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

SummaryIntroductionPatient age and hospital volume have been shown to affect perioperative outcomes after pediatric pyeloplasty. However, there are few multicenter studies that focus on outcomes at teaching hospitals, where many of the operations are performed.ObjectiveThe goal was to determine if surgical approach, age, case volume, or other factors influence perioperative outcomes in a large contemporary cohort.Study designUsing 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.ResultsA total of 2219 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.DiscussionThe 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.ConclusionsThis 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.Table. LOS by surgery type and multivariate analysis of LOS (all patients).Open (n = 1540)Laparoscopic (n = 46)Robotic (n = 633)LOS (days) mean (SD)2.0 (1.2)2.4 (1.7)1.8 (1.3)Multivariable mixed-effects lognormal-Poisson regression analysisCovariateRate ratio (95% CI)p Surgery: laparoscopic vs. open1.06 (0.86, 1.31)0.57 Surgery: robotic vs. open0.90 (0.82, 0.99)0.03 Surgery: robotic vs. laparoscopic0.85 (0.68, 1.05)0.12 Age (years)1.00 (0.98, 1.02)0.81 Sex: female vs. male1.00 (0.94, 1.07)0.99 Insurance: private/military vs. other0.89 (0.83, 0.95)<0.001 Comorbidities (yes vs. no)1.34 (1.23, 1.46)<0.001 Surgeon volume (cases/year)0.99 (0.97, 1.01)0.53 Hospital volume (cases/year)1.00 (0.99, 1.01)0.92Bold indicates the statistically significant p values