URINARY TRACT DEBRIS IN PEDIATRIC URINARY TRACT INFECTIONS: A DIAGNOSTIC APPLICATION Unwanaobong Nseyo, MD, MHS, Kelly Swords, MD, MPH

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1 URINARY TRACT DEBRIS IN PEDIATRIC URINARY TRACT INFECTIONS: A DIAGNOSTIC APPLICATION Unwanaobong Nseyo, MD, MHS, Kelly Swords, MD, MPH Background: Traditionally, UTIs are defined by a combination of symptoms and urine culture results, which are highly susceptible to contamination and false positives. Routine imaging, such as renal/bladder ultrasound (RBUS), are also used in order to evaluate for genitourinary anatomic abnormalities. While RBUS has been well-established for outlining anatomy, the utilization of non-specific aspects of the imaging study are not as well-documented. Bladder wall thickening and bladder debris are commonly mentioned as nonspecific yet potential indicators of infection. We present the use of bladder debris on renal/bladder ultrasound in a diagnostic capacity by evaluating the presence of debris in the context of urine culture data. Methods: We performed a retrospective review of renal/bladder ultrasounds performed at a single pediatric institution between 2006 and Procedure codes were used to identify the RBUS and the urine culture. Inclusion criteria were limited to study reports with the terms bladder and debris that also had urine culture data within 14 days of the ultrasound. We did not exclude patients who had a GU tract anomaly or those who perform CIC. Data on concomitant genitourinary pathology and demographics were also collected. A paired student t-test and Chi-squared test were used to analyze the data. Results: We identified a total of 24,713 individuals who had undergone renal bladder ultrasound during our study period. Of which 1056 patients were identified that had a renal/bladder ultrasound performed during the study period that included the terms bladder and debris. Of those, 196 patients met the inclusion criteria; 103 of had bladder debris present and 93 without debris. The median age of the study population was 6.6 (range 0.2 to 21.6). There was no difference In age distribution between the groups. There were more girls in the non-debris group as compared to the debris group (64% vs 50%). CIC was performed infrequently (3 in the non-debris group, 1 in the debris group). GU tract anomalies were present in similar proportions between the two groups (26% in debris, 17% in the non-debris). The presence of debris in the bladder was associated with a 44% positive urine culture rate and a 12% rate when no debris was present, a statistically significant difference (p<0.05). There was also a statistically significant difference for the presence of bladder wall thickening (20% vs 3%) and presence of hydronephrosis (35% vs 14%) for those with and without debris, respectively. There was no statistically significant difference between the number of patients in each group with VUR. Conclusions: A combination of vague symptoms, nonspecific objective findings and delayed results from laboratory testing characterize the diagnosis of UTIs in the pediatric population. While, radiologic studies are typically used to identify anatomic abnormalities, our study highlights the potential application of a commonly recognized finding to clinical data. Noting the absence or presence of debris may serve as a possible adjuvant to current evaluations for UTI in children.

2 THE FATE OF THE CONTRALATERAL TESTIS: HOW TO MANAGE THE REMAINING NORMAL TESTIS Irene M. McAleer, MD, JD, MBA and Blake Selby*, DNP, CPNP, RNFA, MS Orange, CA (Presentation to be made by Dr. McAleer) Introduction: The management of the uninvolved contralateral testis by many urologists during acute testis torsion is generally to fix that testis to prevent torsion and potential testicular loss if that testis was to experience torsion in the future. The un-involved testis is generally not explored in patients presenting with trauma, tumor or upon exploration for a non-palpable undescended testis where a nubbin is found and presumed to be due to testicular loss during descent or malformation. Management of the otherwise normal opposite testis is somewhat controversial in these scenarios and in acute testis torsion by non-urologists. Exploration for a small nubbin is also controversial with American Urological Association (AUA) recommending further research on management of the contralateral testes in these cases. We queried pediatric urologists as to their practice patterns concerning the normal contralateral testis in various patient scenarios. Methods: An online survey (Survey Monkey) was sent to members of the American Academy of Pediatrics (AAP) Urology Section concerning their practice in managing the healthy contralateral testis at varying ages in several different scenarios (testis torsion, undescended testes with significant atrophy or scarring as a nubbin, testis trauma, and testis tumor). Demographic data and member answers were recorded anonymously. Answers were reviewed and compared as percentages. Results: The survey was sent three times to over 250 section members through the office of the AAP over several months. Responses were recorded once per submission and the survey could only be answered once per member. 53 surveys were completed for a response rate of 21%. There were 19 questions concerning 10 different patient scenarios for normal contralateral testis management. 10 demographic questions were included. In boys presenting with acute testis torsion, 98.1% would explore immediately, handle the torsed testis and surgically fix the contralateral testis. There was less agreement in management the contralateral testis with torsion of undescended testes, newborns with torsion, late torsion in all ages and in treating those patients with nubbins on the explored side. (see table, number and percent answers) Involved testis Contralateral testis Infarcted testis birth Observed torsion birth Pre pubertal UDT torsion Postpubertal UDT torsion Nubbin exploration Late Torsion after birth Immediate No explore (20.8%) 10(18.9%) 30(56.6%) 0 Immediate Yes explore 29(54.7 %) 50(94.3%) 42(79.2%) 43(81.1%) 21(39.6%) 30(56.6%) Delayed No explore 2(3.8%) Delayed Yes explore 15(28.3 %) 1(1.9%) (37.7%) No surgery No surgery 7(13.2%) 2(3.8%) 0 0 2(3.8%) 3(5.7%) Most members would not explore the contralateral testis in trauma, tumor or pre-existing atrophy on involved testis. 13 members who perform contralateral testis fixation in non-torsion cases do so due to high morbidity if remaining testis may be lost in future (8) or had patient where that did happen (3). For those that do not perform contralateral fixation except for torsion (42), they do not because only perform with torsion (26), no scientific data (12) and due to risk of injury with fixation (4). Conclusions: Our survey demonstrated that there is no real consensus on contralateral testis management of patients with unilateral small nubbin testis but all agreed on immediate exploration for torsion of undescended testis but there was no agreement on contralateral testis fixation at the same time. All members would fix the contralateral testis in non-newborn testis torsion but there was some variability in how the contralateral testis would be managed in late or observed torsion in the newborn. Even with trained pediatric urologists, some would not explore for torsion at any age on either the involved or contralateral testes. Source of Funding: None

