Journal of Pediatric Urology最新文献

Introduction: Hypospadias is a common congenital anomaly of the male genitalia that poses significant management and treatment challenges. Gaining a comprehensive understanding of priority research questions in hypospadiology will be essential to reach agreement on the optimal approach to assessment, treatment, and outcome prediction for affected patients.

Methods: We employed a consensus-building Delphi method to identify and prioritize research questions in the hypospadias field. Additionally, we integrated questions sourced from the artificial intelligence platform ChatGPT to capture multiple perspectives. Engaging a diverse panel of experts including clinicians, researchers, and patient advocates from across the globe, the Delphi process aimed to distill collective expertise and insights through iterative rounds of structured questionnaires and feedback.

Results: The analysis identified key themes in hypospadias research, covering etiology, tissue engineering, pre-clinical models, device/technology evaluation, phenotyping, surgical techniques, surgical training and postoperative outcomes. These themes highlight crucial areas for future investigation to improve understanding of hypospadias, treatment options, and patient outcomes, thereby guiding both research and clinical practice.

Discussion: By harnessing the collective wisdom and perspectives of multiple stakeholders, this Delphi study establishes a roadmap for prioritizing research initiatives to effectively unravel the complexities of hypospadias. Integration of ChatGPT outputs into our Delphi-based approach also outlined how future studies can harness the collective wisdom of human experts together with artificial intelligence methods. The outcomes of this novel endeavor hold promise for shaping future research agendas, informing clinical practice guidelines, and fostering multidisciplinary collaborations to drive innovation and ultimately improve outcomes for hypospadias patients worldwide.

Anthropometry of the penis holds significant cultural and clinical importance, reflecting male genital development and aiding in the early identification of abnormalities.

Objectives: To develop an age-related penile length nomogram for Indian children, to define a range of normalcy, and to develop age-matched controls for penile length assessment in managing conditions like hypospadias.

Methods: This is a cross-sectional study (Design) initiated post-Institute Ethics Committee clearance (Ethics) based on 1276 volunteers (boys) aged 1-14 years (Participants) presenting to a pediatric surgery clinic (Setting) for conditions not affecting penile length. Participants were registered for the study and their age(years), weight(kg), and stretched penile length (SPL in cm) were recorded (Intervention). Generalized additive models for Location, Scale, and Shape (GAMLSS/extension of LMS method) were used. Outcome measures included weight (mean/range) and SPL (mean/range/standard deviation/median/centiles). The four distribution parameters were modeled as non-parametric smoothing cubic-spline functions of x with Box-Cox Power Exponential (BCPE) distribution and centiles (3, 5, 10, 25, 50, 75, 90, 95, 97) were calculated for the stretched penile length.

Results: SPL increases with age (3.4 cm in a 1-year-old to 12.7 cm in a 14-year-old) of the child in a non-linear fashion (r = 0.67, p < 0.001). Centile curves showed two phases of steep SPL increase, at ages 2-4 years and 10-14 years, reflecting early childhood growth and pubertal spurt respectively.

Conclusions: This is the largest cross-sectional study on the pediatric SPL in the Indian population. The data will serve as a useful resource for both parents and physicians in assessing penile development and guiding patient management.

Introduction: Vesicoureteral reflux (VUR) is a common congenital or acquired urinary disorder in children. Chat Generative Pre-trained Transformer (ChatGPT) is an artificial intelligence-driven platform offering medical information. This research aims to assess the reliability and readability of ChatGPT-4o's answers regarding pediatric VUR for general, non-medical audience.

Materials and methods: Twenty of the most frequently asked English-language questions about VUR in children were used to evaluate ChatGPT-4o's responses. Two independent reviewers rated the reliability and quality using the Global Quality Scale (GQS) and a modified version of the DISCERN tool. The readability of ChatGPT responses was assessed through the Flesch Reading Ease (FRE) Score, Flesch-Kincaid Grade Level (FKGL), Gunning Fog Index (GFI), Coleman-Liau Index (CLI), and Simple Measure of Gobbledygook (SMOG).

