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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

Published:February 21, 2018DOI:https://doi.org/10.1016/j.jpurol.2017.12.010

      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

      TablePropensity-score weighted multivariable-adjusted analyses for perioperative outcomes and cost associated with robotic pyeloplasty (as compared with the open approach).
      OR 95% CI p-value
      Prolonged LOS (>2 days) 0.14 (0.05–0.38) 0.001
      Prolonged OT (>200 min) 5.4 (3.1–9.2) <0.001
      Complications 0.80 (0.34, 1.9) 0.62
      Open Robotic p-value
      Median cost (USD) $10,817 $11,877 0.03
      LOS = length of stay; OT = operative time.

      Keywords

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      References

        • Akhavan A.
        • Avery D.
        • Lendvay T.S.
        Robot-assisted extravesical ureteral reimplantation: outcomes and conclusions from 78 ureters.
        J Pediatr Urol. 2014; 10: 864-868
        • Varda B.K.
        • Johnson E.K.
        • Clark C.
        • Chung B.I.
        • Nelson C.P.
        • Chang S.L.
        National trends of perioperative outcomes and costs for open, laparoscopic and robotic pediatric pyeloplasty.
        J Urol. 2014; 191: 1090-1096
        • Monn M.F.
        • Bahler C.D.
        • Schneider E.B.
        • Whittam B.M.
        • Misseri R.
        • Rink R.C.
        • et al.
        Trends in robot-assisted laparoscopic pyeloplasty in pediatric patients.
        Urology. 2013; 81: 1336-1341
        • Mahida J.B.
        • Cooper J.N.
        • Herz D.
        • Diefenbach K.A.
        • Deans K.J.
        • Minneci P.C.
        • et al.
        Utilization and costs associated with robotic surgery in children.
        J Surg Res. 2015; 199: 169-176
        • Rowe C.K.
        • Pierce M.W.
        • Tecci K.C.
        • Houck C.S.
        • Mandell J.
        • Retik A.B.
        • et al.
        A comparative direct cost analysis of pediatric urologic robot-assisted laparoscopic surgery versus open surgery: could robot-assisted surgery Be less expensive?.
        J Endourol. 2012; 26: 871-877
        • Liu D.B.
        • Ellimoottil C.
        • Flum A.S.
        • Casey J.T.
        • Gong E.M.
        Contemporary national comparison of open, laparoscopic, and robotic-assisted laparoscopic pediatric pyeloplasty.
        J Pediatr Urol. 2014; 10: 610-615
        • Sukumar S.
        • Sun M.
        • Karakiewicz P.I.
        • Friedman A.A.
        • Chun F.K.
        • Sammon J.
        • et al.
        National trends and disparities in the use of minimally invasive adult pyeloplasty.
        J Urol. 2012; 188: 913-918
        • Sorensen M.D.
        • Delostrinos C.
        • Johnson M.H.
        • Grady R.W.
        • Lendvay T.S.
        Comparison of the learning curve and outcomes of robotic assisted pediatric pyeloplasty.
        J Urol. 2011; 185: 2517-2522
        • Minnillo B.J.
        • Cruz J.A.S.
        • Sayao R.H.
        • Passerotti C.C.
        • Houck C.S.
        • Meier P.M.
        • et al.
        Long-term experience and outcomes of robotic assisted laparoscopic pyeloplasty in children and young adults.
        J Urol. 2011; 185: 1455-1460
        • Casella D.P.
        • Fox J.A.
        • Schneck F.X.
        • Cannon G.M.
        • Ost M.C.
        Cost analysis of pediatric robot-assisted and laparoscopic pyeloplasty.
        J Urol. 2013; 189: 1083-1086
        • Leow J.J.
        • Chang S.L.
        • Meyer C.P.
        • Wang Y.
        • Hanske J.
        • Sammon J.D.
        • et al.
        Robot-assisted versus open radical prostatectomy: a contemporary analysis of an all-payer discharge database.
        Eur Urol. 2016 Nov; 70: 837-845
        • Tinay I.
        • Gelpi-Hammerschmidt F.
        • Leow J.J.
        • Allard C.B.
        • Rodriguez D.
        • Wang Y.
        • et al.
        Trends in utilisation, perioperative outcomes, and costs of nephroureterectomies in the management of upper tract urothelial carcinoma: a 10-year population-based analysis.
        BJU Int. 2016; 117: 954-960
        • Gandaglia G.
        • Varda B.
        • Sood A.
        • Pucheril D.
        • Konijeti R.
        • Sammon J.D.
        • et al.
        Short-term perioperative outcomes of patients treated with radical cystectomy for bladder cancer included in the national surgical quality improvement program (NSQIP) database.
        Can Urol Assoc J. 2014; 8
        • Atug F.
        • Woods M.
        • Burgess S.V.
        • Castle E.P.
        • Thomas R.
        Robotic assisted laparoscopic pyeloplasty in children.
        J Urol. 2005; 174: 1440-1442
        • Casale P.
        Robotic pyeloplasty in the pediatric population.
        Curr Opin Urol. 2009; 19: 97-101
        • Kutikov A.
        • Resnick M.
        • Casale P.
        Laparoscopic pyeloplasty in the infant younger than 6 Months—is it technically possible?.
        J Urol. 2006; 175: 1477-1479
        • Lee R.S.
        • Retik A.B.
        • Borer J.G.
        • Peters C.A.
        Pediatric robot assisted laparoscopic dismembered pyeloplasty: comparison with a cohort of open surgery.
        J Urol. 2006; 175: 683-687
        • O'Brien S.T.
        • Shukla A.R.
        Transition from open to robotic-assisted pediatric pyeloplasty: a feasibility and outcome study.
