable to allow for further advancement of surgical coaching, particularly within the field of pediatric urology.

Reducing post-operative caregiver after-hours phone calls to pediatric urology providers: A quality improvement study

INTRODUCTION

Caregiver phone calls are an important part of caring for pediatric patients. At our institution, residents respond to after-hours caregiver calls. While it is critical for families to be able to reach us for urgent concerns, the ease of access has led to overutilization with many phone calls not meeting the urgent nature that is intended for these calls. The primary aim of this quality improvement project was to decrease the number of non-urgent caregiver calls after-hours. Our secondary aim was to improve compliance with telephone encounter documentation and to standardize the documentation content.

STUDY DESIGN

We conducted a single institution, multiphase quality improvement project. This started with a preintervention phase which included evaluation of our current state, identifying that most calls were for post-operative patients and that our discharge instructions inadequately detailed when caregivers should call. Notes were also inconsistently documented with no standard format. In the first PDSA cycle, launched on November 1, 2021, a standardized note template was created for documentation of caregiver telephone encounters. The PDSA cycle began on January 1, 2022 and included updates to our post-operative instructions with explicit guidance detailing when to call after-hours. Call data from September 2021 to February 2022 was reviewed including variables such as caller demographics, reason for call, and operative details. Primary outcomes were proportion of post-operative calls within 30 days and non-urgent calls. Secondary outcome was proportion of calls documented appropriately. Phases were categorized as current state (Sep/Oct 2021), PDSA cycle 1 (Nov/Dec 2021), PDSA cycle 2 (Jan/Feb 2022).

RESULTS

In our current state, the majority of the calls (66%) were for post-operative patients and 59% of all calls during this period were non-urgent. The proportion of post-operative phone calls stayed stable at 67% during PDSA cycle 1, but decreased to 38% with PDSA cycle 2 with implementation of updated post-operative instructions (Summary figure) (p < 0.001). The proportion of non-urgent calls was similar (current state - 68%, PDSA cycle 1 - 72%, PDSA cycle 2-73%, p = 0.39) (Summary figure). Call documentation was also similar with a documentation rate of 79% pre-intervention and 87% post-intervention (p = 0.21) (Summary figure).

CONCLUSIONS

With interventions focused on post-operative caregiver instructions, the number of post-operative phone calls decreased. Standardization of documentation was achieved. However, the overall call volume did not change, nor the proportion of non-urgent calls.

Long term renal outcome and risk of elevated blood pressure in children undergoing complete primary repair of bladder exstrophy (CPRE)

INTRODUCTION

Since the initiation of staged reconstruction for bladder exstrophy (BE), hypertension has been a known complication of the procedure. Hypertension is a well-established risk factor for chronic kidney disease (CKD) progression and associated with cardiovascular/cerebrovascular morbidity and mortality. Few studies exist evaluating the risk of developing hypertension among patients with bladder exstrophy who underwent CPRE. We hypothesized that long-term blood pressure levels may be elevated in males vs females, and may be correlated with presence of hydronephrosis, bladder neck reconstruction, or continence status.

OBJECTIVE

We sought to revisit our long-term experience with CPRE and determine factors associated with incidence of elevated blood pressures.

METHODS

We reviewed all BE patients undergoing CPRE at our institution from 1999 to 2019. Patients were considered eligible for inclusion if last renal ultrasound was obtained at least 5 years after repair. Upper tract outcomes based on imaging, history of pyelonephritis and renal function tests measured by serum creatinine and estimated glomerular filtration rate (eGFR, Schwartz formula) were reviewed. Systolic/diastolic blood pressures (SBP/DBP) from all encounters were captured. All blood pressure values were age adjusted by percentile.

RESULTS

A total of 36 patients were considered eligible for review. Median follow-up of this cohort was 10.01 (5.16-21.47) years. The mean creatinine for the patients available was 0.58 mg/dL (SD = 0.20), at mean age of 8.90 years Neither SBP or DBP were significantly elevated in males vs females, but had lower odds of elevation >90th percentile for those with higher eGFR, lower renal length, and reimplantation. Pyelonephritis incidence was 38% (n = 14) with first episode at mean age of 8.8 years, and mean of 3.7 episodes per patient.

DISCUSSION

At long term follow up, blood pressures following CPRE were not significantly elevated, despite the relatively frequent occurrence of CKD, and hydronephrosis. Male gender does appear to suggest higher risk for long-term deterioration in this regard. Higher eGFR, higher renal length, and presence of ureteral reimplantation were associated with lower likelihood of systolic/diastolic blood pressure elevation. Continence status and bladder neck reconstruction were not associated with likelihood of blood pressure elevation.

CONCLUSIONS

Blood pressure and upper-tract outcomes for patients undergoing CPRE at birth are positive for the majority of patients. To avoid complications from hypertension, patients should be closely evaluated as the risks associated with elevated blood pressure are significant. Ultimately, larger-scale prospective and multi-institutional studies are further needed to characterize risks of hypertension in this complex patient population.

Kidney function outcomes in patients after complete primary repair of bladder exstrophy and penopubic epispadias: Results from the international bladder exstrophy consortium

INTRODUCTION

Historically, repair of bladder exstrophy (BE) is associated with compromise to the upper tracts; the single stage repair of BE was considered to exacerbate risks of kidney impairment.

OBJECTIVE

We aim to evaluate the risk of upper urinary tract deterioration or chronic kidney disease after the complete primary repair of exstrophy (CPRE).

