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Strine AC, Chu DI, Brockel MA, Wilcox DT, Vricella GJ, Coplen DE, Traxel EJ, Chaudhry R, VanderBrink BA, Yerkes EB, Chan YY, Burjek NE, Zee RS, Herndon CDA, Ahn JJ, Merguerian PA, Meenakshi-Sundaram B, Rensing AJ, Frimberger D, Rove KO. Feasibility of Enhanced Recovery After Surgery (ERAS) implementation in Pediatric Urology: Pilot-phase outcomes of a prospective, multi-center study. J Pediatr Urol 2024; 20:256.e1-256.e11. [PMID: 38212167 PMCID: PMC11032233 DOI: 10.1016/j.jpurol.2023.12.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Revised: 12/11/2023] [Accepted: 12/26/2023] [Indexed: 01/13/2024]
Abstract
INTRODUCTION/BACKGROUND Enhanced Recovery After Surgery (ERAS) is a fundamental shift in perioperative care that has consistently demonstrated an improved outcome for a wide variety of surgeries in adults but has only limited evidence in the pediatric population. OBJECTIVE We aimed to assess the success with and barriers to implementation of ERAS in a prospective, multi-center study on patients undergoing complex lower urinary tract reconstruction. STUDY DESIGN Centers were directed to implement an ERAS protocol using a multidisciplinary team and quality improvement methodologies. Providers completed pre- and post-pilot surveys. An audit committee met after enrolling the first 5 patients at each center. Pilot-phase outcomes included enrollment of ≥2 patients in the first 6 months of enrollment, completion of 90 days of follow-up, identification of barriers to implementation, and protocol adherence. RESULTS A total of 40 patients were enrolled across 8 centers. The median age at surgery was 10.3 years (IQR 6.4-12.5). Sixty five percent had a diagnosis of myelomeningocele, and 33 % had a ventriculoperitoneal shunt. A bladder augmentation was performed in 70 %, Mitrofanoff appendicovesicostomy in 52 %, Monti ileovesicostomy in 15 %, and antegrade continence enema channel in 38 %. The most commonly perceived barriers to implementation on the pre-pilot survey were "difficulty initiating and maintaining compliance with care pathway" in 51 % followed by a "lack of time, money, or clinical resources" in 36 %. The pre-pilot study experience, implementation, and pilot-phase outcomes are provided in the Table. All primary and secondary outcomes were achieved. DISCUSSION The findings of the present study were similar to several small comparative studies with regard to the importance of a multidisciplinary team, strong leadership, and continuous audit for successful implementation of ERAS. Similar barriers were also encountered to other studies, which primarily related to a lack of administrative support, leadership, and buy-in from other services. The limitations of the present study included a relatively small heterogeneous cohort and absence of a comparative group, which will be addressed in the larger exploratory phase of the trial. The findings may also not be generaziable due to the need for sustainable processes that were unique to each center as well as an absence of adequate volume or resources at smaller centers. CONCLUSIONS ERAS was successfully implemented for complex lower urinary tract reconstruction across 8 centers through a multidisciplinary team, structured approach based on the local context, and focus on a continuous audit.
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Affiliation(s)
- Andrew C Strine
- Division of Pediatric Urology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA.
