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Tatanis V, Liatsikos E. Re: Evaluating the Safety of Same-day Discharge Following Pediatric Pyeloplasty and Ureteral Reimplantation; A NSQIP Analysis 2012-2020. Eur Urol 2024; 85:495. [PMID: 38296706 DOI: 10.1016/j.eururo.2024.01.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2023] [Accepted: 01/06/2024] [Indexed: 02/02/2024]
Affiliation(s)
| | - Evangelos Liatsikos
- Department of Urology, University of Patras, Patras, Greece; Department of Urology, Medical University of Vienna, Vienna, Austria.
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Juliebø-Jones P, Pietropaolo A, Haugland JN, Mykoniatis I, Somani BK. Current Status of Ureteric Stents on Extraction Strings and Other Non-cystoscopic Removal Methods in the Paediatric Setting: A Systematic Review on Behalf of the European Association of Urology (EAU) Young Academic Urology (YAU) Urolithiasis Group. Urology 2021; 160:10-16. [PMID: 34910924 DOI: 10.1016/j.urology.2021.11.022] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2021] [Revised: 11/04/2021] [Accepted: 11/18/2021] [Indexed: 11/29/2022]
Abstract
Ureteric stents are an important tool in urology and have a wide range of indications. While they offer a number of advantages, limitations remain despite modern advancements. These include discomfort, migration and encrustation. Standard removal is via cystoscopy but in the paediatric setting this mandates general anaesthetic, which holds disadvantages. Alternative removal methods include use of extraction strings and magnetic retrieval devices, which can be performed in the outpatient setting. This systematic review evaluates the safety and efficacy of different non-cystoscopic methods for stent removal in the paediatric setting.
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Affiliation(s)
- Patrick Juliebø-Jones
- Department of Clinical Medicine, University of Bergen, Bergen, Norway; Department of Urology, Haukeland University Hospital, Bergen, Norway.
| | - Amelia Pietropaolo
- Department of Urology, University Hospital Southampton, Southampton, United Kingdom
| | | | - Ioannis Mykoniatis
- Department of Urology, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Bhaskar K Somani
- Department of Urology, University Hospital Southampton, Southampton, United Kingdom
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Rickard M, Chua M, Kim JK, Keefe DT, Milford K, Hannick JH, Dos Santos J, Koyle MA, Lorenzo AJ. Evolving trends in peri-operative management of pediatric ureteropelvic junction obstruction: working towards quicker recovery and day surgery pyeloplasty. World J Urol 2021; 39:3677-3684. [PMID: 33660089 DOI: 10.1007/s00345-021-03621-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Accepted: 01/30/2021] [Indexed: 12/13/2022] Open
Abstract
OBJECTIVE To describe the evolution of practice patterns for pediatric pyeloplasty and determine how these changes have impacted length of stay (LOS), reoperation rates and return emergency department (ER) visits. METHODS We reviewed our pyeloplasty database from 2008 to 2020 at a quaternary pediatric referral center and we included children 0-18 years undergoing pyeloplasty. Variables captured included: age, sex, baseline and follow-up anteroposterior diameter (APD) and differential renal function (DRF). We also collected data on the use of drains, catheters and/or stents, nausea and vomiting prophylaxis, opioids, regional anesthesia, and non-opioid analgesia. Outcomes were LOS, reoperation rates and ER visits. RESULTS A total of 554 patients (565 kidneys) were included. Reoperation rate was 7%, redo rate 4% and ER visits 17%. There was a trend towards less opioids, indwelling catheters and internal stents and increasing non-opioid analgesia, externalized stents, and regional anesthesia during the study period. Same-day discharge (SDD) was possible for 88 (16%) children with no differences in reoperation or readmission rates between SDD and admitted (ADM). There was a difference in ER visits (21 [24%] vs. 26 [6%]; p = 0.04) for SDD vs. ADM, respectively. On multivariate analysis, the only predictor of ER visits was younger age. Patients < 7 months were more likely to present to ER (15/41; 37% vs. 6/47, 13%; p = 0.009). Multivariate analysis determined indwelling catheters and opioids were associated with ADM while dexamethasone and ketorolac with SDD. CONCLUSION Progressive changes in care have contributed to a shorter LOS and increasing rates of SDD for pyeloplasty patients. SDD appears to be feasible and does not result in higher complication rates. These data support the development of a pediatric pyeloplasty ERAS protocol to maximize quicker recovery and foster SDD as a goal.
