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Ureteral reimplantation: Postoperative management without catheters
PEDIATRIC UROLOGY
URETERAL REIMPLANTATION: MANAGEMENT WITHOUT
POSTOPERATIVE CATHETERS
ROY A. BRANDELL, M.D. JOHN W. BROCK, III, M.D. From the Department of Urology, Vanderbilt Children’s Hospital, and Baptist Hospital, Nashville, Tennessee
ABSTRACT-We reviewed the medical records of 34 consecutive children with reflux who underwent simple ureteroneocystostomy at our institution and an affiliated hospital between 1991 and 1992. Fourteen patients were managed with ureteral and urethral catheters during the initial postoperative period, and 20 patients were managed with a “catheterless” technique employing neither of these devices. The latter group had a 50 percent decrease in length of hospital stay with 20 percent decrease in hospital costs when compared with the former. They also seemed to have less postoperative discomfort as evidenced by a 50 percent decrease in administered pain medicine. Complete followup was obtained in all cases, and there were no complications or failures. Ureteroneocystostomy is widely regarded as a safe and effective procedure for the surgical correction of vesicoureteral reflux. In 1981 So and associates’ described the “catheterless” ureteral reimplantation as a means for reducing morbidity and patient discomfort. We have traditionally used ureteral and urethral catheters following ureteroneocystostomy In January 1992 we abandoned this practice and began using the catheterless technique in all uncomplicated cases. We report our two-year experience using both methods. MATERIAL AND METHODS Between April 1991 and December 1992, 46 ureteroneocystostomies were performed by one urologist (J.W.B.) at our institution and an affiliated hospital. Patients with complicating circumstances such as severe neurogenic bladder, solitary kidney, pelvic irradiation, or previous failed reimplant were excluded from the analysis, as were those patients requiring an adjunctive procedure at the time of reimplantation (such as ureteral tailoring, bladder augmentation, or diverticulum excision). This left 34 patients for review. Between April 1991 and January 1992, 14 children were managed with both ureteral and urethral catheters. The catheters were left in place for an average of three days, and the children were Submitted: July 29, 1993, accepted (with revisions): August 25, 1993
UROLOGY /
DECEMBER1993
/ VOLUME42, NUMBER6
maintained on antibiotics during this period. From January 1992 to December 1992, 20 children were managed without catheters of any kind. Patients were to be randomized with respect to equal grade of reflux and age. However, after 2 patients without catheters, we could no longer continue randomization because of the remarkable improvement in postoperative course. Those without catheters received twenty-four hours of antibiotics postoperatively as opposed to seventytwo hours in the other group. There was no significant difference between the age, sex, and distribution of the various grades of reflux (Table I> between the two groups. In all patients a Penrose drain was placed in the prevesical space which was removed prior to discharge. No suprapubic TABLE I. Grade of Reflux
Number of Ureters With Catheter (%)
0’
3 3 6 9 3 2 26
I Ii III IV V TOTAL ‘Ureters
without
Distribution of feflux grades in 57 ureters
reflex,
Without Catheter (%)
(11.5) (11.5) (231 (351 (11 .5) (7.5) (100)
reimplanted
with
2 (7) 4(131 6 (1% 11 (35) 5 (16) 3 (101 31 (100) contralateral
rejluing
unit due to a
grossly abnormal orijce.
705
Length of hospital stay for 20 children FIGURE 1. managed with catheters and 14 children managed without catheters.
tubes were placed. No children received caudal anesthetics. There were 2 children in the catheterless group that underwent a common sheath reimplant of a duplicated ureter. The primary indication for surgical intervention was urinary infection despite prophylaxis with antibiotics. Ureteroneocystostomy was performed intravesically by either a Glenn-Anderson ureteral advancement,2 a Stephen’s modification of the Politano-Leadbetter technique,3,4 or a Cohen technique.5 All pain medication was administered on a PRN (as needed) basis. Although pain management was not standardized, there was no consistent difference in the types or dosages of pain medication ordered for the two groups. The total number of times that pain medication was requested by the child or the child’s parents was counted. Information regarding total hospital costs was obtained from the billing offices of the respective hospitals. A nonpaired Student’s t-test was used for determination of statistical significance between groups. RESULTS The length of hospitalization is depicted in Figure 1. For those children managed with catheters the length of stay ranged from four to eight days (mean 5.4 days; median 5, mode 5). Children undergoing the catheterless technique averaged 2.7 days with a range from two to four days (median 3, mode 3). This represents a 50 percent decrease in the mean length of stay for those children receiving no catheters (p < 0.0001). As might be expected, this translated into a substantial cost savings of 20 percent (p c 0.02). Requests for pain medication were made during the postoperative period an average of 16.4 times for those children managed with stents and catheters and 8.2 times for those without (median 16, mode 16; median 8, mode 7, respectively).
