Grahame H. H. Smith

Background: Paediatric urinary tract infections (UTIs) place a major burden on healthcare systems. Urological management has traditionally focused heavily on diagnosing and surgically treating vesicoureteric reflux (VUR). However, VUR is absent in 70% of children presenting with a UTI. This review examines clinical gaps, treatment efficacy and systemic delays in updating clinical practices. Methods: The paper synthesises historical definitions of bacteriuria, recent clinical trials (PRIVENT, RIVUR and PREDICT), data from the Cochrane review and a 10‐year epidemiological dataset comprising 152 286 UTI presentations from New South Wales, Australia. Results: Pooled Cochrane data show that low‐dose antibiotic prophylaxis makes little or no difference to the risk of repeat symptomatic or febrile UTI. Surgical intervention benefits only severe cases (Grades 4 and 5) presenting with distal ureteric dilatation greater than 7 mm. For infant males, circumcision reduces UTI risk 10‐fold. Epidemiological data show that male and female UTI incidence peaks during infancy and declines rapidly after 12 months, making uncontrolled cohort studies in infants misleadingly positive. Despite poor evidence for operative correction of VUR, 798 surgical papers were published between 2015 and 2025. Conclusion: Few effective treatments exist to prevent paediatric UTIs. Targeted circumcision in infant males with ureteric dilatation provides a reasonable number needed to treat. Surgical intervention and routine antibiotic prophylaxis yield minimal clinical benefit.

To assess the long-term risk of reoperation following hypospadias repair in childhood and identify the risk factors associated with reoperation. We hypothesised that the technique used to repair hypospadias would influence the re-operation rate. Consecutive children who underwent hypospadias repair in New South Wales, Australia between 1991 and 2006 were included. The reoperations were identified using data linkages. The reoperation rate was calculated, and potential risk factors identified (hypospadias severity, type of repair, urethral plate division, and persistent chordee after degloving). Time-to-first event analyses were conducted using the Kaplan-Meier method. 1105 children (median follow-up 15.2 years, interquartile range 3.3 to 17.1) with a cumulative follow-up of 16,790 patient-years were included. The rates of penile reoperations was 7.3 per 100-patient years in the first, 1.7 in the second, and 0.6 in the third decade of life (p<0.001). The highest rates of penile reoperations occurred after multi-stage hypospadias repair (9.94), single-stage proximal hypospadias repair (5.7), and tubularized incised urethroplasty (TIP) (3.64). The overall probability of reoperation-free survival was 62%. Approximately 40% of children who require hypospadias repair require an additional corrective procedure, usually before their fifth birthday, with a low risk of penile reoperation in the second and third decades of life. The risk is higher after TIP repair among repairs for distal hypospadias, multistage repair, and single-stage proximal repair.

Background: Acute appendicitis is the most common paediatric emergency presentation requiring timely surgical intervention. The Sydney Children's Hospital Network (SCHN) noted in their National Surgical Quality Improvement Program‐Pediatrics (NSQIP‐P) data that their appendicectomy postoperative length of stay (LOS) was longer than that of other hospitals. Study Design: NSQIP‐P reports are calculated from case reviews with a 30‐day post‐operative follow‐up. From 2020 to 2022, the post‐operative LOS for uncomplicated appendicectomy at SCHN was a median of 24 h ( n = 714). A quality improvement project was initiated using Clinical Redesign Methodology. The project team developed an Uncomplicated Appendicectomy Guideline to standardize care. The Guideline also included a criteria‐led discharge that could be applied after 6 h of post‐operative recovery. Comprehensive information was provided for parents/carers on discharge. Results: In 2024, the median postoperative LOS was reduced from 24 to 16 h ( n = 185). This represents a statistically significant reduction in post‐operative length of stay of 33% (p < 0.001). There were no statistically significant increase in post‐operative readmissions (p = 0.95) or in NSQIP‐P morbidity rates, although there was an increase in post‐operative Emergency Department presentations noted, from a median of 7–10 annual presentations ( p < 0.05, n = 444). There was positive feedback from parents/carers with the earlier discharge ( n = 16). Parents/carers who received the discharge information sheet reported that they were better informed about their child's care. Staff in focus groups highlighted a greater autonomy in post‐operative care ( n = 24). Conclusion: Paediatric patients with uncomplicated appendicitis can be safely discharged from 6 h post‐operatively with comprehensive discharge information.