Determining the Utility of Pathologic Analysis of Ureteral Specimens Obtained from Repair of Vesicoureteral Reflux and Ureterovesical Junction Obstruction in Children: Potential for Physician-Initiated Cost-Reduction

doi:10.4236/oju.2013.38057

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Open Journal of Urology, 2013, 3, 304-307

Published Online December 2013 (http://www.scirp.org/journal/oju)

http://dx.doi.org/10.4236/oju.2013.38057

Open Access OJU

Determining the Utility of Pathologic Analysis of Ureteral

Specimens Obtained from Repair of Vesicoureteral Reflux

and Ureterovesical Junction Obstruction in Children:

Potential for Physician-Initiated Cost-Reduction*

Unwanaobong Nseyo, Mark R. Anderson, John S. Wiener#

Division of Urologic Surgery, Department of Surgery, Duke University Medical Center, Durham, USA

Email: #[email protected]

Received October 28, 2013; revised November 20, 2013; accepted November 28, 2013

License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

ABSTRACT

Purpose: Partial resection of the distal ureter is commonly perfor med dur ing recon stru ctiv e surg ery in pediatr ic urology;

particularly for correction of vesicoureteral reflux (VUR) and ureterovesical junction obstruction (UVJO). Many ho spi-

tals require pathologic examination of all excised tissues. We examined the pathologic findings in such specimens to

evaluate the utility of this practice. Methods: We reviewed the findings on pathologic examination of distal ureteral

segments excised during surgical correction of VUR and UVJO in children by a single surgeon over a 13-year period.

Results: One hundred and ninety-one specimens from 126 patients were reviewed. None were found to have any sig-

nificant pathologic findings that impacted therapy. Conclusion: Routine pathological examination of distal ureteral

segments excised during surgical correction of VUR and UVJO is not warranted. This presents potential for cost and

resource reduction in care of these patients.

Keywords: Vesicoureteral Reflux; Ureterovesical Junction Obstruction; Surgical Reimplantation; Ureteral Pathology

1. Introduction

Both vesicoureteral reflux (VUR) and ureterovesical

junction obstruction (UVJO) are the result of a congeni-

tal malformation of the ureterovesical junction. VUR is a

relatively common pediatric urological condition present

in up to 1% to 2% of all children, while UVJO is a much

less common disease. Surgical intervention is warranted

for UVJO when renal function is impacted, while, con-

troversies exist regarding diagnosis and management of

VUR. Surgical correction remains a mainstay of treat-

ment and can be achieved via an open intravesical or

extravesical approach or, more recently, by endoscopic

injection of a bulking agent. An analysis of correction of

VUR at 40 US children’s hospitals encompassing more

than 15,000 cases over a five-year period found that 63%

of the repairs used an open surgical approach [1]. With

the intravesical approach in VUR repair and with repairs

of UVJO, a portion of the distal ureter is usually excised

prior to reimplantation.

At our hospital, institutional policy requires that all

surgical specimens be subject to histopathologic analysis.

The only exempt specimens with respect to urological

procedures are foreskin from pediatric or adult circumci-

sion, calculi, and penile implants [2]. A protocol exists

by which a physician can r equest examination of a sp eci-

men, but no specimen may be withheld from analysis

unless it is previously exempt. According to institutional

policy, the excised ureteral specimens from surgical re-

pair of VUR and UVJO are submitted for routine histo-

pathologic processing and analysis.

*Conflict of Interest: J.S.W has served on advisory panels for Glaxo

Smith Kline and Lilly.

Funding Source: None.

Ethical Approval: This study was approved by our institutional review

board.

#Corresponding author.

The goal of our study was to identify and confirm the

histopathologic findings associated with ureteral tissue

excised during surgical repair of VUR and UVJO. In

particular, we were concerned with the presence of any

U. NSEYO ET AL. 305

pathology with a poten tial to impact patient man age ment.

A primary endpoint of the study was to evaluate the cost-

effectiveness of this practice and as such a cost analysis

for the pathological processing of the specimen was also

included.

2. Materials and Methods

We conducted a single-center, single-surgeon retrospec-

tive/historical case series study of patients who under-

went open repair of VUR or UVJO from September 1997

to January 2011. Patient data was identified through

electronic medical records. We identified all patients

with a CPT code for ureteral reimplantation (50780.00—

unilateral, 50780.50—bilateral, 50783.00—tapered re-

implantation, 50782.00—duplicated system, 50780.22—

revision) in that time period. Indications for repair were

typically breakthrough UTI and lack of resolution for

VUR and progressive hydronephrosis, decreased renal

function, or UTI in UVJO. Most cases of VUR were

higher grade due to surgeon preference to observe most

cases of low grade VUR or perform endoscopic correc-

tion (once available in 2001) when intervention was

warranted. Intravesical ureteral reimplantation techniques

was mostly common the Cohen technique with Glenn-

Anderson and Politano-Leadbetter repairs used in select

cases. Patients were subsequently selected with the

ICD-9 codes for VUR (593.70) or UVJO (753.22). Pa-

tients were excluded who did not have pathology speci-

mens in the case of reimplantation without distal ureter

excision (e.g. extravesical approach for ureteral reim-

plantation). Patients were also excluded who were older

than 18 years of age at the time of surgery.