| | - David I Chu
- Division of Urology, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Megan A Brockel
- Department of Anesthesiology, Children's Hospital Colorado, University of Colorado, Aurora, CO, USA
| | - Duncan T Wilcox
- Department of Pediatric Urology, Children's Hospital Colorado, University of Colorado, Aurora, CO, USA
| | - Gino J Vricella
- Division of Pediatric Urology, St. Louis Children's Hospital, Washington University in St. Louis, St. Louis, MO, USA
| | - Douglas E Coplen
- Division of Pediatric Urology, St. Louis Children's Hospital, Washington University in St. Louis, St. Louis, MO, USA
| | - Erica J Traxel
- Division of Pediatric Urology, St. Louis Children's Hospital, Washington University in St. Louis, St. Louis, MO, USA
| | - Rajeev Chaudhry
- Division of Pediatric Urology, Children's Hospital of Pittsburgh, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Brian A VanderBrink
- Division of Pediatric Urology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Elizabeth B Yerkes
- Division of Urology, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Yvonne Y Chan
- Division of Pediatric Urology, Children's Health Texas, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Nicholas E Burjek
- Department of Anesthesiology, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Rebecca S Zee
- Division of Urology, Children's Hospital of Richmond at VCU, Richmond, VA, USA
| | - C D Anthony Herndon
- Division of Urology, Children's Hospital of Richmond at VCU, Richmond, VA, USA
| | - Jennifer J Ahn
- Department of Urology, Seattle Children's Hospital, University of Washington, Seattle, WA, USA
| | - Paul A Merguerian
- Department of Urology, Seattle Children's Hospital, University of Washington, Seattle, WA, USA
| | - Bhalaajee Meenakshi-Sundaram
- Department of Urology, Oklahoma Children's Hospital at OU Health, University of Oklahoma, Oklahoma City, OK, USA
| | - Adam J Rensing
- Department of Urology, Oklahoma Children's Hospital at OU Health, University of Oklahoma, Oklahoma City, OK, USA
| | - Dominic Frimberger
- Department of Urology, Oklahoma Children's Hospital at OU Health, University of Oklahoma, Oklahoma City, OK, USA
| | - Kyle O Rove
- Department of Pediatric Urology, Children's Hospital Colorado, University of Colorado, Aurora, CO, USA
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Xu R, Balthazar A, Sherlock R, Estrada C. Cost analysis for mirabegron use in the treatment of children with neurogenic bladder. J Pediatr Urol 2023; 19:535.e1-535.e10. [PMID: 37423791 DOI: 10.1016/j.jpurol.2023.06.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Revised: 06/08/2023] [Accepted: 06/12/2023] [Indexed: 07/11/2023]
Abstract
INTRODUCTION Mirabegron is a beta-3 adrenergic receptor agonist that received FDA approval in 2021 to treat neurogenic detrusor overactivity (NDO) in children ages three years and older. Despite its safety and efficacy, access to mirabegron frequently remains restricted by payor coverage policies. OBJECTIVE This cost minimization study sought to determine the cost implications from a payor perspective of mirabegron use at different points in the treatment pathway for pediatric NDO. STUDY DESIGN A Markov decision analytic model was constructed to assess the costs for eight treatment strategies over a 10-year period, using six-month cycles (Table). Five strategies involve mirabegron use as first-, second-, third-, or fourth-line therapy. Two strategies, including the "base case," entail use of anticholinergic medications followed by onabotulinum toxin type A (Botox) injection and augmentation cystoplasty. A strategy involving first-line Botox was also modeled. The effectiveness, adverse event rates, attrition rates, and costs associated with each treatment option were obtained from the clinical literature and adjusted to a six-month cycle. Costs were adjusted to 2021-dollar value. A discount rate of 3% was used. To quantify uncertainty, costs and treatment transition probabilities were modeled as gamma and PERT distributions, respectively. One-way sensitivity analyses were performed. Probabilistic sensitivity analysis (PSA) was conducted using a Monte Carlo simulation with 100,000 iterations. Analyses were performed using Treeage Pro (Healthcare Version). RESULTS The least costly strategy involved first-line mirabegron (expected cost $37,954). All strategies involving mirabegron were less costly than the base case ($56,417). On PSA, first-line mirabegron was the least costly strategy in 88.9% of cases (mean $37,604, 95% CI: $37,579-37,628); in 100% of cases, the least costly strategy involved mirabegron use. Cost savings associated with mirabegron use were attributable to decreased use of augmentation cystoplasty and Botox injections. DISCUSSION This is the first study to compare costs across multiple strategies involving mirabegron to treat pediatric NDO. Mirabegron use likely yields cost savings for the payor: the least costly strategy involved first-line mirabegron, and all pathways incorporating mirabegron were less costly than those without mirabegron use. These findings provide an updated cost analysis for the treatment of NDO by investigating mirabegron use alongside more established treatment options. CONCLUSION Use of mirabegron for the treatment of pediatric NDO is likely associated with cost savings as compared to treatment pathways without mirabegron. Expansion of payor coverage for mirabegron, as well as clinical studies to study first-line mirabegron use, should be considered.
