PEDIATRIC UROLOGY - CLINICAL

Early hospital discharge for intravesical ureteroneocystostomy
Miller OF, Bloom TL, Smith LJ, McAleer IM, Kaplan GW, Kolon TF
Naval Medical Center and Children’s Hospital and Health Center, San Diego, California, USA
J Urol. 2002; 167:2556-9

• Purpose: Inpatient stays of 3 to 5 days are common in the surgical management of vesicoureteral reflux and often include the use of bladder catheters, ureteral stents and perivesical drains. We reviewed our recent experience, in which patients undergoing routine ureteroneocystostomy were often discharged home on postoperative day 1 to determine the safety and efficacy of our management.
• Materials and Methods: Between July 1998 and March 2001 patients who underwent intravesical ureteroneocystostomy at 2 major tertiary care institutions were identified. Patients who also underwent simultaneous additional operative procedures, bilateral ureteral duplication or ureteral tapering were excluded from study. Data recorded included patient demographics, the procedure, operative and postoperative pain, nausea and bladder spasm management, hospital stay, post-hospital discharge problems and operative success.
• Results: Of the 113 patients with complete data available for analysis 101 received ketorolac postoperatively, including 75 females and 26 males with a mean age of 5.01 years (range 6 weeks to 16 years). There were 67 bilateral and 34 unilateral reimplantations. No ureteral stents or perivesical drains were placed. A perioperative urethral Foley catheter was removed on postoperative day 1 in all except 3 cases. Caudal analgesia with 0.25% bupivacaine before or after the operation was given in 91% of cases as a single injection. Epidural catheters were not used. In the ketorolac group average hospitalization was 29.5 hours (range 14 to 72). Of the 101 patients 58% were discharged home within 24 hours (average 21.3) and a further 11% were discharged home within 36 hours (average 27.4). All except 4 patients (4%) were discharged home within 48 hours of surgery. In the 12 patients who did not receive ketorolac average hospital stay was 43.8 hours (p<0.001). Gender did not affect the duration of hospitalization. Patients younger than 1 or older than 5 years old had a longer hospital stay than children between 1 and 5 years old (average 32.8 versus 25.5 hours). All patients received anticholinergics. The 9 complications (8%) involved urinary tract infection in 3 cases, and persistent nausea and vomiting, medication reaction and reoperation for clot evacuation in 1 each. Postoperatively 3 patients had persistent refluxing ureters.
• Conclusions: Routine surgical repair of vesicoureteral reflux can be successful with early bladder catheter removal and without stents or drains, necessitating only overnight hospitalization in the majority of patients. Ketorolac can be given safely in children with minimal risk and when combined with caudal analgesia it facilitates early discharge home.
  
  
• Editorial Comment
  We are witnessing an explosion of new inventions in the medical field, that include new surgical techniques, new pharmaceuticals in addition to many other advances. These improvements in technology should result not only in better patient outcomes, but in reduced patient and family morbidity as well. Nonetheless, often there are precious little data documenting the efficacy of these advances. This is particularly concerning when the advances may also jeopardize the health of the patients.
  The field of Pediatric Urology has been a leader in reducing patient morbidity. Many procedures are already performed as an outpatient, e.g. hypospadias repair, and orchiopexy. In contrast, ureteroneocystostomy is most often performed via a transvesical approach, resulting in a longer hospitalization and recovery period. The main factors that limit early recovery and discharge from hospital are the presence of a Foley catheter and/or a perivesical drain, bladder spasms and pain. This article reports a shortened hospital stay (over 95% of patients were discharged in 48 hours) after ureteroneocystostomy, utilizing newer pain management techniques. In addition, there were few re-admissions to the hospital and no more than standard complications.
  There are several weaknesses of the study. Although it is intuitive that better pain management is beneficial, the authors present little objective data on the success of their pain management (i.e. there were no pain scales used). Furthermore, patients were not randomized to one protocol vs. another. Hence any cause-effect relationship between early discharge and the pain management is not clear. The cause might just as well have been better surgical techniques, improved postoperative nursing or more successful education and discharge planning (or all of the above). Furthermore, although early discharge may be cost-effective and safe, there are no data presented on patient satisfaction. Were patients/families happy with their care or did they feel rushed out of the hospital with significant negative consequences for the family left to deal with the patient at home? (1) Nonetheless, the authors’ experience is similar to others, indicating that early discharge truly is feasible and safe after ureteroneocystostomy. Further studies of the outcome of the use of newer technologies should be encouraged.

Reference
1. Kogan BA, LS Baskin, MJ Allison: Length of stay for specialized pediatric urologic care. Arch Pediatr Adolesc Med.
1998; 152:1126-31.

Dr. Barry A. Kogan
Chief and Professor of Urology and Pediatrics
Albany Medical College
Albany, New York, USA