The Institutional Review Board at our institution pro-

vided approval for the development and analysis of this

dataset.

We obtained pathology reports for the selected patients

from the electronic medical record and microfilm. All

specimens had undergone both gross and microscopic

examination. The specimens were routinely processed in

formalin and stained with hematoxylin/eosin. The pa-

thology reports for each specimen were evaluated for the

presence of the folllowing terms: “malignancy,” “abnor-

mality,” “inflammation,” “fibrosis,” “hyperplasia,” “dys-

plasia,” “benign,” and “normal.” We focused on reports

with results ot her tha n beni g n or normal ureteral tissue.

The costs associated with pathology analysis and proc-

essing of the ureteral specimens were obtained from the

Department of Pathology and hospital b illing. The finan-

cial information was based upon the actual billed

amounts standard for the surgical and pathology compo-

nents of the hospital visit.

3. Results

Our retrospective chart review yielded 165 patients who

had undergone open surgical repair of VUR or UVJO. Of

these, 126 patients had verifiable pathology specimens

from 191 ureters. Nine of the patients had UVJO repair,

nine had an ureteroneocystotomy for a ureterocele and

the remainder had VUR. Two-thirds of the patient popu-

lation was female. The median age was 4 years of age,

with an age range of 2 months to 18 years. There was an

equal distribution of right and left specimens. Sixty-four

cases yielded bilateral specimens.

None of the 191 ureteral specimens were found to

have any ureteral pathology suggestive of malignancy,

carcinoma or dysplasia. The most common ureteral

specimen finding was that of benign or normal ureteral

tissue. The normal ureteral specimens were designated in

many cases by stating that the specimen was a ureter,

negative for malignancy or dysplasia. The most common

pathologic “abnormality” noted was mild, often chronic,

inflammatory changes.

As no additional staining was completed, our results

were limited to changes that could be identified micro-

scopically. Of the ureteral specimens with identifiable

variations from normal tissue, the histological findings

included urothelial hyperplasia, chronic inflammation,

and chronic ureteritis. Often in cases of UVJO repair, a

segment of dilated ureter was also included in the speci-

men. In a small number of cases, the ureteral specimen

showed evidence of acute hemorrhage and electrocautery.

There were several cases in which the urothelium was

noted as being completed denuded. In one unique case, a

tubular specimen was removed that was thought to be the

ureter although anatomically attached to the testicle. Ul-

timately, the specimen was composed of urothelium and

determined to be ureter in an abnormal anatomical con-

figuration.

A cost analysis of the charges associated with the pa-

thology processing was conducted and compared to the

overall charges of the hospitalization associated with

surgical repair of VUR and UVJO. Current charges for

each pathology specimen analysis are $549: $189 of

which is the hospital charge and $360 of which are pro-

fessional fees from the surgical pathologist. Total charges

for open surgical repair of VUR/UVJO followed by a

two-day hosp ital stay were $24 ,461 : $14,741w as deno ted

for the hospital charges and $9720 for professional fees

for the surgeon and th e anesthesiologist.

4. Discussion

In our review of histopathology of ureteral specimens

excised during the open repair of VUR and UVJO in

children, no concerning findings were noted. We believe

that this is first study to address the lack of meaningful

pathologic findings in ureters excised during routine pe-

diatric reconstructive surgery. The only finding noted

were benign inflammatory changes associated with the

Open Access OJU

U. NSEYO ET AL.

Open Access OJU

306

mechanism of disease. Chronic inflammation in a patient

with VUR can be secondary to the urinary tract infec-

tions often associated with VUR. The backflow of urine

in VUR may also be responsible for the hyperplastic

changes observed. The ureters in individuals with UVJO

are thought to be hypoplastic in nature, resulting in ab-

normal peristalsis [3,4].

Due to the lack of additional staining, the architecture

of the ureteral connective tissue could not be examined in

this study. A study of children with grade IV and V VUR

without concurrent renal pathology found decreased col-

lagen thickness of the ureteral wall compared to controls

[5]. Analysis of smooth muscle fiber architecture in distal

ureteral specimens excised after correction of VUR

demonstrated smooth muscle atrophy, architectural de-

rangement, and decreased fiber expression [6]. The den-

sity and architecture of the smooth muscle fibers of the

intravesical ureter appear to correlate with the degree of

ureteral dilation [7]. Muscle hypertrophy of the ureter

proximal to the obstruction defines the histopathologic

findings in UVJO and is thought to develop through a

compensatory mechanism. Although the body of litera-

ture is minimal, these studies establish the benign mor-

phological changes found in ureters with VUR and

UVJO which fail to provide any clinically relevant in-

formation. The morphological changes and histological

changes found in our specimens in no way impacted fur-

ther management of patients following surgical repair of

VUR or UVJ O.

