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Objectives: To determine if patient variables were associated with intervention in pediatric patients presenting with high-grade renal injuries., Methods: A retrospective review of pediatric patients presenting with grade IV/V renal injury between 2003 and 2021 at a Level 1 trauma center was performed. Renal injury grade was verified and updated based upon the 2018 American Association for the Surgery of Trauma injury scale. Multivariable logistic regression analyses were performed., Results: Seventy-five patients (median age 13 years old, IQR 9-16) with Grade IV (n = 53) or Grade V (n = 22) injury were identified. 33% (25/75) had immediate renal intervention within 24 h of admission. Of the remaining 50 children who were observed, 47 had blunt trauma, and outcomes were analyzed. The median age of observed patients was 12 years (IQR 8-14) and 30% (14/47) had intervention. Delayed images on CT showed ureteral contrast was present in 87% (41/47) of observed patients. Multivariable analysis demonstrated that the presence of contrast in the ureter is associated with significantly lower odds of intervention, OR 0.06 [0-0.73, 95% CI], p = 0.03., Conclusion: After grades IV and V blunt renal injury, for those children who are considered safe to observe, AAST grade of injury did not associate with procedural intervention. The presence of contrast in the ureter on delayed CT imaging was associated with a significantly lower odds of procedural intervention., (© 2025 The Author(s). International Journal of Urology published by John Wiley & Sons Australia, Ltd on behalf of The Japanese Urological Association.)

Introduction: For children with duplex systems and severe hydroureteronephrosis of the upper pole, heminephrectomy is one of many suitable treatments, particularly if there is no associated lower pole reflux. Distal ureteral stump syndrome (DSS) is a very difficult complication and manifests as stump empyema, urinary tract infection and/or vulvar discharge and can occur months to years later in 10-20 percent of patients. Secondary distal ureterectomy is an extremely difficult surgery due to inflammation and adhesions. To avoid DSS, distal ureterectomy at the time of heminephrectomy can be performed concurrently but carries a risk of lower pole ureter devascularization and injury. Current literature on DSS has shown associations with subtotal ureterectomy or long ureteral stumps. We hypothesized that there may be preoperative variables prior to heminephrectomy that are associated with the development of DSS., Objective: Identify pre-operative risk factors for the development of DSS in pediatric patients who underwent upper pole heminephrectomy for duplex kidneys., Study Methods: Retrospective analysis of pediatric patients who underwent upper pole heminephrectomy at single, academic institution from 1999 to 2021. Pre-operative patient age, gender, history, imaging, and lab results were extracted from patient charts to assess for factors that may predict the development of DSS. Patient groups with and without DSS were compared using Fischer's Exact Test., Results: Five (14%) of 36 patients developed DSS and required secondary distal ureterectomy at a median time of 22 months (IQR 6-27) after heminephrectomy. The presence of ureteral debris (80% of DSS) on preoperative ultrasound (p < 0.001), reflux into the upper pole (p = 0.005), and mucus discharge (100% of DSS) (p < 0.001) prior to surgery were found to be significantly associated with those who developed DSS, compared to those who did not. These three pre-operative factors had high specificity (97-100%) and negative predictive value (94-97%)., Discussion: Substantial experience has shown that less than 20% of patients benefit from distal ureterectomy during upper heminephrectomy. Whether using an open or laparoscopic approach, selection of at-risk patients should lower operative time and avoid injury and devascularization of the lower pole ureter for most patients., Conclusion: The presence or absence of ureteral debris, mucus discharge and/or upper pole reflux prior to heminephrectomy may be useful guides in selecting which patients would benefit from concurrent distal ureterectomy and conversely which patients may safely avoid the additional dissection., Competing Interests: Conflict of interest None., (Copyright © 2023 The Author(s). Published by Elsevier Ltd.. All rights reserved.)

Background: Although hypospadias outcomes studies typically report a level or type of repair performed, these studies often lack applicability to each surgical practice due to technical variability that is not fully delineated. An example is the tubularized incised plate (TIP) urethroplasty procedure, for which modifications have been associated with significantly decreased complication rates in single center series. However, many studies fail to report specificity in techniques utilized, thereby limiting comparison between series., Objective: With the goal of developing a surgical atlas of hypospadias repair techniques, this study examined 1) current techniques used by surgeons in our network for recording operative notes and 2) operative technical details by surgeon for two common procedures, tubularized incised plate (TIP) distal and proximal hypospadias repairs across a multi-institutional surgical network., Study Design: A two-part study was completed. First, a survey was distributed to the network to assess surgeon volume and methods of recording hypospadias repair operative notes. Subsequently, an operative template or a representative de-identified operative note describing a TIP and/or proximal repair with urethroplasty was obtained from participating surgeons. Each was analyzed by at least two individuals for natural language that signified specified portions of the procedure. Procedural details from each note were tabulated and confirmed with each surgeon, clarifying that the recorded findings reflected their current practice techniques and instrumentation., Results: Twenty-five surgeons from 12 institutions completed the survey. The number of primary distal hypospadias repairs performed per surgeon in the past year ranged from 1-10 to >50, with 40% performing 1-20. Primary proximal hypospadias repairs performed in the past year ranged from 1-30, with 60% performing 1-10. 96% of surgeons maintain operative notes within an electronic health record. Of these, 66.7% edited a template as their primary method of note entry; 76.5% of these surgeons reported that the template captures their operative techniques very or moderately well. Operative notes or templates from 16 surgeons at 10 institutions were analyzed. In 7 proximal and 14 distal repairs, parameters for chordee correction, urethroplasty suture selection and technique, tissue utilized, and catheter selection varied widely across surgeons., Conclusion: Wide variability in technical surgical details of categorically similar hypospadias repairs was demonstrated across a large surgical network. Surgeon-specific modifications of commonly described procedures are common, and further evaluation of short- and long-term outcomes accounting for these technical variations is needed to determine their relative influence., Competing Interests: Conflicts of interest All authors have confirmed that there are no conflict of interests. This includes any financial and personal relationships with people or organizations that could inappropriately influence (bias) this work., (Copyright © 2022 The Author(s). Published by Elsevier Ltd.. All rights reserved.)

Introduction: There is controversy surrounding the association between caudal block and complication rates after hypospadias repair. Conflicting results have been reported mostly from single-center, low volume studies and those that did not include relevant variables., Objectives: We hypothesized that caudal block is not associated with increased rates of reoperation after primary repair and is associated with more complex hypospadias surgery., Study Design: The Clinical Practice Solutions Center database was queried to identify patients who received a primary hypospadias repair between 2009 and 2010. Primary hypospadias repair was further categorized as meatal advancement and glanduloplasty, distal, one-stage proximal, or one-stage perineal repair. Anesthesia coding was evaluated to identify those who received a caudal block. Any revision surgery was captured between 2009 and 2019 and the types of revision surgeries were identified. Variables such as caudal block, age, insurance type, surgeon volume, and surgeon years in practice were analyzed with mixed effects multiple logistic regression models., Results: The dataset query identified 3343 pediatric males who had primary hypospadias repair. The procedures were performed by 50 surgeons at 27 hospitals. Primary surgeries included meatal advancement and glanduloplasty (23%), distal (69%), proximal (6.9%), and perineal repairs (1%). Caudal block was administered to 42% of patients. Utilization of caudal block was not associated with type of primary surgery (p = 0.21). Adjusting for all other variables, increased patient age was associated with decreased usage of caudal block (p < 0.001). Analysis did not demonstrate a statistically significant association between utilization of caudal block with rates of revision surgery., Conclusions: This large, multi-institution study demonstrates that the use of caudal block was not associated with more complex hypospadias surgery nor statistically significantly associated with increased rates of revision surgery after primary hypospadias repair., (Copyright © 2023 The Author(s). Published by Elsevier Ltd.. All rights reserved.)

