CHOC-UCI Pediatric Urology study illustrates how COVID-19 delayed emergency care

CHOC’s pediatric urology team, in a partnership with UCI Health, has published the largest study of its kind on an emergency condition that afflicts young males, adding to the emerging body of data on how the COVID-19 pandemic has caused patients to delay seeking emergency treatment.

The CHOC/UCI-led study, recently published in the Journal of Pediatric Urology, also marks a first for the Western Pediatric Urology Consortium (WPUC), a group of several leading pediatric healthcare centers that CHOC was instrumental in founding in 2020.

“This study is a good example of CHOC leading the way and bringing together institutions to answer questions that haven’t been answered before,” says Carol Davis-Dao, PhD, a clinical epidemiologist in CHOC’s Department of Pediatric Urology who has a joint appointment in the UC Irvine Department of Urology.

Dr. Davis-Dao leads urology research efforts at CHOC to provide patients and their families with the most current, evidence-based diagnoses and treatments.

The lead author of “A Multicenter Study of Acute Testicular Torsion in the Time of COVID-10,” Dr. Sarah Holzman, a research fellow at UCI-CHOC, says the research paper is the only multicenter urology study and the largest one related to torsion and COVID-19. Most importantly, she adds, it’s the only study that shows patients were delaying presenting to the Emergency Department for testicular torsion.  

The study’s key finding: Patients significantly delayed seeking treatment in the Emergency Department following the onset of symptoms of a testicular torsion during the early months of the pandemic, and, as a result, more of them had to have a testicle removed compared to patients with the same condition who sought care before the pandemic.

“This is the largest study of testicular torsion during COVID-19 and the first to show a significantly longer time from symptom onset to presentation (in the Emergency Department),” the paper states.

“Low baseline awareness of torsion may contribute to delays in care that were present even before the pandemic, making patients and their families less likely to present for emergency care during the pandemic when there is concern for exposure to COVID-19.”

Also participating as authors of the study were CHOC pediatric urologists Dr. Heidi Stephany, Dr. Kai-wen Chuang, Dr. Elias Wehbi, and Dr. Antoine Khoury, chief of pediatric urology at both CHOC and UC Irvine Medical Center. 

Testicular torsion occurs when the spermatic cord that supplies blood to the testicle twists, cutting off the testicle’s blood supply. It presents as acute and severe scrotal pain that quickly worsens, as well as nausea and vomiting.

Testicular torsion occurs when the spermatic cord that supplies blood to the testicle twists, cutting off the blood supply.

It’s a relatively rare surgical emergency, with an incidence rate of around 4 per 100,000 males per year in the United States. It most frequently occurs in males between the ages of 10 and 19, with one peak in the neonatal period and the second peak around puberty.

Surgery is required for all patients with testicular torsion.

When torsion is caught early — typically within the first six hours — a detorsion orchiopexy can be performed. In the detorsion surgery, the spermatic cord is untwisted and the blood flow returns to the testicle. The surgeon then secures the testis to the inner scrotum so it can never twist again. However, if patients delay coming to the hospital and the testicle does not have blood supply for several hours, the testicle may have to be removed in a procedure called an orchiectomy.

The CHOC-UCI led study involved a total of 221 patients enrolled at one of seven hospitals in the WPUC (CHOC, Children’s Hospital Los Angeles, Seattle Children’s, UC San Francisco, UCLA, UC San Diego and Western University in Ontario, Canada).

A total of 84 patients with testicular torsion, ages 2 months to 18 years, made up the first cohort. They were studied from March 2020 through July 2020.

The second cohort totaled 137 patients who were treated from January 2019 through February 2020.

The median time it took patients in the COVID-19 cohort to show up at the Emergency Department from the onset of symptoms was 17.9 hours, the study found. This compares to 7.5 hours for patients in the pre-pandemic cohort.

A total of 42 percent of patients in the COVID-19 cohort underwent an orchiectomy (removal of the twisted testicle), compared to 29 percent in the pre-pandemic population.

