The Northeastern Society of Plastic Surgeons

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National trends in management of primary vesicoureteral reflux in children
Michael Garcia-Roig, MD1, Curtis Travers, MPH2, Courtney E. McCracken, PhD2, Andrew J. Kirsch, MD1.
1Emory University and Childrens Healthcare of Atlanta, Atlanta, GA, USA, 2Department of Pediatrics - Biostatistics Core, Emory University, Atlanta, GA, USA.

Introduction: In September 2011, the American Academy of Pediatrics (AAP) released updated guidelines for workup of children 2-24 months old presenting with a febrile urinary tract infection (UTI). We aimed to document the impact of these guidelines on national trends in diagnosis and surgical management of VUR. We hypothesize that a decrease in VCUG and VUR treatment rate occurred nationally concurrent with guideline release.
Methods: The Pediatric Health Information System (PHIS) was queried for children (<18 years) with primary VUR, along with their anti-reflux surgical history. VCUG orders were recorded. Patients were excluded for secondary VUR and no VUR diagnosis. Hospitals not contributing data during the entire study period, or with <80% CPT reporting. Interrupted time series (ITS) analysis quantified trends before and after several seminal VUR publications(2007) and guideline publication(2011).
Results: 61,330 VCUG encounters were analyzed (male: 33,157(54.1%)), median age 3 months (IQR 1-24). The table outlines the interrupted time series analysis for both VCUG orders and surgical procedures. The figures graphically represent actual VCUG orders and surgical procedures. For all children and those 2-24 months old, monthly VCUG orders significantly increased to December 2006, then decreased to October 2011, then did not change significantly. 28,484 surgical procedures were analyzed. Total surgical procedures did not change significantly until October 2011, then the monthly rate of procedures declined significantly. Monthly cases of endoscopic correction increased
significantly until December 2006, then declined after October 2011. Open ureteral reimplantation declined consistently throughout the study period. Robot-assisted reimplantation was first reported in 2008 and the monthly rate of procedures did not change after 2011.
Conclusion: A steady decline in the number of procedures performed for VUR occurred after the release of the 2011 AAP UTI guidelines for children 2-24 months old. A decline in the number of VCUG's performed began in approximately 2007, prior to guideline publication, and the rate was unchanged after 2011. Anti-reflux surgery steadily decreased during our study period, however, the most common procedure for VUR treatment continues to be open ureteral reimplantation, followed closely by endoscopic injection of bulking substance. Robot-assisted ureteroneocystostomy is steadily increasing in popularity since its introduction but represents a small percentage of total anti-reflux procedures.


Monthly Change by Interval
Jan '04-Dec '06pJan '07-Sept '11pOct '11- Jun '15pR2
Endoscopic Correction+10.008*+0.40.058-1<0.001*0.60
Open Reimplant-0.50.025*-0.20.019-0.8<0.001*0.65
Robot-Assisted Reimplant0-+0.1<0.001*No change0.9570.79
Total Procedures+0.50.24+0.40.108-1.5<0.001*0.66
VCUG, 0-18 years old+3.8<0.001*-3.2<0.001*-0.70.1460.9
VCUG 2 24 months old+1.7<0.001*-1.7<0.001*-0.30.2610.87


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