title: Bilateral extravesical ureteral reimplantation in toilet-trained children: short-stay procedure without urinary retention.
abstract: OBJECTIVE
  We have previously reported on the ability of toilet-trained children to undergo bilateral extravesical ureteral reimplantation with a 1-day hospitalization and without urinary retention using a critical pathway and modification of the surgical technique. The objective of this study was to determine whether additional refinement of the critical pathway and surgical technique could continue to result in 1-day hospitalization and possibly an outpatient procedure, without urinary retention, in toilet-trained children.
  
  
  METHODS
  We evaluated all toilet-trained children undergoing bilateral extravesical ureteroneocystostomy, with a critical pathway for preoperative education, operative management, and postoperative care. A modified technique was used that limits ureteral dissection, ureteral mobilization, and detrusor dissection to as distally as possible such that a 5:1 ratio of tunnel length to ureteral diameter can be accomplished. Patients followed a strict postoperative critical pathway, and parents received extensive preoperative and postoperative education. A child was required to fulfill 5 strict criteria to be discharged from the hospital.
  
  
  RESULTS
  A total of 84 patients underwent bilateral extravesical ureteral reimplantation. Of the 84 patients, 64 were girls and 20 were boys. The age range was 1.9-12.8 years (mean 4.6). The first 78 patients were discharged on the first postoperative day as planned. The next 6 patients in this series were discharged the same day as surgery as planned, using the modification of the critical pathway. All patients were able to spontaneously void postoperatively without any instances of acute or chronic urinary retention, acute urinary tract infection, or rehospitalization.
  
  
  CONCLUSIONS
  The results of this study further support our initial findings that bilateral extravesical ureteral reimplantation can be performed in toilet-trained children after a 1-day hospitalization without postoperative urinary retention. In the present study, this was also accomplished as an outpatient procedure.
authors.affiliation: Center for Pediatric Urology, Glickman Urological and Kidney Institute, Cleveland Clinic Children's Hospital, Cleveland, Ohio 44195, USA. palmerjs@ccf.org
authors.forename: Jeffrey S
authors.initials: JS
authors.lastname: Palmer
mesh_terms: D000556:Ambulatory Surgical Procedures; D002648:Child; D002675:Child, Preschool; D019091:Critical Pathways; D005260:Female; D006801:Humans; D007223:Infant; D007902:Length of Stay; D008297:Male; D014039:Toilet Training; D014513:Ureter / Q000601:surgery*; D013520:Urologic Surgical Procedures / Q000379:methods; D014718:Vesico-Ureteral Reflux / Q000601:surgery*