Distribution of patterns in acute testicular torsion presentation by month of the COVID-19 pandemic. Blue bars represent rate of orchiectomy by month, while the navy-blue line represents median time from onset of symptoms to presentation by month.

Other studies have shown that COVID-19 has caused people to delay Emergency Department treatment, including one that examined acute appendicitis from the New York metropolitan region and another similar study in Virginia.

During the last week of June 2020, 41 percent of U.S. adults admitted to avoiding medical care because of COVID-19 exposure concerns and 12 percent avoided urgent or emergent care, according to the Morbidity and Mortality Weekly Report, an epidemiological digest for the United States published by the Centers for Disease Control and Prevention.

Drs. Holzman and Davis-Dao say they plan to continue the study as the pandemic progresses.

Read more about CHOC’s Department of Urology.

Western Pediatric Urology Consortium (WPUC) Aims to Develop More Impactful and Meaningful Research in Pediatric Urology

The merging of clinical experience, surgical expertise and evidence-based practices is critical for obtaining the best outcomes for patients and their families. Guided by these criteria, CHOC established the Western Pediatric Urology Consortium (WPUC) to develop impactful and innovative research to benefit pediatric urology patients in the years ahead.

“Pediatric urology is a small community,” says Dr. Antoine “Tony” Khoury, chief of pediatric urology at CHOC. “Relatively speaking, the number of pediatric urology patients with complex anomalies is low, so it can be challenging to design studies robust enough to answer the important questions, the questions we need to answer to care for our patients in the best way possible.”

Dr. Antoine "Tony" Khoury
Dr. Antoine “Tony” Khoury, chief of pediatric urology at CHOC

In an effort to bring together the leading pediatric urology groups, Dr. Khoury initiated the development of the WPUC. “With a larger patient pool and our collective resources, our consortium can design collaborative studies that none of us could accomplish on our own, which we hope will ultimately improve diagnosis and treatment in pediatric urology,” Dr. Khoury says.

The WPUC currently has 15 centers involved in the consortium, including three centers in Canada and two in the eastern United States. There are several active studies WPUC is investigating, including:

  • The effect of the COVID-19 pandemic on testicular torsion, a urologic emergency requiring surgery. The WPUC is investigating whether delaying treatment for torsion during COVID-19 increased the risk of testicular loss.
  • Posterior urethral valves, a serious congenital condition seen in boys, frequently leads to renal failure requiring kidney transplant. Are the graft survival rates of boys with this condition equivalent to patients with other conditions that lead to kidney failure?
  • Hypospadias repair, a surgery that is both an art and a science. The WPUC is using artificial intelligence to study surgical reports across the consortium to better understand decision-making and improve surgical techniques.

“These are long-term studies we are working on today that we’re hoping will effect change for our patients in the future,” says Dr. Khoury.

Dr. Antoine "Tony" Khoury at CHOC
Dr. Khoury

When asked if the COVID-19 pandemic had any impact on the WPUC, Dr. Khoury says their first inaugural meeting, which was scheduled to be held In March of 2020, was cancelled. “We were anticipating an amazing turn-out for the meeting in Orange County, but fortunately we were able to successfully transition to online collaboration. We have had several productive virtual meetings since March, and we have since launched three stellar research studies.”

Dr. Khoury stresses how important the collaboration is between the centers in the WPUC when it comes to advancing pediatric urology care. “In pediatric urology, there are not enough large-scale studies, so it’s important to involve multiple centers so we can accumulate enough data to come up with meaningful results in a reasonable timeframe. If we only rely on one center, we’ll never gather enough data to determine the best treatments and how to make the most appropriate decisions for these children.”

Dr. Khoury believes the WPUC will lead to new avenues of research, which could assist in developing new treatment protocols. “My hope is that we will change academic pediatric urology through the collaboration of the WPUC,” Dr. Khoury says. “The work we’re doing as a group right now will improve urologic diagnosis, treatment and research for the next generation of pediatric urology patients.”

