Publications by authors named "Armando J Lorenzo"

208 Publications

Utility of pre-transplant lower urinary tract investigation in pediatric renal transplant population after referral: A 16-year institutional experience.

Pediatr Transplant 2021 Mar 18:e14006. Epub 2021 Mar 18.

Division of Urology, The Hospital for Sick Children, Toronto, ON, Canada.

To evaluate the clinical utility of pre-renal transplant LUT investigations in pediatric populations after their referral for transplant evaluation based on the etiology of their ESRD. A 16 year retrospective review of patients undergoing RT performed at our institution was performed. Patients were stratified into two groups: Group 1-non-urologic and Group 2-urologic etiology for ESRD. Baseline characteristics, pre-transplant LUT investigations, and urologic interventions were assessed. One-year clinical outcomes were compared between those with and without LUT investigations following referral for renal transplantation (RT). 227 patients and 97 patients were identified for Groups 1 and 2, respectively. 19% of Group 1 and 73% of Group 2 had VCUG, while 1% and 13%, respectively, had UDS ordered following referral for RT. In both groups, >50% of VCUG and UDS were ordered without specific clinical concerns. These had low likelihood of prompting interventions, both pre-transplant (Group 1-VCUG 0%, UDS 0%; Group 2-VCUG 0%, UDS 8%) or post-transplant (Group 1-0%, Group 2-5%). In both groups, LUT investigation following referral for RT did not lead to differences in 1 year outcomes assessed. In anticipation of pediatric RT, LUT investigations ordered without clinical indications did not provide information that altered management prior to transplantation.
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http://dx.doi.org/10.1111/petr.14006DOI Listing
March 2021

Evolving trends in peri-operative management of pediatric ureteropelvic junction obstruction: working towards quicker recovery and day surgery pyeloplasty.

World J Urol 2021 Mar 3. Epub 2021 Mar 3.

Division of Urology, Department of Surgery, Hospital for Sick Children, University of Toronto, 555 University Avenue, Toronto, ON, M5G 1X8, Canada.

Objective: To describe the evolution of practice patterns for pediatric pyeloplasty and determine how these changes have impacted length of stay (LOS), reoperation rates and return emergency department (ER) visits.

Methods: We reviewed our pyeloplasty database from 2008 to 2020 at a quaternary pediatric referral center and we included children 0-18 years undergoing pyeloplasty. Variables captured included: age, sex, baseline and follow-up anteroposterior diameter (APD) and differential renal function (DRF). We also collected data on the use of drains, catheters and/or stents, nausea and vomiting prophylaxis, opioids, regional anesthesia, and non-opioid analgesia. Outcomes were LOS, reoperation rates and ER visits.

Results: A total of 554 patients (565 kidneys) were included. Reoperation rate was 7%, redo rate 4% and ER visits 17%. There was a trend towards less opioids, indwelling catheters and internal stents and increasing non-opioid analgesia, externalized stents, and regional anesthesia during the study period. Same-day discharge (SDD) was possible for 88 (16%) children with no differences in reoperation or readmission rates between SDD and admitted (ADM). There was a difference in ER visits (21 [24%] vs. 26 [6%]; p = 0.04) for SDD vs. ADM, respectively. On multivariate analysis, the only predictor of ER visits was younger age. Patients < 7 months were more likely to present to ER (15/41; 37% vs. 6/47, 13%; p = 0.009). Multivariate analysis determined indwelling catheters and opioids were associated with ADM while dexamethasone and ketorolac with SDD.

Conclusion: Progressive changes in care have contributed to a shorter LOS and increasing rates of SDD for pyeloplasty patients. SDD appears to be feasible and does not result in higher complication rates. These data support the development of a pediatric pyeloplasty ERAS protocol to maximize quicker recovery and foster SDD as a goal.
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http://dx.doi.org/10.1007/s00345-021-03621-9DOI Listing
March 2021

Vascular hitch for paediatric pelvi-ureteric junction obstruction with crossing vessels: institutional analysis and systematic review with meta-analysis.

BJU Int 2021 Jan 19. Epub 2021 Jan 19.

Division of Urology, Department of Surgery, The Hospital for Sick Children, Toronto, ON, Canada.

Objective: To compare the outcomes for laparoscopic vascular hitch (VH) and dismembered pyeloplasty in patients with pelvi-ureteric junction obstruction (PUJO) secondary to crossing vessels (CV).

Patients And Methods: Patients who underwent laparoscopic management of CV at our institution were identified between 2008 and 2020. Baseline characteristics and outcome measures were compared between those who underwent VH and those who underwent dismembered pyeloplasty. Those who underwent VH were selected intraoperatively by identifying CV in the absence of intrinsic obstruction by assessing resolution of hydronephrosis after cranially displacing the CV away from the PUJ, followed by intraoperative fluid bolus and diuretic test. In addition, a systematic search and meta-analysis were performed in June 2020 (International Prospective Register of Systematic Reviews [PROSPERO] ID CRD42020195833).

Results: A total of 20 patients underwent VH and 74 dismembered pyeloplasty. On multivariate analysis, VH was associated with: shorter operative time (P = 0.001; odds ratio [OR] 0.455, 95% confidence interval [CI] 0.294-0.705) and length of stay (P = 0.012; OR 0.383, 95% CI 0.183-0.803), lower use of stents (P < 0.001; OR 0.024, 95% CI 0.004-0.141) and opioid administration (P = 0.005; OR 0.157, 95% CI 0.044-0.567). From our literature search, 194 records were identified and 18 records were included (three comparative and 16 non-comparative). Meta-analysis of the comparative studies and our institutional data showed similar success rates (relative risk [RR] 1.77, 95% CI 0.33-9.52) and complication rates (RR 0.75, 95% CI 0.20-2.82). VH was associated with shorter operative time (standardised mean difference [SMD] -1.65, 95% CI -2.58 to -0.72 h) and hospital stay (SMD -1.41, 95% CI -2.36 to -0.47 days). The VH success rates ranged from 87.5% to 100% in the identified studies. Failure of VH was associated with unrecognised concomitant intrinsic obstruction in addition to CV.

Conclusions: A VH, for well-selected patients with CV without concomitant intrinsic obstruction, offers a high success rate with shorter operative times.
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http://dx.doi.org/10.1111/bju.15342DOI Listing
January 2021

Diagnosis and therapeutic strategies for nutcracker syndrome.

Curr Opin Urol 2021 Mar;31(2):135-137

Division of Urology, The Hospital for Sick Children, Toronto, Ontario, Canada.

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http://dx.doi.org/10.1097/MOU.0000000000000831DOI Listing
March 2021

Do post-operative phone calls enhance family satisfaction and outcomes after outpatient pediatric urological surgeries? A prospective study.

Pediatr Surg Int 2021 Jan 2;37(1):161-167. Epub 2020 Nov 2.

Division of Urology, Department of Surgery, University of Toronto, Hospital for Sick Children, 555 University Ave, Toronto, ON, M5G 1X8, Canada.