706
This represents a 50 percent decrease in the number of times patients in the catheterless group required pain medicine (p = 0.0001). These results are summarized in Table II. There was no subjective difference in Penrose drain output between the two groups. All children in the group without catheters were able to void spontaneously following the procedure. There were no wound infections, urinary tract infections, hematomas, urine leaks, or other immediate complications in either group. There was clearly a higher percentage of patients in the group receiving catheters that underwent bilateral reimplantation (86% versus 55%). As this represents a possible selection bias, we reevaluated our data to compare only patients undergoing bilateral reimplants with and without catheters. The reduction in length of hospital stay, administered pain medicine, and hospital costs in this group without catheters was identical to that of the study population as a whole. Thus, the incidence of bilaterality, although different between the two groups, did not have an impact on overall results. All children underwent follow-up evaluation at three months with voiding cystourethrogram, renal ultrasound, and/or an intravenous pyelogram. There was no evidence of persistent reflux or ureteral obstruction in any patient. COMMENT In this era of escalating hospital costs and emphasis on reform, it is imperative that physicians maintain those practices which are clearly beneficial to the patient and abandon those which, after careful scrutiny, appear to be unnecessary. Many urologists have stopped using ureteral catheters following ureteroneocystostomy but continue to use urethral catheters. Others routinely use both. We believe that the use of ureteral or urethral catheters is not only unnecessary but also may result in increased morbidity, patient discomfort, and hospital costs.
TABLE II.
Summary of results With Catheters IN = 141
Mean length of hospital stay Mean number of times pain medicine requested Hospital cost reduction
5.4 16.4
Without Catheters IN = 201 2.7 (p < O.OOOl)* 8.2 (p = 0.0001) 20% (p cO.02)
‘P values indicatestatisticalsignificanceo$di#fewnce betweenvncanvaluesfor two gm”PS.
UROLOGY
I DECEMBER1993
/ VOLUME42, NUMBER6
We report a success rate of 100 percent and a complication rate of zero. Since all operations carry some risk, it is clear that these unblemished results will not continue indefinitely. However, they convincingly support previous reports regarding the safety and reliability of the “catheterless” technique.’ A major reason for our excellent results is that only “simple” cases were considered. Any patient requiring ureteral tapering, diverticulum resection, ureterocele resection, bladder augmentation, or a redo procedure was excluded. It appears that duplicated systems amenable to common sheath reimplantation can be safely carried out without catheters. The 50 percent decrease in length of hospitalization may have several explanations including decreased patient discomfort, nosocomial urinary tract infection, and incidence of ileus from narcotics. Although sophisticated financial analysis of hospital costs was not the purpose of this study, there does appear to be a genuine cost reduction with the routine omission of catheters. Since the pain medication regimens were not standardized, it is difficult to draw firm conclusions regarding patient discomfort. However, there is a clear trend toward decreased need for pain medication in the patients managed without catheters. It has been proposed that this is partly secondary to a decreased incidence of bladder spasm. l The endoscopic treatment of vesicoureteral reflux with cross-linked collagen or various other
UROLOGY
I DECEMBER 1993
I VOLUME42, NUMBER6
substances has generated considerable interest. Several studies have demonstrated the relative safety and effectiveness of these techniques.6 Nevertheless, it will be sometime before the best substance is clearly identified and approved for use by the Food and Drug Administration. It will be even longer until the procedure becomes the standard of care performed by most urologists. In the meantime, we believe that the catheterless ureteral reimplant provides a safe, reliable, and cost effective alternative which results in less morbidity than traditional methods. John
W. Brock,
III, M.D.
Department of Urology Vanderbilt Medical Center North Nashville. Tennessee 37232-2765 REFERENCES 1. So EP Brock WA, and Kaplan GW: Ureteral reimplantation without catheters. J Urol 125: 551-553, 1981. 2. Glenn JF, and Anderson EE: Distal tunnel ureteral reimplantation. J Uro197: 623-626, 1967. 3. Politano VA, and Leadbetter WF: An operative technique for the correction of vesicoureteral reflux. J Urol 79: 932-941.1958. 4. Stephens FD: The normal and abnormal ureterovesical hiatus: methods of correction of vesicoureteral reflux and paraureteral diverticula. JCE Urol 12: 12-14, 1978. 5. Cohen SJ: Ureterozystoneostomie: eine neue antirefluxtechnik, Aktuel Uro16: 1-8, 1975. 6. Leonard MP, Canning DA, Peters CA, Gearhart JP, and Jeffs RD: Endoscopic injection of glutaraldehyde crosslinked bovine dermal collagen for the correction of vesicoureteral reflux. J Urol 145: 115-119, 1991.
