Surgical Correction Of Vesicoureteral Reflux Research Articles

Long-Term Follow-Up after Ureteral Reimplantation in Children: A 12-Year Analysis

Abstract Background Ureteral reimplantation (UR) is a well-established procedure, yet there exists a notable absence of evidence-based guidelines for postoperative follow-up. Existing literature suggests that routine follow-up extending beyond one year may not yield significant advantages, particularly for asymptomatic children. However, it is crucial to acknowledge that many studies supporting this assertion rely on relatively short observation periods. Aims This study seeks to address the potential emergence of late-presenting complications post UR. Our objective is to comprehensively evaluate our patient cohort for the incidence of conditions warranting the establishment of standardized, long-term follow-up practices after UR. Methods Retrospective review of 137 medical records from children who underwent UR at our institution between January 2006 and June 2013. Inclusion criteria required a minimum 10-year postoperative follow-up. Results Fifty-three renal units in 34 children met inclusion criteria. Ureterovesical junction (UVJ) obstruction occurred in 7.5% of the units and was diagnosed within eight months after UR. Obstruction occurred exclusively after Politano-Leadbetter reimplantation and was silent in all cases. Postoperative UTIs occurred in 9 children. Notably, these were all singular events without signs for recurrent reflux. A decade after surgery, one child developed chronic kidney disease (CKD) due to preexisting reflux nephropathy (RN), while one child was newly diagnosed with RN during follow-up despite the timely surgical correction of vesicoureteral reflux (VUR). or hypertension linked to RN were recorded. Conclusion Children with uncomplicated postoperative recoveries within the first-year, devoid of evident UVJ obstruction, exhibit a low subsequent risk, suggesting limited benefit from repeated scheduled long-term follow-up. Nevertheless, we recommend that general practitioners conduct regular monitoring, considering individual risk factors, to enhance the detection of late-onset hypertension or proteinuria as potential indicators of RN during adolescence.

Vesicoureteral Reflux: Special Considerations and Specific Populations

This review will hopefully serve as a brief update on the current approaches to vesicoureteral reflux (VUR) within the context of historical approaches to this disorder and dispelling some of the myths surrounding its treatment. There is also greater focus on certain populations with VUR that may (or may not) be at particular risk. Despite several large studies showing the benefit of antibiotic prophylaxis in preventing infections in VUR, there continues to be conflicting results in smaller scale studies or in regard to renal scarring that prevent its accepted use universally. Some of these conflicting results are a product of comparing a mixed population of individuals, as there are certain populations that seem to benefit from antibiotic prophylaxis and for which it should be considered. Similarly, surgical correction of VUR is not beneficial for many individuals even within certain higher risk populations, such as higher grade VUR, pre-pubertal females, and renal transplant recipients. Preceding febrile infections and the presence of renal scarring are two indicators of higher risk individuals. However, renal scarring in some individuals may not be secondary to infections. Therefore, an individualized approach to each patient with VUR is needed, with some needing treatment by surgery, some needing antibiotic prophylaxis, some needing optimal bladder care, and even others needing treatment of the sequelae of renal scarring.

P0305DIAGNOSTIC VALUE OF TGF-B-1 AND ANG II EXCRERION IN URINE IN CHILDREN WITH VESICOURETERAL REFLUX DEPENDING ON THE THERAPEUTIC APPROACH

Abstract Background and Aims to determine the diagnostic value of profibrogenic cytokines of transforming growth factor (TGF-β1) and angiotensin II (AngII) in urine to detect the severity of tubulointerstitial fibrosis in children with vesicoureteral reflux (VUR) depending on the therapeutic approach. Method 117 patients aged 3 to 16 years (mean age 10.2 ± 4.5, 70.1% of girls) with VUR were examined. The control group consisted of 20 healthy children. All children underwent a complete nephrological examination. The levels of TGF-β1 and AngII were determined in morning urine using the ELISA method and counted for urine creatinine. To identify the severity of the lesion of the renal parenchyma, a static DMSA scintigraphy was performed. Results depending on the therapeutic approach, the children were divided into 2 groups: 1 gr. - children on conservative treatment (63.2%), 2 gr. - children, after surgical correction of VUR (36.8%). In each group, 3 subgroups were identified depending on the development of tubulo-interstitial fibrosis according to DMSA: A subgr. - without signs of sclerosis (15.4%), B subgr. - 1-2 foci (44.74%) and C subgr - > 3-4 foci of sclerosis (40.1%). All patients with VUR had a high urinary excretion of TGF-β1/Cr and AngII/Cr when compared with the control group (p<0.05). Regardless of the therapeutic approach, in subgroups A (without foci of sclerosis) and B (1-2 foci of sclerosis), patients had a statistically significantly lower level of excretion of these cytokines when compared with patients from subgroup C (p <0.05). No significant difference was found in the urinary excretion of TGF-β1/Cr and AngII/Cr depending on the therapeutic approach. Conclusion we established a reliable dependence of the excretion of TGF-β1/Cr and AngII /Cr in the urine on the severity of tubulo-interstitial fibrosis according to DMSA scintigraphy in children with VUR. At the same time, we did not note the dependence of the excretion of TGF-β1/Cr and AngII/Cr in the urine on the method of the therapeutic approach. Therefore, the study of the excretion of TGF-β1/Cr and AngII/Cr in the urine as non-invasive markers can be used as a criterion for the progression of nephropathy in VUR, regardless of treatment methods.