Introduction: This study assesses whether post-operative check-in phone calls (POPC) performed within 48 h of outpatient pediatric urological surgeries by a non-medical professional (NMP) would increase patient/family satisfaction and minimize extraneous resource use by increasing email/telephone communication, while reducing emergency department (ED) visits within 30 days of that procedure.

Methods: Families of patients undergoing ambulatory pediatric urology surgeries were enrolled over 8 weeks. Group 1 did not receive POPC. Group 2 received a POPC within 48 h of their operation by a NMP. Both groups received a phone-call survey 2 weeks after surgery to assess families' perioperative satisfaction.

Results: In total, 74 families were enrolled (Group 1 = 44, Group 2 = 31). The response rates to phone surveys for Groups 1 and 2 were 59.1% and 77.4%, respectively. POPC did not improve perioperative satisfaction, nor did it significantly promote the use of nursing email/telephone communication (19.2% vs. 4.2%, p = 0.128) or reduce ED visits (15.4% vs. 0.0%, p = 0.111). However, all families in Group 2 thought POPC was timed appropriately and 79.1% perceived it to be helpful in reducing post-operative anxiety.

Conclusion: POPC by a NMP within 48 h of surgery may not affect perioperative satisfaction of families of patients undergoing same-day pediatric urology surgery but may have an impact in reducing post-operative anxiety.
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http://dx.doi.org/10.1007/s00383-020-04770-5DOI Listing
January 2021

Spermatogenesis in pre-pubertal boys with Leydig cell neoplasms suggests paracrine stimulation by testosterone.

J Pediatr Urol 2021 02 15;17(1):48.e1-48.e6. Epub 2020 Oct 15.

Division of Urology, The Hospital for Sick Children, Toronto, Ontario, Canada. Electronic address:

Introduction: Pediatric Leydig cell tumors (LCTs) represent approximately 4% of pre-pubertal testicular tumors and are known to cause precocious puberty secondary to testosterone production. While gonadotropins and testosterone are known to initiate spermatogenesis beginning in puberty, it is yet to be determined if a similar phenomenon is triggered by isolated testosterone production in prepubescent boys.

Objective: To determine if testicular pathology in pre-pubertal pediatric patients with LCTs exhibit spermatogenesis secondary to paracrine testosterone stimulation.

Study Design: We reviewed patients who underwent orchiectomy for a testicular tumor from 2003-17. We included patients with LCTs and compared them to children with non-LCT pathology (teratomas and epidermoid cysts). We excluded other pathologies and tumors in pubertal patients. Data were collected on the presence of spermatogenesis on pathology, tumor markers and serum hormone results.

Results: Orchiectomy for testicular tumors were completed in 66 patients, of which 20 were included in the non-LCT group and 9 in the LCT group. Two of the 9 LCT patients had bilateral pathology. Age at presentation was 6.3 ± 5.8 years for the non-LCT group vs. 8.4 ± 1.6 years for LCTs (p = 0.261). Spermatogenesis was detected in 7 (64%) LCT specimens vs 2 (10%) non-LCT specimens (p = 0.002). Age of the spermatogenesis patients in the non-LCT group (11.08 ± 2.5 years) was older than LCT ones (8.3 ± 2.0 years), suggesting that spermatogenesis in the non-LCT group may be due to early pubertal development. The summary figure demonstrates spermatogenesis identified in a pre-pubertal LCT patient.

Discussion: In this study, pre-pubertal males with LCTs were identified to have pathology evidence of spermatogenesis compared to controls with non-LCT pathology. This represents the first study assessing paracrine testosterone effects on spermatogenesis in pre-pubertal patients with LCTs. In contrast, adult literature on LCTs primarily report on resulting concerns for fertility, gynecomastia and testicular atrophy.

Conclusion: LCTs can induce spermatogenesis in prepubertal patients. This reinforces the hypothesis that paracrine testosterone signaling plays a role in spermatogenesis. Our findings could help explore novel fertility preservation opportunities in children.
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http://dx.doi.org/10.1016/j.jpurol.2020.10.015DOI Listing
February 2021

Meta-analysis of retroperitoneal vs transperitoneal laparoscopic and robot-assisted pyeloplasty for the management of pelvi-ureteric junction obstruction.

BJU Int 2020 Oct 8. Epub 2020 Oct 8.

Division of Urology, The Hospital for Sick Children, Toronto, ON, Canada.

Objective: To determine differences in perioperative outcomes between retroperitoneal and transperitoneal approaches for laparoscopic pyeloplasty (LP) to manage pelvi-ureteric junction obstruction (PUJO) through a meta-analysis of comparative studies.

Methods: A systematic search was performed in January 2020. Comparative studies were evaluated according to Cochrane Collaboration recommendations. Assessed outcomes included success and complication rates, conversion to open surgery, operative time (OT), length of hospital stay (LOS), estimated blood loss (EBL), analgesic requirements, regular diet resumption, and drain duration. Relative risk (RR) and standardised mean difference (SMD) with 95% confidence intervals (CIs) were extrapolated. Subgroup analyses were performed according to study design and techniques. International Prospective Register of Systematic Reviews (PROSPERO) number: CRD42020163303.

Results: A total of 18 studies describing 2007 cases were included. Overall pooled effect estimates did not show statistically significant differences between the approaches with regards to success rate (RR 0.99; 95% CI 0.97, 1.01), complications (RR 1.09; 95% CI 0.82, 1.45), OT (SMD 0.61; 95% CI -0.04, 1.26), LOS (SMD -0.30; 95% CI -0.63, 0.04), EBL (SMD -0.53; 95% CI -1.26, 0.21), or analgesic requirements (SMD -0.51; 95% CI -1.23, 0.21). Compared to the transperitoneal approach, retroperitoneal LP had a higher conversion rate (RR 2.40; 95% CI 1.23, 4.66); however, patients resumed diets earlier (SMD -2.49; 95% CI -4.17, -0.82) and had shorter drain duration (SMD -0.31; 95% CI -0.57, -0.05).

Conclusion: The evidence suggests that there are no significant differences in success rate, OT and complications between transperitoneal and retroperitoneal LP. Conversion rates are higher with the retroperitoneal approach; however, return to diet occurs faster and drain duration is shorter when compared to the transperitoneal approach.
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http://dx.doi.org/10.1111/bju.15264DOI Listing
October 2020

Digital Pattern Recognition for the Identification and Classification of Hypospadias Using Artificial Intelligence vs Experienced Pediatric Urologist.

Urology 2021 Jan 26;147:264-269. Epub 2020 Sep 26.

Department of Anesthesia, Hospital for Sick Children, University of Toronto, Canada. Electronic address:

Objective: To improve hypospadias classification system, we hereby, show the use of machine learning/image recognition to increase objectivity of hypospadias recognition and classification. Hypospadias anatomical variables such as meatal location, quality of urethral plate, glans size, and ventral curvature have been identified as predictors for postoperative outcomes but there is still significant subjectivity between evaluators.

Materials And Methods: A hypospadias image database with 1169 anonymized images (837 distal and 332 proximal) was used. Images were standardized (ventral aspect of the penis including the glans, shaft, and scrotum) and classified into distal or proximal and uploaded for training with TensorFlow. Data from the training were outputted to TensorBoard, to assess for the loss function. The model was then run on a set of 29 "Test" images randomly selected. Same set of images were distributed among expert clinicians in pediatric urology. Inter- and intrarater analyses were performed using Fleiss Kappa statistical analysis using the same 29 images shown to the algorithm.

