title: Bilateral extravesical ureteral reimplantation in toilet trained children: Is 1-day hospitalization without urinary retention possible?
abstract: OBJECTIVE
  Bilateral extravesical ureteral reimplantation has been associated with urinary retention. We developed a critical pathway and modification of surgical technique to determine whether the bilateral extravesical procedure could be performed in toilet trained children with patients discharged home after a 1-day hospitalization and without urinary retention.
  
  
  METHODS
  A total of 50 consecutive toilet trained children were evaluated after undergoing bilateral extravesical ureteral reimplantation using a modified technique that limits ureteral dissection, ureteral mobilization and detrusor dissection to as distally as possible so that a 5:1 ratio of tunnel length to ureteral diameter can be accomplished. No surgical dissection occurs in proximity to the obliterated umbilical artery, nor is the artery ligated. Patients follow a strict postoperative critical pathway, and parents receive extensive preoperative and postoperative education. A child is required to fulfill 5 strict criteria to be discharged from the hospital.
  
  
  RESULTS
  Patient age ranged from 1.9 to 12.8 years (mean 4.9), with 37 girls and 13 boys participating. All patients were discharged home on postoperative day 1. All patients were able to void postoperatively without any instances of urinary retention. None of the children had acute urinary tract infections or required rehospitalization. All patients had radiographic resolution of the vesicoureteral reflux on postoperative voiding cystourethrogram.
  
  
  CONCLUSIONS
  To our knowledge this is the first study to demonstrate that bilateral extravesical ureteroneocystostomy can be performed in selected patients without postoperative urinary retention and with uniform hospital discharge in 1 day. The critical pathway and limited dissection extravesical approach are essential for this success.
authors.affiliation: Division of Pediatric Urology, Rainbow Babies and Children's Hospital, Case Western Reserve University School of Medicine, Cleveland, Ohio 44106, USA.
authors.forename: Sarah E
authors.initials: SE
authors.lastname: McAchran
authors.forename: Jeffrey S
authors.initials: JS
authors.lastname: Palmer
mesh_terms: D002648:Child; D002675:Child, Preschool; D003558:Cystoscopy / Q000379:methods; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D007902:Length of Stay; D008297:Male; D010351:Patient Discharge; D010353:Patient Education as Topic; D011182:Postoperative Care / Q000379:methods; D011183:Postoperative Complications / Q000517:prevention & control; D020127:Recovery of Function; D012092:Replantation / Q000009:adverse effects* / Q000379:methods; D018570:Risk Assessment; D014039:Toilet Training; D016896:Treatment Outcome; D014513:Ureter / Q000601:surgery*; D018666:Ureteroscopy; D016055:Urinary Retention / Q000209:etiology / Q000517:prevention & control*; D014554:Urination / Q000502:physiology; D014718:Vesico-Ureteral Reflux / Q000175:diagnosis / Q000601:surgery*