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Re: Referral to Pediatric Surgical Specialists
Urological Survey Pediatric Urology Re: Referral to Pediatric Surgical Specialists M. D. Klein, C. F. Bannister, C. S. Houck, J. S. Tweddell, M. S. Dias, D. B. Granet, A. Segura, J. B. Ruben, W. L. Hennrikus, R. M. Schwend, S. R. Schoem, D. R. Mackay, P. J. Taub, C. I. Cassady, M. L. Brandt, F. J. Rescorla, W. C. Hulbert, C. A. Peters and J. Couto Surgical Advisory Panel, American Academy of Pediatrics, Elk Grove Village, Illinois Pediatrics 2014; 133: 350e356.
Abstract for this article http://dx.doi.org/10.1016/j.juro.2015.02.023 available at http://jurology.com/ Editorial Comment: The American Academy of Pediatrics (AAP) in collaboration with the surgical section of the AAP created referral recommendations intended to serve as voluntary practice parameters to help pediatricians determine when and where to refer children for surgical specialty care. These recommendations have been extended to heart surgeons as well as to pediatric dentists, neurosurgeons, ophthalmologists, orthopedists, otolaryngologists, plastic surgeons, general surgeons and urologists. For us (pediatric urologists) the AAP recommends referral to a pediatric urologist for 1) undescended testes and elective congenital hydrocele and hernias corrected in infancy and early childhood; 2) hypospadias, complex urogenital problems, ie duplex systems, ureterocele, bladder and cloacal exstrophy, moderate or severe vesicoureteral reflux, posterior urethral valves, and other structural anomalies such as urogenital sinus and cloacal anomalies; 3) solid malignancies of the kidney, bladder and testis (pediatric urologist or surgical specialist in conjunction with pediatric medical cancer specialist); 4) disorders of sex development (pediatric urologist or surgical specialist in conjunction with management team that should include a pediatric endocrinologist and psychologist in consultation with primary care pediatrician); 5) cystoscopy procedures in infants and children; 6) prolonged severe daytime voiding difficulty; 7) spinal cord disorders (eg myelomeningocele, spinal cord injuries); 8) major urological injuries after stabilization at the nearest medical center; 9) evaluation of infants and children with testicular torsion at the nearest medical center, and performance of surgery promptly, and 10) evaluation of prenatal urinary tract abnormalities by a pediatric urologist and a surgical member of a fetal treatment team prenatally or as soon as possible following birth. Douglas A. Canning, MD
Re: Clinical and Radiological Course of Simple Renal Cysts in Children lu, H. Cakmakc¸ı and S. Kavukc¸u M. T. Bayram, D. Alaygut, A. Soylu, E. Serdarog Departments of Pediatrics and Radiology, Dokuz Eylul University, Medical Faculty, and Dr. Behc¸ et Uz Children’s Disease and Pediatric Surgery Research and Training Hospital, Balcova, Izmir, Turkey Urology 2014; 83: 433e437.
Abstract for this article http://dx.doi.org/10.1016/j.juro.2015.02.024 available at http://jurology.com/
0022-5347/15/1935-1646/0 THE JOURNAL OF UROLOGY® © 2015 by AMERICAN UROLOGICAL ASSOCIATION EDUCATION
1646
j
www.jurology.com
AND
RESEARCH, INC.
http://dx.doi.org/10.1016/j.juro.2015.02.023 Vol. 193, 1646-1648, May 2015 Printed in U.S.A.
PEDIATRIC UROLOGY
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Editorial Comment: The authors retrospectively studied medical records of 45 patients who were diagnosed by ultrasound with simple renal cysts between January 2001 and August 2011. Cysts were defined as anechoic homogeneous lesions involving water content with no internal calcifications or distal enhancement and a thin wall on ultrasound. The maximum diameter of the cyst increased in 49% of the children, remained unchanged in 31% and decreased in 10%, and the cyst disappeared in 10% during a mean followup of 2.9 years. In most cases the change occurred within 20 months. Only 2 of the 41 patients required operative intervention, 1 for rapid expansion of the cyst with renal artery and vein compression, and 1 with severe pain resulting in aspiration. To me, these findings mean that observation with careful followup is safe for simple renal cysts in boys and girls. Douglas A. Canning, MD
Re: Minimally Invasive vs Open Pyeloplasty in Children: The Differential Effect of Procedure Volume on Operative Outcomes S. Sukumar, O. Djahangirian, A. Sood, J. D. Sammon, B. Varda, K. Janosek-Albright, A. E. Abd-El-Barr, M. Sun and Q. D. Trinh Center for Outcomes Research and Analytics, and Vattikuti Urology Institute, Henry Ford Health System, Detroit, Michigan, Division of Urologic Surgery, and Center for Surgery and Public Health, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, and Cancer Prognostics and Health Outcomes Unit, University of Montreal, Montreal, Quebec, Canada Urology 2014; 84: 180e184.
