US04 - Factors and Outcomes Leading to Postoperative Emergency Department Visits after Ureteroneocystostomy

Introduction/Purpose: Vesicoureteral reflux (VUR) is one condition that can result in significant complications without timely treatment. The gold standard treatment for VUR in the pediatric population is considered to be ureteroneocystostomy (UNC). Studies have identified the UNC success rate as greater than 90%. UNC prevents renal damage from scarring or infection with the reimplantation of the ureter into the bladder. Previous studies have demonstrated that although UNC provided lower rates of future VUR procedures, hospital readmissions as well as emergency department (ED) visit rates were higher after treatment. The most common causes of ED visits following a urologic procedure are urinary tract infections and catheter concerns. UNC is more likely to have complications that are related to surgical site infections, longer sedation time, and postoperative pain. There are limited studies identifying predisposing factors to UNC that increase the risk of these surgical complications. The aim of this study is to identify predictive factors that lead to increased post-discharge readmissions and ED visit rates after UNC.

Methods or Case Description: The American College of Surgeons National Surgical Quality Improvement Program (NSQIP) 2020 Pediatric data was retrospectively analyzed for pediatric patients undergoing ureteroneocystostomy for VUR. 1,742 total patients were evaluated with 1,495 meeting inclusion criteria. 247 samples were not included due to postoperative variables unreported. The patients were divided into two groups: ED visits within 0-30 days following anti-reflux procedure (n=164) and no ED visits after reflux procedure (n=1,331). For categorical variables, Pearson chi-square tests were performed. T-test analysis was performed for continuous variables with mean +/- SD presented. To predict factors associated with postoperative ED visits after UNC, a univariate and multivariate analysis was performed with significant variables from the basic statistical analysis.

Outcomes: Among the 1,495 pediatric patients, 11.0% reported ED visits postoperatively after ureteroneocystostomy. These patients were more likely to have been of Hispanic ethnicity, have increased structural pulmonary irregularities, gastrointestinal diseases, ostomy presence, minor cardiac risk factors, or born prematurely between 35-36 weeks (Table 1). Further, patients that required a postoperative ED visit following UNC were more likely to have had a longer mean operative time, surgical site infection, postoperative urinary tract infection (UTI), postoperative sepsis, prior readmission, renal insufficiency, unplanned reoperation, blood transfusion, as well as placement of an unplanned urinary catheter (Table 2). Univariate and multivariate analysis displayed postoperative UTI (p < 0.001), superficial surgical site infection (p = 0.022), unplanned procedure (p < 0.001), unplanned urinary catheter (p < 0.001), and 35-36 weeks gestation (p=0.004) were all independent risk factors for postoperative-UNC ED visits (Table 3).


Table 1. Patient Demographics and Preoperative Characteristics For Patients Requiring Postoperative ED Visits




P Value represents tests for significant variation from chi-square analysis of categorical variables and t-tests and Welch tests for continuous factors. Significant p values in bold.

VUR = Vesicoureteral Reflux, VCUG = Voiding Cystourethrogram, RNC = Radionuclide Cystogram, CNS = Central Nervous System, SIRS = Systemic Inflammatory Response Syndrome, ASA = American Society of Anesthesiology



Table 2. Post Operative Outcomes for Patients Requiring Postoperative Emergency Department Visits



P Value represents tests for significant variation from chi-square analysis of categorical variables, t-test for continuous factors with equal variance, and Welch test for continuous factors with unequal variance. MIS = Minimally Invasive Surgery, SSI = Surgical Site Infection, UTI = Urinary Tract Infection


Table 3. Univariate and Multivariate Analysis of Factors Leading to Postoperative ED Visits






Conclusion: ED visits are one complication amongst pediatric populations after UNC. It is vital to effectively minimize postoperative complications by taking caution before discharge after surgery. Our study shows that factors such as UTI, surgical site infection, unplanned urinary catheter, unplanned reoperation, and prematurity were all associated with increased ED visits after UNC.