Skip to main content

Advertisement

SpringerLink
Log in

Evolving trends in peri-operative management of pediatric ureteropelvic junction obstruction: working towards quicker recovery and day surgery pyeloplasty

  • Original Article
  • Published:
World Journal of Urology Aims and scope Submit manuscript

A Letter to the Editor to this article was published on 07 January 2022

Abstract

Objective

To describe the evolution of practice patterns for pediatric pyeloplasty and determine how these changes have impacted length of stay (LOS), reoperation rates and return emergency department (ER) visits.

Methods

We reviewed our pyeloplasty database from 2008 to 2020 at a quaternary pediatric referral center and we included children 0–18 years undergoing pyeloplasty. Variables captured included: age, sex, baseline and follow-up anteroposterior diameter (APD) and differential renal function (DRF). We also collected data on the use of drains, catheters and/or stents, nausea and vomiting prophylaxis, opioids, regional anesthesia, and non-opioid analgesia. Outcomes were LOS, reoperation rates and ER visits.

Results

A total of 554 patients (565 kidneys) were included. Reoperation rate was 7%, redo rate 4% and ER visits 17%. There was a trend towards less opioids, indwelling catheters and internal stents and increasing non-opioid analgesia, externalized stents, and regional anesthesia during the study period. Same-day discharge (SDD) was possible for 88 (16%) children with no differences in reoperation or readmission rates between SDD and admitted (ADM). There was a difference in ER visits (21 [24%] vs. 26 [6%]; p = 0.04) for SDD vs. ADM, respectively. On multivariate analysis, the only predictor of ER visits was younger age. Patients < 7 months were more likely to present to ER (15/41; 37% vs. 6/47, 13%; p = 0.009). Multivariate analysis determined indwelling catheters and opioids were associated with ADM while dexamethasone and ketorolac with SDD.

Conclusion

Progressive changes in care have contributed to a shorter LOS and increasing rates of SDD for pyeloplasty patients. SDD appears to be feasible and does not result in higher complication rates. These data support the development of a pediatric pyeloplasty ERAS protocol to maximize quicker recovery and foster SDD as a goal.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1

Similar content being viewed by others

Abbreviations

HN:

Hydronephrosis

LOS:

Length of stay

ERAS:

Enhanced recovery after surgery

IVF:

Intravenous fluids

APD:

Anteroposterior diameter

DRF:

Differential renal function

RPG:

Retrograde pyelogram

ADM:

Admission

SDD:

Same-day discharge

TAP:

Transverse abdominis plane block

PCA:

Patient-controlled anesthesia

US:

Ultrasound

References

  1. Rickard M, Lorenzo AJ, Braga LH, Munoz C (2017) Parenchyma-to-hydronephrosis area ratio is a promising outcome measure to quantify upper tract changes in infants with high-grade prenatal hydronephrosis. Urology 104:166–171. https://doi.org/10.1016/j.urology.2017.01.015

    Article  PubMed  Google Scholar 

  2. Akhavan A, Merguerian PA, Larison C, Goldin AB, Shnorhavorian M (2014) Trends in the rates of pediatric pyeloplasty for ureteropelvic junction obstruction over 19 years: a phis database study. Adv Urol 2014:142625–142625. https://doi.org/10.1155/2014/142625

    Article  PubMed  PubMed Central  Google Scholar 

  3. Salo M, Sjoberg Altemani T, Anderberg M (2016) Pyeloplasty in children: perioperative results and long-term outcomes of robotic-assisted laparoscopic surgery compared to open surgery. Pediatr Surg Int 32(6):599–607. https://doi.org/10.1007/s00383-016-3869-2

    Article  PubMed  Google Scholar 

  4. Hopf HL, Bahler CD, Sundaram CP (2016) Long-term outcomes of robot-assisted laparoscopic pyeloplasty for ureteropelvic junction obstruction. Urology 90:106–110. https://doi.org/10.1016/j.urology.2015.12.050

    Article  PubMed  Google Scholar 

  5. Gatti JM, Amstutz SP, Bowlin PR, Stephany HA, Murphy JP (2017) Laparoscopic vs open pyeloplasty in children: results of a randomized, prospective, controlled trial. J Urol 197(3 Pt 1):792–797. https://doi.org/10.1016/j.juro.2016.10.056

    Article  PubMed  Google Scholar 

  6. Brindle ME, Heiss K, Scott MJ et al (2019) Embracing change: the era for pediatric ERAS is here. Pediatr Surg Int 35(6):631–634. https://doi.org/10.1007/s00383-019-04476-3

    Article  PubMed  Google Scholar 

  7. Ljungqvist O, Scott M, Fearon KC (2017) enhanced recovery after surgery: a review. JAMA Surg 152(3):292–298. https://doi.org/10.1001/jamasurg.2016.4952