STUDY DESIGN

As part of the U.S.-India Multi-institutional Bladder Exstrophy Collaboration, we prospectively performed data collection on all patients managed at the Civil Hospital, Ahmedabad from 2010 to 2020. All patients who underwent primary or redo BE or primary penopubic epispadias (PE) repair using CPRE were included. Data on annual VCUG and DMSA, serum creatinine and cystatin-C, urinary albumin, and creatinine were aggregated.

RESULTS

72/104 patients who underwent CPRE at a median age of 1.7 years (IQR: 1.1-4.6) were included: 43(60%) patients with primary BE, 17(24%) with redo BE, and 12(17%) with primary PE. At a median follow-up of 4 years (IQR: 3-6), the overall median eGFR was 105 for BE, and 128 ml/min for PE. 14(19%) patients had eGFR<90, and 22(31%) had microalbuminuria. 21(30%) patients had kidney scarring in DMSA and 31(44%) had VUR. Multivariate analysis showed that neither kidney scarring nor VUR could predict the presence of eGFR<90 or microalbuminuria. Of 72 patients, 2 (3%) patients had dry intervals >3 h, 9 (13%) patients have dry intervals of 1-3 h and 44 (61%) patients had dry intervals <1 h during follow-up. We found that kidney function outcomes (i.e., eGFR and microalbuminuria) were not associated with continence status (p = 0.3).

DISCUSSION

In this series, we report a 5% incidence of CKD stage 2 or above that was not impacted by continence status. Furthermore, a 40% incidence of VUR and a 30% incidence of kidney scarring during follow-up was observed within this cohort, neither of which had a significant impact on renal function deterioration (i.e, decline in eGFR), but underscores the need for close kidney surveillance in children that have undergone bladder exstrophy repair.

CONCLUSIONS

Modern CPRE technique for the repair of BE may increase the risk of kidney scarring in the intermediate-term follow-up, however, this finding does not correlate with low eGFR and presence of albuminuria inpatients. Therefore, close follow-up with serial kidney function measurements is warranted and necessary after CPRE.

Short term reoperation rates after artificial urinary sphincter placement in pediatric patients

INTRODUCTION

Artificial urinary sphincters (AUS) have demonstrated good functional outcomes in pediatric populations. We sought to examine the nationwide short term reoperation rates in pediatric patients after AUS placement.

MATERIALS AND METHODS

An observational cohort study was designed utilizing claims from the Truven MarketScan Commercial Claims and Encounters database from 2007 to 2018. Patients under 18 years of age undergoing an AUS procedure were identified using CPT and ICD9/10 codes. Reoperations included any removal, replacement, or AUS placement codes which occurred after the initially identified placement code. Follow up time was the amount of time between AUS placement and the end of MarketScan enrollment.

RESULTS

From 2007-2018, we identified 57 patients under the age of 18 who underwent AUS placement and after excluding 8 for concurrent AUS complication procedure codes and 4 for follow up < 60 days, the final cohort included 45 patients. The median age was 13 years (IQR 9-16 years) at the time of AUS placement, and the median follow up time after AUS placement was 787 days (IQR 442-1562 days), approximately 2.2 years. Total reoperation rate was 22%. Reoperations included 40% device removals (4/10) and 60% replacements (6/10). Neither gender (p = 0.70) nor age (p = 0.23) was associated with need for reoperation. Patients who had a concurrent bladder surgery had a higher rate of undergoing reoperation (50% vs. 12%, p = 0.007).

CONCLUSIONS

The rate of reoperation after AUS placement approached 1 in 4 in pediatric patients. These data may be instrumental for providers and parents in counseling and decision-making regarding risks of prosthetic implantation.

Recovering from COVID - Improving operating room capacity

INTRODUCTION

COVID-19 pandemic required that health systems made great efforts to mitigate the impact of high demands of patients requiring treatment. Triaging surgical cases reduced operating room capacity. Immunizations, massive testing, and personal protective equipment enabled re-activation of operating rooms. Delayed and newly added cases has placed stress on the system. We hypothesize that standardization in practice for tasks performed between anesthesia ready and surgery start time, also known as "prepping time", can reduce operative time, improve efficiency and increase capacity. The aim of our project was to create and implement a best practice standardized prepping protocol, to explore its impact on operating room capacity.

METHODS

Once local policies allowed re-opening of the operating rooms, our multidisciplinary group developed a working plan following Adaptive Clinical Management (ACM) principles to optimize surgical prepping time. Using electronic medical record (EMR) data, surgeons with the lowest surgical prepping times were identified (positive deviants). Their surgical prepping time workflows were reviewed. A clinical standard work (CSW) protocol was created by the team leader. New CSW protocol was defined and implemented by the leader and then by the rest of the surgeons. Baseline data was automatically extracted from EMR and analyzed by statistical process control (SPC) charts using AdaptX. Balancing measures included "last case end time" and rates of surgical site infections.

RESULTS

A total of 2506 patients were included for analysis with 1333 prior to intervention and 1173 after. Team leader implementated the new CSW prepping protocol showing a special cause variation with an average time improvement from 14.6 min to 11.6 min and for all surgeons from 13.8 to 12.0 min. Total cases per month increased from 70 to 90 cases per month. Baseline 'Last Case End Time' was 15.7 min later than the scheduled. New CSW improve end time with an average of 20.8 min before the schedule. Baseline surgical site infection was 0.1% for the study population. No difference was seen after implementation.

DISCUSSION

Variations in performance can be quantified using funnel plots showing individual practices allowing best practice to be identified, tested and scaled. Implementation of our surgical prepping time protocol showed a sustainable increase in efficiency without affecting quality, safety or workload. This additional increase is estimated to represent approximately $2-2.5M additional revenue per year.

