- Email: [email protected]
Extravesical Ureteral Reimplantation: An Outpatient Procedure
Clinical Research Extravesical Ureteral Reimplantation: An Outpatient Procedure Jeffrey S. Palmer* From the Center for Pediatric Urology, Glickman Urological and Kidney Institute, Cleveland Clinic Children’s Hospital, Cleveland, Ohio
Purpose: We determined whether implementation of a critical pathway and modification of the extravesical ureteral reimplantation surgical technique to repair unilateral and bilateral vesicoureteral reflux would consistently result in same day patient hospital discharge without increased morbidity. Materials and Methods: We evaluated all children undergoing extravesical ureteral reimplantation using a modified technique that limits ureteral dissection, ureteral mobilization and detrusor dissection to as distal as possible. No surgical dissection is done in proximity to the obliterated umbilical artery, nor is the artery ligated. Patients follow a strict postoperative critical pathway, and parents receive extensive preoperative and postoperative education. The child is required to fulfill strict criteria to be discharged home. Results: A total of 51 girls and 9 boys 0.9 to 10.5 years old (mean age 5.1) were evaluated. A total of 24 unilateral and 36 bilateral procedures were performed with and without ureteral tapering, and for single systems, duplex systems and an associated Hutch diverticulum. Overall 54 children (90%) were discharged home the same day, while only 6 (10%) went home the next day. All patients who underwent a unilateral procedure and 83% who underwent a bilateral procedure were outpatients. However, when evaluating the last 40 consecutive patients, including 14 with a unilateral and 26 with a bilateral procedure, all (100%) were discharged home the day of surgery without increased morbidity or an additional analgesic requirement. All outpatients were discharged within 5 hours after surgery. All patients tolerated the procedure well without major complications and without any patients requiring an emergency department visit or hospitalization after discharge home. After the urinary catheter was removed all patients were able to spontaneously void postoperatively without any acute or chronic urinary retention. Conclusions: This study demonstrates that implementation of a strict critical pathway and a unilateral or bilateral extravesical ureteral reimplantation surgical technique with limited dissection can consistently result in same day discharge from the hospital within a few hours postoperatively without increased morbidity or rehospitalization. Key Words: bladder, ureter, cystostomy, vesico-ureteral reflux, outpatients
xtravesical ureteroneocystostomy has been associated with a decreased incidence of hematuria, bladder spasms and convalescence.1–3 Marotte and Smith,4 and Duong et al5 have evaluated methods to decrease hospitalization with some children discharged home the day of surgery. Some groups have cautioned against simultaneous bilateral extravesical repair since this has been associated with transient urinary retention requiring bladder catheter replacement.1,3 To our knowledge we were the first to report the ability of toilet trained children to undergo bilateral extravesical ureteral reimplantation resulting in patient discharge after a 1-day hospitalization and without urinary retention through a critical pathway and modification of surgical technique.6 In this study we determined whether further refinement of the critical pathway and the extravesical ureteral reimplantation surgical technique could be implemented to consistently perform the extravesical technique to repair unilateral and bilateral vesicoureteral reflux as an outpatient procedure without increased morbidity.
E
* Correspondence: Center for Pediatric Urology, Glickman Urological and Kidney Institute, Cleveland Clinic Children’s Hospital, 9500 Euclid Ave., Cleveland, Ohio 44195 (telephone: 216-445-7504; FAX: 216-445-2267; e-mail: [email protected]).
0022-5347/08/1804-1828/0 THE JOURNAL OF UROLOGY® Copyright © 2008 by AMERICAN UROLOGICAL ASSOCIATION
MATERIALS AND METHODS We evaluated all children undergoing extravesical ureteroneocystostomy and following an outpatient oriented critical pathway for preoperative education, operative management and postoperative care. The indications for surgery were persistent or worsening vesicoureteral reflux and/or breakthrough urinary tract infections. Preoperatively parents received extensive education on the specific preoperative and postoperative instructions, expectations and goals. Patients received caudal anesthesia for preventive analgesia, intraoperative ketorolac (Toradol®) and subcutaneous Marcaine® unless contraindicated. The extravesical detrusorrhaphy technique performed is closely related to the modification of the Lich-Gregoir antireflux procedure, which includes ureteral advancement, described by Zaontz et al.7 As previously reported, our modification of this approach involves limiting ureteral dissection, ureteral mobilization and detrusor dissection to as distal as possible, so that a 5:1 ratio of tunnel length to ureteral diameter can be accomplished (see figure). We have recently further limited ureteral dissection. The obliterated umbilical artery is not ligated and no surgical dissection is done in proximity to the obliterated umbilical artery. A low coagulation current, needle tip Bovie coagulator is used for dissection.
