Re: Continuous Epidural Anesthesia after Ureteroneocystostomy in Children

48 1

LETTERS TO THE EDITOR We would like to clarify the citation to our study.3 In our experience, solid lesions usually appeared to arise de novo and not from cystic lesions. With longer followup, we are beginning to see solid components arise from cystic structures. We believe multiple renal operations are a possibility in each von Hippel-Lindau disease patient with renal cancer. A key issue in their care is the timing of renal operations. Since these patients are a t high risk for recurrence after partial nephrectomy, we do not believe these operations are curative in the classical sense. Rather, we are resetting the clock and hoping that new lesions do not develop in the near future. Our goal is to preserve renal function as long as possible, while minimizing the risk of metastasis. We believe that part of this preservation effort is minimizing renal hilar surgery, which will make future renal operations more difficult and, hopefully, preserve renal tissue longer. Respectfully, McClellan M . Walther and W. Marston Linehan Urologic Oncology Section NIHISBICOPIDCTINCI 9000 Rockville Pike Building 10, Room 2B-43 10 Center Drive MSC 1502 Bethesda, Maryland 20898-1502

eter) leR tumors in patient T. K. was because these tumors were near the renal hilus. In patient Y. N. the sheer size of the tumor (7.5cm. in diameter) precluded complete in situ partial excision. Fortunately, no significant intraoperative or postoperative complications were encountered, and the outcome of ex vivo renal surgery and autotransplantation has been satisfactory or even better than that of in situ surgery as we reported previously.2 In view of the feasibility and satisfactory outcome of ex vivo repair, we believe that it is more important to be armed with this technical option whenever the situation demands.

1. Spencer, W. F.,Novick, A. C., Montie, J. E., Streem, S. B. and Levin, H. S.: Surgical treatment of localized renal cell carcinoma in von Hi pel Lindau’s disease. J. Urol., 139 507,1988. 2. Tanda, K., Togasgi, M., Seki, T., Shinohara, N., Nonomura, K. and Koyanagi, T.: Comparison of extracorporeal versus in situ surgery for renovascular disease and renal cell carcinoma. J. Urol., part 2, 151:522A,abstract 1179, 1994.

RE: CONTINUOUS EPIDURAL ANESTHESIA AFTER URETERONEOCYSTOSTOMY IN CHILDREN M. P. Cain, D. A. Husmann, R. H. McLaren and S. A. Kramer

J. Urol., 154:791-793, 1995

I A ,Solomon, D., Zbar, B., Linehan. W. M. and Walther, Characterization of the renal patholo of a familial form of renal cell carcinoma associated w i g von Hippel-Lindau disease: clinical and molecular genetic implication. J. Urol., 15% 22, 1995. 2. Walther. M. M., Choyke, P. L., Weiss, G., Manolatos, C., Long, J., Reiter, R., Alexander, R. B. and Linehan, W. M.: Parenchymal sparing surgery in patients with hereditary renal cell carcinoma. J. Urol., part 2,15% 913,1995. 3. Choyke. P. L.. Glenn, G. M., Walther, M. M., Zbar, B., Weiss, G. H., Alexander, R. B., Hayes, W. S., Long, J. P., Thakore, K. N. and Linehan, W. M.: The natural history of renal lesions in von Hippel-Lindau disease: a serial CT study in 28 patients. AJR, 159 1229, 1992. 4. Walther, M. M., Thompson, N. and Linehan, W.: Enucleation Kocedures in patients with multiple hereditary renal tumors. orld J. Urol., 13: 248, 1995. 5. Walther, M. M., Choyke, P. L., Hayes, W., Shawker, T. H., Alexander, R. B. and Linehan, W. M.: Evaluation of color Doppler intrao rative ultrasound in parenchymal sparing renal surgery. rUrol., 152 1984,1994. 6. Chen, F., Kishida, T., Yao, M., Hustad, T., Glavac, D., Dean, M., Gnarra, J. R., Orcutt, M. L., Duh, F. M., Glenn, G., Green, J., Hsia, Y. E., Lamiell, J., Li, H., Wei, M. H., Schmidt, L., Tory, K., Kuzmin, I., Stackhouse, T., Latif, F., Linehan, W. M., Lerman, M. and Zbar, B.: Germline mutations in the von Hippel-Lindau disease tumor suppressor gene: correlations with phenotype. Hum. Mut., 5: 66, 1995. 1. Poston, C. D.. Jaffe, G. S., Lubensk

dx’M.:

