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Incidence and predictors of febrile urinary tract infection after robot assisted ureteral reimplantation for primary vesicoureteral reflux in a modern cohort
Sahar Eftekharzadeh, MD, MPH, Aznive Aghababian, BS, Sameer Mittal, MD, MSc, Katherine Fischer, MD, John Weaver, MD, Dana Weiss, MD, Christopher Long, MD, Arun Srinivasan, MD, Aseem Shukla, MD.
Children's Hospital of Philadelphia, Philadelphia, PA, USA.

Background: The objective of anti-reflux surgery is to reduce the incidence of febrile UTIs(f-UTI). We assessed predictive factors for post-operative f-UTI after robot-assisted laparoscopic extravesical ureteral reimplantation (RALUR-EV) and hypothesized that post-operative f-UTI is more common in girls and children with voiding dysfunction.Methods: An IRB approved prospective single institutional registry was utilized to retrospectively identify all patients younger than 18 years of age who underwent RALUR for primary VUR between 2012 and 2019. Patients who underwent concomitant procedures including ureteroureterostomy and diverticulectomy, and those with duplex renal collecting systems were excluded. Preoperative details including history of recurrent and breakthrough UTI, prior procedures, preoperative imaging findings, post-operative details including complications, and long-term outcomes including incidence of UTI and need for further interventions were aggregated and evaluated. Results: From a total of 172 patients who underwent RALUR, 113 patients (171 ureters); 98 females (87%) and 15 males (13%) with median age of 6 years (IQR: 3, 8) were included. A total of 111 (98%) children had a preoperative history of recurrent UTI. Pre-operatively, moderate to severe reflux (G3-5) was seen in 87 (79%) and 113 ureters (66%). Patients were followed for a median of 37 months (IQR: 20, 63). Of the 113 patients, 26 patients (23%) experienced at least one episode of fUTI during their follow-up, with 100% of the patients being female. Only six patients of 113 (5.3%) had more than 1 episode of fUTI. The median time from surgery to first fUTI was 8 months (IQR: 3, 13), and the first fUTI occurred within a year of surgery in 18/26 (69%) patients [Figure 1]. Patients were followed for a median of 11 months (2, 25) since their last fUTI. Multivariate logistic regression showed that presence of dysfunctional voiding post-operatively (OR:5.4 95%CI: 1.4 - 20.8) was associated with higher incidence of fUTI [Table 1]. Five out of the 113 patients (5%) required surgical intervention after RALUR. Three were patients with a post-operative fUTI: 1 underwent redo bilateral open ureteral reimplant, 1 had Botox injection into bladder neck and urethral sphincter and then vesicostomy, and 1 required bilateral Deflux® injection. The remaining 2 patients who did not have post-op UTI required open redo reimplant due to persistent VUR in 1 patient and UVJ obstruction in the other patient. Conclusion: Post-operative febrile UTI after RALUR mostly occurs in girls in the first year after surgery and in most patients does not recur and rarely needs reoperation. Post-operative dysfunctional voiding is an independent risk factor for post-operative febrile urinary tract infection.

Table 1: Logistic regression evaluating factors that might affect incidence of Febrile UTI at after RALUR
Sex (Ref: Female)0.13**0.00 - 0.850.042Omitted‡
Age at reimplant0.930.82 - 1.050.2450.83*0.67 - 1.020.079
Dysfunctional voiding prior to reimplant1.940.71 - 5.330.1991.300.30 - 5.580.721
Bilateral VUR1.140.47 - 2.740.7701.480.43 - 5.120.538
Grade of initial VURG1Reference.Reference.
G20.540.15 - 2.020.3610.800.15 - 4.260.797
G30.640.23 - 1.770.391.100.27 - 4.460.895
G411.00 - - 1.00.
G511.00 - - 1.00.
30-day post-operative complication2.060.62 - 6.810.2350.990.20 - 4.820.989
Dysfunctional voiding after reimplant4.08***1.40 - 11.840.0105.36**1.38 - 20.790.015
Duration of follow-up1.001.00 - 1.000.3391.010.99 - 1.030.339
‡ Since all cases of fUTI occurred in female patients the OR for sex cannot be calculated.*** p<0.01, ** p<0.05, * p<0.1

Figure 1: Kaplan-Meier plots display UTI-free survival over time, based on gender.

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