1828
Vol. 180, 1828-1831, October 2008 Printed in U.S.A. DOI:10.1016/j.juro.2008.04.080
OUTPATIENT EXTRAVESICAL URETERAL REIMPLANTATION
1829
Modified Lich-Gregoir extravesical detrusorrhaphy technique with ureteral advancement. A, limited distal ureteral dissection and use of low coagulation current, needle tip Bovie coagulator. B, limited proximal ureteral dissection with all dissection distal to obliterated umbilical artery. C, complete extravesical detrusorrhaphy and fully mobilized ureter. D, placement of 2 ureteral advancing sutures between detrusor and ureteral adventitia. E, ureteral advancement. F, detrusor flaps sutured over ureter in interrupted fashion, completing extravesical procedure.
Postoperatively patients were started on a regular diet in the recovery room and ketorolac was used for analgesia when repeat dosing was indicated. Also, extensive ambulation was started immediately. A patient was discharged home with a urethral catheter if the patient underwent 1) a bilateral procedure and was not toilet trained since a timed voiding schedule could not be followed, 2) ureteral tapering and/or 3) diverticulectomy. When a catheter was left in place, it was removed within a few days depending on the parental schedule. The child was discharged from the surgical facility if 5 strict criteria were fulfilled, including 1) the patient urinated 3 times in the recovery room without any suprapubic distention or urinary incontinence if the catheter was removed, 2) the patient tolerated a regular diet, 3) pain was controlled without requiring narcotics, 4) the patient ambulated without difficulty (age appropriate) and 5) parents stated that they were comfortable with taking the child home. Patients also followed specific instructions at home, including 1) strict timed voiding every 2 hours after catheter removal, 2) extensive ambulation, 3) analgesia managed by acetaminophen and/or acetaminophen with codeine depending on the pain level and 4) continued antibiotic suppression until radiographic confirmation of vesicoureteral reflux resolution. Parents were given detailed postoperative written instructions and a telephone number for 24-hour surgeon access. Two weeks postoperatively renal ultrasonography was performed. This was repeated several months later along with a voiding cystourethrogram. RESULTS A total of 60 patients underwent extravesical ureteral reimplantation, including 51 girls and 9 boys 0.9 to 10.5 years old (mean age 5.1). Reflux was grades 1 to 5. A total of 24 unilateral and 36 bilateral procedures were done with and
without ureteral tapering, and for single systems, duplex systems and an associated Hutch diverticulum. Overall 54 children (90%) were discharged home the same day, while only 6 (10%) went home the next day. All patients who underwent a unilateral procedure and 83% a bilateral procedure were outpatients. However, when evaluating the last 40 consecutive patients, including 14 with a unilateral and 26 with a bilateral procedure, all (100%) were discharged home the day of surgery without increased morbidity or additional analgesic requirements. All outpatient patients were discharged home within 5 hours after surgery. All patients tolerated the procedure well without major complications and without any requiring an emergency department visit or hospitalization after discharge. After the urinary catheter was removed all patients were spontaneously able to void postoperatively without any acute or chronic urinary retention. No patients had acute urinary tract infections. All patients tested had radiographic resolution of vesicoureteral reflux on postoperative voiding cystourethrogram. DISCUSSION Outpatient surgery has several advantages to inpatient care, including a decreased risk of hospital acquired infections and a more familiar environment for recovery. During the last decade endoscopic treatment for vesicoureteral reflux has had the advantage of being a uniformly outpatient procedure compared to open and laparoscopic ureteral reimplantation. The disadvantage of the endoscopic approach is that the success rate is variable among published reports with none approaching the almost 100% success of ureteral reimplantation.6,8 Also, the endoscopic success rate is inversely related to reflux grade.9 Therefore, the ability to uniformly perform outpatient ureteral reimplantation for all grades of vesicoureteral reflux, including unilateral and bi-
1830
OUTPATIENT EXTRAVESICAL URETERAL REIMPLANTATION