3 THE MODERN FLAP TECHNIQUE FOR HYPOSPADIAS REPAIR: FEWER STEPS TO SUCCESS (COMPARED TO STAGED TECHNIQUES) Joshua D. Chamberlin MD, Orchidee Djahangirian MD, Peter Z. T. Wang MD, Blake Selby DNP, RNFA, Ahmed Abdelhalim MD, Irene M. McAleer MD, Elias Wehbi MD, Antoine E. Khoury MD, Orange, CA (Presentation to be made by Dr Joshua Chamberlin) Introduction: Successful repair of proximal hypospadias or any hypospadias condition associated with significant chordee requires the ventral transfer of healthy tissue. This can be carried out using a twostage approach or a one-stage flap procedure. We propose modifications to onlay or tubularized flap procedures with associated glansplasty and meatal creation that result in a slit-like meatus, a conical glans, and fewer overall surgical procedures. Methods: Severe chordee was corrected by mobilizing a tunica vaginalis flap for ventral erectile body lengthening. In these cases, the accompanying short urethral plate was divided in the middle and replaced using a mobilized onlay-tube-onlay flap. Hypospadiac urethral plates of adequate length were augmented using an onlay-flap only. If the patient had deficient ventral skin, penoscrotal transposition or webbing, double-faced flaps were used to provide ventral skin coverage. Glans wings were created widely by mobilizing and elevating the glans off of the erectile bodies and urethral plate. Results: From , 33 transverse-island tube or onlay flap procedures were performed as a primary hypospadias repair in patients with severe hypospadias defects. Sixteen (48%) required a second surgical procedure; nine (27%) required extensive reconstructive surgeries. Three patients (9%) required a third procedure. Currently, all patients have a straight phallus, without urethral strictures or diverticula. Conclusions: Only 48% of our patients required a second procedure with 9% requiring a third procedure to achieve normal function and cosmesis. Our modern flap one-stage technique compares favorably with the two-stage repairs where 100% of patients undergo two procedures and 25-30% of two-stage repair patients undergo three or more procedures.

