Purpose The management of the contralateral inguinal canal in children with clinical unilateral inguinal hernia is controversial. Our objective was to systematically review the literature regarding management of the contralateral inguinal canal. Methods We searched MEDLINE, EMBASE, and Cochrane databases (1940–2011) using ‘hernia’ and ‘inguinal’ and either ‘pediatric,’ ‘infant,’ or ‘child,’ to identify studies of pediatric (age≤21 yrs) patients with inguinal hernia. Among clinical unilateral hernia patients, we assessed the number of cases with contralateral patent processus (CPP) and incidence of subsequent clinical metachronous contralateral hernia (MCH). We evaluated three strategies for contralateral management: expectant management, laparoscopic evaluation or pre-operative ultrasound. Pooled estimates of MCH or CPP were generated with random effects by study when heterogeneity was found (I2>50%, or Cochrane’s Q p≥0.10). Results We identified 2,477 non-duplicated studies, 129 of which met our inclusion criteria and had sufficient information for quantitative analysis. The pooled incidence of MCH after open unilateral repair was 7.3% (95% CI 6.5%–8.1%). Laparoscopic examination identified CPP in 30% (95% CI 26%–34%). Lower age was associated with higher incidence of CPP (p<0.01). The incidence of MCH after a negative laparoscopic evaluation was 0.9% (95% CI 0.5%–1.3%). Significant heterogeneity was found in studies and pooled estimates should be interpreted with caution. Conclusions The literature suggests that laparoscopically identified CPP is a poor indicator of future contralateral hernia. Almost a third of patients will have a CPP, while less than one in 10 will develop MCH when managed expectantly. Performing contralateral hernia repair in patients with CPP results in overtreatment in roughly 2 out of 3 patients.

There is wide variation in procedure choice for children with kidney stones at freestanding children's hospitals in the United States. Treatment choice depends significantly on the hospital at which a patient undergoes treatment.

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surgeons are directed to a hub center for surgery, there was an absence of income level influence on quality of care metrics used in kidney cancer, including the use of nephron-sparing surgery and minimally invasive surgery, and survival outcomes. These findings may suggest a benefit of centralizing cancer care to ensure patients have access to adequate expertise. Importantly, the surgical management of kidney cancer is quite different than prostate cancer and is largely based on the experience and recommendation of the surgeon, including the decision to undergo radical vs partial nephrectomy or open vs minimally invasive surgery. While centralization may improve access to specialized services, it is important to remember that patients often incur additional costs and logistical complexities with this required travel that can be a barrier. 3 In fact, some patients may choose to have treatment closer to home even at the expense of inferior survival outcomes. 4 In the present study, we included patient residence (rural vs urban) as a surrogate for access to care and found that this was not significantly associated with treatment selection. Part of this may be due to the unique preexisting organization of prostate cancer care in our province, whereby the vast majority of patients are treated (with either surgery or radiation) in the capital city. Since treatments are naturally centralized in our jurisdiction, the referral hospital or volume of the center has a null effect. Outside of this unique position, we acknowledge that for specialized cancer care a centralized model of care delivery may work well in a universal health care system; however, we must remain sensitive to the unintended costs and sacrifices that patients are required to make to travel for such care.