CONCLUSION

Adaptive clinical management is a practical solution to increase OR capacity by improving efficiency to reduce extra burden presented during COVID19 pandemic.

Understanding why caregivers call after ambulatory pediatric urologic surgery

INTRODUCTION

To uncover factors associated with an increased likelihood of a postoperative triage phone call from caregivers after pediatric ambulatory urologic surgery with a focus on social determinants of health.

MATERIALS AND METHODS

This was a retrospective cohort study from July 2014-January 2020. Patients undergoing ambulatory urologic surgery by three different pediatric urologists were included. The primary outcome was the number of patient families that called within 30 days after surgery. Univariable tests and multivariable logistic regression analysis were used to identify factors associated with the increased likelihood of a postoperative phone call.

RESULTS

The families of 460 patients out of 1618 patients called at least once within 30 days of surgery (28%). There were 665 total calls, an average number of 1.5 (SD+/-0.8) phone calls per family. Families who live further away (OR 0.66, 95%CI 0.46-0.93), who do not speak English as a primary language (OR 0.61, 95%CI 0.38-1.00), and who were Native American/Alaskan Native (OR 0.33, 95%CI 0.11-0.99) were less likely to call after surgery. Those with commercial insurance (OR 1.42, 95%CI 1.09-1.85), recovering from non-hypospadias penile surgery (OR 3.20, 95%CI 2.46-4.32), or from hypospadias repair (OR 5.14, 95%CI 3.28-8.18) were more likely to call after surgery.

CONCLUSIONS

Nearly 1 in 3 families call the hospital triage line after ambulatory urologic surgery with postoperative concerns. Families with children who undergo penile surgery are 3-5 times more likely to call after surgery. Social determinants of health may have a role in postoperative phone call rates as medically underserved patients are less likely to call.

Caregiver distress: A mixed methods evaluation of the mental health burden of caring for children with bladder exstrophy

INTRODUCTION

Caring for children with bladder exstrophy-epispadias complex (BEEC) exacts a long-term emotional toll on caregivers. Previous studies leave a gap in understanding the impact that caring for a child with BEEC has on caregivers in low- and middle-income countries (LMIC). We hypothesize that families and caregivers experience psychological distress that has long gone unaddressed.

MATERIALS AND METHODS

From 2018 to 2020, researchers conducted a multi-method evaluation of caregiver distress with participants recruited as part of the annual International Bladder Exstrophy Collaboration based in Ahmedabad, Gujarat, India. In 2018, pilot data was collected through cognitive interviews. In 2019, researchers conducted structured interviews predicated on themes from the previous year, which subsequently prompted formal mental health screenings in 2020. Caregivers who reported suicidal thoughts were immediately referred for intervention.

RESULTS

In 2018, caregivers described the primary source of stigma arose from their village (n = 9, 26.5%). Caregivers also identified long-term concerns (n = 18, 52.9%), including future fertility and marital prospects, as sources of anxiety. In 2019, caregivers substantiated preliminary findings with the primary source of anticipated (n = 9, 31%) and experienced (n = 19, 65.5%) stigma again stemming from their communities. Both cohorts identified the collaboration as a positive source of support (n = 23, 36.5%). In 2020, caregivers stated decreased emotional wellbeing as number of subsequent repairs increased (n = 54, 75%, p = 0.002). Caregivers of children who underwent initial surgery within 5 years of screening reported higher anxiety (n = 46, 63.8%) and this was exacerbated as the number of subsequent repairs increased (p = 0.043).

CONCLUSION

Complex, long-term course of care, including additional surgeries, significantly impacts caregiver distress in the LMIC setting. Screening for caregivers of children with complex congenital anomalies, like BEEC, should be an essential element of any comprehensive effort to alleviate the global burden of disease.

Urinary continence disparities in patients with anorectal malformations

PURPOSE

While fecal incontinence is a primary concern for many children with anorectal malformations (ARM), urinary incontinence is also prevalent in this population. Racial, ethnic, and socioeconomic disparities in urinary continence have been observed in other conditions, but have not been previously evaluated in ARM. We aimed to evaluate urinary continence and associated demographic and socioeconomic characteristics in individuals with ARM.

METHODS

We performed a multicenter retrospective study of ARM patients evaluated at sites participating in the Pediatric Colorectal and Pelvic Learning Consortium (PCPLC).  We included all patients with ARM 3 years and older. The primary outcome was urinary continence which was categorized as complete (no accidents), daytime (accidents at night), partial (rare or occasional accidents), and none (frequent accidents or no continence). We evaluated for associations between urinary continence and race, sex, age, insurance status, and adoption status, employing Kruskal-Wallis and trend tests. Secondary outcomes included bladder management strategies such as clean intermittent catheterization and continence surgery. P-value < 0.05 was considered significant.

RESULTS

A total of 525 patients with ARM were included. Overall, 48% reported complete urinary continence, and continence was associated with greater age. For school-aged children (age ≥ 5 years), 58% reported complete continence, while 30% reported none. Public insurance and adoption status were associated with decreased likelihood of incontinence.

CONCLUSIONS

We observed a novel finding of disparities in urinary continence for children with ARM related to insurance and adoption status. Further investigation regarding the etiologies of these inequities is needed in order to affect clinical outcomes.

