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
Received October 28, 2013; revised November 20, 2013; accepted November 28, 2013
Copyright © 2013 Unwanaobong Nseyo et al. This is an open access article distributed under the Creative Commons Attribution
License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
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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
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U. NSEYO ET AL.
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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.
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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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