Vesicoureteral Reflux Severity and Its Association with Unplanned Urinary Catheter Placement and Length of Hospital Stay After Ureteroneocystostomy
Young Son, DO1, Mark E. Quiring, BS2, Ronald Clearie, DO1, Benjamin A. Fink, BS3, Ranel Thaker, BS4, Edward Wu, MS5, Virgil K. DeMario, MA6, Dayna DeVincentz, MA7, Nathaniel B. Gentry, MBMS8, Angie Yossef, BS9, Aditi Patel, BS10, Gregory Dean, MD1.
1Department of Urology, Jefferson New Jersey, Stratford, NJ, USA, 2University of North Texas Health Science Center, Fort Worth, TX, USA, 3Rowan University, School of Osteopathic Medicine, Stratford, NJ, USA, 4Lake Erie College of Osteopathic Medicine, Elmira, NY, USA, 5Alabama College of Osteopathic Medicine, Dothan, AL, USA, 6University of the Incarnate Word School of Osteopathic Medicine, San Antonio, TX, USA, 7Rowan University, Glassboro, NJ, USA, 8New York Institute of Technology, College of Osteopathic Medicine, Jonesboro, AR, USA, 9Pacific Northwest University of Health Sciences College of Osteopathic Medicine, Yakima, WA, USA, 10Edward Via College of Osteopathic Medicine, Blacksburg, VA, USA.
Background: Vesicoureteral reflux (VUR) is the retrograde flow of urine into the kidney and is a common condition in pediatric urology, affecting 1% of all children. Surgical success often depends on the grade of VUR, as patients with VUR grades IV or V have been associated with greater comorbid complications and longer postoperative recovery time. Unplanned urinary catheter placement postoperatively can be a source of infection. The aim of this study is to determine if the severity of VUR is associated with higher rates of unplanned urinary catheter placement and length of hospital stay. We hypothesize that greater VUR severity correlates with higher rates of unplanned catheter insertion and longer length of stay (LOS).
Methods: The 2020 American College of Surgeons National Surgical Quality Improvement Program (NSQIP) Pediatric data was analyzed for patients with VUR. A total of 1742 patients were evaluated with 1373 meeting inclusion criteria. The patients were divided into 3 groups of varying voiding cystourethrogram (VCUG) or radionucleotide cystogram (RNC) severity: VCUG Grade 1 or RNC Grade 1 (Group A), VCUG Grade 2 or 3 or RNC Grade 2 (Group B), and VCUG Grade 4 or 5 or RNC Grade 3 (Group C). Basic statistical analysis was performed using ANOVA analysis. Univariate and multivariate analyses were performed for unplanned urinary catheter placement and LOS after ureteroneocystostomy.
Results: Among the 1373 patients, 2.9% were in Group A, 32.5% were in Group B, and 64.6% were in Group C. On ANOVA, age, male gender, inpatient status, operative approach (MIS), congenital malformation, unilateral procedure, pre/intraoperative urine culture, total operative time, length of stay, postoperative UTI, blood transfusion, superficial surgical site infection, postoperative emergency department visits, unplanned procedure, and unplanned urinary catheter were different among the groups (Table 1&2). Univariate and multivariate analysis showed that UTI (p<0.001), unplanned procedure related to anti-reflux procedure (p<0.001), and 24-30 weeks gestation (p=0.032) were the independent factors contributing to unplanned urinary catheter postoperatively. Nutritional support was associated with less unplanned urinary catheter insertion (p=0.017)(Table 3). Additionally, total operation time, ureteral stent, UTI, unplanned procedure, and ASA classification 3 were associated with increased LOS. Unplanned urinary catheter placement was associated with decreased LOS (Table 4).
Conclusions: Higher VCUG VUR grade does not appear to increase unplanned urethral catheter insertion or length of hospital stay. UTI was associated with both increased length of stay and unplanned urinary catheterization. Interestingly, unplanned urinary catheterization was associated with decreased LOS. 
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