To investigate the biomechanical properties of rat bladder tissue after spinal cord injury (SCI) using uniaxial tensile testing. Evidence suggests the bladder wall undergoes remodeling following SCI. There is limited data describing the biomechanical properties of bladder wall after SCI. This study describes the changes in elastic and viscoelastic mechanical properties of bladder tissue using a rat model after SCI. Seventeen adult rats received mid-thoracic SCI. Basso, Beattie, and Bresnahan (BBB) locomotor testing was performed on the rats 7-14 days after injury quantifying the degree of SCI. Bladder tissue samples were collected from controls and spinal injured rats at 2- and 9-weeks post-injury. Tissue samples underwent uniaxial stress relaxation to determine instantaneous and relaxation modulus as well as monotonic load-to failure to determine Young's modulus, yield stress and strain, and ultimate stress. SCI resulted in abnormal BBB locomotor scores. Nine weeks post-injury, instantaneous modulus decreased by 71.0% (p = 0.03) compared to controls. Yield strain showed no difference at 2 weeks post-injury but increased 78% (p = 0.003) in SCI rats at 9 weeks post-injury. Compared to controls, ultimate stress decreased 46.5% (p = 0.05) at 2 weeks post-injury in SCI rats but demonstrated no difference at 9 weeks post-injury. The biomechanical properties of rat bladder wall 2 weeks after SCI showed minimal difference compared to controls. By week 9, SCI bladders had a reduction in instantaneous modulus and increased yield strain. The findings indicate biomechanical differences can be identified between control and experimental groups at 2- and 9-week intervals using uniaxial testing., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2023 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Introduction: Cloacal dysgenesis occurs from failure of embryological division of urogenital sinus and hindgut, leading to a single common perineal opening for genitourinary and gastrointestinal tracts. The prenatal diagnosis of cloacal malformation is imprecise, but the clinical correlation of postnatal findings to prenatal history can help reveal explanations for unusual pathological findings in patients with urogenital abnormalities., Case Presentation: A 21-year-old woman was referred after her 20-week ultrasound demonstrated anhydramnios and concern for dilated fetal bowel. Fetal MRI confirmed anhydramnios and a dilated fetal colon, in addition to hydronephrosis and a pelvic cyst. Repeat ultrasound at 27 weeks showed unexpected complete resolution of her anhydramnios but new fetal ascites. The newborn girl was postnatally diagnosed with a cloacal malformation and an unusual near-complete fusion of her labia. She underwent proximal sigmoid colostomy and a tube vaginostomy at birth followed by cloacal reconstruction at 1.5 years old., Conclusion: In female fetus with a pelvic cyst, one should have a high index of suspicion for cloacal anomaly and consider the possibility of urinary obstruction leading to alteration in amniotic fluid., (© 2023 S. Karger AG, Basel.)

In this study, the rates of reoperation for stress urinary incontinence (SUI) and pelvic organ prolapse (POP) in women who underwent a mid-urethral sling (MUS) with or without concurrent colporrhaphy were evaluated. An academic faculty practice consortium database was used to identify a cohort of patients treated surgically for SUI with or without concurrent POP repair (apical, anterior, posterior, or a combination of the three) with or without hysterectomy between 2009 and 2011. A total of 20,484 patients matched the criteria. Of patients who underwent a MUS, 7.2% underwent secondary surgery, with a higher rate of 8.6% associated with those who underwent concurrent prolapse repair (Apical repair HR 1.84, p  < .01; Anterior compartment repair HR 1.47, p  < .01). Concurrent hysterectomy was associated with a lower hazard of secondary prolapse surgery (HR 0.48; p < .01 ) if the initial surgery involved a complete POP repair. Prolapse mesh repair resulted in a higher hazard of additional surgery (HR 1.43, p  < .01). Medicaid insurance was also associated with an increased hazard ratio compared to commercial insurance for secondary surgery (HR 1.32, p  < .01). For women undergoing MUS with complete prolapse repair, concurrent hysterectomy is associated with lower secondary surgery rates. Concurrent prolapse repair with mesh is associated with higher secondary surgery rates. Synopsis: For women undergoing MUS (mid-urethral sling) with complete prolapse repair, concurrent hysterectomy is associated with lower secondary surgery rates. Concurrent prolapse repair with mesh is associated with higher secondary surgery rates.Impact Statement What is already known on this subject? Stress urinary incontinence (SUI) and pelvic organ prolapse (POP) can present at the same time and negatively impact patients' quality of life. There is little data regarding reoperation rates for patients who undergo both MUS and colporrhaphy in one setting. What do the results of this study add? This study found that patients who undergo concurrent MUS (mid-urethral sling) and complete POP repair with the addition of hysterectomy had a lower risk of secondary surgery. What are the implications of these findings for clinical practice and/or further research? Our data can be used by surgeons to counsel patients on the risks of re-operation for SUI for those who would like to undergo concurrent POP repair with or without hysterectomy.

Large animal testing and clinical trials using bioengineered bladder for augmentation have revealed that large grafts fail due to insufficient blood supply. To address this critical issue, an in vivo staged implant strategy was developed and evaluated to create autologous, vascularized bioengineered bladder tissue with potential for clinical translation. Pig bladders were used to create acellular urinary bladder matrices (UBMs), which were implanted on the rectus abdominus muscles of rats and pigs to generate cellular and vascular grafts. Rectus-regenerated bladder grafts (rrBGs) were highly cellularized and contained an abundance of CD31-positive blood vessels, which were shown to be functional by perfusion studies. Muscle patterns within grafts showed increased smooth muscle formation over time and specifically within the detrusor compartment, with no evidence of striated muscle. Large, autologous rrBGs were transplanted to the pig bladder after partial cystectomy and compared to transplantation of control UBMs at 2 weeks and 3 months post-transplant. Functional, ink-perfused blood vessels were found in the central portion of all rrBGs at 2 weeks, while UBM grafts were significantly deteriorated, contracted and lacked central cellularization and vascularization. By 3 months, rrBGs had mature smooth muscle bundles and were morphologically similar to native bladder. This staged implantation technique allows for regeneration and harvest of large bladder grafts that are morphologically similar to native tissue with functional vessels capable of inosculating with host bladder vessels to provide quick perfusion to the central area of the large graft, thereby preventing early ischemia and contraction., (© 2022 John Wiley & Sons Ltd.)

A combination product of human mesenchymal stem/stromal cells (MSCs) embedded in an extracellular matrix scaffold and preconditioned with hypoxia and the beta-adrenergic receptor antagonist, timolol, combined with sustained timolol application post implantation, has shown promising results for improving wound healing in a diabetic mouse model. In the present study, we extend those findings to the more translatable large animal porcine wound model and show that the combined treatment promotes wound reepithelialization in these excisional wounds by 40.2% and increases the CD31 immunostaining marker of angiogenesis compared with the matrix control, while maintaining an accumulated timolol plasma concentration below the clinically safe level of 0.3 ng/mL after the 15-day course of topical application. Human GAPDH was not elevated in the day 15 wounds treated with MSC-containing device relative to wounds treated with matrix alone, indicating that the xenografted human MSCs in the treatment do not persist in these immune-competent animals after 15 days. The work demonstrates the efficacy and safety of the combined treatment for improving healing in the clinically relevant porcine wound model., (© 2022 Wiley Periodicals LLC.)