Does de novo hydronephrosis after pediatric robot-assisted laparoscopic ureteral re-implantation behave similarly to open re-implantation?

While open ureteral re-implantation surgery is the gold standard for surgical correction of vesicoureteral reflux (VUR), robot-assisted laparoscopic ureteral re-implantation via an extravesical approach (RALUR-EV) has become a minimally invasive alternative. Previous studies have shown that transient hydronephrosis after open re-implantation can occur in up to 28% of patients. However, previous studies have also shown that de novo hydronephrosis after open re-implantation is not predictive of final differential renal function. A retrospective review was performed to characterize the natural history of postoperative hydronephrosis after RALUR-EV for primary VUR in pediatric patients. A retrospective chart review of a single-surgeon series was performed for pediatric patients who underwent RALUR-EV for primary VUR. The severity of de novo hydronephrosis was assessed using the Society for Fetal Urology (SFU) grading system via renal ultrasound at the 1-month postoperative follow-up. Renal ultrasound was performed at least every six months. Radiographic success was defined as complete resolution of VUR on the voiding cystourethrogram at the 4-month mark. Patient demographics, surgery duration, length of hospital stay, pre-operative and postoperative VUR grades, and follow-up time periods were collected. Patients with other associated urinary pathology and patients lost to follow-up were excluded from the study. A total of 87 patients (121 kidney units) with primary VUR who underwent RALUR-EV met the inclusion criteria. SFU grade 1-3 hydronephrosis was noted in 30.3% (36/119) of kidney units at the 1-month mark, but 83.9% (26/31) cases with hydronephrosis completely resolved in a median time of 7.9 months (range: 3.4-21.0 months), and all four cases with unresolved hydronephrosis were downgraded to SFU grade 1 without the need for intervention. A radiographic success rate of 96% was demonstrated in this cohort, which is comparable with that of historical open re-implantation series. A similar rate of de novo hydronephrosis was also noted in this cohort when compared with that of previous open re-implantation series, but de novo hydronephrosis after RALUR-EV had a similar or more rapid resolution rate than that previously reported after open intravesical and extravesical re-implantation series. De novo hydronephrosis after RALUR-EV behaves similarly to de novo hydronephrosis after open ureteral re-implantation, where de novo hydronephrosis is present in up to 30% of pediatric patients who underwent RALUR-EV. The hydronephrosis self-resolves without the need for intervention in the overwhelming majority of casesand resolves at a median time of 7.9 months after surgery.

Interventions for primary vesicoureteric reflux.

Interventions for primary vesicoureteric reflux.

A meta-analysis of the incidence and fate of contralateral vesicoureteral reflux in unilateral multicystic dysplastic kidney

