Correspondence Trends and Perioperative Outcomes of Pediatric Urological Procedures

Findings of the GRAND Study

Some of the most important pediatric urological procedures are pyeloplasty, correction of vesicoureteral reflux, and hypospadias repair (1). Obstruction of the ureteropelvic junction has a prevalence of about 0.1% and is surgically corrected by means of pyeloplasty, which can be performed either as an open or a minimally invasive procedure. Persistent vesicoureteral reflux has a prevalence of about 0.2%. Depending on its severity, it is commonly corrected by endoscopic injection of bulking agents, anti-reflux surgery (Lich–Gregoir technique), or ureteral reimplantation (2). Hypospadias has a prevalence of about 0.2%. It is typically corrected with meatoplasty or glanuloplasty (3), while reconstruction of the urethra is performed with either a preputial or a buccal mucosal graft, depending on the degree of hypospadias and the existence or otherwise of penile curvature (4).

Understanding the current trends and outcomes of these procedures is crucial for guiding clinical decision-making and contributes to optimizing patient outcomes, and ensuring appropriate referral pathways to specialized centers. These interventions are complex, often requiring specialized expertise to optimize outcomes. Given that the prevalence of pediatric ureteropelvic junction obstruction, vesicoureteral reflux, and hypospadias is slightly increasing, we aimed to evaluate the current trends in treatment and the perioperative outcomes.

Methods

For the present analysis, we used the GeRmAn Nationwide Inpatient Data (GRAND), provided by the Federal Statistical Office. This database contains all inpatient billing records from 2005 to 2023 (5). GRAND encompasses nationwide data on all hospitalizations in Germany, including diagnoses, procedures, and perioperative outcomes. We included all pediatric patients (below 18 years of age) who received one of the following treatments:

• Correction of ureteropelvic junction obstruction
• Open pyeloplasty (German Operations and Procedures code [OPS]: 5–557.4)
• Laparoscopic pyeloplasty (5–557.43)
• Robot-assisted pyeloplasty (5–987)
• Correction of vesicoureteral reflux
• Endoscopic injection of bulking agents (5–569.62)
• Ureteral reimplantation (5–568.9)
• Reconstruction of the urethra for hypospadias
• Meatoplasty and glanuloplasty (5–645.0)
• Preputial graft (5–645.20, 5–645.21) or
• Buccal mucosal graft (5–645.22)

Results

From 2005 to 2023, 16 239 pediatric patients underwent pyeloplasty in Germany (11 695 open, 3762 laparoscopic and 782 robot-assisted). Although the number of robotic and laparoscopic pyeloplasties increased exponentially, while the number of open pyeloplasties decreased substantially, the majority of child with obstruction of the ureteropelvic junction still underwent open surgery. Surgical correction of vesicoureteral reflux was carried out in 23 752 patients (8862 ureteral reimplantations and 14 890 endoscopic injections). These trends indicate that more and more patients are being managed conservatively, although the endoscopic use of bulking agents peaked around 10 years ago. Moreover, 42 321 patients underwent urethral repair for hypospadias (13 391 with meatoplasty and glanuloplasty, 27 394 with preputial graft, and 1536 with buccal mucosal graft). It seems that buccal mucosal grafts are reserved for complex cases at high-volume centers. The majority of patients who underwent surgery were under 6 years old and were treated in non-urological departments. The perioperative outcomes are presented in the Table and their annual trends in the Figure.

Figure

The annual trends

Table

Perioperative outcomes of children undergoing pyeloplasty, correction of vesicoureteral reflux, or urethral repair for hypospadias

Discussion

The present nationwide in-hospital data from Germany indicate that pyeloplasty, correction of vesicoureteral reflux, and urethral repair for hypospadias are associated with low rates of major perioperative complications. The majority of these procedures are performed by pediatric surgeons. Nevertheless, the number of patients undergoing these intervention in pediatric urology is decreasing year on year. Indeed, most children with obstruction of the ureteropelvic junction are not operated on until they reach adulthood (5). Accordingly, it seems that vesicoureteral reflux is more often managed conservatively, and a partial change in the treatment strategy for more severe cases (grade 3 and higher) can be observed in Germany (2).

The different techniques for these pediatric urological procedures were associated with similar perioperative outcomes. Still, it should be highlighted that these findings must be interpreted with caution since they derive from billing data and are, therefore, prone to coding errors and misclassifications. Similarly, no information on functional outcomes as well as complications after hospital discharge is available. It was also not the aim of the present analysis to compare the perioperative outcomes of various surgical techniques. The outcomes were evaluated across different indications, so our time-independent analysis may not fully capture the dynamic evolution of surgical techniques and their impact on outcomes. Moreover, preferences in the selection of patients and hospitals may influence the determination of trends in different surgical techniques.

This study on the trends and perioperative outcomes of important pediatric urological procedures in Germany suggests that, although these operations are associated with low perioperative rates of major complications, the annual number of cases performed is steadily decreasing.

Nikolaos Pyrgidis*, Regina Stredele*, Gerald B. Schulz, Michael Chaloupka, Benedikt Ebner, Troya Ivanova, Michael Atzler, Paulo L. Pfitzinger, Philipp Weinhold, Christian G. Stief, Julian Marcon

Department of Urology, University Hospital, LMU Munich, Germany (Pyrgidis, Stredele, Schulz, Chaloupka, Ebner, Ivanova, Atzler, Pfitzinger, Weinhold, Stief, Marcon)

*Joint first authors

Conflict of interest statement
The authors declare that no conflict of interest exists.

Manuscript submitted on 26 September 2024, revised version accepted on 13 January 2025

Cite this as:
Pyrgidis N, Stredele R, Schulz GB, Chaloupka M, Ebner B, Ivanova T, Atzler M, Pfitzinger PL, Weinhold P, Stief CG, Marcon J: Trends and perioperative outcomes of pediatric urological procedures: Findings of the GRAND study. Dtsch Arztebl Int 2025; 122: 193–4. DOI: 10.3238/arztebl.m2025.0007

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