Purpose: While the true incidence of secondary hypospadias repair is unknown, the current literature cites a 3.3% to 6.7% reoperation rate after distal hypospadias repair and an association with age. We hypothesized that secondary surgery rates are associated with patient factors and have been underreported due to limited followup., Materials and Methods: We used an academic practice plan consortium database to identify a population that underwent primary hypospadias repair in 2009 and 2010. Secondary surgeries between 2009 and 2019 were captured. The association of variables such as age, insurance type, region, surgeon volume and surgeon years in practice with all-inclusive and specific secondary surgery procedures were analyzed using mixed effects multiple logistic regression models., Results: We identified 5,178 boys who had primary hypospadias repair performed by 84 pediatric urologists at 46 hospitals in 2009 and 2010. During the ensuing 9 to 10 years, distal, proximal and perineal hypospadias repair had a 12.6%, 37.9% and 46.6% rate of secondary surgery, respectively. After adjusting for all other variables in the model, patients with noncommercial insurance had a 26% (OR 1.26, p=0.04) increased odds of secondary surgery. Patient age and surgeon years in practice were not associated with all-inclusive secondary surgery except for endoscopic treatment. Surgeon volume was not associated with secondary surgery., Conclusions: This study demonstrated that secondary surgery rates are underreported if followup is limited to less than 6 years. Patient age, surgeon volume and experience did not associate with all-inclusive reoperation rates whereas insurance status was a major predictor of reoperation.

Introduction: Abdominoscrotal hydroceles (ASH) are uncommon occurrences in boys and usually treated similarly to a hernia with the assumption that there is an associated patent processus vaginalis. Treatment in this manner may be challenging due to sac size, extension and adherence to the spermatic cord. Due to the rarity of ASH, the literature is mostly limited to small, single-institution case studies., Objective: Our goal was to evaluate two techniques in large number. We hypothesized a simplified scrotal technique with eversion, Jaboulay procedure, would demonstrate less complications and equivalent efficacy to standard excision., Methods: We retrospectively reviewed medical records at three tertiary children's hospitals to identify boys who underwent surgical repair of ASH between 1998 and 2018. Group 1 had excision and/or ligation of the hydrocele sac. Group 2 had a scrotal incision with limited excision and then eversion of the hydrocele sac (Jaboulay procedure). Variables that were analyzed included preoperative imaging, surgical technique, surgical findings, length of follow up, complications and recurrence of swelling., Results: We identified 61 boys, who had 77 abdominoscrotal hydroceles. Group 1 included 38 patients with 48 hydroceles. Group 2 included 23 patients with 29 hydroceles. Complications were more common in Group 1 patients (18% vs 0%) but complication rate and operative time were not statistically associated with surgery type or age. No patient in either group had recurrence of hydrocele., Discussion: Although this is a large study for this rare condition, the analysis is limited by number and its retrospective nature., Conclusion: For the rare and difficult to treat abdominoscrotal hydrocele, we were unable to prove with statistical significance that a simplified technique of eversion via the scrotum is safer. However, this large series did demonstrate that the simplified procedure provides equal efficacy as excision., (Copyright © 2020 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved.)

Objectives: To evaluate an alternative to clean intermittent catheterization (CIC) for individuals with neurogenic bladder for its effects on independence, privacy, and convenience. This prospective cohort study provides an initial assessment of quality of life, safety, and efficacy of closed diurnal indwelling catheterization (CDIC)., Materials and Methods: Individuals with spinal cord disorders using CIC were prospectively screened at multidisciplinary clinic appointments. During the 24-week intervention, a foley was placed each morning and capped between scheduled bladder drainage each 3-4 hours. After a maximum of 8 hours of CDIC use, CIC was resumed. Quality of life outcome measures (the Short Form Health Survey, King's Health Questionnaire, and Pediatric Quality of Life InventoryTM (PedsQL) questionnaires), clinic evaluations, labs, imaging, and urodynamics were obtained at specified interval visits planned after 4-, 12-, and 24 weeks of study participation and compared to baseline., Results: A total of 11 subjects enrolled; 8 completed the 24-week intervention. No significant difference with CDIC was observed in the Short Form Health Survey or PedsQL summary scores as compared to baseline. For the King's Health Questionnaire, physical limitations secondary to bladder function decreased significantly from baseline to the 4-week and 12-week (P = .02) but not 24-week visits. All 8 subjects who completed the 24-week intervention requested continued use. Early discontinuation occurred in 3 male participants due to urethral trauma (1) and incontinence (2). No increase in bacteriuria, urinary tract infections, or renal anatomic changes was observed., Conclusion: This prospective study demonstrates that CDIC may be safe and effective for short-term use. This alternative to CIC for scheduled daytime bladder drainage for neurogenic bladder warrants further consideration., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Purpose: Stomal stenosis has been reported to occur in 12% to 45% of patients following Malone antegrade continence enema and Mitrofanoff appendicostomy. The standard stoma technique entails excision of the distal appendix. We evaluated a novel technique with preservation of the appendiceal tip and vessels, and opening the lumen in a more proximal and vascular area to determine whether the incidence of stenosis would be decreased., Materials and Methods: Medical records of patients who underwent appendicostomy for Malone antegrade continence enema or urinary diversion were retrospectively evaluated. We included cases with a minimum of 1 year of followup and those in which the distal portion of a complete appendix was oriented for use as the stomal end in the umbilicus. Variables such as age, gender, body mass index, antegrade continence enema or urinary diversion, open or laparoscopic approach, cecal and appendiceal adhesions, retrocecal position, cecal imbrication, technique and stenosis were recorded. Cox proportional hazards analyses were performed to determine association of covariates., Results: A total of 123 patients met inclusion criteria. The incidence of stenosis following standard stoma technique was 13% (12 of 93 patients) with a median followup of 9.4 years. Of these cases 75% occurred within 1 year of surgery. Stomal stenosis did not occur after the new stoma technique in 30 patients with a median followup of 3.3 years. Only technique cohort (standard vs new) was associated with stenosis (p=0.04)., Conclusions: Stomal stenosis of appendicostomy may be lessened by preservation of the distal appendiceal vasculature and tip, and opening the lumen in a more proximal location.

Introduction: Diagnostic laparoscopy is recommended for boys with non-palpable testis (NPT) by American and European guidelines with the decision to pursue inguinal exploration based upon testicular vessel appearance. We hypothesized that management decisions are not consistent with the guidelines, and that assessment of vessels is subjective., Materials and Methods: Pediatric urologist management decisions were evaluated via an electronic survey to determine impact of contralateral testicle size, sonographic findings, surgeon region, and years in practice. In a digital image survey, surgeons were asked to interpret gonadal vessel status of 32 consecutive cases of NPT with absent abdominal testis as normal, atretic, or blind-ending to determine intra- and inter-rater reliability., Results: Of the 339 participants, more Europeans (49%) chose sonography as the first management step for NPT compared to US surgeons (12%). Regardless of sonographic findings, over 80% chose laparoscopy as the first step. In the presence of normal, atretic, and blind-ending vessels, the decisions to proceed with inguinal/scrotal exploration were 88%, 68%, and 17%, respectively. Contralateral hypertrophy and sonography findings had no significant impact on the decision to proceed with inguinal/scrotal exploration. The visual gonadal vessel survey showed surgeon interpretation of normal or blind-ending vessels had moderate inter-rater reliability. Surgeons did not agree on normal status 37% of the time and did not agree on atretic status 66% of the time. There was no statistical difference between European and US respondents (P = 0.23). Intra-rater reliability was fair for blind-ending vessels. When the first interpretation was blind-ending, the same surgeon changed interpretation of the same image 39% of the time. There was no statistical difference by years of practice., Conclusions: Non-visualization of NPT on sonography and contralateral testis size had no significant impact upon management decisions. Surgeons chose to pursue inguinal/scrotal exploration based upon laparoscopic gonadal vessel status. However, these interpretations were subjective with low inter- and intra-rater reliability., (Published by Elsevier Ltd.)

