Clinical care pathway for the management of ureteroneocystostomy in the pediatric urology population

Purpose: The management of vesicoureteral reflux continues to evolve, Endoscopic and laparoscopic techniques have been reported as alternatives to standard surgical techniques, However, the newer modalities have no long-term track record and there is some question as to efficacy. We sought to establish a clinical care pathway for managing ureteroneocystostomy in children. Materials and Methods: In the last 4 years we have developed a management technique based on a clinical collaborative care pathway with the help of surgeon, house staff, clinical nurse specialist and support personnel, that is floor, operating room and post-anesthesia nurses. The pathway includes extensive preoperative parent and child education, standard intraoperative management and postoperative care without catheter drainage. It is based on a postoperative hospital stay of 2 days without a ureteral or urethral catheter. We report on the care of 110 consecutive patients (190 ureters) who underwent simple or common sheath ureteroneocystostomy from April 1992 to July 1996. Results: No patient required the use of a urethral catheter or ureteral stent. Average length of hospital stay was 2.8 days and there were no immediate postoperative complications. At an average followup of 26 months (range 5 to 53) an overall success rate of 97% per patient and 98% per ureter was achieved. Analysis of the costs of simple and common sheath ureteroneocystostomy in the clinical care pathway revealed a 4% increase over those in an ideal case with no deviations from the pathway. Costs and length of hospital stay were then compared to those for institutions of the university hospital consortium and they were found to be 39 and 45% less, respectively. Outcome based analysis by telephone interview revealed 100% patient or parent satisfaction. Conclusions: We believe that the management of vesicoureteral reflux using a coordinated clinical care pathway significantly improves length of hospitalization and inpatient costs with a high satisfaction score from parents and patients. This health care delivery style provides a standard to which other vesicoureteral reflux procedures must be compared.