Multicystic dysplastic kidney (MCDK) is the most common type of renal cystic disease. It is associated with urinary tract abnormalities in the contralateral kidney in up to 30% of cases, most commonly vesicoureteral reflux (VUR). The objective of this study was to describe the incidence and selected issues in management and evolution for each VUR grade in the contralateral kidney of patients with unilateral MCDK, in order to strengthen the scientific basis regarding the need for voiding cystourethrography (VCUG) screening. A comprehensive search of standard and gray literature was performed. Full-text screening, data abstraction, and quality appraisal were conducted in duplicates. Included studies reported a primary diagnosis of unilateral MCDK with contralateral VUR determined by VCUG. Articles had to include a distribution of VUR grade to meet the eligibility criteria. From 698 retrieved articles, 37 studies enrolling 2057 patients were analyzed. Of the patients, 80% were male; 50% had left unilateral MCDK; and 87% were diagnosed prenatally. A total of 1800 patients had VCUG, of whom 303 had VUR (weighted proportion: 17%; 95% confidence interval [CI]: 14-20%). Weighted proportions of VUR were 9%, 7%, and 17% for grades I-II, III-V, and I-V, respectively. Of the patients, 99% (95% CI: 97-100%) were on continuous antibiotic prophylaxis (CAP) and 18% (95% CI: 8-37%) had urinary tract infections (UTIs), with a higher rate of UTIs (23% vs 10%) in patients with dilating (grades III-V) VUR, over a mean follow-up of 40 months. In patients with dilating VUR, reflux resolved or downgraded to grade I in 52% (95% CI: 37-67%) of patients, and 32% (95% CI: 19-49%) had surgical correction of VUR. Among patients with unilateral MCDK, 17% have VUR in the contralateral kidney, 41% of which is dilating VUR. Of the cases with dilating VUR, half will resolve or downgrade to grade I during follow-up; 23% will develop a UTI despite CAP; and one-third will undergo ureteral re-implantation. While many physicians may thus choose to forego routine VCUG screening of the single functional kidney, shared decision-making with the patient's caregivers is currently recommended, where the risks and benefits of the different approaches can be discussed. The data from this analysis can help inform the discussions.

Technique of Antireflux Procedure without Creating Submucosal Tunnel for Surgical Correction of Vesicoureteric Reflux during Bladder Closure in Exstrophy.

Aim:To report the clinical application of the new surgical technique of antireflux procedure without creating submucosal tunnel for surgical correction of vesicoureteric reflux during bladder closure in exstrophy.Materials and Methods:Based on the report of published experimental technique, the procedure was clinically executed in seven patients of classic exstrophy bladder with small bladder plate with polyps, where the creation of submucosal tunnel was not possible, in last 18 months. Ureters were mobilized. A rectangular patch of bladder mucosa at trigone was removed exposing the detrusor. Mobilized urteres were advanced, crossed and anchored to exposed detrusor parallel to each other. Reconstruction included bladder and epispadias repair with abdominal wall closure. The outcome was measured with the assessment of complications, abolition of reflux on cystogram and upper tract status.Results:At 3-month follow-up cystogram, reflux was absent in all. Follow-up ultrasound revealed mild dilatation of pelvis and ureter in one.Conclusions:The technique of extra-mucosal ureteric reimplantation without the creation of submucosal tunnel is simple to execute without risk and complications and effectively provides an antireflux mechanism for the preservation of upper tract in bladder exstrophy. With the use of this technique, reflux can be prevented since the very beginning of exstrophy reconstruction.

Comparison of intravesical (Cohen) and extravesical (Lich–Gregoir) ureteroneocystostomy in the treatment of unilateral primary vesicoureteric reflux in children

Various intravesical and extravesical techniques have been described for the surgical correction of vesicoureteral reflux (VUR). Among those techniques Cohen (intra-vesical) and Lich-Gregoir (extra-vesical) are the most commonly used ones. However, there are limited studies that compare those two surgical techniques in the literature. In this study, we aim to compare the outcomes of the open intravesical and extravesical procedures for unilateral primary VUR in children. We analyzed the records of 118 consecutive children with primary VUR who underwent open ureteral reimplantation surgery by single surgeon from January 2011 to October 2015 at our institution. Among them, intravesical reimplantation was group A, and extravesical reimplantation procedure was group B. We retrospectively analyzed the clinical data of both groups, including age, sex, preoperative reflux grade, presence of lower urinary tract symptoms (LUTS), operative time, postoperative complications and hospitalization period. Success of surgery was defined as the resolution of the VUR as determined by voiding cystourethrography 6 -12 months after surgery. All the parameters were statistically compared. A total of 58 patients were found eligible for the study. In 23 cases intravesical (group A) and in 35 cases extravesical (group B) procedure were performed. The operative time in group A was significantly higher than group B (110.3±16.9 and 87±29.8 min, respectively, p = 0.002). The mean hospital stay was also longer in group A (2.8±0.8 and 1.2±0.6 days, respectively, p = 0.007). The ureteral catheterization periods were 14.1±6.1 days for group A and there was no ureteral catheter placement in group B. The success rate of the two groups were comparable (100% vs 94.9%, p = 0.513). No intraoperative complications were detected in either group. The number of febrile urinary tract infections were similar between the groups after a mean follow up of 18.2 months (p = 0.746). Our results confirmed that both Cohen and Lich-Gregoir procedures had equivalent success and complication rates. Lich-Gregoir technique was found superior to Cohen technique in terms of hospital stay and operative time. Moreover, it avoids the necessity of urethral and ureteral stenting which probably might increase the comfort of the patients postoperatively. The main limitations of our study are unrecorded pain scores and amount of analgesics taken the after surgery and retrospective analysis of the data. Both the open intravesical and extravesical ureteroneocystostomy procedures are equally effective in the treatment of primary unilateral VUR. Any of the techniques can be opted by the surgeons depending on their surgical experience.

