title: Extravesical ureteral reimplantations for the correction of primary reflux can be done as outpatient procedures.
abstract: OBJECTIVE
  Extravesical ureteral reimplantations are thought to be less morbid compared with traditional intravesical techniques. We believe a shorter length of stay can be achieved in children undergoing extravesical reimplantation for the correction of primary reflux without experiencing a reduction in quality of care.
  
  
  METHODS
  During a 16-month period 2 boys and 42 girls underwent extravesical ureteral reimplantation and received similar postoperative care by a single pediatric urologist (D. P. S.). These children were 1 to 14 years old (mean age 4.7) and underwent reimplantation for correction of primary vesicoureteral reflux due to breakthrough urinary tract infections, moderate/high grade reflux and parental desire. Unilateral and bilateral reimplantations were done in 21 and 23 children, respectively, and 9 underwent reimplantation of duplex systems. Each child received 0.25 to 0.5% marcaine locally instead of caudal at termination of the surgical procedure. Criteria for patient discharge home included sufficient urine output, toleration of a liquid diet, adequate pain control with oral analgesics and "parental readiness." Renal and bladder ultrasound was obtained no earlier than 1 month following surgery. Postoperative cystograms were obtained in any child with a febrile urinary tract infection or at parental request. Charts were reviewed for demographics, operative procedures, postoperative intravenous analgesic doses, catheter requirements and length of stay, defined as hours from surgery to discharge home. Surgical outcomes were analyzed specifically for perioperative complications and resolution of reflux on postoperative cystograms.
  
  
  RESULTS
  The length of stay for all children ranged from 5 to 30 hours (average plus or minus standard deviation 13.3 +/- 6.8). Of the children 31 (70.5%) were discharged home the same day while the remaining 13 (29.5%) went home the next day. When comparing the outpatient surgical group to those hospitalized for 1 night, there were no significant differences in age, operative times and technique (unilateral versus bilateral). Children discharged home the same day required significantly fewer doses of intravenous analgesics (1.7 +/- 0.23 versus 2.7 +/- 0.36, p = 0.025). Intravenous narcotics were primarily used in the recovery room and ketorolac tromethamine was administered on the surgical ward. Seven children were discharged home with urethral catheters due to urinary tract infection in 1, transient urinary retention in 4 and surgeon preference in 2. Those patients discharged home with an indwelling catheter had a significantly longer length of stay (hours) compared to those without catheters (20.3 +/- 8.3 versus 12.0 +/- 5.6, p = 0.026). The child discharged home with a catheter due to urinary tract infection was rehospitalized 2 days later and received 48 hours of intravenous antibiotics. Postoperative cystograms revealed resolution of reflux in 12 of 13 children (92.3%). One child with preoperative bilateral high grade reflux had unilateral reflux on postoperative cystogram. Followup of 41 children at 3 to 19 months (mean 9.1) revealed no other significant complications.
  
  
  CONCLUSIONS
  In our experience extravesical ureteral reimplantation for the correction of primary reflux can be done on an outpatient basis in the majority of children without an increase in morbidity. Pain management and catheter placement significantly influence length of stay in children undergoing extravesical ureteral reimplantation.
authors.affiliation: East Tennessee Children's Hospital and Division of Urology, Department of Pediatrics, University of Tennessee Medical Center, Knoxville, Tennessee, USA.
authors.forename: J B
authors.initials: JB
authors.lastname: Marotte
authors.forename: D P
authors.initials: DP
authors.lastname: Smith
mesh_terms: D000293:Adolescent; D000556:Ambulatory Surgical Procedures; D002408:Catheters, Indwelling; D002648:Child; D002675:Child, Preschool; D005260:Female; D006801:Humans; D007223:Infant; D007902:Length of Stay; D008297:Male; D012092:Replantation / Q000379:methods*; D014513:Ureter / Q000601:surgery*; D014718:Vesico-Ureteral Reflux / Q000601:surgery*