A drain- and catheter-free enhanced recovery protocol to achieve discharge within 23 hours of laparoscopic pyeloplasty surgery: Is this feasible and safe?

Abstract

Pelvi-ureteric junction (PUJ) obstruction occurs when there is delayed or impaired drainage of urine at the PUJ. 1 Since 1993 when the first reports of laparoscopic pyeloplasty (LP) surgery were published, 2,3 laparoscopic/robotic pyeloplasty is considered the gold-standard surgical treatment for patients with PUJ obstruction. 4 AbstractObjective: The objective of this article is to review the outcomes of our updated single-centre extended experience of an innovative enhanced recovery pathway to perform catheter-and drain-free laparoscopic pyeloplasties, achieving safe discharge within 23 hours of surgery. Patients and methods: We conducted a retrospective review of patients who underwent a standard trans-peritoneal laparoscopic pyeloplasty repair over an antegrade stent in our centre by a single surgeon, between 1 September 2007 and 1 February 2015.Patients who had a urinary catheter and/or peri-nephric drain inserted intraoperatively and were not planned for day-case discharge were excluded.Data were collected for duration of in-patient stay, readmission rates and reasons for these. Successful outcome was deemed both in subjective improvement of patient symptoms and/or objective improvement in post-operative MAG-3 renogram curve. Results: Fifty-eight patients were included. A total of 74% (n = 43) were successfully discharged as day-case, and four of these were readmitted. Fifteen patients required in-patient stay, of whom two were readmitted. Successful outcome was recorded in 93% (n = 54). Conclusion: The insertion of a drain and catheter are not essential in laparoscopic pyeloplasty. Avoidance of unnecessary tubes facilitates day-case surgery with no adverse effect on outcome.At our institute all patients are now offered the enhanced recovery protocol for laparoscopic pyeloplasty with resulting benefits both to patients and the local health economy.

Should a Refluxing Internal Diversion Be Considered a Temporizing Procedure? Extended Follow-up and Outcomes After Side-to-Side Ureterovesicostomy for Primary Obstructive Megaureter in Young Children

“…23,24 Ureteral stents and catheters were seldomly required, total operating time was less than 2 hours, and the patients can be discharged on the same day, which are attractive aspects for this operation. 25-27 The most common postoperative complication during follow-up was UTI, with a rate that is comparable to the baseline for children with POM off prophylaxis. 28,29 The patients who developed UTI > 1 year after operation were all at toilet-training age and may be a consequence of bladder-bowel dysfunction, as opposed to VUR alone.…”

Day‐case catheterless and drainless minimal‐access pyeloplasty in adults: A single‐center experience of 13 years

“…Our center initially published our data on daycase LP in 32 patients in 2011, 14 which were updated with 58 patients in 2016. 15 Approximately 72% of patients were discharged successfully as day cases and a total of 90% were discharged within 23 h of surgery. The present study is actually an update including all the minimally invasive pyeloplasty procedures (LP/RAP) performed over the last 13 years.…”

Catheter-free nephrectomy: A safe change to routine practice

“…9 Catheter- and drain-free pyeloplasty has similarly demonstrated to offer a benefit in length of stay facilitating day case surgery, with no increase in complications. 10…”

“…9 Catheter-and drain-free pyeloplasty has similarly demonstrated to offer a benefit in length of stay facilitating day case surgery, with no increase in complications. 10 There remain some cases for which a drain may be indicated intra-operatively in high-risk procedures, for example where bleeding is encountered or when the hilum has been breached; however, routine use is not indicated. Again, the use of a routine catheter does not appear to confer any benefit and prolongs LOS.…”

“…[2][3][4][5][6][7][8] Reducing unnecessary catheters and drains may be associated with benefits such as earlier mobilisation and a reduced infection risk. 9,10 In December 2015, British Association of Urological Surgeons (BAUS) published updated ERP guidance to include the avoidance of routine catheterisation and drains in minimally invasive renal surgery, unless there is deemed a high risk of AUR or the patient is haemodynamically unstable. 11 We integrated catheter-free nephrectomy into our ERP in May 2014 and present a retrospective comparative case series case-note review of our outcomes.…”