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Affiliation(s)
- Mandy Rickard
- Division of Urology, Department of Surgery, Hospital for Sick Children, University of Toronto, 555 University Avenue, Toronto, ON, M5G 1X8, Canada
| | - Michael Chua
- Division of Urology, Department of Surgery, Hospital for Sick Children, University of Toronto, 555 University Avenue, Toronto, ON, M5G 1X8, Canada
| | - Jin Kyu Kim
- Department of Urology, University of Toronto, Toronto, ON, Canada
| | - Daniel T Keefe
- Division of Urology, Department of Surgery, Hospital for Sick Children, University of Toronto, 555 University Avenue, Toronto, ON, M5G 1X8, Canada
| | - Karen Milford
- Division of Urology, Department of Surgery, Hospital for Sick Children, University of Toronto, 555 University Avenue, Toronto, ON, M5G 1X8, Canada
| | - Jessica H Hannick
- Division of Pediatric Urology, UH Rainbow Babies and Children's Hospital, Cleveland, OH, USA
| | - Joana Dos Santos
- Division of Urology, Department of Surgery, Hospital for Sick Children, University of Toronto, 555 University Avenue, Toronto, ON, M5G 1X8, Canada
| | - Martin A Koyle
- Division of Urology, Department of Surgery, Hospital for Sick Children, University of Toronto, 555 University Avenue, Toronto, ON, M5G 1X8, Canada
| | - Armando J Lorenzo
- Division of Urology, Department of Surgery, Hospital for Sick Children, University of Toronto, 555 University Avenue, Toronto, ON, M5G 1X8, Canada.
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Sarhan O, Al Awwad A, Al Otay A, Al Faddagh A, El Helaly A, Al Ghanbar M, Al Kawai F, Nakshabandi Z. Comparison between internal double J and external pyeloureteral stents in open pediatric pyeloplasty: A multicenter study. J Pediatr Urol 2021; 17:511.e1-511.e7. [PMID: 33865709 DOI: 10.1016/j.jpurol.2021.03.027] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Revised: 03/09/2021] [Accepted: 03/25/2021] [Indexed: 11/25/2022]
Abstract
INTRODUCTION AND OBJECTIVE Anderson-Hynes dismembered pyeloplasty is considered the standard surgical treatment for ureteropelvic junction obstruction (UPJO). After pyeloplasty, stent drainage remains controversial. The commonly used stents are either an internal double-J (DJ) or an externalized pyeloureteral (PU) stents. We evaluated the outcome of using DJ versus PU stents following open pyeloplasty for UPJO in children. STUDY DESIGN We retrospectively evaluated 175 patients who underwent primary open pyeloplasty in two tertiary hospitals. A total of 110 patients underwent internal DJ stent insertion (63%) while 65 patients (37%) underwent placement of external PU stent. The type of stent used at the time of surgery was according to surgeon preference and experience. Operative time, postoperative hospital stay, overall complications and success rates were compared between the two groups. RESULTS The mean age was 3.8 years, and the mean follow-up was 4 years. Mean operative time was similar in the two groups (145 min). Mean hospital stay was 3.7 and 4.2 days in DJ and PU stent, respectively (p = 0.003) Summary Table . Postoperative complication developed in 9 out of 110 patients with DJ stent (8%), while complications developed in 6 out of 65 patients with PU stent (9%) (p = 0.81). Success rate of pyeloplasty was 95.5% for DJ group versus 97% for PU group (p = 0.63). DISCUSSION Dismembered pyeloplasty remains the standard treatment of choice as a surgical management for UPJO. A debate is still there in respect to the method of PU anastomotic stenting and which stent can be used. The major advantage for external PU stents is that it can be removed safely in the outpatient clinic without any sedation preventing the risk of repeated exposure to general anesthesia. Internal DJ stent provides a shorter hospital stay and comparable complication and success rates compared with PU stent. If we manage to overcome the longer DJ stent duration and facilitate early removal by an easy mode, that does not require another anesthesia at that moment we can find the optimal stent for all pyeloplasty cases. CONCLUSIONS The two types of stents are comparable as regard overall complication and success rates after pyeloplasty. Although internal DJ stent insertion provides a relatively shorter hospital stay, a second operating room visit and anesthesia for removal remains unavoidable.
