Comparing inpatient versus outpatient bowel preparation in children and adolescents undergoing appendicovesicostomy



      The need for mechanical inpatient bowel preparation (IBP) in reconstructive pediatric urology has come under scrutiny, secondary to literature demonstrating little benefit regarding outcomes. Starting in 2013, a majority of patients undergoing reconstructive procedures at our institution no longer underwent IBP. We hypothesized that outpatient bowel preparation (OBP) would reduce length of stay (LOS) without increasing postoperative complications after appendicovesicostomy surgery.

      Materials and methods

      An institutional database of patients undergoing lower urinary tract reconstruction between May 2010 and December 2014 was reviewed. Starting in 2013, a departmental decision was made to replace IBP with OBP. Patients undergoing an augmentation cystoplasty or continent ileovesicostomy were excluded because of insufficient numbers undergoing OBP. Patients undergoing IBP were admitted 1 day prior to surgery and received polyethylene glycol/electrolyte solution. A personalized preoperative OBP was introduced in 2013. Cost data were obtained from the Pediatric Health Information System.


      Sixty-seven patients met the inclusion criteria, with 30 (44.8%) undergoing IBP. There were no differences with respect to gender, age, presence of ventriculoperitoneal shunt, body mass index, glomerular filtration rate, preoperative diagnosis, operative time, and prior or simultaneous associated surgeries (p ≥ 0.07). Patients undergoing an IBP had a longer median LOS (7 vs. 5 days, p = 0.0002) and a higher median cost (US$4,288, p = 0.01). Postoperative complications in both groups were uncommon and were classified as Clavien–Dindo grade 1–2, with no statistical difference (IBP 20.0% vs. OBP 5.4%, p = 0.13). No serious postoperative complication occurred, such as a dehiscence, bowel obstruction, or shunt infection.


      This is the first analysis of hospitalization costs and IBP, showing a higher median cost of US$4288 compared with OBP. The LOS was shorter with an OBP (figure), similar to a previous report. Similar complication rates between the groups add to the growing body of literature that avoidance of IBP is safe in pediatric lower urinary tract reconstruction. Being a retrospective review of a practice change, differences in care that influenced cost and LOS may be missing. Also, as the surgeons do not know if a usable appendix is initially present, our data may not extrapolate to all patients. Despite these potential limitations, our data support the safety of utilizing OBP in patients with a high likelihood of a usable appendix, including those undergoing a synchronous Malone antegrade continence enema via a split-appendix technique.


      Summary Fig
      Graphical AbstractLength of hospital admission for children and adolescents undergoing appendicovesicostomy.


      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Journal of Pediatric Urology
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Nichols R.L.
        • Smith J.W.
        • Garcia R.Y.
        • Waterman R.S.
        • Holmes J.W.
        Current practices of preoperative bowel preparation among north American colorectal surgeons.
        Clin Infect Dis. 1997; 24: 609-619
        • Platell C.
        • Hall J.
        What is the role of mechanical bowel preparation in patients undergoing colorectal surgery.
        Dis Colon Rectum. 1998; 41: 875-883
        • Leys C.M.
        • Austin M.T.
        • Pietsch J.B.
        • Lovvorn 3rd, H.N.
        • Pietsch J.B.
        Elective intestinal operations in infants and children without mechanical bowel preparation: a pilot study.
        J Pediatr Surg. 2005; 40: 978-982
        • Gundeti M.
        • Godbole P.
        • Wilcox D.
        Is bowel preparation required before cystoplasty in children.
        J Urol. 2006; 176: 1574-1577
        • Fa-Si-Oen P.R.
        • Verwaest C.
        • Buitenweg J.
        • Putter H.
        • de Waard J.W.
        • van de Velde C.J.
        • et al.
        Effect of mechanical bowel preparation with polyethyleneglycol on bacterial contamination and wound infection in patients undergoing elective open colon surgery.
        Clin Microbiol Infect. 2005; 11: 158-160
        • Víctor D.
        • Burek C.
        • Corbetta J.P.
        • Sentagne A.
        • Sager C.
        • Weller S.
        • et al.
        Augmentation cystoplasty in children without preoperative mechanical bowel preparation.
        J Pediatr Urol. 2012; 8: 201-204
        • Dindo D.
        • Demartines N.
        • Clavien P.A.
        Classification of surgical complications.
        Ann Surg. 2004; 240: 205-213
        • Veugelers R.
        • Benninga M.A.
        • Calis E.A.
        • Willemsen S.P.
        • Evenhuis H.
        • Tibboel D.
        • et al.
        Prevalence and clinical presentation of constipation in children with severe generalized cerebral palsy.
        Dev Med Child Neurol. 2010; : e216-e221
        • Krogh K.
        • Lie H.R.
        • Bilenberg N.
        • Laurberg S.
        Bowel function in Danish children with myelomeningocele.
        APMIS Suppl. 2003; 109: 81-85
        • Lie H.R.
        • Lagergren J.
        • Rasmussen F.
        • Lagerkvist B.
        • Hagelsteen J.
        • Börjeson M.C.
        • et al.
        Bowel and bladder control of children with myelomeningocele: a Nordic study.
        Dev Med Child Neurol. 1991; 33: 1053-1061
        • Pigeon N.
        • Leroi A.M.
        • Devroede G.
        • Watier A.
        • Denis P.
        • Weber J.
        • et al.
        Colonic transit time in patients with myelomeningocele.
        Neurogastroenterol Motil. 1997; 9: 63-70
        • Bischoff A.
        • Levitt M.
        Bowel management for the treatment of pediatric fecal incontinence.
        Pediatr Surg Int. 2009; 25: 1027-1042
        • Thorpe D.M.
        Management of opioid-induced constipation.
        Curr Pain Headache Rep. 2001; 5: 237-240
        • Cameron J.C.
        Constipation related to narcotic therapy. A protocol for nurses and patients.
        Cancer Nurs. 1992; 15: 372-377
        • Canty S.L.
        Constipation as a side effect of opioids.
        Oncol Nurs Forum. 1994; 21: 739-745
        • Iovino P.
        • Chiarioni G.
        • Bilancio G.
        • Cirillo M.
        • Mekjavic I.B.
        • Pisot R.
        • et al.
        New onset of constipation during long-term physical inactivity: a proof-of-concept study on the immobility-induced bowel changes.
        PLoS One. 2013; 8: e72608
        • Casperson K.J.
        • Fronczak C.M.
        • Siparsky G.
        • O'Donnell C.
        • Gundeti M.S.
        • Campbell J.B.
        • et al.
        Ventriculoperitoneal shunt infections after bladder surgery: is mechanical bowel preparation necessary.
        J Urol. 2011; 186: 1571-1575
        • Yerkes E.
        • Rink R.
        • Cain M.
        Shunt infection and malfunction after augmentation cystoplasty.
        J Urol. 2001; 165: 2262-2264
        • Matthews G.J.
        • Churchill B.A.
        • McLorie G.A.
        Ventriculoperitoneal shunt infection after augmentation cystoplasty.
        J Urol. 1996; 155: 686-688
        • Kreder K.J.
        • Webster G.D.
        • Oakes W.J.
        Augmentation cystoplasty complicated by postoperative ventriculoperitoneal shunt infection.
        J Urol. 1990; 144