5th Joint Meeting of ESPU-SPU - Virtual

S21: OTHER CATEGORY

Moderators: Luis Braga (Canada)

ESPU-SPU Meeting on Saturday 25, September 2021, 16:05 - 16:44


16:05 - 16:08
S21-1 (PP)

★ GOVERNMENT MANDATED CONSENT DRAMATICALLY REDUCES PEDIATRIC UROLOGIST POSTOPERATIVE OPIOID UTILIZATION

Valentina GRAJALES, Jeffrey VILLANUEVA, Marc COLACO, Omar AYYASH, Rajeev CHAUDHRY, Francis SCHNECK, Glenn CANNON and Janelle FOX
Children's Hospital of Pittsburgh, Urology, Pittsburgh, USA

PURPOSE

Post-surgical opioids are overprescribed in the United States. On November 2016, our state mandated that an opioid consent is completed for all outpatient prescriptions to minors. Our hypothesis is that this mandate decreased the frequency of post-surgical opioid prescriptions in our department.

MATERIAL AND METHODS

All patients who underwent urologic outpatient surgery from May 2015 to August 2019 at our institution were identified. Perioperative data including case type was retrospectively extracted by a clinical datawarehouse from preexisting fields within the health record. The frequencies of post-surgical prescriptions, delayed prescriptions, and readmission were assessed. A multivariable logistic regression to identify predictors of opioid prescription at discharge was performed.  No other intervention to affect opioid prescription rates was implemented after the state mandate. 

RESULTS

4,394 patients were analyzed. Six months after mandate implementation, the frequency of postsurgical opioid prescriptions decreased from 37.2% to 2% (p less than 0.001).  The average outpatient morphine equivalents decreased by 21 milligrams among children prescribed an opioid (p less than 0.05). Rates of readmission (3.5% vs 3.5%) or delayed prescriptions (1.1% vs 0.8%) within 30 days from discharge were unchanged (p greater than 0.05). Female patients were less likely (OR = 0.7,0.51-0.95, p less than 0.01) and patients with a personal or family mental health diagnosis were more likely (OR = 1.6,1.29-1.96,p less than 0.001) to be prescribed opioids at discharge. Insurance, ethnicity, and prior opioid prescriptions were not significant.

CONCLUSIONS

Our state mandate for outpatient opioid consent for minors has reduced post urologic surgery opioid prescription rates, without increasing rates of readmission or delayed prescriptions.


16:08 - 16:11
S21-2 (PP)

SAMPLE SIZE, POWER, AND RISK OF TYPE I/II ERROR IN US NEWS & WORLD REPORT RANKING METHODOLOGY FOR PEDIATRIC UROLOGY

Katherine HERBST 1, Zoe BAKER 2, James I HAGADORN 3 and Paul KOKOROWSKI 2
1) Connecticut Children's Medical Center, Research, Hartford, USA - 2) Children's Hospital Los Angeles, Urology, Los Angeles, USA - 3) Connecticut Children's Medical Center, Neonatology, Hartford, USA

PURPOSE

US News & World Report (USNWR) rankings influence the public’s perception of a hospital’s quality. Our purpose was to investigate current USNWR methodology to determine the power and misclassification risks.

MATERIAL AND METHODS

Average annual distal hypospadias and pyeloplasty procedure volumes by hospital from 2016-2018 were calculated using the Pediatric Health Information Systems database. Median volume was used to calculate power to detect differences, and avoid type II error, in complication rates between USNWR categories (<1%, 1-3%, 3-5%, and >5%). Risk of type I, or false positive, error was investigated using the Wilson score interval and Fisher’s exact tests.

RESULTS

Median (IQR) annual hospital procedure volume was 68 cases (40-96) for hypospadias surgeries and 18 (9-32) for pyeloplasty. In order to achieve 80% power, 768 cases/hospital are required to detect a 1% vs. 3% complication rate, 1506 cases/hospital are required to detect a 3% vs. 5% complication rate, and 284 cases/hospital are required to detect a 1% vs. 5% complication rate. Comparing two median-volume hospitals, the power to detect a difference in complication rates of 1% vs. 3%, 3% vs. 5%, and 1% vs. 5% was 13%, 9%, and 27% for hypospadias procedures and 6%, 5%, and 10% for pyeloplasty procedures.           