Long-term urological and gynecological outcomes following complete primary repair in females with bladder exstrophy

INTRODUCTION

Long-term continence outcomes in patients undergoing complete primary repair of exstrophy (CPRE) have shown that a subset of patients do not achieve continence until after puberty. We aim to update the continence outcomes as well as describe gynecological outcomes for females having undergone CPRE.

MATERIALS AND METHODS

This was a retrospective review between 1989 and 2019 at a single institution. Inclusion criteria were females with classic bladder exstrophy who underwent CPRE. Exclusion criteria were variant diagnoses and age <4 years. Continence was defined as dry for ≥3 h (volitional voiding or clean intermittent catheterization (CIC)). Partial continence was defined as minor stress incontinence or enuresis. Vaginal stenosis was evaluated in post-pubertal patients.

RESULTS

Eighteen patients met inclusion criteria. Median age at last follow-up was 15.9 years (IQR 13.1, 18.4). All patients underwent primary closure <30 days of life (n = 18). Subsequent procedures included bladder augmentation (n = 4), continent catheterizable channel (n = 7), bladder neck injections (n = 12) and bladder neck reconstruction (n = 12). Continence and partial continence were achieved in 6/18 (33.3%) and 9/18 (50.0%), respectively, with mean 3.2 ± 2.5 continence procedures at 9.6 years (IQR 7.3, 15.2). Volitional voiding was seen in 11/18 (61.1%) and 7/18 (38.9%) performed CIC, with no significant difference in continence. Mean bladder capacity was 199 ml ± 96 versus 90 ml ± 29 in the volitional voiding versus CIC group (P = 0.0047). Eleven women with median age of 18.0 years (IQR 15.2, 21.4) had recorded menarche: 6/11 (54.5%) patients reported painful/irregular menses, controlled with hormonal therapy. Six of 11 (54.5%) women had vaginal stenosis managed with vaginal dilation (n = 2) or vaginoplasty (n = 4). Three (27.3%) reported tampon use and penetrative intercourse.

CONCLUSION

Overall, the majority of women who have undergone CPRE achieved complete or partial continence, though most required additional procedures and time to attain it. Additionally, volitional voiding was achievable. Bladder capacity was significantly lower in patients dependent on CIC. Most required medical or surgical interventions for gynecologic concerns post menarche. This study underscores the unique needs of girls and young women with bladder exstrophy and further supports the importance of close long-term urologic and gynecologic management throughout development.

Experiences and attitudes of young adults with congenital bowel and bladder conditions

INTRODUCTION

Young adults with complex congenital bowel and bladder anomalies are a vulnerable population at risk for poor health outcomes. Their experiences with the healthcare system and attitudes towards their health are understudied.

OBJECTIVE

Our objective was to describe how young adults with congenital bladder and bowel conditions perceive their current healthcare in the domains of bladder and bowel management, reproductive health, and transition from pediatric to adult care.

STUDY DESIGN

At a camp for children with chronic bowel and bladder conditions, we offered a 50-question survey to the 62 adult chaperones who themselves had chronic bowel and bladder conditions. Of the 51 chaperones who completed the survey (a response rate of 82%), 30 reported a congenital condition and were included.

RESULTS

The cohort of 30 respondents had a median age of 23 years and almost half of the subjects (46%) reported not having transitioned into adult care. Most reported bowel (81%) and bladder (73%) management satisfaction despite high rates of stool accidents (85%), urinary accidents (46%), and recurrent urinary tract infections (70%). The majority of respondents (90%) expressed interest in having a reproductive health provider as part of their healthcare team. The median ages of the first conversation regarding transition to adult care and feeling confident in managing self-healthcare were 18 and 14 years, respectively. Most (85%) reported feeling confident in navigating the medical system.

DISCUSSION

In this cohort of young adults who reported confidence with self-care and navigating the medical system, the proportion who had successfully transitioned into to adult care was low. These data highlight the need for improved transitional care and the importance of patient-provider and provider-provider communication throughout the transition process.

CONCLUSION

These data highlight the need to understand the experience of each individual patient in order to provide care that aligns with their goals.

The impact of the dependent care provision on individuals with spina bifida transitioning to adulthood

INTRODUCTION

Under the Affordable Care Act, the Dependent Care Provision (DCP) was enacted in 2010 and expanded healthcare coverage for millions of young adults ages 19-25 by allowing them to stay on their parents' insurance until age 26. It is unknown whether the DCP has impacted young adults with SB who are at risk for lapses in insurance coverage as they transition into adult care.

OBJECTIVE

Our aim was to determine the impact of the DCP on access to care (insurance status) and healthcare-quality (hospital admissions for potentially preventable conditions).

METHODS

Using the National Inpatient Sample (an all-payor national dataset of hospital admissions), we analyzed pre/post DCP changes for admissions of SB patients ages 19-25. Our outcomes of interest were rates of insurance coverage and proportion of admissions due to potentially preventable conditions (UTI, pyelonephritis, skin conditions, osteomyelitis, sepsis, and pneumonia). Analysis included a difference-in-differences logistic regression model which compared the pre/post DCP difference (2006-s quarter of 2010 vs. 2011-2013) in patients ages 19-25 to the difference in patients ages 26-32 who were ineligible for the DCP policy.

RESULTS

For admissions of SB patients ages 19-25, the DCP was not associated with improved insurance status compared to admissions ages 26-32 (0% vs. -0.4%, p = 0.10) and rates of private insurance decreased in both age groups, but more so in ages 26-32 (-2.0% vs. -3.9%, p < 0.001). Private insurance rates increased for admissions of white patients ages 19-25 but not for black and Hispanic groups. An increase in overall insurance status was also seen in young adults from high-income zip codes. Admissions for potentially preventable conditions increased in both age groups by a similar degree (+2.6% vs. +2.5%, p = 0.82).

