Catherine Devries - Academia.edu (original) (raw)

Papers by Catherine Devries

The Journal of Urology, 2003

Recent advances in laparoscopic surgery as well as increasing experience with these techniques ha... more Recent advances in laparoscopic surgery as well as increasing experience with these techniques have led to the selection of laparoscopic surgery for many urological procedures. A lesser number of pediatric laparoscopic surgical studies have been reported. Few pediatric comparative laparoscopic versus open surgical procedure studies have been published. We compared 2 groups of similar pediatric patients who underwent partial nephrectomy via the laparoscopic or open technique. A total of 22 consecutive partial nephrectomies were performed in pediatric patients 3 months to 15 years old. Of these procedures 11 chosen according to surgeon preference were performed laparoscopically and 11 were done by the open technique. Clinical data were obtained by chart review and compared retrospectively in the 2 groups. Demographic data, operative time and blood loss, the perioperative complication rate, hospital stay and costs, postoperative analgesic use and followup findings were compared. Mean operative time in the laparoscopic and open groups was 200.4 and 113.5 minutes, respectively (p <0.0005). Blood loss was less than 50 cc in all patients. In the laparoscopic and open groups mean hospital stay was 25.5 and 32.6 hours (p = 0.068), and mean cost was 6,125and6,125 and 6,125and4,244 (p = 0.016), respectively. Patients in the laparoscopic group required fewer doses of analgesics than those who underwent open surgery (mean 10.9 versus 21, p = 0.041). Our findings show that increased operative time and costs are disadvantages of pediatric laparoscopic nephrectomy compared with open techniques. Conversely decreased hospital stay, lower analgesic requirements and cosmesis support the use of laparoscopy for pediatric partial nephrectomy. These differences must be considered when deciding which technique is best for overall patient care.

International Public Health curricula typically do not include detailed analysis of the surgical ... more International Public Health curricula typically do not include detailed analysis of the surgical components of healthcare. Yet the surgical ecosystem deserves its own study because of specific needs for infrastructure, personnel, supply chain and outcomes measures. A complete consideration of traditional topics such as infectious disease, injuries, chronic disease and reproductive health would include the surgical components of these and their link to the surgical ecosystem. In most texts and curricula, surgery and surgical issues are not addressed except in as incidental to other primary themes. The infrastructure and manpower required for surgical care should be considered in its own right because of the complexity of the system and the commonality of these requirements for many types of care. Infrastructure for trauma, for example, is similar to, but currently programmatically uncoupled from that of emergency maternal care and caesarian section in many public health initiatives. ...

Background: Surgery is an irreplaceable health intervention that can be thought of as an ecosyste... more Background: Surgery is an irreplaceable health intervention that can be thought of as an ecosystem, with distinct infrastructure, personnel, and supply chain needs. Challenges inherent to providing surgical care include the need for skilled professionals and specialized sterilization equipment and processes. Surgical centers in the developed world possess a wealth of knowledge that can benefit those seeking to establish or improve surgical care in the developing world, though the cost of sophisticated systems can be prohibitive in low resource settings. Methods: Interviews were conducted with key surgical services personnel at 7 hospitals in Salt Lake City, Utah. Participants were asked to discuss their professional roles, the daily tasks associated with their roles, and perspectives of how their roles fit into the overall system of surgical services as well as the wider context of health care. Participants included surgeons, anesthesiologists, nurses, clinical engineers, administra...

The Lancet, 2015

The benefits of laparoscopic cholecystectomy have been largely unavailable to most people in deve... more The benefits of laparoscopic cholecystectomy have been largely unavailable to most people in developing countries. Mongolia has an extremely high incidence of gallbladder disease. In 2005, only 2% of cholecystectomies were being done laparoscopically. Open cholecystectomies were associated with high rates of wound infections, complications, and increased recovery time. Because of the unacceptable complications associated with open cholecystectomies, and nearly 50% of the nomadic population needing faster post-operative recovery times, a national project for the development of laparoscopic surgery was organised. Multi-institutional collaboration between the Mongolia Health Sciences University, the Dr W C Swanson Family Foundation (SFF), the University of Utah, Intermountain Healthcare, and the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) led to the promulgation of a formalised countrywide laparoscopic training programme during the past 9 years. This is a retrospective review of the transition from open to laparoscopic cholecystectomy throughout Mongolia. Demographic patient data, diagnosis, and operation preformed-laparoscopic versus open cholecystectomy, between January, 2005, and September, 2013, were collected and trends were analysed from seven regional diagnostic referral and treatment centres, and two tertiary academic medical centres from six of the 21 provinces (Aimags) throughout Mongolia. Data were analysed by individual training centre, by year, and then compared between rural and urban centres. Nearly 16 000 cholecystectomies were analysed and compared (4417 [28·2%] men; 11 244 [71·8%] women). Men and women underwent laparoscopic cholecystectomy with the same frequency (41·2% men, 43·2% women) and had similar age (men, mean 52·2 years [SD 14·8]; women, mean 49·4 years [SD 15·7]). By 2013, 62% of gallbladders were removed laparoscopically countrywide as opposed to only 2% in 2005. More than 315 Mongolian practitioners have received laparoscopic training in 19 of 21 Aimags. On average 60% of cholecystectomies are done laparoscopically in urban surgical centres, up from 2%, versus 55% in rural surgical centres, up from 0%, in 2005. Laparoscopic cholecystectomy surpassed open cholecystectomy as the primary method for gallbladder removal countrywide in 2011. By 2013, 62% of cholecystectomies countrywide were done laparoscopically, a great increase from 9 years ago. Despite being a resource limited country, the expansion of laparoscopic cholecystectomy has transformed the care of biliary tract disease in Mongolia. The University of Utah Center for Global Surgery.