Purpose: Bladder fullness and urgency are difficult for some patients to express. We hypothesized that images on a pictorial urgency scale would correlate with International Continence Society standard verbal descriptors and bladder volume., Materials and Methods: The study population consisted of 267 toilet trained children with a mean age of 7.2 years and their parents (91 adults). Patients were excluded if they had a history of urinary infection, voiding dysfunction, genitourinary surgery or reflux. Participants were read each of the 4 descriptors and asked to point to an image. Correlation between descriptors and figures was analyzed using a mixed effects proportional odds logistic regression model (aim 1 of study). In addition, 73 children undergoing voiding cystourethrography were asked to point to the images during bladder filling. Correlation between percent of expected capacity and image was analyzed using a linear mixed effects model (aim 2 of study)., Results: Correlation between descriptors and images (aim 1) was 0.87 (95% CI 0.84 to 0.89) for all participants, 0.84 (95% CI 0.81 to 0.88) for patients younger than age 6 years and 0.88 (95% CI 0.85 to 0.90) for patients 6 to 17 years old. Sequencing of the images was appropriate for increasing degree of urgency. In 73 children undergoing voiding cystourethrography correlation between image and percent of expected capacity (aim 2) was 0.75 (95% CI 0.67 to 0.81, p <0.001)., Conclusions: Figures on the pictorial urgency scale correlate with standard verbal descriptors and bladder volume. The pictorial scale could be a supplemental tool to improve communication of urgency sensation in younger children.

Introduction: The Malone antegrade continence enema (MACE) procedure is effective in management of fecal incontinence and intractable constipation. Stomal incontinence and stenosis are the most common issues reported, and a recent large study of imbricated MACE procedures reports a surgical revision rate of 17%. The laparoscopic approach is now widely used and precludes imbrication. To date, few studies have reported revision rates in these patients who have undergone non-imbricated MACE creation., Objective: Our goal was to report the long-term outcomes of our non-imbricated patients focusing on complication rates and need for revision., Study Design: Records of patients younger than 18 years of age who underwent non-imbricated MACE between January 2000 and March 2016 at our institution were reviewed. Patients with less than 2 years of follow-up or non-compliance with MACE usage were excluded from analysis. Patient age, ambulatory status, surgical technique, stomal site, and complications including stomal leakage, stomal stenosis, and need for revision were evaluated. Stomal leakage was classified based on our previously reported system., Results: A total of 81 patients met inclusion criteria. Mean age at time of surgery was 8.4 years. Mean and median follow-up were 6.7 and 6.7 years, respectively. Overall revision rate, for stenosis or incontinence, was 16% with a mean time to any revision of 2.1 years (range 28 days to 7.8 years). Four patients required revision for stomal incontinence while others improved spontaneously without intervention. At the last follow-up, stomal leakage was grade 0 in 93.8% of patients, grade 2 in 2.4%, and grade 3a in 3.7% (summary Table). Stomal stenosis was noted in 11 patients, eight of whom required revision., Discussion: Our study is limited by its retrospective nature with some component of recall bias. A single surgeon experience is also not representative of others' experiences. However, our results indicate that incontinence improves spontaneously in a majority of patients without need for revision in this non-imbricated cohort., Conclusions: Our series shows a similar long-term revision rate in line with that reported in the literature. While imbrication is still recommended during open surgery when the anatomy is suitable, equitable success without imbrication supports the laparoscopic approach and a more liberal approach during open surgery if the anatomy does not permit imbrication., (Copyright © 2018 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved.)

Bioengineering of bladder tissue, particularly for those patients who have advanced bladder disease, requires a source of urothelium that is healthy, capable of significant proliferation in vitro and immunologically tolerated upon transplant. As pluripotent stem cells have the potential to fulfill such criteria, they provide a critical cell source from which urothelium might be derived in vitro and used clinically. Herein, we describe the in vitro differentiation of urothelium from the H9 human embryonic stem cell (hESC) line through the definitive endoderm (DE) phase via selective culture techniques. The protocol can be used to derive urothelium from other hESCs or human-induced pluripotent stem cells.

Purpose of Review: Spina bifida is caused by incomplete neural tube closure during the first trimester. This condition may lead to bowel and bladder dysfunction as well as truncal weakness and motor anomalies. Presentations vary between myelomeningoceles and lipomeningoceles and may result in different outcomes. This review seeks to explore our current understanding of the variations in outcomes between individuals with myelomeningocele and lipomeningocele., Recent Findings: Prenatal intervention has become a standard of care for prenatal diagnoses of myelomeningocele and has been shown to reduce shunt placement and improve motor skills. However, urological benefit from early intervention remains to be seen. Early surgical repair, however, may be beneficial for patients with lipomeningocele. Literature on the urological outcomes of patients with myelomeningocele and lipomeningocele is lacking. Further research is needed to better elucidate differences in long-term urological outcomes between these two pathologies.

Introduction: Patient age and hospital volume have been shown to affect perioperative outcomes after pediatric pyeloplasty. However, there are few multicenter studies that focus on outcomes at teaching hospitals, where many of the operations are performed., Objective: The goal was to determine if surgical approach, age, case volume, or other factors influence perioperative outcomes in a large contemporary cohort., Study Design: Using the clinical database/resource manager (CDB/RM) of the University Health-System Consortium (UHC), children who underwent open, laparoscopic, or robotic pyeloplasty from 2011 to 2014 were identified at 102 academic institutions. Surgery type, age, race, gender, insurance type, geographic region, comorbidities, surgeon volume, and hospital volume were measured. Multivariable mixed-effects logistic regression analysis was used to analyze independent variables associated with complication rates, length of stay (LOS), readmission rates, and ICU admission., Results: A total of 2219 patients were identified. Complication rates were 2.1%, 2.2%, and 3% after open, laparoscopic, and robotic pyeloplasty, respectively. Approximately 12% of patients had underlying comorbidities. Comorbidities were associated with 3.1 times increased odds for complication (p = 0.001) and a 35% longer length of stay (p < 0.001). Age, gender, insurance type, and hospital volume had no effect on complication rates. A trend was seen towards a lower rate of complications with higher surgeon volume (p = 0.08). The mean LOS was 2.0 days in the open pyeloplasty group, 2.4 days in the laparoscopic group and 1.8 days in the robotic group. Patients who underwent robotic surgery had an estimated LOS 11% shorter than those after open surgery (p = 0.03) (Table). Patients aged 5 years and under who had robotic surgery had an estimated LOS 14% shorter than those after open surgery (p = 0.06). ICU admission and hospital readmission were not associated with any variables., Discussion: The study is limited by the accuracy of the data submitted by the hospitals and is subject to coding error. Complication rates remain low in all three approaches, validating their safety. Patients, including younger patients, had shorter lengths of stay after robotic surgery. The statistically significant differences between approaches were small so clinically there may not be a difference., Conclusions: This large multicenter analysis demonstrates that patient comorbidity had the greatest impact upon complication rates and length of stay. Previous work showed that the benefits of laparoscopy were limited to older children. However, this large multicenter study suggests that these benefits now extend to young children with the application of robotics., (Copyright © 2016 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved.)

Aims: There is a lack of data describing the current state of stress urinary incontinence (SUI) procedures in academic centers. Urologists, gynecologists, and urogynecologists perform these operations, but the relative volume each group accounts for is unknown. The purpose of this study was to evaluate the distribution of cases in academic centers between specialties and associated patient characteristics., Methods: A hospital consortium database was used to identify patients treated surgically for SUI between 2009 and 2014. Patient and surgeon variables were evaluated. Patient variables (age, region, insurance, race) and surgeon volume were analyzed. Sub-analysis was conducted to determine concomitant prolapse repairs., Results: Of the 50,315 stress urinary incontinence procedures performed, 22% were performed by urologists. Overall volume dropped 39% and mean surgeon volumes for all three groups decreased with time. Average median volume for urogynecologists (29/year) differed from both urologists (3/year) and non-urogynecologists (2/year). There was a significant difference in rate of concomitant prolapse repairs performed by urogynecologists (56%), gynecologists (54%), and urologists (26%)., Conclusions: These data portray the changing pattern of SUI procedure practice in academic centers. Academic urologists are performing less than 25% of SUI procedures, with an overall decline in number of procedures across all specialties. Urogynecologists and gynecologists are performing a significantly higher proportion of concomitant prolapse repairs. Neurourol. Urodynam. 36:394-398, 2017. © 2015 Wiley Periodicals, Inc., (© 2015 Wiley Periodicals, Inc.)

