Has the robot caught up? National trends in utilization, perioperative outcomes, and cost for open, laparoscopic, and robotic pediatric pyeloplasty in the United States from 2003 to 2015

Abstract

Summary Introduction Since 2010, there have been few new data comparing perioperative outcomes and cost between open (OP) and robotic pyeloplasty (RP). In a post-adoption era, the value of RP may be converging with that of OP. Objective To 1) characterize national trends in pyeloplasty utilization through 2015, 2) compare adjusted outcomes and median costs between OP and RP, and 3) determine the primary cost drivers for each procedure. Study design We performed a retrospective cohort study using the Premier database, which provides a nationally representative sample of U.S. hospitalizations between 2003 and 2015. ICD9 codes and itemized billing were used to abstract our cohorts. Trends in utilization and cost were calculated and then stratified by age. We used propensity scores to weight our cohorts and then applied regression models to measure differences in the probability of prolonged operative time (pOT), prolonged length of stay (pLOS), complications, and cost. Results During the study period 11,899 pyeloplasties were performed: 75% open, 10% laparoscopic, and 15% robotic. The total number of pyeloplasty cases decreased by 7% annually; OP decreased by a rate of 10% while RP grew by 29% annually. In 2015, RP accounted for 40% of cases. The largest growth in RPs was among children and adolescents. The average annual rate of change in cost for RP and OP was near stagnant: −0.5% for open and −0.2% for robotic. The summary table provides results from our regression analyses. RP conferred an increased likelihood of pOT, but a reduced likelihood of pLOS. The odds of complications were equivalent. RP was associated with a significantly higher median cost, but the absolute difference per case was $1060. Discussion Despite advantages in room and board costs for RP, we found that the cost of equipment and OR time continue to make it more expensive. Although the absolute difference may be nominal, we likely underestimate the true cost because we did not capture amortization, hidden or down-stream costs. In addition, we did not measure patient satisfaction and pain control, which may provide the non-monetary data needed for comparative value. Conclusion Despite an overall decline in pyeloplasties, RP utilization continues to increase. There has been little change in cost over time, and RP remains more expensive because of equipment and OR costs. The robotic approach confers a reduced likelihood of pLOS, but an increased likelihood of pOT. Complication rates are low and similar in each cohort.

Surgery for Pediatric Ureteropelvic Junction Obstruction—Comparison of Outcomes in Relation to Surgical Technique and Operating Discipline in Germany

“…Possible reasons for the underrepresentation of RP in our cohort include a limited availability of the robot, higher costs, and larger trocar incisions compared with conventional laparoscopy in Germany. [16][17][18] In line with reports from others, girls underwent minimal invasive pyeloplasty more often than boys did. 19,20 The reasons for this finding remain unclear since the individual steps of pyeloplasty do not differ between males and females.…”

“…15 Since the introduction of laparoscopy for the treatment of UPJO in 1995, the number of LP slightly increased from around 2% in 2002 to only 10% in 2006 in the United States 3,8,12 However, the number of pediatric RP markedly increased and accounted for 40% of all pyeloplasties in 2015 according to a retrospective cohort study on a nationally representative sample of the US hospitalizations between 2003 and 2015. 16 Hence, the moderate increase in LP might be attributed to the steep increase in RP in the United States. Possible reasons for the underrepresentation of RP in our cohort include a limited availability of the robot, higher costs, and larger trocar incisions compared with conventional laparoscopy in Germany.…”

Robotics in Pediatric Urology

“…A recent longitudinal evaluation of practice patterns across the US showed that in 2003, 10 years after being first described, laparoscopic pyeloplasty only accounted for <20 % of the pyeloplasties performed in patients aged 13-18 years. In contrast, ten years after robotic pyeloplasty was introduced in 2015, >80% of pyeloplasties were being performed robotically in this same age group in the United States (5). This study reinforces the sentiment that robotic assisted technique is more readily adoptable and has a more favorable learning curve compared to standard laparoscopy.…”

“…As previously mentioned, the popularity of robotic pyeloplasty rose quickly and is now the gold standard for adolescent patients across the United States. In patients between 1-12 years of age, it is becoming the procedure of choice and in 2015, >40% of these patients were done robotically (5). In infants (<1 year of age), the use of robotic technique remains controversial, despite multiple reports showing the feasibility and excellent outcomes comparable to open surgery (6).…”

Managing Ureteropelvic Junction Obstruction in the Young Infant

“…However, this growth was mainly in children and adolescents. While 40% of pyeloplasties in children and adolescents in 2015 were performed robotically, 85% of infant cases were still performed via an open approach (72). Infant patients accounted for 2% and 19% of all robotic and laparoscopic pyeloplasties performed (73), but these trends are likely to change as more surgeons are trained in minimally invasive approaches.…”