Pyeloplasty v4.0

Approval & Citation Summary of Version Changes Explanation of Evidence Ratings

Inclusion Criteria · Age 4 months – 21 years requiring robotic pyeloplasty

Exclusion Criteria · Age <4 months · Open surgery · Redo pyeloplasty

Intraoperative Management

Circulating Nurse Anesthesia/Pain · Put in line to use 8.5o scope and calibrate for 0o and 30o ! · IV Fluids: After IV placement give NPO deficit over first hour down with 0o scope to enter first then resume maintenance fluids through the remaining of the · Set insufflation pressures case · < 12 years: 10 mmHg · Patient to be paralyzed to ease insufflation · ≥ 12 years: 12 mmHg · Place oral/gastric tube to be removed at end of case · Set cautery · Local anesthetic · Cut on “1” · Bupivacaine 0.25% 0.5 ml/kg · Coag on “Blend 15” · Incisional subcutaneous 2-5ml · Bipolar on “25” · Aerosolized intraabdominal, remaining volume · SCD or TED stockings for thrombosis prevention if over · Repeat at end of case age 12 (OR Protocol) ! · Age ≥ 3 years: Dexamethasone 0.15 mg/kg max 8mg and · Sonosite Ultrasound (big probe) to confirm stent position ondansetron 0.15 mg/kg max 4mg to prevent nausea and · Age-appropriate active warming vomiting

Infection Prevention · First-line: cefazolin 30 mg/kg IV q 3 h max 2,000 mg/dose · If history of resistant infection: ceftriaxone 75 mg/kg IV max 2,000 mg/dose · If allergic to penicillin or history of MRSA with known sensitivity: clindamycin 10 mg/kg IV q 3 h max 900mg/dose · If history of MRSA resistant to clindamycin: vancomycin 15 mg/kg IV max 1,000 mg/dose over 60 minutes

Patient fit for transport to PACU, then acute care unit Safety Alerts

Deviation from protocol expected (fluids, ketorolac, morphine) · Renal insufficiency, for example Phase Change · Low GFR (< 90 mL/min/1.73m2) · Solitary kidney · Nephrostomy tube in place ! · Heart disease Safety Alerts Dexamethasone · Contraindicated if malignancy

For questions concerning this pathway, Last Updated: February 2020 contact: [email protected] Next Expected Review: June 2018 © 2020 Seattle Children’s Hospital, all rights reserved, Medical Disclaimer Pyeloplasty v4.0

Approval & Citation Summary of Version Changes Explanation of Evidence Ratings

Inclusion Criteria · Age 4 months – 21 years Safety Alerts requiring robotic pyeloplasty

Deviation from protocol expected Exclusion Criteria (fluids, ketorolac, morphine) · Age <4 months · Renal insufficiency, for example · Open surgery · Low GFR (< 90 mL/min/1.73m2) · Redo pyeloplasty · Solitary kidney Phase Change · Nephrostomy tube in place · Heart disease !

Safety Alerts

Postoperative Management Vital signs IV Fluids · Standard vital signs per acute care guidelines ! · D5½NS 1 x maintenance IV plus PO (no potassium) · Strict I/O Medications Activity · Acetaminophen PO/PR q 4h · Out of bed ad lib · When urine output >1 ml/kg/hr, ketorolac IV q 6 h x 72 h; hold · May bathe ! for urine output <1 mg/kg/hr · Ondansetron q 6h prn nausea Nursing · Diphenhydramine q 6h prn itching · Follow Ureteropelvic Junction Guidelines of Care (for · Morphine IV q 2h and oxycodone PO q 4h prn breakthrough SCH only) ! pain · Foley catheter to gravity drainage · Polyethylene glycol (Miralax) · Continue thrombosis prevention, if indicated · If pills tolerated, docusate · Encourage ambulation · Oxybutynin TID as needed for bladder spasms · Home meds Diet · Regular

Discharge Criteria · Temperature <38oC · Ambulating · Tolerating oral intake and oral pain medicine · Family comfort with post-operative management plan established · Voiding spontaneously

Discharge Instructions · No restrictions · Return for JJ stent removal 2-6 weeks postop · Postop constipation

