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PEDIATRIC UROLOGY

1

EXPERIENCE IN PERFORMING PYELOLITHOTOMY ANDPYELOPLASTY IN CHILDREN ON DAY-SURGERY BASIS

MAHMOUD MOHAMED, GRAHAM HOLLINS, AND MOHAMED EISSA

ABSTRACTbjectives. To evaluate the success of implementing a day-surgery admission policy for pyelolithotomy andyeloplasty in pediatric cases.ethods. A retrospective audit of the urology day-surgery unit records was performed for the period of

anuary 1994 to December 1998. The data included the number of patients and their sex, type ofrocedures performed, the criteria for case selection, and reported complications that required readmis-ion. The mean patient age was 2.6 years. The decision to perform these procedures on a day-surgery basisas taken after completing preoperative investigations and making the decision for surgery. Several criteriaere developed to ensure the success of this application. The parents’ understanding of the day surgeryoncept was the most important criterion. Pyeloplasties were performed using the Anderson-Hynes tech-ique without stenting and were performed only for patients with an extrarenal pelvis. Pain control waselivered through wound infiltration with long-acting local anesthetic followed by oral non-narcotic analge-ics. The immediate follow-up period was 4 to 5 weeks postoperatively, and long-term follow-up data werevailable for 2.5 to 3 years.esults. During the study period, 209 patients underwent surgery for pelviureteral junction obstructionepair and 305 underwent pyelolithotomy for renal stones. Of these children, 85% were discharged theame day, with no reported readmissions during the immediate or delayed follow-up period.onclusions. The results of this study have demonstrated that day surgery can be safely used for childrenequiring open renal surgical procedures that have more traditionally been performed on an inpatient basis.his has considerable resource implications at little cost in terms of patient morbidity. UROLOGY 64:220–1223, 2004. © 2004 Elsevier Inc.

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ay-case or ambulatory surgery can be used totreat large numbers of patients with consider-

ble resource and cost savings. Day-case surgeryesults in less workload for primary and commu-ity health services than does inpatient surgery.1–6

ecently, the number of patients and proceduresonsidered suitable for day-case surgery and anes-hesia have increased. It is estimated that about0% to 60% of all operations are performed on aay-case basis.7–10 Children, in particular, are con-

rom the Department of Urology, Craigavon Area Hospital,ortadown, United Kingdom; Department of Urology, Ayr Hos-ital, Ayr, United Kingdom; and Department of Paediatric Urol-gy, Cairo University Hospitals, Abu-Elrish Paediatric Hospital,airo, EgyptReprint requests: Mahmoud Mohamed, M.B.Ch.B., M.D.,

epartment of Urology, Craigavon Area Hospital, 64 Lurganoad, Portadown, Northern Ireland BT63 5QQ United King-om. E-mail: mahmoud_elfar@yahoo.comSubmitted: February 2, 2004, accepted (with revisions): Au-

aust 4, 2004

© 2004 ELSEVIER INC.220 ALL RIGHTS RESERVED

idered to be good candidates for day-case surgeryecause of their rapid recovery from surgery andnesthesia and their minimal requirement for post-perative nursing care, allowing easy provision ofostoperative care by their parents.1,3

Our department delivers urologic services toarge numbers of children, despite limited re-ources. This has been accomplished by perform-ng standard open urologic procedures on a day-urgery basis. Surgical techniques and patientelection criteria have been modified to achieveost-effective surgery without compromising theuality of healthcare provided or parent satisfac-ion. At present, we offer 18 open surgical and en-oscopic urologic procedures as day-surgery casesithin our department, all meeting strict selection

riteria.The objective of this study was to evaluate the

uccess of implementing a day-surgery admissionsolicy for pyelolithotomy and pyeloplasty in pedi-

tric cases.

0090-4295/04/$30.00doi:10.1016/j.urology.2004.08.065

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MATERIAL AND METHODS

A retrospective audit of pediatric urology day surgery unitecords in Abu-Elrish University Hospital (Cairo, Egypt) waserformed for the period of January 1994 to December 1998.he data collected included patient numbers, sex, procedureerformed, criteria for case selection, and reported complica-ions requiring readmission. All patients were referred fromutpatient clinics in the hospital, and all preoperative investi-ations were performed on an outpatient basis. The mean ageor renal surgery was 2 years, 6 months (range 4 months to 3ears, 2 months). All children lived within the city of Cairo.he parents of the patients had a method of communicationith the hospital and understood the issues of day surgery. Allatients underwent urinalysis before surgery to exclude infec-ion. Patients with bilateral renal pathologic features or recur-ent pelviureteral junction obstruction were not treated on aay-surgery basis.All pyeloplasties were performed using the Anderson-

ynes technique, with a ureteral catheter used only during therocedure. The ureteral catheter was not passed across thereterovesical junction to avoid edema of the distal ureter andas removed after completion of the anastomosis. Opticalagnification was used to ensure a watertight closure with

ntraoperative testing of the anastomosis. No nephrostomyube was used. At the end of the procedure, a tube drain waslaced and connected to a nonsuction collecting bag. A doubleressing was applied to the wound, the inner leaf of which hadn outer waterproof layer.

