title: Extravesical ureteral reimplantation: an outpatient procedure.
abstract: OBJECTIVE
  We determined whether implementation of a critical pathway and modification of the extravesical ureteral reimplantation surgical technique to repair unilateral and bilateral vesicoureteral reflux would consistently result in same day patient hospital discharge without increased morbidity.
  
  
  METHODS
  We evaluated all children undergoing extravesical ureteral reimplantation using a modified technique that limits ureteral dissection, ureteral mobilization and detrusor dissection to as distal as possible. No surgical dissection is done 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. The child is required to fulfill strict criteria to be discharged home.
  
  
  RESULTS
  A total of 51 girls and 9 boys 0.9 to 10.5 years old (mean age 5.1) were evaluated. A total of 24 unilateral and 36 bilateral procedures were performed with and without ureteral tapering, and for single systems, duplex systems and an associated Hutch diverticulum. Overall 54 children (90%) were discharged home the same day, while only 6 (10%) went home the next day. All patients who underwent a unilateral procedure and 83% who underwent a bilateral procedure were outpatients. However, when evaluating the last 40 consecutive patients, including 14 with a unilateral and 26 with a bilateral procedure, all (100%) were discharged home the day of surgery without increased morbidity or an additional analgesic requirement. All outpatients were discharged within 5 hours after surgery. All patients tolerated the procedure well without major complications and without any patients requiring an emergency department visit or hospitalization after discharge home. After the urinary catheter was removed all patients were able to spontaneously void postoperatively without any acute or chronic urinary retention.
  
  
  CONCLUSIONS
  This study demonstrates that implementation of a strict critical pathway and a unilateral or bilateral extravesical ureteral reimplantation surgical technique with limited dissection can consistently result in same day discharge from the hospital within a few hours postoperatively without increased morbidity or rehospitalization.
authors: Center for Pediatric Urology, Glickman Urological and Kidney Institute, Cleveland Clinic Children's Hospital, Cleveland, Ohio 44195, USA. palmerjs@ccf.org
authors: Jeffrey S
authors: JS
authors: Palmer
mesh_terms: D000556:Ambulatory Surgical Procedures; D002648:Child; D002675:Child, Preschool; D019091:Critical Pathways; D003559:Cystostomy; D005260:Female; D006801:Humans; D007223:Infant; D008297:Male; D012092:Replantation; D014513:Ureter / Q000601:surgery*; D013520:Urologic Surgical Procedures / Q000379:methods*; D014718:Vesico-Ureteral Reflux / Q000601:surgery*