lateral conditions with and without ureteral tapering, and single systems, duplex systems and associated Hutch diverticula, without increased morbidity or readmissions would be advantageous. In our series all parents were educated by the pediatric urologist on the advantages and disadvantages of endoscopic treatment and extravesical reimplantation. Parents were offered each procedure unless the endoscopic technique was contraindicated and then they chose their preference for treatment of their child. Putman et al evaluated outpatient unilateral extravesical ureteral reimplantation.10 Four of the 60 outpatients (6.7%) were hospitalized postoperatively or rehospitalized on postoperative day 1. Average hospitalization in the outpatient group was 6.6 hours (range 3.25 to 11.20). Although our outpatient success rate was 90%, this included unilateral and bilateral procedures. Also, 100% of all children undergoing unilateral reimplantation and 100% of the last 40 consecutive patients undergoing unilateral or bilateral procedures successfully underwent an outpatient procedure. Also, all 54 patients who underwent an outpatient operation were discharged home within 5 hours postoperatively. Although the study by Putman et al does not provide specific postoperative recovery times, several children must have stayed greater than 5 hours since operative time was 40 to 145 minutes, while average hospitalization was 6.6 hours. Furthermore, none of our patients required rehospitalization after discharge home. Marotte and Smith evaluated 46 children undergoing unilateral (21) and bilateral (23) extravesical reimplantations with 70.5% discharged as an outpatient.4 Recovery room time was 5 to 30 hours and patients discharged home with an indwelling catheter had a longer stay than those without a urinary catheter. Our study in a greater number of patients resulted in a significantly higher success rate for outpatient surgery with a shorter recovery room course. We found that patients with an indwelling catheter had a shorter stay in the recovery room for the main reason that they were not required to void before discharge home. Furthermore, there was no incidence of urinary retention in the unilateral or bilateral cases in our study. We attribute our outpatient success to the modification of surgical technique and implemented critical pathway for patient care. The extravesical detrusorrhaphy technique used involves limited ureteral dissection, ureteral mobilization and detrusor dissection to as distal as possible. Also, no surgical dissection is done in proximity to the obliterated umbilical artery and the artery is not ligated. We have further limited this ureteral dissection, thereby decreasing the amount of ureteral manipulation. Also, a low coagulation current, needle tip Bovie coagulator continues to be used for dissection. Our experience with the first 20 patients allowed us to accomplish 100% outpatient success in the last 40. As we have reported previously, pain control is also an important factor when permitting the patient to ambulate and be discharged home on postoperative day 1. Caudal anesthesia and ketorolac are essential for pain control. In our initial series only caudal anesthesia was performed before the surgical incision as preemptive analgesia, which decreased the need for postoperative analgesia.11,12 Also, ketorolac was used for postoperative pain control in our initial protocol, which tends not have the nausea, emesis and decreased bowel activity associated with narcotics.
However, our protocol has been modified with further experience with ketorolac administration before the surgical incision, resulting in additional preemptive analgesia, and subcutaneous injection of Marcaine before skin closure. Our critical pathway stresses extensive early ambulation and timed voiding, which have been shown to be important factors for preventing urinary retention.13–15 Also, preoperative parental and patient education of a goal oriented parental approach to ureteral reimplantation is another important factor of the critical pathway. Parents and child become part of the team focusing on optimal care. Parents are actively involved in postoperative ambulation and timed voiding. Children are instructed preoperatively that each is required to allow discharge home and prevent a urethral catheter. Additionally, the parents and child are educated on the additional criteria that are required for discharge home, including tolerating a regular diet and most importantly the fact that parents state that they are comfortable taking the child home. The parents and child find that this approach is comforting and it decreases unnecessary stress in the postoperative period. We now routinely tell all patients that they will be discharged home the same day or the next day by the latest.