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Affiliation(s)
- Osama Sarhan
- Urology and Nephrology Center, Faculty of Medicine, Mansoura University, Mansoura, Egypt; Urology Department, King Fahad Specialist Hospital, Dammam, Saudi Arabia.
| | - Ahmed Al Awwad
- Urology Department, King Fahad Military Medical Complex, Dhahran, Saudi Arabia
| | - Abdulhakim Al Otay
- Urology Department, Prince Sultan Military Medical City, Riyadh, Saudi Arabia
| | | | - Ahmed El Helaly
- Urology Department, Prince Sultan Military Medical City, Riyadh, Saudi Arabia
| | - Mustafa Al Ghanbar
- Urology Department, Prince Sultan Military Medical City, Riyadh, Saudi Arabia
| | - Fouad Al Kawai
- Urology Department, King Fahad Specialist Hospital, Dammam, Saudi Arabia
| | - Ziad Nakshabandi
- Urology Department, Prince Sultan Military Medical City, Riyadh, Saudi Arabia
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Paraboschi I, Jannello L, Mantica G, Roberts L, Olubajo S, Paul A, Mishra P, Taghizadeh A, Garriboli M. Outcomes and costs analysis of Externalized PyeloUreteral versus internal Double-J ureteral stents after paediatric laparoscopic Anderson-Hynes pyeloplasty. J Pediatr Urol 2021; 17:232.e1-232.e7. [PMID: 33388262 DOI: 10.1016/j.jpurol.2020.12.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2020] [Revised: 12/02/2020] [Accepted: 12/03/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND The gold standard treatment for Uretero-Pelvic Junction Obstruction (UPJO) is laparoscopic dismembered pyeloplasty according to the Anderson-Hynes technique. The internal Double-J ureteral (DJ) and the Externalized PyeloUreteral (EPU) stents are usually the drainage of choice. Only a few articles have compared the clinical impact of the different drainage techniques on the perioperative morbidity and none presented a cost analysis of the incurred hospital stay. OBJECTIVE To present the clinical outcome and financial analysis of a cohort of children who underwent a laparoscopic pyeloplasty comparing the use of the DJ versus EPU stent. STUDY DESIGN Retrospective study of consecutives children who underwent laparoscopic Anderson-Hynes pyeloplasty in a single tertiary paediatric referral centre from January 2017 to March 2020. Patients were grouped according to the type of stent used: DJ stent vs EPU stent. RESULTS Fifty-three laparoscopic pyeloplasties were performed on 51 patients: 27 (50.9%) had an EPU stent and 26 (49.1%) a DJ stent. There was no statistically significant difference between the two patient groups with regards to surgical time, hospital stay, stent-related complications or the need for re-do surgery. All the EPU stents were removed with an outpatient admission 8.1 days ± 3.1 after surgery while the DJ stents were removed with a cystoscopy 61.6 days ± 30.2 after surgery (p value < 0.001). On a financial analysis (Figure), the hospital costs for stent removal were significantly lower for the EPU stent group (£ 686.7 ± 263.4 vs £ 1425 ± 299.5, p value < 0.01). DISCUSSION Both drainage methods have some disadvantages. Possible complications associated with DJ stents include migration and artificial vesicoureteral reflux which may lead to higher incidence of Urinary Tract Infections. Possible disadvantages of the EPU stent insertion are related to the damage of the renal parenchyma and to the risk of developing skin site infections and urinary leaks. However, in our series the EPU stent has not been associated with a higher incidence of bleeding, leakage or discomfort. In addition to clinical considerations, there is a financial implication to be considered. With this regard, the EPU stent was associated with a significant reduction in the incurred hospital costs. CONCLUSIONS The use of DJ and EPU stents is equivalent in regards of overall complications and success rates. DJ and EPU stents provided comparable success and complication rates, however the latter avoids the need of an additional general anaesthesia and reduces the overall incurred hospital costs.