Annals of Global Health, 2014

Low- and middle-income countries (LMICs) face both training and infrastructural challenges for su... more Low- and middle-income countries (LMICs) face both training and infrastructural challenges for surgical care, particularly for specialty care, such as for urology. Practitioners charged with caring for these patients have few options for basic or advanced training. IVUmed, a nonprofit organization, has for 20 years supported urological educational programs in 30 LMICs by coordinating a network of US and international academic and private providers, institutions, industry partners, and professional societies. IVUmed's motto, "Teach One, Reach Many" has emphasized a teach-the-teacher approach. Program partners, such as Hopital General de Grand Yoff in Dakar, Senegal, have advanced from little urological subspecialty availability to having the capacity to treat a wide range of conditions while also teaching surgeons from Senegal and neighboring countries. Long-term program commitments; effective communication; and a shared vision among the program site, the coordinating nongovernmental organization, and supporting organizations facilitate the development of thriving surgical teaching programs capable of serving local communities and conducting outreach training.

Urology, 1997

Ataxia-telangiectasia (A-T) is a rare autosomal recessive disease notable for neurodegeneration, ... more Ataxia-telangiectasia (A-T) is a rare autosomal recessive disease notable for neurodegeneration, chromosomal instability, and a predisposition to cancer. It presents in childhood with a variable phenotype. We report the first case of an A-T related tumor presenting as urinary incontinence, and the first case of 2-year survival in an A-T patient with metastatic dysgerminoma.

The Prostate, 1992

The histologic features of prostatic duct-acinar dysplasia have been difficult to analyze ~Itrast... more The histologic features of prostatic duct-acinar dysplasia have been difficult to analyze ~Itrastructurally , because of the difficulty in properly selecting and processing such small, randomly situated grossly invisible lesions. We have succeeded in identifying dysplastic foci by examination of the cut surfaces of tissue slices under low magnification. Dsyplasia foci were excised from the slices and were compared to adjacent normal tissue by both light and electron microscopy. By electron microscopy (EM), normal secretory cells were filled with myriad tiny clear vacuoles, which were markedly diminished to absent in the cytoplasm of dysplastic cells. Both apocrine and eccrine secretion characterized normal epithelium and were diminished in dysplasia. EM showed striking features of nuclear abnormality more prominently than light microscopy, and qualitative basement membrane abnormalities were revealed. By EM analysis, dysplastic epithelium resembled that of invasive carcinoma more than normal epithelial cells. o 1992 Wiley-Liss, Inc.

The Journal of Urology, 2010

Purpose: Unilateral extravesical ureteral reimplantation is comparable to intravesical procedures... more Purpose: Unilateral extravesical ureteral reimplantation is comparable to intravesical procedures and more effective than subureteral injection to resolve vesicoureteral reflux. Initial reports showed that the procedure could be feasibly done on an outpatient basis. We present further data on a large series of consecutive, planned, outpatient unilateral extravesical ureteral reimplantations. Materials and Methods: A total of 250 consecutive patients underwent scheduled outpatient unilateral extravesical ureteral reimplantation. We retrospectively reviewed their records. Patient data were collected on reflux laterality and grade, operative time, hospital stay, complications, need for rehospitalization and resolution rate on radiography 1 month postoperatively. Results: A total of 209 females (84%) and 41 males (16%) underwent planned outpatient extravesical ureteral reimplantation, including on the left side in 158 (63%) and on the right side in 92 (37%). Mean reflux grade was 3.2 with grades II to V in 64 (26%), 96 (38%), 74 (30%) and 16 cases (7%), respectively. Average operative time was 63 minutes and average length of stay, defined as time from initial admission in to discharge home, was 6.2 hours (range 3 to 10 hours). Short-term and late complications occurred in 9 (3.6%) and 8 patients (3.2%), respectively. Conclusions: Extravesical ureteral reimplantation for unilateral vesicoureteral reflux may be consistently done on an outpatient basis with a reasonable complication rate and a low postoperative hospital admission rate.

The Journal of Urology, 2005

Unilateral extravesical ureteral reimplantation is comparable to intravesical procedures for reso... more Unilateral extravesical ureteral reimplantation is comparable to intravesical procedures for resolution of primary vesicoureteral reflux (VUR). Defining whether this operation can be consistently performed on an outpatient basis is important. A total of 80 patients with unilateral VUR were treated with extravesical ureteral reimplantation, of whom 20 were treated on an inpatient basis and 60 on an outpatient basis. We retrospectively reviewed these groups and conducted a telephone survey to evaluate overall patient satisfaction, and pain and nausea on postoperative days 1 and 14. There were no significant differences in age, gender, laterality or operative time between the groups. Average length of hospital stay was 31.25 hours (range 20 to 120) for the inpatient group and 6.6 hours (3.25 to 11.20) for the outpatient group. Average intravenous narcotic use in the inpatient group was 0.39 mg/kg, compared to 0.14 mg/kg for the outpatient group (p < 0.005), and included 1.76 mg/kg ketorolac in inpatients and 0.74 ketorolac in outpatients (p < 0.005), and 0.2 mg/kg ondansetron in inpatients and 0.12 mg/kg ondansetron in outpatients (p = 0.004). Four of the 60 outpatients (6.7%) were either hospitalized postoperatively or rehospitalized on postoperative day 1. The results of the survey for the 2 groups were not significantly different. Extravesical ureteral reimplantation for unilateral VUR may be performed without compromise in quality on an outpatient basis with significantly less use of intravenous analgesics and anti-emetics.

The Journal of Urology, 2004

We assess the incidence of electrolyte and creatinine changes following unstented bilateral urete... more We assess the incidence of electrolyte and creatinine changes following unstented bilateral ureteral reimplantation and attempt to identify associated risk factors. A total of 107 consecutive children with bilateral vesicoureteral reflux underwent bilateral unstented ureteral reimplantation. Study exclusion criteria were plication or tapering of any ureter, age less than 1 year and/or baseline serum creatinine greater than twice normal for age. Postoperatively serum electrolytes and creatinine were assessed by venous puncture until values normalized. The presence of nausea, vomiting, urinary retention and oliguria were recorded. Of the patients 46 females and 10 males 1.0 to 10.9 years old met the study criteria and had complete data available. Four patients (7.1%) had postoperative potassium greater than or equal to 5.0 mmol/l (range 5.0 to 5.3), including 3 (75%, p = 0.0238) who received potassium supplemented intravenous fluid postoperatively. Eight (14.3%) patients had postoperative creatinine greater than 1 mg/dl (range 1.3 to 2.3) and concurrent hyperkalemia with increased creatinine occurred in 2 (25%, p = 0.0295). Nausea and vomiting beyond postoperative day 1 were noted in 6 patients (75%, p = 0.0122). Neither oliguria nor urinary retention reached statistical significance in correlation with increased potassium and/or creatinine. However, urine retention approached statistical significance in patients with increased creatinine (p = 0.0747). No adverse effects from hyperkalemia were noted. Adverse effects from hyperkalemia following unstented bilateral ureteral reimplantation are uncommon. Potassium containing intravenous fluids should be avoided in the early postoperative period. Routine serum electrolyte determination may be helpful in patients undergoing unstented bilateral ureteral reimplantation when persistent nausea, emesis or urinary retention is present.

