Initially thought to be a primarily respiratory disease process, the hypercoagulable state associated with COVID-19 has been associated with myriad clinical sequelae. We report a case of stuttering ischemic priapism associated with COVID-19, and describe a management approach to achieve detumescence in patients undergoing ventilatory proning limiting penile access. Level of evidence: Not applicable for this single center case report.

BACKGROUND Hospital and provider surgical volume have been increasingly linked to surgical outcomes. However, this topic has rarely been addressed in children. Our objective was to investigate whether hospital surgical volume impacts complication rates in pediatric urology. METHODS We retrospectively reviewed the Nationwide Inpatient Sample (1998–2011) for pediatric (≤ 18 years) admissions for urologic procedures. We used ICD-9-CM codes to identify elective urologic interventions and National Surgical Quality Improvement Program (NSQIP) inhospital post-operative complications. Annual hospital surgical volume was calculated and dichotomized as high-volume (>90th percentile) or non-high-volume hospitals (<90th percentile). RESULTS In total, we identified 158,804 urologic admissions (114,634 high-volume hospital admissions and 44,171 non-high-volume hospital admissions). 75% of hospitals performed fewer than 5 major pediatric urology cases per year. High-volume hospitals treated significantly younger patients (mean 5.4 vs 9.6 years, p<0.001), and were more likely to be teaching hospitals (93% vs 71%, p<0.001). The overall rate of NSQIP-identified postoperative complications was higher at non-high-volume hospitals (11.6%) than at high-volume hospitals (9.3%, p=0.003). After adjusting for confounding effects, patients treated at non-high-volume hospitals remained more likely to suffer multiple NSQIP-tracked postoperative complications: acute renal failure (OR 1.4, p=0.04), UTI (OR 1.3, p=0.01), post-op respiratory complications (OR 1.5, p=0.01), systemic sepsis (OR 2.0, p=<0.001), post-op bleeding (OR 2.5, p<0.001), and in-hospital death (OR=2.2, p=0.007). CONCLUSIONS Urologic procedures performed on children at non-high-volume hospitals were associated with an elevated risk of in-hospital, NSQIP-identified postoperative complications, including a small but significant increase in postoperative mortality mostly in nephrectomy and percutaneous nephrolithotomy.

Purpose: Shock wave lithotripsy has been commonly used to treat children with renal and ureteral calculi but recently ureteroscopy has been used more frequently. We examined postoperative outcomes from these 2 modalities in children. Materials and Methods: We reviewed linked inpatient, ambulatory surgery and emergency department data from 2007 to 2010 for 5 states to identify pediatric admissions for renal/ureteral calculi treated with shock wave lithotripsy or ureteroscopy. Unplanned readmissions, additional procedures and emergency room visits were extracted. Multivariate logistic regression using generalized estimating equations to adjust for hospital level clustering was performed. Results: We identified 2,281 admissions (1,087 for shock wave lithotripsy and 1,194 for ureteroscopy). Ages of patients undergoing ureteroscopy and those undergoing shock wave lithotripsy were similar (median 17.0 years for both cohorts, p = 0.001) but patients were more likely to be female (63.4% vs 54.7%, p <0.0001), to be privately insured (69.8% vs 62.2%, p <0.0005) and to have a ureteral stone (81.0% vs 34.8%, p <0.0001). Patients undergoing ureteroscopy demonstrated a lower rate of additional stone related procedures within 12 months (13.6% vs 18.8%, p <0.0007) but a higher rate of readmissions (10.8% vs 6.3%, p <0.0002) and emergency room visits (7.9% vs 4.9%, p <0.0036) within 30 days postoperatively. On multivariable analysis patients undergoing ureteroscopy were nearly twice as likely to visit an emergency room within 30 days of the procedure (OR 1.97, p <0.001) and to be readmitted to inpatient services (OR 1.71, p <0.01). Conclusions: Ureteroscopy is now used more commonly than shock wave lithotripsy for initial pediatric stone intervention. Although repeat treatment rates did not differ between procedures, ureteroscopy patients were more likely to be seen at an emergency room or hospitalized within 30 days of the initial procedure.

