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Biomedical subjects

Andrew E MacNeily

Publications and source records attributed to Andrew E MacNeily.

11 recordsLinked to original sources
PubMed2006

The challenge of pediatric continent urinary diversion.

OBJECTIVE: Continent urinary diversion (CUD) may be required for refractory incontinence in children with various malformations. We review our experience with CUD to identify determinants of success and ongoing challenges. METHODS: Retrospective chart review of 43 consecutive patients undergoing CUD since 1991 at British Columbia Children's Hospital. RESULTS: Our preferred surgery was intestinal cystoplasty and either appendicovesicostomy (77%) or ileal-vesicostomy. Concomitant bladder neck surgery was performed in 67%. Mean follow-up was 2.5 years. There was a 16% revision rate for persistent leakage, the most common being cystoscopic injection of bulking agents. Continence was ultimately achieved in 88%. Early major and minor postoperative complications each occurred in 21% of cases. Delayed minor complications requiring surgical intervention occurred in 30% including stomal stenosis in 6 patients and stomal prolapse in 2. Urolithiasis required intervention in 5 patients. CONCLUSIONS: Pediatric CUD is a challenging endeavor. Most patients achieve continence although many require additional minor procedures to do so. Early major and minor complications are common. A significant minority of patients require reoperation for delayed minor complications. Patients and families should be informed of these frustrations as part of their preoperative counseling. A high degree of family motivation and commitment is essential.

Adolescent↗
PubMed2006

Randomized controlled trials in pediatric urology: room for improvement.

PURPOSE: The primary purpose of this study was to ascertain what proportion of the body of published literature in pediatric urology is represented by randomized controlled trials. The secondary purpose was to assess the quality of these trials. MATERIALS AND METHODS: Using a predefined strategy, we conducted systematic computerized searches of the MEDLINE (years 1966 to 2004) and EMBASE (1980 to 2004) databases to identify all English language randomized controlled trials related to pediatric urology. Full text versions of identified studies were reviewed in blinded fashion for key demographic, methodological and statistical characteristics. Trial quality was assessed with the previously validated Jadad tool. RESULTS: The 77 identified randomized controlled trials represented only 0.4% to 0.9% of the indexed pediatric urology literature. The origins of these trials were Europe (40%), North America (26%) and a variety of other geographic centers (34%). A primarily surgical focus was present in 43% of the studies. Trials with negative results represented only 19% of the total randomized controlled trials. Generally, the trials were of low to fair quality (median Jadad score 3), with substandard methodological reporting and planning. There was not a significant trend toward improved quality in recent years. Trials from North America and Europe had higher quality (p = 0.007), as did those reporting negative results (p = 0.0001). CONCLUSIONS: Randomized controlled trials in pediatric urology constitute only a small proportion of the body of published literature in the field. High quality studies are uncommon. Efforts should be made to increase the number of well designed, randomized controlled trials in pediatric urology.

Bibliometrics↗
PubMed2006

Core competencies in surgery: evaluating the goals of urology residency training in Canada.

BACKGROUND: In Canada and the United States, the relevance and utility of training objectives as perceived by practising surgeons is rarely examined. We sought to determine if urology residency training objectives reflect the broad realities of urologic practice. METHODS: A survey, based on the Royal College of Physicians and Surgeons of Canada training objectives for urology, was designed and validated. All 418 full-time practising members of the Canadian Urological Association were surveyed. RESULTS: The overall response rate was 63%. Many specialized clinical areas of urology that receive little emphasis in the training objectives were rated as useful by the majority: laparoscopic surgery (92%), percutaneous renal access (86%), transrectal ultrasonography (84%), pediatric urology (81%), extracorporeal shockwave lithotripsy (70%), urethral reconstruction (66%) and adrenal surgery (62%). Microsurgery and transplantation were perceived as less useful (54% and 22% respectively). Virtually all nonsurgical training objectives were regarded as useful components of training; however, in the opinion of the majority of respondents residency did not prepare them for many of these: the challenges of office and hospital administration (91% and 89% not prepared [NP]), building a referral base (67% NP), time management (60% NP) and providing care under financial constraints (60% NP). CONCLUSION: The study results support the current training objectives and indicate areas requiring increased emphasis.

Canada↗
PubMed2005

Renal leiomyoma associated with Epstein-Barr virus in a pediatric transplant patient.

