Journal of Pediatric Urology最新文献

Introduction: Vesicostomy button drainage is a recognised alternative to clean intermittent catheterization (CIC) in children with urethral obstruction, sensate urethra or neurological/behavioural issues.

Aim: To report the indications, complications and long-term bladder functional outcomes in a 15-year cohort of patients with button vesicostomy.

Materials and methods: AMT Mini one gastrostomy button^R was inserted via a surgical vesicostomy, or percutaneously under cystoscopic guidance. Retrospective data included demographics, indications, complications, and long-term bladder capacity/emptying pre-post-button removal.

Results: 29 children (23 males) underwent vesicostomy button insertion at 3.5 (0.5-14.5) years. Diagnosis was neurogenic (11), bladder outlet obstruction (9), cloaca/urogenital sinus (3), anorectal malformation (ARM) (2), other bladder dysfunction (3) and diversion (1). There were no short-term complications. UTI occurred in 31 %, leakage in 28 % and blockage in 7 %. At a median of 10 (2-18) years, 14 (48 %) are still on button drainage; 6 (21 %) progressed to Mitrofanoff catheterisation. In 9 (31 %) who no longer require the button, all children were able to void urethrally, with good emptying, at 4.5 (1-7) years follow-up.

Discussion: Continent vesicostomy allows toilet-training and improved quality of life. We estimated that the cost of a button vesicostomy and tubing approximates £1502 per year. 5-6 Speedicaths per day (costing £38 per pack) cost £2772 per year. Asymptomatic bacterial colonisation does not require antibiotic treatment; it is best avoided by changing the button every 12 weeks. Symptomatic febrile UTI's are commonly secondary to the underlying pathology; we recommend changing the button half-way through the antibiotic treatment course. Leakage was managed by increasing the water in the balloon. Button blockage, commonly due to balloon encrustation, is preventable by regular button changes. Button drainage may be temporary (until bladder dysfunction resolves, or changed to a Mitrofanoff), or a long-term (in life-long neuro-developmental/behavioural issues). The button was no longer required in 9: bladder function improved post spinal cord un-tethering in 3; 2 PUV; 2 ARM; 1 myopathy and 1 diversion. Of note, the button did not appear to affect bladder dynamics with sustained resolution of bladder dysfunction in 31 %. Our main limitation was diversity of pathologies, making comparison of urodynamics more challenging: a larger study with more numbers in each patient group would be the next step.

Conclusion: Suprapubic buttons are a safe second-line bladder drainage option in patients who are unable to CIC. The technique may be a temporary solution where bladder dysfunction may resolve, or until the child is ready for catheterisation via a Mitrofanoff.

Introduction: Testicular torsion is a surgical emergency that is managed with either septopexy-only or tunica vaginalis flap with septopexy if the testis is potentially viable or orchiectomy if not. Minimizing time from ischemia onset to surgery maximizes the likelihood of testicular preservation. While factors such as time from door to OR can be easily targeted, others such as inequalities in access to care are more difficult to address.

Objective: We sought to determine whether patient transfer affects testicular outcomes intraoperatively and in the long-term. Secondary goals included investigating the impact of race and Child Opportunity Index (COI) on testicular torsion outcomes and defining the optimal time cutoff from symptom onset to presentation that predicts salvage.

Methods: We reviewed our prospective testicular torsion database to identify boys who underwent operative intervention for testicular torsion between January 2015 and March 2022. The association of race and COI with testicular salvage, defined as septopexy-only, was evaluated with univariate and multivariate logistic regression controlling for time to presentation, while the association of transfer with salvage was evaluated with univariate and multivariate logistic regression controlling for age, time to presentation, and time to OR. To determine the optimal cutoff for time to presentation to predict testicular salvage, the Youden index was calculated.

Results: Race and COI were not associated with testicular salvage on either univariate or multivariate logistic regression that controlled for time to presentation. Transfer status was not associated with salvage, while age, time from symptoms to presentation, and time from institutional arrival to OR were associated with salvage. The optimal time cutoff to predict salvage using the Youden index was 10.5 hours from symptom onset to presentation and 14.5 hours from symptom onset to detorsion.

Discussion: Time to presentation was the strongest, modifiable risk factor associated with testicular salvage. As it may be difficult for children to accurately communicate their symptoms, diagnosis and prompt management of testicular torsion can be delayed. Improvement in outcomes can be achieved by placing greater efforts into patient, parental, and primary care provider education of the signs and symptoms of testicular torsion.

Conclusions: Race, COI, and transfer status were not found to have a statistically significant effect on testicular salvage outcomes in patients presenting with testicular torsion. Despite the common premise of a 6-hour window until testicular loss, we found that intervention within the acute window of 14.5 hours from symptom onset is still associated with salvage.

Background: Patients with neurogenic bladder are at risk of developing renal deterioration secondary to increased intravesical pressures. To date, urodynamics is the gold standard test to properly assess bladder dynamics. Home bladder manometry is a low-cost and simple method to evaluate bladder pressures and volumes during clean intermittent catheterization (CIC). Previous literature has shown that home manometry measurements correlate with urodynamic pressures and hydronephrosis on ultrasound. However, no studies have evaluated the challenges and barriers faced by caregivers with the process.