    Article  PubMed  Google Scholar 

  8. (2015) The impact of enhanced recovery protocol compliance on elective colorectal cancer resection: results from an international registry. Ann Surg 261(6):1153–1159. https://doi.org/10.1097/SLA.0000000000001029

  9. Haverkamp MP, de Roos MAJ, Ong KH (2012) The ERAS protocol reduces the length of stay after laparoscopic colectomies. Surg Endosc 26(2):361–367. https://doi.org/10.1007/s00464-011-1877-9

    Article  CAS  PubMed  Google Scholar 

  10. Gustafsson UO, Scott MJ, Schwenk W et al (2013) Guidelines for perioperative care in elective colonic surgery: enhanced recovery after surgery (ERAS®) society recommendations. World J Surg 37(2):259–284. https://doi.org/10.1007/s00268-012-1772-0

    Article  CAS  PubMed  Google Scholar 

  11. Shinnick JK, Short HL, Heiss KF, Santore MT, Blakely ML, Raval MV (2016) Enhancing recovery in pediatric surgery: a review of the literature. J Surg Res 202(1):165–176. https://doi.org/10.1016/j.jss.2015.12.051

    Article  PubMed  Google Scholar 

  12. Haid B, Karl A, Koen M, Mottl W, Haid A, Oswald J (2018) Enhanced recovery after surgery protocol for pediatric urological augmentation and diversion surgery using small bowel. J Urol 200(5):1100–1106. https://doi.org/10.1016/j.juro.2018.06.011

    Article  PubMed  Google Scholar 

  13. Rove KO, Brockel MA, Saltzman AF et al (2018) Prospective study of enhanced recovery after surgery protocol in children undergoing reconstructive operations. J Pediatr Urol 14(3):252.e1-252.e9. https://doi.org/10.1016/j.jpurol.2018.01.001

    Article  CAS  Google Scholar 

  14. Garin C (2020) Enhanced recovery after surgery in pediatric orthopedics (ERAS-PO). Orthop Traumatol Surg Res 106(1, Supplement):S101–S107. https://doi.org/10.1016/j.otsr.2019.05.012

    Article  PubMed  Google Scholar 

  15. Roy N, Parra MF, Brown ML et al (2019) Initial experience introducing an enhanced recovery program in congenital cardiac surgery. J Thorac Cardiovascr Surg. https://doi.org/10.1016/j.jtcvs.2019.10.049

    Article  Google Scholar 

  16. Short HL, Heiss KF, Burch K et al (2018) Implementation of an enhanced recovery protocol in pediatric colorectal surgery. J Pediatr Surg 53(4):688–692. https://doi.org/10.1016/j.jpedsurg.2017.05.004

    Article  PubMed  Google Scholar 

  17. Gao R, Yang H, Li Y et al (2019) Enhanced recovery after surgery in pediatric gastrointestinal surgery. J Int Med Res 47(10):4815–4826. https://doi.org/10.1177/0300060519865350

    Article  PubMed  PubMed Central  Google Scholar 

  18. Brindle ME, McDiarmid C, Short K et al (2020) Consensus guidelines for perioperative care in neonatal intestinal surgery: enhanced recovery after surgery (ERAS®) society recommendations. World J Surg. https://doi.org/10.1007/s00268-020-05530-1

    Article  PubMed  PubMed Central  Google Scholar 

  19. Sethi AK, Chatterji C, Bhargava SK, Narang P, Tyagi A (1999) Safe pre-operative fasting times after milk or clear fluid in children A preliminary study using real-time ultrasound. Anaesthesia 54(1):51–59. https://doi.org/10.1046/j.1365-2044.1999.00660.x

    Article  CAS  PubMed  Google Scholar 

  20. Lorenzo AJ, Lynch J, Matava C, El-Beheiry H, Hayes J (2014) Ultrasound guided transversus abdominis plane vs surgeon administered intraoperative regional field infiltration with bupivacaine for early postoperative pain control in children undergoing open pyeloplasty. J Urol 192(1):207–213. https://doi.org/10.1016/j.juro.2014.01.026

    Article  PubMed  Google Scholar 

  21. Braga LHP, Lorenzo AJ, Bägli DJ et al (2010) Comparison of flank, dorsal lumbotomy and laparoscopic approaches for dismembered pyeloplasty in children older than 3 years with ureteropelvic junction obstruction. J Urol 183(1):306–311. https://doi.org/10.1016/j.juro.2009.09.008

    Article  PubMed  Google Scholar 

  22. Esposito C, Bleve C, Escolino M et al (2017) Laparoscopic transposition of lower pole crossing vessels (vascular hitch) in children with pelviureteric junction obstruction. Transl Pediatr 5(4):256–261. https://doi.org/10.21037/tp.2016.09.08

