Society For Pediatric Urology

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Robotic Ureteral Reimplantation is not Associated with Increased Costs for Families and Payers: A Single Institution Analysis of Hospital Charges and Outcomes
Rodolfo A. Elizondo, MD1, Jason K. Au, MD1, Kathleen Puttmann, BS1, Gene O. Huang, MD1, Minki Baek, MD2, Wei Zhang, MPH1, Huirong Zhu, MPH1, Allen J. Orr, BS1, Edmond T. Gonzales, MD1, Nicolette Janzen, MD1, Abhishek Seth, MD1, David R. Roth, MD1, Duong Tu, MD1, Chester J. Koh, MD1.
1Texas Children's Hospital / Baylor College of Medicine, Houston, TX, USA, 2Samsung Medical Center, Seoul, Korea, Republic of.

BACKGROUND:
While the current gold standard in surgical correction of vesicoureteral reimplantation is open ureteral reimplantation (OUR), robot-assisted laparoscopic ureteral reimplantation (RALUR) is emerging as a minimally invasive surgical approach. However, concerns for pediatric robotic surgery have been raised due to its capital costs and heterogeneous clinical outcomes. We hypothesized that similar hospital charges and clinical outcomes occur when comparing OUR and RALUR in matched cohorts.
MATERIALS AND METHODS:
OUR and RALUR cases from 2013 to 2015 for primary vesicoureteral reflux (VUR) were compared for direct itemized charges of operating room (OR), anesthesia, post anesthetic care unit (PACU), inpatient stay, additional supplies, laboratory, pharmacy and clinical outcomes. Matching by age with the use of propensity scoring was performed for the open and robotic cohorts by using logistic regression to estimate the propensity score and using 1:1 nearest neighbor matching. The matched cohorts were analyzed using Fisher's exact, Mann Whitney U, or independent t-test. Postoperative Clavien grade complications and clinical outcomes were compared.
RESULTS:
A total of 135 patients were included initially: 97 OUR and 38 RALUR. There were 38 patients in each group after matching by age of the 135 patients. No differences were noted between the groups except for the incidence of preoperative breakthrough urinary tract infections (p = 0.036). Operating room charges were significantly higher for the robotic group compared to the open group (p=0.002). However, there were no significant differences in total overall charges between the open and robotic groups either with cystoscopy or without cystoscopy (p=0.346, p=0.533), since the median hospital stay length was shorter for the robotic group (p <0.001). OR times did not differ between the open (175 min) and robotic without cystoscopy (212 min) groups (p= 0.962). Clinical success rates were identical for the two groups (open 94.8% vs robotic 94.8%).
CONCLUSIONS:
RALUR was not associated with increased costs for families and payers in this matched study comparing the hospital charges and clinical outcomes of pediatric OUR and RALUR. While operating room charges were higher for the robotic cohort, lower hospitalization charges led to equivalent overall hospital charges, as well as equivalent clinical outcomes for both cohorts. The avoidance of major complications is needed to avoid increased costs.

Table 1. Patient Demographics
TotalOpenRoboticP value
Total Renal Units10256 (55%)46 (46%)
Total Patients763838
Male6 (16%)11 (29%)0.270 *
Female32 (84%)27 (71%)
Age (Median)6.01 (3.70 8.07)6.3 (3.8 9.3)0.369 **
Circumcised2 (33%)4 (36%)1.000 *
% Bilateral Cases3518/38 (47%)17/38 (44%)1.000 *
RNC grade 33216 (43%)16 (42%)1.000 ***
RNC grade 24122 (57%)19 (50%)
RNC grade 130 (0%)3 (8%)
Preoperative antibiotic prophylaxis5830/38 (78%)28/38 (73%)0.863 *
Preoperative febrile breakthrough UTI246/38 (15%)18/38 (47%)0.036 *
DMSA scar/defect2419/23 (82%)15/18 (83%)1.000 *
Follow-up (months)7.7 (1.72 13.02)11.06 (4.34 16)0.084 **
* Fisher's Exact Test** Independent T-test*** Mann-Whitney Test

Table 2. Adjusted Fiscal Year 2014 Direct Charge Analysis (in dollars)
OpenRoboticRobotic without Cystoscopyp-value(Open vs. Robotic)p-value(Open vs. Robotic without Cystoscopy)Robotic vs Robotic without Cystoscopy
Adjusted Direct Charges (dollars)
OR8,759 (8,759 -10,903)11,436 (9,831 -11,975)9,831 (8,759 -10,903)<0.001* 0.031 * 0.002 *
Anesthesia2,642 (2,640 -2,954)3,111 (2,799 -3,151)2,950 (2,755 -2,957)<0.001 * 0.025 * 0.003 *
OR +Anesthesia11,401 (11,399 13,857)14,546 (12,630 15,128)12,785 (11,517 13,860)<0.001 * 0.016 * 0.002 *
Supplies129 (37 - 270)628 (473 - 785)<0.001 *
Post-Anesthesia Care Unit (PACU)2,391 (2,128 -2,916)2,391 (2,129 -2,917)0.367 *
Inpatient Stay4,736 (2,961 -5,922)2,961 (2,961 -2,961)0.065 *
Laboratory814 (249 -1,154)588 (130 - 775) 0.008 *
Pharmacy (Anesthesia)572 (459 - 793)702 (486 - 937)0.063 **
Pharmacy (Others)944 (724 -1,105)735 (530 - 854)0.004 *
Total Costs21,461 (19,331 -24,532)22,860 (20,724- 24,791)0.346 **0.553 **0.094 **
OR Time175 min (153 -229)240 min (202 -264)212 min (178 -243)<0.001 * 0.962 ** 0.023 *
OR Time in B/L Reimplantation175 min (155 229)264 min (250 283)243 (227 252) <0.001 * 0.002 * 0.002 **
Length of Stay2 days (1 - 2)1 day (0 - 1) <0.001 *
* Mann-Whitney Test** Independent T-testDollar values are Median (Inter Quartile Range)


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