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Assessment of Post-Operative Pain and Discomfort In Children Undergoing Open Ureteral Reimplantation Surgery

Sunday, October 21, 2012: 9:12 AM
Grand Ballroom B (Hilton Riverside)
Guilherme A. Rossini1, Lorenzo F. M. Trevisani1, Brian M. Rosman1, Vitor C. Zanetta1, Sabrina T. Reis1, Gustavo N. C. Inoue1, Carlos A. O. Buchalla1, Daniela C. J. Sanchez1, Constance S. Houck2, Petra M. Meier2, Carlos Munoz-San Julian, M.D.3, Carlo C. Passerotti4 and Hiep T. Nguyen1, (1)Urology, Children's Hospital Boston, Boston, MA, (2)Anesthesiology, Perioperative and Pain Medicine, Children's Hospital Boston, Boston, MA, (3)Anesthesiology, Perioperative and Pain Medicine, Children's Hospital Boston, (4)Urology, University Nove de Julho, São Paulo, Brazil

Purpose: Open ureteral reimplantation has an excellent success rate (>95%) in the correction of vesicoureteral reflux (VUR) in children. However, some physicians believe that more conservative options are preferable to surgery due to the high associated post-operative morbidities for the patient. The aim of this study was to evaluate the intensity of post-operative pain and incidence and severity of bladder spasms after open ureteral reimplantation surgery and assess the overall impact of this surgery on the patients' quality of life (QoL). 

Methods : All patients who underwent open ureteral reimplantation at our institution from 2010-2011 were approached for the study.  Patients had a standard anesthetic which included a caudal block with bupivacaine and clonidine and intravenous morphine intraoperatively. Pain scores were obtained from subjects prospectively by the nurses in the post-anesthesia care unit and on a scheduled basis until 24 hours postoperatively, using the faces pain scale or verbal pain scale (0-10). The highest pain score and pain characterized as bladder spasm were considered for analysis. Parents were instructed to record bladder spasm episodes prospectively by using a standardized time-flow diary system: 0 = no spasm; 1 = mild; 2 = moderate; and 3 = severe. A 6-month follow-up QoL survey was administered by mail. The survey assessed 5 life domains, each with 1 to 7 questions. A Likert scale accompanied each question, with a score of 0 indicating “very much,” 1“quite a bit,” 2“somewhat,” 3“a little bit,” 4“not at all” and 5“not applicable.” For statistical analysis we combined the answers into 4 categories. Statistical analysis of the responses was performed with Chi-square and T-test using SPSS 20.0, and significance was set at p ≤ 0.05.

Results: 79 patients were enrolled in the study, 13(16.5%) were male and 66(83.5%) were female, with a mean age of 6.2(±1.5) years. The majority (75.9%) of the patients had postoperative bladder spasms during the hospital stay, however after 24hours, 88.3% had no pain.. Bladder spasms were generally in the mild to moderate range. 67 QoL surveys were returned by parents and showed that the answer "a little bit⁄not at all" was the most frequent in all categories (Figure-1A). Moreover, most patients had no postoperative complications.

Conclusion: Patients undergoing open ureteral reimplantation surgery reported mild to moderate incisional pain and bladder spasms post-operatively, which had mostly resolved within 24 hours of surgery. Parents overwhelmingly reported that the surgery had minimal impact on their child's quality of life. Based on our experience, the postoperative morbidities associated with open re-implantation do not appear to be a deterrent in the management of children with VUR.

Table-1

 

PACU

At 24hours

**p-value

Pain scores 0-10  (n=79)

4.49

0.47

<0.001

 

First 12 hours

At 24hours

**p-value

Bladder spasm severity 0-3 (n=53)

1.91

0.43

<0.001

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