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Affiliation(s)
- Rena Xu
- Department of Urology, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA 02115, USA.
| | - Andrea Balthazar
- Department of Urology, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA 02115, USA.
| | - Rebecca Sherlock
- Department of Urology, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA 02115, USA.
| | - Carlos Estrada
- Department of Urology, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA 02115, USA.
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Suria Cordero NF, Johnston AW, Dangle PP. Optimal Management of Neurogenic Bladder due to Spinal Cord Injury in Pediatric Patients. CURRENT BLADDER DYSFUNCTION REPORTS 2022. [DOI: 10.1007/s11884-022-00681-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/05/2022]
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Kim SJ, Nang QG, RoyChoudhury A, Kern AJM, Sheth K, Jacobs M, Poppas DP, Akhavan A. Cost comparison of intra-detrusor injection of botulinum toxin versus augmentation cystoplasty for refractory neurogenic detrusor overactivity in children. J Pediatr Urol 2022; 18:314-319. [PMID: 35216926 DOI: 10.1016/j.jpurol.2022.01.021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2020] [Revised: 01/07/2022] [Accepted: 01/31/2022] [Indexed: 11/29/2022]
Abstract
INTRODUCTION Treatment options for refractory neurogenic detrusor overactivity (NDO) in children include botulinum toxin type A (BTX-A) and augmentation cystoplasty (AC). Although BTX-A is accepted in contemporary pediatric urologic practice, cost and long-term outcomes data for BTX-A are limited relative to the gold standard, AC. The purpose of this study was to compare the projected 10-year costs of AC versus BTX-A. METHODS We performed a cost analysis from the payer perspective by computationally modeling treatment sequences by a Markov model. In the model, we used probabilities derived from published sources, and costs obtained at a tertiary medical center. The base case was a pediatric patient with refractory NDO. In the model, we assumed biannual BTX-A treatments. Treatment costs over 10 years were compared between immediate AC versus bridging therapy with BTX-A. Using the computational model, we simulated 100,000 instances of 10-year treatment cost for each of the two treatment modalities. The costs for the two treatment approaches were then compared using t-test and Wilcoxon test. RESULTS The projected median and mean 10-year cost of immediately AC were $51,798.72 (95% CI [$51,798.72, $327,483.80]) and $123,473.4 (SD: $98,085.23) respectfully, while the projected median and mean 10-year cost of bridging therapy with BTX-A prior to proceeding to AC as needed were $74,552.46 (95% CI [$53,188.56, $309,913.07]) and $124,858.80 (SD: $84,495.35) (p < 0.001). CONCLUSIONS For a typical index pediatric patient with NDO, bridging therapy with intravesical BTX-A is associated with an increased cost compared to immediate AC over a ten-year period.
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Affiliation(s)
- Soo Jeong Kim
- Division of Pediatric Urology, Texas Children's Hospital, Houston, TX, USA
| | - Quincy G Nang
- Institute for Pediatric Urology, New York Presbyterian Hospital, Weill Cornell Medical College, New York, NY, USA
| | - Arindam RoyChoudhury
- Division of Biostatistics and Epidemiology, Department of Healthcare Policy and Research, Weill Cornell Medicine, New York, NY, USA
| | | | - Kunj Sheth
- Department of Urology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Micah Jacobs
- Department of Urology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Dix Phillip Poppas
- Institute for Pediatric Urology, New York Presbyterian Hospital, Weill Cornell Medical College, New York, NY, USA
| | - Ardavan Akhavan
- Institute for Pediatric Urology, New York Presbyterian Hospital, Weill Cornell Medical College, New York, NY, USA.
