Society For Pediatric Urology

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Retrograde stent with external string for pediatric robotic pyeloplasty: Does it reduce cost and complications?
Adam J. Rensing, MD, Benjamin M. Whittam, MD, Konrad M. Szymanski, MD, William E. Bennett, Jr., MD.
Indiana University, Indianapolis, IN, USA.

Introduction and Objective:
Robotic-assisted pyeloplasty (RAP) has become a mainstay in the treatment of ureteropelvic junction obstruction (UPJO) in children. At our institution, we pursue a strategy that re-examines technique to safely decrease costs. We have sought to limit planned operating rooms visits by placing a ureteral stent with an external string (SWES) just prior to RAP. In this study, we sought to quantify the operative time, complications, and healthcare costs associated with this approach compared to the traditional approach, which always requires subsequent stent removal in the operating room. We hypothesized the SWES cohort would have a decreased cost compared to antegrade stent placement.
We retrospectively collected the electronic records of all RAP performed at our institution using the SWES approach (Aug 2012 – July 2017). We collected 30-day costs linked to the medical record number using the Pediatric Health Information System (PHIS) database. We also obtained RCC (ratio of charge-to-cost) based cost data from PHIS. We compared 30-day costs of all our cases performed with SWES to a national cohort of all pediatric RAP performed during the same time period. Lastly, we sent an anonymous, electronic survey to urologists of all PHIS institutions to clarify the predominant technique for intraoperative stent placement for pediatric RAP nationally.
A total of 85 children were identified who were treated RAP with SWES. Median operative time of 174 minutes (Table 1). There was a 15.5 % rate of unplanned return to the hospital, including 8.2% (7/85) undergoing of unplanned return for a procedure (3 for stent removal secondary to string retraction or failure, 2 for nephrostomy tube for acute postoperative obstruction, 1 for port site omental herniation, and 1 for stent replacement). Median 30-day cost of $10,548 (Table 2). This was 25.3% less than the overall, national cohort of all RAP during the same period ($14,119).
Survey results (42.5%, 37/87, response rate), showed that 84.6% pediatric urologists primarily leave stents WITHOUT a string, 7.7 % use nephrostomy tubes, and 7.7% (3) use SWES. This survey results suggest that most pediatric urologist performing RAP utilize no strings.
During pediatric RAP, placement of a SWES takes little time, carries a small risk of unplanned visit to the operating room, saves the patient a guaranteed, second anesthetic for stent removal, and amounts to a cost savings of approximately 25%.
Table 1: Stent Without External String Cohort
String (SWES)
Median Operative Time (1-3 IQR)173.5 min (151.5-208.8)
Cystoscopy/RPG Time (avg)15 min
Complications (all)16 (19.0 %)
Clavien Grade I3 (3.6 %)
Clavien Grade II6 (7.1 %)
Clavien Grade III7 (8.2 %)
Clavien Grade IV0
Second Procedure Rate8.2 %

Table 2: Comparative Cost Analysis of Stent Without External String and National Cohorts
SWESNational Cohort
Median 30 Day Costs$10,548$14,119
Predominant Means of Stent Placement100 % cystoscopic with string84.6 % antegrade without string*

*Based upon the above-mentioned survey results.

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