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The Disappearing Surgical Ureteral Reimplant: National Data from 2003-2013
Michael P. Kurtz, MD, MPH1, Jeffrey J. Leow, MBBS, MPH2, Brioney K. Varda, MD2, Tanya Logvinenko, PhD3, Joseph W. McQuaid, MD1, Richard N. Yu, MD, PhD1, Caleb P. Nelson, MD, MPH1, Benjamin I. Chung, MD4, Steven L. Chang, MD, MS2.
1Boston Children's Hospital, Boston, MA, USA, 2Division of Urology and Center for Surgery and Public Health, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA, 3Center for Clinical Research, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA, 4Stanford University School of Medicined, Stanford, CA, USA.

BACKGROUND: Substantial changes have occurred in management of vesicoureteral reflux over time, as diagnostic recommendations have changed, knowledge has developed about the spontaneous resolution of the condition, and endoscopic alternatives have been popularized. The trends in use of the gold-standard therapy, ureteral reimplantation, have yet to be investigated on a national scale with annual data. We hypothesized that the number of cases of primary vesicoureteral reflux managed by ureteral reimplantation has fallen nationally over the last decade.
METHODS: The Premier Hospital Database (Premier, Inc., Charlotte, NC, USA) is an inpatient dataset created for national quality and utilization benchmarking and includes approximately 20% of inpatient discharges from nonfederal hospitals in the United States. We extracted hospital discharge data for pediatric patients (age <= 18 years) with an International Classification of Diseases, Ninth Revision (ICD-9-CM) procedure code for ureteroneocystostomy (ICD-9 56.74) between January 1, 2003 and December 31, 2013. From these, we selected patients with ICD-9 diagnosis codes for VUR (593.7), and excluded patients with diagnosis codes indicative of secondary VUR. We analysed our results with descriptive statistics; the presence of a temporal trend in reimplantation was examined via regression using generalized estimating equations (including clustering of the data within hospital and within a physician). A nominal p<0.05 was used to define the threshold of significance.
RESULTS: Initial criteria including patients without diagnoses consistent with secondary causes of VUR undergoing ureteral reimplant between 2003-2013 (inclusive) yielded 6,973 reimplants, corresponding to 40,916 weighted cases. We removed 2423 cases (15,903 weighted) who were over age 18, and then 249 (weighted 1411) cases without a diagnosis of VUR, leaving 4,301 cases (23,602 weighted). There was a substantial decrease in the number of ureteral reimplants performed during the study period, with an estimated decline in the rate of 0.239 cases per attending for each quarter (p=0.006). Average patient age declined 0.9 months in each quarter (p<0.0001). Investigating this further, the decline in age was driven by a sharp decline in reimplants in those over age 2, which fell by 0.15 reimplants per attending per quarter (p=0.025); we did not detect a change in reimplantation for children under age 2 (p=0.15). There was no difference between rates of decline in reimplantation for children with and without reflux nephropathy (p=0.21)
CONCLUSIONS: Nationally there has been a marked decrease in the incidence of ureteral reimplantation among children with primary VUR. The potential factors contributing to this are broad, including changes in diagnostic patterns, treatment recommendations, or the rise of endoscopic intervention. Regardless of the cause, this has a great impact on the patients treated, and on the practice and training of pediatric urologists.


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