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Chan YY, Chu DI, Hirsch J, Kim S, Rosoklija I, Studer A, Brockel MA, Cheng EY, Raval MV, Burjek NE, Rove KO, Yerkes EB. Implementation and sustainability of an enhanced recovery pathway in pediatric bladder reconstruction: Flexibility, commitment, teamwork. J Pediatr Urol 2021; 17:782-789. [PMID: 34521600 PMCID: PMC8678202 DOI: 10.1016/j.jpurol.2021.08.023] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2021] [Revised: 08/22/2021] [Accepted: 08/28/2021] [Indexed: 12/25/2022]
Abstract
INTRODUCTION Although enhanced recovery pathways (ERP) provide a safe and effective way to improve the recovery of children undergoing bladder reconstruction, ERPs have not been widely adopted in pediatric urology. We describe a quality improvement initiative and outcomes after implementing a 24-element ERP at a single, freestanding children's hospital. STUDY DESIGN Multiple stakeholder meetings were planned and executed, initially with pediatric practitioners with ERP experience to understand potential implementation barriers then with anesthesiologists, nurses, case managers, and other ancillary staff to draft our institution-specific ERP. A standardized order set was generated to improve ERP adherence. ERP adherence audits and cyclic performance evaluations held every 6-9 months facilitated continuous pathway refinement. Patient outcomes were compared with a pre-ERP historic cohort. RESULTS Time from initial ERP planning to first implementation was 7 months. ERP was implemented in twenty consecutive patients undergoing bladder reconstruction (median age 11.3 years, range 4.1-21.1) who were compared to twenty consecutive pre-ERP patients (median age 11.4 years, range 7.7-25.1). Median post-operative length of stay (LOS) significantly decreased from 9 days (range 2-31) pre-ERP to 4 days (range 3-29) post-ERP (p < 0.05). A median of 16 (range 12-19) of 24 institutional pathway elements were implemented for each patient. Balancing measures showed no significant increases in highest Clavien complication grade, readmission rate, or unplanned return to the operating room within 30 post-operative days. DISCUSSION Implementation of ERP is feasible but requires commitment from multi-disciplinary stakeholders. While we were unable to consistently achieve 80% of the elements, we successfully implemented the pathway and improved our patients' recovery processes (indirectly reflected by a decreased post-operative LOS) with adherence to a median of 67% of elements. Our implementation and effectiveness results are specific to our center and may not be generalizable. However, our experience may offer some insight for others interested in ERP implementation and encourage initiation of their own institutional pathways. CONCLUSION Successful ERP implementation at our hospital for children undergoing bladder reconstruction was facilitated by open communication, early stakeholder involvement, and monitoring ERP adherence. ERP implementation significantly decreased LOS without increasing post-operative complications and readmissions (Summary figure).
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Affiliation(s)
- Yvonne Y Chan
- Division of Pediatric Urology, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - David I Chu
- Division of Pediatric Urology, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA.
| | - Josephine Hirsch
- Division of Pediatric Urology, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Soojin Kim
- Department of Urologic Sciences, University of British Columbia, Vancouver, BC, Canada
| | - Ilina Rosoklija
- Division of Pediatric Urology, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Abbey Studer
- Center for Clinical Quality and Safety, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Megan A Brockel
- Department of Anesthesiology, Children's Hospital Colorado, Aurora, CO, USA
| | - Earl Y Cheng
- Division of Pediatric Urology, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Mehul V Raval
- Division of Pediatric Surgery, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Nicholas E Burjek
- Department of Pediatric Anesthesia, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Kyle O Rove
- Department of Pediatric Urology, Children's Hospital Colorado, Aurora, CO, USA
| | - Elizabeth B Yerkes
- Division of Pediatric Urology, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA. https://twitter.com/ebyerkes
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Prindeze NJ, Shupp JW, Johnson LS. Utility of 30-Day Readmission Metrics in the Burn Population: Navigating Quality Metric Limitations in Special Populations. J Burn Care Res 2021; 42:711-715. [PMID: 33591321 DOI: 10.1093/jbcr/iraa203] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Hospital readmission data may be a useful tool in identifying risk factors leading to higher costs of care or poorer overall outcomes. Several studies have emerged utilizing these datasets to examine the trauma and burn population, which have been unable to distinguish planned from unplanned readmissions. The 2014 Nationwide Readmissions Database was queried for 363 burn-specific ICD-9 DX codes and filtered by age and readmission status to capture the adult burn population. Additionally, burn-related excision and grafting procedures were filtered from 25 ICD-9 SG codes to distinguish planned readmissions. A total of 26,719 burn patients were identified with 781 all-cause unscheduled 30-day readmissions. Further filtering by burn-related excision and grafting procedures then identified 468 patients undergoing a burn-related excision and grafting procedure on readmission, reducing the dataset to 313 patients and identifying up to 60% of readmissions as possibly improperly coded planned readmissions. From this dataset, nonoperative management on initial admission was found to have the strongest correlation with readmission (OR 5.00; 3.33-7.14). Notably corrected data, when stratified by annual burn patient admission volume, identified a significant likelihood of readmission (OR 4.57; 2.15-9.70) of centers receiving the lowest annual number of burn patients, which was not identified in the unfiltered dataset. Healthcare performance statistics may be a powerful metric when utilized appropriately; however, these databases must be carefully applied to small and special populations. This study has determined that as many as 60% of burn patient readmissions included in prior studies may be improperly coded planned readmissions.
