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In 2003, Florida Medicaid discontinued coverage of routine neonatal circumcision (NC) resulting in an increase in nonneonatal circumcisions. Florida Medicaid is one of 16 state healthcare plans that do not cover NC. Florida Medicaid covers male circumcision in a child ≥3 years for a defined medical indication or persistent phimosis refractory to topical steroid therapy (TST). We sought to assess the economic impact of the evaluation and management of phimosis/circumcision in Florida Medicaid males ≥3 years treated at Nemours Children's Hospital.We performed an IRB approved retrospective chart review of all male Florida Medicaid patients ≥3 years seen at NCH for phimosis/circumcision from Sept. 2016-Sept. 2019. Data extracted included demographics, age at presentation, prior treatment with TST, response to TST, and surgical interventions. The patients were stratified into three management groups. Total costs for each group were based upon estimated Medicaid reimbursement rates. Data were analyzed using descriptive analysis on SPSS.Seven hundred and sixty-three males were evaluated. Age at presentation ranged from 3 to 17 years and 59% of patients were 3-6 years at initial presentation. Three hundred and forty patients underwent circumcision. The total estimated cost of care for all patients was $1,345,533.90. This compares to an estimated cost of $171,675 if all individuals underwent NC at 2020 costs.The total estimated cost associated with the evaluation and management of 763 patients ≥3 years for phimosis/circumcision was 7.8 times the estimated cost of NC for all these patients and likely is an underestimation of the true difference in cost as we did not account for additional visits outside of the initial consultation and follow-up, post-operative visits outside of the global period, emergency room visits, and returns to operating room. Of the circumcisions performed, only 18.5% met Florida Medicaid defined medical indications. Success rates for TST range from 53.8 to 95% in the literature, however, our success rate was 34.3%. The reason for the variation in response rate between our results and the literature may reflect that caretakers desiring circumcision may be less compliant with TST use. Only 6.6% of patients had a documented failure of TST prior to initial presentation. Further education of PCPs on current Medicaid/MCG guidelines for the evaluation and management of phimosis, as well as PCP adoption of TST, could reduce the number of unnecessary office visits, healthcare costs, and family burden.

Circumcisions are among the most commonly performed procedures in the pediatric population, but the value of the preputial skin often goes unrecognized as a potential graft (Ehrlichman et al., 2018). We highlight three patients who underwent coordinated circumcision and use of the excised preputial skin as a graft for syndactyly repair. Syndactyly, a condition where fingers are fused together, is often repaired utilizing skin from the groin region, which can result in unwanted hair growth and subcutaneous fat growth. The utilization of the prepuce is a convenient alternative that may have fewer undesirable qualities.

Summary Introduction The natural history of asymptomatic nephrolithiasis (AN) in children is not well defined. Furthermore, there is no guidance on the utility of repeated renal ultrasound evaluations in this same population. Follow-up ultrasound studies are often obtained as frequently as every 6 months. The goal of this study is to assess the follow-up ultrasound interval in the management of these patients. Methods A retrospective IRB approved chart review was performed for patients seen for non-cysteine AN between 2012 and 2019. AN was defined as patients without obstructive uropathy abdominal, flank pain and/or gross hematuria. Asymptomatic stones were discovered incidentally or after an acute stone event. Patients with pre-existing renal anomalies and the timepoints with stone passage or stone procedure were excluded. Descriptive statistics were used for demographic information. Multiple linear regression was used to analyze risk factors. Statistical significance was set to p Results Twenty-nine patients had 90 ultrasounds. The average age at diagnosis was 10.8 ± 6.2 years. The average number of ultrasound studies per patient was 3.2 ± 1.7. The median time between follow-up ultrasounds was 5.2 months [IQR 2.8–10.0]. Median follow-up of patients was 10.6 months [IQR 4.9–21.9]. The change in total stone burden occurred at a rate of 0.11 mm/month (CI [-0.06–0.28], p = 0.20, r2 = 0.42) or 0.66 mm/6 months. Patients with more renal stones had almost a threefold increase in stone burden compared to patients with fewer renal stones (2.98 [CI 1.34–4.62], p=0.001, r2=0.33). Patients with a family history of stones had a twofold increase in the size of their largest stone when compared to patients without a family history (1.97 [CI 0.26–3.68], p=0.02, r2=0.60. Conclusion A complex interplay of multiple factors influence the progression of AN in children. Children with a greater number of stones have a higher increase in total stone burden and children with a family history of stones have a faster increase in largest stone size. These patients may require more frequent imaging studies. The small change in stone size over time favors a longer than 6-month interval for many children.