Reply b-y Authors. We appreciate the remarks by Walther and Linehan, and are pleased that our study stirred some interest. We wish to clarify some issues raised. One concern is how we should deal with cystic renal lesions in patients with von Hippel-Lindau disease. As noted by Walther and Linehan, we usually performed preopera. tive ultrasonography for renal lesions. However, although preoperative ultrasonography revealed simple cysts without a solid component in our patients Y.I. and A.K., these renal lesions were pathologically confirmed as cystic type renal cell carcinoma. Although it may be correct that simple or complex cystic renal lesions without a solid component are not indications for operation in patients with von Hippel-Lindau disease, we believe to date that cystic as well as solid lesions should be excised a t initial and repeat operation as described by Spencer et al.1 In fact, if it is clarified with longer followup that solid lesions do arise de novo and not from CYStic lesions. we should consider the different options to treat cystic renal lesions in patients with von Hippel-Lindau disease. Another point raised by Walther and Linehan is how to operate on renal lesions in patients with von Hippel-Lindau disease. We agree that in situ partial nephrectomy and enucleation techniques are appropriate in these patients. However, we believe that the selection of operative technique should be individualized based on the location and size of the renal lesions. In fact, the reason we chose ex vivo surgery and autotransplantation for relatively small (3cm.in diam-

To the Editor. The authors made several interesting observations in their retrospective review of children who underwent ureteral reimplantation while under combined epidural and general anesthesia. I wish to comment on some of the observations and conclusions. The most troublesome feature of epidural analgesia is, indeed, the incidence of side effects, and the authors are correct in addressing the question of the cost of epidural analgesia in terms of these side effects and the financial cost as well. It is notable that the incidence of nausea and vomiting did not differ between the epidural analgesia and control groups (31 and 28%, respectively). Despite this observation, the authors stated in the discussion we also observed an increased frequency of nausea, vomiting.. .- which contradicts the results. Their observation of a n increased incidence of fever is a novel and interesting finding for which no explanation is obvious. To attribute this condition to atelectasis is conjectural in the absence of radiographic or auscultative findings. Other investigations suggest an improvement in pulmonary function and a decrease in respiratory morbidity associated with epidural analgesia in children who have undergone upper1 or lower2 abdominal surgery. I also wonder about the attribution of another side effect (severe pruritic rash) of epidural analgesia. While pruritus is common with epidural analgesia, it is a neurological phenomenon believed to be related to opiate receptor activation in the cervical spinal cord, and it is not associated with a cutaneous manifestation other than the erythema associated with a child rubbing the face. If indeed a rash were present in the patients studied it would indicate another etiology for pruritus. Regarding the cost of epidural analgesia, the authors are incorrect to state that there is a fee associated with catheter placement. Current anesthesia billing practices do not allow for a separate fee over and above the usual fee for general anesthesia with insertion of an epidural catheter if such placement occurs in the operating room, which is generally the case for children. Regardless of the calculation of costs, the authors present only half of a cost-benefit analysis because they do not address the benefits conferred to the patients in terms of better analgesia. Were the children indeed more comfortable and, if so, how much more? Might superior pain relief be associated with other cost savings? This was the observation of McNeely et all and has been our own experience as we reviewed the use of epidural analgesia in the cardiac surgical population, in whom epidural analgesia is associated with shorter intensive care unit stays and earlier hospital discharges.3.4 Without an answer to these questions, how is the clinical urologist or anesthesiologist to determine the most advantageous course of action? Respectfully, Elliot J. Krane Department of Anesthesia Stanford University School of Medicine Stanford, California 9 4 3 0 5 5 115

