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Long-term Change in the Rate of Surgical Procedures for Vesicoureteral Reflux: Is the Pendulum Swinging Back?
Ricardo Antonio Arceo-Olaiz, MD, Shuvro De, MD, Andrew J. Kirsch, MD.
Emory University School of Medicine / Childrenīs Healthcare of Atlanta, Atlanta, GA, USA.

Background: In 2011, the American Academy of Pediatrics (AAP) guidelines on urinary tract infection recommended against routine use of VCUGs in children 2 to 24 months of age following an initial febrile UTI, unless the initial renal ultrasound was abnormal1. Since guideline publication, our group has reported a significant decrease in VCUGs, renal sonograms, surgical procedures for VUR2,3, as well as an increase in ER visits and hospital admissions for UTI. A more recent study documented the negative impact on renal function4. The objective of our study is to document trends of surgical management of VUR over the past 18 years.
Methods: We retrospectively reviewed our database of children who underwent anti-reflux surgery, either Deflux (Dx/HA) injection or ureteral reimplantation, from April 2003 to December 2021. We divided our population in 2 groups: Group A underwent endoscopic Dx/HA injection, and Group B underwent ureteral reimplantation. Our aim was to assess the long-term change in these 2 groups over the past 18 years, with subgroup analysis over the past 4 years.
Results: A total of 4,749 anti-reflux procedures were performed by 8 surgeons (3,059 Deflux injections and 1690 ureteral reimplants) in this timeframe. We excluded patients < 1 and >18 years of age and those undergoing megaureter repair ureterocele and cecocureterocele, ectopic ureter, neurogenic bladder, leaving 2,983 Dx/HA injections (2,501 girls; 482 boys) and 945 ureteral reimplants (585 girls; 360 boys) for analysis. Our data document a decrease in anti-reflux procedures done after 2011 (AAP UTI guidelines published). In Group A, 2,020 injections (mean 224/year) were done before, and 963 (mean 96/year) after 2012, representing a 52% decrease. In Group B, 525 reimplants (mean 58/year) were performed before, and 420 (mean 42/year) after 2012, representing an 20% decrease. At the time of surgery, there was no difference in mean patient age before and after 2012 in both groups (Group A: 6 years; Group B: 4 years). A statistically significant 46% increase in the mean number of injections were seen during the last 4 years (63/year between 2014 and 2017 vs 108/year between 2018 and 2021, p<0.001). However, no rise in the number of ureteral reimplants 45/year vs 36/year, p=0.06) were seen during the same time.
Conclusions: The AAP UTI guidelines have led to a significant decrease in the number of patients treated surgically for VUR. However, over the past 4 years, there appears to be an upward shift in the rate of patients undergoing endoscopic injection compared to ureteral reimplantation. Reports documenting a greater rate of renal scarring, as well as increased hospitalizations/ER visits in children managed after publication of the AAP UTI guideline may account for this newly documented trend. Our study is limited by its retrospective nature and single center experience. National trends will need to be analyzed to further support trends documented by our experience.


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