Journal of Pediatric Urology最新文献

Purpose: To evaluate the role of manual detorsion (MD) in gonadal salvage and determining non-emergency surgery in testicular torsion (TT).

Methods: We retrospectively analysed paediatric patients treated for TT over 10 years at a tertiary centre. MD was attempted based on surgeon preference. Successful MD was defined by complete pain resolution, and normal colour Doppler ultrasound showing no spermatic cord torsion and normal perfusion. All patients underwent surgical exploration. Data analysed included age, referral status, pain duration, MD attempt and result, time to surgery, surgical findings, and outcomes. A comparative analysis between data from previous a published series (2014-2018) and after previous published series (2019-2023) was executed.

Results: Two hundred and seventy-six patients were included. Sixty percent were referred from other centres (165/276). MD was attempted in 57 % (156/276), resulting in significantly less gonadal loss (9 % vs 46 %, p < 0.05). MD was successful in 44 % (68/156) of attempts; all underwent non-emergency bilateral orchiopexy; one patient developed new TT during the waiting period, successfully treated with MD; at surgery, three (3/68, 4 %) cases had partial non-ischemic cord torsion and none suffered testicular loss. After unsuccessful MD, residual cord torsion was 33 % (29/88). After median follow-up of 8 months, gonadal loss (14/156, 9 %) occurred after unsuccessful MD; no losses occurred following successful MD. Successful MD correlated with significantly improved gonadal salvage (p < 0.05). There was no gonadal loss after non-emergency surgery.

Conclusion: Our data shows that attempting MD results in increased testicular salvage rates, and that a successful manoeuvre may safely enable non-emergency orchiopexy.

Introduction: Timely diagnosis and management of acute testicular torsion (ATT) is a benchmark for quality of care. We sought to evaluate whether patient sociodemographic factors and transfer status had an impact on hospital throughput and orchiectomy in ATT patients.

Methods: From 1/1/2022 to 9/9/2023, patients were identified by CPT code for operations to treat ATT and confirmed by chart review. Patient demographics were noted, and socioeconomic status (SES) was estimated using a distress score produced via the Distressed Communities Index (DCI), a multidimensional measure of social context. We denoted patients who were transferred to our urban tertiary care children's hospital and tracked emergency department (ED) registration time, time of arrival in the operating room (OR), and whether a repeat scrotal ultrasound (SUS) was performed for transfer patients. Based on a quality improvement measurement framework, the time between ED and OR (i.e., hospital throughput) served as our process measure, and orchiectomy rate was our outcome measure.

Results: 100 patients were diagnosed with ATT at a median age of 14 years (IQR 12-15). Median time from ED to OR was 110 min (IQR 79-144). Sixty-one patients were transferred to our institution, and this cohort reflected a higher proportion of White, non-Hispanic patients (p = 0.04) with a lower median distress score (14.4 vs 36.8, p = 0.03). Obtaining a repeat SUS in 25 transfer patients (41 %) prolonged the time to OR by a median of 20 min (p < 0.01). Regardless of repeat SUS, transfer patients had faster hospital throughput than those patients who presented primarily to our institution (p < 0.01). Overall, the orchiectomy rate was 18 %, and this outcome was associated with younger patient age (p < 0.01) and longer reported duration of symptoms (p < 0.01).

Discussion: Transfer patients had a higher SES and experienced faster hospital throughput than patients presenting primarily to our institution. Repeating SUS in transfer patients added modestly to the time to OR but did not impact the likelihood of orchiectomy. In fact, neither transfer status nor sociodemographic factors, other than patient age, were associated with orchiectomy. Further research is needed to identify factors that affect testicular viability and what efforts might improve surgical outcomes.

Conclusions: Patients with ATT transferred to our institution after presenting to a local hospital experienced prompt management with quicker time from ED to OR, though this did not impact their surgical outcome. Only younger patient age and longer reported duration of symptoms increased the likelihood of orchiectomy.

Introduction: Unilateral multicystic dysplastic kidney (UMCDK) is a congenital anomaly detectable already in utero. The affected kidney is non-functioning. While the ureter is typically absent, UMCDK may rarely associate with mesonephric duct (MND) remnants such as ureterocele or ureteral stump.

Objectives: To determine the frequency, clinical implications, and management of ipsilateral MND anomalies in children with UMCDK under comprehensive prenatal and postnatal surveillance.

Patients and methods: Retrospective analysis of 349 children (0-19 years) with UMCDK, followed by pediatric nephrologists and/or urologists in two tertiary centers between 2005 and 2024, was performed. MND anomalies were classified as: - Type Ia: Orthotopic ureterocele; - Type Ib: Orthotopic ureterocele plus ureteral remnant (stump); - Type II: Ectopic ureteral remnant (stump); - Type III: Complex anomalies involving seminal vesicles/epididymis.