Abstract for this article http://dx.doi.org/10.1016/j.juro.2015.02.025 available at http://jurology.com/ Editorial Comment: The authors share a weighted estimate of 6,006 pediatric patients with ureteropelvic junction obstruction who underwent either open pyeloplasty (OP) or minimally invasive pyeloplasty (MIP) between 2008 and 2010. This series was taken from the Nationwide Inpatient Sample (the largest publicly accessible, all payer inpatient data set in the United States). The authors report that MIP accounted for 17.2% of the cases during the study years. In individual multivariate models centers with high OP volumes had the lowest risk of postoperative complications, genitourinary complications and excessive hospital charges compared to centers with high volume MIP, or low volume OP or MIP. However, regardless of hospital volume, patients undergoing MIP experienced shorter hospital stays. I was surprised that MIP is still performed in a minority of children. Since postoperative stay drives much of our cost, I believe that MIP will become increasingly frequent. It will be interesting to see how these numbers change in the next 10 years. This study suggests that, at least for now, OP still provides good results for the majority of children with ureteropelvic junction obstruction. Douglas A. Canning, MD
Re: Growth and Function in Childhood of a Normal Solitary Kidney from Birth or from Early Infancy E. Siomou, V. Giapros, F. Papadopoulou, M. Pavlou, A. Fotopoulos and A. Siamopoulou Department of Pediatrics, University Hospital of Ioannina, Ioannina, Greece Pediatr Nephrol 2014; 29: 249e256.
Abstract for this article http://dx.doi.org/10.1016/j.juro.2015.02.026 available at http://jurology.com/ Editorial Comment: The authors followed a group of 38 children with a solitary kidney and compared them to 40 matched control subjects. They found that systolic and diastolic blood pressures and resistive index of the arcuate arteries were increased in children with a solitary kidney. There
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was no difference in creatinine clearance or 24-hour protein. All but 7 children with a solitary kidney had a normal glomerular filtration rate (GFR) as measured with a diethylenetriaminepentaacetic acid GFR test. However, there was a correlation between length of followup and 24-hour albumin urinary excretion in those with a solitary kidney. Children with a solitary kidney and compensatory hypertrophy do well at least with intermediate followup (in older children more than 10 years). The presence of higher systolic and diastolic blood pressure and increased resistive indices in some is worrisome, and underscores the importance of monitoring these children for evidence of GFR deterioration in longer followup. Douglas A. Canning, MD
Abstract for this article http://dx.doi.org/10.1016/j.juro.2015.02.023 available at http://jurology.com/ Editorial Comment: The American Academy of Pediatrics (AAP) in collaboration with the surgical section of the AAP created referral recommendations intended to serve as voluntary practice parameters to help pediatricians determine when and where to refer children for surgical specialty care. These recommendations have been extended to heart surgeons as well as to pediatric dentists, neurosurgeons, ophthalmologists, orthopedists, otolaryngologists, plastic surgeons, general surgeons and urologists. For us (pediatric urologists) the AAP recommends referral to a pediatric urologist for 1) undescended testes and elective congenital hydrocele and hernias corrected in infancy and early childhood; 2) hypospadias, complex urogenital problems, ie duplex systems, ureterocele, bladder and cloacal exstrophy, moderate or severe vesicoureteral reflux, posterior urethral valves, and other structural anomalies such as urogenital sinus and cloacal anomalies; 3) solid malignancies of the kidney, bladder and testis (pediatric urologist or surgical specialist in conjunction with pediatric medical cancer specialist); 4) disorders of sex development (pediatric urologist or surgical specialist in conjunction with management team that should include a pediatric endocrinologist and psychologist in consultation with primary care pediatrician); 5) cystoscopy procedures in infants and children; 6) prolonged severe daytime voiding difficulty; 7) spinal cord disorders (eg myelomeningocele, spinal cord injuries); 8) major urological injuries after stabilization at the nearest medical center; 9) evaluation of infants and children with testicular torsion at the nearest medical center, and performance of surgery promptly, and 10) evaluation of prenatal urinary tract abnormalities by a pediatric urologist and a surgical member of a fetal treatment team prenatally or as soon as possible following birth. Douglas A. Canning, MD
Re: Clinical and Radiological Course of Simple Renal Cysts in Children lu, H. Cakmakc¸ı and S. Kavukc¸u M. T. Bayram, D. Alaygut, A. Soylu, E. Serdarog Departments of Pediatrics and Radiology, Dokuz Eylul University, Medical Faculty, and Dr. Behc¸ et Uz Children’s Disease and Pediatric Surgery Research and Training Hospital, Balcova, Izmir, Turkey Urology 2014; 83: 433e437.
