Ureteroneocystostomy in primary vesicoureteral reflux: critical retrospective analysis of factors affecting the postoperative urinary tract infection rates

Abstract

ARTICLE INFO ______________________________________________________________ ______________________Introduction: To determine the parameters affecting the outcome of ureteroneocystostomy (UNC) procedure for vesicoureteral reflux (VUR). Materials and Methods:Data of 398 patients who underwent UNC procedure from 2001 to 2012 were analyzed retrospectively. Different UNC techniques were used according to laterality of reflux and ureteral orifice configuration. Effects of several parameters on outcome were examined. Disappearance of reflux on control VCUG or absence of any kind of UTI/symptoms in patients without control VCUG was considered as clinical improvement.Results: Mean age at operation was 59.2 ± 39.8 months and follow-up was 25.6 ± 23.3 months. Grade of VUR was 1-2, 3 and 4-5 in 17, 79, 302 patients, respectively. Male to female ratio was 163/235. UNC was performed bilaterally in 235 patients and intravesical approach was used in 373 patients. The frequency of voiding dysfunction, scar on preoperative DMSA, breakthrough infection and previous surgery was 28.4%, 70.7%, 49.3% and 22.4%, respectively. Twelve patients (8.9%) with postoperative contralateral reflux were excluded from the analysis. Overall clinical improvement rate for UNC was 92%. Gender, age at diagnosis and operation, laterality and grade of reflux, mode of presentation, breakthrough infections (BTI) under antibiotic prophylaxis, presence of voiding dysfunction and renal scar, and operation technique did not affect the surgical outcome. However, the clinical improvement rate was lower in patients with a history of previous endoscopic intervention (83.9% vs. 94%). Postoperative UTI rate was 27.2% and factors affecting the occurrence of postoperative UTI were previous failed endoscopic injection on univariate analysis and gender, preoperative BTI, postoperative VUR state, voiding dysfunction on multivariate analysis. Surgery related complication rate was 2% (8/398). These were all low grade complications (blood transfusion in 1, hematoma under incision in 3 and prolonged hospitalization secondary to UTI in 4 patients).In long term, 12 patients are under nephrologic follow-up because of hypertension in 5, increased serum creatinine in 5, proteinuria in 1 and hematuria in 1 patient and all these patients had preoperative scarred kidneys. Conclusions: Despite its invasive nature, UNC has a very high success rate with a negligible percent of complications. In our cohort, the only factor that negatively affected the clinical improvement rate was the history of previous antireflux interventions where the predictive factors for postoperative UTI were previous failed endoscopic injection, female gender, preoperative BTI, persistent VUR and voiding dysfunction.

Lower urinary tract dysfunction in pediatric patients after ureteroneocystostomy due to vesicoureteral reflux: Long‐term follow‐up

“…As the most effective management technique, surgical VUR repair has the highest success rate (>90%) and there is no significant difference with regard to the success rates of the different methods used . In the present study, the success rate of the UNC was 92%, which is in accordance with the rates reported in the literature . The criteria for success in the present study were both radiologic and clinical improvement.…”

“…In this regard, a Swedish reflux study demonstrated that the most vulnerable to UTI of treated reflux patients were those with LUTD . The data in the literature indicate that the grade and preoperative presence of LUTD do not affect the radiologic success rates for surgical management . However, the rate of clinical improvement is lower in patients with LUTD: the rate of postoperative UTI is higher in LUTD patients, even if the VUR has improved on radiological examination …”

“…The time is getting worse the bladder dynamics due to increasing of the upper urinary tract reservoir. Evaluation of published data shows that pre‐ and postoperative assessment of bladder dynamics by appropriate means were lacking in most studies dealing with classical reflux surgery …”

Ureter Visualization on Tc-99m DMSA Scintigraphy in Pediatric Patients

“…Ureteroneocystostomy operations has high rate of improvement (92%) [11]. However, this is not the case in case of presence of lower urinary tract pathology.…”

Risk Factors of Febrile Urinary Tract Infection after Ureteral Reimplantation in Infant

“…The causative risk factors of fUTI after ureteral reimplantation in children with VUR reported thus far were a preoperative grade of reflux, the presence of dysfunctional elimination syndrome, the presence of renal scar and preoperative breakthrough infection, female gender, and voiding dysfunction [7,[9][10][11][12][13]. Nevertheless, the incidence and risk factors of fUTI after ureteral reimplantation in infants have received little attention.…”