The effect of prior endoscopic correction of vesicoureteral reflux on open ureteral reimplantation: Surgical outcomes and costs.

Summary Introduction Endoscopic injection of a bulking agent is a common first-line approach to the treatment of vesicoureteral reflux (VUR). While early outcomes are comparable to open ureteroneocystotomy, 5–25% of children will eventually develop recurrent reflux necessitating repeat injections or open ureteral reimplantation. Objective To determine whether prior endoscopic injection of a bulking agent impacts outcomes of subsequent open ureteral reimplantation. Study design Using a retrospective cohort design, radiographic and clinical outcomes of open ureteral reimplantation were compared between patients with and without prior endoscopic correction of reflux. Surgical and hospitalization data were also compared between groups and a cost comparison was performed to assess differences in healthcare costs between the two cohorts. Units of analysis included total ureters or total patients. For certain variables, subanalysis of unilateral versus bilateral reimplantation was included. Results A total of 258 patients underwent open reimplantation for VUR between 2007 and 2016 by five pediatric urologists. Final analysis (see Summary Table ) included 192 patients with pre-operative and postoperative voiding cystourethrogram (VCUG) and follow-up data at a median 4.95 months. Among 317 reimplanted refluxing ureters, radiographic resolution was reached in 26/27 (96.3%) patients with and 279/290 (96.2%) without prior endoscopic treatment (P = 0.981). Clinical success was achieved in 17/17 (100%) patients with and 174/175 (99.4%) without prior endoscopic treatment (P = 0.755). There were no statistically significant differences between duration of surgery or length of hospital stay. There were no statistically significant differences between total charges, total costs, and operating room (OR) costs between groups. Discussion This study indicated that prior endoscopic injection of a bulking agent did not impact the outcomes or costs of subsequent open ureteroneocystotomy. While prior studies have demonstrated tissue changes associated with injection of a bulking agent, these did not seem to significantly impact the difficulty of later open surgery or the success rates compared to patients who proceeded directly to open correction of reflux. Conclusion Open ureteral reimplantation for recurrent VUR after failed endoscopic injection of a bulking agent was safe and effective, with comparable outcomes and costs to open surgery in patients without prior endoscopic correction. Summary Table . No prior endoscopic treatment (n = 175) Prior endoscopic treatment (n = 17) P-value Reimplanted ureters 311 31 – Median duration of surgery, minutes (range) a 144 (46–269) 144 (83–334) 0.595 Median length of stay, days (range) 3 (1–17) 3 (2–7) 0.793 Radiographic resolution per ureter (%) b 279 (96.2) 26 (96.3) 0.981 Clinical resolution (%) 174 (99.4) 17 (100) 0.755 Total charges, USD (range) $12,069 ($5528–45,570) $11,911 ($8756–22,918) 0.925 Total costs, USD (range) $9876 ($4977–33,315) $9557 ($7321–17,016) 0.990 OR charges, USD (range) $4930 ($1847–12,359) $5455 ($4007–8093) 0.128 Select outcomes of open ureteral reimplantation for VUR in patients with and without prior endoscopic correction. a Includes 145 patients with available data (133 without prior endoscopic treatment, 12 with prior endoscopic treatment). b Includes 317 reimplanted refluxing ureters (290 without prior endoscopic treatment, 27 with prior endoscopic treatment).