O3301: Factors and Outcomes Associated with Reoperative Ureteroneocystectomy for Vesicoureteral Reflux

Background: Vesicoureteral reflux (VUR) is characterized by a deficiency at the ureterovesical junction leading to backflow of urine up one or both ureters. Ureteroneocystostomy (UNC) and endoscopic injection (EI) are surgical options for VUR. Success rates for EI have a reported success rate of 70-90% which is lower than UNC at greater than 95%, yet this procedure is attractive due its minimally invasive nature yielding a well-tolerated out-patient procedure. One advantage of UNC is that most clinicians do not recommend post procedural voiding cystourethrogram (VCUG) given the reported high success rate. The objective of this study is to identify predictive factors and outcomes of patients receiving UNC following failed previous VUR reoperation compared with patients receiving primary UNC.

Methods: The American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) Pediatric 2020 data was retrospectively analyzed for pediatric patients undergoing UNC for VUR. A total of 1,742 patients were evaluated with 1,495 meeting inclusion criteria. Patients were divided into 4 groups: No previous reflux procedure, previous UNC, previous SI, and previous UNC and SI. Chi-square analysis and analysis of variance (ANOVA) were used to compare categorical and continuous variables, respectively. Patient demographics, preoperative characteristics, and post operative outcomes were analyzed (Tables 1). Univariate and multivariate analyses were performed to identify outcomes associated with UNC after previous reflux procedure (Table 2).

Results: Among 1,495 patients receiving UNC, 89.4% had no previous reflux procedures, 5.6% had previous UNC, 4.3% had previous SI, and 0.8% had previous UNC and SI. Differences in age, male gender, non-Caucasian race, VUR disease severity, esophageal/gastric/intestinal disease, developmental delay, structural central nervous system (CNS) abnormality, nutritional support, and ASA classifications were found between groups. Total operation time, length of stay (LOS), readmission, unplanned reoperation, unplanned urinary catheter insertion, and preoperative/intraoperative bacterial growth with UTI were different between groups.
On multivariate analysis, patients with previous UNC and previous EI had a higher likelihood of increased operative time. Previous EI has a higher likelihood of increased LOS. Previous UNC has a higher likelihood of readmission. Patients with previous UNC and EI had a higher likelihood of unplanned urinary catheter than patients receiving primary UNC.

Conclusion: Success of reimplantation is less than reported in literature at 94.4%. Repeat anti-reflux procedure is associated with increasing age and esophageal/gastric/intestinal disease. Although non-Caucasian race, developmental delay, structural CNS abnormality, and ASA classifications were initially thought to be related to previous reflux procedure, we find that on multivariate analysis that these were confounding factors.