CONCLUSIONS This study demonstrates that implementing a strict critical pathway and a limited dissection, extravesical ureteral reimplantation surgical technique can consistently result in same day discharge home within a few hours postoperatively without increased morbidity or rehospitalization. This protocol has been successful for treating all grades of vesicoureteral reflux, unilateral and bilateral conditions with and without ureteral tapering, and for single systems, duplex systems and associated Hutch diverticula it would be advantageous. Although endoscopic treatment does not require an incision, the proclaimed advantage of being an outpatient procedure is no longer supported by the current experience with ureteral reimplantation. Also, the former surgical technique has a relative contraindication for use for grade 5 reflux and for an associated Hutch diverticulum. Further studies are required to determine whether this continued success can be routinely achieved as an outpatient procedure.
REFERENCES 1.
2.
3.
4.
5.
Houle AM, McLorie GA, Heritz DM, McKenna PH, Churchill BM and Khoury AE: Extravesical nondismembered ureteroplasty with detrusorrhaphy: a renewed technique to correct vesicoureteral reflux in children. J Urol 1992; 148: 704. Wacksman J, Gilbert A and Sheldon CA: Results of the renewed extravesical reimplant for surgical correction of vesicoureteral reflux. J Urol 1992; 148: 359. Fung LCT, McLorie GA, Jain U, Khoury AE and Churchill BM: Voiding efficiency after ureteral reimplantation: a comparison or extravesical and intravesical techniques. J Urol 1995; 153: 1972. Marotte JB and Smith DP: Extravesical ureteral reimplantations for the correction of primary reflux can be done as outpatient procedures. J Urol 2001; 165: 2228. Duong D, Parekh DJ, Pope J, Adams MC and Brock JW: Ureteroneocystostomy without urethral catheterization
OUTPATIENT EXTRAVESICAL URETERAL REIMPLANTATION
6.
7.
8. 9.
10.
shortens hospital stay without compromising postoperative success. J Urol 2003; 170: 1570. McAchran SE and Palmer JS: Bilateral extravesical ureteral reimplantation in toilet trained children: is 1-day hospitalization without urinary retention possible? J Urol 2005; 174: 1991. Zaontz MR, Maizels M, Sugar EC and Firlit CF: Detrusorrhaphy: extravesical ureteral advancement to correct vesicoureteral reflux in children. J Urol 1987: 138: 947. Capozza N and Caione P: Vesicoureteral reflux: surgical and endoscopic treatment. Pediatr Nephrol 2007; 22: 1261. Elder JS, Diaz M, Caldamone AA, Cendron M, Greenfield S, Hurwitz R et al: Endoscopic therapy for vesicoureteral reflux: a meta-analysis. I. Reflux resolution and urinary tract infection. J Urol 2006; 175: 716. Putman S, Wicher C, Wayment R, Harrell B, Devries C, Snow B et al: Unilateral extravesical ureteral reimplantation in children performed on an outpatient basis. J Urol 2005; 174: 1987.
1831
11.
Kundra P, Deepalakshmi K and Ravishankar M: Preemptive caudal bupivacaine and morphine for postoperative analgesia in children. Anesth Analg 1998; 87: 52. 12. Ozcengiz D, Gunduz M, Ozbek H and Isik G: Comparison of caudal morphine and tramadol for postoperative pain control in children undergoing inguinal herniorrhaphy. Paediatr Anaesth 2001; 11: 459. 13. Wein AJ: Neuromuscular dysfunction of the lower urinary tract and its treatment. In: Campbell’s Urology, 7th ed. Edited by PC Walsh, AB Retik, ED Vaughan Jr and AJ Wein. Philadelphia: WB Saunders 1998; pp 953–1006. 14. Michelson JD, Lotke PA and Steinberg ME: Urinary bladder management after total joint replacement surgery. N Engl J Med 1988; 319: 321. 15. Carpiniello VL, Cendron M, Altman HG, Malloy TR and Booth R: Treatment of urinary complications after total joint replacement in elderly females. Urology 1988; 32: 186.
DISCUSSION Dr. Mark Zaontz. I want to thank Jeff Palmer for pushing the envelope on outpatient surgical techniques for reimplants. I am sure the next time I try and “pre-cert” they will give me 3 hours. Are you doing this through a Pfannenstiel incision or 2 small inguinal incisions. Dr. Jeffrey Palmer. I typically, whether it is unilateral or bilateral, use the same 6 cm Pfannenstiel incision.