Readmissions, unplanned emergency room visits, and surgical retreatment rates after anti-reflux procedures

The choice between endoscopic injection (EI) and ureteroneocystotomy (UNC) for surgical correction of vesicoureteral reflux (VUR) is controversial. To compare postoperative outcomes of EI vs UNC. This study reviewed linked inpatient (SID), ambulatory surgery (SASD), and emergency department (SEDD) data from five states in the United States (2007-10) to identify pediatric patients with primary VUR undergoing EI or UNC as an initial surgical intervention. Unplanned readmissions, additional procedures, and emergency room (ER) visits were extracted. Statistical analysis was performed using multivariate logistic regression using generalized estimating equation (GEE) to adjust for hospital-level clustering. The study identified 2556 UNC and 1997 EI procedures. Compared with patients undergoing EI, those who underwent UNC were more likely to be younger (4.6 vs 6.0 years, P<0.001), male (30 vs 20%, P<0.001), and publicly insured (34 vs 29%, P<0.001). As shown in Summary Figure, compared with EI, UNC patients had lower rates of additional anti-reflux procedures within 12 months (25 (1.0) vs 121 (6.1%), P<0.001), but a higher rate of 30-day and 90-day readmissions and ER visits. On multivariate analysis, patients treated by UNC remained at higher odds of being readmitted (OR=4.45; 2.69 in 30 days; 90 days, P<0.001) and to have postoperative ER visits (OR=3.33; 2.26 in 30 days; 90 days, P<0.001); however, EI had significantly higher odds of repeat anti-reflux procedures in the subsequent year (OR=7.12, P<0.001). Endoscopic injection constituted nearly half of initial anti-reflux procedures in children. However, patients treated with UNC had significantly lower odds of requiring re-treatment in the first year relative to those treated with EI. By contrast, patients treated with UNC had more than twice the odds of being readmitted or visiting an ER postoperatively. Although the available data were amongst the largest and most well validated, the major limitation was the retrospective nature of the administrative database. The practice setting may not be generalizable to states not included in the analysis. Postoperative readmissions and ER visits were uncommon after any surgical intervention for VUR, but were more common among children undergoing UNC. The EI patients had a more than seven-fold increased risk of surgical re-treatment within 1 year.

Transient Fanconi syndrome in two preterm infants with hydronephrosis and urinary tract infection.

Type IV renal tubular acidosis is known to occur in obstructive uropathy with urinary tract infection. Fanconi syndrome, however, has not been described in these settings. We report two preterm infants who developed Fanconi syndrome associated with hydronephrosis and urinary tract infection. Patient 1 is a boy with 21 trisomy, bilateral renal hypoplasia and bilateral vesicoureteral reflux delivered at 35weeks' gestation. At postnatal day 42, he developed Fanconi syndrome after urinary tract infection, which persisted until the surgical correction of vesicoureteral reflux. Patient 2 was delivered at 35weeks' gestation. At postnatal day 9, he was admitted for severe dehydration. He had phimosis and ultrasonography showed left pelviectasis. Laboratory data were compatible with Fanconi syndrome, which resolved spontaneously after fluid therapy. Subsequently urine culture grew bacteria and treatment for infection and topical corticosteroid for phimosis were performed. DMSA scintigraphy performed later showed left renal scar. Tubular cell stretch, due to vesicoureteral reflux in Patient 1 and phimosis in Patient 2, and urinary tract infection in association with immaturity of tubules are thought to have caused Fanconi syndrome.

Current status of robotic-assisted surgery for the treatment of vesicoureteral reflux in children.