DISCUSSION

Under the Affordable Care Act, the DCP failed to improve rates of private insurance or decrease rates of noninsurance for admissions of young adults with SB. Certain race and socioeconomic groups benefited more from this national healthcare policy. Meanwhile, admissions for potentially preventable conditions are common in spina bifida patients, and increased over the study period, suggesting a need for further investigation into optimizing the delivery of healthcare to this complex patient population.

CONCLUSION

The DCP did not result in improved overall insurance rates or in improved rates of private insurance for admissions of SB patients 18-25 years old.

A Novel Surgical Approach for the Management of Cloacal Exstrophy with a Giant Omphalocele

Cloacal exstrophy is a rare malformation that presents as a lower midline abdominal wall defect which affects the gastrointestinal and genitourinary systems. The components of cloacal exstrophy characteristically include omphalocele, exstrophy of perineal structures, and imperforate anus. Most of these patients also have renal anomalies such as pelvic kidney, fused kidneys, or solitary kidneys. This congenital condition can also be associated with spinal issues, such as spinal dysraphism. When combined with spinal defects, it is referred to as the omphalocele, exstrophy, imperforate anus, and spinal defects (OEIS) complex, and is one of the most challenging surgical conditions to manage. Here, we present a unique case of a low-birth-weight patient with OEIS and a liver containing giant omphalocele and the novel surgical technique used to manage her cloacal exstrophy whereby the cecal plate was not separated from the bladder halves, but rather left for an autoaugment, and the ileum was connected to the hindgut.

Gender and Invited Authorship in the Journal of Pediatric Urology

OBJECTIVE

To evaluate the evolving role of gender in invited authorship and editorial positions in the Journal of Pediatric Urology.

MATERIALS AND METHODS

We recorded editorial board members and first and senior authors for all editorials and invited commentaries for all issues of the Journal of Pediatric Urology from 2005 to August 2018. We also recorded first and senior authors for original research articles from selected years for comparison. Gender was confirmed for each individual by visiting institutional websites and performing internet searches. The same was done for the Societies for Pediatric Urology membership.

RESULTS

A total of 143 editorials and 162 invited commentaries were identified within the study period, with numbers increasing each year. Overall, these publications had 448 first and senior authorships, of which 10% were female. Of the 898 editorial board positions over the study period, 7% were held by females. The proportion of female authorships increased over time (P = .04), while the proportion of female board members did not (P = .9).

CONCLUSIONS

Female invited authorship has increased over the past 13 years in the Journal of Pediatric Urology. However, editorial board membership has lagged, indicating an opportunity for improvement.

A clinical pathway to minimize computed tomography for suspected nephrolithiasis in children

INTRODUCTION

Ultrasound (US) imaging is preferred in the initial evaluation for children with suspected nephrolithiasis; however, computed tomography (CT) continues to be used in this setting with resultant unnecessary ionizing radiation exposure. The study institution implemented a standardized clinical pathway to reduce rates of CT utilization for children with nephrolithiasis.

OBJECTIVE

The aim of this study was to evaluate the impact of this pathway on initial imaging strategies for children with suspected nephrolithiasis.

STUDY DESIGN

A standardized pathway was designed and implemented using a systematic quality improvement process. A suspected cohort was created using 'reason for study' search terms consistent with a nephrolithiasis diagnosis. A confirmed cohort of children with a final diagnosis of nephrolithiasis was derived from this suspected cohort. The primary outcome was CT use as the initial imaging study in children with suspected or confirmed nephrolithiasis presenting to the emergency department (ED) between October 2013 and February 2018. Comparisons were made before and after pathway implementation (October 2015). Secondary outcomes included rates of CT scan within 30 days, while balancing measures included rates of admission, ED length of stay, and return visits.

RESULTS

A total of 534 children with suspected (220 prepathway; 314 postpathway) and 90 children with confirmed (37 prepathway; 53 postpathway) nephrolithiasis were included. For the suspected cohort, CT scans performed as the initial imaging evaluation (9.2% vs 2.5%, P = 0.001) and at any time during the index visit (15.7% vs 5.7%, P = 0.001) decreased after pathway implementation. Within the confirmed cohort, a non-significant decrease in initial CT rates was observed after implementation. No differences were observed in admission rates or ED length of stay after implementation. A trend toward lower return visits to the ED was seen after pathway implementation (5.5% vs 2.2%, P = 0.058).

DISCUSSION

Within a tertiary care pediatric ED associated with a strong institutional experience with clinical pathways, initial CT rates were decreased after pathway implementation for children with suspected nephrolithiasis. While retrospective assessment of suspected disease is limited, this is one of the first studies to address imaging patterns for nephrolithiasis beyond the final discharge diagnosis, thus capturing a broader cohort of children. Children with suspected nephrolithiasis can be safely managed with an US-first approach, and postvisit CT scans are rarely necessary for management.

CONCLUSIONS

A standardized clinical pathway for suspected nephrolithiasis can reduce rates of initial and overall CT utilization without adversely impacting downstream care.

Robot-assisted laparoscopic management of duplex renal anomaly: Comparison of surgical outcomes to traditional pure laparoscopic and open surgery

INTRODUCTION

Surgical management of duplex renal anomaly (DRA) is complex because of individual anatomic variation, competing priorities of vesicoureteral reflux (VUR) and ureteral obstruction present in the same child, the varied differential function of the different renal moieties, and the presence of voiding dysfunction and recurrent urinary tract infection (UTI). Robot-assisted laparoscopic (RAL) surgical management has been under-reported in this group of children but is becoming a viable alternative to traditional open surgery.

