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Multi-institutional review of postoperative urinary retention after bilateral robotic-assisted laparoscopic extravesical ureteral reimplantation
Liza M. Aguiar, MD1, Katherine Herbst, MSc2, Thomas S. Lendvay, MD3, Ardavan Akhavan, MD3, Mohan S. Gundeti, M.Ch.4, David Hatcher, MD4, Paul H. Noh, MD5, Marion Schulte, R.N.5, Gerald Mingin, Jr., MD6, Jared Wachterman, MD6, Christine Kim, MD1.
1Connecticut Childrens Medical Center/University of Connecticut, Hartford, CT, USA, 2Connecticut Childrens Medical Center, Hartford, CT, USA, 3Seattle Children’s Hospital/University of Washington School of Medicine, Seattle, WA, USA, 4Comer Children's Hospital/University of Chicago Medical Center, Chicago, IL, USA, 5Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA, 6Vermont Children's Hospital/University of Vermont School of Medicine, Burlington, VT, USA.

BACKGROUND:
Postoperative urinary retention is a known complication of bilateral extravesical ureteral reimplantation. Although the exact etiology is unknown, it may be secondary to damage to the pelvic nerve plexus during operative dissection. Robotic assisted laparoscopic surgery is an evolving technique in pediatric urology, and can potentially allow for improved visualization of the neurovascular bundle. We report the experience of multiple institutions with bilateral robotic-assisted laparoscopic extravesical ureteral reimplantation (RALUR) and postoperative urinary retention.
METHODS:
We reviewed the records of patients who underwent bilateral RALUR for vesicoureteral reflux (VUR) at 5 centers between the years 2009-2012. Patients with no post-void residual (PVR) recorded postoperatively were excluded. Data was collected prospectively for 12 subjects and retrospectively for the remaining 30. Primary outcomes included: percentage of estimated bladder capacity retained (PVR/EBC) and retention requiring catheter drainage. Estimated bladder capacity (EBC) was calculated using the formula: EBC= (age+2) x 30. Pre-surgical data collected included: age, sex, VUR grade, co-existing urologic diagnoses, co-morbidities, PVR/EBC, diagnosis of bladder/bowel dysfunction (BBD), and prior VUR surgery. Data collected postoperatively included: weight, length of hospital stay, PVR/EBC, timing of PVR, and surgical details including nerve sparing approach. Comparisons were made using t-test, Fisher’s Exact, or Mann-Whitney U.
RESULTS:
Seventy-five patients were identified, and 33 excluded due to lack of post-operative PVR, resulting in a cohort of 42 patients were included in the study; 7 (17%) male, 35 (83%) female. The majority of patients (55%, n=23) had a pre-surgical diagnosis of BBD. Mean surgical age was 5.9 years (SD ± 2.1yrs). Twenty patients (48%) underwent a nerve sparing approach. Postoperatively, 12 patients (29%) had a PVR/EBC >50%. Five patients (12%) had retention requiring catheter drainage; three were discharged with a urethral Foley catheter and two with suprapubic tubes. There was no statistically significant difference in retention rates between patients with BBD vs no BBD, nerve sparing vs non-nerve sparing, male vs female, or age. (Table 1)
Table 1
CharacteristicNo RetentionRetentionp-value
Gender (female, n, percent)32 (87%)3 (60%)0.188a
Age at Surgery (months, mean, ±SD, mos)68.22 (±27.76)89.00 (±47.72)0.391b
Surgical Weight (kg, median, range)20 (12 - 81)23 (16 - 51)0.547c
Diagnosis of BBD (n, percent)19 (51%)5 (100%)0.06a
Nerve Sparing Approach (n, percent)17 (46%)3 (60%)0.656a
1st PVR/EBC (percent, median, range)25% (0-127)71% (33-133)<0.05c
POD of 1st PVR/EBC (median, range)1 (0 - 7)1 (1 - 2)0.647c

a Fisher’s Exact Test
b t-test
c Mann-Whitney U
CONCLUSIONS:
Transient voiding inefficiency has been described in up to 20% of patients after open bilateral extravesical reimplantation. Unlike previous studies, ours did not demonstrate a decreased rate of retention after a nerve sparing approach. Although not statistically significant, our study suggested a trend of increased rates of retention in patients with a history of BBD. Twenty-nine percent of patients had a PVR/EBC greater than 50%, but most patients did not require catheterization. Arguably, this is the most concerning outcome for parents when considering the complication of retention. We hope continued outcomes analysis will guide parental and physician expectations for recovery from this surgery.


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