Renal leiomyoma is a rare smooth muscle tumor of the kidney. An association between Epstein-Barr virus and smooth muscle tumors in immunocompromised patients recently has been recognized. We describe a pediatric renal transplant patient who developed an Epstein-Barr virus-associated renal leiomyoma in his transplant kidney 5 years posttransplantation. Possible factors involved in the tumor pathogenesis in our patient are discussed, including immunosuppression, growth hormone therapy, and Epstein-Barr virus induction.

Child, Preschool↗
PubMed2005

Personal finances of residents at three Canadian universities.

OBJECTIVES: To address 3 research questions (What financial choices do residents make? Are the financial choices of residents similar to those of the general public? Are the financial choices of surgical residents reasonable?), we examined financial data from Canadian residents. METHODS: A written survey was administered to 338 residents (103 of them surgical residents) at 3 Canadian training institutions (University of Toronto, Queen's University and University of Manitoba). Resident household cash flows, assets and liabilities were characterized. Finances for residents were compared with those of the general public, by means of the Survey of Household Spending and Survey of Financial Security. RESULTS: Median resident income was 45,000 dollars annually (Can dollars throughout). With a working spouse, median household income was 87,500 dollars. Among residents, 62% had educational debt (median 37,500 dollars), 39% maintained unpaid credit-card balances (median 1750 dollars), 36% did not budget expenses, 25% maintained cash reserves <275 dollars, and 22% contributed neither to retirement nor nonretirement investments. Residents spent more on vehicles compared with members of the general public (median 17,500 dollars v. 10,720 dollars, p = 0.002) and on monthly housing (median 875 dollars v. 729 dollars, p < 0.001), respectively. Residents were more likely to carry student loans than people in the general population (61% v. 21%), more likely to carry vehicle loans (74% v. 29%) and less likely to carry credit-card debts (39% v. 50%, respectively). Surgical residents had income expectations after graduation higher than current billings justified. Fewer surgical (69%) than anesthesiology residents (88%, p < 0.05) contributed to Registered Retirement Savings Plans. CONCLUSIONS: From this limited sample, residents spend more than age- and income-matched members of the general public. Many residents save too little, fail to budget, and carry high educational and credit-card debts. Surgical residents' expectations of future income may be unrealistic. Further study is warranted.

Adult↗
PubMed2003

Treatment of phimosis with topical steroids in 194 children.

PURPOSE: Topical steroids have been advocated as an effective economical alternative to circumcision in boys with phimosis. We evaluated the effectiveness of topical steroid therapy as primary treatment in 194 patients with phimosis. METHODS: Between January 1996 and November 2000, 228 boys 16 years old or younger were referred for consideration of circumcision. When intervention was determined to be necessary, a 6-week course of topical steroids was used as primary treatment. Efficacy of treatment was evaluated at 3 months from initiation of therapy. RESULTS: Of the 228 patients 15 had such a mild degree of phimosis that no intervention was believed to be necessary, 19 were scheduled directly for circumcision due to cosmetic reasons, parent wishes, or severe phimosis with associated voiding problems and the remaining 194 received topical steroids as primary treatment. Of these 194 patients 25 had coexisting balanitis and 4 had a history of urinary tract infection. Conservative treatment was successful in 87%, 88% and 75% of patients with phimosis alone, coexisting balanitis and history of urinary tract infection, respectively. Overall, circumcision was avoided in 87% of patients treated with topical steroids. CONCLUSION: Topical steroids are becoming the standard conservative measure for treating phimosis. Our study supports this trend, with an overall efficacy of 87%.

Administration, Topical↗
PubMed2003

Autoaugmentation by detrusor myotomy: its lack of effectiveness in the management of congenital neuropathic bladder.

