Constipation status and the enhanced recovery pathway in bladder reconstruction

Preoperative constipation may contribute to postoperative recovery and has been associated with increased postoperative complications in adults, but its impact in pediatric urology patients remains unclear. Enhanced recovery pathways (ERPs) have been shown to improve recovery through standardized perioperative protocols, although they are not well-studied in pediatric populations. We assessed whether surgical outcomes differ between patients with and without constipation undergoing bladder reconstruction under an ERP, hypothesizing that constipation would increase length of stay and delay return of bowel function.

We conducted a post hoc analysis of prospectively enrolled patients aged 4-25 years undergoing bladder reconstruction from 2019 to 2024 at our single institution as part of a multi-institutional ERP study. Patients with constipation, defined as Bristol type ≤2 or stools less frequent than every other day, were included at our institution but excluded from the multi-institutional study. Study outcomes were length of stay, time to return of bowel function, and 90-day adverse outcomes (composite of Clavien grade ≥2 complications, emergency department visits, readmissions, and reoperations). All patients followed the same ERP regardless of constipation status. Propensity score weighting was applied to balance baseline covariates. Weighted Poisson and logistic regression models then fit associations between constipation and study outcomes and included unbalanced covariates for doubly robust estimation.

We included a total of 59 patients (median age 11 years [IQR 9-13]), 22 (37%) with constipation. Patients with constipation were more likely to be female (86% v 60%, p = 0.03) and have no prior abdominal surgery (68% v 38%, p = 0.02) when compared to patients without constipation. In final weighted and adjusted outcome models, constipation was not significantly associated with length of stay or time to return of bowel function. In contrast, constipation was significantly associated with higher odds of 90-day adverse outcomes (OR 5.13, 95% CI 1.64-16.1). However, the significant association with 90-day adverse outcomes was driven by unplanned reoperations and emergency department visits, which were predominantly related to channel/catheter troubleshooting rather than constipation-related reasons.

Our findings suggest that constipation was not associated with length of stay or return of bowel function following bladder reconstruction within an ERP, though in a stratified analysis of patients with spina bifida, constipation was associated with longer length of stay, a finding that warrants further investigation. These findings provide a foundation for future prospective studies to validate and expand upon these observations in larger, multi-institutional cohorts.