1. McNeely, J. M.: Comparison of epidural opioids and intravenoue opioids in the postoperative management of pediatric antireflux surgery. Anesthesiology, 75: A689, 1991. A

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LETTERS TO THE EDITOR

2. Berde,

C.B., Sethna, N. F., Yemen, T. A., Pullerits, J. and Miler,

V.: Continuous epidural bupivacrune-fentanyl infusions in

children followinE ureteral reimplantation. Anesthesiology, 7 3 A1128, 1990. 3. Frank, R. S., Boltz, M. G., Sentivany, S. K. and Krane, E. J.: Combined epidural-general anesthesia for the repair of atnal septa1 defects in children results in shorter ICU stays. Anesthesiology, 83: A1176, 1995. 4. Lin, Y. C., Sentivany, S. K, Boltz, M. C. and Krane, E. J.: Outcomes after single caudal injection versus continuous epidural infusion for postoperative analgesia in children undergoing patent ductus arteriosus ligation. Anesthesiology, 83: A1142, 1995.

5. Yaster, M. and Deshpande, J. K: Management of pediatric pain with opioid analgesics. J. Ped., 113 421, 1988.

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Reply by Authors. With regard to the comments on the incidence of postoperative nausea and vomiting, Krane is correct in noting that there was a n insignificant difference in the epidural anesthesia and control groups. The sentence cited was intended to note the 25% incidence of overall morbidity associated with epidural catheter use as cited in table 2 in the text. Nausea and vomiting were only 2 of many side effects of epidural infusion and, although the incidence was no different from the control group, these symptoms in the epidural group abated after removal of the catheter. Pmritis has been observed in 30 to 35% of patients managed with epidural anesthesia in other and in our patients this symptom also To the Editor. We are greatly concerned by the methods and resolved with removal of the catheter (as did the rash, which may conclusions of this recent report regarding the use of continuous well have been the cutaneous manifestation o f itching in the paepidural analgesia following ureteroneocystostomy in children. This tient). was a retrospective, nonblinded study of postoperative analgesia and Regarding the cost of epidural analgesia, we believe that alnot anesthesia. We are not convinced that this was a randomized though the remarks made by Krane may reflect the standard a t study as the authors claim. They made no attempt to randomize his institution, they may not reflect the national practice. At the patients, blind patients or observers (for example sham dressing and institution where the study was performed as well as a t Georgeso forth) or even obtain informed consent for this study. The fact that town University Medical Center common practice is to generate a patients elected not to have an epidural catheter placed is hardly fee for placement of the epidural catheter if the epidural is not what we or others should consider randomization. Were these pa- used as a dual anesthetic during the operation (for instance, if it tients different with respect to previous type or number of opera- is placed at the end of the procedure for postoperative managetions, pain experiences and so forth? ment). Even when the catheter is placed preoperatively and no fee The outcome measures discussed are inadequate. Pain, a subjec- is generated for placement, the total fee for epidural pain mantive experience, was never assessed and patient and parental satis- agement would still range from $360 to $570 ($60 t o $120 for faction was not considered.1.2 Measurement of supplemental opioid anesthesia operating room time during catheter placement plus administration by nursing staff has consistently been shown to be a n $150 per day for management of the catheter). The cost analysis inadequate indicator of pain. Additionally, by present standards of was performed to alert pediatric urologists, many of whom are practice the epidural drug dosing regimen in this study is perplex- discharging patients 2 or 3 days following ureteral reimplantation ing.3 Did patients actually receive continuous infusions of 0.25% to minimize the global cost of the procedure, that this form of bupivacaine for 3 days? This concentration of bupivacaine produces postoperative analgesia is associated with significant costs. motor blockade and has a significant likelihood of producing sysRegarding the comments of Greenberg et al, our primary purpose temic toxicity when administered by continuous i n f u ~ i o n . ~ for reviewing our experience with the use of epidural anesthesia was