Pyelolithotomy was performed on a day-surgery basis foratients with an extrarenal pelvis. The duration of the proce-ure was not to exceed 50 minutes, and clear urine drainingrom the pelvis after stone removal with minimal overall sur-ical blood loss was required. A watertight closure was per-ormed using optical magnification and testing as with pyelo-lasty. A drain was left in place at the end of the procedureith a dressing similar to that used after pyeloplasty.Anesthetic gas induction and maintenance was accom-

lished using halothane. After an inpatient auditing study, aostoperative pain control protocol was established. Pain con-rol was delivered through wound infiltration at the end of therocedure with a long-acting local anesthetic (bupivacaine.25 mg/kg of 5 mg/mL with 1:200,000 adrenaline). This wasollowed by oral non-narcotic analgesia using diclofenac so-ium (1 to 3 mg/kg/24 hr) in divided doses by mouth or perectum (12.5-mg suppositories) and/or paracetamol oral sus-ension (120/5 mL; 120 mg every 6 hours for children olderhan 3 months).

All patients were discharged the same day if they had eaten,assed urine, and had bowel sounds. The parents were givenospital contact numbers with 24-hour access to medical ad-ice. The parents were instructed to contact the hospital in thevent of poor feeding, fever, pain, nausea, vomiting, or generalisturbances. They were also instructed to look for soaking ofhe dressings and how to care for the wound drains.

Children were seen 48 hours postoperatively in the outpa-ient clinic. Additional follow-up was undertaken 4 to 5 weeksfter surgery, with long-term follow-up data available for 2.5o 3 years.

RESULTS

During the study period, 514 children underwentpen renal surgery on a day-surgery basis. Of these14 children, 209 underwent surgery for pelvi-reteral junction obstruction using the Anderson-

ynes technique (116 boys and 93 girls) and 305 m

ROLOGY 64 (6), 2004

nderwent pyelolithotomy for removal of renaltones (228 boys and 77 girls; Table I).Of the 514 patients, 437 (85%) were discharged

ome on the day of surgery and 77 (15%) requiredospitalization after surgery and before discharge.he causes for hospitalization were diminished orbsent bowel sounds in 23 (30%), parents express-ng doubts regarding their ability to provide theequired postoperative care of the child at homefter surgery in 39 (50%), excessive nausea andomiting in 5 (7%), and inadequate postoperativeain control in 10 patients (13%). All 39 patientsdmitted postoperatively at the parents’ request methe department discharge criteria. All hospitalizationecisions were made during the recovery period, be-ore the children left the hospital (Table II).

The mean postoperative hospitalization timeexcluding operating room time) was 7 hoursrange 6 to 8). In the 437 children discharged theame day of renal surgery, no major complicationsequiring readmission during the immediate (4 toweeks) or long-term (2.5 to 3 years) follow-up

eriod were reported. All reported postdischargeomplications were treated on an outpatient basis.ausea and vomiting were the only reported im-

TABLE I. Procedures performed by number,sex and year

Pyelolithotomy (n) Pyeloplasty (n)

994Male 43 19Female 17 13

995Male 40 20Female 15 18

996Male 43 23Female 18 21

997Male 48 24Female 14 19

998Male 54 30Female 13 22

otal 305 209Male 228 116Female 77 93

TABLE II. Causes of readmissionause n %

arent request 39 50bsent bowel sounds 23 30

nadequate pain control 10 13xcessive nausea and vomiting 5 7otal 77 100

ediate complications in 11% of discharged pa-

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ients (48 children). Nausea did not occur on morehan three occasions and vomiting occurred noore than twice and did not interfere with the

hild eating. These complications were treated suc-essfully using either ondansetron syrup (4 mg/5L) or metoclopramide oral solution (5 mg/5 mL),ith the dose not exceeding 500 �g/kg/24 hr. Re-

urrence of renal stones was not considered a sur-ical complication in this study.

