Heminephrectomy vs. Ureteroureterostomy: Surgeon Preference can safely be used for Management of Duplicated Kidneys with an Upper Pole Obstruction
Kiersten M. Craig, M.D., M.S.E.1, Lauren Balsamo, M.P.H.1, Dix P. Poppas, M.D., F.A.C.S.2, Ardavan Akhavan, M.D., F.A.C.S.2.
1New York Presbyterian/ Weill Cornell Medicine Department of Urology, New York, NY, USA, 2Komansky Children's Hospital, Institute for Pediatric Urology New York Presbyterian/ Weill Cornell Medicine Department of Urology, New York, NY, USA.
INTRODUCTION: Both upper pole heminephrectomy (HN) and ureteroureterostomy (UU) are both viable options for the management of an obstructing ureterocele in a duplex system. This study attempts to determine superiority of by examining outcomes of patients undergoing either procedure in a large national database. We hypothesize that neither modality is advantageous.
METHODS: We performed a retrospective database review of 426 patients with a discharge diagnosis of a duplicated ureter and congenital ureterocele or cecoureterocele in the Pediatric Health Information System (PHIS) database from 1/2004 - 12/2018 between the ages of 0-18 years. We identified records with ICD9 (before 2015) codes 753.4 for a duplicated system and 753.23 for ureterocele and cecoureterocele and ICD10 (after 2015) codes equal to Q62.5 for a duplicated system, Q62.31 for ureterocele, and Q62.32 for cecoureterocele. Patient age, gender, procedure type, surgical approach (for ICD10 only), disposition, LOS, complications (infectious, surgical, and medical), and readmission rate were recorded for each procedure. Complications were defined based on the Children's Hospital Association PHIS algorithm using discharge diagnosis codes to flag any surgical, infectious, or medical complication associated with each discharge. Patients were excluded if they did not undergo HN or UU.
RESULTS: Of 726 patients with both a duplicated system and congenital ureterocele, 416 had either a HN (66) or a UU (350). In both groups, females predominated (78.6% UU, 74.2% HN, p=0.431). Demographically, there was no significant difference in either Caucasian (45.5% HN vs 52.6% UU) or African American race (7.6% HN vs 4% UU) (p=0.208), or in age (0.96 HN vs 0.82 UU years, p=0.6702). Similarly, there was no difference in the rate of utilization of minimally invasive surgery (17.7% HN vs 22.2% UU, p=0.397). With respect to outcomes, there was no difference in length of hospital stay (2.9 HN vs 2.4 UU days, p=0.3982), infectious complications (10.6% HN vs 15.9% UU, p=0.275), surgical complications (4.2% HN vs 4.5% UU, p=0.888), or readmissions (16.7% HN vs 24.4% UU, p=0.169). The presence of an infection increased the hospital length of stay for UU only (2.1 days without infection vs 7.0 days with an infection, p<0.001), but not for HN (2.2 days without an infection vs 3.6 days with an infection, p=0.130). Similarly, surgical complications increased the length of stay following UU (2.7 days without a complication vs 7.7 days with a complication, p=0.001), but not following HN (2.3 vs 2.6 days, p>0.05).
CONCLUSIONS: Our retrospective review of a large national databased suggests failed to demonstrate a superiority of HN or UU for management of ureterocele in an obstructed duplex system when considering length of hospitalization, infections, complications or readmissions. However, there was a greater impact of infections and complications on hospitalization duration in the UU group compared with the same in the HN group.
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