Enhanced Recovery After Surgery for an Uncommon Complex Urological Procedure: The Complete Primary Repair of Bladder Exstrophy.

PURPOSE: ERAS (enhanced recovery after surgery) protocols are designed to optimize perioperative care and expedite recovery. Historically, complete primary repair of bladder exstrophy has included postoperative recovery in the intensive care unit and extended length of stay. We hypothesized that instituting ERAS principles would benefit children undergoing complete primary repair of bladder exstrophy, decreasing length of stay. We describe implementation of a complete primary repair of bladder exstrophy-ERAS pathway at a single, freestanding children's hospital. MATERIALS AND METHODS: A multidisciplinary team developed an ERAS pathway for complete primary repair of bladder exstrophy, which launched in June 2020 and included a new surgical approach that divided the lengthy procedure into 2 consecutive operative days. The complete primary repair of bladder exstrophy-ERAS pathway was continuously refined, and the final pathway went into effect in May 2021. Post-ERAS patient outcomes were compared with a pre-ERAS historical cohort (2013-2020). RESULTS: A total of 30 historical and 10 post-ERAS patients were included. All post-ERAS patients had immediate extubation (P = .04) and 90% received early feeding (P < .001). The median intensive care unit and overall length of stay decreased from 2.5 to 1 days (P = .005) and from 14.5 to 7.5 days (P < .001), respectively. After final pathway implementation, there was no intensive care unit use (n=4). Postoperatively, no ERAS patient required escalation of care, and there was no difference in emergency department visits or readmissions. CONCLUSIONS: Applying ERAS principles to complete primary repair of bladder exstrophy was associated with decreased variations in care, improved patient outcomes, and effective resource utilization. Although ERAS has typically been utilized for high-volume procedures, our study highlights that an enhanced recovery pathway is both feasible and adaptable to less common urological surgeries.

Comparison of Sensation Event Descriptors in Participants with Overactive and Normal Bladders during Non-Invasive Hydration Studies.

PURPOSE: Despite the importance of alterations in bladder sensation, objective metrics to characterize sensation outside of urodynamics remain limited. A real-time sensation meter enables recording of sensation event descriptors throughout filling. The purpose of this study was to evaluate the differences in sensation event descriptor patterns between normal participants and those with OAB. METHODS: Normal and OAB participants were enrolled from responses to the ICIq-OAB survey question on urgency (Q5a: 0 vs. ≥ 3). Real-time bladder sensation on a 0%-100% scale was recorded on a validated tablet sensation meter throughout two fill-void cycles. The first and second fills were considered "slow" and "fast" respectively. After each sensation meter change (sensation event), a pop-up screen asked participants to characterize sensation with one or more of these descriptors: "tense," "pressure," "tingling," "painful," and/or "other." Oral hydration was achieved by rapid consumption of 2L G2® Gatorade. RESULTS: Data from 29 participants (12 normal/17 OAB) were analyzed. The rate of filling from bladder volume and fill duration, was greater for the fast fill in both groups. In the slow fill, "tingling" (64 ± 3% OAB vs. 77 ± 3% normal, p=0.008) and "tense" (78 ± 3% OAB vs. 94 ± 1% normal, p<0.001) occurred at lower sensations in OAB participants. CONCLUSION: During only the slow fill, OAB individuals experience the sensation descriptors of "tingling" and "tense" at earlier sensations than normal individuals. Therefore, this non-invasive method to evaluate real-time sensation descriptors during filling may identify important sensation patterns and improve understanding and phenotyping of OAB.

Lower Genitourinary Foreign Bodies: An Institutional Experience and Description of a Novel, Minimally-invasive Extraction Technique for Anterior Urethral Objects.

OBJECTIVE: To describe our experience with management of lower genitourinary foreign bodies (FBs); to introduce our novel, but simple and minimally-invasive retrieval method compared with standard techniques for anterior urethral FBs; and to propose a derived, practical management algorithm. METHODS: We reviewed all male patients presenting with inserted urethral and/or bladder FBs between January2000 and October 2018. Patient characteristics and number of episodes were identified. Episodes were stratified by FB type, FB location, diagnostic modality, and removal method. We performed a subgroup analysis of anterior urethral FB management techniques comparing retrieval outcomes using our novel Retrieval of Anterior urethral Materials Safely (RAMS) technique which utilizes urethral hydrodistension via retrograde injection of lidocaine jelly to expel FBs vs forceps extraction. Cost analyses were performed, and a management algorithm was then derived. RESULTS: We identified 116 episodes. Eighty-seven of 116 (75%) episodes involved items located within the anterior urethra. A subset of episodes (14/116, 12%) was managed using the RAMS technique. There was no difference in FB extraction success rates between RAMS (13/14, 92.9%) and forceps extraction (37/40, 92.7%), P = 1.00. FBs were successfully removed using RAMS when utilized for nonembedded FBs located entirely within the anterior urethra. Among FBs located within the anterior urethra, the median total hospital cost was nearly 10 times less with utilization of RAMS compared with cystoscopic extraction ($379.09 v s$3,214.21, P <.05). CONCLUSION: Because an overwhelming majority of FBs are located within the anterior urethra, the RAMS technique represents a simple, cost-conscious, and minimally-invasive strategy with low risk and potentially high-yield for initial extraction in the emergency department.