Outcomes after pediatric open, laparoscopic, and robotic pyeloplasty at academic institutions

Abstract

Summary Introduction Patient age and hospital volume have been shown to affect perioperative outcomes after pediatric pyeloplasty. However, to date, there are few multicenter studies that focus on outcomes at teaching hospitals, where many of the operations are performed. Objective The goal was to determine if surgical approach, age, case volume, or other factors influence perioperative outcomes in a large contemporary cohort. Study design Using the clinical database/resource manager (CDB/RM) of the University Health-System Consortium (UHC), children who underwent open, laparoscopic, or robotic pyeloplasty from 2011 to 2014 were identified at 102 academic institutions. Surgery type, age, race, gender, insurance type, geographic region, comorbidities, surgeon volume, and hospital volume were measured. Multivariable mixed-effects logistic regression analysis was used to analyze independent variables associated with complication rates, length of stay (LOS), readmission rates, and ICU admission. Results A total of 2,219 patients were identified. Complication rates were 2.1%, 2.2%, and 3% after open, laparoscopic, and robotic pyeloplasty, respectively. Approximately 12% of patients had underlying comorbidities. Comorbidities were associated with 3.1 times increased odds for complication (p = 0.001) and a 35% longer length of stay (p < 0.001). Age, gender, insurance type, and hospital volume had no effect on complication rates. A trend was seen towards a lower rate of complications with higher surgeon volume (p = 0.08). The mean LOS was 2.0 days in the open pyeloplasty group, 2.4 days in the laparoscopic group and 1.8 days in the robotic group. Patients who underwent robotic surgery had an estimated LOS 11% shorter than those after open surgery (p = 0.03) (table). Patients aged 5 years and under who had robotic surgery had an estimated LOS 14% shorter than those after open surgery (p = 0.06). ICU admission and hospital readmission were not associated with any variables. Discussion The study is limited by the accuracy of the data submitted by the hospitals and is subject to coding error. Complication rates remain low in all three approaches, validating their safety. Patients, including younger patients, had shorter lengths of stay after robotic surgery. The statistically significant differences between approaches were small so clinically there may not be a difference. Conclusions This large multicenter analysis demonstrates that patient comorbidity had the greatest impact upon complication rates and length of stay. Previous work showed that the benefits of laparoscopy were limited to older children. However, this large multicenter study suggests that these benefits now extend to young children with the application of robotics.

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

“…30 We found an overall complication rate of 15% within the initial hospital stay, which was higher than rates of others reporting on 2.1 to 5% in open and 2.2 to 2.5% in laparoscopic pyeloplasty. 12,27 The higher percentage in our study population might be explained by a more inclusive definition of complications (including minor complications, such as wound infection) based on ICD10 codes. Logistic regression analysis however revealed that the risk for complications was independent from the surgical technique applied and the age of the patients at surgery, which is in line with other reports.…”

“…24 In line with our findings, Chan et al reported a 14% shorter LOS in children up to 5 years of age undergoing robotic laparoscopic pyeloplasty. 27 Taking LOS as an indicator for well-being, one may speculate that LP is superior compared with an open approach especially in infants up to 2 years.…”

“…In contrast, a group from Sacramento reported a mean LOS of 2.0 days in the open pyeloplasty group and 2.4 days in the laparoscopic group only. 27 Others referred to a significant decrease in LOS after pyeloplasty from 6.7 days in 1988 to 1991 to 3.7 days in 1997 to 2000. 28 Significantly higher LOS rates in Germany compared with international studies have been reported before.…”

Endoscopic High Pressure Balloon Dilitation as a Method of Treatment of Ureteropelvic Junction Obstruction in Children

“…DOI:10.21886/2306DOI:10.21886/ -6424-2017 Введение В детской хирургии основным направле-нием является поиск и внедрение ма-лоинвазивных методов лечения. При врожденных пороках развития органов моче-выделительного тракта, в первую очередь, об-струкции лоханочно-мочеточникового сегмента (ЛМС), лапароскопические и ретроперитоне-оскопические методы стали занимать главен-ствующую позицию [1,2]. И сегодня эти виды эндовидеохирургического лечения можно уже считать «золотым стандартом» при лечении данной проблемы.…”

Paediatric robotic surgery and urology: where are we?

“…The main difference between the two approaches was operative time and cost, with robotic significantly slower and more expensive. Other multi-centre studies since then have shown some reduction in hospital stay [8,9] but a multi-centre prospective RCT trial would be needed to accurately compare the laparoscopic and the robotic approach.…”