The Journal of Urology, 2002

We evaluate variables affecting the success of repairs of urethrocutaneous fistula after hypospad... more We evaluate variables affecting the success of repairs of urethrocutaneous fistula after hypospadias surgery. The records of 123 boys who underwent fistula repair at Primary Children's Medical Center were reviewed. Of these patients 100 underwent initial fistula repair at our center (surgery was performed at our center in 82 and elsewhere in 18) and 23 were referred from elsewhere after unsuccessful fistula repairs. Patient age was 6 months to 34 years (median 3.21 years) and interval between surgeries was 3.7 months to 12 years (median 12.6 months). Several variables potentially affecting the success of fistula closure were retrospectively assessed. Including those patients referred from outside hospitals, fistulas were successfully closed in 71%, 72%, 77%, 100% and 100% of these patients after fistula repairs 1 to 5, respectively. Variables studied yielded stent 67.7% (36 of 54 cases) versus no stent 76.1% (35 of 46) and operating microscope 70.4% (59 of 71) versus loupes 72.4% (21 of 29) in terms of success. Success based on patient age yielded 65.5% for younger than 2 years (n = 29 patients), 71.7% for 2 to 5 (46), 64.7% for 6 to 12 (17) and 87.5% for older than 12 (8). When considering the type of original hypospadias repair and its affect on fistula closure success, a significantly lower success was noted with Yoke and King procedures (p = 0.007 and 0.037, respectively). In patients who underwent hypospadias surgery and all subsequent fistula closure attempts at our center, fistulas were successfully repaired in 72%, 67% and 100% of patients after attempts 1 to 3, respectively. Initial fistula repair was successful in 72% (59 of 82) of patients who underwent original hypospadias surgery at our center and in 67% (12 of 18) of those referred after hypospadias surgery at an outside hospital. Regarding urethrocutaneous fistula closure, the data from this study suggest that there is no clear difference in stent versus no stent and microscope versus loupes, age at fistula closure does not affect success, type of original hypospadias procedure may influence success (King and Yoke procedures were least successful), success rate is not negatively impacted in recurrent fistula cases, given a diverse group of fistulas, success of fistula repair for attempts 1 to 5 was 71%, 72%, 77%, 100% and 100%, respectively, and success rate in a tertiary pediatric urology setting is not influenced by whether the original hypospadias procedure or initial fistula closure was performed in the pediatric urology setting versus outside hospital.

The Journal of Urology, 2014

This study was designed to assess perceptions of untreated hypospadias and quality of life in cul... more This study was designed to assess perceptions of untreated hypospadias and quality of life in culturally disparate low or middle income countries, to highlight the demographic and care differences of patient groups treated for hypospadias in the surgical workshop context, and to evaluate the long-term outcomes achieved by these workshop groups. Family member perceptions of hypospadias, perioperative process measures and urethrocutaneous fistula rates were compared between 60 patients from Vietnam and Senegal treated for hypospadias through training workshops by local surgeons and pediatric urologists from the U.S. between 2009 and 2012, of whom approximately 42% had previously undergone repair attempts. More than 90% of respondents surveyed believed that untreated hypospadias would affect the future of their child at least to some degree. Patient cohorts between the 2 sites differed from each other and published high income country cohorts regarding age, weight for age and frequency of reoperation. Telephone based outcomes assessment achieved an 80% response rate. Urethrocutaneous fistula was reported in 39% and 47% of patients in Vietnam and Senegal, respectively. Family members perceived that the social consequences of untreated hypospadias would be severe. Relative to patient cohorts reported in practices of high income countries, our patients were older, presented with more severe defects, required more reoperations and were often undernourished. Urethrocutaneous fistula rates were higher in cohorts from low or middle income countries relative to published rates for cohorts from high income countries. Our study suggests that outcomes measurement is a feasible and essential component of ethical international health care delivery and improvement.

The Journal of Urology, 2014

We describe patient characteristics and age distribution of epididymitis in an outpatient pediatr... more We describe patient characteristics and age distribution of epididymitis in an outpatient pediatric urology referral practice during a 21-year period. We retrospectively reviewed all pediatric patients diagnosed with epididymitis or epididymo-orchitis (ICD9 604.9) either clinically or with the aid of scrotal ultrasound at Primary Children's Medical Center from 1992 through 2012. Charts were reviewed to record demographic and clinical features, as well as radiological and laboratory data. Multiple acute episodes occurring in individual patients were recorded. A total of 252 patients were identified. Mean ± SD age at first presentation was 10.92 ± 4.08 years. The majority of cases occurred during the pubertal period (11 to 14 years) and few patients younger than 2 years were diagnosed with epididymitis (4%). A total of 69 boys (27.4%) experienced a second episode of epididymitis. Scrotal ultrasound results were consistent with epididymitis in 87.3% of cases (144 of 165). Urine culture results were available in 38 patients and were positive in 7 (21%). Positive urine culture was associated with an anatomical abnormality on followup voiding cystourethrogram (RR 5.7, 95% CI 1.37-23.4). Physical activity was noted as a likely precipitating factor in 23 patients and a recent urinary tract infection was identified in 20. The majority of cases of epididymitis occur around the time of puberty in early adolescence, with relatively few cases occurring during infancy. Recurrent episodes of epididymitis are more common than previously reported and may affect as many as a fourth of all boys with acute epididymitis.