Although open ureteral reimplantation remains the gold standard for surgical correction of vesicoureteral reflux (VUR), robotic-assisted laparoscopic ureteral reimplantation (RALUR) holds promise and is becoming more widely utilized. The present article outlines primary operative techniques for RALUR, summarizes the current literature with respect to surgical outcomes and costs, and discusses early applications of RALUR to complex and reoperative cases. Intravesical and extravesical techniques for RALUR have been described. Published outcomes vary with respect to operational definitions of surgical success and reporting of complications. Several studies have directly compared RALUR and open reimplant, suggesting equivalent efficacy and safety. Recent noncomparative studies have reported lower VUR resolution rates and higher complication rates for RALUR, particularly in bilateral cases. The application of RALUR to reoperative surgery and cases requiring tapering and dismemberment is under very early investigation. RALUR is consistently associated with lower postoperative analgesic requirements and decreased hospital stay, but longer operative times and higher costs compared to open reimplant. Published outcomes after RALUR show mixed results that, on average, may be inferior to open reimplant. Future investigations should seek to identify patient-related and intraoperative factors associated with successful and unsuccessful outcomes.

Open versus minimally invasive ureteroneocystostomy: A population-level analysis

Open ureteroneocystostomy (UNC) is the gold standard for surgical correction of vesicoureteral reflux (VUR). Beyond single-center reports, there are few published data on outcomes of minimally-invasive (MIS) UNC. Our objective was to compare postoperative outcomes of open and MIS UNC using national, population-level data. We reviewed the 1998-2012 Nationwide Inpatient Sample to identify pediatric (≤18 years) VUR patients who underwent either open or MIS UNC. Demographics, National Surgical Quality Improvement Program (NSQIP) complications, length of stay (LOS), and cost data were extracted. Statistical analysis was performed using weighted, hierarchical multivariate logistic regression (complications) and negative binomial regression (LOS, cost). We identified 780 MIS and 75,976 open UNC admissions. Compared with patients undergoing open UNC, patients who underwent MIS UNC were likely to be older (6.2 versus 4.8 years, p<0.001), publically insured (43 versus 26%, p<0.001), and treated in recent years (90 versus 46% after 2005, p<0.001). MIS admissions were associated with a significantly shorter length of stay (1.0 versus 1.8 days, p<0.001) and higher cost ($9230 versus $6,304, p=0.002). After adjusting for patient-level confounders (age, gender, insurance, treatment year, and comorbidity), and hospital-level factors (region, bedsize, and teaching status), MIS UNC was associated with a significantly higher rate of postoperative urinary complications such as UTIs, urinary retention, and renal injury (OR 3.1, p=0.02), shorter LOS (RR 0.8, p=0.02), and higher cost (RR 1.4, p=0.008). Strengths of this study are its large cohort size, long time horizon, national estimation, and cost data. Most prior studies are case-series limited to the size of the institutional cohort. Our analysis of 76,756 operative encounters revealed that open UNC continues to be performed at far greater frequency than MIS UNC, outpacing the latter modality by nearly 100:1. Children treated with MIS UNC had three times greater odds of developing postoperative urinary complications, and MIS UNC patients incurred average costs per admission that were nearly 1.5 times higher than those of children who underwent open UNC. These children were also likely to be older, publically insured, and treated in more recent years. On the other hand, patients treated with MIS UNC required substantially shorter postoperative hospitalization, with an average LOS roughly half that of open UNC cases. Limitations include the retrospective nature of the administrative database, lack of detailed patient-level data, and no available long-term postoperative outcomes. Compared with open surgery, MIS UNC was associated with shorter LOS but higher costs and possibly higher urinary complication rates.

Epidural insertion height for ureteric reimplant surgery; does location matter?