        J Pediatr Urol. 2012; 8: 276-281
        • Riachy E.
        • Cost N.G.
        • Defoor W.R.
        • Reddy P.P.
        • Minevich E.A.
        • Noh P.H.
        Pediatric Standard Pyeloplasty: a comparative single institution study.
        J Urol. 2013; 189: 283-287
        • Yee D.S.
        • Shanberg A.M.
        • Duel B.P.
        • Rodriguez E.
        • Eichel L.
        • Rajpoot D.
        Initial comparison of robotic-assisted laparoscopic versus open pyeloplasty in children.
        Urology. 2006; 67: 599-602
        • Seideman C.A.
        • Sleeper J.P.
        • Lotan Y.
        Cost comparison of robot-assisted and laparoscopic pyeloplasty.
        J Endourol. 2012; 26: 1044-1048
        • Bell M.C.
        • Torgerson J.
        • Seshadri-Kreaden U.
        • Suttle A.W.
        • Hunt S.
        Comparison of outcomes and cost for endometrial cancer staging via traditional laparotomy, standard laparoscopy and robotic techniques.
        Gynecol Oncol. 2008; 111: 407-411
        • Boggess J.F.
        Robotic surgery in gynecologic oncology: evolution of a new surgical paradigm.
        J Robot Surg. 2007; 1: 31-37
        • Payne T.N.
        • Dauterive F.R.
        A comparison of total laparoscopic hysterectomy to robotically assisted hysterectomy: surgical outcomes in a community practice.
        J Minim Invasive Gynecol. 2008; 15: 286-291
        • Hohwü L.
        • Akre O.
        • Pedersen K.V.
        • Jonsson M.
        • Nielsen C.V.
        • Gustafsson O.
        Open retropubic prostatectomy versus robot-assisted laparoscopic prostatectomy: a comparison of length of sick leave.
        Scand J Urol Nephrol. 2009; 43: 259-264
        • Bowen D.K.
        • Faasse M.A.
        • Liu D.B.
        • Gong E.M.
        • Lindgren B.W.
        • Johnson E.K.
        Use of pediatric open, laparoscopic and robot-assisted laparoscopic ureteral reimplantation in the United States: 2000 to 2012.
        J Urol. 2016 Jul; 196: 207-212
        • Dy G.W.
        • Hsi R.S.
        • Holt S.K.
        • Lendvay T.S.
        • Gore J.L.
        • Harper J.D.
        National trends in secondary procedures following pediatric pyeloplasty.
        J Urol. 2016; 195: 1209-1214
        • Autorino R.
        • Eden C.
        • El-Ghoneimi A.
        • Guazzoni G.
        • Buffi N.
        • Peters C.A.
        • et al.
        Robot-assisted and laparoscopic repair of ureteropelvic junction obstruction: a systematic review and meta-analysis.
        Eur Urol. 2014; 65: 430-452
        • Thomas J.C.
        • DeMarco R.T.
        • Donohoe J.M.
        • Adams M.C.
        • Pope J.C.
        4th, Brock JW 3rd. Management of the failed pyeloplasty: a contemporary review.
        J Urol. 2005 Dec; 174: 2363-2366
        • Romao R.L.P.
        • Koyle M.A.
        • Pippi Salle J.L.
        • Alotay A.
        • Figueroa V.H.
        • Lorenzo A.J.
        • et al.
        Failed pyeloplasty in children: revisiting the unknown.
        Urology. 2013; 82: 1145-1147
        • Barbash G.I.
        • Glied S.A.
        New technology and Health care costs — the case of robot-assisted surgery.
        N Engl J Med. 2010; 363: 701-704
        • Palmer K.J.
        • Lowe G.J.
        • Coughlin G.D.
        • Patil N.
        • Patel V.R.
        Launching a successful robotic surgery program.
        J Endourol. 2008; 22: 819-824
        • Murthy P.B.
        • Schadler E.D.
        • Orvieto M.
        • Zagaja G.
        • Shalhav A.L.
        • Gundeti M.S.
        Setting up a pediatric robotic urology program: a USA institution experience.
        Int J Urol. 2017; ([Epub ahead of print])https://doi.org/10.1111/iju.13415
        • Garcia-Roig M.L.
        • Travers C.
        • McCracken C.
        • Cerwinka W.
        • Kirsch J.M.
        • Kirsch A.J.
        Surgical scar location preference for pediatric kidney and pelvic surgery: a crowdsourced survey.
        J Urol. 2017 Mar; 197: 911-919
        • Freilich D.A.
        • Penna F.J.
        • Nelson C.P.
        • Retik A.B.
        • Nguyen H.T.
        Parental satisfaction after open versus robot assisted laparoscopic pyeloplasty: results from modified glasgow Children's benefit inventory survey.
        J Urol. 2010; 183: 704-708
        • Behan J.W.
        • Kim S.S.
        • Dorey F.
        • De Filippo R.E.
        • Chang A.Y.
        • Hardy B.E.
        • et al.
        Human capital gains associated with robotic assisted laparoscopic pyeloplasty in children compared to open pyeloplasty.
        J Urol. 2011; 186: 1663-1667
        • Liu J.S.
        • Greiman A.
        • Casey J.T.
        • Mukherjee S.
        • Kielb S.J.
        A snapshot of the adult spina bifida patient–high incidence of urologic procedures.
        Cent European J Urol. 2016; 69: 72-77
        • Johnson E.K.
        • Nelson C.P.
        Values and pitfalls of the use of administrative databases for outcomes assessment.
        J Urol. 2013; 190: 17-18
        • Feudtner C.
        • Feinstein J.A.
        • Zhong W.
        • Hall M.
        • Dai D.
        Pediatric complex chronic conditions classification system version 2: updated for ICD-10 and complex medical technology dependence and transplantation.
        BMC Pediatr. 2014 Aug 8; 14: 199