The Journal of Urology, 2008

Extravesical ureteral reimplantation and subureteral Deflux injection are used to correct vesicou... more Extravesical ureteral reimplantation and subureteral Deflux injection are used to correct vesicoureteral reflux with success rates of 94% to 99% and up to 89%, respectively. It was reported that unilateral extravesical reimplantation may be performed safely in an outpatient setting. Given that, we analyzed total system reimbursement to compare planned outpatient unilateral extravesical reimplantation to subureteral Deflux injection in patients with unilateral vesicoureteral reflux. Data were collected on consecutive patients undergoing outpatient procedures for unilateral vesicoureteral reflux. Assessment of total system reimbursement was made using a payer mix adjusted calculation of surgery plus anesthesia plus hospital reimbursement. This was compared per procedure and in terms of total system reimbursement for each approach to obtain a similar resolution rate. A total of 209 consecutive patients were identified, of whom 26 underwent subureteral Deflux injection and 183 underwent unilateral extravesical reimplantation. Mean operative time was 93 minutes for reimplantation and 45 minutes for injection. The mean volume of dextranomer-hyaluronic acid was 1.2 ml. Total initial system reimbursement per patient was 3,813forreimplantationand3,813 for reimplantation and 3,813forreimplantationand4,259 for injection. A 3% hospital admission rate for reimplantation increased the total to $3,945. Higher reimbursement for injection depended largely on the material expense for dextranomer-hyaluronic acid. In terms of total system reimbursement it is less expensive in our system to treat unilateral vesicoureteral reflux with unilateral extravesical reimplantation than with subureteral Deflux injection using dextranomer-hyaluronic acid. The ability to perform unilateral reimplantation as an outpatient procedure has shifted this relationship.

The Journal of Urology, 2011

Parameatal urethral cyst in boys is an uncommon and often poorly understood condition. We describ... more Parameatal urethral cyst in boys is an uncommon and often poorly understood condition. We describe the largest known series of 18 prepubertal boys with parameatal cysts. We retrospectively reviewed the charts of all pediatric patients at our institution diagnosed with a penile cyst according to our office database between 1992 and 2010. Charts were reviewed to determine patient demographics, symptomatology, pathology, cyst characteristics and treatment. We identified 18 patients during the last 18 years who were diagnosed with a parameatal cyst. Most patients (66%) were asymptomatic. All cysts were less than 1 cm in diameter. Of the patients 50% were circumcised before presentation and 78% underwent surgical excision. There have been no recurrences in patients who underwent excision. One patient had spontaneous resolution of the cyst during the first few weeks of life. Pathology results were available for 6 patients. Three specimens contained a single type of epithelium and 3 contained a combination of transitional, cuboidal and/or columnar epithelia. The transitional and cuboidal epithelia were the most common components. There was no evidence of malignancy in any of the specimens and only 1 specimen contained an inflammatory infiltrate. Parameatal cysts are a benign, usually asymptomatic condition that may contain a variety of epithelial types. The cysts may resolve spontaneously in neonates but are also easily excised with minimal risk of recurrence.

International Journal of Urology, 2006

The presentation, and medical and surgical management of all new onset non-congenital hydroceles ... more The presentation, and medical and surgical management of all new onset non-congenital hydroceles in boys older than 1 year of age were examined. Of particular interest was the outcome of those patients who presented with a non-communicating hydrocele that developed after the first year of life and was managed conservatively. Methods: All patients older than 12 months of age who were evaluated as outpatients with the diagnosis of hydrocele from January 1994 to January 2001 were identified. Possible risk factors and predisposing conditions were determined. For the patients who had surgical correction, surgical indications were identified. For non-surgical patients, long-term outcomes were recorded. Results: A total of 302 patients older than 12 months of age with the diagnosis of new onset hydrocele were identified. Of these, 35% were non-communicating, 59% were communicating, and 6% were hydroceles of the spermatic cord. In terms of surgery, 97% of communicating hydroceles, 71% of hydroceles of the spermatic cord, and 34% of non-communicating hydroceles had operative management. Seventy patients with non-communicating hydroceles did not receive surgery and 51 (73%) were contacted for long term follow-up. In these 51 patients, 76% of non-communicating hydroceles resolved completely, 6% decreased in size but were still present, 14% remained the same size, and 4% had an unknown status. The average time to resolution was 5.6 months with a median time of 3 months. The time range to resolution was from 1 day to 24 months. Follow-up averaged 73.7 months with a range of 33 to 120 months. Conclusions: Approximately 75% of new onset, non-congenital, non-communicating hydroceles resolve spontaneously irrespective of size. An observation period of 6-12 months would be appropriate prior to repair.

Journal of Pediatric Urology, 2010

Objective: To answer the question: 'Is there a learning curve associated with a subureteric injec... more Objective: To answer the question: 'Is there a learning curve associated with a subureteric injection of Deflux â ?' Materials and Methods: We retrospectively reviewed charts of patients who received subureteric injection of dextranomer/hyaluronic acid (Deflux â {AQ2}) (225 procedures) for treatment of vesicoureteral reflux (VUR) by four surgeons. The study included 55 patients, 82 ureters, who had postoperative follow-up with a voiding cystogram or nuclear medicine cystogram. Exclusion criteria were prior anti-refluxing procedures, duplicated collecting systems, and non-achievement of a negative intraoperative cystogram. Patients were divided into two groups based on whether or not they received an intraoperative cystogram after the injection. The two groups were compared for VUR resolution rates on follow-up imaging. Results: Twenty patients underwent an intraoperative cystogram (Group 1, 33 ureters) and 35 did not (Group 2, 49 ureters). The two groups were similar in age, preoperative reflux grade, amount of Deflux injected into each ureter, and time to postoperative studies. In Group 1, 11 ureters (33.3%) and also, in Group 2, 11 ureters (22.4%) had reflux on follow-up imaging. Conclusions: There was no improvement in VUR resolution rate following subureteric injection of Deflux â when an intraoperative cystogram demonstrated no reflux to be present immediately after injection. Of ureters that did not reflux on intraoperative cystograms, one-third displayed return of reflux on follow-up imaging, which suggests no learning curve and that failures are not likely to be caused by poor surgical technique.

