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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, MSc1, Thomas S. Lendvay, MD2, Ardavan Akhavan, MD2, Mohan S. Gundeti, M.Ch3, David Hatcher, MD3, Paul H. Noh, MD4, Marion Schulte, RN4, Gerald Mingin, Jr., MD5, Jared Wachterman, MD5, Christine Kim, MD1.
1Connecticut Childrens Medical Center/University of Connecticut, Hartford, CT, USA, 2Seattle Children’s Hospital/University of Washington School of Medicine, Seattle, WA, USA, 3Comer Children's Hospital/University of Chicago Medical Center, Chicago, IL, USA, 4Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA, 5Vermont Children's Hospital/University of Vermont School of Medicine, Burlington, VT, USA.

Postoperative urinary retention is a known complication of bilateral extravesical ureteral reimplantation. Damage to the pelvic plexus may contribute to the retention. This is particularly concerning with bilateral repairs. Magnified optics with robotic surgery may minimize trauma to these fibers. We report the experience of multiple institutions with bilateral robotic-assisted laparoscopic extravesical ureteral reimplantation (RALUR) and postoperative urinary retention.
We reviewed the records of patients who underwent bilateral RALUR for vesicoureteral reflux (VUR) at 5 centers between the years 2009-2012. We excluded patients without recordings of their postoperaitve post-void residual (PVR). Data was collected on 42 patients. Our primary focus was the incidence of catheter placement due to urinary retention. In addition, we assessed percentage of estimated bladder capacity (EBC) retained. EBC was calculated using the formula: EBC= (age+2) x 30 mL. 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, and timing of PVR. Comparisons were made using t-test, Fisher’s Exact, or Mann-Whitney U.
Seventy-five patients were identified. 33 were excluded due to lack of post-operative PVR, resulting in a final cohort of 42 patients; 7 (17%) male, 35 (83%) female. 55% of patients (n=23) had a pre-surgical diagnosis of BBD. Mean surgical age was 5.9 years (SD ± 2.1yrs). Five patients (12%) had catheter drainage after surgery. Two of these patients had preoperative urine retention and intraoperative suprapubic catheters were placed. Three patients had urethral foley catheters placed because of elevated PVR/EBC volumes. These three patients had their foley catheters removed within 7 days. There was no statistically significant difference in retention rates for patients with BBD vs no BBD, male vs female, or age. (Table 1)
Transient voiding inefficiency has been described in up to 20% of patients after open bilateral extravesical reimplantation. In our cohort, 12% required postoperative catheterization. Only 3 (7%) had new urinary retention postoperatively. Twenty nine percent of patients had a PVR/EBC greater than 50%, but most patients did not require catheterization. We did not identify clear risk factors for postoperative retention, but we saw a trend of increased retention rates in patients with a history of BBD. Conclusions are challenging with this small sample size. We hope continued outcomes analysis will guide parental and physician expectations for recovery from this surgery.
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
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

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