    Article  Google Scholar 

  23. Lee LC, Kanaroglou N, Gleason JM et al (2015) Impact of drainage technique on pediatric pyeloplasty: Comparative analysis of externalized uretero-pyelostomy versus double-J internal stents. CUAJ 9(7–8):453. https://doi.org/10.5489/cuaj.2697

    Article  Google Scholar 

  24. Ljungqvist O, Thanh NX, Nelson G (2017) ERAS-value based surgery. J Surg Oncol 116(5):608–612. https://doi.org/10.1002/jso.24820

    Article  PubMed  Google Scholar 

  25. Bain J, Kelly H, Snadden D, Staines H (1999) Day surgery in Scotland: patient satisfaction and outcomes. Qual Saf Health Care 8(2):86–91. https://doi.org/10.1136/qshc.8.2.86

    Article  CAS  Google Scholar 

  26. Braga LHP, Lorenzo AJ, Farhat WA, Bägli DJ, Khoury AE, Pippi Salle JL (2008) Outcome analysis and cost comparison between externalized pyeloureteral and standard stents in 470 consecutive open pyeloplasties. J Urol 180(4S):1693–1699. https://doi.org/10.1016/j.juro.2008.05.084

    Article  PubMed  Google Scholar 

  27. Donati-Bourne J, Husaini MI, Pillai P et al (2016) A drain- and catheter-free enhanced recovery protocol to achieve discharge within 23 hours of laparoscopic pyeloplasty surgery: Is this feasible and safe? J Clin Urol 9(4):239–243. https://doi.org/10.1177/2051415815626321

    Article  Google Scholar 

  28. Kajbafzadeh A-M, Tourchi A, Nezami BG, Khakpour M, Mousavian A-A, Talab SS (2011) Miniature pyeloplasty as a minimally invasive surgery with less than 1 day admission in infants. J Pediatr Urol 7(3):283–288. https://doi.org/10.1016/j.jpurol.2011.02.030

    Article  PubMed  Google Scholar 

  29. Mitchell A, Bolduc S, Moore K, Cook A, Fermin C, Weber B (2020) Use of a magnetic double J stent in pediatric patients: a case–control study at two Canadian pediatric centers. J Pediatr Surg 55(3):486–489. https://doi.org/10.1016/j.jpedsurg.2019.03.014

    Article  PubMed  Google Scholar 

  30. Sundaramurthy S, Joseph Thomas R, Herle K, Jeyaseelan, Mathai J, Jacob Kurian J (2019) Double J stent removal in paediatric patients by Vellore Catheter Snare technique: a randomised control trial. J Pediatr Urol 15(6):6611–6618. https://doi.org/10.1016/j.jpurol.2019.08.009

    Article  Google Scholar 

Download references

Funding

The authors did not receive support from any organization for the submitted work. No funding was received to assist with the preparation of this manuscript. No funding was received for conducting this study. No funds, grants, or other support was received.

Author information

Authors and Affiliations

  1. Division of Urology, Department of Surgery, Hospital for Sick Children, University of Toronto, 555 University Avenue, Toronto, ON, M5G 1X8, Canada

    Mandy Rickard, Michael Chua, Daniel T. Keefe, Karen Milford, Joana Dos Santos, Martin A. Koyle & Armando J. Lorenzo

  2. Department of Urology, University of Toronto, Toronto, ON, Canada

    Jin Kyu Kim

  3. Division of Pediatric Urology, UH Rainbow Babies and Children’s Hospital, Cleveland, OH, USA

    Jessica H. Hannick

Authors
  1. Mandy Rickard
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Michael Chua
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Jin Kyu Kim
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Daniel T. Keefe
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Karen Milford
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Jessica H. Hannick
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Joana Dos Santos
    View author publications

    You can also search for this author in PubMed Google Scholar

  8. Martin A. Koyle
    View author publications

    You can also search for this author in PubMed Google Scholar

  9. Armando J. Lorenzo
    View author publications

    You can also search for this author in PubMed Google Scholar

Contributions

MRR, MC, JKK, DK, KM, JH, JDS, MK, AJL: project development, data collection, data analysis, manuscript writing.

Corresponding author

Correspondence to Armando J. Lorenzo.

Ethics declarations

Research involving human participants

This retrospective chart review study involving human participants was in accordance with the ethical standards of the institutional and national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. The Research and Ethics Board of The Hospital for Sick Children approved this study.

Informed consent

Due to the retrospective nature of this study, informed consent was not required.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Supplementary Information

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Rickard, M., Chua, M., Kim, J.K. et al. Evolving trends in peri-operative management of pediatric ureteropelvic junction obstruction: working towards quicker recovery and day surgery pyeloplasty. World J Urol 39, 3677–3684 (2021). https://doi.org/10.1007/s00345-021-03621-9

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00345-021-03621-9

Keywords

Search

Navigation