The Journal of Urology, 2003

Recent advances in laparoscopic surgery as well as increasing experience with these techniques ha... more Recent advances in laparoscopic surgery as well as increasing experience with these techniques have led to the selection of laparoscopic surgery for many urological procedures. A lesser number of pediatric laparoscopic surgical studies have been reported. Few pediatric comparative laparoscopic versus open surgical procedure studies have been published. We compared 2 groups of similar pediatric patients who underwent partial nephrectomy via the laparoscopic or open technique. A total of 22 consecutive partial nephrectomies were performed in pediatric patients 3 months to 15 years old. Of these procedures 11 chosen according to surgeon preference were performed laparoscopically and 11 were done by the open technique. Clinical data were obtained by chart review and compared retrospectively in the 2 groups. Demographic data, operative time and blood loss, the perioperative complication rate, hospital stay and costs, postoperative analgesic use and followup findings were compared. Mean operative time in the laparoscopic and open groups was 200.4 and 113.5 minutes, respectively (p <0.0005). Blood loss was less than 50 cc in all patients. In the laparoscopic and open groups mean hospital stay was 25.5 and 32.6 hours (p = 0.068), and mean cost was 6,125and6,125 and 6,125and4,244 (p = 0.016), respectively. Patients in the laparoscopic group required fewer doses of analgesics than those who underwent open surgery (mean 10.9 versus 21, p = 0.041). Our findings show that increased operative time and costs are disadvantages of pediatric laparoscopic nephrectomy compared with open techniques. Conversely decreased hospital stay, lower analgesic requirements and cosmesis support the use of laparoscopy for pediatric partial nephrectomy. These differences must be considered when deciding which technique is best for overall patient care.

International Public Health curricula typically do not include detailed analysis of the surgical ... more International Public Health curricula typically do not include detailed analysis of the surgical components of healthcare. Yet the surgical ecosystem deserves its own study because of specific needs for infrastructure, personnel, supply chain and outcomes measures. A complete consideration of traditional topics such as infectious disease, injuries, chronic disease and reproductive health would include the surgical components of these and their link to the surgical ecosystem. In most texts and curricula, surgery and surgical issues are not addressed except in as incidental to other primary themes. The infrastructure and manpower required for surgical care should be considered in its own right because of the complexity of the system and the commonality of these requirements for many types of care. Infrastructure for trauma, for example, is similar to, but currently programmatically uncoupled from that of emergency maternal care and caesarian section in many public health initiatives. ...

Background: Surgery is an irreplaceable health intervention that can be thought of as an ecosyste... more Background: Surgery is an irreplaceable health intervention that can be thought of as an ecosystem, with distinct infrastructure, personnel, and supply chain needs. Challenges inherent to providing surgical care include the need for skilled professionals and specialized sterilization equipment and processes. Surgical centers in the developed world possess a wealth of knowledge that can benefit those seeking to establish or improve surgical care in the developing world, though the cost of sophisticated systems can be prohibitive in low resource settings. Methods: Interviews were conducted with key surgical services personnel at 7 hospitals in Salt Lake City, Utah. Participants were asked to discuss their professional roles, the daily tasks associated with their roles, and perspectives of how their roles fit into the overall system of surgical services as well as the wider context of health care. Participants included surgeons, anesthesiologists, nurses, clinical engineers, administra...

The Lancet, 2015

The benefits of laparoscopic cholecystectomy have been largely unavailable to most people in deve... more The benefits of laparoscopic cholecystectomy have been largely unavailable to most people in developing countries. Mongolia has an extremely high incidence of gallbladder disease. In 2005, only 2% of cholecystectomies were being done laparoscopically. Open cholecystectomies were associated with high rates of wound infections, complications, and increased recovery time. Because of the unacceptable complications associated with open cholecystectomies, and nearly 50% of the nomadic population needing faster post-operative recovery times, a national project for the development of laparoscopic surgery was organised. Multi-institutional collaboration between the Mongolia Health Sciences University, the Dr W C Swanson Family Foundation (SFF), the University of Utah, Intermountain Healthcare, and the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) led to the promulgation of a formalised countrywide laparoscopic training programme during the past 9 years. This is a retrospective review of the transition from open to laparoscopic cholecystectomy throughout Mongolia. Demographic patient data, diagnosis, and operation preformed-laparoscopic versus open cholecystectomy, between January, 2005, and September, 2013, were collected and trends were analysed from seven regional diagnostic referral and treatment centres, and two tertiary academic medical centres from six of the 21 provinces (Aimags) throughout Mongolia. Data were analysed by individual training centre, by year, and then compared between rural and urban centres. Nearly 16 000 cholecystectomies were analysed and compared (4417 [28·2%] men; 11 244 [71·8%] women). Men and women underwent laparoscopic cholecystectomy with the same frequency (41·2% men, 43·2% women) and had similar age (men, mean 52·2 years [SD 14·8]; women, mean 49·4 years [SD 15·7]). By 2013, 62% of gallbladders were removed laparoscopically countrywide as opposed to only 2% in 2005. More than 315 Mongolian practitioners have received laparoscopic training in 19 of 21 Aimags. On average 60% of cholecystectomies are done laparoscopically in urban surgical centres, up from 2%, versus 55% in rural surgical centres, up from 0%, in 2005. Laparoscopic cholecystectomy surpassed open cholecystectomy as the primary method for gallbladder removal countrywide in 2011. By 2013, 62% of cholecystectomies countrywide were done laparoscopically, a great increase from 9 years ago. Despite being a resource limited country, the expansion of laparoscopic cholecystectomy has transformed the care of biliary tract disease in Mongolia. The University of Utah Center for Global Surgery.