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Affiliation(s)
- Irene Paraboschi
- Paediatric Urology, Evelina London Children's Hospital, London, United Kingdom; DINOGMI University of Genoa, Genoa, Italy; Paediatric Surgery Unit, Giannina Gaslini Research Institute and Children Hospital, Genoa, Italy
| | - Letizia Jannello
- Paediatric Urology, Evelina London Children's Hospital, London, United Kingdom
| | - Guglielmo Mantica
- DINOGMI University of Genoa, Genoa, Italy; Department of Urology, San Martino Hospital, University of Genoa, Genoa, Italy
| | - Luke Roberts
- Health Informatics, Evelina London Children's Hospital, London, United Kingdom
| | - Seyi Olubajo
- Financial Developments and Costing, Finance, Guy's and St Thomas Foundation Trust
| | - Anu Paul
- Paediatric Urology, Evelina London Children's Hospital, London, United Kingdom
| | - Pankaj Mishra
- Paediatric Urology, Evelina London Children's Hospital, London, United Kingdom
| | - Arash Taghizadeh
- Paediatric Urology, Evelina London Children's Hospital, London, United Kingdom
| | - Massimo Garriboli
- Paediatric Urology, Evelina London Children's Hospital, London, United Kingdom; Stem Cells & Regenerative Medicine Section, Developmental Biology & Cancer Programme, UCL Institute of Child Health.
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Sheth KR, White JT, Puttmann K, Waters D, Soto M, Bell M, Aboufadel T, Heffernan MJ, Richardson E, Song SH, Koh CJ. Quantifying the forces needed for ureteral stent removal: Initial evaluation of magnetic stent removal devices on benchtop and porcine models. J Pediatr Urol 2020; 16:596.e1-596.e8. [PMID: 32340884 DOI: 10.1016/j.jpurol.2020.03.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2019] [Accepted: 03/21/2020] [Indexed: 11/16/2022]
Abstract
BACKGROUND Indwelling ureteral stents are commonly used in pediatric surgeries for kidney stones and urinary tract obstruction, but often require instrumentation or anesthesia for removal. We evaluated the use of novel magnet devices to remove indwelling ureteral stents with a distally attached magnetic bead. Since the forces required for stent removal are unknown, we aimed to characterize and quantify the forces required for stent removal for future prototype testing. METHODS A custom 3-D urinary tract model was used for benchtop testing, and 6 female porcine subjects were used for in vivo testing after obtaining institutional approval. A modified porcine urethral model that patterned the human female urethral anatomy with approximately 4.5 cm urethral length was used. A HF-10 digital force gauge measured the force required to remove stents with varying properties (stent size, presence of curl, and size of distal magnetic bead). These force measurements were compared to the quantified magnetic forces generated by external magnets and catheter tip magnets. Furthermore, the magnetic retrieval devices were tested with various magnetic beads on both benchtop and porcine models. RESULTS The required force for removal of a 5 Fr x 14 cm double J stent was significantly higher in the benchtop model compared to the porcine model (4.7N v. 0.8N, p < 0.001). Forces of at least 1N were required from the external magnets to move the stent and bead across a 4-5 cm distance from the bladder neck to the urethral meatus. External magnets at a distance of 4-5 cm produced insufficient forces for removal, and thus they failed to remove the magnetic bead and stent from the bladder. The catheter-based retrieval device showed better success with a variety of different magnet pairs on the retrieval device and stent. Furthermore, the addition of saline to the bladder allowed for better retrieval rates of the smallest beads, even by the smallest magnetic tip catheters. CONCLUSIONS The forces required for ureteral stent removal are <1N in the porcine model, and improved benchtop models that emulate such parameters will facilitate future stent removal device testing. Given this threshold, external magnets did not generate sufficient force for stent removal at the required distance of 4-5 cm, whereas catheter tip magnetic retrieval overcomes the minimum distance limitation and showed successful retrieval. While these results are encouraging, further studies will define the optimal combination of catheter magnetic tip size and stent magnetic bead size.
