Development of a postoperative care pathway for children with renal tumors.

Summary Purpose To identify the factors associated with a shorter postoperative stay, as an initial step to develop a care pathway for children undergoing extirpative kidney surgery. Study design This study retrospectively reviewed patients managed with upfront open radical nephrectomy for renal tumors between 2005 and 2016 at a pediatric tertiary care facility. Univariate and multivariate logistic regression were performed to identify factors associated with early discharge (by postoperative day 4). Results A total of 84 patients met inclusion criteria. Median age was 28.1 months (range 1.8–193.1). Thirty-four (40.5%) patients had a nasogastric tube postoperatively. The patients were advanced to a clear liquid diet on a median postoperative day 2 (range 0–7) and regular diet on a median postoperative day 3 (range 1–8). Median time from surgery to discharge was 5 days (range 2–12), with 38 (45.2%) discharged early. Univariate and multivariate logistic regression analyses showed that earlier resumption of regular diet (OR 0.523, P = 0.028) was positively associated with early discharge. Other analyzed factors were not significant (see Table). Discussion Timely initiation of adjuvant therapy is a specific requirement of Children's Oncology Group (COG) protocols. Chemotherapy and radiation therapy are ideally initiated simultaneously, as early as possible, within 2 weeks of surgery. Thus, factors that can facilitate early discharge from the hospital can maximize protocol adherence with respect to timing of adjuvant therapy initiation and optimize patient outcome. This study shed light on several postoperative factors and how these relate to postoperative stay and recovery. Specifically, tumor size, pre-operative bowel preparation, extent of lymph node sampling, stage, operative time, estimated blood loss, surgical service, postoperative nasogastric tube use, transfusion, and chemotherapy prior to discharge were not associated with discharge timing. Early re-feeding was associated with early discharge. Thus, it seems reasonable that, when developing a postoperative care pathway for these patients, these factors be considered and specifically encourage early re-feeding. In pediatrics, data on early recovery after surgery protocols are limited, and high-quality studies are unavailable. Within pediatric urology, early recovery after surgery protocols in children undergoing major urologic reconstruction have been shown to reduce hospital stay and can decrease complication rates. It seems reasonable that a similar pathway can be applied to children undergoing radical nephrectomy for suspected malignancy. Conclusions For children with renal tumors who underwent radical nephrectomy, early re-feeding was associated with a shorter time to discharge. Use of bowel preparation and nasogastric tube did not appear to shorten time to discharge. These data are important for developing postoperative care pathways for these patients. Table . Logistic regression for postoperative discharge by postoperative day 4. Univariate Multivariate OR 95% CI P-value OR 95% CI P-value Age (continuous) 0.992 0.98–1.005 0.209 0.992 0.976–1.009 0.359 Year of surgery (continuous) 1.027 0.909–1.16 0.673 Tumor diameter (continuous) 0.91 0.809–1.024 0.118 0.983 0.844–1.144 0.824 Malignant histology 0.372 0.086–1.601 0.184 0.784 0.137–4.482 0.784 Stage I/II 1 III/IV 0.676 0.278–1.643 0.388 Pre-operative bowel preparation 0.595 0.052–6.821 0.676 Surgical service Surgery alone 1 1 Urology involved 3.25 1.149–9.196 0.026 1.061 0.219–5.126 0.942 Operating room time (continuous) 1 0.993–1.006 0.919 Number of lymph nodes examined (continuous) 1.072 1.003–1.145 0.039 1.06 0.977–1.149 0.162 Estimated blood loss (continuous) 0.993 0.0985–1.001 0.095 0.997 0.988–1.005 0.416 Postoperative nasogastric tube 0.407 0.164–1.011 0.053 0.996 0.323–3.075 0.994 Postoperative day clears started (continuous) 0.451 0.267–1.764 0.003 Postoperative day regular diet started (continuous) 0.435 0.264–0.715 0.001 0.507 0.279–0.921 0.026 Chemotherapy prior to discharge 0.352 0.122–1.017 0.054 0.566 0.166–1.93 0.363