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Affiliation(s)
- Nicholas J Prindeze
- Firefighters' Burn and Surgical Research Laboratory, MedStar Health Research Institute, Washington, DC, USA.,Department of Surgery, MedStar Georgetown University Hospital and the Washington Hospital Center, Washington, DC, USA
| | - Jeffrey W Shupp
- Firefighters' Burn and Surgical Research Laboratory, MedStar Health Research Institute, Washington, DC, USA.,The Burn Center, Department of Surgery, MedStar Washington Hospital Center, Washington, DC, USA.,Department of Surgery, Georgetown University School of Medicine, Washington, DC, USA
| | - Laura S Johnson
- Firefighters' Burn and Surgical Research Laboratory, MedStar Health Research Institute, Washington, DC, USA.,The Burn Center, Department of Surgery, MedStar Washington Hospital Center, Washington, DC, USA.,Department of Surgery, Georgetown University School of Medicine, Washington, DC, USA
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The Current Positioning of Augmentation Enterocystoplasty in the Treatment for Neurogenic Bladder. Int Neurourol J 2020; 24:200-210. [PMID: 33017891 PMCID: PMC7538291 DOI: 10.5213/inj.2040120.060] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Accepted: 06/14/2020] [Indexed: 11/13/2022] Open
Abstract
Augmentation enterocystoplasty (AEC) is a surgical procedure in which the bladder is enlarged using an intestinal segment in patients with lower urinary tract dysfunction who fail to achieve satisfactory results with all conservative treatments. Currently, surgical materials and procedures, concomitant correction of upper urinary tract abnormalities, or bladder neck reconstruction may vary depending on the experience and preferences of the surgeons. AEC has been proven to be successful with respect to surgical goals, such as achieving urinary continence, improving quality of life, and preserving the upper urinary tract over the long term. The advantage of AEC over intravesical injection of botulinum toxin—a more recent and less invasive procedure—is that the prevention of upper urinary tract damage and the improvement of urinary incontinence are more reliably guaranteed, especially considering that these surgical effects are permanent. Compared to less invasive treatments, the quality of life of patients after surgery is also much higher, and AEC may be more cost-effective in the long run. Thus, in patients with neurogenic bladder, AEC is still the gold standard surgical procedure with strong evidence in support of its efficacy. In this article, the indications, surgical methods, possible complications, long-term follow-up, and current positioning of AEC in lower urinary tract dysfunction is discussed.
