Vesicoureteral reflux severity is not associated with unplanned urinary catheterization or length of hospital stay after ureteroneocystostomy

• Published in: Journal of pediatric urology Vol. 20; no. 2; pp. 183 - 190
• Main Authors: Quiring, Mark E., Son, Young, Thaker, Ranel, Davidson, Noah, Wu, Edward, Fink, Benjamin A., Thomas, Brian, Gentry, Nathaniel B., Yossef, Angie, DeMario, Virgil K., Earnshaw, Lance, Weldekidan, Blen, Dean, Gregory
• Format: Journal Article
• Language: English
• Published: England Elsevier Ltd 01-04-2024
• Subjects: Child; Humans; Infant; Length of Stay; Retrospective Studies; Treatment Outcome; Unplanned catheterization; Ureteral reimplantation; Ureteroneocystostomy; Urinary Catheterization; Vesico-Ureteral Reflux - complications; Vesico-Ureteral Reflux - surgery; Vesicoureteral reflux; NSQIP; UCP; RNC; UNC; UTI; Ureteroneocystostomy; Unplanned catheterization; ASA; ACS; LOS; VUR; Vesicoureteral reflux; VCUG; Ureteral reimplantation; Length of stay; ED
• ISSN: 1477-5131; 1873-4898; 1873-4898
• DOI: 10.1016/j.jpurol.2023.08.034

Vesicoureteral reflux (VUR) is a common urologic condition affecting approximately 1% of all children. Surgical success often depends on the grade of VUR, as patients with grades 4 or 5 have been have a greater risk for postoperative complications. Unplanned urinary catheter placement (UCP) postoperatively and prolonged length of hospital stay (LOS) are indicative of unexpected complications. The association between VUR severity and such metrics remain unclear.
The study's objective is to determine if the severity of VUR is associated with higher rates of UCP or prolonged LOS after ureteroneocystostomy (UNC).
The 2020 National Surgical Quality Improvement Program Pediatric database was analyzed for patients with VUR. A total of 1742 patients were initially evaluated with 1373 meeting exclusion criteria. The patients were divided into 3 groups of varying voiding cystourethrogram (VCUG) or radionuclide 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, and logistic regression was performed with both UCP and LOS as dependent variables.
Among the 1373 patients, 2.9% were included in Group A, 32.5% were in Group B, and 64.6% were in Group C. Significant differences were found among the groups for mean age, gender, inpatient status, rate of congenital malformation, ureteral stents, and ASA classification. Regarding surgical treatment, differences were also found comparing mean operative time, LOS, laterality and type of procedure, urine culture results, rates of UTI, surgical site infections, postoperative returns to the emergency department, and unplanned procedures and catheterization. Multivariate analysis demonstrated no significant association between the rate of UCP and VUR severity, while postoperative UTI and unplanned procedure were both independent factors associated with UCP postoperatively. Additionally, postoperative UTI, ASA classification, mean operation time, ureteral stent placement, unplanned procedure, and UCP were independent factors found to contribute to LOS.
Greater VUR severity does not appear to increase the need for catheterization or prolong hospital stay, while the development of a UTI postoperatively or having an additional unplanned procedure are associated with an increased likelihood of both. The postoperative course after UNC also appears to be influenced more so by other factors such as the operative approach and whether complications arise.Summary TableSummary TableReflux Severity and Unplanned Urinary Catheter InsertionUnivariate AnalysisMultivariate AnalysisOR (95% CI)p–valueOR (95% CI)p–valueTotal Operation Time1.00 (1.00–1.01)0.0061.00 (1.00–1.01)0.335Length of Total Hospital Stay1.12 (1.03–1.22)0.0040.94 (0.77–1.08)0.413Urinary Tract Infection8.46 (3.45–18.81)<0.00110.1 (3.10–29.7)<0.001Superficial Incisional Surgical Site Infection15.43 (0.70–164)0.0279.80 (0.14–690)0.306Nutritional Support1.45 (0.08–7.18)0.7200.03 (0.00–0.55)0.018Unplanned Procedure Related to Anti–reflux Procedure (0–30 days postoperatively)56.8 (26.2–125)<0.001116 (39.8–373)<0.001VUR Severity0.7030.663VCUG Grade 1ReferentReferentVCUG Grade 2 or 31.08 (0.20–19.9)0.9432.85 (0.35–69.1)0.409VCUG Grade 4 or 51.41 (0.29–25.5)0.7372.42 (0.32–56.4)0.474Preoperative/Intraoperative Urine Culture0.3610.513No Bacterial GrowthReferentReferentBacterial Growth, Not UTI1.55 (0.44–4.23)0.4330.72 (0.13–3.01)0.675Bacterial Growth, UTI2.21 (0.63–6.09)0.1591.83 (0.39–6.85)0.399Reflux Severity and Length of Stayβ (95% CI)p–valueβ (95% CI)p–valueTotal Operation Time0.01 (0.01–0.01)<0.0010.01 (0.01–0.01)<0.001Male Gender0.31 (0.09–0.54)0.0060.07 (–0.14–0.28)0.528Congenital Malformation0.32 (0.08–0.55)0.0100.18 (–0.04–0.40)0.101Ureteral Stent/Catheter0.73 (0.53–0.93)<0.0010.38 (0.19–0.57)<0.001Urinary Tract Infection1.60 (1.00–2.20)<0.0011.00 (0.43–1.50)<0.001Unplanned Procedure3.50 (2.80–4.10)<0.0013.20 (2.60–4.00)<0.001Unplanned Urinary Catheter1.20 (0.58–1.70)<0.001–0.79 (–1.40– –0.19)0.010VUR Severity0.2640.631VCUG Grade 1ReferentReferentVCUG Grade 2 or 3–0.17 (–0.79–0.45)0.5920.26 (–0.30–0.82)0.366VCUG Grade 4 or 50.10 (–0.60–0.62)0.9700.21 (–0.34–0.75)0.457Preoperative/Intraoperative Urine Culture<0.0010.057No Bacterial GrowthReferentReferentBacterial Growth, Not UTI0.67 (0.28–1.10)<0.0010.35 (–0.02–0.71)0.061Bacterial Growth, UTI0.70 (0.23–1.20)0.0030.44 (0.01–0.86)0.046