Many pathological processes including neurogenic bladder and malignancy necessitate bladder reconstruction, which is currently performed using intestinal tissue. The use of intestinal tissue, however, subjects patients to metabolic abnormalities, bladder stones, and other long-term sequelae, raising the need for a source of safe and reliable bladder tissue. Advancements in stem cell biology have catapulted stem cells to the center of many current tissue regeneration and bioengineering strategies. This review presents the recent advancements in the use of stem cells in bladder tissue bioengineering.

Purpose: Both pediatric urologists and pediatric surgeons perform hernia repairs, hydrocelectomies and orchiopexies. We hypothesized that surgeons perform more incarcerated and female hernia repairs while urologists perform more orchiopexies and hydrocelectomies., Methods: The Vizient-AAMC Faculty Practice Solutions Center® database was queried from January 2009 to December 2014 to identify patients 10years or younger who underwent the above procedures performed by pediatric specialists. Age, gender, race, insurance, geographic region and surgeon volume were examined., Results: In the study 55,893 surgeries were identified: 26,073 primary hernia repairs, 462 recurrent hernia repairs, 3399 laparoscopic hernia repairs, 9414 hydrocele repairs and 16,545 orchiopexies. Pediatric surgeons performed 89% of primary hernia repairs with an annual median surgeon volume of 4 cases/year. Pediatric urologists performed 62% of hydrocelectomies and 83% of orchiopexies with annual median surgeon volumes of 6 and 24, respectively. Pediatric surgeons performed all procedures in younger patients and performed more female and incarcerated hernia repairs., Conclusions: Pediatric surgeons operate on younger patients and treat more patients with inguinal hernias while pediatric urologists care for more boys with undescended testes and hydroceles. This knowledge of referral patterns and care between specialties with overlapping expertise will allow improvements in training and access., Levels of Evidence: Cost Effectiveness Study, Level of Evidence III., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Objective: After varicocelectomy a wide range of recurrence rates have been reported from 0 to 18%, and rates of post-operative hydrocele formation between 0 and 29%. Controversy exists as to the appropriate approach for varicocele treatment, whether open, laparoscopic, or percutaneous embolization (PE) is best for young men. The literature on treatment of adolescent varicocele is limited to high-volume single surgeon, single institution, or small multi-institution series. Our goal was to evaluate the retreatment and complication rates from numerous institutions to determine more generalizable results., Study Design: The Faculty Practice Solutions Center database was queried to identify males under age 19 years with a diagnosis and/or treatment of varicocele between January 2009 and December 2012. Patients were followed until December 2013 (1-5 years follow-up) to determine if they had occurrence of outcome variables: retreatment, diagnosis, or treatment of hydrocele. Associations of the variables age, race, insurance type, geographical region, surgeon-volume, and surgical approach, with outcome variables were analyzed using a mixed-effects Cox proportional hazard model., Results: Of 6,729 patients with a diagnosis of varicocele, 1,036 underwent open (405), laparoscopic (530), or percutaneous embolization (PE) (101) treatment by 213 physicians. Retreatment rates after open, laparoscopic, and PE treatments were 1.5%, 3.4% and 9.9%, respectively. Race, region, insurance type, and age were not independently associated with outcomes. The incidence of hydrocele after open, laparoscopic, and PE treatments was 4.9%, 8.1%, and 5%, respectively. No approach was independently associated with diagnosis or treatment of hydrocele. Young age was associated with a significantly higher rate of hydrocele formation. For each year of age, there was a 14% decreased rate of hydrocele formation., Discussion: Although this series contains the largest cohort of patients, physicians, and institutions, we were limited by the inability to determine actual recurrence rates. Only patients receiving retreatment at the same institution within the 1-5 year follow-up period were captured. As such, the true rate of varicocele recurrence may be higher. The retreatment rate is influenced by the physician's threshold to retreat and the patient's desire to undergo another procedure. Despite its limitations, this is the first study to compare open, laparoscopic, and percutaneous approaches to varicocele treatment., Conclusions: Percutaneous embolization has a significantly higher retreatment rate compared with either open or laparoscopic varicocelectomy. Retreatment and hydrocele formation after open and laparoscopic approaches were not significantly different. This supports a surgeon and family choosing an approach based on patient characteristics and surgeon preference., Competing Interests: The authors have no conflict of interest to disclose., (Copyright © 2015 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved.)

Bioengineered bladder tissue is needed for patients with neurogenic bladder disease as well as for cancer. Current technologies in bladder tissue engineering have been hampered by an inability to efficiently initiate blood supply to the graft, ultimately leading to complications that include graft contraction, ischemia, and perforation. To date, the biological mechanisms of vascularization on transplant have not been suitably investigated for urologic tissues. To better understand the mechanisms of neovascularization on bladder wall transplant, a chimeric mouse model was generated such that angiogenesis and vasculogenesis could be independently assessed in vivo. Green fluorescence protein (GFP) transgenic mice received bone marrow transplants from β-galactosidase (LacZ) transgenic animals and then subsequent bladder wall transplants from wild-type donor mice. Before euthanization, the aorta was infused with fluorescent microbeads (fluorospheres) to identify perfused vessels. The contributions of GFP (angiogenesis) and LacZ (vasculogenesis) to the formation of CD31-expressing blood vessels within the wild-type graft were evaluated by immunohistochemistry at different time points and locations within the graft (proximal, middle, and distal) to provide a spatiotemporal analysis of neovascularization. The GFP index, a measure of angiogenic host ingrowth, was significantly higher at proximal versus mid or distal regions in animals 2-16 weeks post-transplant. However, GFP index did not increase over time in any area. Within 7 days post-transplant, perfusion of primarily wild-type, donor blood vessels in the most distal areas of the graft was observed by intraluminal fluorospheres. In addition, chimeric host-donor (GFP-wild type) blood vessels were evident in proximal areas. The contribution of vasculogenesis to vascularization of the graft was limited, as LacZ cells were not specifically associated with the endothelial cells of blood vessels, but rather found primarily in areas of inflammation. The data suggest that angiogenesis of host blood vessels into the proximal region leads to inosculation between host and donor vessels and subsequent perfusion of the graft via pre-existing graft vessels within the first week after transplant. As such, the engineering of graft blood vessels and the promotion of inosculation might prevent graft contraction, thereby potentiating the use of bioengineered bladder tissue for transplantation.

Purpose: Controversy exists on the necessity for and timing of genitoplasty in girls with congenital adrenal hyperplasia. Our knowledge of surgical preferences is limited to retrospective series from single institutions and physician surveys, which suggest a high rate of early reconstruction. We evaluated current surgical treatment for congenital adrenal hyperplasia at academic centers., Materials and Methods: We queried the Faculty Practice Solutions Center database to identify all female patients younger than 18 years with a diagnosis of congenital adrenal hyperplasia between 2009 and 2012. Procedures were identified by CPT codes for vaginoplasty, clitoroplasty and other genital procedures. Reconstruction type, age at surgery and surgeon volume were analyzed., Results: We identified 2,614 females in the database with a diagnosis of congenital adrenal hyperplasia who were seen at a total of 60 institutions. Of infants younger than 12 months between 2009 and 2011 as few as 18% proceeded to surgery within a 1 to 4-year followup. Of those referred to a pediatric urologist 46% proceeded to surgery. Of patients who underwent surgery before age 2 years clitoroplasty and vaginoplasty were performed in 73% and 89%, respectively, while 68% were treated with a combined procedure. A medium or high volume surgeon was involved in 63% of cases., Conclusions: Many patients with congenital adrenal hyperplasia in the database did not proceed to early reconstructive surgery. Of those referred to surgeons, who were possibly the most virilized patients, about half proceeded to early surgery and almost all underwent vaginoplasty as a component of surgery. About two-thirds of the procedures were performed by medium or high volume surgeons, indicative of the surgical centralization of disorders of sexual development., (Copyright © 2015 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.)