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Pediatric Neurogenic Bladder and Bowel Dysfunction: Will My Child Ever Be out of Diapers? Eur Urol Focus 2020; 6:838-867. [PMID: 31982364 DOI: 10.1016/j.euf.2020.01.003] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2019] [Revised: 12/02/2019] [Accepted: 01/13/2020] [Indexed: 02/07/2023]
Abstract
CONTEXT Managing patient and parent expectations regarding urinary and fecal continence is important with congenital conditions that produce neurogenic bladder and bowel dysfunction. Physicians need to be aware of common treatment algorithms and expected outcomes to best counsel these families. OBJECTIVE To systematically evaluate evidence regarding the utilization and success of various modalities in achieving continence, as well as related outcomes, in children with neurogenic bladder and bowel dysfunction. EVIDENCE ACQUISITION We performed a systematic review of the literature in PubMed/Medline in August 2019. A total of 114 publications were included in the analysis, including 49 for bladder management and 65 for bowel management. EVIDENCE SYNTHESIS Children with neurogenic bladder conditions achieved urinary continence 50% of the time, including 44% of children treated with nonsurgical methods and 64% with surgical interventions. Patients with neurogenic bowel problems achieved fecal continence 75% of the time, including 78% of patients treated with nonsurgical methods and 73% with surgical treatment. Surgical complications and need for revisions were high in both categories. CONCLUSIONS Approximately half of children with neurogenic bladder dysfunction will achieve urinary continence and about three-quarters of children with neurogenic bowel dysfunction will become fecally continent. Surgical intervention can be successful in patients refractory to nonsurgical management, but the high complication and revision rates support their use as second-line therapy. This is consistent with guidelines issued by the International Children's Continence Society. PATIENT SUMMARY Approximately half of children with neurogenic bladder dysfunction will achieve urinary continence, and about three-quarters of children with neurogenic bowel dysfunction will become fecally continent. Most children can be managed without surgery. Patients who do not achieve continence with nonsurgical methods frequently have success with operative procedures, but complications and requirements for additional procedures must be expected.
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Barashi NS, Andolfi C, Wallace A, Rodriguez MV, Schadler E, Gundeti MS. Lessons learned from a single-surgeon series of paediatric robot-assisted laparoscopic urological procedures: predictors of high-grade postoperative complications. BJU Int 2019; 124:649-655. [PMID: 30933406 DOI: 10.1111/bju.14757] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
OBJECTIVES To describe postoperative complications after robot-assisted laparoscopic urological surgery in children, and identify potential predictors of these complications by analysing the outcomes of a large-volume single-surgeon experience. PATIENTS AND METHODS We reviewed our institutional database to identify all robot-assisted laparoscopy (RAL) cases performed between December 2007 and December 2017. Patients were grouped into three cohorts based on the anatomical location of the procedure: upper urinary tract (kidney and renal pelvis); lower urinary tract (ureter); and lower urinary tract reconstruction with bowel (bladder reconstruction). A descriptive analysis of baseline characteristics, intra-operative variables and postoperative outcomes was carried out. All complications were graded using the Clavien-Dindo scale, and grouped based on type and time of occurrence (<30, 30-90, >90 days). Multivariable logistic regression analysis was performed to identify predictors of high-grade complications (Clavien-Dindo grade ≥ III). We also measured complication rates based on year of surgery and surgical caseload. RESULTS Our database included a total of 326 patients, of whom 57% (n = 186) underwent upper urinary tract procedures, 30% (n = 97) ureteric procedures, and 13% bladder reconstruction. The median follow-up for each procedure was 13, 11 and 57 months, respectively. Of the total, 10 cases were converted to an open approach and excluded from further analysis. The most common types of complication in all groups were infections (urinary tract infections) and urinary complications (urine leaks and urolithiasis). Bladder reconstructive procedures, which require the use of bowel, presented the highest rate of high-grade complications (32%). Length of hospital stay (LOS; odds ratio [OR] 1.33, confidence interval [CI] 1.16-1.53), estimated blood loss (EBL) in surgery (OR 1.01, CI 1.002-1.019) and operating time (OR 1.004, CI 1.002-1.006) were all associated with increased odds of high-grade complications on multivariate analysis (P < 0.05). CONCLUSIONS In this single-surgeon series, we have described the most commonly encountered complications after RAL in paediatric urology, finding rates similar to the complication rates reported in the current literature on other surgical approaches. In addition, LOS, operating time and EBL, which are probable surrogates of case complexity, were associated with increased odds of high-grade complications.