Purpose: We determined whether implementation of a critical pathway and modification of the extravesical ureteral reimplantation surgical technique to repair unilateral and bilateral vesicoureteral reflux would consistently result in same day patient hospital discharge without increased morbidity. Materials and Methods: We evaluated all children undergoing extravesical ureteral reimplantation using a modified technique that limits ureteral dissection, ureteral mobilization and detrusor dissection to as distal as possible. No surgical dissection is done in proximity to the obliterated umbilical artery, nor is the artery ligated. Patients follow a strict postoperative critical pathway, and parents receive extensive preoperative and postoperative education. The child is required to fulfill strict criteria to be discharged home. Results: A total of 51 girls and 9 boys 0.9 to 10.5 years old (mean age 5.1) were evaluated. A total of 24 unilateral and 36 bilateral procedures were performed with and without ureteral tapering, and for single systems, duplex systems and an associated Hutch diverticulum. Overall 54 children (90%) were discharged home the same day, while only 6 (10%) went home the next day. All patients who underwent a unilateral procedure and 83% who underwent a bilateral procedure were outpatients. However, when evaluating the last 40 consecutive patients, including 14 with a unilateral and 26 with a bilateral procedure, all (100%) were discharged home the day of surgery without increased morbidity or an additional analgesic requirement. All outpatients were discharged within 5 hours after surgery. All patients tolerated the procedure well without major complications and without any patients requiring an emergency department visit or hospitalization after discharge home. After the urinary catheter was removed all patients were able to spontaneously void postoperatively without any acute or chronic urinary retention. Conclusions: This study demonstrates that implementation of a strict critical pathway and a unilateral or bilateral extravesical ureteral reimplantation surgical technique with limited dissection can consistently result in same day discharge from the hospital within a few hours postoperatively without increased morbidity or rehospitalization. Key Words: bladder, ureter, cystostomy, vesico-ureteral reflux, outpatients
xtravesical ureteroneocystostomy has been associated with a decreased incidence of hematuria, bladder spasms and convalescence.1–3 Marotte and Smith,4 and Duong et al5 have evaluated methods to decrease hospitalization with some children discharged home the day of surgery. Some groups have cautioned against simultaneous bilateral extravesical repair since this has been associated with transient urinary retention requiring bladder catheter replacement.1,3 To our knowledge we were the first to report the ability of toilet trained children to undergo bilateral extravesical ureteral reimplantation resulting in patient discharge after a 1-day hospitalization and without urinary retention through a critical pathway and modification of surgical technique.6 In this study we determined whether further refinement of the critical pathway and the extravesical ureteral reimplantation surgical technique could be implemented to consistently perform the extravesical technique to repair unilateral and bilateral vesicoureteral reflux as an outpatient procedure without increased morbidity.
E
* Correspondence: Center for Pediatric Urology, Glickman Urological and Kidney Institute, Cleveland Clinic Children’s Hospital, 9500 Euclid Ave., Cleveland, Ohio 44195 (telephone: 216-445-7504; FAX: 216-445-2267; e-mail: [email protected]).
0022-5347/08/1804-1828/0 THE JOURNAL OF UROLOGY® Copyright © 2008 by AMERICAN UROLOGICAL ASSOCIATION
MATERIALS AND METHODS We evaluated all children undergoing extravesical ureteroneocystostomy and following an outpatient oriented critical pathway for preoperative education, operative management and postoperative care. The indications for surgery were persistent or worsening vesicoureteral reflux and/or breakthrough urinary tract infections. Preoperatively parents received extensive education on the specific preoperative and postoperative instructions, expectations and goals. Patients received caudal anesthesia for preventive analgesia, intraoperative ketorolac (Toradol®) and subcutaneous Marcaine® unless contraindicated. The extravesical detrusorrhaphy technique performed is closely related to the modification of the Lich-Gregoir antireflux procedure, which includes ureteral advancement, described by Zaontz et al.7 As previously reported, our modification of this approach involves limiting ureteral dissection, ureteral mobilization and detrusor dissection to as distal as possible, so that a 5:1 ratio of tunnel length to ureteral diameter can be accomplished (see figure). We have recently further limited ureteral dissection. The obliterated umbilical artery is not ligated and no surgical dissection is done in proximity to the obliterated umbilical artery. A low coagulation current, needle tip Bovie coagulator is used for dissection.