Abstract for this article http://dx.doi.org/10.1016/j.juro.2015.02.024 available at http://jurology.com/
0022-5347/15/1935-1646/0 THE JOURNAL OF UROLOGY® © 2015 by AMERICAN UROLOGICAL ASSOCIATION EDUCATION
1646
j
www.jurology.com
AND
RESEARCH, INC.
http://dx.doi.org/10.1016/j.juro.2015.02.023 Vol. 193, 1646-1648, May 2015 Printed in U.S.A.
PEDIATRIC UROLOGY
1647
Editorial Comment: The authors retrospectively studied medical records of 45 patients who were diagnosed by ultrasound with simple renal cysts between January 2001 and August 2011. Cysts were defined as anechoic homogeneous lesions involving water content with no internal calcifications or distal enhancement and a thin wall on ultrasound. The maximum diameter of the cyst increased in 49% of the children, remained unchanged in 31% and decreased in 10%, and the cyst disappeared in 10% during a mean followup of 2.9 years. In most cases the change occurred within 20 months. Only 2 of the 41 patients required operative intervention, 1 for rapid expansion of the cyst with renal artery and vein compression, and 1 with severe pain resulting in aspiration. To me, these findings mean that observation with careful followup is safe for simple renal cysts in boys and girls. Douglas A. Canning, MD
Re: Minimally Invasive vs Open Pyeloplasty in Children: The Differential Effect of Procedure Volume on Operative Outcomes S. Sukumar, O. Djahangirian, A. Sood, J. D. Sammon, B. Varda, K. Janosek-Albright, A. E. Abd-El-Barr, M. Sun and Q. D. Trinh Center for Outcomes Research and Analytics, and Vattikuti Urology Institute, Henry Ford Health System, Detroit, Michigan, Division of Urologic Surgery, and Center for Surgery and Public Health, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, and Cancer Prognostics and Health Outcomes Unit, University of Montreal, Montreal, Quebec, Canada Urology 2014; 84: 180e184.
Abstract for this article http://dx.doi.org/10.1016/j.juro.2015.02.025 available at http://jurology.com/ Editorial Comment: The authors share a weighted estimate of 6,006 pediatric patients with ureteropelvic junction obstruction who underwent either open pyeloplasty (OP) or minimally invasive pyeloplasty (MIP) between 2008 and 2010. This series was taken from the Nationwide Inpatient Sample (the largest publicly accessible, all payer inpatient data set in the United States). The authors report that MIP accounted for 17.2% of the cases during the study years. In individual multivariate models centers with high OP volumes had the lowest risk of postoperative complications, genitourinary complications and excessive hospital charges compared to centers with high volume MIP, or low volume OP or MIP. However, regardless of hospital volume, patients undergoing MIP experienced shorter hospital stays. I was surprised that MIP is still performed in a minority of children. Since postoperative stay drives much of our cost, I believe that MIP will become increasingly frequent. It will be interesting to see how these numbers change in the next 10 years. This study suggests that, at least for now, OP still provides good results for the majority of children with ureteropelvic junction obstruction. Douglas A. Canning, MD
Re: Growth and Function in Childhood of a Normal Solitary Kidney from Birth or from Early Infancy E. Siomou, V. Giapros, F. Papadopoulou, M. Pavlou, A. Fotopoulos and A. Siamopoulou Department of Pediatrics, University Hospital of Ioannina, Ioannina, Greece Pediatr Nephrol 2014; 29: 249e256.
Abstract for this article http://dx.doi.org/10.1016/j.juro.2015.02.026 available at http://jurology.com/ Editorial Comment: The authors followed a group of 38 children with a solitary kidney and compared them to 40 matched control subjects. They found that systolic and diastolic blood pressures and resistive index of the arcuate arteries were increased in children with a solitary kidney. There
1648
PEDIATRIC UROLOGY
was no difference in creatinine clearance or 24-hour protein. All but 7 children with a solitary kidney had a normal glomerular filtration rate (GFR) as measured with a diethylenetriaminepentaacetic acid GFR test. However, there was a correlation between length of followup and 24-hour albumin urinary excretion in those with a solitary kidney. Children with a solitary kidney and compensatory hypertrophy do well at least with intermediate followup (in older children more than 10 years). The presence of higher systolic and diastolic blood pressure and increased resistive indices in some is worrisome, and underscores the importance of monitoring these children for evidence of GFR deterioration in longer followup. Douglas A. Canning, MD