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Robotic Versus Open Pediatric Ureteral Reimplantation - Costs and Complications from a National Sample
Michael P. Kurtz, MD, MPH1, Jeffrey Leow, MBBS, MPH2, Briony K. Varda, MD3, Benjamin I. Chung, MD4, Curtis C. Clark, MD5, Richard N. Yu, MD, PhD1, Caleb P. Nelson, MD, MPH1, Steven L. Chang, MD, MS2.
1Department of Urology, Boston Children's Hospital, Boston, MA, USA, 2Division of Urology and Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, MA, USA, 3Division of Urology, Brigham and Women's Hospital, Boston, MA, USA, 4Department of Urology, Stanford University Medical Center, Stanford, CA, USA, 5Pediatric and Adolescent Urology, Inc., Akron, OH, USA.

BACKGROUND: While anecdotal reports suggest that use of robotic-assisted laparoscopic ureteral reimplantation (RALUR) is increasing, little is known of the outcomes, costs, and complications of this procedure on a national scale. We sought to compare 90-day complications and direct costs for open ureteral reimplant (OUR) vs. RALUR in a national sample of hospitals performing both procedures.
METHODS: The Premier Hospital Database (Premier, Inc. Chartlotte, NC) is a nationally-representative dataset of inpatient hospitalization that includes detailed coding and charge data for procedures, supplies, and pharmacy during a hospitalization. We queried the data for ICD-9 procedure codes to identify ureteral reimplants occurring from 2003-2012, at hospitals performing both RALUR and OUR.. RALUR cases were identified based on presence of detailed charge data for RALUR-specific equipment. Cost data in Premier represent direct, non-allocated costs converted to 2012 dollars; charges, amortization, and maintenance of the robotic platform were not included in analysis. We compared the incidence of complications, based on the Clavien Classification System, and cost data for RALUR vs. OUR, controlling for patient factors using logistic models for complications and hierarchical models for cost, to control for covariates including gender, age, and hospital.
RESULTS: We identified 18 hospitals where both RALUR and OUR were performed, resulting in a cohort of 381 OUR cases and 90 RALUR cases. The group undergoing RALUR was slightly older (median 5 vs. 4 years, p<0.004). Gender distribution was similar (71.0 vs. 73.3% female, p=0.7). Incidence of any 90-day complication was higher in the RALUR group: 16.7% of RALURvs. 6.8% of OUR (OR: 2.7; 95%CI: 1.4-5.4, p=0.0006). The difference remained significant in a multivariable model adjusting for age, gender, and comorbidity (OR 2.5; CI: 1.2,5.1; p=0.02)
The median hospital cost for OUR was $5991 vs. $8908 for RALUR (p<0.0001, Wilcoxon rank sum). This difference persisted after controlling for gender, age, and hospital (p<0.0001). The majority of the excess cost in the RALUR group was attributable to higher operating room costs and supplies. Median operative time was 240 minutes for RALUR vs. 163 minutes for OUR (p<0.0001). Median length of stay was 2 days in both groups (p=0.22).
CONCLUSIONS: Nationally, RALUR was associated with a significantly higher rate of complications as well as higher costs. Complication rates (and costs) are often higher when new technology is introduced into surgical practice, but the high rate of complications seen in this national sample suggest that RALUR should be implemented with caution, particularly at sites with limited robotic experience, and that outcomes for these procedures should be carefully and systematically tracked.

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