707
URETERAL REIMPLANTATION: MANAGEMENT WITHOUT
POSTOPERATIVE CATHETERS
ROY A. BRANDELL, M.D. JOHN W. BROCK, III, M.D. From the Department of Urology, Vanderbilt Children’s Hospital, and Baptist Hospital, Nashville, Tennessee
ABSTRACT-We reviewed the medical records of 34 consecutive children with reflux who underwent simple ureteroneocystostomy at our institution and an affiliated hospital between 1991 and 1992. Fourteen patients were managed with ureteral and urethral catheters during the initial postoperative period, and 20 patients were managed with a “catheterless” technique employing neither of these devices. The latter group had a 50 percent decrease in length of hospital stay with 20 percent decrease in hospital costs when compared with the former. They also seemed to have less postoperative discomfort as evidenced by a 50 percent decrease in administered pain medicine. Complete followup was obtained in all cases, and there were no complications or failures. Ureteroneocystostomy is widely regarded as a safe and effective procedure for the surgical correction of vesicoureteral reflux. In 1981 So and associates’ described the “catheterless” ureteral reimplantation as a means for reducing morbidity and patient discomfort. We have traditionally used ureteral and urethral catheters following ureteroneocystostomy In January 1992 we abandoned this practice and began using the catheterless technique in all uncomplicated cases. We report our two-year experience using both methods. MATERIAL AND METHODS Between April 1991 and December 1992, 46 ureteroneocystostomies were performed by one urologist (J.W.B.) at our institution and an affiliated hospital. Patients with complicating circumstances such as severe neurogenic bladder, solitary kidney, pelvic irradiation, or previous failed reimplant were excluded from the analysis, as were those patients requiring an adjunctive procedure at the time of reimplantation (such as ureteral tailoring, bladder augmentation, or diverticulum excision). This left 34 patients for review. Between April 1991 and January 1992, 14 children were managed with both ureteral and urethral catheters. The catheters were left in place for an average of three days, and the children were Submitted: July 29, 1993, accepted (with revisions): August 25, 1993
UROLOGY /
DECEMBER1993
/ VOLUME42, NUMBER6
maintained on antibiotics during this period. From January 1992 to December 1992, 20 children were managed without catheters of any kind. Patients were to be randomized with respect to equal grade of reflux and age. However, after 2 patients without catheters, we could no longer continue randomization because of the remarkable improvement in postoperative course. Those without catheters received twenty-four hours of antibiotics postoperatively as opposed to seventytwo hours in the other group. There was no significant difference between the age, sex, and distribution of the various grades of reflux (Table I> between the two groups. In all patients a Penrose drain was placed in the prevesical space which was removed prior to discharge. No suprapubic TABLE I. Grade of Reflux
Number of Ureters With Catheter (%)
0’
3 3 6 9 3 2 26
I Ii III IV V TOTAL ‘Ureters
without
Distribution of feflux grades in 57 ureters
reflex,
Without Catheter (%)
(11.5) (11.5) (231 (351 (11 .5) (7.5) (100)
reimplanted
with
2 (7) 4(131 6 (1% 11 (35) 5 (16) 3 (101 31 (100) contralateral
rejluing
unit due to a
grossly abnormal orijce.
705
Length of hospital stay for 20 children FIGURE 1. managed with catheters and 14 children managed without catheters.
tubes were placed. No children received caudal anesthetics. There were 2 children in the catheterless group that underwent a common sheath reimplant of a duplicated ureter. The primary indication for surgical intervention was urinary infection despite prophylaxis with antibiotics. Ureteroneocystostomy was performed intravesically by either a Glenn-Anderson ureteral advancement,2 a Stephen’s modification of the Politano-Leadbetter technique,3,4 or a Cohen technique.5 All pain medication was administered on a PRN (as needed) basis. Although pain management was not standardized, there was no consistent difference in the types or dosages of pain medication ordered for the two groups. The total number of times that pain medication was requested by the child or the child’s parents was counted. Information regarding total hospital costs was obtained from the billing offices of the respective hospitals. A nonpaired Student’s t-test was used for determination of statistical significance between groups. RESULTS The length of hospitalization is depicted in Figure 1. For those children managed with catheters the length of stay ranged from four to eight days (mean 5.4 days; median 5, mode 5). Children undergoing the catheterless technique averaged 2.7 days with a range from two to four days (median 3, mode 3). This represents a 50 percent decrease in the mean length of stay for those children receiving no catheters (p < 0.0001). As might be expected, this translated into a substantial cost savings of 20 percent (p c 0.02). Requests for pain medication were made during the postoperative period an average of 16.4 times for those children managed with stents and catheters and 8.2 times for those without (median 16, mode 16; median 8, mode 7, respectively).