Objective: The literature on treatment of meatal stenosis is limited to single center series. Controversy exists regarding choice of meatotomy versus meatoplasty and need for general anesthesia. Our objective was to analyze treatment efficacy, current practice patterns and utilization of anesthesia. We hypothesized that meatoplasty would be associated with a lower re-operative rate., Study Design: We used a hospital consortium database to identify children who were diagnosed with meatal stenosis between January 1, 2009 and December 31, 2012. Both univariate and multivariate analyses were completed to evaluate correlations between patient, surgeon and hospital characteristics and type of procedure. The propensity of surgeons to operate with or without general anesthesia was analyzed., Results: We identified 4373 male patients with a diagnosis of meatal stenosis treated by 123 surgeons. Fifty-percent of boys had procedural intervention during the 4-year period. Median follow-up was 25 and 22 months after meatotomy and meatoplasty, respectively. There was a re-operative rate of 3.5% and 0.2% for office meatotomy versus meatoplasty with general anesthesia. Multivariate analysis demonstrated that being White and living in the Northeast independently increased odds of intervention. Half of the surgeons treated meatal stenosis exclusively under general anesthesia., Discussion: This study is limited by an inability to determine recurrence rates. Only patients having secondary surgery at the same institution within the time period captured by the database (6 months-4 years) could be identified. As such, the true recurrence of meatal stenosis is likely higher. Although the re-operative rate is not equivalent to the recurrence rate, the two are correlated. Likewise, the surgeon's propensity to operate could be biased by their propensity to diagnosis meatal stenosis and this could affect the rates cited. In addition to the cost benefit achieved with avoidance of general anesthesia (estimated to be a 10-fold cost reduction, the 2012 Consensus Statement of the International Anesthesia Research Society has highlighted that there is increasing evidence from research studies suggesting the benefits of general anesthesia should be considered in the context of its possible harmful effects. Although this study and others have highlighted that in-office procedures are a viable alternative to meatoplasty with general anesthesia, there are multiple factors in being able to perform an office meatotomy. Arguably, the two most important are the patient's ability to cooperate and his anatomy., Conclusions: The large sample size, over 4000 patients, allowed us to show that the hypothesis, that meatoplasty would be associated with a lower re-operative rate (0.2%), is true. With a low re-operative rate (3.5%), office meatotomy is a reasonable choice of surgical treatment if the child can cooperate and the anatomy is appropriate. On the other hand, if general anesthesia is utilized, formal meatoplasty is associated with a lower re-operative rate., (Copyright © 2015 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved.)

As bladder reconstruction strategies evolve, a feasible and safe source of transplantable urothelium becomes a major consideration for patients with advanced bladder disease, particularly cancer. Pluripotent stem cells, such as embryonic stem cells (ESCs) and induced pluripotent stem cells (iPSCs), are attractive candidates from which to derive urothelium as they renew and proliferate indefinitely in vitro and fulfill the non-autologous and/or non-urologic criteria, respectively, that is required for many patients. This review presents the latest advancements in differentiating urothelium from pluripotent stem cells in vitro in the context of current bladder tissue engineering strategies.

Background: Known factors affecting the management of vesicoureteral reflux (VUR) include reflux grade, infection frequency, age and gender. We hypothesized that provider preference is highly associated with management., Methods: Utilizing the national billing database, Faculty Practice Solutions Center, a multivariable logistic regression model, was applied to analyze the association of pediatric urologist treatment patterns, patient age, gender, uni- or bilateral disease, insurance type, presence of nephropathy and race with the type of VUR treatment a patient would receive., Results: We identified 59 pediatric urologists who managed 7,882 new reflux patients from 2009 to 2011. Over this 3-year period there was wide variation in surgical utilization between surgeons (mean 50 %) but minimal change for each surgeon (5 %). For every 100 new reflux patients, median utilization of reimplantation surgery and injection of dextranomer/hyaluronic acid copolymer (Deflux) was 26 and 20 %, respectively. Age ranked highest in predicting surgical versus non-surgical management, while a surgeon's historic Deflux utilization rate ranked highest in predicting surgery type. Older age, female gender and white race also increased the odds of Deflux utilization over reimplantation., Conclusions: A surgeon's historic Deflux utilization was the most important predictor of VUR surgery type. Although data on reflux grade were not available, analysis of patient and surgeon characteristics suggests that surgeon preference is the first or second most critical factor in determining a patient's treatment., Competing Interests: The authors have no conflicts of interest to disclose.

Purpose: We evaluated the use and efficacy of intraoperative urinary diversion with ureteral stent or nephrostomy tube during pyeloplasty in children., Materials and Methods: The Faculty Practice Solutions Center® national billing database was queried to identify all pediatric pyeloplasties performed from 2009 to 2012. Patient variables, surgical approach, use of intraoperative stent/nephrostomy tube and return for postoperative stent/nephrostomy tube or second pyeloplasty were obtained., Results: A total of 2,435 children underwent open (1,792) or laparoscopic/robotic (643) pyeloplasty, with intraoperative urinary diversion rates of 45% and 83%, respectively. Comparing patients with and without an intraoperative stent/nephrostomy tube, 5.6% and 7.4%, respectively, returned to the hospital for urinary diversion. Multivariable analysis revealed no association with surgical approach, but higher surgeon volume (p <0.01) and use of an intraoperative stent/nephrostomy tube (p <0.01) were associated with decreased odds of requiring postoperative urinary diversion. Second pyeloplasty rate was 3.8% and was not associated with surgical approach or use of intraoperative stent/nephrostomy tube., Conclusions: Intraoperative stent/nephrostomy tube use and increased surgeon volume were each independently associated with a significant but small decrease in risk of postoperative stent/nephrostomy tube placement. Use of an intraoperative stent/nephrostomy tube was not associated with rate of second (redo ipsilateral or contralateral metachronous) pyeloplasty., (Copyright © 2014 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.)

In vitro generation of human urothelium from stem cells would be a major advancement in the regenerative medicine field, providing alternate nonurologic and/or nonautologous tissue sources for bladder grafts. Such a model would also help decipher the mechanisms of urothelial differentiation and would facilitate investigation of deviated differentiation of normal progenitors into urothelial cancer stem cells, perhaps elucidating areas of intervention for improved treatments. Thus far, in vitro derivation of urothelium from human embryonic stem cells (hESCs) or human induced pluripotent stem (hiPS) cells has not been reported. The goal of this work was to develop an efficient in vitro protocol for the induction of hESCs into urothelium through an intermediary definitive endoderm step and free of matrices and cell contact. During directed differentiation in a urothelial-specific medium ("Uromedium"), hESCs produced up to 60% urothelium, as determined by uroplakin expression; subsequent propagation selected for 90% urothelium. Alteration of the epithelial and mesenchymal cell signaling contribution through noncell contact coculture or conditioned media did not enhance the production of urothelium. Temporospatial evaluation of transcription factors known to be involved in urothelial specification showed association of IRF1, GET1, and GATA4 with uroplakin expression. Additional hESC and hiPS cell lines could also be induced into urothelium using this in vitro system. These results demonstrate that derivation and propagation of urothelium from hESCs and hiPS cells can be efficiently accomplished in vitro in the absence of matrices, cell contact, or adult cell signaling and that the induction process appears to mimic normal differentiation.

