Vesicoureteral reflux and ureteroceles

Framing the picture: Impact of radiographic imaging on parental vesicoureteral reflux management preferences

INTRODUCTION/OBJECTIVE

Given the variety of treatment options for vesicoureteral reflux (VUR), shared decision making between clinicians and parents is essential. Despite its importance, shared decision making is limited by the framing effect - people process the same information differently depending on how it is presented. Studies have also demonstrated that showing patients their radiology images can impact behaviors. In this pilot study, we sought to determine if showing parents radiographic images could serve as a framing tool that impacts the decision of whether to pursue surgery, endoscopic intervention, or conservative management for VUR.

METHODS

We designed a survey instrument which provided background on VUR and a hypothetical scenario of a 2-year-old child with VUR who had a breakthrough febrile urinary tract infection (UTI). Guideline-concordant management options were presented: (1) change antibiotics, (2) endoscopic management, or (3) open or laparoscopic surgery. All options were similarly presented regarding risks, benefits, and length of stay. Respondents were randomized into a group with no image accompanying the clinical scenario or a group which had a labeled image of a voiding cystourethrogram (VCUG) demonstrating unilateral VUR. Respondents also answered demographic and health experience questions. The instrument was published on Amazon's Mechanical Turk online work interface which provides reliable and validated results in VUR experiments. Parents aged 18-60 years old were eligible. Responses with failed attention questions, duplicate internet addresses, or submission times <1 or >30 min were disqualified. Data were analyzed using t-test, chi-square, and multinomial logistic regression. Sensitivity analyses were performed after excluding all responses submitted under 2, 3, and 5 min.

RESULTS

There were a total of 914 responses, 426 met inclusion criteria. The presence or absence of a VCUG image did not result in a statically significant difference in the management decision (p = 0.081). Multinomial logistic regression demonstrated that prior UTI experience influenced the management decision (p = 0.027). Sensitivity analyses revealed a significant difference in the management decision when excluding responses <5 min (p = 0.039).

CONCLUSION

In this analysis, there was no statistically significant framing effect by radiographic images on parental management decision for VUR. Multinomial analyses suggested that prior experience with UTI has an impact on VUR management decisions. These results need to be considered within the limitations of this pilot study - the respondents were given a hypothetical clinical scenario and the survey instrument cannot replace an in-office discussion. Further analyses on framing and its role in pre-operative counseling is warranted.

Parental preferences for vesicoureteral reflux treatment: Profile case best-worst scaling

INTRODUCTION

Vesicoureteral reflux is a common pediatric urologic condition that often has several reasonable treatment options depending on condition severity. In order to choose the best treatment for their child, parents are expected to make judgements that weigh attributes such as treatment cost, effectiveness, and complication rate. Prior research has shown that factors such as treating hospital and surgeon also influence patient treatment choice.

OBJECTIVES

This study evaluates parental preferences for reflux treatment using profile case best-worst scaling, an emerging technique in both urologic and health care preference estimation. The study also uses latent class analysis (LCA) to identify parental sub-classes with different preferences.

STUDY DESIGN

Data were collected from a community sample of parents via a multimedia best-worst scaling survey instrument published to Amazon's Mechanical Turk online community. After extensive review of the literature, reflux attributes and attribute levels were selected to correspond with available treatments. The profile case best-worst scaling exercise elicited preferences for granular attributes of reflux treatments. Data were analyzed using multinomial logistic regression and class analysis to distinguish preference heterogeneity. Probability scaled values (PSVs) reflected the order of desirability of the attributes. Attribute preference importance was rescaled into dollar units for comparison as well.

RESULTS

We analyzed data for 248 respondents. The highest treatment effectiveness was more desirable than all other leveled treatment attributes (PSV 17.8, all p < 0.01) (Table). Low complication rate and doctor recommendation were amongst the other most desirable treatment attributes (PSV 11.3 and 9.0, respectively). Latent class analysis identified a class with more extreme preferences, for whom doctor recommendation and avoiding hospitalization were particularly desirable.

DISCUSSION

In this community-based sample, high treatment effectiveness and low complication rate were the most desirable treatment attributes to parents, though parents likely have heterogenous treatment preference structures. Shared parent-physician decision-making that incorporates parental preferences will likely allow more effective, targeted decision-making in the future.

Immune Expression in Children With Vesicoureteral Reflux: A Pilot Study

OBJECTIVE

To perform an exploratory, descriptive pilot study of the systemic and local immune environment in patients with vesicoureteral reflux (VUR) and bladder-bowel dysfunction (BBD).

