US08 - Reoperative Rate for Previous Reflux Operation Undergoing Ureteroneocystostomy for Vesicoureteral Reflux

Introduction/Purpose: Vesicoureteral reflux (VUR) is characterized by a deficiency at the ureterovesical junction leading to backflow of urine up one or both ureters. This condition occurs in 1-2% of newborns and is closely linked with urinary tract infections (UTIs). Antibiotic therapy and prophylaxis are typically used to manage VUR. However, antibiotic treatment outcomes depend on patient compliance and pose the risk of antibiotic-resistant UTIs. Ongoing pain, declining kidney function, hydronephrosis, breakthrough febrile UTIs, and pyelonephritis are indications for surgical intervention. Endoscopic injection (EI) and Ureteroneocystostomy (UNC) are surgical options for VUR. Success rates for EI have a reported success rate of 70-90%. EI is an attractive procedure since it requires no postoperative foley catheter insertion, has lower infection rates, can be done as outpatient, and usually has less reported postoperative pain; however, open UNC is the gold standard and most common surgical treatment of VUR with 98% success rates. Reoperation for UNC is reported in 0.3 - 9.1% of cases versus 14% preoperative in EI. Although success rates are similar in reoperations, the procedure becomes more technically difficult due to UVJ fibrosis requiring extensive ureteral mobilization. The objective of this study is to explore available data for VUR reoperations to identify predictive factors and outcomes of patients and compare these among patients with failed previous VUR reoperation receiving UNC and patients receiving primary UNC.

Methods or Case Description: Among the 1495, 89.4% had no previous reflux procedures, 5.6% had previous reimplant, 4.3% had previous subureteric injections, and 0.8% had both. ANOVA analysis identified several demographic variables that were different among the groups. Age, male gender, non-Caucasian race, VUR disease severity were found to be statistically significant and have an association with previous VUR intervention. Past medical history of esophageal/gastric/intestinal disease, developmental delay, structural central nervous system (CNS) abnormality, or requiring nutritional support were also statistically significant Preoperatively, Class 3 ASA classification was statistically significant. Operative outcomes showed that total operation time, length of stay (LOS), duration of anesthesia, and operating room time were statistically significant and noted to be different among these groups. UNC had the longest total operative time and anesthesia time at 218 minutes and 279.7 minutes subsequently versus 185 minutes and 246.1 minutes in the EI group. The EI group however had the longest length of stay at 2.8 versus 2.4 in the UNC group. Readmission, unplanned reoperation, unplanned foley catheter, and preoperative/ intraoperative urine cultures were not significant, but noted to be different among the groups. Univariate analysis showed age, non-Caucasian race, esophageal/gastric/intestinal disease, developmental delay, structural CNS abnormality, ASA classification was predictive of previous reflux procedure. However, on multivariate analysis, we show that only age (p< 0.001), non-Caucasian race (p=0.01) and total operation time (p=0.002) were significant.

The American College of Surgeons National Surgical Quality Improvement Program (NSQIP) Pediatric 2020 data was retrospectively analyzed for pediatric patients undergoing UNC for VUR. A total of 1742 patients were evaluated with 1495 meeting inclusion criteria. Patients were divided into 4 groups: No previous reflux procedure, previous reimplant, previous subureteric injection, and both. Basic statistics was performed between the groups using ANOVA analysis. Patient demographics, VUR disease severity, preoperative characteristics, and post operative outcomes were analyzed (Tables 1 and 2). Univariate and multivariate analysis was performed to identify independent variables contributing to previous reflux procedures (Table 3). A multivariable logistic regression model was used to identify the independent variables associated with VUR reoperation. 95% confidence intervals (CI) were calculated for Z test and odds ratio, and statistical significance was accepted at P < 0.05.

Outcomes: Table 1. Patient Demographics and Preoperative Considerations, Categorized by Previous Reflux Procedure

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,, ASA: American Society of Anesthesiologists






Table 2. Postoperative Outcomes, Categorized by Previous Reflux Procedure

P Values represent chi-square analysis for all categorical variables and one-way analysis of variance (ANOVA) for all continuous variables. (*) In minutes. MIS: Minimally Invasive Surgery, UTI: Urinary Tract Infection






Table 3. Univariate and Multivariate Analysis of Factors Associated with Previous Reflux Procedure






Dependent variable: total operation time, LOS, readmission, unplanned urinary catheter

Independent variable to control for: age, male gender, non-caucaisna race, VUR, esophageal/gastric/intestinal disease, developmental delay, structural cns abnormalities, nutrition support, and ASA classification

Conclusion: Success of reimplantation is less than reported in literature at 94.4%. Repeat anti-reflux procedure is associated with age, non-Caucasian race, esophageal/gastric/intestinal disease, developmental delay, structural CNS abnormality, ASA classification. However, our multivariate analysis shows that these were confounding factors and the only true associations with re-operation were increasing age, total operative time, and non-Caucasion race.