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Introduction/Objective
Complete resolution of VUR is the desired outcome in anti-reflux surgery, but all interventions have potential for continued reflux. Technical and patient factors predicting success would be integral in counseling patients and families in their treatment. The objective of this study was to identify characteristics associated with failed VUR surgical correction.
Methods
VUR surgical cases performed 2001- 2010 were reviewed for potential factors that may affect surgical outcome. Failure was defined as persistent VUR Grade II or higher or subsequent surgery. Patients without follow-up voiding cystourethrograms (VCUG) and ureters treated for risk of VUR were excluded. Demographic factors, pre-surgical VUR grade, type of procedure, and surgeon were compared between ureters that had failed intervention and ureters that had successful intervention using Fischer’s Exact test, t-test, Mann-Whitney U, or logistic regression when sample size allowed. Bonferroni adjustment was used when making pair-wise comparisons.
Results
Included in the study were 420 patients (656 ureters) treated by five urologic surgeons. Age at diagnosis (p=0.137), age at surgery (p=0.666), dysfunctional
elimination syndrome (p=0.868), or other co-existing urologic diagnoses (p=0.713) did not differ significantly between the fail and the success groups. Patients in the failed group were significantly younger (p<0.01), and their time from diagnosis to intervention was significantly shorter (p=0.05).
As a whole, there was no significant difference in pre-surgical VUR grades between the groups (p=0.431), however, when analyzed by type of intervention, half (50%) of ureters with grade IV-V VUR treated with Deflux failed, while only 20% of ureters with grade I-III failed (p=0.001). No significant difference was found in pre-surgical VUR grade for either open or robotic reimplantation.
Open surgery had a lowest lower failure rate than Deflux (p<.001). We could not make a meaningful comparison between open and robotic reimplantation due to the small robotic sample size. When comparing success of open procedures, the surgeon with highest volume of cases attained significantly higher rates of resolution ( p<0.001).
Conclusion
Lowest failure rates of anti-VUR surgery were associated with older patients, open reimplant, and surgeons with high case volume. These factors are only part of the predictive equation. Lower success rate in younger patients may be due to bladder capacity, and disease progression may be a factor. But we could not reach these conclusions with this data set. Continued research can determine factors that remain inconclusive. Increased data on methods like robotic intervention may also elucidate more predictive factors.

Factor	Complete Resolution	Incomplete Resolution	Total
Ureters	84% (553)	16% (103)	656
Surgical Age (mos, median,range)	71 (2-256)	53 (3-162)	69 (2-256)
Dx to Surgery (mos, median,range)	16 (1-132)	12 (1-69)	15 (1-132)
Open Intervention	91% (287)	9% (28)	315
Robotic Intervention	90% (18)	10% (2)	20
Dextranomer/Hyaluronic Acid injection (Deflux)	78% (249)	22% (72)	321
Highest Volume Surgeon	98% (n=125)	2% (n=3)	128