PURPOSE: We present our long-term results in 17 patients with myelomeningocele undergoing autoaugmentation by vesicomyotomy. MATERIALS AND METHODS: Surgery was performed from 1990 to 1994 on 17 patients with neurogenic bladder due to spinal dysraphism. Indications for autoaugmentation included upper tract deterioration and/or incontinence secondary to hypperreflexia, hypocompliance or low bladder volume. All patients had failed to respond to conservative medical and pharmacological treatments. Median patient age at surgery was 10.2 years (range 2.2 to 13.2). Outcomes were evaluated retrospectively according to changes in upper tract status, continence and urodynamic parameters. Median clinical and urodynamic followup is 75 months (range 4 to 126). RESULTS: Progressive hydronephrosis developed in 5 patients, which required subsequent enterocystoplasty in 4. Of 13 patients 8 (62%) remain incontinent. Of the 17 cases 12 (71%) were considered clinical failures on the basis of upper tract deterioration and/or ongoing incontinence. There were few clinically significant improvements in urodynamic parameters, as 14 of 15 cases (93%) were considered urodynamic failures on the basis of persistent hypocompliance and/or less than expected gains in safe bladder capacity with somatic growth. CONCLUSIONS: Although short-term reports of autoaugmentation have been promising, they do not appear durable. This procedure cannot be endorsed for the management of congenital neuropathic bladder.

Adolescent↗
PubMed2003

Implementation of a PDA based program to quantify urology resident in-training experience.

INTRODUCTION: There currently is no simple and reliable mechanism for Residency program directors to assess how well their trainees are being exposed to all spheres of their specialty. We report on the use of hand-held personal digital assistants (PDA's) to document all clinical and academic activities of urology residents at one academic institution. MATERIALS AND METHODS: Software was developed to create customized pick lists allowing residents to record all activities on their individual PDA's. Categories included Adult Ambulatory, Pediatric Ambulatory, Adult operative, Pediatric operative, and Academic. Activities were subcategorized into detailed pick lists and time-tracking fields. Residents synchronized with a central database on a standalone hotsync server. RESULTS: In the first 8 months, 21 178 resident-hours and 5333 activities were recorded. Preliminary observations can be made regarding how residents spend the majority of their time: 28% operative, 20% self-study, 19% ward work, 10% Academics, 6% ER consultations, 5% clinic, and 4% inpatient consultations. The most common adult diagnoses encountered while attending to clinic, ward, or ER consultations were lower urinary tract symptoms, urolithiasis and hematuria. Similarly for Pediatrics: neurogenic bladder, antenatal hydronephrosis, infection, and hypospadias were most often reported. Residents reported 5,333 activities, relating to the following spheres of Urology: academics (23%), endourology (18%), oncology (15%), lower urinary tract symptoms (10%), congenital anomalies (5%), urolithiasis (5%), reconstruction (5%), and infection (3%). CONCLUSIONS: This tool provides an objective assessment of resident experience as it relates to selection of rotations, and for addressing curriculum weaknesses. It is applicable at a national level for the study of regional differences in training experience, and trends in graduate Urological education. With minimal effort it could be modified for application to other specialty training programs.

Adult↗
PubMed2003

Assessing the goals of urology residency training: perceptions of practicing urologists in British Columbia.

PURPOSE: In an effort to evaluate the perceived utility of specific Royal College of Physicians and Surgeons of Canada (RCPSC) urology residency training objectives we conducted a survey of the practicing urologists of British Columbia (BC). MATERIALS AND METHODS: A two page semi-structured survey was designed. Validity was evaluated for clarity, content and ease of completion. The survey was mailed-out to all 61 practicing urologists in BC. The survey population was divided into urban, rural, and academic according to location of practice. RESULTS: Survey response rate was 79% with varying subgroup rates: urban-69% (20/29), rural-94% (17/18) and academic 86% (12/14). Specific clinical components of training were rated as "useful" by the majority of all respondents: pediatric urology (93%), laparoscopy (88%), TRUS (77%), percutaneous renal access (74%), urethral surgery (72%), microsurgery (62%). Renal transplantation was rated "not useful" by 74% of respondents. TRUS, percutaneous renal access and adrenal surgery were perceived as useful by the majority of those practicing in rural and non-academic urban centers compared to those in academic centers where the majority rated these skills as "not useful". Virtually all non-clinical components of training were rated as "useful". The majority of respondents felt that residency training prepared them for the following challenges: accepting responsibility for patient care, assessing scientific literature, ethical decision-making and communication. The majority of respondents felt that residency did not prepare them for the following challenges: time and office management, hospital administration and providing care within a constrained system. CONCLUSION: Specific clinical and non-clinical areas of training have high perceived utility in all settings of practice. Certain clinical components of training have high perceived utility only in specific settings of practice. There are many non-clinical components of practice, which are perceived to be important, but for which BC urologists feel inadequately prepared for by their residency training programs. If consistent across Canada, these findings may facilitate a rational approach to the modification of the objectives for urology residency training.

British Columbia↗