US13 - Vesicoureteral Reflux Severity and Its Association with Unplanned Urinary Catheter and Length of Hospital Stay After Ureteroneocystostomy

Introduction/Purpose: Vesicoureteral reflux (VUR) is the retrograde flow of urine into the kidney and is a common condition in pediatric urology, affecting 1% of all children. Surgical success often depends on the grade of VUR, as patients with VUR grades IV or V have been associated with greater comorbid complications and longer postoperative recovery time. VUR is associated with an increased risk of urinary tract infections (UTI), hydronephrosis, perinatal urinary tract dilation, and reflux nephropathy. Approximately 30% of those with VUR are found to have an abnormal renal ultrasound, characterized by the presence of either hydronephrosis or at least a one-centimeter difference in relative renal size. Hydronephrosis is a known risk factor for worsening reflux, and although curable, early detection is challenging as the patient may be asymptomatic until the development of a UTI or even renal scarring. VUR should be suspected in children with UTI, as studies have shown 30-40% of infants presenting with a UTI have VUR. Unplanned urinary catheter placement postoperatively can be a source of infection. The aim of this study is to determine if the severity of VUR is associated with higher rates of unplanned urinary catheter placement and length of hospital stay. We hypothesize that greater VUR severity correlates with higher rates of unplanned catheter insertion and longer length of stay (LOS).

Methods or Case Description: The 2020 American College of Surgeons National Surgical Quality Improvement Program Pediatric (NSQIP) data was analyzed for patients with VUR. A total of 1742 patients were evaluated with 1373 meeting inclusion criteria. The patients were divided into 3 groups of varying voiding cystourethrogram (VCUG) or radionucleotide cystogram (RNC) severity: VCUG Grade 1 or RNC Grade 1 (Group A), VCUG Grade 2 or 3 or RNC Grade 2 (Group B), and VCUG Grade 4 or 5 or RNC Grade 3 (Group C). Basic statistical analysis was performed using ANOVA analysis. Mann Whitney U Test/Wilcoxon rank-sum test was used for continuous dependent variables and categorical independent variables where the data does not follow a normal distribution. Logistic fit was used for categorical dependent variables and continuous independent variables. Data were reported as the Mean ± Standard Deviation for numerical variables, n (%) for categorical variables and adjusted ORs (AOR; 95% confidence intervals [CI]). Statistical significance was accepted at P < .05.



Outcomes: Among the 1373 patients, 2.9% were in Group A, 32.5% were in Group B, and 64.6% were in Group C. On ANOVA, age, male gender, inpatient status, operative approach (MIS), congenital malformation, unilateral procedure, pre/intraoperative urine culture, total operative time, length of stay, postoperative UTI, blood transfusion, superficial surgical site infection, postoperative emergency department visits, unplanned procedure, and unplanned urinary catheter were different among the groups (Table 1 and 2). Univariate and multivariate analysis showed that UTI (p< 0.001), unplanned procedure related to anti-reflux procedure (p< 0.001), and 24-30 weeks gestation (p=0.032) were the independent factors contributing to unplanned urinary catheter postoperatively. Nutritional support was associated with less unplanned urinary catheter insertion (p=0.017) (Table 3). Additionally, total operation time, ureteral stent, UTI, unplanned procedure, and ASA classification 3 were associated with increased LOS. Unplanned urinary catheter placement was associated with decreased LOS (Table 4).



Conclusion: We report that higher VCUG VUR grade does not appear to increase unplanned urethral catheter insertion or length of hospital stay. UTI was associated with both increased length of stay and unplanned urinary catheterization. Additionally, nutritional support, unplanned procedures, and prematurity at 24-30 weeks gestations were associated with unplanned urinary catheter insertion. There were increasing LOS in groups that had ureteral catheters, increasing total operation time, unplanned procedure, and ASA classification of 3.

Table 1. Patient Demographics and Preoperative Characteristics for VCUG Grade Groups



P Values represent chi-square analysis for all categorical variables and one-way analysis of variance (ANOVA) for all continuous variables. VCUG: Voiding Cystourethrogram, CNS: Central Nervous System, Lap: Laparoscopic, MIS: Minimally Invasive Surgery, SIRS: Systemic Inflammatory Response Syndrome, UTI: Urinary Tract Infection, ASA: American Society of Anesthesiologists



Table 2. Patient Postoperative Outcomes for VCUG Grade Groups



*Occurring 0 – 30 Days After VUR Procedure

P Values represent chi-square analysis for all categorical variables and one-way analysis of variance (ANOVA) for all continuous variables.



Table 3. Univariate and Multivariate Analysis for Factors Leading to Unplanned Urinary Catheter Insertion



VUR = Vesicoureteral Reflux, VCUG = Voiding Cystourethrography, UTI = Urinary Tract Infection, ASA = American Society of Anesthesiology



Table 4. Univariate and Multivariate Analysis for Factors Increasing LOS After Ureteroneocystostomy



VUR = Vesicoureteral Reflux, VCUG = Voiding Cystourethrography, UTI = Urinary Tract Infection, ASA = American Society of Anesthesiology