Wang Hsin-Hsiao S, Tejwani Rohit, Wolf Steven, Wiener John S, Routh Jonathan C
Division of Urologic Surgery, Duke University Medical Center, Durham, NC, USA.
Duke University School of Medicine, Durham, NC, USA.
J Pediatr Urol. 2017 Oct;13(5):507.e1-507.e7. doi: 10.1016/j.jpurol.2017.03.016. Epub 2017 Apr 7.
INTRODUCTION/BACKGROUND: The choice between endoscopic injection (EI) and ureteroneocystotomy (UNC) for surgical correction of vesicoureteral reflux (VUR) is controversial.
To compare postoperative outcomes of EI vs UNC.
This study reviewed linked inpatient (SID), ambulatory surgery (SASD), and emergency department (SEDD) data from five states in the United States (2007-10) to identify pediatric patients with primary VUR undergoing EI or UNC as an initial surgical intervention. Unplanned readmissions, additional procedures, and emergency room (ER) visits were extracted. Statistical analysis was performed using multivariate logistic regression using generalized estimating equation (GEE) to adjust for hospital-level clustering.
The study identified 2556 UNC and 1997 EI procedures. Compared with patients undergoing EI, those who underwent UNC were more likely to be younger (4.6 vs 6.0 years, P < 0.001), male (30 vs 20%, P < 0.001), and publicly insured (34 vs 29%, P < 0.001). As shown in Summary Figure, compared with EI, UNC patients had lower rates of additional anti-reflux procedures within 12 months (25 (1.0) vs 121 (6.1%), P < 0.001), but a higher rate of 30-day and 90-day readmissions and ER visits. On multivariate analysis, patients treated by UNC remained at higher odds of being readmitted (OR = 4.45; 2.69 in 30 days; 90 days, P < 0.001) and to have postoperative ER visits (OR = 3.33; 2.26 in 30 days; 90 days, P < 0.001); however, EI had significantly higher odds of repeat anti-reflux procedures in the subsequent year (OR = 7.12, P < 0.001).
Endoscopic injection constituted nearly half of initial anti-reflux procedures in children. However, patients treated with UNC had significantly lower odds of requiring re-treatment in the first year relative to those treated with EI. By contrast, patients treated with UNC had more than twice the odds of being readmitted or visiting an ER postoperatively. Although the available data were amongst the largest and most well validated, the major limitation was the retrospective nature of the administrative database. The practice setting may not be generalizable to states not included in the analysis.
Postoperative readmissions and ER visits were uncommon after any surgical intervention for VUR, but were more common among children undergoing UNC. The EI patients had a more than seven-fold increased risk of surgical re-treatment within 1 year.
引言/背景：对于膀胱输尿管反流（VUR）的手术矫正，内镜注射（EI）和输尿管膀胱再植术（UNC）之间的选择存在争议。
比较EI与UNC的术后结局。
本研究回顾了美国五个州（2007 - 2010年）的住院患者（SID）、门诊手术（SASD）和急诊科（SEDD）的关联数据，以确定接受EI或UNC作为初始手术干预的原发性VUR儿科患者。提取了非计划再入院、额外手术和急诊室（ER）就诊情况。使用广义估计方程（GEE）进行多变量逻辑回归分析以调整医院层面的聚类。
该研究确定了2556例UNC手术和1997例EI手术。与接受EI的患者相比，接受UNC的患者更可能年龄较小（4.6岁对6.0岁，P < 0.001）、为男性（30%对20%，P < 0.001）且有公共保险（34%对29%，P < 0.001）。如图表总结所示，与EI相比，UNC患者在12个月内进行额外抗反流手术的比例较低（25例（1.0%）对121例（6.1%），P < 0.001），但30天和90天再入院及急诊室就诊率较高。多变量分析显示，接受UNC治疗的患者再入院几率仍然较高（OR = 4.45；30天为2.69；90天，P < 0.001）且术后急诊室就诊几率较高（OR = 3.33；30天为2.26；90天，P < 0.001）；然而，EI患者在随后一年进行重复抗反流手术的几率显著更高（OR = 7.12，P < 0.001）。
内镜注射占儿童初始抗反流手术的近一半。然而，与接受EI治疗的患者相比，接受UNC治疗的患者在第一年需要再次治疗的几率显著更低。相比之下，接受UNC治疗的患者术后再入院或急诊室就诊的几率是前者的两倍多。尽管现有数据是规模最大且验证最充分的之一，但主要局限性是管理数据库的回顾性性质。实践环境可能不适用于未纳入分析的州。
VUR的任何手术干预后，术后再入院和急诊室就诊并不常见，但在接受UNC治疗的儿童中更常见。EI患者在1年内手术再治疗的风险增加了七倍多。