706
This represents a 50 percent decrease in the number of times patients in the catheterless group required pain medicine (p = 0.0001). These results are summarized in Table II. There was no subjective difference in Penrose drain output between the two groups. All children in the group without catheters were able to void spontaneously following the procedure. There were no wound infections, urinary tract infections, hematomas, urine leaks, or other immediate complications in either group. There was clearly a higher percentage of patients in the group receiving catheters that underwent bilateral reimplantation (86% versus 55%). As this represents a possible selection bias, we reevaluated our data to compare only patients undergoing bilateral reimplants with and without catheters. The reduction in length of hospital stay, administered pain medicine, and hospital costs in this group without catheters was identical to that of the study population as a whole. Thus, the incidence of bilaterality, although different between the two groups, did not have an impact on overall results. All children underwent follow-up evaluation at three months with voiding cystourethrogram, renal ultrasound, and/or an intravenous pyelogram. There was no evidence of persistent reflux or ureteral obstruction in any patient. COMMENT In this era of escalating hospital costs and emphasis on reform, it is imperative that physicians maintain those practices which are clearly beneficial to the patient and abandon those which, after careful scrutiny, appear to be unnecessary. Many urologists have stopped using ureteral catheters following ureteroneocystostomy but continue to use urethral catheters. Others routinely use both. We believe that the use of ureteral or urethral catheters is not only unnecessary but also may result in increased morbidity, patient discomfort, and hospital costs.
TABLE II.
Summary of results With Catheters IN = 141
Mean length of hospital stay Mean number of times pain medicine requested Hospital cost reduction
5.4 16.4
Without Catheters IN = 201 2.7 (p < O.OOOl)* 8.2 (p = 0.0001) 20% (p cO.02)
‘P values indicatestatisticalsignificanceo$di#fewnce betweenvncanvaluesfor two gm”PS.
UROLOGY
I DECEMBER1993
/ VOLUME42, NUMBER6
We report a success rate of 100 percent and a complication rate of zero. Since all operations carry some risk, it is clear that these unblemished results will not continue indefinitely. However, they convincingly support previous reports regarding the safety and reliability of the “catheterless” technique.’ A major reason for our excellent results is that only “simple” cases were considered. Any patient requiring ureteral tapering, diverticulum resection, ureterocele resection, bladder augmentation, or a redo procedure was excluded. It appears that duplicated systems amenable to common sheath reimplantation can be safely carried out without catheters. The 50 percent decrease in length of hospitalization may have several explanations including decreased patient discomfort, nosocomial urinary tract infection, and incidence of ileus from narcotics. Although sophisticated financial analysis of hospital costs was not the purpose of this study, there does appear to be a genuine cost reduction with the routine omission of catheters. Since the pain medication regimens were not standardized, it is difficult to draw firm conclusions regarding patient discomfort. However, there is a clear trend toward decreased need for pain medication in the patients managed without catheters. It has been proposed that this is partly secondary to a decreased incidence of bladder spasm. l The endoscopic treatment of vesicoureteral reflux with cross-linked collagen or various other
UROLOGY
I DECEMBER 1993
I VOLUME42, NUMBER6
substances has generated considerable interest. Several studies have demonstrated the relative safety and effectiveness of these techniques.6 Nevertheless, it will be sometime before the best substance is clearly identified and approved for use by the Food and Drug Administration. It will be even longer until the procedure becomes the standard of care performed by most urologists. In the meantime, we believe that the catheterless ureteral reimplant provides a safe, reliable, and cost effective alternative which results in less morbidity than traditional methods. John
W. Brock,
III, M.D.
Department of Urology Vanderbilt Medical Center North Nashville. Tennessee 37232-2765 REFERENCES 1. So EP Brock WA, and Kaplan GW: Ureteral reimplantation without catheters. J Urol 125: 551-553, 1981. 2. Glenn JF, and Anderson EE: Distal tunnel ureteral reimplantation. J Uro197: 623-626, 1967. 3. Politano VA, and Leadbetter WF: An operative technique for the correction of vesicoureteral reflux. J Urol 79: 932-941.1958. 4. Stephens FD: The normal and abnormal ureterovesical hiatus: methods of correction of vesicoureteral reflux and paraureteral diverticula. JCE Urol 12: 12-14, 1978. 5. Cohen SJ: Ureterozystoneostomie: eine neue antirefluxtechnik, Aktuel Uro16: 1-8, 1975. 6. Leonard MP, Canning DA, Peters CA, Gearhart JP, and Jeffs RD: Endoscopic injection of glutaraldehyde crosslinked bovine dermal collagen for the correction of vesicoureteral reflux. J Urol 145: 115-119, 1991.
707