METHODS

Consecutive children with VUR undergoing intravesical ureteral reimplantation were enrolled. Patients were assessed for presence of BBD by reported patient history and validated questionnaire. Fresh blood and bladder tissue, collected at the time of surgery, were immediately processed for analysis. Immune cell compositions were determined via flow cytometry. Immune cell activation was also defined at the time of analysis. LegendPlex assay analysis was utilized to define levels of circulating chemokines and cytokines.

RESULTS

A total of 7 patients were enrolled. Although percentages of circulating immune cells in the blood of those with VUR/BBD and VUR alone were similar, within bladder tissue, VUR/BBD demonstrated increased immune infiltrates compared to VUR alone. Bladder sample analysis showed that B cells, and Effector Memory and Naïve T cell percentages were significantly increased in VUR/BBD patients compared to VUR patients. T cell expression of PD1 was increased in bladder tissues of BBD/VUR. Additionally, analysis of circulating neutrophils displayed significantly increased upregulation of PDL-1 in patients with VUR/BBD vs those with VUR only.

CONCLUSION

These pilot data suggest an immune-rich microenvironment is present within VUR. Severity of inflammation appeared to correlate with presence of BBD. This implies that targeting pelvic inflammation may be a novel therapy for children with VUR- or non-VUR-related BBD. Follow-up studies are currently underway.

Parental Preferences for Vesicoureteral Reflux Treatment: A Crowd-sourced, Best-worst Scaling Study

OBJECTIVE

To quantitatively evaluate parental preferences for the various treatments for vesicoureteral reflux using crowd-sourced best-worst scaling, a novel technique in urologic preference estimation.

METHODS

Preference data were collected from a community sample of parents via 2 best-worst scaling survey instruments published to Amazon's Mechanical Turk online community. Attributes and attribute levels were selected following extensive review of the reflux literature. Respondents completed an object case best-worst scaling exercise to prioritize general aspects of reflux treatments and multiprofile case best-worst scaling to elicit their preferences for the specific differences in reflux treatments. Data were analyzed using multinomial logistic regression. Results from the object-case provided probability scaled values (PSV) that reflected the order of importance of attributes.

RESULTS

We analyzed data for 248 and 228 respondents for object and multiprofile case BWS, respectively. When prioritizing general aspects of reflux treatment, effectiveness (PSV = 20.37), risk of future urinary tract infection (PSV = 14.85), and complication rate (PSV = 14.55) were most important to parents. Societal cost (PSV = 1.41), length of hospitalization (PSV = 1.09), and cosmesis (PSV = 0.91) were least important. Parents perceived no difference in preference for the cosmetic outcome of open vs minimally invasive surgery (P = .791). Bundling attribute preference weights, parents in our study would choose open surgery 74.9% of the time.

CONCLUSION

High treatment effectiveness was the most important and preferred attribute to parents. Alternatively, cost and cosmesis were among the least important. Our findings serve to inform shared parent-physician decision-making for vesicoureteral reflux.

Readmissions, unplanned emergency room visits, and surgical retreatment rates after anti-reflux procedures

INTRODUCTION/BACKGROUND

The choice between endoscopic injection (EI) and ureteroneocystotomy (UNC) for surgical correction of vesicoureteral reflux (VUR) is controversial.

OBJECTIVE

To compare postoperative outcomes of EI vs UNC.

STUDY DESIGN

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.

RESULTS

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).

DISCUSSIONS

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.

CONCLUSIONS

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.

Utility Estimation for Pediatric Vesicoureteral Reflux: Methodological Considerations Using an Online Survey Platform

PURPOSE

The advent of online task distribution has opened a new avenue for efficiently gathering community perspectives needed for utility estimation. Methodological consensus for estimating pediatric utilities is lacking, with disagreement over whom to sample, what perspective to use (patient vs parent) and whether instrument induced anchoring bias is significant. We evaluated what methodological factors potentially impact utility estimates for vesicoureteral reflux.

MATERIALS AND METHODS

Cross-sectional surveys using a time trade-off instrument were conducted via the Amazon Mechanical Turk® (https://www.mturk.com) online interface. Respondents were randomized to answer questions from child, parent or dyad perspectives on the utility of a vesicoureteral reflux health state and 1 of 3 "warm-up" scenarios (paralysis, common cold, none) before a vesicoureteral reflux scenario. Utility estimates and potential predictors were fitted to a generalized linear model to determine what factors most impacted utilities.

RESULTS

A total of 1,627 responses were obtained. Mean respondent age was 34.9 years. Of the respondents 48% were female, 38% were married and 44% had children. Utility values were uninfluenced by child/personal vesicoureteral reflux/urinary tract infection history, income or race. Utilities were affected by perspective and were higher in the child group (34% lower in parent vs child, p <0.001, and 13% lower in dyad vs child, p <0.001). Vesicoureteral reflux utility was not significantly affected by the presence or type of time trade-off warm-up scenario (p = 0.17).