Results: Median mDISCERN and GQS scores were 4 (4-5) and 5 (3-5), respectively. Most of the responses of ChatGPT have moderate (55 %) and good (45 %) reliability according to the mDISCERN score and high quality (95 %) according to GQS. The mean ± standard deviation scores for FRE, FKGL, SMOG, GFI, and CLI of the text were 26 ± 12, 15 ± 2.5, 16.3 ± 2, 18.8 ± 2.9, and 15.3 ± 2.2, respectively, indicating a high level of reading difficulty.

Discussion: While ChatGPT-4o offers accurate and high-quality information about pediatric VUR, its readability poses challenges, as the content is difficult to understand for a general audience.

Conclusion: ChatGPT provides high-quality, accessible information about VUR. However, improving readability should be a priority to make this information more user-friendly for a broader audience.

Background: Significant efforts have been undertaken to decrease opioid prescribing, but there is little research into patient-specific factors presenting as barriers in the pediatric surgical population. Non-steroidal anti-inflammatory drugs (NSAIDs) have been shown to be a safe and effective alternative to opioids for pain control, however, concerns about their impact on renal function limit their use in patients with chronic kidney disease (CKD). Data is limited on the interplay of CKD on opioid prescribing.

Objective: We hypothesized that opioid reduction efforts were successful, but patients with CKD would be more likely to receive an opioid prescription than those without CKD.

Study design: A retrospective cohort study of patients ≤18 years old undergoing urologic surgery from 2014 to 2022 was performed. Patients were stratified by CKD diagnosis, determined by chart diagnosis and confirmed with CKiD U25 eGFR calculations, excluding those with normal eGFR or Stage 1 CKD. Patients without a documented CKD diagnosis and without preoperative renal function testing were presumed not to have CKD. Patients were propensity matched using the optimal full algorithm across 12 different variables. Outcomes of interest were discharge opioid prescriptions, non-opioid analgesic prescriptions, and unscheduled healthcare encounters (urology clinic visits within 5 days, emergency department visits, readmissions, or reoperations within 30 days).

Results: 10,604 patients were included. 603 patients (5.7 %) had a pre-existing CKD diagnosis; the majority were CKD stage 2 (77.8 %, 466 patients). A significant decrease in discharge opioid prescriptions was seen for patients with and without CKD. Patients with CKD had greater opioid exposure prior to surgery (17.2 %, 104 versus 2.8 %, 280, p = 0.04). Those with CKD were equally likely to be prescribed NSAIDs (p = 0.36) and opioids (p = 0.09) at discharge. Patients with CKD were more likely to present to the emergency department (ED) within 30 days of surgery (17.6 % versus 7.9 %, p = 0.007).

Discussion: Similar proportions of patients with and without CKD received an opioid prescription at discharge. Patients with CKD were more likely to be exposed to opioids in-hospital earlier than non-CKD counterparts.

Conclusions: Multiple interventions and a dedicated postoperative opioid reduction protocol worked well, even in patients with CKD where there is concern about safely receiving NSAIDs. All-cause unplanned healthcare encounters did not differ significantly within groups with introduction of these interventions.

Background: Continent catheterizable channels (CCC) are a mainstay for reconstruction in patients with neurogenic bladders. Common complications include false passage, channel stenosis/difficult catheterization, channel incontinence, and stomal stenosis. This may result in the need for surgical revision or replacement. It has been suggested that stabilization of the bladder to the anterior abdominal wall or "hitching" can reduce complications, but evidence is lacking.

Objective: Review our single institution experience with CCCs to determine if "hitching" the bladder reduced complications.

Study design: A retrospective, single-institution cohort study of patients with CCC to the bladder created between 2/2005-6/2019 was performed. Patients whose channel was implanted into augmented bowel and those with <6 months of follow-up after channel creation were excluded. The cohort was further divided into 2 groups: those that were done with "hitching" and those without. Complications, including subfascial revision for difficulty with catheterization, channel incontinence (leakage despite favorable bladder dynamics and adherence to clean intermittent catheterization), and stomal stenosis, were compared between the groups using Cox proportional hazards regression.

