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.

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.

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.

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.

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.

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.

Purpose

To study the prevalence and effect of smoking on cervical cancer recurrence and mortality in patients undergoing definitive treatment with radiation.

Materials and methods

Between July 2007 and September 2013, 96 locally advanced cervical cancer patients received definitive radiation or chemoradiation followed by brachytherapy. Smoking status was obtained from prospective intake questionnaires and quantified by pack-years. Pelvic control (PC), disease-free survival (DFS), and overall survival (OS) were analyzed by multivariable Cox proportional hazards models.

Results

Smoking history included 51 (53.1%) nonsmokers, 45 active smokers, and former smokers: 20 (20.8%) with 1 to 20 pack-years and 25 (26%) with 21+ pack-years. With a median follow-up of 2 years on univariate analysis, the impact of 1 to 20 pack-years on PC, DFS, and OS relative to nonsmokers was hazard ratio (HR) 4.29 (95% confidence interval [CI], 1.36-14.1; P=0.014), 4.99 (95% CI, 1.21-22.4; P=0.027), and 4.77 (95% CI, 1.34-17.8; P=0.017), respectively. For patients with 21+ pack-years, the impact on PC, DFS, and OS was HR=6.13 (95% CI, 2.29-18.6; P<0.001), 7.24 (95% CI, 2.28-29.1; P=0.001), and 4.21 (95% CI, 1.26-15.4; P=0.02). On multivariate analysis, there remained a significant difference of 1 to 20 pack-years smoking history on OS relative to nonsmokers, HR=4.68 (95% CI, 1.02-29; P=0.047). For patients with 21+ pack-years smoking history, there continued to be a negative impact on PC and DFS, HR=5.66 (95% CI, 1.7-22.18; P=0.004) and HR=6.89 (95% CI, 1.54-42; P=0.011), respectively.

Conclusions

Former and active tobacco smoking during radiation therapy for cervical cancer is associated with unfavorable PC, DFS, and OS outcomes. The increased number of smoking pack-years conferred a worse outcome effect in those treated with radiation.

Motivation: An important property of a valid method for testing for differential expression is that the false positive rate should at least roughly correspond to the p-value cutoff, so that if 10,000 genes are tested at a p-value cutoff of 10−4, and if all the null hypotheses are true, then there should be only about 1 gene declared to be significantly differentially expressed. We tested this by resampling from existing RNA-Seq data sets and also by matched negative binomial simulations.

Results:

Methods we examined, which rely strongly on a negative binomial model, such as edgeR, DESeq, and DESeq2, show large numbers of false positives in both the resampled real-data case and in the simulated negative binomial case. This also occurs with a negative binomial generalized linear model function in R. Methods that use only the variance function, such as limma-voom, do not show excessive false positives, as is also the case with a variance stabilizing transformation followed by linear model analysis with limma. The excess false positives are likely caused by apparently small biases in estimation of negative binomial dispersion and, perhaps surprisingly, occur mostly when the mean and/or the dis-persion is high, rather than for low-count genes.

Objectives/hypothesis

The objective of this study was to determine if there are differences in decannulation rates and duration of cannulation between pediatric patients undergoing tracheotomy for different indications.

Study design

Retrospective chart review.

Methods

Medical records for pediatric patients (age 0-18 years) undergoing tracheotomy between January 1, 2003, and May 31, 2012, were retrospectively reviewed. Patients were assigned an indication for tracheotomy from five categories: neurological, cardiopulmonary, upper airway obstruction, craniofacial anomalies, and maxillofacial/laryngotracheal trauma.

Results

Initial chart review identified 124 patients, 113 for whom complete data was available. Of these patients, the indications for tracheotomy were cardiopulmonary disease in 24 (21.2%), craniofacial anomalies in 12 (10.6%), neurological impairment in 44 (38.9%), traumatic injury in 11 (9.7%), and upper airway obstruction in 22 (19.5%). The time to decannulation was shorter for trauma patients compared to cardiopulmonary (P = 0.044) and neurological patients (P = 0.001). A total of 32 (31.9%) patients were decannulated during the study period, with a higher rate in trauma patients (72.7%) and a lower rate in those with upper airway obstruction (36.4%) than would be expected under homogeneity. Of the 32 patients who were decannulated, 11 (30.6%) were decannulated during the same hospitalization in which the tracheotomy was performed.

Conclusion

This study demonstrates a difference in overall decannulation rates and a shorter time to decannulation in children undergoing tracheotomy for maxillofacial and laryngotracheal trauma compared to cardiopulmonary and neurological indications.

Objective

We examined the association of urine complement proteins with progression to end-stage renal disease (ESRD) or death in people with type 2 diabetes and proteinuric diabetic kidney disease (DKD).

Research design and methods

Using targeted mass spectrometry, we quantified urinary abundance of 12 complement proteins in a predominantly Mexican American cohort with type 2 diabetes and proteinuric DKD (n = 141). The association of urine complement proteins with progression to ESRD or death was evaluated using time-to-event analyses.

Results

At baseline, median estimated glomerular filtration rate (eGFR) was 54 mL/min/1.73 m² and urine protein-to-creatinine ratio 2.6 g/g. Sixty-seven participants developed ESRD or died, of whom 39 progressed to ESRD over a median of 3.1 years and 40 died over a median 3.6 years. Higher urine CD59, an inhibitor of terminal complement complex formation, was associated with a lower risk of ESRD (hazard ratio [HR] [95% CI per doubling] 0.50 [0.29-0.87]) and death (HR [95% CI] 0.56 [0.34-0.93]), after adjustment for demographic and clinical covariates, including baseline eGFR and proteinuria. Higher urine complement components 4 and 8 were associated with lower risk of death (HR [95% CI] 0.57 [0.41-0.79] and 0.66 [0.44-0.97], respectively); higher urine factor H-related protein 2, a positive regulator of the alternative complement pathway, was associated with greater risk of death (HR [95% CI] 1.61 [1.05-2.48]) in fully adjusted models.

Conclusions

In a largely Mexican American cohort with type 2 diabetes and proteinuric DKD, urine abundance of several complement and complement regulatory proteins was strongly associated with progression to ESRD and death.