Our Care and Commitment to Children Has Been Recognized

CHOC Hospital was named one of the nation’s best children’s hospitals by U.S. News & World Report in its 2020-21 Best Children’s Hospitals rankings and ranked in the urology specialty.

Learn how CHOC’s urology care, ongoing treatment and surgical interventions preserve childhood for children in Orange County, Calif., and beyond.

Virtual pediatric lecture series: Bladder function and dysfunction

CHOC’s virtual pediatric lecture series continues with “Bladder function and dysfunction: Woes for primary care clinicians.”

This online discussion will be held Friday, Nov. 13 from 12:30 p.m. to 1:30 p.m. and is designed for general practitioners, family practitioners and other healthcare providers.

 Dr. Antoine “Tony” E. Khoury, medical director of urology at CHOC, will discuss several topics, including:

  • The basics of normal bladder function.
  • Understanding the relationship between bladder and bowel dysfunction.
  • Diagnosing the different causes of urinary incontinence.
  • Managing the different therapeutic modalities to correct bladder and bowel dysfunction.

This virtual lecture is part of a series provided by CHOC that aims to bring the latest, most relevant news to community providers. You can register here.

CHOC is accredited by the California Medical Association (CMA) to provide continuing medical education for physicians and has designated this live activity for a maximum of one AMA PRA Category 1 Credit™. Continuing Medical Education is also acceptable for meeting RN continuing education requirements, as long as the course is Category 1, and has been taken within the appropriate time frames.

Please contact CHOC Business Development at 714-509-4291 or with any questions.

Silk Biomaterial Research Advances Urologic Treatment Capabilities

The Urology Center at CHOC is collaborating with Joshua Mauney, PhD, associate professor of urology/biomedical engineering and Jerry D. Choate Presidential Chair in Urology Tissue Engineering in the University of California, Irvine Urology Department, who focuses his research on tissue engineering with the development of silk biomaterials for the repair of visceral hollow organs. Dr. Mauney has a productive basic science laboratory with NIH grant funding and was previously a staff scientist in the Department of Urology at Boston Children’s Hospital and associate professor of surgery at Harvard Medical School.

“The overall goal is the creation of clinically useful scaffold configurations for hollow organ regeneration by engineering materials which fulfill structural and mechanical requirements of native tissues as well as present microenvironmental cues necessary for host tissue integration and defect consolidation,” said Dr. Mauney.

3D matrix designs using silk biomaterials can be used to restore function related to injury or fibrotic disease. Silk scaffolds offer advantages over non-biomaterial implants for human bladder augmentation and can support bladder storage, voiding function and defect correction.

“The addition of Dr. Mauney allows the CHOC team to focus on the reconstruction of bladders and organs using his 3D matrix designs to offer options for children born with missing or abnormal parts of their urinary tract,” said Dr. Antoine “Tony” Khoury, chief of pediatric urology.

Dr. Tony Khoury, chief of pediatric urology at CHOC
Dr. Tony Khoury, chief of pediatric urology at CHOC

Our Care and Commitment to Children Has Been Recognized

CHOC Hospital was named one of the nation’s best children’s hospitals by U.S. News & World Report in its 2020-21 Best Children’s Hospitals rankings and ranked in the urology specialty.

US News and World Report, Urology

Learn now CHOC’s urology care, ongoing treatment and surgical interventions preserve childhood for children in Orange County, Calif., and beyond.

CHOC makes advancements for neurogenic bladder patients

The Urology Center at CHOC has implemented and evaluated a bladder pressure and volume diary for patients at risk for increased intravesical pressures.

“Patients dependent on clean intermittent catheterization used ruler-based manometry to measure intravesical pressures before leakage or scheduled drainage at home,” said Dr. Antoine Khoury, chief of pediatric urology. Patients were asked to record measurements while relaxed in a supine position.

Dr. Antoine Khoury, chief of pediatric urology at CHOC Children's
Dr. Antoine Khoury, chief of pediatric urology at CHOC

Study results

The study included 30 patients ranging in age from 1 to 20, with a mean age of 10.