Results: After training with 627 images, detection accuracy was 60%. With1169 images, accuracy increased to 90%. Inter-rater analysis among expert pediatric urologists was k= 0.86 and intrarater 0.74. Image recognition model emulates the almost perfect inter-rater agreement between experts.

Conclusion: Our model emulates expert human classification of patients with distal/proximal hypospadias. Future applicability will be on standardizing the use of these technologies and their clinical applicability. The ability of using variables different than only anatomical will feed deep learning algorithms and possibly better assessments and predictions for surgical outcomes.
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http://dx.doi.org/10.1016/j.urology.2020.09.019DOI Listing
January 2021

Vascular inflow after renal transplantation: Does the arteriotomy technique impact early allograft perfusion and function?

Pediatr Transplant 2020 12 24;24(8):e13814. Epub 2020 Aug 24.

Division of Urology, Department of Surgery, The Hospital for Sick Children, Toronto, ON, Canada.

Background: There are two main techniques for arterial reconstruction in RT: TA using a stab longitudinal incision which creates an elliptical opening and AP which fashions a circular defect. We hypothesized that AP creates a natural anastomosis lumen, similar to the donor renal artery, which optimizes RT perfusion.

Methods: A retrospective review of a single-institution database was performed between 2000 and 2018. Twenty patients who underwent AP arteriotomy were compared to 40 TA-matched controls. Data were collected on creatinine (preoperative, nadir, and time to nadir), and DUS RI and PSV at 1 week, 3 months, and 6-12 months post-RT.

Results: ttNC was shorter in the AP group (5 ± 4 vs 12 ± 13 days; P = .03). PSV at 1 week was lower in the AP group (186 ± 65 cm/s vs 232 ± 89 cm/s; P = .04). There was no difference in nadir creatinine value (P = .26), preoperative creatinine (P = .66), and initial postoperative creatinine (P = .80). RI at week 1 were not different between groups (P = .37). Follow-up DUS showed the difference in PSV between groups became non-significant (1 month P = .50 and 6-12 months P = .53).

Conclusions: AP arteriotomy in RT improves early perfusion and function parameters (ttNC and initial PSV) as compared to TA. AP arteriotomy optimizes early allograft reperfusion, which may have important long-term implications and deserves further evaluation.
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http://dx.doi.org/10.1111/petr.13814DOI Listing
December 2020

In-hospital resource utilization, outcome analysis and radiation exposure in children undergoing appendicostomy vs cecostomy tube placement.

J Pediatr Urol 2020 10 25;16(5):648.e1-648.e8. Epub 2020 Jul 25.

The Division of Urology, The Hospital for Sick Children, University of Toronto, Toronto, Canada. Electronic address:

Introduction And Objectives: Continence enemas for the purpose of bowel management may be delivered via trans-anal retrograde irrigations, and via antegrade conduits including surgical appendicostomy or placement of cecostomy tube (CT). An appreciation of the relative advantages and disadvantages of each antegrade continence enema (ACE) procedure allows clinicians, parents and children to make an informed decision regarding which procedure is most appropriate in individual cases. The objective of this study was to evaluate the differences in in-hospital resource utilization, surgical outcomes and radiation exposure between children undergoing appendicostomy creation and CT placement at our institution.

Methods: We conducted a retrospective chart review of children undergoing these procedures at our institution over a 10-year period. All patients 0-18 years of age undergoing either procedure for any indication were included. Data on demographics, length of stay (LOS), radiation exposure events (REE), and surgical outcomes were collected.

Results: One hundred fifteen (63 appendicostomy/52 CT) patients were included. Those undergoing CT placement had significantly increased post-procedural LOS, catheter exchanges and REE compared to those undergoing appendicostomy (see Table). Reported rates of bowel control were similar between the two groups, and there was no significant difference in rates of surgical complications, although each group had unique, procedure-specific complications.

Discussion And Conclusion: In our study, appendicostomy holds a clear advantage over CT in terms of post-procedural LOS, as well as REE. In general, children with CTs require more planned and unplanned device maintenance procedures than those with appendicostomy. These findings aside, the rates of success for bowel control between the two groups are similar, and the incidence of complications does not differ significantly between the two groups. CT remains a safe and effective conduit for delivery of ACEs, and is a particularly good option in patients whose appendix has been lost or used for another conduit. However, patients wishing to avoid repeated procedures and radiation exposure may find the option of appendicostomy more attractive.
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http://dx.doi.org/10.1016/j.jpurol.2020.07.022DOI Listing
October 2020

Medical conferences in the era of environmental conscientiousness and a global health crisis: The carbon footprint of presenter flights to pre-COVID pediatric urology conferences and a consideration of future options.

J Pediatr Surg 2020 Jul 16. Epub 2020 Jul 16.

Division of Urology, Hospital for Sick Children and Department of Surgery, University of Toronto, Ontario, Canada.

Introduction: Medical conferences are integral to academic medicine, with academic posters being a well-established medium for presenting research. However, conferences carry an ecological footprint due to greenhouse gas emissions. Furthermore, traditional conference formats have recently not been possible due to the COVID-19 pandemic. Herein we examine the carbon footprint associated with travel by presenting delegates to the Fall SPU conferences from 2013 to 2019, and the 2015 ESPU conference.

Methods: Online programs for the targeted SPU Fall meetings and the 2015 ESPU Annual Meeting were retrospectively reviewed. Variables collected included meeting location and presenter home base. Distance traveled by the presenter, and likely COe of this return trip were estimated using online calculators. Analysis was performed using the Kruskal-Wallis-H test with pairwise comparisons to detect differences in round trip distances and COe between meeting locations.

Results: Six Fall SPU conferences and one ESPU conference were reviewed. The majority of presenters were from the region (North America and Europe, respectively), for both SPU and ESPU. The median round trip distance was 2596.34 miles (IQR 1420.96-4438.30), and the median COe 0.61 metric tons (IQR 0.36-1.02). We found that the distances traveled to conferences in the Western USA and Europe were slightly further than those to conferences in Central Canada and the Southern US. The difference in COe between these locations did not achieve statistical significance.

Conclusion: Presenter travel to and from pediatric urological conferences generates an important carbon footprint and may not be possible in the medium-term future due to a global pandemic. We should explore strategies to allow meetings and knowledge exchange to continue whilst reducing the need for travel and the ecological burden of conferences.

Level Of Evidence: Level III: Most comparative level of evidence.
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http://dx.doi.org/10.1016/j.jpedsurg.2020.07.013DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7364154PMC
July 2020

Comparative outcome analysis of pediatric kidney transplant in posterior urethral valves children with or without pretransplant Mitrofanoff procedure.

Pediatr Transplant 2020 12 2;24(8):e13798. Epub 2020 Aug 2.

Division of Urology, Hospital for Sick Children and Department of Surgery, University of Toronto, Toronto, Ontario, Canada.

