After a few years of practice, I have developed explicit or implicit algorithms to deal with the most common problems I treat.
I read journal articles in the following order: title, abstract discussion, full abstract, methods, and finally the whole article, moving from section to section only if I find the information potentially likely to alter any of my algorithms. My attention follows a similar pattern during abstract presentations at national and international meetings.
Basic science articles, for example, are immediately discarded, as they have absolutely no potential to alter any of my pathways and I do zero basic science research myself.
Here are several examples from the latest issue of the Journal of Pediatric Urology.
Kosmeri et al found that recurrent pyelonephritis and VUR grades 4 and 5 increase the risk of renal scarring, and suggested ordering DMSA scans for patients with those risk factors. Since neither surgery nor preventative antibiotics have been found to be effective at preventing renal scars, I do not take renal scarring into account when making clinical decisions, and thus never order DMSA scans.
Kim et al from the Houston group found that post reimplant hydronephrosis is similar after robotic reimplant compared to open reimplant. This article confirms my belief that the same open operation can be done with the robot, just through smaller incisions and maybe with less retention risk –as the reimplant can be done more posteriorly and away from the nerves. However, I am only marginally interested in this article since it does not alter my VUR algorithm.
A study from Japan, looked at long term nephrologic outcomes on 51 patients (37 boys and 14 girls) that had surgery for VUR. The authors found –not surprisingly– that the more severe the VUR and scarring at baseline, the more likely the patients were to show chronic kidney disease at follow up. I found this uninteresting since the information seems self-evident and does not affect my current algorithms.
Then there are other studies which findings could potentially change my algorithms, but whose conclusions I am not so sure of. For example, the study by Unsal et al, suggests that UTIs with Klebsiella and Enterococcus, might not present with pyuria 50% of the time. In this study, younger boys were more likely to not have pyuria compared to older girls. The authors did not mention if the boys were uncircumcised or not. Symptoms of UTIs for infants were non-specific, such as fever and thus, I would think that some of the negative UA’s could have been associated with false-positive cultures from uncircumcised boys. In other words, I do not believe that as much as 50% of UTI’s with Klebsiella or Enterococcus can have no pyuria. I believe the authors might have overdiagnosed some uncircumcised young boys with UTI’s which led them to those conclusions.
On the other hand, you find articles such as the one by Sundaramurthy et al, that raise my eyebrows and focus my mind. These authors removed indwelling ureteral stents under sedation (midazolam and ketamine) using a MacGyver-conceived-do-it-yourself device consisting of a 6-8 Fr feeding tube and a 90-cm-long monofilament 3-0 polypropylene suture. If they were not able to fish out the stent on the first try, a maximum of 4 more tries were attempted. The authors were able to remove 26/30 stents using their device.
Although a 20-second stent removal under a brief mask general anesthetic with no IV might be preferable than 5 fishing attempts under sedation with an IV, I still liked knowing about this trick, since I have been in situations were the cystoscope or the grasper did not work.
Another excellent article from the Urologic Mythbuster series convinced me to stop ordering VCUG’s in newborns with severe unilateral UPJ obstruction. Up to now, my practice has been ordering a repeat renal US, Mag 3 renal scan, and a VCUG at 6 weeks of life in babies with urinary tract dilation (UTD) grade 3 from unilateral UPJ obstruction diagnosed on postnatal ultrasound. My rationale for getting the VCUG was to make sure there were no valves or severe contralateral reflux. The article dismantled my rationale and thus will no longer order VCUG’s unless I suspect valves based on bladder enlargement/wall thickening, hydroureteronephrosis, echogenic kidneys, history of oligohydramnios or a combination of the above.
Articles, abstracts, and meetings that do not challenge your current implicit or explicit algorithms will likely put you to sleep.