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Affiliation(s)
- Kunj R Sheth
- Division of Pediatric Urology, Stanford Medicine, Palo Alto, CA, USA.
| | - Jeffrey T White
- Division of Pediatric Urology, Norton Children's Hospital, Louisville, KY, USA
| | - Kathleen Puttmann
- Department of Urology, Ohio State University College of Medicine, Columbus, OH, USA
| | | | | | | | - Tasha Aboufadel
- Department of Bioengineering, Rice University, Houston, TX, USA
| | | | - Eric Richardson
- Department of Biomedical Engineering, Duke University Pratt School of Engineering, Durham, NC, USA
| | - Sang Hoon Song
- Division of Pediatric Urology, Department of Surgery, Texas Children's Hospital, Houston, TX, USA; Scott Department of Urology, Baylor College of Medicine, Houston, TX, USA
| | - Chester J Koh
- Division of Pediatric Urology, Department of Surgery, Texas Children's Hospital, Houston, TX, USA; Scott Department of Urology, Baylor College of Medicine, Houston, TX, USA
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Chalhoub M, Kohaut J, Vinit N, Botto N, Aigrain Y, Héloury Y, Lottmann H, Blanc T. Feasibility and safety of magnetic-end double-J ureteral stent insertion and removal in children. World J Urol 2020; 39:1649-1655. [PMID: 32623499 DOI: 10.1007/s00345-020-03339-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Accepted: 06/28/2020] [Indexed: 10/23/2022] Open
Abstract
PURPOSE The need for surgical removal of a double-J ureteral stent (DJUS) is considered one of its disadvantages. Apart from increased cost, repeated exposure to general anesthesia is a concern in children. Alternative techniques have been described, all failing to become integrated into mainstream practice. Stents with a distal magnetic end, although introduced in the early 1980s, have only recently gained acceptance. We report the feasibility and safety of insertion and removal of a magnetic-end double-J ureteral stent (MEDJUS) in a pediatric population. MATERIALS AND METHODS We retrospectively analyzed the use of the Magnetic Black-Star Urotech® MEDJUS between 11/2016 and 12/2019 in children. Stents were removed in the outpatient clinic using a transurethral catheter with a magnetic tip. RESULTS MEDJUS insertion was attempted in 100 patients (65 boys). Mean age was 7.8 years (0.5-18). The stent was placed in an antegrade procedure (n = 47), by a retrograde route (n = 10), and during open surgery (n = 43). Stent insertion was successful in 84 cases (84%). All 16 failures occurred during the antegrade approach in laparoscopic pyeloplasty, with inability to push the stent and its magnet through the ureterovesical junction in 14. Magnetic removal was attempted in 83 patients, successful in 81 (98%). There was no added morbidity with the MEDJUS. CONCLUSIONS The use of MEDJUS is a safe and effective strategy that obviates the need for additional general anesthesia in children. Its insertion is similar to that with regular DJUS, and its easy and less time-consuming removal benefits both the patient and the hospital and validates its clinical use.
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Affiliation(s)
- Marc Chalhoub
- Service de Chirurgie Viscérale et Urologie Pédiatriques, APHP, Hôpital Necker, Paris, France.,Université de Paris, Paris, France
| | - Jules Kohaut
- Service de Chirurgie Viscérale et Urologie Pédiatriques, APHP, Hôpital Necker, Paris, France.,Université de Paris, Paris, France
| | - Nicolas Vinit
- Service de Chirurgie Viscérale et Urologie Pédiatriques, APHP, Hôpital Necker, Paris, France.,Université de Paris, Paris, France
| | - Nathalie Botto
- Service de Chirurgie Viscérale et Urologie Pédiatriques, APHP, Hôpital Necker, Paris, France
| | - Yves Aigrain
- Service de Chirurgie Viscérale et Urologie Pédiatriques, APHP, Hôpital Necker, Paris, France.,Université de Paris, Paris, France
| | - Yves Héloury
- Service de Chirurgie Viscérale et Urologie Pédiatriques, APHP, Hôpital Necker, Paris, France.,Université de Paris, Paris, France
| | - Henri Lottmann
- Service de Chirurgie Viscérale et Urologie Pédiatriques, APHP, Hôpital Necker, Paris, France
| | - Thomas Blanc
- Service de Chirurgie Viscérale et Urologie Pédiatriques, APHP, Hôpital Necker, Paris, France. .,Université de Paris, Paris, France. .,Département Croissance et Signalisation, Hôpital Necker Enfants Malades, Institut Necker Enfants Malades, INSERM U1151-CNRS UMR 8253, Université Paris Descartes, Paris, France.
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