Annals of Global Health, 2014

Low- and middle-income countries (LMICs) face both training and infrastructural challenges for su... more Low- and middle-income countries (LMICs) face both training and infrastructural challenges for surgical care, particularly for specialty care, such as for urology. Practitioners charged with caring for these patients have few options for basic or advanced training. IVUmed, a nonprofit organization, has for 20 years supported urological educational programs in 30 LMICs by coordinating a network of US and international academic and private providers, institutions, industry partners, and professional societies. IVUmed's motto, "Teach One, Reach Many" has emphasized a teach-the-teacher approach. Program partners, such as Hopital General de Grand Yoff in Dakar, Senegal, have advanced from little urological subspecialty availability to having the capacity to treat a wide range of conditions while also teaching surgeons from Senegal and neighboring countries. Long-term program commitments; effective communication; and a shared vision among the program site, the coordinating nongovernmental organization, and supporting organizations facilitate the development of thriving surgical teaching programs capable of serving local communities and conducting outreach training.

Urology, 1997

Ataxia-telangiectasia (A-T) is a rare autosomal recessive disease notable for neurodegeneration, ... more Ataxia-telangiectasia (A-T) is a rare autosomal recessive disease notable for neurodegeneration, chromosomal instability, and a predisposition to cancer. It presents in childhood with a variable phenotype. We report the first case of an A-T related tumor presenting as urinary incontinence, and the first case of 2-year survival in an A-T patient with metastatic dysgerminoma.

The Prostate, 1992

The histologic features of prostatic duct-acinar dysplasia have been difficult to analyze ~Itrast... more The histologic features of prostatic duct-acinar dysplasia have been difficult to analyze ~Itrastructurally , because of the difficulty in properly selecting and processing such small, randomly situated grossly invisible lesions. We have succeeded in identifying dysplastic foci by examination of the cut surfaces of tissue slices under low magnification. Dsyplasia foci were excised from the slices and were compared to adjacent normal tissue by both light and electron microscopy. By electron microscopy (EM), normal secretory cells were filled with myriad tiny clear vacuoles, which were markedly diminished to absent in the cytoplasm of dysplastic cells. Both apocrine and eccrine secretion characterized normal epithelium and were diminished in dysplasia. EM showed striking features of nuclear abnormality more prominently than light microscopy, and qualitative basement membrane abnormalities were revealed. By EM analysis, dysplastic epithelium resembled that of invasive carcinoma more than normal epithelial cells. o 1992 Wiley-Liss, Inc.

The Journal of Urology, 2010

Purpose: Unilateral extravesical ureteral reimplantation is comparable to intravesical procedures... more Purpose: Unilateral extravesical ureteral reimplantation is comparable to intravesical procedures and more effective than subureteral injection to resolve vesicoureteral reflux. Initial reports showed that the procedure could be feasibly done on an outpatient basis. We present further data on a large series of consecutive, planned, outpatient unilateral extravesical ureteral reimplantations. Materials and Methods: A total of 250 consecutive patients underwent scheduled outpatient unilateral extravesical ureteral reimplantation. We retrospectively reviewed their records. Patient data were collected on reflux laterality and grade, operative time, hospital stay, complications, need for rehospitalization and resolution rate on radiography 1 month postoperatively. Results: A total of 209 females (84%) and 41 males (16%) underwent planned outpatient extravesical ureteral reimplantation, including on the left side in 158 (63%) and on the right side in 92 (37%). Mean reflux grade was 3.2 with grades II to V in 64 (26%), 96 (38%), 74 (30%) and 16 cases (7%), respectively. Average operative time was 63 minutes and average length of stay, defined as time from initial admission in to discharge home, was 6.2 hours (range 3 to 10 hours). Short-term and late complications occurred in 9 (3.6%) and 8 patients (3.2%), respectively. Conclusions: Extravesical ureteral reimplantation for unilateral vesicoureteral reflux may be consistently done on an outpatient basis with a reasonable complication rate and a low postoperative hospital admission rate.

The Journal of Urology, 2005

Unilateral extravesical ureteral reimplantation is comparable to intravesical procedures for reso... more Unilateral extravesical ureteral reimplantation is comparable to intravesical procedures for resolution of primary vesicoureteral reflux (VUR). Defining whether this operation can be consistently performed on an outpatient basis is important. A total of 80 patients with unilateral VUR were treated with extravesical ureteral reimplantation, of whom 20 were treated on an inpatient basis and 60 on an outpatient basis. We retrospectively reviewed these groups and conducted a telephone survey to evaluate overall patient satisfaction, and pain and nausea on postoperative days 1 and 14. There were no significant differences in age, gender, laterality or operative time between the groups. Average length of hospital stay was 31.25 hours (range 20 to 120) for the inpatient group and 6.6 hours (3.25 to 11.20) for the outpatient group. Average intravenous narcotic use in the inpatient group was 0.39 mg/kg, compared to 0.14 mg/kg for the outpatient group (p < 0.005), and included 1.76 mg/kg ketorolac in inpatients and 0.74 ketorolac in outpatients (p < 0.005), and 0.2 mg/kg ondansetron in inpatients and 0.12 mg/kg ondansetron in outpatients (p = 0.004). Four of the 60 outpatients (6.7%) were either hospitalized postoperatively or rehospitalized on postoperative day 1. The results of the survey for the 2 groups were not significantly different. Extravesical ureteral reimplantation for unilateral VUR may be performed without compromise in quality on an outpatient basis with significantly less use of intravenous analgesics and anti-emetics.

The Journal of Urology, 2004

We assess the incidence of electrolyte and creatinine changes following unstented bilateral urete... more We assess the incidence of electrolyte and creatinine changes following unstented bilateral ureteral reimplantation and attempt to identify associated risk factors. A total of 107 consecutive children with bilateral vesicoureteral reflux underwent bilateral unstented ureteral reimplantation. Study exclusion criteria were plication or tapering of any ureter, age less than 1 year and/or baseline serum creatinine greater than twice normal for age. Postoperatively serum electrolytes and creatinine were assessed by venous puncture until values normalized. The presence of nausea, vomiting, urinary retention and oliguria were recorded. Of the patients 46 females and 10 males 1.0 to 10.9 years old met the study criteria and had complete data available. Four patients (7.1%) had postoperative potassium greater than or equal to 5.0 mmol/l (range 5.0 to 5.3), including 3 (75%, p = 0.0238) who received potassium supplemented intravenous fluid postoperatively. Eight (14.3%) patients had postoperative creatinine greater than 1 mg/dl (range 1.3 to 2.3) and concurrent hyperkalemia with increased creatinine occurred in 2 (25%, p = 0.0295). Nausea and vomiting beyond postoperative day 1 were noted in 6 patients (75%, p = 0.0122). Neither oliguria nor urinary retention reached statistical significance in correlation with increased potassium and/or creatinine. However, urine retention approached statistical significance in patients with increased creatinine (p = 0.0747). No adverse effects from hyperkalemia were noted. Adverse effects from hyperkalemia following unstented bilateral ureteral reimplantation are uncommon. Potassium containing intravenous fluids should be avoided in the early postoperative period. Routine serum electrolyte determination may be helpful in patients undergoing unstented bilateral ureteral reimplantation when persistent nausea, emesis or urinary retention is present.