For median-volume hospitals, complication rate 95% confidence intervals for hypospadias and pyeloplasty procedures were 1% (0.1-7.1%), 3% (0.8-10.2%), 5% (1.8-13.0%) and 1% (0.004-19.2%), 3% (0.03-22.2%), 5% (0.1-25.0%) respectively. Statistical testing comparing these complication rates were not significant (p>0.05).

CONCLUSIONS

Current USNWR methodology has insufficient power and high risks of type I and type II error.


16:11 - 16:14
S21-3 (PP)

★ A SECOND-LOOK AT REPORTED STATISTICS: CHALLENGES IN REPLICATING REPORTED P-VALUES IN PEDIATRIC UROLOGY LITERATURE

Erik DRYSDALE 1, Lauren ERDMAN 1, Mandy RICKARD 2, Daniel T. KEEFE 2, Jessica HANNICK 3, Joana DOS SANTOS 2 and Armando J. LORENZO 2
1) The Hospital for Sick Children, Centre for Computational Medicine, Toronto, CANADA - 2) The Hospital for Sick Children, Urology, Toronto, CANADA - 3) Rainbow Babies and Children's Hospital, Pediatric Urology, Cleveland, USA

PURPOSE

P-values are the most commonly employed metric for reporting statistically significant findings in science. Ensuring that p-values are robust, reproducible, and generated from the proper tests is essential for ensuring accurate scientific inference. It is assumed that omissions or mistakes in the analyses are detected during the peer review process. We explored this issue by attempting to verify reported p-values from binary outcome tests and assessing the reproducibility of p-value reporting in the hydronephrosis (HN) and bowel and bladder dysfunction (BBD) literature.

MATERIAL AND METHODS

We analyzed 254 papers that were included in previously-reported projects regarding HN (n=129) and BBD (n=125). All studies reviewed had at least 2 comparison groups and reported a significant difference between them. We extracted group counts from the sampled papers and recalculated the statistics employing Fisher's exact test.

RESULTS

We found that 38 of the 254 (BBD=15, HN=23, 15%) papers sampled had insignificant p-values using our approach, but were reported as significant at <0.05. Of these 38 papers, 16 had results that could not be reproduced through any attempted approach, including chi-squared statistics (even in not adequate for the analysis). Twelve could achieve significance through a chi-squared test without a Yates continuity correction, and the remaining 10 could be accounted for by differing methodologies (e.g. more than two groups or different test procedures).

CONCLUSIONS

An important number of studies from the pediatric urology literature appear to report p-values that are difficult to reproduce. A combination of reproducible code, sensitivity analyses, as well as arms-length reproduction attempts can help to reduce non-robust results. There is opportunity for addressing these potential problems during the peer-review process, before publication.


16:14 - 16:23
Discussion
 

16:23 - 16:26
S21-4 (PP)

VIRTUAL REALITY AS PROCEDURAL SUPPORT FOR URODYNAMIC STUDIES

Julia FINKELSTEIN 1, Ian MCCARTHY 1, Katherine SEXTON 1, Dylan CAHILL 1, Kelsey TULLEY 2, Brianna O'CONNELL 3, Lauren MEDNICK 4, James ROSOFF 5, Peter WEINSTOCK 6 and Carlos ESTRADA 1
1) Boston Children's Hospital, Urology, Boston, USA - 2) Boston Children's Hospital, Urology, Child Life Services, Boston, USA - 3) Boston Children's Hospital, Child Life Services, Simulator Program, Boston, USA - 4) Boston Children's Hospital, Simulator Program, Psychiatry, Boston, USA - 5) Yale School of Medicine, Urology, New Haven, USA - 6) Boston Children's Hospital, Simulator Program, Boston, USA

PURPOSE

Children need improved ways to experience urodynamic studies (UDS).  We sought to investigate the use of immersive virtual reality (iVR) as an active distraction tool for children undergoing UDS.