Even the most important conclusion, namely that epidural anal- to determine whether this form of postoperative pain management gesia is more expensive than intravenous narcotics, is never fully delayed hospital discharge and was cost-effective. In this era of cost documented. Some explanation of the underlying costs of pain man- containment by second party payers and the focus towards early agement at their hospital might offer some basis for this interpreta- hospital discharge following ureteral reimplantation procedures, we tion (physician fees, pain se&ce consultation, pharmacy, supplies, believed it was &portant 6 document the impact ofkpidural anesequipment and so forth). In fact, we do not even know how much or thesia on the global costs of this operation (for example extra hospiwhich standard pain medications patients received. tal days, added morbidity and additional fees). We did not intend to Finally, there were extraordinarily high failure and complication challenge the effectiveness of epidural anesthesia as an excellent rates among the patients receiving epidural analgesia. The authors technique for children, which has been well documented in prospecdo not state what type of catheters were used (gauge, length, com- tive studies. We clearly stated in our article that this study was position and so forth), the insertion technique or location of place- retrospective with no attempt to randomize patients. The retrospecment. Interestingly, the authors also fail to inform us of complica- tive nature of the study made it impossible to assess carefully patient tions related to the standard pain management. Opioids, regardless pain by current standards. We specifically avoided drawing concluof route of administration, produce nausea, vomiting, pruritus and sions regarding the comparison of the 2 techniques in the discussion, respiratory depressi~n.~ except the 25%incidence of catheter related problems and increased Our practice and that of many centers across North America is to incidence of postoperative fever with epidural anesthesia. Our incluuse epidural analgesia in the management of genitourinary surgical sion criteria for this study were also clearly selected and stated, that patients because epidural analgesia provides profound and incom- is all patients were healthy children with primary vesicoureteral parable pain relief. Because of the many concerns that we have reflux who underwent uncomplicated ureteral reimplantation, so raised, we believe that children should not be deprived of this ben- that there would be minimal difference in operative technique and eficial therapeutic modality based on this study. postoperative recovery. The nonepidural anesthesia group was treated with standard narcotics and suppositories as mentioned in Respectllly, table 1 of the article. Robert S. Greenberg, Myron Yaster The additional cost of epidural anesthesia cited in our study inand John P. Gearhart cludes a fee for catheter placement (if the epidural is placed a t the Division of Pediatric Anesthesia end of the procedure or if it is not used in combination with the Halsted 842 general anesthetic) plus a daily fee for management. The manageThe Johns Hopkins University ment fee ranges from $120 to $180 per day (or $360 to $540 for the 600 North Wolfe Street hospital stay), and the catheter placement fee is approximately $400. Baltimore, Maryland 21287 The total fees will certainly vary with geographic location and the timing of the catheter placement but unquestionably they add significantly to the global costs for reimplantation procedures. 1. McGrath, P. A.: An assessment of children’s pain: a review of We continue to use epidural anesthesia for postoperative pain behavioral, physiological and direct scaling techniques. Pain, management in select cases. However, we have used alternative 31: 147, 1987. 2. Wong, D. L. and Baker, C. M.:Pain in children: comparison of methods of analgesia in patients who we expect to be discharged home within 1 or 2 days after ureteral reimplantation. assessment scales. Ped. Nursing, 14: 9, 1988. 3. Berde, C. B.: Convulsions associated with pediatric regional anesthesia. Anesth. Anal., 76 164, 1992. 1. Caudle, C. L., Freid, E. B., Bailey, A. G., Valley, R. D., Lish, M. c . 4. McCloskey, J. J., Haun, S. E. and Deshpande, 3. K.:Bupivacaine and Azizkhan, R. C.: Epidural fentanyl infusion with patienttoxicity secondary to continuous caudal epidural infusion in controlled epidural analgesia for postoperative analgesia in children. Anesth. Anal., 76 287, 1992. children. J. Ped. Surg., 2 8 554, 1993.