The Journal of Urology, 2002

We evaluate variables affecting the success of repairs of urethrocutaneous fistula after hypospad... more We evaluate variables affecting the success of repairs of urethrocutaneous fistula after hypospadias surgery. The records of 123 boys who underwent fistula repair at Primary Children's Medical Center were reviewed. Of these patients 100 underwent initial fistula repair at our center (surgery was performed at our center in 82 and elsewhere in 18) and 23 were referred from elsewhere after unsuccessful fistula repairs. Patient age was 6 months to 34 years (median 3.21 years) and interval between surgeries was 3.7 months to 12 years (median 12.6 months). Several variables potentially affecting the success of fistula closure were retrospectively assessed. Including those patients referred from outside hospitals, fistulas were successfully closed in 71%, 72%, 77%, 100% and 100% of these patients after fistula repairs 1 to 5, respectively. Variables studied yielded stent 67.7% (36 of 54 cases) versus no stent 76.1% (35 of 46) and operating microscope 70.4% (59 of 71) versus loupes 72.4% (21 of 29) in terms of success. Success based on patient age yielded 65.5% for younger than 2 years (n = 29 patients), 71.7% for 2 to 5 (46), 64.7% for 6 to 12 (17) and 87.5% for older than 12 (8). When considering the type of original hypospadias repair and its affect on fistula closure success, a significantly lower success was noted with Yoke and King procedures (p = 0.007 and 0.037, respectively). In patients who underwent hypospadias surgery and all subsequent fistula closure attempts at our center, fistulas were successfully repaired in 72%, 67% and 100% of patients after attempts 1 to 3, respectively. Initial fistula repair was successful in 72% (59 of 82) of patients who underwent original hypospadias surgery at our center and in 67% (12 of 18) of those referred after hypospadias surgery at an outside hospital. Regarding urethrocutaneous fistula closure, the data from this study suggest that there is no clear difference in stent versus no stent and microscope versus loupes, age at fistula closure does not affect success, type of original hypospadias procedure may influence success (King and Yoke procedures were least successful), success rate is not negatively impacted in recurrent fistula cases, given a diverse group of fistulas, success of fistula repair for attempts 1 to 5 was 71%, 72%, 77%, 100% and 100%, respectively, and success rate in a tertiary pediatric urology setting is not influenced by whether the original hypospadias procedure or initial fistula closure was performed in the pediatric urology setting versus outside hospital.

The Journal of Urology, 2014

This study was designed to assess perceptions of untreated hypospadias and quality of life in cul... more This study was designed to assess perceptions of untreated hypospadias and quality of life in culturally disparate low or middle income countries, to highlight the demographic and care differences of patient groups treated for hypospadias in the surgical workshop context, and to evaluate the long-term outcomes achieved by these workshop groups. Family member perceptions of hypospadias, perioperative process measures and urethrocutaneous fistula rates were compared between 60 patients from Vietnam and Senegal treated for hypospadias through training workshops by local surgeons and pediatric urologists from the U.S. between 2009 and 2012, of whom approximately 42% had previously undergone repair attempts. More than 90% of respondents surveyed believed that untreated hypospadias would affect the future of their child at least to some degree. Patient cohorts between the 2 sites differed from each other and published high income country cohorts regarding age, weight for age and frequency of reoperation. Telephone based outcomes assessment achieved an 80% response rate. Urethrocutaneous fistula was reported in 39% and 47% of patients in Vietnam and Senegal, respectively. Family members perceived that the social consequences of untreated hypospadias would be severe. Relative to patient cohorts reported in practices of high income countries, our patients were older, presented with more severe defects, required more reoperations and were often undernourished. Urethrocutaneous fistula rates were higher in cohorts from low or middle income countries relative to published rates for cohorts from high income countries. Our study suggests that outcomes measurement is a feasible and essential component of ethical international health care delivery and improvement.

The Journal of Urology, 2014

We describe patient characteristics and age distribution of epididymitis in an outpatient pediatr... more We describe patient characteristics and age distribution of epididymitis in an outpatient pediatric urology referral practice during a 21-year period. We retrospectively reviewed all pediatric patients diagnosed with epididymitis or epididymo-orchitis (ICD9 604.9) either clinically or with the aid of scrotal ultrasound at Primary Children's Medical Center from 1992 through 2012. Charts were reviewed to record demographic and clinical features, as well as radiological and laboratory data. Multiple acute episodes occurring in individual patients were recorded. A total of 252 patients were identified. Mean ± SD age at first presentation was 10.92 ± 4.08 years. The majority of cases occurred during the pubertal period (11 to 14 years) and few patients younger than 2 years were diagnosed with epididymitis (4%). A total of 69 boys (27.4%) experienced a second episode of epididymitis. Scrotal ultrasound results were consistent with epididymitis in 87.3% of cases (144 of 165). Urine culture results were available in 38 patients and were positive in 7 (21%). Positive urine culture was associated with an anatomical abnormality on followup voiding cystourethrogram (RR 5.7, 95% CI 1.37-23.4). Physical activity was noted as a likely precipitating factor in 23 patients and a recent urinary tract infection was identified in 20. The majority of cases of epididymitis occur around the time of puberty in early adolescence, with relatively few cases occurring during infancy. Recurrent episodes of epididymitis are more common than previously reported and may affect as many as a fourth of all boys with acute epididymitis.