Results: There were a total of 109 patients with CCC created during our study period. Four channels tunneled into augmented bowel were excluded. Median follow up was 5.8 (IQR 3.5-8.3) years. A total of 21/105 (20 %) channels were hitched to the abdominal wall during surgery. There were no significant differences in demographics, surgical characteristics, diagnoses, or channel types in the hitched versus non-hitched groups. The overall rate of subfascial revision or need for channel replacement due to difficulty with catheterization was 9/105 (8.6 %). The rate of revision or replacement was 1/21 (4.8 %) in the hitched group versus 8/84 (9.5 %) in the non-hitched group (p = 0.68). The overall channel incontinence rate was 3/105 (2.9 %). The rate of channel incontinence was 0/21 (0 %) in the hitched group versus 3/84 (3.6 %) in the non-hitched group (p = 1.0). The overall stomal stenosis rate was 23/105 (21.9 %) with 5/105 (4.8 %) going on to a stomal-level surgical revision. The rate of stomal revision for stenosis was 1/21 (4.8 %) in the hitched group versus 4/84 (4.8 %) in the non-hitched group (p = 1.0). Survival analyses indicated no statistically significant differences in time to complications and revisions between hitched and non-hitched groups.

Conclusion: Routine "hitching" of the bladder to the abdominal wall with CCC does not appear to reduce complications or the need for future surgical revision compared to not hitching the bladder.

Background: Children with enuresis are often requested to complete voiding diaries in the diagnostic process. There is no consensus on the optimal number of days of registration in the voiding diary that would allow correct patient characterization.

Objectives: To examine the intra-individual variation in the parameters yielded from voiding diaries and evaluate if one week of registration is sufficient when evaluating the nocturnal urine production (NUP) and maximum voided volume (MVV) in children with monosymptomatic nocturnal enuresis (MNE).

Methods: We analyzed 228 voiding diaries completed for 14 days from treatment naïve children aged 6-14 years with MNE. NUP was estimated by diaper weight and volume of first morning void. MVV was registered both including and excluding first morning void.

Results: We found no significant differences in terms of NUP and MVV between week one and two, between one week or 14 days of registration, or when comparing two and four days of daytime registration. When using current ICCS definitions, 8 % of children with reduced MVV and no nocturnal polyuria and 12 % of children with nocturnal polyuria and normal MVV changed characterization when comparing two weeks of registration with two days of registration.

Conclusion: One week of nighttime-registration and two days of daytime-registration is sufficient to provide valid estimates of NUP and MVV. Two days could be sufficient to calculate subtype characterization according to ICCS definitions and possibly enhance compliance.

Randomized controlled trials (RCTs) are at the top of the pyramid of evidence as they offer the best answer on the efficacy of a new treatment. RCTs are true experiments in which participants are randomly allocated to receive a certain intervention (experimental group) or a different intervention (comparison group), or no treatment at all (control or placebo group). Randomization, along with other methodological features such as blinding and allocation concealment, safeguard against biases. This review will focus on parallel group RCT design as it is the most common design in the field of Pediatric Urology. RCTs can be designed using a superiority, equivalency, or non-inferiority hypothesis, and are usually preceded by a pilot, where the trial protocol is implemented in a small number of patients, mimicking the larger, definitive study. Even though regarded as the best available option to bring out scientific data, RCTs might be prone to mislead. If RCTs are small and underpowered, a difference of even one single event between groups, may completely change the trial results. To safeguard against RCTs weakness, a fragility concept of statistical significance was developed and called the Fragility Index (FI). RCTs may not be appropriate, ethical, or feasible for all surgical interventions. They may have limitations such as prohibitive cost and unrealistic large sample sizes. Nearly 60 % of surgical research questions cannot be answered by RCTs. Therefore, clinical practice should be based on the best available evidence on a given topic, regardless of the study design. However, even in these situations, conclusions drawn from observational studies must be interpreted with caution.