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At the upcoming American Urological Association (AUA) annual meeting in May, Division faculty, including second-year fellow Mary Killian, MD, will be presenting a new research abstract titled “Socioeconomic Factors in the Presentation and Progression of Posterior Urethral Valves.”
Fall 2018 Societies for Pediatric Urology (SPU) Congress
The Fall 2018 SPU Congress saw several moderated poster presentations by Division faculty. Posters presented included the following studies.
The Effect of Oral Steroids on Postoperative Complications in Proximal Hypospadias Repair: A Prospective, Randomized, Placebo-Controlled Trial
Mary Killian, MD, Rajeev Chaudhry, MD, Patrick J. Fox, MD, Michelle J. Barlas, PharmD, Heidi A. Stephany, MD, Pankaj Dangle, MD, Moira Dwyer, MD, Glenn M. Cannon, MD, Francis X. Schneck, MD.
Background: Proximal hypospadias is a complicated diagnosis with the treatment being equally problematic. Complication rates for proximal hypospadias repairs reach as high as 50 percent in the literature. Here we present preliminary data on a novel therapy to attempt to reduce complications and improve wound healing in proximal hypospadias repair.
Methods: We obtained IRB approval and designed a randomized, double-blind, placebo-controlled trial. Patients with proximal hypospadias (proximal shaft, penoscrotal, or scrotal) undergoing single-stage or staged repairs were prospectively enrolled after obtaining informed consent. Patients received either methylprednisolone (1.5 mg/kg/day divided into two doses) or placebo for five days postoperatively. Urethral stents were kept for seven to 10 days postoperatively. Patients had scheduled follow-up at six weeks, six months, and annually thereafter. The primary outcome was postoperative complication rate, while secondary outcomes included compliance with and safety of the medication.
Results: Twenty-two patients were prospectively enrolled in the study. Fourteen patients (64 percent) were penoscrotal, six patients (27 percent) were proximal shaft, and two patients (9 percent) were scrotal. Eighteen patients (82 percent) underwent single-stage repairs, while four patients (18 percent) underwent staged repairs. Median age at surgery was 8.5 months (IQR 7.2-11.2). Thirteen patients (60 percent) were in the prednisone arm and nine patients (40 percent) in the placebo arm. There was one complication in the prednisone group (8 percent), and two complications in the placebo group (24 percent) (p = 0.5), for a total complication rate of 14 percent among both cohorts. Complications were noted as early as 10 days and up to 6 weeks postoperatively, and included one glans dehiscence and two urethrocutaneous fistulae. The patient with the complication in the prednisone arm also had early dislodgement of urethral catheter. There was a 95 percent compliance rate with medication; one patient only completed 9/10 doses. There were no adverse events with the medication.
Conclusion: This is the first randomized, placebo-controlled trial evaluating the effect of postoperative steroids on proximal hypospadias repair. While the results do not reach significance, we had a low overall complication rate with only one complication in the prednisone arm. There were no adverse events from the medication, and all patients tolerated it well. We plan to continue enrolling patients and look to long-term follow-up to better assess the outcomes.
Delayed Presentation of Posterior Urethral Valves
Mary Killian, MD, Rajeev Chaudhry, MD, Francis X. Schneck, MD, Glenn M. Cannon, MD, Omar Ayyash, MD, Patrick J. Fox, MD.
Background: Posterior urethral valves (PUV) are the most common cause of congenital lower urinary tract obstruction. Even with early treatment in the newborn period, children experience long-term effects. Historically, approximately 10 percent of patients have presented with a delayed diagnosis of posterior urethral valves. We reviewed our cohort of patients with a diagnosis of posterior urethral valves to assess patients with a late presentation.
Methods: In accordance with institutional review board approval, we performed a retrospective review of all patients seen in the pediatric urology clinic with a diagnosis of posterior urethral valves between the years of 1988 and 2017. Patient charts were then reviewed and classified by the age of diagnosis. Late presentation was defined as an age at diagnosis of six months or greater. The clinical characteristics of these patients were analyzed and compared with patients with an antenatal or immediate postnatal diagnosis of posterior urethral valves.
Results: Thirty-two percent of the patients were delayed presentation of PUV. When compared with patients diagnosed prior to six months, these patients were noted to have a lower peak creatinine (0.5 versus 1.35 [p < 0.01]). The delayed presentation patients were also less likely to have a postoperative VCUG or require a vesicostomy. While a higher percentage of delayed presentation patients underwent repeat ablation (12 percent versus 6 percent), this was not statistically significant. The majority of patients in both groups were noted with type 1 PUV, but there were more (18 versus 3) type 3 PUV noted in the early diagnosis group. No patients in the delayed presentation group underwent a transplant within the follow-up period.
Conclusion: Our results demonstrate a larger percentage of patients with delayed presentation of PUV. These patients appear to have a less severe form given their lower peak Cr at time of diagnosis, as well as the fact that none of the patients has required a renal transplant. Longer-term follow-up will be needed to assess the continued renal function in both groups.
2018 NSAUA Participation
Division faculty presented three posters at the 2018 Northeastern Section American Urological Association Meeting:
• Robotic Ureteropyelostomy for a Lower Pole Ureteropelvic Junction Obstruction in a Partially Duplicated Kidney
• Delayed Presentation of Posterior Urethral Valves
• The Effect of Oral Steroids on Postoperative Complications in Proximal Hypospadias Repair: A Prospective, Randomized, Placebo-Controlled Study