The Journal of Urology, 2008

Extravesical ureteral reimplantation and subureteral Deflux injection are used to correct vesicou... more Extravesical ureteral reimplantation and subureteral Deflux injection are used to correct vesicoureteral reflux with success rates of 94% to 99% and up to 89%, respectively. It was reported that unilateral extravesical reimplantation may be performed safely in an outpatient setting. Given that, we analyzed total system reimbursement to compare planned outpatient unilateral extravesical reimplantation to subureteral Deflux injection in patients with unilateral vesicoureteral reflux. Data were collected on consecutive patients undergoing outpatient procedures for unilateral vesicoureteral reflux. Assessment of total system reimbursement was made using a payer mix adjusted calculation of surgery plus anesthesia plus hospital reimbursement. This was compared per procedure and in terms of total system reimbursement for each approach to obtain a similar resolution rate. A total of 209 consecutive patients were identified, of whom 26 underwent subureteral Deflux injection and 183 underwent unilateral extravesical reimplantation. Mean operative time was 93 minutes for reimplantation and 45 minutes for injection. The mean volume of dextranomer-hyaluronic acid was 1.2 ml. Total initial system reimbursement per patient was 3,813forreimplantationand3,813 for reimplantation and 3,813forreimplantationand4,259 for injection. A 3% hospital admission rate for reimplantation increased the total to $3,945. Higher reimbursement for injection depended largely on the material expense for dextranomer-hyaluronic acid. In terms of total system reimbursement it is less expensive in our system to treat unilateral vesicoureteral reflux with unilateral extravesical reimplantation than with subureteral Deflux injection using dextranomer-hyaluronic acid. The ability to perform unilateral reimplantation as an outpatient procedure has shifted this relationship.

The Journal of Urology, 2011

Parameatal urethral cyst in boys is an uncommon and often poorly understood condition. We describ... more Parameatal urethral cyst in boys is an uncommon and often poorly understood condition. We describe the largest known series of 18 prepubertal boys with parameatal cysts. We retrospectively reviewed the charts of all pediatric patients at our institution diagnosed with a penile cyst according to our office database between 1992 and 2010. Charts were reviewed to determine patient demographics, symptomatology, pathology, cyst characteristics and treatment. We identified 18 patients during the last 18 years who were diagnosed with a parameatal cyst. Most patients (66%) were asymptomatic. All cysts were less than 1 cm in diameter. Of the patients 50% were circumcised before presentation and 78% underwent surgical excision. There have been no recurrences in patients who underwent excision. One patient had spontaneous resolution of the cyst during the first few weeks of life. Pathology results were available for 6 patients. Three specimens contained a single type of epithelium and 3 contained a combination of transitional, cuboidal and/or columnar epithelia. The transitional and cuboidal epithelia were the most common components. There was no evidence of malignancy in any of the specimens and only 1 specimen contained an inflammatory infiltrate. Parameatal cysts are a benign, usually asymptomatic condition that may contain a variety of epithelial types. The cysts may resolve spontaneously in neonates but are also easily excised with minimal risk of recurrence.

International Journal of Urology, 2006

The presentation, and medical and surgical management of all new onset non-congenital hydroceles ... more The presentation, and medical and surgical management of all new onset non-congenital hydroceles in boys older than 1 year of age were examined. Of particular interest was the outcome of those patients who presented with a non-communicating hydrocele that developed after the first year of life and was managed conservatively. Methods: All patients older than 12 months of age who were evaluated as outpatients with the diagnosis of hydrocele from January 1994 to January 2001 were identified. Possible risk factors and predisposing conditions were determined. For the patients who had surgical correction, surgical indications were identified. For non-surgical patients, long-term outcomes were recorded. Results: A total of 302 patients older than 12 months of age with the diagnosis of new onset hydrocele were identified. Of these, 35% were non-communicating, 59% were communicating, and 6% were hydroceles of the spermatic cord. In terms of surgery, 97% of communicating hydroceles, 71% of hydroceles of the spermatic cord, and 34% of non-communicating hydroceles had operative management. Seventy patients with non-communicating hydroceles did not receive surgery and 51 (73%) were contacted for long term follow-up. In these 51 patients, 76% of non-communicating hydroceles resolved completely, 6% decreased in size but were still present, 14% remained the same size, and 4% had an unknown status. The average time to resolution was 5.6 months with a median time of 3 months. The time range to resolution was from 1 day to 24 months. Follow-up averaged 73.7 months with a range of 33 to 120 months. Conclusions: Approximately 75% of new onset, non-congenital, non-communicating hydroceles resolve spontaneously irrespective of size. An observation period of 6-12 months would be appropriate prior to repair.

Journal of Pediatric Urology, 2010

Objective: To answer the question: 'Is there a learning curve associated with a subureteric injec... more Objective: To answer the question: 'Is there a learning curve associated with a subureteric injection of Deflux â ?' Materials and Methods: We retrospectively reviewed charts of patients who received subureteric injection of dextranomer/hyaluronic acid (Deflux â {AQ2}) (225 procedures) for treatment of vesicoureteral reflux (VUR) by four surgeons. The study included 55 patients, 82 ureters, who had postoperative follow-up with a voiding cystogram or nuclear medicine cystogram. Exclusion criteria were prior anti-refluxing procedures, duplicated collecting systems, and non-achievement of a negative intraoperative cystogram. Patients were divided into two groups based on whether or not they received an intraoperative cystogram after the injection. The two groups were compared for VUR resolution rates on follow-up imaging. Results: Twenty patients underwent an intraoperative cystogram (Group 1, 33 ureters) and 35 did not (Group 2, 49 ureters). The two groups were similar in age, preoperative reflux grade, amount of Deflux injected into each ureter, and time to postoperative studies. In Group 1, 11 ureters (33.3%) and also, in Group 2, 11 ureters (22.4%) had reflux on follow-up imaging. Conclusions: There was no improvement in VUR resolution rate following subureteric injection of Deflux â when an intraoperative cystogram demonstrated no reflux to be present immediately after injection. Of ureters that did not reflux on intraoperative cystograms, one-third displayed return of reflux on follow-up imaging, which suggests no learning curve and that failures are not likely to be caused by poor surgical technique.