Objective: Our objective was to investigate the experiences and perceptions of caregivers, healthcare providers, and nurses with home manometry.

Study design: We conducted semi-structured interviews and focus group discussions with 23 stakeholders. Stakeholders included caregivers of pediatric spina bifida neurogenic bladder patients, providers, and nursing staff. Grounded Theory Methods were used to analyze transcripts and identify preliminary concepts that described attitudes towards the current home bladder manometry process.

Results: Interview participants were composed of 10 (43 %) caregivers, 9 (40 %) healthcare providers, and 4 (17 %) nursing staff. The mean age was 39 years (range 26-66). The four themes identified during discussions were perspectives on home manometry, patient-specific characteristics, challenges with home manometry, and learning experience. All caregivers expressed understanding and agreement with the purpose and importance of home manometry. Emergent concepts identified as targets for improvement were the need for standardization of teaching processes with focus on hands-on practice, understanding of patient characteristics and the home environment that make the process more challenging, and the need for appropriate materials including extension tubing and catheters.

Conclusions: Home bladder manometry is a feasible and beneficial way for neurogenic bladder patients to monitor their bladder pressures and volumes at home. This qualitative study offers valuable insights into the experiences and viewpoints of caregivers, healthcare providers, and nurses regarding both home manometry and the general experience with CIC.

Introduction: Pediatric stone disease incidence has increased steadily over the last few decades. Several interrelated factors have been proposed to contribute to these epidemiologic trends including increased ambient temperature, body habitus, and food insecurity.

Objective: Given the significant cohort of children living with food insecurity in the United States, the aim of this study is to explore the relationship between food desert residence and obstructing stone disease resulting in surgical intervention in a cohort of pediatric patients.

Study design: Records of pediatric patients who presented to a single tertiary pediatric medical center for urolithiasis between 2009 and 2023 were retrospectively reviewed. Patients were included in the study if they had an obstructing stone; were older than 5 years of age; lacked anatomical predispositions to stone formation; and were regularly consuming a solid diet. Variables studied included demographics, BMI, medical comorbidities and family history, procedures performed, and stone burden. Patients' likelihood of living in a food desert was approximated using the United States Department of Agriculture Food Access Research Atlas.

Results: Of 637 patients reviewed, 199 pediatric patients (90 male and 109 female) were included in our analysis. One hundred and thirty patients (65.3%) had undergone ureteroscopy. Fifty-seven patients (28.6%) had a documented psychiatric comorbidity at time of presentation, with ADHD being the most common psychiatric comorbidity treated via medical management (n = 25, 43.9%). Our analysis demonstrated a significant association between surgical intervention, food desert residence (p = 0.003), and increased stone size (p = 0.001). Additionally, increased time between discharge on medical expulsive therapy and surgery decision was associated with past medical history of stones (p = 0.033) and food desert residence while undergoing stimulant treatment for ADHD (p < 0.001).

Conclusion: In this study, we found a significant association between food desert residence and obstructing pediatric stone disease resulting in surgical intervention. We also discuss a potential new association with pediatric stone disease: psychiatric comorbidity and the medical management of such diagnoses. To our knowledge, our study is among the first to assess the association between food insecurity and surgical intervention of pediatric urolithiasis. Given the importance diet plays in medical management of stone development, clinicians should take care to assess food security status of pediatric urolithiasis patients. Limitations to our study include a patient cohort from a singular hospital system, small sample size, and the changing nature of a patients' food security status.

Background: The early detection of the anatomical anomalies (e.g. micropenis) of the male external genital organs is crucial for both medical and psychological reasons. During routine pediatric visits, careful inspection using standards of penis size is beneficial for the diagnosis of micropenis and macropenis. Stretched penile length (SPL) has been shown to be more dependable than the flaccid penis length. Consequently, the SPL must be measured and compared to age-appropriate normal values.

Objective: This cross-sectional study aimed to determine the normal range of stretched penile length in newborns and children aged 1 month to 5 years in Syria and explore the correlation between SPL, height, and weight.

Study design: Data was collected from 300 Syrian males aged 0-5 years. SPL measurements were taken using a standardized procedure. Participants were divided into eight age groups. Statistical analysis determined the mean SPL, standard deviation, range, and rate of increase in SPL for each group. The distribution of SPL data was assessed using the Shapiro-Wilk test. Pearson correlation analysis examined the relationship between SPL and height, weight, and BMI.

Results: Mean SPL increased with age, ranging from 2.36 cm in newborns to 4.29 cm in children aged 48-60 months. The 48-60 months group exhibited the largest range of SPL. The rate of SPL increase was highest in children aged 1-2.9 months. SPL values followed a normal distribution. Significant positive correlations were found between SPL and weight in the 36-47.99 months group and between SPL and height in the 6-11.9 months and 36-47.99 months groups.

Conclusion: This study establishes the normal reference range of SPL in Syrian newborns and children aged 1 month to 5 years. The findings indicate that SPL is influenced significantly by height and weight in certain age groups. These results contribute to understanding penile development and can assist in the diagnosis and treatment of conditions affecting penile size.