For questions concerning this pathway, Last Updated: February 2020 contact: [email protected] Next Expected Review: June 2018 © 2020 Seattle Children’s Hospital, all rights reserved, Medical Disclaimer Aerosolized Intraabdominal Bupivacaine

• Recommendation Aerosolized intraabdominal bupivacaine used intraoperatively has been associated with a reduction in postoperative shoulder pain (24% saline vs 5% bupivacaine, p=0.014). [] (Freilich 2008, Lorenzo 2012)

Return to Home Pyeloplasty Approval & Citation

Approved by the CSW Pyeloplasty for July 9, 2014

CSW Pyeloplasty Team:

Pathway Owner, Urology Thomas Lendvay, MD Clinical Nurse Specialist, PACU Pamela Christenson, MN, RN-BC, CPN Literature Review Support Sarah Denniston, MD Stakeholder, Pharmacy Jeremy Holt, PharmD Nurse Practitioner, Urology Nicole McMannis, ARNP Clinical Nurse Specialist, Surgical Erin Moriarty, MSN, RN Stakeholder, Anesthesia Shilpa Verma, MD

Clinical Effectiveness Team:

Consultant: Jennifer Hrachovec, PharmD, MPH Project Manager: Jennifer Magin, MBA CE Analyst: Brent Jarosek, MBA CE Analyst: Holly Clifton, MPH CIS Informatician: Mike Leu, MD CIS Analyst: Heather Marshall Librarian: Jamie Graham, MLS Program Coordinator: Asa Herrman

Executive Approval:

Sr. VP, Chief Medical Officer Mark Del Beccaro, MD Sr. VP, Chief Nursing Officer Madlyn Murrey, RN, MN Surgeon-in-Chief Bob Sawin, MD

Retrieval Website: http://www.seattlechildrens.org/pdf/pyeloplasty-pathway.pdf

Please cite as: Seattle Children’s Hospital, Lendvay, T., Hrachovec J., Magin, J., McMannis, N., Moriarty, E., Leu, M., Verma, S. 2014 July. Pyeloplasty Pathway. Available from: http://www.seattlechildrens.org/pdf/ pyeloplasty-pathway.pdf

Return to Home Evidence Ratings

We used the GRADE method of rating evidence quality. Evidence is first assessed as to whether it is from randomized trial, or observational studies. The rating is then adjusted in the following manner:

Quality ratings are downgraded if studies: • Have serious limitations • Have inconsistent results • If evidence does not directly address clinical questions • If estimates are imprecise OR • If it is felt that there is substantial publication bias

Quality ratings can be upgraded if it is felt that: • The effect size is large • If studies are designed in a way that confounding would likely underreport the magnitude of the effect OR • If a dose-response gradient is evident

Quality of Evidence:  High quality  Moderate quality  Low quality  Very low quality Expert Opinion (E)

Reference: Guyatt G et al. J Clin Epi 2011: 383-394

To Bibliography Return to Home Summary of Version Changes

· Version 1.0 (6/26/2013): Go live · Version 2.0 (7/9/2014): Updated maintenance fluids rate in OR care · Version 3.0 (3/3/2016): Removed tamsulosin from medications · Version 3.1 (6/19/2017): Updated cefazolin to new standard from 20mg/kg to 30mg/kg · Version 4.0 (2/3/2020): Updated maintenance fluids rate in OR care

Return to Home Medical Disclaimer

Medicine is an ever-changing science. As new research and clinical experience broaden our knowledge, changes in treatment and drug therapy are required.

The authors have checked with sources believed to be reliable in their efforts to provide information that is complete and generally in accord with the standards accepted at the time of publication.

However, in view of the possibility of human error or changes in medical sciences, neither the authors nor Seattle Children’s Healthcare System nor any other party who has been involved in the preparation or publication of this work warrants that the information contained herein is in every respect accurate or complete, and they are not responsible for any errors or omissions or for the results obtained from the use of such information.

Readers should confirm the information contained herein with other sources and are encouraged to consult with their health care provider before making any health care decision.