Background: Urinary diversion using catheterizable channel among posterior urethral valve (PUV) patients may help to alleviate the functional concerns of the bladder on the allograft. Herein, we review our series of PUV patients undergoing renal transplants at a single institution to determine outcomes between those with and without pretransplant Mitrofanoff.

Methods: PUV cases in our transplant database from 2000 to 2017 were identified. Data collected included clinical demographics, presentation of PUV, bladder function, implementation of dialysis and donor type. Post-transplant variables included graft function, and bladder function including incontinence and UTI development. Comparison between with vs without pretransplant Mitrofanoff patient groups was performed using Fisher's exact and t test analysis.

Results: Overall, 22 cases were analyzed. The majority (77%) had a prenatal diagnosis of PUV, and 23% had a symptomatic presentation. Pretransplant Mitrofanoffs were performed in 40.9% of cases. The overall age at transplant was 10 ± 5 years. Five percent experienced post-transplant incontinence and 23% UTIs. No difference between groups was noted in variables including age at transplant, the timing of PUV diagnosis. Mitrofanoff group patients had more symptomatic febrile UTIs than those without Mitrofanoff (67% vs 15%; P = .03); however, there was no difference in post-transplant UTI development. Furthermore, the Mitrofanoff group seems to have later onset of dialysis or need for transplant (age at the start of dialysis 36 ± 56 vs 156 ± 25 months, P < .001).

Conclusion: Our study suggests that patients with early PUV diagnoses who develop symptomatic UTI may benefit from early creation of a Mitrofanoff cathetherizable channel, which is associated with delayed ESRD progression and need for dialysis.
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http://dx.doi.org/10.1111/petr.13798DOI Listing
December 2020

Trends and relevance in the bladder and bowel dysfunction literature: PlumX metrics contrasted with fragility indicators.

J Pediatr Urol 2020 Aug 20;16(4):477.e1-477.e7. Epub 2020 Jun 20.

Division of Urology, Hospital for Sick Children and Department of Surgery, University of Toronto, Ontario, Canada.

Introduction: The concepts of fragility index (FI) and fragility quotient (FQ) have been previously described. PlumX metrics encompass online "footprints" of research in addition to traditional citations. Herein we explore PlumX metrics against the quality of BBD literature.

Objective: To explore altmetrics against the quality of bladder and bowel dysfunction (BBD) literature.

Study Design: A literature search was conducted using Pubmed, Medline, Embase for BBD and related terms. A total of 54,045 abstracts were screened, followed by 693 full text reviews and data extraction from 126. Studies were included if they reported on 2 groups being compared, had dichotomous outcomes, and had significant results.

Results: The median FI score was 4 (0-500) and there were 20 studies which had a FI of 0. The FQ had a median of 0.04 (0-0.32). PlumX usage was 263 ± 540, captures were 45 ± 60 and social media attention was 2 ± 2. Overall, 42% of papers were clinical trials (RCTs). When compared to other study designs, we noted a significant difference in PlumX captures (57 ± 72 RCT vs. 35 ± 47 other; p = 0.03). RCTs had higher usage, social media engagement and citations however, the differences were not significant. H-Index had a significant correlation with FI (p = 0.036), however correlations for PlumX usage and captures, while modestly positive (0.04-0.10) for the FI and FQ, were not significant. A comparison of FI and FQ by topic can be reviewed in the Summary Table.

Discussion: When considering the FI and FQ robustness indicators of the BBD literature, we found similarities when compared to other studies. It was reported that overall, the hydronephrosis literature was fragile with many studies requiring only a few events to nullify significance, regardless of the study design. Similarly, in a review of pediatric vesicoureteral reflux (VUR) clinical trials, results were also fragile. When comparing fragility measures to altmetric variables we noted that despite the growing popularity of altmetrics, citation counts, and h-indices remain the traditional measures to monitor research consumption. There has been a reported correlation between manuscript citation counts, author h-index, altmetrics measures in several specialties and across many domains of research including medical sciences, arts, and the humanities, however in the present study only weak correlations were noted.

Conclusion: The body of BBD comparative studies is fragile in keeping with other pediatric urology literature populations. Despite fragile results, RCTs generate slightly moreattention as measured by select PlumX metrics. These results suggest the need for including fragility measures in our literature, aiming to focus attention towards more robust articles.
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http://dx.doi.org/10.1016/j.jpurol.2020.06.015DOI Listing
August 2020

Pediatric Kidney Transplant Experience in Ontario: A Review of Division of the Surgical and Medical Management Across Local Tertiary Care Institutions.

Can J Kidney Health Dis 2020 8;7:2054358120925712. Epub 2020 Jun 8.

Division of Urology, The Hospital for Sick Children, Toronto, ON, Canada.

Background: Our institution is the largest pediatric kidney transplantation (KT) center in Canada and the referral center for pediatric KT in Ontario. Pediatric KT recipients are referred to our center for KT and transferred back to their local tertiary care institutions for post-transplant care. This investigation assesses whether the current system of transferring patients back to their local tertiary care institutions following KT allows decreased burden and distribution of resources from a single centralized surgical center.

Methods: A retrospective review of KT performed at our institution between 2000 and 2015 was performed. Patients were divided into those who began their chronic kidney disease (CKD) care at our institution and those who began their care elsewhere. Readmission to our institution within 1 year of KT for surgical and nonsurgical complications was compared. The geographical proximity of patients to our institution and institution of initial CKD care was assessed quantitatively and mapped visually.

Results: Of 324 patients who underwent KT, 244 (75.3%) began their CKD care at our institution. Those who began their CKD care at other institutions had shorter initial admissions to our institution (17 [14-24] vs 14 [12-17], < .0001) and were less likely to be readmitted to our institution for nonsurgical concerns at <6 months after transplant ( < .0001) and 6 to 12 months after transplant ( < .0001). There were similar readmissions for complications requiring surgical management. The relationship between the center of CKD initiation and readmission remained significant on multivariate analysis. There was a significant difference in distance (km) to our institution between the 2 groups (46 [interquartile range = 24-109] vs 203 [117-406], < .0001).

Conclusion: Patients who are geographically distanced from our institution began their CKD care at their closest institution and were managed effectively at those institutions following initial discharge/transfer of care, suggesting that there is an effective distribution of health care resources with regard to CKD and KT care.
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http://dx.doi.org/10.1177/2054358120925712DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7285935PMC
June 2020

Turning a new “page”: ways to decrease the number of pages after hours without compromising patient care

Can J Surg 2020 03 27;63(2):E155-E160. Epub 2020 Mar 27.

From the Department of Urology and Pediatric Urology, University Medical Center, Johannes Gutenberg University of Mainz, Mainz, Germany (Schröder); and the Department of Urology, Hospital for Sick Children, Toronto, Ont. (Farhat, Bägli, Lorenzo, Koyle).

Background: Pages to house staff after hours, especially overnight, lead to interrupted sleep and fatigue the next day. Although some pages are urgent, others may not need an immediate response. In this study we aimed to identify unwarranted pages and to establish ways to reduce them.