1828
Vol. 180, 1828-1831, October 2008 Printed in U.S.A. DOI:10.1016/j.juro.2008.04.080
OUTPATIENT EXTRAVESICAL URETERAL REIMPLANTATION
1829
Modified Lich-Gregoir extravesical detrusorrhaphy technique with ureteral advancement. A, limited distal ureteral dissection and use of low coagulation current, needle tip Bovie coagulator. B, limited proximal ureteral dissection with all dissection distal to obliterated umbilical artery. C, complete extravesical detrusorrhaphy and fully mobilized ureter. D, placement of 2 ureteral advancing sutures between detrusor and ureteral adventitia. E, ureteral advancement. F, detrusor flaps sutured over ureter in interrupted fashion, completing extravesical procedure.
Postoperatively patients were started on a regular diet in the recovery room and ketorolac was used for analgesia when repeat dosing was indicated. Also, extensive ambulation was started immediately. A patient was discharged home with a urethral catheter if the patient underwent 1) a bilateral procedure and was not toilet trained since a timed voiding schedule could not be followed, 2) ureteral tapering and/or 3) diverticulectomy. When a catheter was left in place, it was removed within a few days depending on the parental schedule. The child was discharged from the surgical facility if 5 strict criteria were fulfilled, including 1) the patient urinated 3 times in the recovery room without any suprapubic distention or urinary incontinence if the catheter was removed, 2) the patient tolerated a regular diet, 3) pain was controlled without requiring narcotics, 4) the patient ambulated without difficulty (age appropriate) and 5) parents stated that they were comfortable with taking the child home. Patients also followed specific instructions at home, including 1) strict timed voiding every 2 hours after catheter removal, 2) extensive ambulation, 3) analgesia managed by acetaminophen and/or acetaminophen with codeine depending on the pain level and 4) continued antibiotic suppression until radiographic confirmation of vesicoureteral reflux resolution. Parents were given detailed postoperative written instructions and a telephone number for 24-hour surgeon access. Two weeks postoperatively renal ultrasonography was performed. This was repeated several months later along with a voiding cystourethrogram. RESULTS A total of 60 patients underwent extravesical ureteral reimplantation, including 51 girls and 9 boys 0.9 to 10.5 years old (mean age 5.1). Reflux was grades 1 to 5. A total of 24 unilateral and 36 bilateral procedures were done with and
without ureteral tapering, and for single systems, duplex systems and an associated Hutch diverticulum. Overall 54 children (90%) were discharged home the same day, while only 6 (10%) went home the next day. All patients who underwent a unilateral procedure and 83% a bilateral procedure were outpatients. However, when evaluating the last 40 consecutive patients, including 14 with a unilateral and 26 with a bilateral procedure, all (100%) were discharged home the day of surgery without increased morbidity or additional analgesic requirements. All outpatient patients were discharged home within 5 hours after surgery. All patients tolerated the procedure well without major complications and without any requiring an emergency department visit or hospitalization after discharge. After the urinary catheter was removed all patients were spontaneously able to void postoperatively without any acute or chronic urinary retention. No patients had acute urinary tract infections. All patients tested had radiographic resolution of vesicoureteral reflux on postoperative voiding cystourethrogram. DISCUSSION Outpatient surgery has several advantages to inpatient care, including a decreased risk of hospital acquired infections and a more familiar environment for recovery. During the last decade endoscopic treatment for vesicoureteral reflux has had the advantage of being a uniformly outpatient procedure compared to open and laparoscopic ureteral reimplantation. The disadvantage of the endoscopic approach is that the success rate is variable among published reports with none approaching the almost 100% success of ureteral reimplantation.6,8 Also, the endoscopic success rate is inversely related to reflux grade.9 Therefore, the ability to uniformly perform outpatient ureteral reimplantation for all grades of vesicoureteral reflux, including unilateral and bi-
1830
OUTPATIENT EXTRAVESICAL URETERAL REIMPLANTATION