Purpose: The literature on secondary surgery after hypospadias repair is limited. We determined risk factors for secondary surgery via a population based approach., Materials and Methods: We used a hospital consortium database to identify a population that underwent hypospadias repair in 2009 and 2010. Specifically meatal advancement and glanuloplasty, distal, proximal and perineal hypospadias repairs were evaluated. Secondary surgeries performed between 2009 and 2011 were captured and the variables of age at primary surgery, insurance, region and surgeon volume were measured. Mixed effects logistic regression analysis was used to analyze independent variables associated with secondary surgery., Results: We identified 5,326 subjects who underwent primary hypospadias repair by 114 surgeons at 47 hospitals in 2009 and 2010. Distal hypospadias repair is associated with a 9% secondary surgery rate. After adjusting for other factors every additional 10 distal repairs that a surgeon performed yearly was associated with a 29% decreased risk of requiring fistula, stricture or diverticulum repair. There were regional differences for secondary surgery following meatal advancement and glanuloplasty and distal repairs. Finally, each additional year of patient age at distal repair was associated with a 15% increased risk of requiring secondary cystoscopy and a 21% increased risk of requiring urethral dilation/incision., Conclusions: This population based study produced significantly different results than small studies of select patients and techniques. Distal hypospadias repair is associated with a 9% secondary surgery rate. Low surgeon volume independently increases the risk of fistula, stricture or diverticulum repair. Increased patient age at primary distal hypospadias repair increases the risk of cystoscopy and urethral dilation/incision., (Copyright © 2013 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.)

Objective: Reports in the literature increasingly have demonstrated a shorter length of stay (LOS) with the laparoscopic approach to partial nephrectomy compared to historic open partial nephrectomy. We present data from the largest open series to date, to provide a more contemporary perspective., Methods: A retrospective review was performed on all pediatric patients who underwent upper pole partial nephrectomy from 1999 to 2011. Using univariate and multivariate linear regression, the associations between multiple explanatory covariates and outcomes such as pain and length of stay were analyzed., Results: Twenty-five surgeries were performed via a supracostal-12 approach. The mean incision length and operative time was 3.7 cm and 137 min, respectively. The average pain score was 1.7/10 and 72% of patients did not require morphine. The mean LOS was 36 h and all patients with postoperative imaging had normal blood flow. Multivariate analysis demonstrated that a later date of surgery was the only covariate significantly associated with decreased operative time and LOS., Conclusion: Open partial nephrectomy can be performed in a minimally invasive manner via a small supracostal-12 incision with minimal pain and LOS. Surgeon experience is associated with decreased operative time and LOS. These contemporary open results should be considered when comparisons are made with laparoscopic surgery., (Copyright © 2011 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved.)

Purpose: Most patients who need a bioengineered bladder wall have bladder cancer. A graft made with autologous urothelium would not be safe. To investigate the feasibility of providing bioengineered tissue for patients with partial cystectomy we evaluated the host and graft response after transplanting an epithelium-free graft., Materials and Methods: De-epithelialized bladder wall grafts from male rats were transplanted on syngeneic female rat bladders after partial cystectomy. Urothelial morphology, vessel density, inflammation, stromal thickness and uroplakin expression were evaluated 1, 3, 6 and 9 months after surgery. Cell gender was distinguished by fluorescent in situ hybridization using unique X and Y chromosome probes., Results: There was no significant graft contraction at any time. Male graft urothelial morphology and uroplakin expression were similar to those of controls at all time points. The donor bladder had decreased vessel density at early time points while the host had increased vascularity, which normalized in each by 6 months. Graft inflammation and edema normalized by 9 months. There was no muscular hypertrophy. Fluorescence in situ hybridization revealed early ingrowth of host female urothelium and a small fraction of male urothelial cells, which appeared between 1 and 3 months., Conclusions: Within 9 months de-epithelialized grafts appeared histologically as normal bladder, surprisingly faster than an equivalent model with full-thickness grafts. The safety and function of an epithelium-free graft must be determined in a large animal model. These early data in a small animal model substantiate the feasibility and equivalency of using grafts without epithelium, which would allow application in patients with cancer., (Copyright © 2012 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.)

Purpose: The Malone antegrade continence enema procedure improves quality of life for patients with bowel dysfunction. Stomal leakage has been reported, although no objective scale describes this type of incontinence. The value of cecal imbrication has not been fully elucidated on a large scale., Materials and Methods: We retrospectively reviewed pediatric patients who underwent Malone antegrade continence enema by a single surgeon between 2000 and 2010. Detailed information regarding degree and frequency of stomal incontinence was longitudinally recorded and analyzed. A classification system was developed, with grade 0 defined as no stomal incontinence, grade 1 a drop at the stoma or spotting on clothes 1 time or less per month, grade 2 spotting on clothing 2 to 4 times per month and grade 3 any leakage greater than 4 times per month., Results: The Malone antegrade continence enema procedure was laparoscopic nonimbricated in 51 patients, open nonimbricated in 16 and open imbricated in 12. Mean followup was 3.5 years. Of cases where the appendix was not imbricated stomal incontinence was grade 0 in 69%, grade 1 in 19%, grade 2 in 7.5% and grade 3 in 4.5%. Two patients (3%) requested revision due to stomal incontinence. No patient who underwent Malone antegrade continence enema with imbrication had stomal leakage (p = 0.001)., Conclusions: We reviewed the spectrum of stomal incontinence following Malone antegrade continence enema in 75 patients and developed a new grading scale to help standardize this complication. Imbrication provided stomal continence in all patients. Without imbrication almost 90% had no stomal incontinence or grade 1 leakage after long-term followup., (Copyright © 2012 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.)

Background: Men on active surveillance for clinical stage I nonseminomatous germ cell tumor (NSGCT) undergo frequent computed tomography imaging to avoid delayed detection of disease. Irradiation from frequent imaging and chemotherapy upon progression may place patients at increased risk of a second malignancy. In this study, the authors sought to identify such an increased risk among men who chose initial surveillance for NSGCT., Methods: The authors utilized data from the Surveillance, Epidemiology and End Results Program and stratified the cohort based on whether they underwent retroperitoneal lymph node dissection (RPLND). A propensity-score model was used to adjust for covariates, and a competing-risks regression analysis was performed to estimate cumulative incidence rates of second malignancy. Incidence risk ratios were predicted by using the cumulative incidence rates per 10,000 patients., Results: There was no statistically significant increase in the incidence of a secondary malignancy for the entire cohort of testicular cancer survivors. However, when the analysis was restricted to patients with clinical stage I NSGCT, nonsurgical management only in those aged >45 years was an independent predictor of developing a second malignancy. For every 10,000 patients with stage I NSGCT who chose to forego RPLND, an absolute excess incidence of 22, 52, and 73 secondary malignancies would be diagnosed at 5 years, 10 years, and 15 years, respectively., Conclusions: The current results indicated that patients aged >45 years who forego RPLND for T1 or T2 clinical stage I NSGCT are more likely to develop a second malignancy than those who do undergo RPLND. Nonsurgical management of NSGCT may be associated with more long-term health risks than primary RPLND., (Copyright © 2011 American Cancer Society.)