Results: Based on medical record and imaging result evaluation, twenty-five patients (7.2 %) with MND anomalies (21 males, 4 females) were identified. Of those, four males (16 %) developed clinical complications (lower urinary tract dysfunction, urinary tract infection (UTI), recurring epididymitis) at different age (3, 8, 12 and 16 years). These symptomatic cases involved Type Ib and Type III anomalies. Median age at diagnosis of MND anomalies was 2 months and median follow-up duration was 10.7 years. All patients had normal glomerular filtration rate (GFR) at the beginning of the observation period, however, two children developed stage 2 chronic kidney disease (CKD 2) until the end of the follow-up. UMCDK resolved spontaneously in 15 patients. MND anomalies regressed below the USG detection threshold only in 3 conservatively managed children (type Ia or Ib). Five patients with MND anomalies required surgical management: 3 children endoscopic incision of ureterocele and 2 children exstirpation of ureterocele with ureteral stump.

Conclusions: MND anomalies in UMCDK are uncommon and mostly follow a benign course. Nevertheless, endoscopic or surgical intervention may be required due to late-onset complications, predominantly lower urinary tract dysfunction. Lifelong monitoring is suggested.

Background: Despite technological advances in minimally invasive surgery for pediatric oncology over recent decades and the fundamental role of surgery in Wilms tumor (WT) management, there are no standardized guidelines for these techniques in this population. This study compares outcomes between laparoscopic nephrectomy (LN) and open nephrectomy (ON) in pediatric patients with WT treated under the International Society of Paediatric Oncology (SIOP) protocol.

Methods: A systematic review and meta-analysis were conducted. Inclusion criteria encompassed randomized trials or nonrandomized cohorts comparing LN to ON, with patients treated according to the SIOP protocol. Clinical outcomes, including mortality, surgical morbidity, and oncological outcomes, were analyzed.

Results: Four nonrandomized cohort studies comprising 160 patients (60 LN, 100 ON) met the inclusion criteria. LN was associated with longer surgical times (mean difference, 23.79 min; p = 0.0002). There were no statistically significant differences between groups in postoperative complications (RR 0.56, p = 0.44), disease recurrence (RR 0.49, p = 0.26), mortality (RR 0.75, p = 0.70), local recurrence (RR 0.58, p = 0.45), or lymph node harvest (mean difference -2.71 nodes, p = 0.06).

Conclusion: Laparoscopic nephrectomy provides comparable oncological outcomes to open nephrectomy in pediatric WT. While numerical differences were observed in some outcomes, they did not reach statistical significance, likely due to the limited sample size.

Introduction and background: The aim of this study is to determine if spinal anesthesia (SA) for infant surgical circumcision results in shorter postoperative times compared to general anesthesia (GA). We hypothesized that, relative to GA, SA would have significantly shorter post-operative recovery times without increasing operative time or postoperative complications relative to GA.

Material and methods: A retrospective cohort study was conducted among infants receiving an outpatient surgical circumcision in the operating room (OR). The exposure was undergoing spinal anesthesia (n = 88) relative to unexposed patients undergoing general anesthesia (n = 105). The primary outcome was the total postoperative time (in minutes) from arriving in the post-anesthesia care unit (PACU) to discharging from the hospital. Secondary outcomes included total time in the operating room, time from entering the operating room to starting surgery, duration of the surgery, time from the end of surgery to leaving the operating room, and 30-day postoperative complications. Covariates of interest were age, weight, ASA class, anesthesiologist, and whether adjuvant anesthetics were administered. Patient and surgical characteristics were compared using non-parametric tests of association. Mixed-effect linear regression models were fit to test the association between SA and total post-op time and other outcomes.

Results: There were 88 male infants in the SA group and 105 male infants in the GA group; both groups were similar in age, weight, ASA class and insurance status. The unadjusted analysis demonstrated that median total postoperative time was significantly lower for the SA group (39.5 min) compared to the GA group (104 min; p < 0.001) (see figure). There was no difference in total OR time (median 51 versus 48, p = 0.1) (see figure), pre-surgery OR time (median 18 versus 18, p = 0.6) or surgical time (median 27 versus 24, p = 0.6). There was a very slight statistical difference in post-surgery OR time favoring spinal anesthesia (mean 6.5 vs. 4.8, p < 0.001). When controlling for anesthesiologist, age, weight and ASA class, patients receiving SA had a 65.5 min (p < 0.001) shorter PACU stay compared to GA. There was no difference in postoperative complications between the two groups.

Discussion: When compared to GA, male infants who underwent circumcision under SA had a faster hospital discharge by over an hour without impacting surgical or total OR times or complications. This reduction in recovery time may lead to cost savings for patients and hospitals, possibly allow for higher daily OR throughput and alleviate strain on PACU nurse staffing.