OBJECTIVE

The aim was to report the surgical outcomes of a series of children with DRA who had RAL surgery and compare these outcomes to historical cohorts of open and laparoscopic surgery.

STUDY DESIGN

This was a retrospective analysis of a prospective series of children who had RAL surgery for DRA over an 8-year period. Forty-five RAL surgeries were performed in 47 children. RAL heminephrectomy (RAL HN) was performed in 19 children for poorly or non-functional renal moiety. One had staged bilateral RAL HN. RAL ureteroureterostomy (RAL UU) was performed in 14 children for upper pole ureteral obstruction. Thirteen RAL common sheath ureteral reimplants (RAL csUN) with or without ureteral tapering were performed in 12 children with VUR and UTI. Diagnosis and demographics, results of preoperative imaging, intraoperative time stamps, perioperative complications, success rate, and renal outcomes were recorded.

RESULTS

Low-grade VUR present preoperatively in the RAL UU group all resolved within the follow-up period. Four (25%) children in the RAL HN group developed de novo VUR after surgery, which resolved in two (50%) and required surgery in two (50%). Grade I VUR after RAL csUR that occurred in two (14.3%) children was asymptomatic and observed when off preventative antibiotics.

DISCUSSION

Most children with DRA who need surgical treatment can be offered RAL surgery. We report good outcomes and improved operative times for RAL HN and UU that approach historical open and pure laparoscopic cohorts. However, RAL csUR, especially with ureteral tapering, is more complex and inherently susceptible to complications, and has not met the outcomes of the open gold standard. The limits of this study are that selection bias is present, and there is no study control cohort.

CONCLUSIONS

This report achieves its aim to report surgical outcomes of children who had RAL surgery for DRA.

High resolution ultrasound characterization of early allograft hemodynamics in pediatric living related renal transplantation

PURPOSE

Allograft vascular thrombosis occurs in 5% to 10% of pediatric renal transplants. The hemodynamics of renal allograft immediately after implantation is unclear. High resolution Doppler ultrasound of the renal allograft performed in the operating room after incision closure is an effective and objective method to advance our understanding of baseline renal allograft hemodynamics, and identify unsuspected vascular complications early enough to ensure prompt surgical repair.

MATERIALS AND METHODS

Between September 1998 and July 2000 high resolution, color power Doppler ultrasound was prospectively performed on 21 living related renal transplants in the operating room immediately after incision closure. Each ultrasound described allograft anastomotic blood flow, direction of diastolic flow, parenchymal perfusion and resistive indexes.

RESULTS

There were 20 (95%) allografts with good power Doppler perfusion that had satisfactory immediate function with no vascular complications at 9 to 26-month followup. Initially, anastomotic turbulence was described in 15 (71%) allografts, and resistive indexes were abnormal in 8 (38%). Turbulence and abnormal resistive index normalized in all allografts by 1-month followup. Ultrasound of 1 allograft identified unsuspected poor perfusion and reversal of diastolic flow in the operating room after incision closure. In another allograft in which a 4-hour post-transplant ultrasound was compared with the baseline study in the operating room an unsuspected thrombosis of the right common iliac vein was confirmed.

CONCLUSIONS

Good parenchymal perfusion and forward diastolic flow after renal reperfusion correlated well with immediate graft function. Initial turbulence and abnormal resistive index in the presence of favorable perfusion are misleading and not independent predictors of graft function. Ultrasound performed in the operating room identified 2 unsuspected major vascular complications facilitating prompt surgical correction.

A prospective randomized clinical trial to evaluate methods of postoperative care of hypospadias

PURPOSE

Hypospadias repair is a common operation performed by pediatric urologists. Perhaps the greatest variable and source of controversy of postoperative care is the surgical dressing. We hypothesized that using no dressing would achieve surgically comparable results to those traditionally achieved by a postoperative dressing and it would also simplify postoperative parent delivered home care. Accordingly we designed a prospective randomized clinical trial to compare surgical outcome and postoperative care after hypospadias repair in boys with no dressing and those who received 1 of the 2 most common types of dressing.

MATERIALS AND METHODS

In a 12-month period 120 boys with an average age of 2.2 years underwent primary 1-stage hypospadias repair at a single center with 4 participating surgeons. Repair was performed in 60 boys with proximal and 60 with distal hypospadias on an outpatient basis. Ethics and Internal Review Board approval, and informed consent were obtained. Boys were then prospectively randomized to receive no dressing, an adhesive biomembrane dressing or a compressive wrap dressing. Comprehensive instructions on postoperative care were distributed to all families and a questionnaire was distributed to the parents at the initial followup. Surgical outcome was evaluated and questionnaire responses were analyzed. Fisher's exact test was done to test the significance of differences in surgical outcomes and questionnaire responses.

RESULTS

A total of 117 boys completed the prospective randomized trial. Surgical staff withdrew 3 cases from randomized selection to place a dressing for postoperative hemostasis. We obtained 101 questionnaires for response analysis. The type or absence of the dressing did not correlate with the need for repeat procedures, urethrocutaneous fistula, or meatal stenosis or regression. Analysis revealed less narcotic use in the no dressing group and fewer telephone calls to the urology nurse, or on-call resident and/or fellow. These findings were statistically significant. In addition, there were more unscheduled visits to the urology clinic, emergency room or primary physician office by boys with than without a dressing. Furthermore, 29% of the parents were not psychologically prepared to remove the dressing and 12% were so reluctant that the dressing was removed at the urology outpatient clinic.