The histopathologic findings in our study have a po-

tential to inform policy change within our institution as

there is potential for cost-savings. Currently, ureteral

specimens excised during the repair of VUR and UVJO

must undergo mandatory gross and microscopic patho-

logic examination . Utilizing the cost analysis from above,

the pathology charges, therefore, represents 2.2% of the

total charges fo r the procedure, but th is proportion would

likely rise as hospital charges have trended downward

with shorter lengths of stays following open surgery for

VUR. Modest savings could, therefore, be realized with

our proposed elimination of histopatholgic analysis of

excised ureteral tissue in correction of VUR and UVJO.

Additionally, hospital resources can be used on more

clinically impactful efforts. We believe that it is eth ically

sound to take this step to reduce financial and health car e

resources with little to no perceivable detriment to the

patient.

Limitations of our study include its retrospective na-

ture. Also we were limited to pathology reports and

therefore were not able to verify the findings or poten-

tially stains for connective tissue analysis. Over the pe-

riod of the study, healthcare costs and delivery have

changed; for instance, the length of stay following many

surgical procedures in children has decreased. Also,

when looking for a very rare event, it is possible that our

sample size was insufficient to detect potentially delete-

rious pathology; however, the benign nature of the con-

genital disorders examined makes that possibility highly

unlikely. Regardless, if elements of the repair are not

routine, it is reasonable to submit the excised ureteral

tissue for histopathologic analysis.

5. Conclusion

Our review of histopathologic analysis of ureters excised

during a 13-year experience with the open repair of VUR

and UVJO in children found no clinically significant

pathology. The uniformly benign histological changes

noted had no influence upon clinical management of

these patients. Elimination of routine histopathological

analysis of ureteral tissue excised during repair of these

congenital anomalies cou ld result in cost reduction in the

management of these disorders in children.

REFERENCES

[1] J. C. Routh, C. P. Nelson, D. A. Graham and T. A. Lieu,

“Variation in Surgical Management of Vesicoureteral Re-

flux: Influence of Hospital and Patient Factors,” Pediat-

rics, Vol. 183, 2010, pp. 1568-1572.

[2] “Tissue Medical Devices Exemption List,” Health Sys-

tems Policies, Duke University Health System.

[3] M. Murakumo, K. Nonomura, T. Yamashita, T. Ushiki, K.

Abe and T. Koyanagi, “Structural Changes of Collagen

Components and Diminution of Nerves in Congenital

Ureteropelvic Junction Obstruction,” The Journal of Uro-

logy, Vol. 157, No. 5, 1997, pp. 1963-1968.

http://dx.doi.org/10.1016/S0022-5347(01)64910-3

[4] J. M. Park and D. A. Bloom, “The Pathophysiology of

UPJ Obstruction. Current Concepts,” Urologic Clinics of

North America, Vol. 25, No. 2, 1998, pp. 161-169.

http://dx.doi.org/10.1016/S0094-0143(05)70004-5

[5] M. Yurtcu, G. Nilifer, F. Siddika, C. A. Mustafa and G.

Engin, “Investigation of Histopathologic Changes in the

Ureter Walls in Vesicoureteral Reflux,” Journal of Pedi-

atric Surgery, Vol. 44, No. 4, 2009, pp. 802-805.

http://dx.doi.org/10.1016/j.jpedsurg.2008.08.018

[6] J. Oswald, E. Brenner, C. Schwentner, M. Deibl, G. Bartsch,

H. Fritsch and C. Radmayr, “The Intravesical Ureter in

Children with Vesicoureteral Reflux: A Morphological

and Immunohistochemical Characterization,” The Journal

of Urology, Vol. 170, No. 6, 2003, pp. 2423-2427.

http://dx.doi.org/10.1097/01.ju.0000097146.26432.9a

[7] B. Lee, A. Partin, J. Epstein, D. Qiunlan, J. Goslin and J.

Gearhart, “A Quantitative Histological Analysis of the

Dilated Ureter of Childhood,” The Journal of Urology,

Vol. 148, 1991, pp. 1482-1486.

U. NSEYO ET AL. 307

Abbreviations

CPT: Current Proced ural Ter minology

ICD: International Statistical Classification of Diseases

and Related Health Problems

VUR: Vesicorureteral Reflux

UVJO: Ureterovesical Junc tio n Ob struction

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