Surgical correction of vesicoureteric reflux through ureteric reimplantation is a common, highly successful treatment. Postoperative pain can be severe and may relate to somatic wound pain from the lower abdominal incision or from visceral bladder spasm pain. To conduct a prospective quality improvement audit to compare four perioperative analgesic techniques. Observational data were collected on 217 patients following open ureteroneocystostomy over 5 days. The patients were split into four groups: (i) 'morphine' infusion; (ii) 'caudal'-single-shot caudal; (iii) 'epidural'-epidural catheter inserted at T10-L2 given a bolus, followed by an infusion of 0.125% bupivacaine with fentanyl 2 μg·ml(-1) ; (iv) 'caudal catheter'-caudal placed epidural catheter was treated similar to the epidural catheter. Data regarding postoperative analgesic interventions were recorded. Intravesical pethidine was used for bladder spasm pain and i.v. morphine for wound pain. Over the study period, the caudal catheter technique (mean interventions/patient = 1.8 ± 2.6) and the single-shot caudal (6.1 ± 4) needed significantly less bladder spasm interventions than morphine (9.2 ± 4) and epidural (8.0 ± 4.4) patients. For wound pain, the caudal catheter (8.8 ± 3.3) and epidural groups (11.4 ± 3.2) needed significantly less interventions than morphine (16.1 ± 3) and caudal (15.3 ± 3.3) patients. Overall, caudal catheter patients on average required about half the number of pain interventions and were associated with less high nursing workload. Despite some limitations in data collection and study design, the caudal catheter technique was superior at reducing pain interventions, particularly bladder spasm interventions. Overall epidural analgesia was not superior to a single-shot caudal followed by opioid infusion. The issue of bladder spasm may be similar to the phenomenon of sacral sparing in obstetric epidural anesthesia. Thus, regional techniques, such as caudal epidural, targeting a better balance between sacral and lumber nerves are required.

Extravesical (modified Gregoir Lich) versus intravesical (Cohen's) ureteric reimplantation for vesicoureteral reflux in children: A single center experience.

Introduction:There are multiple techniques for surgical correction of vesicoureteral reflux (VUR). We compared the outcomes of extravesical versus Cohen's reimplantation for VUR in children.Methods:Records of all children (n = 118) who underwent reimplantation for VUR between 2003 and 2014 were analyzed (male: female = 43:75). Children with secondary VUR, duplication anomalies, and ectopic ureter were excluded from our study. Extravesical reimplantation (EVR) was performed bilateral in 32 children (Group 1a) and unilateral in 19 (Group 1b), while bilateral Cohen's reimplantation was performed in 67 (Group 2). Parameters compared were length of the surgical procedure, average duration of stay in the hospital, postoperative bladder spasms, significant hematuria >72 h, and long-term complications.Results:The mean age at operation was 15 months in Group 1, and 36 months in Group 2. The mean duration of surgery was significantly less (P = 0.0001) in Group 1a (n = 32; mean 104 min; standard deviation [SD] 18 min) compared to Group 2 (n = 67; mean 128 min; SD 15 min). The mean (SD) postoperative stay was significantly lower (P = 0.0001) at 4.5 (1.5) days in Group 1a compared to 6.5 (0.5) days in Group 2. Postoperative bladder spasms were significantly lower (P = 0.03) at 10/32 in Group 1a compared to 37/67 in Group 2. All patients responded well with anticholinergics. Postoperative hematuria and bladder spasms were significantly lower (P = 0.03) in Group 1a compared to Group 2. There was no significant difference in persistent VUR between Group 1 and Group 2. At 1 year follow, none of them had any evidence of ureteral obstruction.Conclusions:EVR has lower operative time, less postoperative discomfort and shorter hospital stay compared to Cohen's reimplantation. Both techniques are equally effective in treating reflux.

MP54-11 READMISSION, UNPLANNED EMERGENCY ROOM VISITS, AND SURGICAL RETREATMENT RATES AFTER VESICOURETERAL REFLUX PROCEDURES