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Literature Search

Studies were identified by searching electronic databases using search strategies developed and executed by a medical librarian. Searches were performed on September 20th & 21st, 2012 in the following databases: on the Ovid platform – Medline (1946 to date), Cochrane Database of Systematic Reviews (2005 – June 2011); elsewhere – Embase, National Guideline Clearinghouse, Clinical Evidence, and TRIP. Retrieval was limited to literature from 1992-forward. There were no age restrictions included. Results were limited to English language. As per the owners request, the search was focused broadly on pyeloplasty. In Medline, appropriate Medical Subject Headings (MeSH) were used, along with text words, and the search strategy was adapted for other databases using their controlled vocabularies, where available, along with text words. Owner assisted with identifying appropriate MeSH. Only synthesized, high levels of evidence were included. Scout Search publication limits of consensus development, guidelines, meta-analyses, and practice guidelines were used. Additional MeSH publication headings of critical pathways, clinical protocols, guidelines as topic, and practice guidelines as topic were also included. Systematic reviews as a title word rounded out the publications search. Jamie Graham January 22, 2013

Identification

114 records identified through 3 additional records identified database searching through other sources

Screening 115 records after duplicates removed

115 records screened 62 records excluded

Elgibility 42 full-text articles excluded, 53 full-text articles assessed for eligibility 32 did not answer clinical question 10 did not meet quality threshold

Included 11 studies included in pathway

Flow diagram adapted from Moher D et al. BMJ 2009;339:bmj.b2535

Return to Home To Bibliography, Pg 2 Bibliography

Bader P, Echtle D, Fonteyne V, Livadas K, De Meerleer G, Paez Borda A, Papaioannou EG, Vranken JH. Non- traumatic acute flank pain. In: Guidelines on pain management. 2010; Available at: http://www.ngc.gov/ content.aspx?id=23898&search=ureteropelvic+junction+and+pyeloplasty+or+surgery+or+surgical. Accessed September 21, 2012.

Braga LH, Pace K, DeMaria J, Lorenzo AJ. Systematic review and meta-analysis of robotic-assisted versus conventional laparoscopic pyeloplasty for patients with ureteropelvic junction obstruction: effect on operative time, length of hospital stay, postoperative complications, and success rate. Eur Urol 2009 Nov;56(5):848-857.

Castagnetti M, Novara G, Beniamin F, Vezzu B, Rigamonti W, Artibani W. Scintigraphic renal function after unilateral pyeloplasty in children: a systematic review. BJU Int 2008 Sep;102(7):862-868.

Freilich DA, Houck CS, Meier PM, Passerotti CC, Retik AB, Nguyen HT. The effectiveness of aerosolized intraperitoneal bupivacaine in reducing postoperative pain in children undergoing robotic-assisted laparoscopic pyeloplasty. J Pediatr Urol. 2008 Oct;4(5):337-40.

Gettman MT, Lotan Y, Roerhborn CG, Cadeddu JA, Pearle MS. Cost-effective treatment for ureteropelvic junction obstruction: a decision tree analysis. J Urol 2003 Jan;169(1):228-232.

Mei H, Pu J, Yang C, Zhang H, Zheng L, Tong Q. Laparoscopic versus open pyeloplasty for ureteropelvic junction obstruction in children: a systematic review and meta-analysis. J Endourol 2011 May;25(5):727-736.

Nebulization of Bupivicaine Intra-Abdominally Reduces Post-Operative Shoulder Pain and Opioid Use In Children Undergoing Robotic-Assisted Urologic Surgery AAP Section on Urology; 2012; ; 2012.

Seixas-Mikelus SA, Jenkins LC, Williot P, Greenfield SP. Pediatric pyeloplasty: comparison of literature meta- analysis of laparoscopic and open techniques with open surgery at a single institution. J Urol 2009 Nov;182(5):2428-2432.

Sheldon CA, Duckett JW, Snyder HM. Evolution in the management of infant pyeloplasty. J Pediatr Surg 1992 Apr;27(4):501-505.

Webster TM, Baumgartner R, Sprunger JK, Baldwin DD, McDougall EM, Herrell SD. A clinical pathway for laparoscopic pyeloplasty decreases length of stay. J Urol 2005 Jun;173(6):2081-2084.

Yakoubi R, Lemdani M, Monga M, Villers A, Koenig P. Is there a role for (alpha)-blockers in ureteral stent related symptoms? A systematic review and meta-analysis. J Urol 2011 /;186(3):928-934.

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