MATERIAL AND METHODS

A prospective randomized study involving children aged 5 years or older undergoing UDS over a three-month period. Children were randomized to receive iVR or the standard of care (SoC), which includes passive distraction with a video monitor. Upon arrival, patients completed a visual analog scale for anxiety (VAS-A, 0-10) about the upcoming procedure. Patient’s behavior during UDS was assessed using a validated brief behavioral distress scale. Immediately after UDS, each child completed a survey about the experience, including the helpfulness of iVR and how it felt to wear VR goggles (5-point Likert scale) if applicable. 

RESULTS

Overall baseline patient characteristics (N=20) are listed in the below table. 10 children were randomized to SoC and 10 to iVR.  Mean VAS-A scores were 4.9 and 3.1 prior to UDS for SoC and iVR patients, respectively.  Two SoC patients were unable to complete testing.  30% of SoC patients, compared to 10% of iVR patients, exhibited at least one interfering or potentially interfering behavior during UDS.  90% of iVR patients reported the technology was helpful, rating it as feeling “very good” or “excellent” to wear the goggles. One iVR child, who had previously undergone 7 UDS, noted the experience was “the best ever.”

Patient Characteristics

Number

Median Age (years, range)

8.2 (5.9-25.0)

Female Sex

13 (65%)

Perineal Sensation Present

16 (80%)

History of Prior UDS

18 (90%)

     Median # of Prior Studies (range)

2.5 (0-9)

History of Urologic Surgery

9 (45%)

CONCLUSIONS

Active distraction with iVR is a feasible technique that may improve the pediatric UDS experience. While limited numbers precluded statistical analysis, ongoing enrollment will allow for future determination of significant outcomes.


16:26 - 16:29
S21-5 (PP)

A QUALITATIVE ASSESSMENT OF UROLOGIC CALL COVERAGE AT A MULTI-HOSPITAL ACADEMIC RESIDENCY TRAINING PROGRAM

Anand MOHAPATRA, Oluwaseun ORIKOGBO, Liam MACLEOD, Jathin BANDARI, Stephen JACKMAN, Benjamin DAVIES and Bruce JACOBS
University of Pittsburgh, Department of Urology, Pittsburgh, USA

PURPOSE

In our residency program, junior residents (post-graduate year [PGY]-2 and -3) previously covered 5 hospitals every 5-7 nights and then completed a regular work period the following day (home call). We recently transitioned to a night float system, where a resident provides overnight coverage for one month and is off duty during the day. This study evaluated the two systems on measures of patient care, communication, quality of life, resident education, sleep, and interaction with nurses.

MATERIAL AND METHODS

A survey was administered to junior residents, senior residents (PGY-4 and higher), and faculty to evaluate the two systems on the aforementioned domains. A separate survey was administered to nurses evaluating promptness, availability, knowledge of patients, respect, communication, and ability to identify the on-call resident. Both surveys were administered before and after the transition. Sleep duration was collected for home call, nights off, and night float using actigraphy.

RESULTS

Junior residents rated night float as equivalent to home call for surgical case volume and superior in all other respects. Senior residents rated night float as superior for continuity of care, compassion, safety, efficiency for the day team, communication with nurses, quality of life, and time for reading and research. Faculty rated night float as superior for efficiency for the day team, handoffs, quality of life, and time for research. Nurses rated night float as a significant improvement for availability, knowledge of plan for patient, respectfulness, communication, and ability to identify the resident on call. Mean duration of sleep was 2.5, 7.1, and 6.8 hours for home call, night float, and nights off, respectively (p<0.001 home call versus night float).

CONCLUSIONS

Physicians and nurses perceived night float to improve multiple domains, and residents slept more on night float.


16:26 - 16:32
Discussion
 

16:32 - 16:35
S21-6 (PP)

FERTILITY PRESERVATION IN THE TRANSGENDER POPULATION

Niki PARIKH, Bridget FINDLAY, Patricio GARGOLLO and Candace GRANBERG
Mayo Clinic- Rochester, Urology, Rochester, USA

PURPOSE

The transgender population has largely been marginalized by society, causing inequities in health care delivery.  The dearth of provider knowledge on transgender health issues further exacerbates these disparities. A survey of the transgender population was conducted to help call attention to the often-overlooked aspect of care: fertility preservation prior to hormone therapy or gender affirmation surgery.