You have accessJournal of UrologyPediatrics: Urinary Tract Infections/Vesicoureteral Reflux1 Apr 2015MP54-11 READMISSION, UNPLANNED EMERGENCY ROOM VISITS, AND SURGICAL RETREATMENT RATES AFTER VESICOURETERAL REFLUX PROCEDURES Hsin-Hsiao Wang, Rohit Tejwani, John Wiener, and Jonathan Routh Hsin-Hsiao WangHsin-Hsiao Wang More articles by this author , Rohit TejwaniRohit Tejwani More articles by this author , John WienerJohn Wiener More articles by this author , and Jonathan RouthJonathan Routh More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2015.02.2034AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES The choice between endoscopic injection (EI) and ureteroneocystotomy (UNC) for surgical correction of vesicoureteral reflux (VUR) is controversial. There is little data on VUR surgical outcomes from a population-level perspective. Our objective was to compare post-operative outcomes of both modalities using statewide datasets. METHODS We reviewed the 2007-2010 CA, FL, NC, and UT State Ambulatory Surgery and Service Databases (SASD), State Emergency Department Databases (SEDD) and State Inpatient Databases (SID) to identify pediatric (<= 18y) VUR patients who received either EI or UNC as an initial surgical intervention. States were chosen solely due to data completeness. Patients with neurogenic bladder, ureterocele, megaureter, posterior urethral valves, bladder extrophy, kidney transplant, or prune belly syndrome were excluded. Unplanned readmissions, additional procedures, and ER visits were extracted. Statistical analysis was performed using multivariate logistic regression using GEE to adjust for hospital-level clustering. RESULTS We identified 1,802 UNC and 1,768 EI procedures. Compared with patients underwent EI, patients who underwent UNC were more likely to be younger (4.8 v. 5.8 years, p<0.001), male (30 v. 22%, p<0.001), & publically insured (53 v. 50%, p<0.001). Compared with EI patients, UNC patients had a significantly lower rate of additional anti-reflux procedures within 12 months (19 (1.1%) v. 178 (10%), p<0.001) but a higher rate of 90-day readmissions (109 (6.0%) v. 42 (2.4%), p<0.001) and ER visits (263 (15%) v. 128 (7.2%), p<0.001). After adjusting for age, gender, insurance status, Charlson comorbidity score, treatment year, and hospital clustering, patients treated by UNC remained significantly more likely to be readmitted (OR=2.74, p<0.001) and to have postoperative ER visits (OR=2.12, p<0.001); however, patients treated by EI remained significantly more likely to undergo repeat anti-reflux procedures (OR=12.48, p<0.001). CONCLUSIONS Postoperative readmissions and ER visits were uncommon after any surgical intervention for VUR, but UNC was associated with 2-fold increased odds of readmission and postoperative ER visits. Strikingly, 10% of EI patients required retreatment; compared to UNC pts, this represents 12-fold increased odds of surgical retreatment. © 2015 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 193Issue 4SApril 2015Page: e669 Advertisement Copyright & Permissions© 2015 by American Urological Association Education and Research, Inc.MetricsAuthor Information Hsin-Hsiao Wang More articles by this author Rohit Tejwani More articles by this author John Wiener More articles by this author Jonathan Routh More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Creation of effective antireflux mechanism without creation of submucosal tunnel in surgical correction of vesicoureteric reflux: Myth or reality?-An experimental study

Objective:To evaluate the possibility of creating an effective antireflux mechanism without the need to create submucosal tunnel in surgical correction of vesicoureteric reflux.Materials and Methods:Ethical clearance was obtained from the institute ethical committee. The prospective experimental study was conducted on fresh postmortem specimens comprising of intact ureter-bladder-urethra of slaughtered lamb. Through perurethral tube, bladder distension revealed intact antireflux mechanism which disappeared following a cephalad slit of ureteric orifice. After intravesical advancement, mobilized ureters were anchored to the hiatus and the exposed detrusor along the proposed submucosal tunnel after stripping the bladder mucosa. Limited nonobstructed narrowing of the advanced ureteric ends was fashioned. After closure, bladder was distended and reflux was observed through proximal transected ureteric orifices with check cystogram. In second part of experiment, in a rectal reservoir, two intestinal segments as dilated ureters were implanted without creating submucosal tunnel, but anchoring the intrarectal segment to exposed submucosa. Intraluminal end of one segment was narrowed, while other left as such. Reservoir distension test was done to notice the status of reflux. In 24 months, 12 experiments were conducted.Results:In first part of experiment, successful antireflux mechanism was created in 11 ureters. In second part of experiment, reflux persisted in the ureteral segment implanted with obliquity but without distal nonobstructed narrowing, while there was no reflux in the ureteral segment with both obliquity and narrowing.Conclusion:Advancement and anchoring of the ureteral segment to the exposed detrusor with creation of nonobstructive and limited narrowing can create effective antireflux mechanism without the need to create submucosal tunnel.

PUK36 - Evaluation of a Process of Care Model for Open Intravesical Ureteral Reimplantation from a Contemporary Health Care Perspective

