Early hospital discharge for intravesical ureteroneocystostomy

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.

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.

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.

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.