COMMENT

Shortened periods of hospitalization for childrenesults in a reduction of health service costs and pre-ents development of short-term and long-term be-avioral changes.11,12 In this study, we demonstratedhat day surgery can be performed safely in childrenequiring open renal pyeloplasty and pyelolithotomy.he decision to perform these procedures on a day-urgery basis was taken after complete outpatientvaluation followed by the decision to operate. Sev-ral criteria were developed to ensure the success ofhis application. The parents’ acceptance to performostoperative care at home after counseling and pro-edure explanations was the most important. Never-heless, 50% of readmitted cases were a result of thearents’ refusal to provide postoperative care atome, although their children met the departmentischarge criteria.Application of adequate postoperative analgesia

s vital for the child’s comfort at home and to pre-ent parental anxiety. This is best achieved by au-iting the pain management protocol on an inpa-ient basis before its application with day surgery.The use of pyelolithotomy in this study should

ot be considered standard treatment for kidneytones in children. Our use of pyelolithotomy sim-ly reflects the pediatric stone workload of our unituring the study period. At the time of this study,yelolithotomy was favored by the unit over per-utaneous nephrolithotomy for children between

and 2.5 years old (as judged by their bodyeight) to avoid excessive fluid absorption and cir-

ulatory overload. In children older than 2 years ofge with no parenchyma dilation, pyelolithotomyas preferred to percutaneous nephrolithotomy to

void parenchymal damage. Also, at the time ofhis study, extracorporeal shock wave lithotripsyas not considered for renal stone management in

hildren owing to the lack of reported data regard-ng its long-term effects on children’s kidneys.

For the pyeloplasties, a standard Anderson-Hynesechnique was used without stenting for all cases,ulfilling the selection criteria for day surgery.

The data presented in this study were consistentith those of a similar study by Sprunger et al.13 Instudy that included 51 children, of whom 26 re-

eived a flank incision, they concluded that stan- n

222

ard open pediatric urologic procedures could beafely conducted on an outpatient basis with min-mal complications.

CONCLUSIONS

In our study, 85% of the children who under-ent renal surgery on a day-surgery basis were dis-

harged the same day and none required readmis-ion. Day surgery has proved to be effective andafe in pediatric urology cases that have more tra-itionally been performed on an inpatient basis.his has considerable resource implications at lit-

le cost in terms of patient morbidity.

ACKNOWLEDGMENT. To A. O’Brien, Consultant Urologist,nd T. Glakin, Urology Research Registrar, Craigavon Areaospital, for their assistance in the review of this report.

REFERENCES1. Davenport M: ABC of general surgery in children: sur-

ically correctable causes of vomiting in infancy. BMJ 312:36–239, 1996.

2. Crew JP, Turner KJ, Millar J, et al: Is day case surgery inrology associated with high admission rates? Ann R Coll Surgngl 79: 416–419, 1997.

3. Essa MA: Evaluation of outpatient surgery in paediatricrology. Egypt J Urol 1: 50–52, 1994.

4. de la Hunt MN: Paediatric day care surgery: a hidden bur-en for primary care? Ann R Coll Surg Engl 81: 179–182, 1999.

5. McCallum J: Implementing an ambulatory surgical unitn pediatric urology. Urol Nurs 18: 117–119, 1998.

6. Hunter JD, Chambers WA, and Penny KI: Minor mor-idity after day-case surgery. Scott Med J 43: 54–56, 1998.

7. Philip BK: New approaches to anesthesia for day caseurgery. Acta Anaesthesiol Belg 48: 167–174, 1997.

8. Lim SK, and Lew YS: Paediatric day care anaesthesia—ur first two years’ experience at the Paediatric Institute, Hos-ital Kuala Lumpur. Med J Malaysia 52: 151–154, 1997.

9. Chung F, Mezei G, and Tong D: Pre-existing medicalonditions as predictors of adverse events in day-case surgery.r J Anaesth 83: 262–270, 1999.10. Huth MM: Pediatric day surgery outcomes manage-ent: the role of preoperative anxiety and a home pain man-

gement protocol. J Child Fam Nurs 2: 273–275, 1999.11. Vernon DTA: The Psychological Responses of Children to

ospitalization and Illness: A Review of the Literature. Spring-eld, Illinois, Thomas, 1965.12. Thompson RH: Where we stand: twenty years of re-

earch on pediatric hospitalization and health care. Childealth Care 14: 200–210, 1986.13. Sprunger JK, Reese CT, and Decter RM: Can standard

pen pediatric urological procedures be performed on an out-atient basis? J Urol 166: 1062–1064, 2001.

EDITORIAL COMMENTThe authors address a timely issue: the increased cost effi-

iency in pediatric urologic surgery. They describe an impressivexperience of open pediatric renal surgical procedures performedn an outpatient basis. This paper raised a question for me. Whyere so many pyelolithotomies performed? McLorie et al.1 de-

cribed the use of extracorporeal shock wave lithotripsy to treat4 children aged 6 to 40 months. Others have reported similaruccess with this procedure in infants. Larger stones in infantsnd small children can be effectively managed by percutaneous

ephrostolithotomy using a “mini-perc” technique.2

UROLOGY 64 (6), 2004