Voiding cystourethrography after uncomplicated ureteral reimplantation in children: Is it necessary?

Purpose: Our aim was to assess whether a voiding cystourethrogram after uncomplicated ureteral reimplantation is necessary or cost-efficient. Materials and Methods: We retrospectively reviewed the records of patients who underwent uncomplicated reimplantation at our institution from 1988 to 1994. We also reviewed the literature to tabulate the reflux resolution rate from all published series of more than 100 ureters reimplanted. Results: At our institution 119 patients (207 ureters) underwent uncomplicated reimplantation and a postoperative voiding cystourethrogram, which documented a 98.6% initial reflux resolution rate. All persistent postoperative reflux resolved spontaneously without treatment for a final resolution rate of 100%. We reviewed 1,494 abstracts using vesicoureteral reflux as a key word and found 19 series of more than 100 ureters reimplanted. The combined results of our series and those 19 from the literature revealed 3,346 patients (5,008 ureters reimplanted). The final reflux resolution rate was 98.58%. Series that included and excluded secondary vesicoureteral reflux documented final reflux resolution rates of 98.4 and 99.04%, respectively. Reflux resolved spontaneously in 85% of the ureters in which it was noted on the initial postoperative cystogram. At our institution the cost of a voiding cystourethrogram is $610 and we perform an average of approximately 20 uncomplicated reimplantations per year. In the United States there are approximately 230 pediatric urologists. If each surgeon performed 20 reimplantations per year at the same cost per voiding cystourethrogram, a cost savings of $2.8 million per year would result if the study were not performed after surgery. Conclusions: In the hands of experienced pediatric urologists uncomplicated ureteral reimplantation has a success rate of 99.04%. The yield of postoperative voiding cystourethrography is exceedingly low and a cost savings of $2.8 million per year would result by omitting the postoperative voiding cystourethrogram.