U. NSEYO ET AL.
Open Access OJU
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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.