4 RESERVOIR LITHIASIS FOLLOWING AUGMENTATION CYSTOPLASTY AND UMBILICAL CONTINENT CATHETERIZABLE CHANNELS Samir Bidnur*, Maryam Noparast*, Koroush Afshar*, Andrew E. MacNeily * Department of Urologic Sciences University of British Columbia British Columbia Children s Hospital 4480 Oak Street Vancouver BC V6H 3N1 Background: Augmentation cystoplasty (AC) and continent urinary diversion (CUD) are widely used in the pediatric neurogenic bladder population but are associated with several late complications, including infection and lithiasis formation. We sought to explore rates of reservoir lithiasis following AC and CUD. Methods: We performed retrospective chart reviews of patients having undergone AC and CUD at our institution between and correlated this to lithiasis formation, composition and treatment. Results: We identified 107 patients, 58 female and 49 male, with a mean age at surgery of 15 years (range 3-59yrs). Mean follow up was 71mo (range 1mo 15yrs). The top three underlying pathologies included myelomeningocoele (62%), bladder exstrophy (16%), and other (15%). The majority of patients underwent ileal cystoplasty (94%) and mitrofanoff appendicovesicostomy (75%) with an umbilical stoma. The bladder neck (BN) was manipulated in 75% of patients (28% closed, 34% burch, 14% sling). The rate of reservoir calculus was 14%, with an average time to first stone of 59mo (range 13mo 10 yrs) from OR. The majority of stone composition was pure or mixed struvite (95%). 20% of patients with reservoir stone formation experienced recurrent stones. 68% of stones were treated with open cystolithopaxy, while 32% were approached endoscopically There was no significant relationship between the presence of bladder stones and bladder neck manipulation, channel type or reservoir type on multivariate analysis. Females appeared more prone to stone formation in follow up regardless of type of AC and CUD (p<0.05). Conclusions: We observed a 14% reservoir lithiasis rate in our population with average time to stone being 71months. This emphasizes the need for long term follow up of this population, especially as they transition to adulthood.

5 TRANSPELVIC ANASTOMOTIC STENT FOLLOWING OPEN DISMEMBERED PYELOPLASTY IN CHILDREN: INITIAL REPORT FROM UNITED STATES Hamed Ahmadi, MD, Christopher Austin, MD, Aaron Bayne, MD: Portland, Oregon (Presentation to be made by Hamed Ahmadi) Purpose: Transanastomotic stenting following dismembered pyeloplasty is traditionally done through internal double J or transparenchymal externalized stent. However, need for second anesthesia for stent removal and bleeding, respectively, are main concerns following abovementioned urinary diversions. Transpelvic externalized anastomotic stenting is a recently defined technique to minimize those concerns. We report the initial experience with this technique in United States. Materials and methods: In this technique, an 8.2-French/4.7-French pediatric nephrostomy tube is used for anastomotic stenting. It is inserted through a stab incision through the flank and was introduced into the renal pelvis and half completed anastomosis. The 4.7-French distal aspect of the nephrostomy tube is advanced to the proximal ureter to complete the stenting of the anastomosis. A small absorbable suture is used to keep the loop in renal pelvis. Tube is secured to the skin on the exit site using a nonabsorbable drain stitch. The Outcome of open dismembered pyeloplasty and urinary diversion using this technique between August 2008 and March 2016 was reviewed. Results: A total of 16 patients (11 boys/5 girls) were included in the study. Median age at time of operation and follow up duration was 8 (range, 1 41) months old and one year (2 month 3.5 years), respectively. Seven children (44%) experienced postoperative complication including inadvertent tube removal in 3 (19%), urinary tract infection in 2 (12%) patients as well as pyelonephritis and tube site infection, each in one (6%) patient. Median time to complication was 14 (range, 0 29) days. There was no urine leak, bleeding, or need for redo pyeloplasty. Conclusion: Externalized transpelvic anastomotic stenting is a safe and effective urinary diversion method following open dismembered pyeloplasty in children. This technique obviates the need for second anesthesia and is not seemingly associated with bleeding and urine leak. Source of Funding: None

6 MIC-KEY VESICOSTOMY BUTTON: WHO TO USE IT FOR AND WHEN? Kelly J Nast, MD, Sarah Marietti, MD, George Chiang, MD: San Diego, CA Background: The Mic-Key button has been shown to be a safe and effective bladder management strategy for short- or medium-term use when CIC cannot be instituted. This study reports our use with the Mic- Key button highlighting the pros and cons of its use and complications. Methods: Retrospective chart review was conducted on children who had a Mic-Key button placed between 2011 and Placement was either through existing vesicostomy or endoscopically. Generally buttons are changed out by urology RN every 6-8 weeks in clinic. Results: Thirteen children have had a Mic-Key button placed at our institution in the 4 year period, ages 7 months to 18 years. Indications for placement included neurogenic bladder (5), non-neurogenic neurogenic bladder (3), and valve bladders (5). Currently 10 children are still using the Mic-Key button while 2 children have had the button removed and are voiding spontaneously and 1 child was converted back to a traditional vesicostomy due to rising creatinine and non-compliance with emptying. Five out of 7 placed via existing vesicostomy had leakage around button. None of the endoscopically placed buttons had leakage. Complications were minor including UTI (3), wound infection (2), and button malfunction/leakage (5). Five children had recurrent UTIs documented before insertion and continued to have infections after placement, two additional children began experiencing recurrent UTIs after placement. Conclusion: The Mic-Key button is an acceptable alternative to traditional vesicostomy and CIC. The morbidity of the button is quite low. Leakage was higher when placed via existing vesicostomy. If patients had frequent UTIs prior to placement, this continued after placement.

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