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Development and validation of a scoring system for objective assessment of clinical failure after pediatric robot-assisted laparoscopic extravesical ureteral reimplantation: a multi-institutional inte |
| Urology, Asan Medical Center, University of Ulsan College of Medicine, Division of Pediatric Urology, Department of Surgery, Texas Children's Hospital, and Scott Department of Urology, Baylor College of Medicine, Houston, TX., Urology, Korea University Ansan Hospital, Urology, Asan Medical Center, University of Ulsan College of Medicine, Division of Pediatric Urology, Department of Surgery, Texas Children's Hospital, and Scott Department of Urology, Baylor College of Medicine, Houston, TX., Division of Pediatric Urology, Department of Surgery, Texas Children's Hospital, and Scott Department of Urology, Baylor College of Medicine, Houston, TX., Outcomes and Impact Service, Department of Surgery, Texas Children’s Hospital, Houston, TX, Urology, Samsung Medical Center, Division of Pediatric Urology, Department of Surgery, Texas Children's Hospital, and Scott Department of Urology, Baylor College of Medicine, Houston, TX. |
| Sang Hoon Song, Il-Hwan Kim, Jae Hyeon Han, Kun Suk Kim, Jonathan Gerber, Vinaya Bhatia, Huirong Zhu, Minki Baek, Chester J. KOH |
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Background: Radiologic resolution rates of VUR and complication rates after robot-assisted laparoscopic extravesical ureteral reimplantation (RALUR-EV) have been reported as comparable to open ureteral reimplantation in previous multicenter studies and reviews. However, there have been reports of suboptimal results with lower success rates and higher complication rates at some centers, which may reflect technical or learning curve differences. We hypothesized that identifying predictive factors for successful VUR resolution after RALUR-EV is needed and will help shorten the learning curve for surgeons and improve outcomes for patients when performed by surgeons at any level of experience. / Objectives: We aimed to develop and validate a scoring system as an objective assessment tool for predicting clinical failure after robotic extravesical ureteral reimplantation. / Materials and Methods: Data for this multi-institutional retrospective cohort study of RALUR-EV patients was obtained from two tertiary referral hospitals (hospitals A and B). The larger cohort between the two institutions was designated as a development cohort and the other as an external validation cohort. The scoring system and risk model for the prediction of clinical success after RALUR-EV were developed. In this study, clinical failure was defined as incomplete radiographic resolution of VUR on follow-up voiding cystourethrogram (VCUG) or radionuclide cystogram (RNC), or postoperative febrile UTI or additional intervention or surgery when follow-up VCUG or RNC was not available. Patients were stratified into low, intermediate, and high-risk groups according to the score. External validation was performed using the model projected to the external validation cohort. / Results and Conclusion: 115 renal units in the development cohort and 46 renal units in the validation cohort were analyzed. Two cohorts showed heterogeneous characteristics regarding vesicoureteral reflux (VUR) grade, bladder bowel dysfunction (BBD) status, and console time. To develop the prediction score, we assigned weighted points to each variable according to their regression coefficient on the logistic regression analysis. The score was calculated as: age (yr) + BMI + BBD times 10 + VUR grade times 7 + console time (hr) + hospital stay times 6. Hosmer-Lemeshow goodness-of-fit test which indicated that the prediction model and scoring system were well-calibrated (p = 0.976). Patients were stratified into low-risk (< 52 points), intermediate-risk (52-70 points), and high-risk groups (≥ 71 points), with a risk of failure after surgery at the time of the first VCUG or RNC follow-up for each group. Clinical failure was significantly different among risk groups: 100% (low-risk), 96.7% (intermediate-risk), and 77.8% (high-risk) (p=0.004) in the development cohort. The C-index of our scoring system was 0.850 (p=0.001) and 0.770 (p=0.040) in the development and validation cohorts, respectively (Figure 1). In conclusion, a novel scoring system using multiple pre- and intraoperative variables including patient’s age, BMI, BBD status, VUR grade, console time, and hospital stay provides a prediction of children at risk for failure after robotic extravesical ureteral reimplantation. |
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keywords : vesicoureteral reflux; reimplantation; robotic surgery |
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