Management of testicular rupture with a large tunical defect may not be feasible without excision of viable tissue. This study describes the use of a vascularized tunica vaginalis flap, without debridement of viable tissue, in four adolescents. Postoperative ultrasound showed good blood flow and 80% volume of the contralateral testis in two cases. Postoperative exam revealed normal exam and ultrasonographic appearance in three patients, the fourth was demonstrated to be small and undescended during evaluation of contralateral testicular torsion. This approach is recommended in cases of large tunical defects, as it avoids the debridement of viable testicular tissue.

Summary Introduction Metachronous undescended testis (mcUDT), an acquired UDT after contralateral orchiopexy, can occur in some boys. If one were able to predict its occurrence, one might consider a proactive approach or at least one would be able to counsel the parents accordingly. Our hypothesis was there may be characteristics evident at the time of initial orchiopexy which could predict the development of contralateral mcUDT. Objective The aim was to Identify factors present at initial orchiopexy that predict development of subsequent mcUDT. Study design Subjects were identified using the Current Procedural Terminology code for inguinal orchiopexy (54640). We included patients from January 1997 to October 2015. We included patients who underwent orchiopexy for unilateral UDT (uUDT). The study population consisted of patients who had undergone metachronous orchiopexies; controls were patients who were 17 years at time of data collection with a single orchiopexy. Cox proportional hazard regression was used to model the relationship between possible predictors of subsequent UDT using PROC PHREG with SAS Software 9.4. Results From 1035 eligible patients we identified 38 with mcUDT and 207 controls (uUDT). Median age at the first orchiopexy of mcUDT patients was 2.5 years (min/max, 0.50/10.4 years) and 8.2 years (min/max 0.70/12.8 years) for uUDT, p Discussion Contralateral retractile UDT was a significant predictor of mcUDT. We believe patients with a contralateral retractile testis at time of orchiopexy should be counseled on bilateral orchiopexy. The risks of complications with orchiopexy should be weighed against risks of a subsequent surgery and anesthesia event. Conclusion A discussion of risks and benefits regarding bilateral orchiopexies should be undertaken with the parents prior to surgery in the setting of an UDT with contralateral retractile testis. Table . Patient characteristics and predictors of mcUDT. Contralateral UDT (38) Unilateral UDT (204) p Age at initial orchiopexy, years 2.5 8.2 Congenital, % 65 52 0.10 Contralateral examination in office (% retractile) 52 18 Contralateral examination under anesthesia (% retractile) 22 2 Ipsilateral PV open, % 48 59 0.14 PV = processus vaginalis.

