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Introduction: Extravesical ureteral reimplantation (EVR) is as effective as intravesical techniques for VUR, without the added morbidity of opening the bladder and the benefit of a shorter hospital stay. Bilateral EVR has been linked however, with higher rates of transient urinary retention. Consequently, many urologists forgo bilateral EVR in favor of an intravesical approach. We believe that bilateral EVR can be done safely with minimal retention risk and those who may be at risk can be identified preoperatively and managed accordingly.
Methods: A retrospective cohort study was performed of patients who underwent bilateral EVR among 4 surgeons at The University of Michigan between 1995-2012. Patients were excluded if they were discharged with an indwelling catheter without an in-hospital voiding trial or if they had a documented neurogenic bladder. Retention was defined as needing a catheter replaced or needing intermittent catheterization within 30 days of surgery. Bivariate and multivariate analysis determined associations between patient and operative factors with the outcome of retention. Rates of residual reflux and recurrent febrile UTIs were also evaluated.
Results: 330 patients were identified as having a bilateral EVR with a median reflux grade of 3. In 85% of cases, the obliterated umbilical arteries were left intact. All cases used bipolar cautery when dissecting the ureter. Mean age at time of surgery was 6.85 years and 79.4% of patients were female. Median follow up was 1.54 years. 93% of patients were free of febrile UTIs postoperatively. Of the 175 patients with a postop VCUG, 23 (13.14%) had residual reflux and 17 of those also had postoperative febrile UTIs. 6 patients were prophylactically discharged with a foley catheter due to surgeon preference and/or young age leaving 324 patients for analysis. The retention rate was 9.63% with a median post re-insertion catheter duration of 6.5 days. 3/31 patients were readmitted to manage the sequelae of retention (mean LOS 2.67 days). All patients voided well after the catheter was removed. Constipation and younger age at time of surgery were strongly associated with postoperative retention on multivariate analyses (Table 1: p<0.001, p=0.02). No complications above Clavien grade I were noted.
Conclusion: Bilateral EVR can be done with low rates of postoperative retention. Preoperative constipation and younger age are risk factors for retention. In planning for surgery, these factors can be addressed and postoperative management can be tailored. Additionally, given the benefits of an extravesical approach, older patients with good toilet habits should not be deterred from having bilateral EVR to correct their reflux.

Predictors of Retention

	Bivariate p value OR (95% CI)	Multivariable p value OR (95% CI)
Constipation	<0.0001	<0.0001
Yes	7.2(3.1, 16.9)	7.8 (3.2, 18.7)
No	1.0	1.0
Operative time	0.28
<164 min	0.7 (0.3, 1.4)
>=164 min	1.0
Age at time of surgery	0.0008 0.84 (0.73, 0.95)	0.02 0.83 (0.72, 0.97)