Purpose: Pediatric urology literature is often biased toward single, high volume institutions. We determined the impact of patient, surgeon and hospital characteristics on immediate outcomes for children undergoing ureteral reimplantation., Materials and Methods: We queried the University Health-System Consortium Clinical Data Base to identify a pediatric population who underwent ureteroneocystostomy between 2004 and 2009. We measured the association of the outcome variables length of stay, number of days in the intensive care unit and complication rates on the independent variables of age, gender, race, insurance status, year of surgery, and surgeon and hospital characteristics. The data were analyzed using multiple logistic, Poisson and Poisson hurdle model regression analyses incorporating random effects for surgeon and hospital., Results: We identified 5,668 subjects who underwent ureteroneocystostomy. Compared with patients treated by high volume providers, those treated by low volume surgeons (less than 13 cases per year) had a longer length of stay (47%), higher odds of intensive care unit admission (OR 8.1), longer intensive care unit stays (103%) and higher rate of surgical related complications (162%). Other independent variables of male gender, nonwhite race and prior comorbidities were independently associated with longer length of stay, higher intensive care unit admissions and higher risk of complications., Conclusions: Surgeon volume, not hospital volume, is an important and consistent predictor of length of stay, intensive care unit admissions, intensive care unit days and complication rate after ureteroneocystostomy. These findings posit that the short length of stay, low intensive care unit admission rate and low complication rate reported in the literature may not be generalizable, but rather limited to higher volume surgeons., (Copyright © 2011 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.)

Purpose: There is little objective data demonstrating improved quality of life after a Malone antegrade continence enema (ACE) despite the dramatic subjective improvements seen by physicians and caretakers., Methods: We utilized the FICQOL survey, a reliable and valid instrument for measuring the impact of fecal incontinence and constipation on quality of life (FICQOL) of caregivers and children with spina bifida. Between 2002 and 2009, 23 families were evaluated prospectively before and after an ACE procedure. Items on the survey were compared with Wilcoxon rank sum or signed rank test., Results: After an ACE Malone the mean number of bowel movements (BM) per day decreased along with a decrease in number of accidents per week from 3.9 to 0.3. There was no change in the time committed to bowel care. The percentage of patients taking oral laxatives decreased from 44% to 6%. Both parent and child were less often prevented from leaving the house and the caretakers' bother, anxiety and depression due to bowel care decreased. Although factors regarding the child's social issues and parent's employment improved, the changes were not statistically significant., Conclusions: Among patients with spina bifida and fecal incontinence who underwent the ACE procedure at our institution, a significant improvement in fecal incontinence and QOL scores was observed using a validated instrument, FICQOL. Without changing the amount of time necessary for bowel care, the ACE procedure decreases the families' worries and anxieties and allows them to leave home with the confidence that their child will not have leakage of stool., (Copyright © 2011 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved.)

Current bioengineered bladder wall substitutes include acellular scaffolds and grafts seeded with autologous cells. The transplanted cells on a seeded graft may regenerate and/or be replaced by cells of the patient's bladder. This may or may not be advantageous depending upon the underlying pathology. A theoretically perfect bioengineered graft would be intact bladder wall. To determine if such a graft is feasible and to study the cellular changes, we transplanted full-thickness bladder grafts from male inbred rats onto bladders of female syngeneic rats. Bladders were harvested at 1, 3, 6, 12, and 16 months after surgery and evaluated for histologic changes. Cell origin (male donor vs. female host) was determined with fluorescent in situ hybridization with unique probes for rat X and Y chromosomes. Urothelial hyperplasia, inflammation, and increased stromal thickness subsided down to control values by 6 months after surgery. At 16 months, graft muscle demonstrated persistence of male cells. On the other hand, graft urothelium was partially replaced by female host cells with a pattern suggestive of a hematogenous route rather than ingrowth from the host bladder. Bladder wall transplantation is feasible. The slow replacement of the transplanted urothelium and persistence of muscle may imply the same fate for engineered grafts.

Objectives: Similar to other epithelia, urothelium in vivo has a hierarchal organization of cells each with specific gradients of differentiation. While distinct cell types have been described as important in bladder cancer in vitro, clonal and proliferative capacities of normal urothelial cells have not been characterized., Materials and Methods: Three cell types and colony types were identified from primary porcine urothelial culture. Proliferative activity, patterns of apoptosis and differentiation, colony forming efficiency and ability to change phenotype with passage were determined and compared., Results: Small, T-I colonies with large flattened (type-1) cells had low levels of proliferation and high levels of apoptosis. Large T-III colonies had a central area of small (type-3) cells surrounded by type-1 and type-2 cells. Proliferation and apoptosis were asymmetrically distributed in the periphery of T-II and T-III colonies. T-III colonies proved to be significantly more clonogenic and proliferative. With appropriate induction, type-1 cells were able to proliferate upon passage and form type-3 cells, yet long-term culture demonstrated that progeny of type-1 cells appeared to have inherited a clonogenic handicap., Conclusions: Type-3 cells in the centre of T-III colonies appear to harbour stem-like qualities with a relatively low proliferative and apoptotic index at homeostasis and the ability to become highly proliferative upon passage. This study demonstrates that distinct urothelial cell types with differing clonal capacities can be isolated from the bladder and these cells may have implications for tissue engineering and carcinogenesis.

Purpose: The recent literature places significant emphasis on decreased pain and length of stay after endoscopic treatment of vesicoureteral reflux compared to historical open ureteroneocystostomy. We documented postoperative pain and outcomes of a contemporary series of minimally invasive ureteral reimplantation., Materials and Methods: For 100 consecutive patients who underwent ureteroneocystostomy we examined the association of the variables patient age, weight, gender, reflux grade, year of surgery, extravesical or intravesical approach and operative time with the outcomes length of hospital stay and pain score (0 to 10), with univariate linear and multivariate regression analyses., Results: Mean patient age was 5.5 years and median followup was 16 months. All patients received ketorolac and acetaminophen with codeine for pain, and early in the series 7 patients received morphine. Average pain scores were mean 1.2, median 0.9 and maximum 3.4. Mean length of stay was 24.4 hours. Multiple regression analyses demonstrated that date of surgery, lower weight, intravesical approach and operative time were independently associated with greater length of stay. A total of 26 patients underwent voiding cystourethrography postoperatively. There was 1 case of recurrent (from bilateral grade V to unilateral grade I) and 1 case of de novo (contralateral grade I) reflux., Conclusions: Open ureteroneocystostomy can be performed in a minimally invasive manner. A small incision combined with administration of ketorolac is associated with a short length of stay and low pain scores. When comparing endoscopic and open treatment of reflux investigators should consider the high success rate and low morbidity of contemporary, minimally invasive open series.

Objectives: To determine the perceived degree of training of residents in laparoscopic nephrectomy. Laparoscopic nephrectomy is well established in the field of urology and has seen increasing penetrance in urologic practice. The degree to which this recent technical shift has been integrated into urologic training at the residency level has not been characterized., Methods: An electronic survey was sent to 518 urology residents and recent graduates and to 85 laparoscopic specialists at academic medical centers. Both residents and practicing urologists were queried regarding the level of resident participation for each step of laparoscopic nephrectomy and opinions on the necessity of fellowship training. The data were analyzed using the Wilcoxon rank-sum and chi(2) tests., Results: Attending surgeons perceived a significantly greater level of resident involvement in performing all aspects of laparoscopic nephrectomy, with the exception of hilar dissection and port closure. To perform laparoscopic nephrectomy, 12.5% of attending physicians and 5% of residents reported that a fellowship is necessary., Conclusions: Significant disagreement exists between attending surgeons and residents on the perceived degree of resident involvement in most aspects of laparoscopic nephrectomy. This could have significant implications on resident education for a procedure that is arguably the standard of care for treatment of uncomplicated renal masses. Most attending physicians and residents were in agreement that fellowship is not necessary to perform this procedure. These results raise questions regarding the future of laparoscopic training and bring to light the need for better regulation of laparoscopic training.

As enterocystoplasty has become a routine procedure in pediatric urology, long-term complications are emerging in adult patients. Pediatric urologists in general do not follow their patients beyond late adolescence. The sequelae of enterocystoplasty have fallen into the hands of their adult colleagues. Some of the complications of enterocystoplasty, such as reservoir stones, malignancy and perforation, are also seen in older adults following continent diversion. On the other hand, problems with bone growth, pregnancy and reflux nephropathy are unique to children and young adults. A better awareness and understanding of these complications will lead to improved prevention, surveillance and treatment.