Summary Introduction Open ureteroneocystostomy (UNC) is the gold standard for surgical correction of vesicoureteral reflux (VUR). Beyond single-center reports, there are few published data on outcomes of minimally invasive (MIS) UNC. Our objective was to compare postoperative outcomes of open and MIS UNC using national, population-level data. Method We reviewed the 1998–2012 Nationwide Inpatient Sample to identify pediatric (≤18 years) VUR patients who underwent either open or MIS UNC. Demographics, National Surgical Quality Improvement Program (NSQIP) complications, length of stay (LOS), and cost data were extracted. Statistical analysis was performed using weighted, hierarchical multivariate logistic regression (complications) and negative binomial regression (LOS, cost). Results We identified 780 MIS and 75,976 open UNC admissions. Compared with patients undergoing open UNC, patients who underwent MIS UNC were likely to be older (6.2 versus 4.8 years, p<0.001), publically insured (43 versus 26%, p<0.001), and treated in recent years (90 versus 46% after 2005, p<0.001). MIS admissions were associated with a significantly shorter length of stay (1.0 versus 1.8 days, p<0.001) and higher cost ($9,230 versus $6,304, p=0.002). After adjusting for patient-level confounders (age, gender, insurance, treatment year, and comorbidity), and hospital-level factors (region, bedsize, and teaching status), MIS UNC was associated with a significantly higher rate of postoperative urinary complications such as UTIs, urinary retention, and renal injury (OR 3.1, p=0.02), shorter LOS (RR 0.8, p=0.02), and higher cost (RR 1.4, p=0.008). Discussion Strengths of this study are its large cohort size, long time horizon, national estimation, and cost data. Most prior studies are case-series limited to the size of the institutional cohort. Our analysis of 76,756 operative encounters revealed that open UNC continues to be performed at far greater frequency than MIS UNC, outpacing the latter modality by nearly 100:1. Children treated with MIS UNC had three times greater odds of developing postoperative urinary complications, and MIS UNC patients incurred average costs per admission that were nearly 1.5 times higher than those of children who underwent open UNC. These children were also likely to be older, publically insured, and treated in more recent years. On the other hand, patients treated with MIS UNC required substantially shorter postoperative hospitalization, with an average LOS roughly half that of open UNC cases. Limitations include the retrospective nature of the administrative database, lack of detailed patient-level data, and no available long-term postoperative outcomes. Compared with open surgery, MIS UNC was associated with shorter LOS but higher costs and possibly higher urinary complication rates.

Summary Introduction Increased case volumes and training are associated with better surgical outcomes. However, the impact of pediatric urology sub-specialization on perioperative complication rates is unknown. Objectives To determine the presence and magnitude of difference in rates of common postoperative complications for elective pediatric urology procedures between specialization levels of urologic surgeons. The Nationwide Inpatient Sample (NIS), a nationally representative administrative database, was used. Study Design The NIS (1998–2009) was retrospectively reviewed for pediatric (≤18 years) admissions, using ICD-9-CM codes to identify urologic surgeries and National Surgical Quality Improvement Program (NSQIP) inpatient postoperative complications. Degree of pediatric sub-specialization was calculated using a Pediatric Proportion Index (PPI), defined as the ratio of children to total patients operated on by each provider. The providers were grouped into PPI quartiles: Q1, 0–25% specialization; Q2, 25–50%; Q3, 50–75%; Q4, 75–100%. Weighted multivariate analysis was performed to test for associations between PPI and surgical complications. Results A total of 71,479 weighted inpatient admissions were identified. Patient age decreased with increasing specialization: Q1, 7.9 vs Q2, 4.8 vs Q3, 4.8 vs Q4, 4.6 years, P<0.01). Specialization was not associated with race (P>0.20), gender (P>0.50), or comorbidity scores (P=0.10). Mortality (1.5% vs 0.2% vs 0.3% vs 0.4%, P<0.01) and complication rates (15.5% vs 11.7% vs 9.6% vs 10.9%, P<0.0001) both decreased with increasing specialization. Patients treated by more highly specialized surgeons incurred slightly higher costs (Q2, +4%; Q3, +1%; Q4 + 2%) but experienced shorter length of hospital stay (Q2, –5%; Q3, –10%; Q4, –3%) compared with the least specialized providers. A greater proportion of patients treated by Q1 and Q3 specialized urologists had CCS ≥2 than those seen by Q2 or Q4 urologists (12.5% and 12.2%, respectively vs 8.4% and 10.9%, respectively, P=0.04). Adjusting for confounding effects, increased pediatric specialization was associated with decreased postoperative complications: Q2 OR 0.78, CI 0.58–1.05; Q3 OR 0.60, CI 0.44–0.84; Q4 OR 0.70, CI 0.58–0.84; P<0.01. Discussion Providers with proportionally higher volumes of pediatric patients achieved better postoperative outcomes than their less sub-specialized counterparts. This may have arisen from increased exposure to pediatric anatomy and physiology, and greater familiarity with pediatric techniques. Limitation The NIS admission-based retrospective design did not enable assessment of long-term outcomes, repeated admissions, or to track a particular patient across time. The study was similarly limited in evaluating the effect of pre-surgical referral patterns on patient distributions. Conclusions Increased pediatric sub-specialization among urologists was associated with a decreased risk of mortality and surgical complications in children undergoing inpatient urologic procedures.