CONCLUSIONS

The surgical outcome and rate of adverse events or complications were not compromised without a postoperative dressing. An absent dressing simplified postoperative ambulatory parent delivered home care. We recommend that dressings should be omitted from routine use after hypospadias repair.

Organ and species specificity in the stimulation of transitional epithelial cell growth by fibroblasts

OBJECTIVES

Culture of transitional epithelium for urinary tract reconstruction has been problematic due, in part, to the dependence of urothelial cells on a basal layer of bladder fibroblasts for growth. In vitro studies on the effect of bladder, ureter, and intestinal fibroblast cocultures and conditioned media upon urothelial cell growth were conducted to better characterize the dependence of urothelial cells of fibroblasts.

METHODS

Primary cultures of human and porcine bladder, ureter, and intestinal fibroblasts and bladder and ureter urothelial cells were established. The urothelial cells were incubated with fibroblasts in a coculture system and growth compared to that of individual fibroblast and urothelial cultures. Urothelium-specific medium was exposed to the fibroblast cultures for 6, 12, and 24 h. Urothelial cell growth in each of the fibroblast-conditioned media was evaluated.

RESULTS

Coculture of human urothelial cells with human bladder and ureter fibroblasts yielded increased cell growth when compared to the cells in individual culture. This improvement was greatest for the bladder fibroblasts in coculture with bladder epithelial cells. The media exposed to bladder and ureter fibroblasts for 24 h significantly increased bladder and ureter urothelial growth compared to fresh medium. Coculture with intestinal fibroblasts and exposure to intestinal fibroblast conditioned media did not significantly stimulate urothelial cell growth. Similarly, coculture and conditioned media studies of porcine urothelial cells with porcine bladder and ureter fibroblasts (but not intestinal fibroblasts) yielded increased cell growth when compared to the cells in individual culture, particularly with bladder fibroblasts. However, human urothelial cells were not stimulated by porcine bladder and ureter fibroblast conditioned media, nor were porcine urothelial cells stimulated by human bladder and ureter fibroblast conditioned media.

CONCLUSIONS

The ability of urinary fibroblasts to stimulate urothelial cell proliferation resides in an unidentified soluble factor secreted into the medium, independent of the presence of the fibroblasts. This factor is relatively organ and species-specific.

The natural history of neonatal vesicoureteral reflux associated with antenatal hydronephrosis

PURPOSE

In an attempt to evaluate the natural history of neonatal vesicoureteral reflux, patients with antenatal history of hydronephrosis and documented reflux in the first 30 days of life were analyzed.

MATERIALS AND METHODS

Between 1993 and 1998, 260 patients with a history of antenatal hydronephrosis were referred for evaluation. Of these patients 31 were diagnosed with unilateral or bilateral refluxing renal units (54 renal units). Patients were treated with a prospective plan of observational therapy and prophylactic antibiotics, and resolution rate was calculated in patients with adequate followup. Reflux grade was correlated with postnatal ultrasonographic findings, urinary tract infections and differential renal function. Outcome analysis of 34 high grade (III to V) refluxing renal units using the Kaplan-Meier survival curves was undertaken with the end point being complete resolution or improvement. Three patients with vesicostomy and 2 who underwent ureteral reimplantation were excluded from analysis.

RESULTS

Reflux was grade I in 5% (33% males), II in 15% (62% males), III in 32% (71% males), IV in 18% (90% males) and V in 30% (100% males) of the patients. Postnatal ultrasound findings correlated poorly with the presence and degree of vesicoureteral reflux. Of 17 patients followed for at least 14 months (average followup 20) there was complete resolution in 60% with grade III, 50% with grade IV and 28% with grade V reflux. Using the Kaplan-Meier estimate there was a 50% chance of improvement (decrease in reflux grade by at least 2 grades) in high grade reflux by age 16 months. Urinary tract infections developed in 8 patients (26%) while on antibiotics. Of 46 renal units in 23 patients evaluated with a renal scan before urinary tract infection, 12 had less than 35% function.

CONCLUSIONS

A normal postnatal ultrasound should not be a basis for excluding the use of cystography. Our Kaplan-Meier estimate shows that high grade reflux does improve and may resolve spontaneously. In addition, renal scarring may be seen with high and low grade reflux in the absence of urinary tract infection but high grade reflux is associated with a higher incidence of infection.

Murine xenogeneic immune responses to the human testis: a presumed immune-privileged tissue

INTRODUCTION

Immune privilege provides a natural paradigm for potentially down-regulating allogeneic and xenogeneic inflammatory immune responses. Fas ligand has been suggested as a general underlying mechanism of immune privilege; the human Fas ligand has been shown to ligate murine Fas in vitro.

METHODS

In this study, we examined whether the human testicular xenograft, a presumed immune-privileged tissue would have prolonged survival in mice. In addition, in vitro and in vivo murine xenogeneic immune responses to the human testicular xenografts were characterized using MHC class I, MHC class II, CD4, CD8, CD4/8 knockout mice.

RESULTS

Unlike in rodent testis, Fas ligand mRNA is not expressed and Fas is highly expressed in human testis. Human testicular xenografts are immunogenic, and do not induce any preferential pattern of recipient systemic Th1 or Th2 cytokine bias. Interestingly, an indefinite survival of the human testicular xenografts is observed in murine MHC class II knockout mice, whereas the human skin xenografts were rejected without a delay. In vivo murine immune responses to human testicular xenografts require a recipient MHC class II-dependent CD4 T cell-mediated process that appears to depend on B7-1/B7-2 costimulatory signals.