“Home pressures measured at maximal clean intermittent catheterization volume and mean bladder pressure/volume diary pressures were most reliable in predicting urodynamic pressures greater than 30 cm water (AUC 0.93 and 0.87, respectively). Home pressures measured at maximal clean intermittent catheterization volumes less than 20 cm water were associated with normal bladder pressures (less than 30 cm water) on urodynamics, with a sensitivity of 100% and a specificity of 80%,” said Dr. Khoury.

To view this study in greater detail, click here.

A bladder pressure/volume diary helps patients monitor pressure at home and reduces the need for frequent video urodynamics (VUDS) or urodynamics (UDS). As a complementary tool to urodynamics, it provides early detection for high bladder pressures that have the potential to cause kidney damage and renal failure.

Our care and commitment to children has been recognized

CHOC Hospital was named one of the nation’s best children’s hospitals by U.S. News & World Report in its 2020-21 Best Children’s Hospitals rankings and ranked in the urology specialty.

Best Children's Hospitals, U.S. News & World Report, Urology, 2020-21

Learn how CHOC’s urology care, ongoing treatment and surgical interventions preserve childhood for children in Orange County, Calif., and beyond

Dr. Antoine Khoury Featured on KNBC-TV Highlighting New Pain Management Technique

CHOC researcher and chief of pediatric urology, Dr. Antoine “Tony” Khoury was recently featured in one of Dr. Bruce Hensel’s health segments on KNBC-TV. Following findings published by him and colleagues in the December 2013 online issue of the Journal of Pediatric Urology, Dr. Khoury has garnered attention for his research into and use of the ON-Q pain relief system to improve pain control in children undergoing urological procedures. While the ON-Q system is well established as an effective pain management technique for adults, Dr. Khoury’s study is the first to evaluate its effectiveness in children.

To learn more, including hearing from a grateful family, watch the segment:

In the Spotlight: Antoine Khoury, M.D. – Pediatric Urologist Brings World-Class Care, Fellowships to CHOC

Antoine Khoury, M.D., medical director of pediatric urology at CHOC Children’s
Antoine Khoury, M.D., medical director of pediatric urology at CHOC

In the relatively short time that Dr. Antoine “Tony” Khoury, medical director of pediatric urology at CHOC and professor of urology at the UC Irvine School of Medicine, has led the CHOC Urology Center, it has become a nationally recognized center of excellence in the subspecialty of pediatric urology.

Dr. Khoury came to CHOC in 2008 and brought leading-edge pediatric urology services to Orange County with the opening of the center in 2010. The center provides comprehensive care for children, from the most common conditions such as hernias and urinary infections to the most complex congenital abnormalities, such as bladder and cloacal exstrophy.

Recently, CHOC was nationally ranked in six specialties –one of them pediatric urology – in the 2013-14 U.S. News & World ranking of Best Children’s Hospitals. In addition, the number of patients the center helps continues to grow.

“We’re seeing 600 outpatients a month from the greater area, from Corona and Long Beach to as far east as Loma Linda and Riverside.  “In addition, we perform 80-100 surgical procedures a month,” Dr. Khoury said.

“The children are getting world-class care. We are now getting some international patients. We just operated on a patient from Israel who came here after having two unsuccessful surgeries.”

Born and raised in Egypt, Dr. Khoury attended Ain Shams University Medical School in Cairo and is board-certified in urology. He completed his residency in urology at the University of Toronto in Canada and a clinical fellowship and a research fellowship in pediatric urology at the Hospital for Sick Children in Toronto. He followed this with a research fellowship at the University of Calgary in Canada, in the area of biomaterial-related infections.

Dr. Khoury didn’t initially plan to become a pediatric urologist; he thought he’d become a surgeon for adults. He fell in love with the field during his residency and noted that pediatric urology was very different than urology for adults.

“Our patients are obviously much smaller and require advanced surgical expertise. Additionally, the majority of our procedures are reconstructive in nature, requiring imagination and constant surgical innovation.”

