Advertisement

Outcomes and costs analysis of Externalized PyeloUreteral versus internal Double-J ureteral stents after paediatric laparoscopic Anderson-Hynes pyeloplasty

Published:December 08, 2020DOI:https://doi.org/10.1016/j.jpurol.2020.12.006

      Summary

      Background

      The gold standard treatment for Uretero-Pelvic Junction Obstruction (UPJO) is laparoscopic dismembered pyeloplasty according to the Anderson-Hynes technique. The internal Double-J ureteral (DJ) and the Externalized PyeloUreteral (EPU) stents are usually the drainage of choice. Only a few articles have compared the clinical impact of the different drainage techniques on the perioperative morbidity and none presented a cost analysis of the incurred hospital stay.

      Objective

      To present the clinical outcome and financial analysis of a cohort of children who underwent a laparoscopic pyeloplasty comparing the use of the DJ versus EPU stent.

      Study design

      Retrospective study of consecutives children who underwent laparoscopic Anderson-Hynes pyeloplasty in a single tertiary paediatric referral centre from January 2017 to March 2020. Patients were grouped according to the type of stent used: DJ stent vs EPU stent.

      Results

      Fifty-three laparoscopic pyeloplasties were performed on 51 patients: 27 (50.9%) had an EPU stent and 26 (49.1%) a DJ stent. There was no statistically significant difference between the two patient groups with regards to surgical time, hospital stay, stent-related complications or the need for re-do surgery. All the EPU stents were removed with an outpatient admission 8.1 days ± 3.1 after surgery while the DJ stents were removed with a cystoscopy 61.6 days ± 30.2 after surgery (p value < 0.001). On a financial analysis (Figure), the hospital costs for stent removal were significantly lower for the EPU stent group (£ 686.7 ± 263.4 vs £ 1425 ± 299.5, p value < 0.01).

      Discussion

      Both drainage methods have some disadvantages. Possible complications associated with DJ stents include migration and artificial vesicoureteral reflux which may lead to higher incidence of Urinary Tract Infections. Possible disadvantages of the EPU stent insertion are related to the damage of the renal parenchyma and to the risk of developing skin site infections and urinary leaks. However, in our series the EPU stent has not been associated with a higher incidence of bleeding, leakage or discomfort. In addition to clinical considerations, there is a financial implication to be considered. With this regard, the EPU stent was associated with a significant reduction in the incurred hospital costs.

      Conclusions

      Summary Figure 1
      Graphical AbstractComparison of incurred hospital costs (British pounds sterling) between DJ stent and EPU stent for pyeloplasty (A) and stent removal (B).

      Keywords

      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:

      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

      References

        • Hashim H.
        • Woodhouse C.R.
        Ureteropelvic junction obstruction.
        Eur Urol Suppl. 2012; 11: 25-32
        • Nguyen H.T.
        • Herndon C.D.
        • Cooper C.
        • Gatti J.
        • Kirsch A.
        • Kokorowski P.
        • et al.
        The Society for Fetal Urology consensus statement on the evaluation and management of antenatal hydronephrosis.
        J Pediatr Urol. 2010; 6: 212-231
        • Chertin B.
        • Pollack A.
        • Koulikov D.
        • Rabinowitz R.
        • Hain D.
        • Hadas-Halpren I.
        • et al.
        Conservative treatment of ureteropelvic junction obstruction in children with antenatal diagnosis of hydronephrosis: lessons learned after 16 years of follow-up.
        Eur Urol. 2006; 49: 734-738
        • Ulman I.
        • Jayanthi V.R.
        • Koff S.A.
        The long-term followup of newborns with severe unilateral hydronephrosis initially treated nonoperatively.
        J Urol. 2000; 164: 1101-1105
        • Peters C.A.
        • Schlussel R.N.
        • Retik A.B.
        Pediatric laparoscopic dismembered pyeloplasty.
        J Urol. 1995; 153: 1962-1965
        • He Y.
        • Song H.
        • Liu P.
        • et al.
        Primary laparoscopic pyeloplasty in children: a single-center experience of 279 patients and analysis of possible factors affecting complications.
        J Pediatr Urol. 2020; 16: 331.e1-331.e11
        • Abdelwahab M.
        • Abdelaziz A.
        • Aboulela W.
        • et al.
        One week stenting after pediatric laparoscopic pyeloplasty; is it enough?.
        J Pediatr Urol. 2020; 16: 98.e1-98.e6
        • Esposito C.
        • Masieri L.
        • Castagnetti M.
        • et al.
        Robot-assisted vs laparoscopic pyeloplasty in children with uretero-pelvic junction obstruction (UPJO): technical considerations and results.
        J Pediatr Urol. 2019; 15: 667.e1-667.e8
        • Kočvara R.
        • Sedláček J.
        • Drlík M.
        • Dítě Z.
        • Běláček J.
        • Fiala V.
        Unstented laparoscopic pyeloplasty in young children (1-5 years old): a comparison with a repair using double-J stent or transanastomotic externalized stent.
        J Pediatr Urol. 2014; 10: 1153-1159
        • Bayne A.P.
        • Lee K.A.
        • Nelson E.D.
        • Cisek L.J.
        • Gonzales E.T.
        • Roth D.R.
        The impact of surgical approach and urinary diversion on patient outcomes in pediatric pyeloplasty.
        J Urol. 2011; 186: 1693-1698
        • Yu J.
        • Wu Z.
        • Xu Y.
        • Li Z.
        • Wang J.
        • Qi F.
        • et al.
        Retroperitoneal laparoscopic dismembered pyeloplasty with a novel technique of JJ stenting in children.
        BJU Int. 2011; 108: 756-759
        • Helmy T.
        • Blanc T.
        • Paye-Jaouen A.
        • El-Ghoneimi A.
        Preliminary experience with external ureteropelvic stent: alternative to double-j stent in laparoscopic pyeloplasty in children.
        J Urol. 2011; 185: 1065-1069
        • Chu D.I.
        • Shrivastava D.
        • Van Batavia J.P.
        • Bowen D.K.
        • Tong C.C.
        • Long C.J.
        • et al.
        Outcomes of externalized pyeloureteral versus internal ureteral stent in pediatric robotic-assisted laparoscopic pyeloplasty.
        J Pediatr Urol. 2018; 14 (450.e1-.e6)
        • Eassa W.
        • Al Zahrani A.
        • Jednak R.
        • El-Sherbiny M.
        • Capolicchio J.P.
        A novel technique of stenting for laparoscopic pyeloplasty in children.
        J Pediatr Urol. 2012; 8: 77-82
        • Hadley D.A.
        • Wicher C.
        • Wallis M.C.
        Retrograde percutaneous access for kidney internal splint stent catheter placement in pediatric laparoscopic pyeloplasty: avoiding stent removal in the operating room.
        J Endourol. 2009; 23: 1991-1994
        • Taveres A.
        • Manaboriboon N.
        • Lorenzo A.J.
        • Farhat W.A.
        Insertion of an internal-external nephroureteral stent during pediatric laparoscopic pyeloplasty: description of the technique.
        Urology. 2008; 71: 1199-1202
        • Upasani A.
        • Paul A.
        • Cherian A.
        External stent in laparoscopic pyeloplasty: the K-wire technique.
        J Pediatr Urol. 2018; 14: 298-299
        • S Tl
        • Hs D.
        • E E.
        • H P.
        • Kv R.
        • N J.M.
        • et al.
        EAU guidelines on paediatric Urology.
        2016
        • Dindo D.
        • Demartines N.
        • Clavien P.A.
        Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey.
        Ann Surg. 2004; 240: 205-213
        • J G.
        • R R.
        • L B.
        • J P.S.
        • Lorenzo A.
        Laparoscopic pediatric pyeloplasty and placement of an externalized pyelo-ureteral stent.
        J Urol. 2014; 191: e424-e425
        • Dangle P.P.
        • Shah A.B.
        • Gundeti M.S.
        Cutaneous pyeloureteral stent for laparoscopic (robot)-assisted pyeloplasty.
        J Endourol. 2014; 28: 1168-1171
        • Noh P.H.
        • Defoor W.R.
        • Reddy P.P.
        Percutaneous antegrade ureteral stent placement during pediatric robot-assisted laparoscopic pyeloplasty.
        J Endourol. 2011; 25: 1847-1851
        • Sancaktutar A.A.
        • Adanur Ş.
        • Reşorlu B.
        • Tepeler A.
        • Ziypak T.
        • Söylemez H.
        • et al.
        The forgotten ureteral stent in children: from diagnosis to treatment.
        J Urol. 2013 Mar; 189: 1054-1060
        • Lee L.C.
        • Kanaroglou N.
        • Gleason J.M.
        • Pippi Salle J.L.
        • Bägli D.J.
        • Koyle M.A.
        • et al.
        Impact of drainage technique on pediatric pyeloplasty: comparative analysis of externalized uretero-pyelostomy versus double-J internal stents.
        Can Urol Assoc J. 2015; 9: E453-E457
        • O'Leary J.D.
        • Janus M.
        • Duku E.
        • Wijeysundera D.N.
        • To T.
        • Li P.
        • et al.
        A population-based study evaluating the association between surgery in early life and child development at primary school entry.
        Anesthesiology. 2016; 125: 272-279
        • Sun L.S.
        • Li G.
        • Miller T.L.
        • Salorio C.
        • Byrne M.W.
        • Bellinger D.C.
        • et al.
        Association between a single general anesthesia exposure before age 36 Months and neurocognitive outcomes in later childhood.
        J Am Med Assoc. 2016; 315: 2312-2320
        • Yucel S.
        • Samuelson M.L.
        • Nguyen M.T.
        • Baker L.A.
        Usefulness of short-term retrievable ureteral stent in pediatric laparoscopic pyeloplasty.
        J Urol. 2007; 177 (discussion 5): 720-725
        • Mitchell A.
        • Bolduc S.
        • Moore K.
        • Cook A.
        • Fermin C.
        • Weber B.
        Use of a magnetic double J stent in pediatric patients: a case-control study at two Canadian pediatric centers.
        J Pediatr Surg. 2020; Mar;55(3): 486-489https://doi.org/10.1016/j.jpedsurg.2019.03.014
        • Mykulak D.J.
        • Herskowitz M.
        • Glassberg K.I.
        Use of magnetic internal ureteral stents in pediatric urology: retrieval without routine requirement for cystoscopy and general anesthesia.
        J Urol. 1994; 152: 976-977
        • Braga L.H.
        • Lorenzo A.J.
        • Farhat W.A.
        • Bägli D.J.
        • Khoury A.E.
        • Pippi Salle J.L.
        Outcome analysis and cost comparison between externalized pyeloureteral and standard stents in 470 consecutive open pyeloplasties.
        J Urol. 2008 Oct; 180 (discussion1698-9): 1693-1698