MATERIAL AND METHODS

A survey of 65 transgender individuals was conducted, with participants recruited through Reddit transgender groups and local transgender associations, to assess their knowledge regarding fertility preservation and their experience with healthcare providers. Results were compiled and analysis was performed.

RESULTS

Out of the 65 individuals who responded to the survey, approximately 88% were between the ages of 18 and 39. Seventy-four percent were assigned male gender at birth and 26% female. Sixty-two percent of individuals identified as female, 20% as male, and 18% as gender non-conforming. Only 35% of individuals had ever been cared for in a multidisciplinary transgender clinic.  Interestingly, while 100% of surveyed individuals were aware that fertility would be irreversibly lost after hormonal or surgical affirmation surgery and 43% believed this to be an important issue, only 46% had any health care providers discuss fertility preservation options with them.  

CONCLUSIONS

Hormonal therapy and gender affirming procedures affect the long-term reproductive potential of transgender individuals. While oncofertility is a prominent area of discussion, transgender care is still lagging. With an increase in medical and surgical therapy in younger individuals, health care providers must discuss fertility preservation options prior to affirmation therapy.


16:35 - 16:38
S21-7 (PP)

TRAUMATIC RENAL INJURY COLLABORATION FOR KIDS (TRICK): NATURAL HISTORY AND DEMOGRAPHICS OF HIGH GRADE RENAL TRAUMA FROM A MULTI-INSTITUTIONAL CONSORTIUM

Ching Man Carmen TONG 1, Vinaya BHATIA 2, Gabriella CRANE 3, Jonathan GERBER 2, Christopher LONG 4, Harold LOVVORN 5, Jacob LUCAS 6, Kirstin SIMMONS 1, Ming-Hsien WANG 2, Dana WEISS 4, Xiaoyi ZHUO 2, Madhushree ZOPE 7 and Douglass CLAYTON 1
1) Monroe Carell Jr. Children's Hospital at Vanderbilt, Pediatric Urology, Nashville, USA - 2) Texas Children's Hospital at Baylor College of Medicine, Pediatric Urology, Houston, USA - 3) Monroe Carell Jr. Children's Hospital at Vanderbilt, Radiology, Nashville, USA - 4) Children's Hospital of Philadelphia, Pediatric Urology, Philadelphia, USA - 5) Monroe Carell Jr. Children's Hospital at Vanderbilt, Pediatric Surgery, Nashville, USA - 6) Einstein Healthcare Network, Urology, Philadelphia, USA - 7) Baylor College of Medicine, Urology, Houston, USA

PURPOSE

Pediatric genitourinary trauma most commonly affects the kidney. While most pediatric renal trauma literature consists of smaller, single-center series, TRICK is a new multi-institutional effort between three high-volume pediatric trauma centers. In this report, we characterize injury mechanisms, surgical intervention rates and hospital outcomes.

MATERIAL AND METHODS

We reviewed retrospective data from three American College of Surgeons designated level 1 pediatric trauma centers between 2007 and 2018. We included patients <18 years old with high grade renal trauma, defined as grade III or higher using the American Association for the Surgery of Trauma grading system. We collected demographics, injury characteristics, outcomes and complications data.

RESULTS

253 children sustained high-grade renal trauma. 73% were male and 74% were Caucasian, with a mean age of 13.36 years. 96% were blunt injuries and the most common mechanism was motor vehicle collision (39.5%). Almost 48% sustained concomitant intra-abdominal injuries. 56% arrived from a referring community hospital; 35% arrived directly from the scene. Over 80% needed only conservative management. The remaining patients required either endoscopic ureteral stent placement (30/253, or 12%) or nephrectomy (6/253, or 2.3%). 5% (13/253) underwent angiographic intervention. Average length of hospital stay was 7.8 days. Readmission within 30 days for urologic issues occurred in 22 patients (8.9%), for which intractable flank pain (50%) was the most common indication.

CONCLUSIONS

The current study introduces TRICK, a new large, multi-institutional consortium of renal trauma characteristics and hospital outcomes. We found that high grade renal trauma overwhelmingly resulted from blunt mechanisms and could be successfully managed with conservative measures in over 80% of cases.


16:38 - 16:44
Discussion