Fellowship and Clinical Research Innovations

Under Dr. Khoury’s leadership, CHOC offers a two-year fellowship in pediatric urology and several research and academic programs are underway. The fellowship program was accredited this year by the American College for Graduate Medical Education and 2013 marked the first time that CHOC, in partnership with UC Irvine, has offered an accredited pediatric urology fellowship.

Dr. Khoury is also proud of the clinical research innovations CHOC has accomplished in recent years in pediatric urology. For example, his team developed a highly regarded new bladder-to-kidney reflux risk calculator designed to help define the best treatment options for children with vesicoureteric reflux. The reflux of urine from the bladder back up into the kidneys is a common problem in children and can lead to infections and scar formation in the kidneys.

“We developed an app that takes into account all the risk factors involved in kidney infections so that the treating physician can determine the risk of a child developing a kidney infection within two years of treatment,” Dr. Khoury said. Patients are categorized into three specific risk categories and then treatment options are evaluated based on the risk.

On the academic front, Dr. Khoury and his colleagues are involved in multiple research projects, including one project for children born without a functioning bladder that involves bladder reconstruction using cell culture techniques. “We’re working on developing this in the lab and hoping to take this to clinical application in a few years. We’ve had three publications on that already. That work has won research prizes at national and international meetings,” he said.

Dr. Khoury’s pediatric urology colleagues and research associates include Dr. Gordon A. McLorie, Dr. Irene McAleer and Dr. Elias Wehbi. All three also have extensive academic and research credentials.

CHOC Urology Center

The CHOC Urology Center is a state-of-the-art, one-stop facility where children with urological issues are tested, diagnosed and treated all in one place, without having to make multiple visits to different physicians and labs. CHOC’s highly specialized physicians diagnose and treat a wide range of urological conditions, including:

• Ureteral reflux, in which urine flows the wrong way

• Bladder and urinary tract infections

• Bedwetting (nocturnal enuresis), incontinence or loss of bladder control

• Kidney stones

• Tumors of the kidney, bladder or testes

• Hernias

• Neurogenic conditions caused by birth defects like spina bifida

• Genital anomalies

• Perinatal urology

To learn more about Dr. Khoury and the CHOC Urology Center, please click here:

New Technique Reduces Post-Surgery Pain in Children

CHOC researchers have identified a new technique that significantly decreases pain and the need for pain medication in children following high-risk urology surgeries, a finding that was recently published in the “Journal of Pediatric Urology.”_MG_7464_1

“While pain management is a fundamental part of pediatric surgical recovery and care for pediatric patients, current options involve strong prescription painkillers that can put patients at risk for adverse side effects and possible complications,” said Antoine E. Khoury, M.D., urology chief at CHOC and a study investigator. “This study demonstrates a major advancement in pain management for pediatric urology patients, significantly reducing postoperative pain and the need for pain medicine.”

The research team evaluated the continuous infusion of local anesthesia using a pump pain relief system commonly used in adults to improve pain control in children who have undergone urological procedures. While the ON-Q system is well-established as an effective pain management technique for adults, this is the first study that evaluates its pain management effectiveness in children.

Published in December 2013, the study found that the ON-Q pump system decreased the amount of pain experienced by children on the first and second postoperative days, and that it significantly reduced the need for narcotics.

Because the device delivers the anesthetic in an automatic continuous drip, patients and their caregivers don’t need to adjust the dosage. It is also contained in a pouch, allowing children to move freely during recovery.

During the study, nurses assessed patients’ pain using the Visual Analog Scale (VAS) and the Face, Legs, Activity, Cry, Consolability (FLACC) scale, depending on the child’s age, for both the test group and a control group, which received standard-of-care pain management.

Researchers recommend conducting additional clinical studies to further validate this technique as a superior option for postoperative pain management in children undergoing surgery.

In addition to Dr. Khoury, authors for the research study, “Application of continuous incisional infusion of local anesthetic after major pediatric urological surgery,” include Guy Hidas, Hak J. Lee, Blake Watts, Maryellen Pribish, Edwin T. Tan and Zeev N. Kain.