The surgical management of vesicoureteral reflux consists of open and minimally invasive approaches. Open approaches are associated with postoperative hospitalization rates of stay typically 2 to 3 days, varying with the type of procedure. We evaluated the impact of a “one night cost-saving stay process of care” model for open surgical correction of vesicoureteral reflux on quality of care, as defined by return to emergency room or office and/or readmission to the hospital within 2 days of discharge. An IRB-approved chart review of all open uncomplicated ureteral reimplantations for vesicoureteral reflux from the January 2009 through January 2013 was performed. Length of postoperative stay, emergency room records, hospitalizations and office records were reviewed to assess for presentation to the emergency room/office and/or readmission to the hospital within 2 days of discharge from the ureteral reimplantation. Ninety-five children (17 males, 78 females) underwent open ureteral reimplantation. Eighty-four (88.4%) were discharged POD #1 , 8 (8.4%) on POD #2 and 3 (3.2%) on the POD #3. Two patients presented to the ER within 2 days of discharge, one in the one night stay group and one in the three night stay group. No child required readmission within 2 days of discharge. Transient ureteral obstruction requiring stent placement occurred in 1 patient (1.05%) 3 days after discharge. Presentation to the ER > 2 days post-discharge was more frequent in those discharged from home POD #1. A process of care model decreased the length of stay to one night in 84 of the 95 patients (88.4%) and did not appear to increase the risk of early (within 2 days of discharge) presentation to the ER/office or readmission. ER/office presentations > 2 days after discharge were increased in the POD #1 group.

Evaluation of a Process-of-Care Model for Open Intravesical Ureteral Reimplantation in Children From a Contemporary Health Care Perspective

Introduction: Surgical management of patients with vesicoureteral reflux consists of both open and minimally invasive approaches. Open approaches are associated with postoperative hospitalization and stays of 2 to 3 days, dependent on the type of procedure; alternately, when endoscopic correction is performed, it is a same-day procedure. Changes in health care policy emphasize reduction in cost while maintaining and improving quality of care. We sought to evaluate the impact of a “1-night cost-saving process-of-care” model for open surgical correction of vesicoureteral reflux in children on quality of care, which was defined as a return to the emergency room (ER)/office or readmission to the hospital within 2 days of discharge. Materials and Methods: An institutional review board-approved retrospective chart review of all open ureteral reimplantations for uncomplicated vesicoureteral reflux from January 2009 through January 2013 was performed. Children who underwent ureteral stent placement and those who did not have a caudal anesthetic were excluded from the study. Length of postoperative stay, ER records, hospitalizations, and office records were reviewed to assess for presentation to the ER/office or readmission to the hospital within 2 days of discharge. Results: During the 4-year study period, 92 children (23 males, 69 females) underwent open ureteral reimplantation–there were 83 (89.1%) discharges on the first postoperative day; 9 (9.8%) on the second postoperative day; and 1 (1.1%) on the third postoperative day. One patient presented to the ER within 2 days of discharge, and 4 patients presented to the ER/office or were readmitted > 2 days after discharge. Conclusion: Use of a caudal anesthetic, earlier catheter removal, a knowledgeable nursing team, and parental education allowed us to decrease the length of stay to 1 night in 82 of 92 patients (89.1%). These procedural changes allowed for a decrease in hospital stay comparable with and potentially shorter than robotic-assisted laparoscopic approaches. Additionally, these changes did not seem to increase the risk of early (≤ 2 days of discharge) presentation to the ER/office or readmission.

Learning from history or the rationale for considering surgical correction of vesicoureteral reflux

Learning from history or the rationale for considering surgical correction of vesicoureteral reflux

Efficacy and safety of the phytotherapeutic drug Canephron&amp;reg; N in prevention and treatment of urogenital and gestational disease: review of clinical experience in Eastern Europe and Central Asia

This review evaluates 17 clinical studies from 18 selected publications concerning the safety, tolerability, and additional effects of the phytotherapeutic drug, Canephron® N (CAN, containing the medicinal plants, Centaurium erythraea, Levisticum officinale, and Rosmarinus officinalis) as standard therapy in various clinical settings. Its role in the prophylaxis and treatment of urinary tract infections in adults and in children, therapy and prophylaxis in adult patients with renal stones, treatment and prevention of urinary tract infections and other gestational diseases in pregnancy, and also its safety and tolerability. The dosage was as recommended and over a varying duration. Overall, CAN was shown to be effective in the treatment and prophylaxis of UTI compared with standard therapy, both in adults and children, and there was a reduced number of relapses. Children undergoing surgical correction of vesicoureteral reflux benefited from a prophylactic course of CAN. Ten-day add on therapy increased the rate of spontaneous elimination of kidney stones compared with standard therapy alone and may also have had a positive effect on stone prevention. Pregnant women showed earlier relief of symptoms and normalization of pyuria on additional treatment with the herbal combination. Only one adverse effect was reported (skin rash) in the 3115 patients included in this review. No teratogenic, embryotoxic, or fetotoxic effects, or negative interference with the psychological development or health of children born of mothers treated with the drug were reported. Because some of the studies were not well designed, their statistical significance remains unclear.