Methods: Over 2 months, all pages to the Department of Pediatric Urology at the Hospital for Sick Children in Toronto, Canada, during call hours were documented, including the assessment of the responding physicians of their medical necessity. After analyzing the reasons for inappropriate pages, we took several steps to try to reduce them without impairing patient care. One year later, pages were tracked again to evaluate the efficacy of our interventions.

Results: In the initial measurement period, no calls from parents and approximately 50% of the in-hospital pages (15 of 36 pages from the wards, 27 of 49 pages from the emergency department, 17 of 31 pages requesting consultations, and 8 of 8 pages from the inhouse pharmacy and outside pharmacies) were considered medically urgent. The reasons for unwarranted pages were inconsistent parent teaching, lack of adequate triaging and prioritizing on the ward and lack of awareness of the structure of the on-call provisions among different services in the hospital. Several steps were taken to streamline the teaching of parents and nurses, standardize information, provide alternative means of communication within the hospital and restrict parents’ access by phone to the urologist on call. One year later, the number of pages had decreased by 70%.

Conclusion: Although physician coverage throughout the day and night is necessary for high-quality and safe patient care, communication with on-call physicians should be only for appropriate reasons. The provision of consistent teaching and alternative communication channels can improve patient care as well as decrease the number of after-hour pages.
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http://dx.doi.org/10.1503/cjs.009119DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7828955PMC
March 2020

Recent advances in pediatric bladder malignancies.

F1000Res 2020 25;9. Epub 2020 Feb 25.

Division of Urology, The Hospital for Sick Children and Department of Surgery, University of Toronto, Toronto, ON, Canada.

Urothelial pediatric neoplasms are relatively rare. Papillary urothelial neoplasms of low malignant potential (PUNLMPs) and rhabdomyosarcoma (RMS) are the most common bladder malignancies in the pediatric population. Clinical presentation encompasses macroscopic hematuria or lower urinary tract symptoms (or both) or is detected incidentally at imaging. Tumors arising from the bladder can originate from any of its four histological layers (urothelium, lamina propria, detrusor, and adventitia) and are divided into tumors that have an epithelial origin (arising from the urothelium) and those that have a non-epithelial origin (mesenchymal neoplasms). RMS is the most common malignant tumor of the urinary bladder in children younger than 10 years. Deriving from the embryonic mesenchymal cell, the histopathologic subtypes of RMS are embryonal RMS (>90%) and alveolar histology (<10%). Pre-treatment imaging should be carried out by computed tomography (CT) or at present is more likely with magnetic resonance imaging of the pelvis. Chest CT and bone scintigraphy are used to screen for metastases. In selected cases, a positron emission tomography scan may be recommended to evaluate suspicious lesions. The current prognostic classification considers age, histologic subtype, tumor site, size, and extent (nodal or distant metastases). Staging is based on pre-operative findings, group is based on intra-operative findings and pathology, and risk stratification is derived from both stage and group data. Pre-operative chemotherapy is the most common first-line intervention for bladder/prostate RMS, before surgery or radiation therapy. Collaborative groups such as the Soft Tissue Sarcoma Committee of the Children's Oncology Group and the European Pediatric Soft Tissue Sarcoma Study Group endorse this therapy. PUNLMPs are generally solitary, small (1-2 cm), non-invasive lesions that do not metastasize. Therapy is usually limited to a transurethral resection of the bladder tumor. About 35% are recurrent and around 10% of them increase in size if they are not treated.
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http://dx.doi.org/10.12688/f1000research.19396.1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7043112PMC
August 2020

Female Authorship Publishing Trends and Forecasting in Pediatric Urology: Are We Closer to Gender Equality?

Urology 2020 May 15;139:141-150. Epub 2020 Feb 15.

Division of Urology, The Hospital for Sick Children, Toronto, Ontario, Canada.

Objective: To review the literature of 5 pediatric urology topics and conduct gender based and forecasting analyses of first and corresponding authors.

Methods: A PubMed search was performed for hypospadias, hydronephrosis, vesicoureteral reflux, bladder and bowel dysfunction, and cryptorchidism over 3 decades from 1990 to 2019. The 50 most relevant "best match" papers from each decade were extracted by topic. Author gender, specialty, and advanced degrees, along with journal and publication variables were collected. Forecasting analyses were conducted through the Holt-Winters method.

Results: Among 750 papers analyzed, 78% of corresponding and 70% of first authors were male. A significant upward trend was observed for female-authored publications in both first and corresponding positions over time (P <.01). Forecasting analyses predicted a continuing upward trend for female corresponding (55%) and first authors (83%) by 2049. Most studies originated from pediatric urology (59%), followed by pediatric surgery (9%) and endocrinology/genetics (5%). Papers focused in The Journal of Urology (30%) with the majority originating from the United States (38%). Most were retrospective (44%) and discussed medical (54%) versus surgical management (20%).

Conclusion: The majority of pediatric urology literature has been generated by male authors. A persistent, rising trend in female authorship across all examined pediatric urology topics was noted. These encouraging findings are projected to continue to increase in the future, suggesting a movement toward equal and fair gender representation in authorship in pediatric urology.
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http://dx.doi.org/10.1016/j.urology.2020.01.037DOI Listing
May 2020

Volumetric assessment of unaffected parenchyma and Wilms' tumours: analysis of response to chemotherapy and surgery using a semi-automated segmentation algorithm in children with renal neoplasms.

BJU Int 2020 05 27;125(5):695-701. Epub 2020 Feb 27.

Division of Urology, Hospital for Sick Children and Department of Surgery, University of Toronto, Toronto, ON, Canada.

Objective: To present our proof of concept with semi-automatic image recognition/segmentation technology for calculation of tumour/parenchyma volume.

Methods: We reviewed Wilms' tumours (WTs) between 2000 and 2018, capturing computed tomography images at baseline, after neoadjuvant chemotherapy (NaC) and postoperatively. Images were uploaded into MATLAB-3-D volumetric image processing software. The program was trained by two clinicians who supervised the demarcation of tumour and parenchyma, followed by automatic recognition and delineation of tumour margins on serial imaging, and differentiation from uninvolved renal parenchyma. Volume was automatically calculated for both.

Results: During the study period, 98 patients were identified. Of these, based on image quality and availability, 32 (38 affected moieties) were selected. Most patients (65%) were girls, diagnosed at age 50 ± 37 months of age. NaC was employed in 64% of patients. Surgical management included 27 radical and 11 partial nephrectomies. Automated volume assessment demonstrated objective response to NaC for unilateral and bilateral tumours (68 ± 20% and 53 ± 39%, respectively), as well as preservation on uninvolved parenchyma with partial nephrectomy (70 ± 46 cm at presentation to 57 ± 41 cm post-surgery).

Conclusion: Volumetric analysis is feasible and allows objective assessment of tumour and parenchyma volume in response to chemotherapy and surgery. Our data show changes after therapy that may be otherwise difficult to quantify. Use of such technology may improve surgical planning and quantification of response to treatment, as well as serving as a tool to predict renal reserve and long-term changes in renal function.
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http://dx.doi.org/10.1111/bju.15026DOI Listing
May 2020

Editorial Comment.