CONCLUSIONS

Our results demonstrate that the concept of immune privilege, as defined by the expression of Fas ligand and prolonged survival after transplantation, cannot be extended to human testis. The stringent restriction of murine xenogeneic immune responses to discordant human testicular xenografts to the indirect MHC class II-dependent CD4 T cell-mediated pathway suggests a potential venue for immune modulation to induce tolerance across a discordant species barrier.

Concomitant modified bladder neck closure and Mitrofanoff urinary diversion

PURPOSE

We describe a modification of bladder neck closure for managing urinary incontinence in children.

MATERIALS AND METHODS

In 11 patients with intractable urinary incontinence that persisted after multiple failed surgical procedures we performed modified bladder neck closure with construction of a catheterizable continent conduit.

RESULTS

Mean followup is 3 years. All patients were continent after the procedure and none had a fistula or urinary leakage. One patient required stomal and conduit revision, and bladder stones in 3 necessitated endoscopic removal.

CONCLUSIONS

We recommend this modified technique of bladder neck closure as an option for managing urinary incontinence in a complex group of children because it allows the achievement of continence with minimal morbidity.

Grafting of cultured uroepithelium and bladder mucosa into de-epithelialized segments of colon in rabbits

Urinary tract reconstruction using bowel can result in acid-base and electrolyte abnormalities. We tested the feasibility of grafting bladder mucosa and urothelial cells grown on a biodegradable polyglactin 910 scaffold onto de-epithelialized segments of bowel in the rabbit. A segment of de-epithelialized colon was either grafted with cultured urothelium on a collagen mesh scaffold (12 rabbits) or with free bladder mucosa (11 rabbits). In 10 rabbits that served as a control group another segment of bowel was isolated and de-epithelialized. No urothelial or bowel epithelial growth was present 4 weeks later in 10 of the isolated de-epithelialized colonic segments grafted with the cultured urothelium. In 2 segments a minute focus of epithelium staining positively for anticytokeratin antibodies AE1 and AE3 was seen but this could not be histologically differentiated as either urothelium or native colonic epithelium. All 7 surviving animals that underwent a bladder mucosal graft had viable urothelium at sacrifice 30 days postoperatively. In 2 of the 7 rabbits microscopic nests of colonic epithelium were also found underneath the urothelial layer. Of the 7 internal controls 6 had no evidence of bowel epithelial regrowth 4 weeks after de-epithelialization. This study demonstrated that a confluent layer of urothelial cells could be grown in culture using a scaffold of biodegradable mesh and rat tail collagen. We also showed that bladder mucosal grafts can be grown on de-epithelialized bowel segments. We were unable to graft successfully cultured urothelial cells onto a de-epithelialized bowel segment. Further improvement in understanding the role of the submucosal matrix in cell growth may lead to future success in covering large segments of de-epithelialized bowel with autologous urothelium.

Animal model for the study of internal anal sphincter activity

This paper describes a simple and reliable model for studying the internal anal sphincter (IAS) in the rat. The activity of the sphincter was recorded by a two-balloon system. The compliance of the balloon allowed measurements of pressure changes lower than 0.1 cm H2O. The anatomical and physiological characteristics of the rat IAS were found to be in many aspects similar to those found in the human. The rectoanal reflex in the rat consists of relaxation followed by contraction. The threshold for this response is 0.4-0.6 ml of air. The response of the IAS to prolonged rectal distension showed adaptation in 50% of the animals. Intraarterial application of drugs produced rapid, dose-dependent and reproducible effects on the IAS. The results described in this work show that the rat is a useful and convenient model for studying anal function. It may be used to investigate both the physiology and pharmacology of the IAS activity.

An experimental model of a submucosally tunnelled valve for the replacement of the ileo-cecal valve

An enteric valve to prevent colonic content reflux and to prolong small bowel transit time was created by passing small bowel through a submucosal tunnel in the colon. Barium enema, Gl tract series, and iso- and antiperistaltic pressure measurements showed the valve to be of competence equal to the ileo-cecal valve. Late pathological examination revealed a patent valve with minimal scar formation. The optimal submucosal tunnel length was between 4 and 6 cm. This valve can, theoretically, increase the absorptive capacity in short bowel syndrome and may serve as a substitute for the critically important ileo-cecal valve.

Physiological and pharmacological studies of the internal anal sphincter in the rat

The rectoanal reflex in the rat consists of relaxation followed by contraction of the internal anal sphincter (IAS). Beta-adrenergic drugs produce prolonged relaxation of the IAS, where alpha-agonists cause brief relaxation followed by contraction. Muscarinic cholinergic drugs contract the IAS. ATP and related purines produce relaxation which is blocked by theophylline. The reflex persists during adregeneric, cholinergic, and purinergic block. The potassium-blocker apamin prevents the relaxation induced by rectal distension. This suggests that the reflex is not mediated by adrenergic, cholinergic, or purinergic transmitters. Blocking potassium conductance was apparently the only way to eliminate this reflex.

Inflammatory fibroid polyp of the small intestine: report of two cases and review of the literature

Two cases of inflammatory fibroid polyp of the ileum presenting clinically as intestinal obstruction due to intussusception are described. The presence of smooth muscle cells within the lesions raises the possibility that some cases of inflammatory fibroid polyp are leiomyomas that have undergone degenerative and secondary inflammatory changes.