Summary Introduction Nocturnal enuresis is a common pediatric condition with limited treatment options. In older children, pharmacologic therapy is often the preferred treatment. Pharmacologic therapies including desmopressin (DDAVP) or imipramine are effective in 40–50% of children. However, imipramine has serious safety concerns. Desmopressin in combination with a fixed dose anticholinergic has been shown to be useful in individuals who fail desmopressin monotherapy, but still fails to achieve success rates greater than 60%. Objective The goal was to explore the efficacy and safety of using combination therapy desmopressin plus oxybutynin with increasing dose of oxybutynin in patients refractory to standard combination therapy. Study design This was a single institution, IRB-approved, retrospective chart review of 61 patients (ages 7–18 years) including those with monosymptomatic primary nocturnal enuresis and non-monosymptomatic enuresis with controlled daytime voiding symptoms (CDVS) treated initially with desmopressin. All patients who failed initial therapy with desmopressin were started on combination therapy desmopressin (0.6 mg) plus standard dose (5 mg) oxybutynin. In patients who failed standard combination therapy, the dose of oxybutynin was titrated upwards until a response or the maximum dose of 10 mg was achieved. Demographic and medical history data were evaluated to determine predictive factors associated with response/failure to different therapy groups. Results The use of escalating doses of oxybutynin in combination with desmopressin achieved an overall response rate of 96.7% defined as a 2-week period without any enuretic events following initiation of treatment. Low-dose combination therapy (LDCT) (0.6 mg of desmopressin + 5 mg of oxybutynin) had a response rate of 68% (Table). Advanced dose combination therapy (ADCT) (0.6 mg of desmopressin + 7.5–10 mg of oxybutynin) had a response rate of 75.0%. A statistically significant relationship was found correlating both attention deficit disorder/attention-deficit hyperactivity disorder(ADD/ADHD) and CDVS with failure on monotherapy. No patients in the study reported any adverse events or side effects from the medications. Discussion The overall success rate of 96.7% with titrated doses of oxybutynin in combination with desmopressin is considerably higher than the response rates on fixed dose combination therapy quoted in the literature and supports the need for further evaluation in larger studies. Additionally, we found a statistically significant association between monotherapy failure and children with either ADD/ADHD or controlled daytime voiding symptoms. Our study is limited by small numbers and larger studies are needed to confirm these results. Conclusion Our results suggest that ADCT is a safe and effective treatment option for primary nocturnal enuresis refractory to standard and low-dose combination therapy. Desmopressin monotherapy LDCT ADCT Total Patients treated 61 25 8 61 Responders 36 17 6 59 Response rate 59.0% 68.0% 75.0% 96.7%

Children presenting with nonpalpable undescended testes are evaluated with diagnostic laparoscopy. The laparoscopic findings of blind-ending vessels and vas deferens are felt to be diagnostic for 'vanished' testes. We present a case of an overweight male in whom the testis was not palpable in the office or under anesthesia and in whom blind-ending vessels were identified on laparoscopy. Inguinal exploration revealed a normal appearing inguinal testis. Although not advocated as a tool in the evaluation of the child presenting with an undescended testis, inguinal ultrasound may have a role in overweight children in whom the examination may be difficult. Furthermore, we would advocate inguinal exploration in overweight children, given the limitations of laparoscopy in this overweight child.

Objective We evaluated long-term (≥12 months) efficacy and safety of tolterodine in children with neurogenic detrusor overactivity. Subjects and methods Subjects successfully completed one of three 12-week, open-label studies and had stable neurologic disease and urodynamic evidence of neurogenic detrusor overactivity requiring intermittent catheterization. Drug formulation and dosing were based on age (4 months–4 years, tolterodine oral solution 0.2–2 mg twice daily; 5–10 years, tolterodine oral solution 0.5–4 mg twice daily; 11–16 years, tolterodine extended-release capsules 2, 4, or 6 mg once daily). Daily doses were individualized for each subject. Efficacy was evaluated urodynamically and using parent-completed 3-day bladder diaries. Results Thirty subjects were enrolled. Functional bladder capacity (volume at first leakage, first sensation of bladder fullness or 40 cm H2O pressure) increased by month 12 in the younger age groups but not in the oldest subjects. Volume to first detrusor contraction >10 cm H2O pressure and detrusor leak point pressure did not change in any age group. The number of incontinence episodes per 24 h decreased in all subjects, as did the number of catheterizations per 24 h. Mean volume per catheterization increased in all subjects. Seven treatment-related adverse events were reported. Conclusions Both tolterodine formulations were effective and well tolerated in children with neurogenic detrusor overactivity.