CONCLUSIONS

Time trade-off perspective affects utilities when estimated via an online interface. However, utilities are unaffected by the presence, type or absence of warm-up scenarios. These findings could have significant methodological implications for future utility elicitations regarding other pediatric conditions.

Open versus minimally invasive ureteroneocystostomy: A population-level analysis

INTRODUCTION

Open ureteroneocystostomy (UNC) is the gold standard for surgical correction of vesicoureteral reflux (VUR). Beyond single-center reports, there are few published data on outcomes of minimally-invasive (MIS) UNC. Our objective was to compare postoperative outcomes of open and MIS UNC using national, population-level data.

METHOD

We reviewed the 1998-2012 Nationwide Inpatient Sample to identify pediatric (≤18 years) VUR patients who underwent either open or MIS UNC. Demographics, National Surgical Quality Improvement Program (NSQIP) complications, length of stay (LOS), and cost data were extracted. Statistical analysis was performed using weighted, hierarchical multivariate logistic regression (complications) and negative binomial regression (LOS, cost).

RESULTS

We identified 780 MIS and 75,976 open UNC admissions. Compared with patients undergoing open UNC, patients who underwent MIS UNC were likely to be older (6.2 versus 4.8 years, p < 0.001), publically insured (43 versus 26%, p < 0.001), and treated in recent years (90 versus 46% after 2005, p < 0.001). MIS admissions were associated with a significantly shorter length of stay (1.0 versus 1.8 days, p < 0.001) and higher cost ($9230 versus $6,304, p = 0.002). After adjusting for patient-level confounders (age, gender, insurance, treatment year, and comorbidity), and hospital-level factors (region, bedsize, and teaching status), MIS UNC was associated with a significantly higher rate of postoperative urinary complications such as UTIs, urinary retention, and renal injury (OR 3.1, p = 0.02), shorter LOS (RR 0.8, p = 0.02), and higher cost (RR 1.4, p = 0.008).

DISCUSSION

Strengths of this study are its large cohort size, long time horizon, national estimation, and cost data. Most prior studies are case-series limited to the size of the institutional cohort. Our analysis of 76,756 operative encounters revealed that open UNC continues to be performed at far greater frequency than MIS UNC, outpacing the latter modality by nearly 100:1. Children treated with MIS UNC had three times greater odds of developing postoperative urinary complications, and MIS UNC patients incurred average costs per admission that were nearly 1.5 times higher than those of children who underwent open UNC. These children were also likely to be older, publically insured, and treated in more recent years. On the other hand, patients treated with MIS UNC required substantially shorter postoperative hospitalization, with an average LOS roughly half that of open UNC cases. Limitations include the retrospective nature of the administrative database, lack of detailed patient-level data, and no available long-term postoperative outcomes. Compared with open surgery, MIS UNC was associated with shorter LOS but higher costs and possibly higher urinary complication rates.

Noninvasive ureterocele puncture using pulsed focused ultrasound: an in vitro study

PURPOSE

To evaluate the feasibility of performing noninvasive puncture of pediatric ureteroceles with cavitation-based focused ultrasound (US) (histotripsy).

MATERIALS AND METHODS

A model for the ureterocele wall was developed from an excised bovine bladder wall. The model was exposed to focused US pulses in a water bath under three different US parameter sets for up to 300 seconds to create localized perforations in the wall. B-mode US imaging was used to monitor the treatment and assess potential imaging guidance and feedback.

RESULTS

Punctures were formed between 46-300 seconds, depending on the focused US exposure parameters and model wall thickness. Puncture diameter was controllable through choice of exposure parameters and could be varied between 0.8-2.8 mm mean diameter. US-induced cavitation was visible on B-mode imaging, which provided targeting and treatment feedback.

CONCLUSIONS

Cavitation-based focused US can create punctures in a model that mimics the tissue properties of a ureterocele wall, under guidance from US imaging.