J Urol 2020 02 18;203(2):412. Epub 2019 Nov 18.

Department of Pediatric Urology, Hospital for Sick Children, University of Toronto, Toronto, Ontario.

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http://dx.doi.org/10.1097/01.JU.0000615352.24199.2eDOI Listing
February 2020

Clinical and Economic Value of Routine Pathological Examination of Hernia Sacs and Scheduled Clinic Follow-Ups After Inguinal Hernia and Hydrocele Repair in a Canadian Tertiary Care Children's Hospital.

J Pediatr Surg 2020 Aug 23;55(8):1463-1469. Epub 2019 Oct 23.

Division of Urology, The Hospital for Sick Children, Toronto, ON, Canada; Department of Surgery, University of Toronto, Toronto, ON, Canada.

Background: The clinical and economical value of routine submission of hernia sacs for pathological examination and scheduled clinic follow-ups after inguinal hernia and hydrocele repair has been questioned. Herein, we assessed the institutional variability in these routine practices.

Methods: We retrospectively reviewed patients who underwent unilateral or bilateral inguinal hernia and/or hydrocele repair, open or laparoscopically, at our institution from 2015 to 2018.

Results: 1181 patients were included (1074 inguinal hernias and 157 hydroceles). Of 531 specimens obtained from 446 (38%) patients, 515 (97%) were normal. 16 (3%) abnormal pathological findings included 7 with mesothelial hyperplasia, 5 with nonfunctional genital ductal remnants, 3 with ectopic adrenal cortical tissues, and 1 epidydimal structure which was not recognized at the time of surgery. 418 (35%) patients had scheduled clinic follow-ups 65 (IQR 46-94) days postoperatively. 44 (4%) patients with unexpected postoperative Emergency Department visits within 30 days of surgery were identified. Only one patient required inpatient treatment, and the rest did not require intervention or admission. The total direct cost of analyzing specimens during the study period was $30,798 CAD ($10,266/year). The average cost to detect a potentially significant finding was $1924.88/specimen and $2053.20/patient.

Conclusions: Routine pathological examination of hernia sacs and scheduled clinic follow-ups were associated with significant costs and predominantly nonsignificant findings. They should therefore be reserved for patients with a high clinical suspicion of injuries/abnormalities or risk factors for potential complications.

Level Of Evidence: This is a level III evidence study.
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http://dx.doi.org/10.1016/j.jpedsurg.2019.09.007DOI Listing
August 2020

Insulin-Like Peptide 3 (INSL3) Serum Concentration During Human Male Fetal Life.

Front Endocrinol (Lausanne) 2019 4;10:596. Epub 2019 Sep 4.

John W. Duckett MD Laboratory in Pediatric Urology, Division of Pediatric Urology, Department of Urology, University of Texas Southwestern Medical Center, Dallas, TX, United States.

Insulin-like peptide 3 (INSL3), a protein hormone produced by Leydig cells, may play a crucial role in testicular descent as male INSL3 knockout mice have bilateral cryptorchidism. Previous studies have measured human fetal INSL3 levels in amniotic fluid only. To measure INSL3 serum levels and mRNA in fetal umbilical cord blood and fetal testes, respectively. INSL3 concentrations were assayed on 50 μl of serum from male human fetal umbilical cord blood by a non-commercial highly sensitive and specific radioimmunoassay. For secondary confirmation, quantitative real-time PCR was used to measure INSL3 relative mRNA expression in 7 age-matched human fetal testes. UT Southwestern Medical Center, Dallas, TX and Medical University of South Carolina, Charleston, SC. Twelve human male umbilical cord blood samples and 7 human male testes were obtained from fetuses 14-21 weeks gestation. Male sex was verified by leukocyte genomic DNA SRY PCR. None. Human male fetal INSL3 cord blood serum concentrations and testicular relative mRNA expression. INSL3 serum concentrations during human male gestational weeks 15-20 were 2-4 times higher than published prepubertal male levels and were 5-100 times higher than previous reports of INSL3 concentrations obtained from amniotic fluid. Testicular fetal INSL3 mRNA relative expression was low from weeks 14-16, rose significantly weeks 17 and 18, and returned to low levels at week 21. These findings further support the role of INSL3 in human testicular descent and could prove relevant in uncovering the pathophysiology of cryptorchidism.
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http://dx.doi.org/10.3389/fendo.2019.00596DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6737488PMC
September 2019

Impact of previous abdominal surgery on the outcome of laparoscopy-assisted open appendicovesicostomy (Mitrofanoff) creation in children: a comparative study.

J Pediatr Urol 2019 Dec 9;15(6):662.e1-662.e7. Epub 2019 Sep 9.

Division of Urology, The Hospital for Sick Children, Toronto, Canada; Department of Surgery, University of Toronto, Toronto, Canada.

Introduction And Objective: For patients who require self-intermittent catheterization, a continent catheterizable stoma is a viable option. This patient population often has had previous abdominal surgery (PAS), a risk factor for complicated laparoscopic procedures. Therefore, the authors aim to determine whether PAS has an impact on the peri-operative outcomes of the laparoscopic-assisted Mitrofanoff procedure in children.

Materials And Methods: A research ethics board-approved retrospective review was performed to assess peri-operative outcomes among pediatric patients who underwent laparoscopic-assisted Mitrofanoff procedures in the authors institution from May 2000 to March 2016. Patients with no PAS were compared with those with intraperitoneal PAS. Demographic/baseline characteristics and peri-operative outcomes such as operative time, estimated blood loss, hospital stay, unanticipated additional operations, stomal stenosis, and urinary continence were compared. To ensure there is no confounding based on PAS characteristics, subgroups were created to compare the recency (PAS <1 year ago) and extent (ventriculoperitoneal (VP) shunt vs non-VP shunt PAS) to assess their peri-operative outcomes. Fisher's exact test and Mann-Whitney U test were used to determine statistical significance.

Results: Thirty-four patients (15 no PAS and 19 PAS) were included in the analysis. No significant difference in demographics and baseline characteristics was noted between the patient groups. The median age was 6.5 years (interquartile range [IQR] 4.8-14.0) and 9.9 years (4.2-14.3), respectively (NS). Peri-operative outcomes of operative time, estimated blood loss, and hospital stay were similar between the PAS and no PAS groups. There was no statistical difference in complications requiring surgical intervention (n = 3, 20.0%; n = 9, 47.4%). The median follow-up period was 25.9 (IQR 7.7-47.2) months and 28.0 (IQR 13.0-53.0) months, respectively (NS). Patients with VP shunts as their only PAS had higher estimated blood loss compared with no PAS group (50 [IQR 25-150], 25 [IQR 25-50], respectively) but without other differences in peri-operative outcomes.

Discussion: Findings support the use of a minimally invasive approach in this patient population as it is feasible, comparable, and safe but with careful consideration for risk factors that may predispose PAS patients to postsurgical complications requiring intervention. Although limited by small sample size, this study provides valuable insight into performing laparoscopic operations in children who have undergone prior surgeries and invites future studies to compare the outcomes between patients undergoing open, pure laparoscopic, and robotic-assisted laparoscopic Mitrofanoff procedures for children with PAS.