lateral conditions with and without ureteral tapering, and single systems, duplex systems and associated Hutch diverticula, without increased morbidity or readmissions would be advantageous. In our series all parents were educated by the pediatric urologist on the advantages and disadvantages of endoscopic treatment and extravesical reimplantation. Parents were offered each procedure unless the endoscopic technique was contraindicated and then they chose their preference for treatment of their child. Putman et al evaluated outpatient unilateral extravesical ureteral reimplantation.10 Four of the 60 outpatients (6.7%) were hospitalized postoperatively or rehospitalized on postoperative day 1. Average hospitalization in the outpatient group was 6.6 hours (range 3.25 to 11.20). Although our outpatient success rate was 90%, this included unilateral and bilateral procedures. Also, 100% of all children undergoing unilateral reimplantation and 100% of the last 40 consecutive patients undergoing unilateral or bilateral procedures successfully underwent an outpatient procedure. Also, all 54 patients who underwent an outpatient operation were discharged home within 5 hours postoperatively. Although the study by Putman et al does not provide specific postoperative recovery times, several children must have stayed greater than 5 hours since operative time was 40 to 145 minutes, while average hospitalization was 6.6 hours. Furthermore, none of our patients required rehospitalization after discharge home. Marotte and Smith evaluated 46 children undergoing unilateral (21) and bilateral (23) extravesical reimplantations with 70.5% discharged as an outpatient.4 Recovery room time was 5 to 30 hours and patients discharged home with an indwelling catheter had a longer stay than those without a urinary catheter. Our study in a greater number of patients resulted in a significantly higher success rate for outpatient surgery with a shorter recovery room course. We found that patients with an indwelling catheter had a shorter stay in the recovery room for the main reason that they were not required to void before discharge home. Furthermore, there was no incidence of urinary retention in the unilateral or bilateral cases in our study. We attribute our outpatient success to the modification of surgical technique and implemented critical pathway for patient care. The extravesical detrusorrhaphy technique used involves limited ureteral dissection, ureteral mobilization and detrusor dissection to as distal as possible. Also, no surgical dissection is done in proximity to the obliterated umbilical artery and the artery is not ligated. We have further limited this ureteral dissection, thereby decreasing the amount of ureteral manipulation. Also, a low coagulation current, needle tip Bovie coagulator continues to be used for dissection. Our experience with the first 20 patients allowed us to accomplish 100% outpatient success in the last 40. As we have reported previously, pain control is also an important factor when permitting the patient to ambulate and be discharged home on postoperative day 1. Caudal anesthesia and ketorolac are essential for pain control. In our initial series only caudal anesthesia was performed before the surgical incision as preemptive analgesia, which decreased the need for postoperative analgesia.11,12 Also, ketorolac was used for postoperative pain control in our initial protocol, which tends not have the nausea, emesis and decreased bowel activity associated with narcotics.
However, our protocol has been modified with further experience with ketorolac administration before the surgical incision, resulting in additional preemptive analgesia, and subcutaneous injection of Marcaine before skin closure. Our critical pathway stresses extensive early ambulation and timed voiding, which have been shown to be important factors for preventing urinary retention.13–15 Also, preoperative parental and patient education of a goal oriented parental approach to ureteral reimplantation is another important factor of the critical pathway. Parents and child become part of the team focusing on optimal care. Parents are actively involved in postoperative ambulation and timed voiding. Children are instructed preoperatively that each is required to allow discharge home and prevent a urethral catheter. Additionally, the parents and child are educated on the additional criteria that are required for discharge home, including tolerating a regular diet and most importantly the fact that parents state that they are comfortable taking the child home. The parents and child find that this approach is comforting and it decreases unnecessary stress in the postoperative period. We now routinely tell all patients that they will be discharged home the same day or the next day by the latest.
