BERKELEY, CA (UroToday.com) - There has been debate regarding the complication of transient urinary retention in extravesical ureteroneocystostomy but it cannot be argued that it has a success rate comparable to the intravesical approach but with a morbidity. McAchran and Palmer developed a critical pathway and modification of surgical technique to determine whether bilateral extravesical ureteral reimplantation could be performed in toilet trained children, resulting in patient discharge after a 1-day hospitalization and without urinary retention.

They evaluated 50 consecutive toilet trained children (37 girls and 13 boys) undergoing bilateral extravesical ureteroneocystostomy and following a critical pathway for preoperative education, operative treatment and postoperative care. The indications for surgery were breakthrough urinary tract infections and/or persistent or worsening vesicoureteral reflux. The grade of VUR varied between 1 and 5. Preoperatively, parents received extensive education on the specific preoperative and postoperative instructions, expectations and goals, including instruction that 1-day hospitalization is possible. Patients received a caudal anesthetic for preventive analgesia and postoperative ketorolac unless contraindicated.

They performed a modification of the Lich-Gregoir antireflux procedure and includes ureteral advancement, however, limiting ureteral dissection, ureteral mobilization and detrusor dissection. Postoperatively, the patient follows a rigorous pathway consisting of no oral intake until the following morning, at which time the child is started on a regular diet, with use of ketorolac for analgesia with narcotics added for breakthrough pain, avoidance of anticholinergics unless there are unrelenting bladder spasms, phenazopyridine starting at 6:00 a.m., removal of Foley catheter at 7:00 a.m. followed by a strict timed voiding schedule of every 2 hours with measured voided volumes and strict bed rest until the following morning followed by extensive ambulation once the catheter is removed. A patient is discharged from the hospital after lunch on postoperative day 1 if 5 strict criteria are fulfilled, namely the patient urinates every 2 hours after Foley catheter removal without any suprapubic distention or urinary incontinence, the patient tolerates a regular diet, pain is controlled without narcotics, the patient ambulates without difficulty and the parents state that they are comfortable taking the child home. The regimen continues with strict timed voiding and extensive ambulation. Analgesia is managed by acetaminophen with or without codeine dependent on the level of pain. Phenazopyridine is used as needed for 2 days. Patients were on prophylaxis until radiographic confirmation of resolution of vesicoureteral reflux.

All patients were discharged home on postop day 1. All patients tolerated the procedure well without major complications. No patient required anticholinergics for bladder spasms. All patients were able to void spontaneously postoperatively without any instances of acute or chronic urinary retention, acute urinary tract infection or rehospitalization. All patients had radiographic resolution of vesicoureteral reflux on postoperative voiding cystourethrogram.

The group stated that extravesical ureteroneocystostomy is an effective surgical procedure to repair vesicoureteral reflux. They stated that the detrusor at the trigone and the bladder base is rich in innervation. The bundles of the pelvic plexus end at the distal ureter, trigone and rectum. They claim that their dissection spares these nerves. They also state that ambulation and timed voiding are important factors in preventing urinary retention. Pain control was also found to be an important factor in permitting the patient to ambulate and to be discharged home on postoperative day 1. Caudal anesthesia and ketorolac seemed to be best for pain control in this study. They also emphasized that parents must become part of the team, focusing on optimal care with active involvement in postoperative ambulation and timed voiding.

The group concluded that they performed bilateral repair in 50 children with vesicoureteral reflux, with a success rate of 100% and a 0% incidence of postoperative urinary retention. They claimed that their critical pathway and limited dissection extravesical approach were essential for this success. An editorial comment by Hrair-George O. Mesrobian commended the authors for their study and surgical approach.

The Journal of Urology. 174(5): 1991-1993, November 2005