Conclusion: Laparoscopic-assisted Mitrofanoff creation may be safely performed in children with PAS.
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http://dx.doi.org/10.1016/j.jpurol.2019.09.003DOI Listing
December 2019

Testis-sparing Surgery for Pediatric Leydig Cell Tumors: Evidence of Favorable Outcomes Irrespective of Surgical Margins.

Urology 2019 Dec 24;134:203-208. Epub 2019 Sep 24.

Division of Urology, Department of Surgery, The Hospital for Sick Children and University of Toronto, Toronto, Ontario, Canada. Electronic address:

Objective: To review our single institution experience, exploring the role of testis-sparing surgical resection in a cohort of children with Testicular Leydig cell tumors (LCTs).

Materials And Methods: We reviewed all consecutive children presenting with testicular tumors between 2003 and 2017 (n = 66), excluding patients with alternative pathologies (n = 57). Subsequently data were collected on age at surgery, laterality, type of surgery, operative time, presenting symptoms, serum markers, imaging findings, frozen section, final pathology, and follow-up.

Results: During the study period, a total of 9 (9/66; 14%) children were treated for LCT of the testis. Age at surgery was 8.4 ± 1.7 years and the majority (7/9; 77%) had unilateral disease. Most presented with a testicular mass, and 3 (33%) complained of testicular pain. None of the patients had elevated tumor markers. The primary method of management was ultrasound-guided testis-sparing surgery, with an operative time of 98.5 ± 58.7 minutes. Mean tumor size was 15 ± 10.8 mm (range 5-40 mm). In 2 of 6 patients with positive margins radical orchidectomy was performed without residual disease encountered. At a mean follow-up of 31.8 ± 26.3 months (range 2-87) none of the patients demonstrated disease recurrence.

Conclusion: Our data suggest that LCT in children is associated with a good prognosis, and that TSS is a reasonable surgical approach without detrimental perioperative morbidity or negative long-term outcomes. Moreover, positive margins should not prompt a reflex decision for completion of orchidectomy.
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http://dx.doi.org/10.1016/j.urology.2019.09.016DOI Listing
December 2019

Over-reliance on P Values in Urology: Fragility of Findings in the Hydronephrosis Literature Calls for Systematic Reporting of Robustness Indicators.

Urology 2019 Nov 30;133:204-210. Epub 2019 Jul 30.

Division of Urology, Hospital for Sick Children and Department of Surgery, University of Toronto, Toronto, Ontario, Canada.

Objective: To review the robustness of hydronephrosis literature with the application of fragility index (FI) and fragility quotient (FQ) calculations.

Methods: A literature review was conducted using Pubmed, Medline, and Ovid for "hydronephrosis" and associated terms and we included all studies with at least 2 groups being compared. FI was calculated by populating study results into a 2-by-2 contingency table and generating a P value using Fisher's exact test. Next, events were manually added to the group with the fewest events, while removing a nonevent from the same group and Fisher's exact test repeated until the P value was >.05. FQ was calculated by dividing FI by the total sample size.

Results: The 130 included articles were published between 1986 and 2018 in 32 journals. Median citation count was 14 (0-252), 30% were RCTs and most papers originated in the United States (28%), Turkey(10%), and Canada(9%). Median FI was 2 (1-112), FQ was 0.023 (0.0010-0.55), and 60 papers (46%) had a FI of 1, indicating extremely fragile results. There was a significant difference in the FI between observational studies and RCTs (10 ± 17 vs 4 ± 5; P = .02); however, there was no difference in FQ (0.032 ± 0.030 vs 0.053 ± 0.080; P = .09) between them.

Conclusion: Nearly half of studies in hydronephrosis literature reporting significant results are extremely fragile, requiring addition of only a couple of events in 1 treatment arm to significantly modify the results. As such, objective reporting of robustness of results should include FI and FQ which may help diminish over-reliance on P values as the main indicator of clinical significance in comparative studies.
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http://dx.doi.org/10.1016/j.urology.2019.03.045DOI Listing
November 2019

Assessment of prophylactic heparin infusion as a safe preventative measure for thrombotic complications in pediatric kidney transplant recipients weighing <20 kg.

Pediatr Transplant 2019 09 6;23(6):e13512. Epub 2019 Jun 6.

Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada.

Small-sized kidney recipients (<20 kg) are at high risk of allograft vessel thrombosis. HP has been used to mitigate this risk but may infer an increase in bleeding risks. Therefore, we aim to determine whether HP is a safe means to prevent thrombosis in small kidney transplant patients by comparing those who have received HP and those who have NHP. A retrospective review of patients < 20 kg who underwent kidney transplant in our institution from 2000 to 2015 was performed. At our institution, unfractionated heparin 10 units/kg/hour is used as HP since 2009. Patients at increased risk of thrombosis (previous thrombosis, thrombophilia, nephrotic syndrome) and bleeding (therapeutic doses of heparin, diagnosis of coagulopathy) were excluded. Fifty-six patients were identified (HP n = 46; NHP n = 10). Baseline demographics were similar between HP and NHP. There was no statistical difference in frequency of transfusions, surgical re-exploration, or thrombotic events between HP and NHP. The HP group was more likely to have drop in Hb > 20 g/L (67.4% vs 30.0%, P = 0.038), and those who had drop in Hb > 20 g/L were more likely to also require pRBC transfusions (63.0% vs 20.0%, P = 0.017). Within the HP group, those who had bleeding complications had similar Hb levels as those who did not at baseline and post-transplant. Outcomes in the HP and NHP groups were no different with respect to thrombosis or significant bleeding complications requiring pRBC transfusions or surgical intervention. Future prospective studies are required to investigate the balance of preventing thrombosis and risks of pRBC transfusions for small-sized kidney recipients.
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http://dx.doi.org/10.1111/petr.13512DOI Listing
September 2019

Publication trends in pediatric renal transplantation: Bibliometric analysis of literature from 1950 to 2017.

Pediatr Transplant 2019 08 13;23(5):e13455. Epub 2019 May 13.

Division of Urology, Hospital for Sick Children and Department of Surgery, University of Toronto, Toronto, Ontario, Canada.

Introduction: Pediatric renal transplantation has been heavily published since the 1950s. Herein, we describe the bibliometrics and impact of the 200 most-cited pediatric renal transplantation manuscripts.

Methods: We identified pediatric renal transplantation publications from 1900 onwards. Year, citations, h-index, geographic origin, impact factor, topic, and design of the 200 top-cited papers were extracted. Impact index was calculated, adjusting for citation volume and time since publication.

Results: Of the top 200 papers, mean citation count was 80 ± 40, impact factor 3.9 ± 3.7, h-index 35 ± 20, and impact index 25 ± 13. Studies were mostly retrospective (31%) or observational (32%). Most papers originated from the United States (58%), Germany (9%), and Italy (6%), which did not correlate with citation counts. Transplantation (18%), Pediatric Nephrology (16%), and American Journal of Transplantation (11%) had the highest publication volume, which did not correlate with citation count. The main topics were medical renal disease, drug monitoring, compliance, and viruses. Most of the top-cited papers (179; 90%) were published after 1991. The difference in the number of times cited between papers published before and after 1991 was insignificant (75 ± 24 vs 80 ± 42; P = 0.59). There was a difference in impact index for the same period (48 ± 15 vs 22 ± 10; P < 0.01).