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Affiliation(s)
- Nimrod S Barashi
- Department of Surgery, Section of Urology, The University of Chicago, Chicago, IL, USA
| | - Ciro Andolfi
- Department of Surgery, Section of Urology, The University of Chicago, Chicago, IL, USA
| | - Aaron Wallace
- Pritzker School of Medicine, The University of Chicago, Chicago, IL, USA
| | - Maria V Rodriguez
- Department of Surgery, Section of Urology, The University of Chicago, Chicago, IL, USA
| | - Eric Schadler
- Pritzker School of Medicine, The University of Chicago, Chicago, IL, USA
| | - Mohan S Gundeti
- Department of Surgery, Section of Urology, The University of Chicago, Chicago, IL, USA
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Strine AC, VanderBrink BA, May T, Riazzi AC, Schulte M, Noh PH, DeFoor WR, Minevich E, Sheldon CA, Reddy PP. Impact of body mass index on 30-day postoperative morbidity in pediatric and adolescent patients undergoing continent urinary tract reconstruction. J Pediatr Urol 2019; 15:521.e1-521.e7. [PMID: 31301974 DOI: 10.1016/j.jpurol.2019.06.009] [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: 09/13/2018] [Revised: 05/06/2019] [Accepted: 06/14/2019] [Indexed: 10/26/2022]
Abstract
INTRODUCTION Obesity has been thought to increase the risk of complications and need for additional resources with surgery, but only a limited amount of evidence is available in the pediatric population. OBJECTIVE The objectives were to describe the weight status of pediatric and adolescent patients undergoing a continent urinary tract reconstruction and to determine the association between obesity and 30-day postoperative morbidity. STUDY DESIGN A retrospective cohort study was performed for pediatric and adolescent patients aged up to 20 years who underwent a continent urinary tract reconstruction between January 2010 and November 2016. Weight status was stratified by the body mass index (BMI) for age z-scores as follows: underweight (<5th percentile), normal (5th to <85th percentiles), overweight (85th to <95th percentiles), and obese (≥95th percentile). Primary outcomes included the duration of intensive care and hospitalization as well as re-admissions and complications within 30 days. RESULTS A total of 182 continent reconstructions were identified during the study period. Demographic and peri-operative data are provided in the Table. Weight status was not associated with any primary outcomes on univariate or multivariate analysis. There was also no association in an analysis between the non-overweight or non-obese group (BMI for age z-score <85th) and overweight or obese group (BMI for age z-score ≥85th percentiles); a subgroup analysis between patients with and without myelomeningocele; or a subgroup analysis for wound, infectious, or high-grade (Clavien-Dindo grades III or higher) complications. DISCUSSION Obesity has been consistently associated with an increased risk of surgical site infections and wound complications after a wide variety of surgeries in adults. The results from the present study conflict with those of the few available studies in the pediatric population. The high-risk nature of the present cohort may have mitigated any effect of obesity on 30-day postoperative morbidity. The limitations of the present study include its retrospective design at a single center and the potential misclassification of weight status with the BMI. CONCLUSIONS Almost 30% of pediatric and adolescent patients undergoing a continent urinary tract reconstruction were overweight or obese. Obesity as determined by the BMI was not associated with 30-day postoperative morbidity.
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Affiliation(s)
- A C Strine
- Division of Pediatric Urology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, 45229-3039, USA.
| | - B A VanderBrink
- Division of Pediatric Urology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, 45229-3039, USA
| | - T May
- Division of Pediatric Urology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, 45229-3039, USA
| | - A C Riazzi
- Division of Pediatric Urology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, 45229-3039, USA
| | - M Schulte
- Division of Pediatric Urology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, 45229-3039, USA
| | - P H Noh
- Division of Pediatric Urology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, 45229-3039, USA
| | - W R DeFoor
- Division of Pediatric Urology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, 45229-3039, USA
| | - E Minevich
- Division of Pediatric Urology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, 45229-3039, USA
| | - C A Sheldon
- Division of Pediatric Urology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, 45229-3039, USA
| | - P P Reddy
- Division of Pediatric Urology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, 45229-3039, USA
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