CONCLUSIONS This study demonstrates that implementing a strict critical pathway and a limited dissection, extravesical ureteral reimplantation surgical technique can consistently result in same day discharge home within a few hours postoperatively without increased morbidity or rehospitalization. This protocol has been successful for treating all grades of vesicoureteral reflux, unilateral and bilateral conditions with and without ureteral tapering, and for single systems, duplex systems and associated Hutch diverticula it would be advantageous. Although endoscopic treatment does not require an incision, the proclaimed advantage of being an outpatient procedure is no longer supported by the current experience with ureteral reimplantation. Also, the former surgical technique has a relative contraindication for use for grade 5 reflux and for an associated Hutch diverticulum. Further studies are required to determine whether this continued success can be routinely achieved as an outpatient procedure.
REFERENCES 1.
2.
3.
4.
5.
Houle AM, McLorie GA, Heritz DM, McKenna PH, Churchill BM and Khoury AE: Extravesical nondismembered ureteroplasty with detrusorrhaphy: a renewed technique to correct vesicoureteral reflux in children. J Urol 1992; 148: 704. Wacksman J, Gilbert A and Sheldon CA: Results of the renewed extravesical reimplant for surgical correction of vesicoureteral reflux. J Urol 1992; 148: 359. Fung LCT, McLorie GA, Jain U, Khoury AE and Churchill BM: Voiding efficiency after ureteral reimplantation: a comparison or extravesical and intravesical techniques. J Urol 1995; 153: 1972. Marotte JB and Smith DP: Extravesical ureteral reimplantations for the correction of primary reflux can be done as outpatient procedures. J Urol 2001; 165: 2228. Duong D, Parekh DJ, Pope J, Adams MC and Brock JW: Ureteroneocystostomy without urethral catheterization
OUTPATIENT EXTRAVESICAL URETERAL REIMPLANTATION
6.
7.
8. 9.
10.
shortens hospital stay without compromising postoperative success. J Urol 2003; 170: 1570. McAchran SE and Palmer JS: Bilateral extravesical ureteral reimplantation in toilet trained children: is 1-day hospitalization without urinary retention possible? J Urol 2005; 174: 1991. Zaontz MR, Maizels M, Sugar EC and Firlit CF: Detrusorrhaphy: extravesical ureteral advancement to correct vesicoureteral reflux in children. J Urol 1987: 138: 947. Capozza N and Caione P: Vesicoureteral reflux: surgical and endoscopic treatment. Pediatr Nephrol 2007; 22: 1261. Elder JS, Diaz M, Caldamone AA, Cendron M, Greenfield S, Hurwitz R et al: Endoscopic therapy for vesicoureteral reflux: a meta-analysis. I. Reflux resolution and urinary tract infection. J Urol 2006; 175: 716. Putman S, Wicher C, Wayment R, Harrell B, Devries C, Snow B et al: Unilateral extravesical ureteral reimplantation in children performed on an outpatient basis. J Urol 2005; 174: 1987.
1831
11.
Kundra P, Deepalakshmi K and Ravishankar M: Preemptive caudal bupivacaine and morphine for postoperative analgesia in children. Anesth Analg 1998; 87: 52. 12. Ozcengiz D, Gunduz M, Ozbek H and Isik G: Comparison of caudal morphine and tramadol for postoperative pain control in children undergoing inguinal herniorrhaphy. Paediatr Anaesth 2001; 11: 459. 13. Wein AJ: Neuromuscular dysfunction of the lower urinary tract and its treatment. In: Campbell’s Urology, 7th ed. Edited by PC Walsh, AB Retik, ED Vaughan Jr and AJ Wein. Philadelphia: WB Saunders 1998; pp 953–1006. 14. Michelson JD, Lotke PA and Steinberg ME: Urinary bladder management after total joint replacement surgery. N Engl J Med 1988; 319: 321. 15. Carpiniello VL, Cendron M, Altman HG, Malloy TR and Booth R: Treatment of urinary complications after total joint replacement in elderly females. Urology 1988; 32: 186.
DISCUSSION Dr. Mark Zaontz. I want to thank Jeff Palmer for pushing the envelope on outpatient surgical techniques for reimplants. I am sure the next time I try and “pre-cert” they will give me 3 hours. Are you doing this through a Pfannenstiel incision or 2 small inguinal incisions. Dr. Jeffrey Palmer. I typically, whether it is unilateral or bilateral, use the same 6 cm Pfannenstiel incision.