The demographics and costs of inpatient vesicoureteral reflux management in the USA

This study evaluates the impact of vesicoureteral reflux (VUR) on the economy and inpatient healthcare utilization in the USA. A retrospective analysis was performed on children ≤ 18 years of age, hospitalized with the principal discharge diagnosis of VUR between 2000 and 2006, using the Healthcare Cost and Utilization Project Kids' Inpatient Database. The results are stratified as follows. First, by hospitalizations: between 2000 and 2006, 6,655  ±  720 (standard error) children/year were hospitalized with VUR. Since 2003, both the length of each hospitalization and the number of hospitalizations have decreased. Second, by related procedures/diagnoses: ureteral reimplantation was the most common procedure, accounting for 89% of hospitalizations. Congenital genitourinary anomalies, disorders of the kidney/ureter/bladder, and urinary tract infections (UTI) were the most common related diagnoses. Thirdly, by hospital economics: since 2000, hospital charges for VUR increased despite decreased lengths of hospitalization. By 2006, hospital charges rose to $18,798/hospitalization, and aggregate national charges exceeded $100 million. Our results indicate that fewer children with VUR are requiring inpatient management. Children with VUR are often hospitalized for ureteral reimplantation or the management of related diagnoses. Since 2000, hospital charges for inpatient VUR management have increased. More efforts are needed to evaluate cost-effective strategies for the evaluation and management of VUR.

Current perspectives on congenital obstructive nephropathy

Congenital obstructive nephropathy is the leading cause of chronic renal disease in children. As a result, it represents a tremendous societal burden in terms of morbidity and mortality, as well as in health care expenses of caring for children with chronic kidney disease and end-stage renal disease. The various diagnostic, prognostic, and therapeutic challenges associated with congenital obstructive nephropathy highlight the importance of developing effective experimental models for studying this disease process. In this review, we define the clinical entity that is congenital obstructive nephropathy, outline the current standards of diagnosis and care, and discuss the utilization of current experimental models designed to help clarify some of the clinical conundrums associated with this important disease.

Variation in surgical management of vesicoureteral reflux: influence of hospital and patient factors

OBJECTIVE

Controversy exists over surgical procedure choice for vesicoureteral reflux (VUR) in children. Either ureteral reimplantation (UR) or a newer procedure, endoscopic injection (EI), may be chosen; however, the factors that determine procedure choice for any individual patient are unclear. The objective of this study was to identify patient and hospital factors associated with the choice of EI for children undergoing antireflux surgery.

PATIENTS AND METHODS

We searched the Pediatric Health Information System, a national database collected by freestanding children's hospitals. We identified children aged <18 years with primary VUR who underwent surgery (UR or EI) between 2003 and 2008. We used multivariate logistic regression models to evaluate whether the type of procedure performed was associated with hospital-level factors including individual hospital, hospital region, size, and teaching status, as well as patient features including age, race, gender, and insurance type.

RESULTS

We identified 15026 children with primary VUR who underwent antireflux surgery between 2003 and 2008. Of these, 3611 children (24%) were treated at hospitals that performed reimplant only. Among children treated at institutions offering both procedures, 5562 (49%) underwent injection and 5853 (51%) underwent reimplant. Patients who received EI were significantly older and more likely to be girls, white, and publicly insured than those who had UR. They were more likely to have been treated at hospitals that were larger, were teaching hospitals, or were located in larger metropolitan areas or the South rather than the Northeast. After adjusting for other covariates, the treating hospital was the most important factor predicting procedure choice.

CONCLUSIONS

The hospital at which a patient receives treatment is the single most important feature that drove procedure choice for children with primary VUR. The patient's age, gender, insurance status, and disease severity played a smaller, although significant, role.

Postnatal evaluation of infants with an abnormal antenatal renal sonogram

PURPOSE OF REVIEW

Antenatally detected renal abnormalities are frequently encountered. Recommended postnatal evaluation of these infants has evolved to minimize invasive testing while maximizing detection of significant abnormalities.

RECENT FINDINGS

There is a low rate of detectable renal abnormalities in infants with a normal postnatal sonogram at 4-6 weeks of age. Routine prophylactic antibiotics are not indicated in infants with isolated antenatal hydronephrosis. Infants with a multicystic dysplastic kidney and a normal contralateral kidney on renal ultrasound do not require further evaluation. Parents of these children should be counseled on symptoms of urinary tract infections to allow prompt diagnosis.

SUMMARY

All infants with abnormalities on antenatal sonogram should undergo postnatal evaluation with a sonogram after birth and at 4-6 weeks of age. Further evaluation can be safely limited when the postnatal sonogram is normal at 6 weeks of age.

The demographic burden of urologic diseases in America

The National Institute of Diabetes and Digestive and Kidney Diseases initiated the Urologic Diseases in America project in 2001 with the goal of quantifying the immense demographic burden of urologic diseases on the American public, in both human and financial terms. This effort was renewed in 2007 with the aim of expanding and deepening analyses of the epidemiology, costs, and quality of medical care in urology. This ongoing commitment recognizes the major public health impact of urologic conditions in the United States. A thoughtful policy response to these changes requires a thorough understanding of the health care resource use and clinical epidemiology relevant to urologic diseases in America. This article details major initial findings from the Urologic Diseases in America project with respect to the demographic impact of the most common benign, malignant, and pediatric urologic conditions.