In the field of pediatric urology, there continues to be debate over whether to use a ureteral catheter for ureteral reimplantation in children with vesicoureteral reflux (VUR). For uncomplicated cases, "stentless" ureteral reimplantation is the accepted method, according to the literature.1,2 However, we believe that indwelling ureteral catheters should be used in children who have undergone ureteral reimplantation with ureteral tailoring or have only a single healthy kidney. Placing a drainage system across the ureterovesical system is a safe and reliable method for complicated cases in which ureteral obstruction may result from postoperative edema. However, establishing which postoperative drainage system is the most appropriate and least troublesome to use has always been controversial; as there are advantages and disadvantages to each of the various drainage systems.

Therefore, we have designed a new drainage system that is easy to remove, minimizes patient discomfort, shortens hospital stay, and eliminates the need for additional sedation for removing the catheter. Herein, we describe our initial experience using this new catheter and discuss its potential advantages and limitations.

Nine patients (eight boys and one girl) ranging in age from 9 months to 12 years old (average age 5.2 years) underwent ureteral reimplantation with and without ureteral tapering. Among the patients, four had refluxing megaureter, four had VUR with a solitary or non-functional contralateral kidney, and one had ureteral stricture due to previous anti-reflux surgery. The urethral catheter was removed as usual when their urine was clear. We routinely remove the cystostomy and ureteral catheters at the end of postoperative week one. The mean hospital stay was 2.4 days (range 1-4 days). Average follow-up was 9.8 months (range 5-14 months). None of the patients had postoperative ureteral obstruction. Three patients stayed in the hospital until postoperative day four due to gross hematuria. In addition, there were no cases of migration or dislodgement of the ureteral catheter (Table 1).

Our new method for ureteral catheter removal can be used in patients for ureteral reimplantation. Based on our results, there is the possibility of early discharge without requiring home care for an external catheter and drainage bag or additional anesthesia for removing the catheter. Although three patients were discharged on postoperative day four, the six other patients were discharged without postoperative hydronephrosis two days after surgery.

In the pediatric urological field, ureteral reimplantation without a catheter is the widely accepted method. Brandell and Brock.1 reviewed the cases of 34 children with reflux who underwent simple ureteroneocystostomy. In their study, ureteral catheters were used for 14 of the 34 patients. Patients who did not receive a ureteral catheter had a 30% decrease in length of hospital stay and a 50% decrease in cost compared to the patients who did receive the ureteral catheter. All patients were followed for three months. During the follow-up period, there was no evidence of persistent reflux or ureteral obstruction. Miller, et al.2 also reported the results of 101 patients who underwent ureteral reimplantation without using a ureteral catheter. They argued that ureter reimplantation without a ureteral catheter shortens hospital stay and reduces major complications. Although their results confirm this conclusion, their study excluded patients who underwent complicated ureteral surgery such as ureteral tapering. Therefore, we still believe that a ureteral catheter is necessary for ureteral reimplantation in patients with complications in order to overcome postoperative ureteral obstruction. Although using a ureteral stent has the advantage of not requiring external tubing, additional sedation is necessary for removing the stent in pediatric patients. In order to easily remove the ureteral stent, some physicians use a stent composed of string and place it outside the urethra. This method does not lead to good morbidity. In addition, many patients treated by this method complain of moderate to intolerable discomfort and a few patients even experience premature migration or dislodgment of the ureteral catheter.4 Therefore, we believe the ureteral stent method is not suitable for children. For open-ended ureteral catheters, the catheter directly penetrates the bladder and suprapubic abdominal wall and is externally located with a drainage bag. The catheter is easy to remove and does not require any additional sedation for removal; however, care of the external catheter is needed to avoid inappropriate migration or dislodgement.

Barbour, et al.5 reported results for an easy to remove catheter system in complicated ureteral reimplantation cases that involved using a combined drainage system consisting of cystostomy and a double J stent. In their study, patients were discharged early and their ureteral stents were easily removed. On postoperative day five, the cystostomy combined with a ureteral stent and a non-absorbable suture were removed without anesthesia. However, their method requires caring for the external drainage tube and the average length of hospital stay was similar to other methods. More recently, the Salle intraoperative pyeloplasty stent was introduced.6 The Salle stent can be placed such that the external portion is passed out suprapubically, which also can obviate the need for a Foley catheter and external tubing structure, so that it can be easily removed after a few days. However, occasionally for younger patients, the Salle stent cannot be used because Salle stents less than 4-Fr are not produced. In addition, the stent is not distributed worldwide like the Foley catheter and ureteral catheter.

To lower anxiety when removing the ureteral catheter and eliminate unnecessary external tubing and a drainage bag, we modified the post ureteral reimplantation procedure using a ureteral catheter and a suprapubic cystostomy catheter. After ureteral reimplantation, a combined internal drainage system consisting of the suprapubic cystostomy and ureteral catheter was installed without external tubing structures. Our new catheter method has several advantages. First, it requires no external catheter or drainage bag, which is difficult to handle at home and is at risk of becoming dislodged. As patients are generally unfamiliar with how to care for external catheters and drainage bags, they usually request to remain in the hospital while the catheter is in place, despite the disadvantages of longer hospital stays. Second, additional sedation was not necessary to remove the ureteral catheter. For most pediatric patients, general anesthesia is needed to remove the ureteral catheter because any unconscious movement or anxiety experienced during the cystoscopic procedure may induce hazardous complications, but our method did not require additional anesthesia. Third, our method has a low risk of postoperative ureteral obstruction. For patients with normal kidneys, unilateral ureteral obstruction might not be hazardous. However, patients with a solitary functional kidney are at risk of postoperative ureteral obstruction which can lead to post-obstructive azotemia. In addition, with our method, patients who have undergone complicated ureteral manipulation such as ureteral tapering can be discharged without fear of ureteral obstruction. Therefore, in cases such as our enrolled patients, a ureteral catheter should be inserted. Fourth, patients are able to be discharged from the hospital immediately if no postoperative complications are present which require the care of a physician (for example: gross hematuria, infection, or bladder leakage). These types of complications can affect the length of hospital stay. Our patients had a mean hospital stay of 2.4 days. The average hospital stay in patients undergoing ureteral reimplantation is reported to be 2.8 to 5.6 days.7,8 Shorter hospital stays for pediatric patients would decrease the incidence of hospital acquired infection, cost, and parental anxiety.9-12 We believe that when the new internal drainage system is used after ureteral reimplantation, care of the catheter and fear of transient ureteral obstruction will not be reasons for prolonged hospitalization. However, there are also some disadvantages in our methods. First, a complicated procedure should be learned and special care is necessary in critical steps such as removing the catheter. If a more simple nephroureterovecial stent set is be introduced, our complicated steps can be made simple. Second, there are possibility of unwanted events such as disconnection between cystostomy catheter and ureteral catheter in the bladder or migration of the cystostomy catheter inside the body. None of these events occurred during our initial experience, however, we had a small sample size. Therefore, the incidence of possible complications should be discussed to verify the effectiveness and safety.

Our study had some limitations. First, the number of enrolled subjects was small. Therefore, the explanatory power of our results is compromised. Our results explain only the possibility of a new method but do not suggest superiority. Therefore, effectiveness of our method should be analyzed using larger scale comparative studies in a future. Second, the internal drainage system has less drainage ability, due to closing of the luminal area, than other systems with the lumen open. In conclusion, our new method can possibly be used for preventing postoperative ureteral obstruction in patients with a solitary functional kidney or who have undergone a complicated ureteral manipulation procedure without necessitating delayed discharge from the hospital and additional sedation to remove the indwelling ureteral catheter.