Conclusions: The most-cited papers were concentrated in three journals, but the top three cited papers were published elsewhere. Recent publications were more cited with a higher impact than older papers. Despite the importance of surgery in transplantation, there is a paucity of high-impact papers on this topic.
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http://dx.doi.org/10.1111/petr.13455DOI Listing
August 2019

Is there a functional disadvantage to using the external iliac vessels for vascular anastomosis in children and adolescents undergoing renal transplantation?

Pediatr Transplant 2019 06 27;23(4):e13398. Epub 2019 Mar 27.

Division of Urology, Hospital for Sick Children and Department of Surgery, University of Toronto, Ontario, Canada.

Purpose: RT remains the best available strategy for addressing stage 5 chronic kidney disease in children and adolescents. Technical aspects of the procedure can have a clear impact on complications and health of the allograft, including DGF. Immediate optimal perfusion is paramount, thus choosing a target vessel has to take into account the flow demands imposed by an adult-size kidney in a proportionally smaller recipient. Herein, we explore the hypothesis that vascular anastomosis location can impact DGF adjusting for patient age and body size.

Methods: Retrospective review of a single institution referral center transplant database, including information on 156 patients. We collected data on patient characteristics (age, height, BSA, gender, preoperative need for dialysis), donor source (deceased vs living), WIT/CIT, hemodynamics during the procedure, use of inotropes or diuretics, and location of the arterial and venous anastomoses. The primary outcome, DGF, was assessed by measuring the ttNC (in days), adjusting for age and BSA.

Results: Location of the arterial anastomosis was clearly impacted by age and donor size (Figure 1A). On univariate analyses, longer ttNC was associated with deceased vs living donor (11.8 ± 11.5 and 4.3 ± 5.0; P < 0.001), preoperative need for dialysis (9.7 ± 11.0 and 6.5 ± 6.0, P = 0.02), location of arterial anastomosis (aorta [n = 21] 4.9 ± 6.1, common iliac [n = 93] 7.1 ± 7.3, external iliac 14.7 ± 14.5; P < 0.001, Figure 1B) and venous anastomosis (vena cava [n = 21] 5.6 ± 6.3, common iliac [n = 89] 7.1 ± 7.6, external iliac [n = 44] 13.8 ± 14); P < 0.001). On multivariable analysis, this association remained statistically significant when adjusting for recipient age, height, BSA, donor source, change in blood pressure with unclamping, and use of inotropes and preoperative dialysis. The detrimental effect on ttNC was more salient when comparing external iliac vs common iliac and aorta or vena cava.

Conclusion: Our data suggest that anastomosis to a smaller caliber target vessel (ie, external iliac) in comparison with the common iliac or aorta/vena cava may be a risk factor for delayed return of graft function, independent of recipient size and donor source. This finding merit further evaluation, as it may help with intraoperative decision making during pediatric and adolescent RT.
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http://dx.doi.org/10.1111/petr.13398DOI Listing
June 2019

Prevalence, Doppler Ultrasound Findings, and Clinical Implications of the Nutcracker Phenomenon in Pediatric Varicoceles.

Urology 2019 Jun 16;128:78-83. Epub 2019 Mar 16.

Division of Urology, Department of Surgery, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada. Electronic address:

Objective: To examine the implications of varicoceles and nutcracker phenomenon (NcP) in a large cohort of adolescent patients. Varicoceles are common in adolescent males, generating concerns regarding etiology and management. At our institution, Doppler ultrasound (US) of the renal vessels is routinely obtained with the goal of assessing for an associated nutcracker phenomenon.

Methods: Between 1/2000 and 3/2017, 182 patients with clinical varicoceles were evaluated with US. Retrospective assessment provided complete data in 137, including maximum varicose vein diameter, testicular measurements, left renal vein velocities at the hilum and impingement point by the superior mesenteric artery, and procedural interventions.

Results: NcP was detected in 77 patients (56.2%), who experienced higher venous velocity ratios (8.33 vs 2.87; P < 0.001) than those without. Overall, 39 patients (28.5%) had a testicular volume discrepancy >20%, without a significant difference based on the presence or absence of NcP (27.3 vs 30.0%, respectively; P = 0.36). Both groups had similar ages at diagnosis, bilateral volume parameters, volume difference, maximum varicose vein sizes, and follow-up duration (P ≥ 0.05 for all). Intervention was more likely in patients with volume difference >20% (P = 0.014). Having NcP was not associated with a higher incidence of initial (P = 0.59) or reoperative surgery (P = 0.73).

Conclusion: NcP is common in adolescent patients with a varicocele, but it is not associated with differences in testicular parameters or an increased frequency of initial or reoperative surgery. As such, NcP may have few clinical ramifications as an isolated finding in this patient population, calling into question routine assessment for its presence.
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http://dx.doi.org/10.1016/j.urology.2019.03.001DOI Listing
June 2019

A comparison of post-transplant renal function in pre-emptive and post-dialysis pediatric kidney transplant recipients.

Pediatr Transplant 2019 05 8;23(3):e13377. Epub 2019 Feb 8.

Division of Urology, The Hospital for Sick Children, Toronto, Ontario, Canada.

Purpose: Little is known regarding post-transplant renal function following pediatric pre-emptive KT. Therefore, this study aims to determine whether there is a difference in 1 year post-transplant renal function outcomes between pre-emptive and post-dialysis KT in pediatric transplant recipients.

Methods: A retrospective review of patients who underwent kidney transplant at our institution between 2000 and 2015 was performed. Kidney transplant recipients were divided into four groups: pre-DD, post-DD, pre-LD, and post-LD. The clinical outcomes, measured in eGFR (mL/min/1.73 m ), acute rejection episodes within 1 year, and hospitalization within 1 year were compared to between groups in their respective donor types (pre-DD vs post-DD; pre-LD vs post-LD).

Results: The 324 patients were identified (21 pre-DD, 151 post-DD, 54 pre-LD, and 98 post-LD). Post-DD group had more females (P = 0.018) and post-operative complications (P = 0.023), although there was no difference in complications requiring intervention (P = 0.129). Post-LD patients were more likely to be females (P = 0.017) and those with intrinsic renal (non-urological/structural) ESRD etiology (P = 0.003). The 1-year eGFR was similar between pre-DD and post-DD groups (70.3 [IQR 53.5-88.5] vs 74.3 [IQR 62.3-90.5], P = 0.613), as well as pre-LD and post-LD groups (66.6 [IQR 47.8-73.7] vs 63.9 [IQR 55.0-77.1], P = 0.600). There were no significant differences in rates of acute rejection episodes or hospitalization within 1 year of transplantation for in LD/DD groups.

Conclusion: There is no significant difference in renal function at 1 year post-transplant in pediatric patients receiving pre-emptive or post-dialysis kidney transplants.
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http://dx.doi.org/10.1111/petr.13377DOI Listing
May 2019