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National Practice Patterns and Outcomes of Pediatric Partial Nephrectomy: Comparison Between Urology and General Surgery
Kristina D. Suson, MD1, Cortney Wolfe-Christensen, PhD1, Jack S. Elder, MD2, Yegappan Lakshmanan, MD1.
1Children's Hospital of Michigan, Detroit, MI, USA, 2Henry Ford Vattikuti Urology Institute, Detroit, MI, USA.

BACKGROUND: Both pediatric urologists (PURO) and general pediatric surgeons (GPS) perform nephron-sparing surgery in children. We compared the contemporary performance and outcome of all-cause partial nephrectomy at free-standing children's hospitals by pediatric urologists and general surgeons.
METHODS: The Pediatric Health Information System (PHIS), which collects data from 44 pediatric hospitals, was queried to identify patients on whom partial nephrectomies were performed between January 1, 2004 and June 30, 2013 by PURO and GPS. Data points included age, gender, severity level, risk of mortality, complications, length of stay, and renal and malignancy flags. Severity level and risk of mortality are assigned on a 4 point scale. Renal flags indicate a congenital renal anomaly or chronic kidney disease, while malignancy flags indicate a cancer diagnosis. Statistical analysis included analyses of covariance (ANCOVA).
RESULTS: A total of 1,482 partial nephrectomies were performed, including 1,269 by PURO and 213 by GPS. The children on whom PURO operated were younger (3.48±5.1 vs 4.32±4.9 years, p=0.021) and more likely to be female (p=0.005). Renal flags were applied to 1,017 patients, and malignancy flags were applied to 289 patients. The most commonly encountered renal flag diagnoses were specificed and unspecified anomalies of the kidney and/or ureter, vesicoureteral reflux, and obstructive anomalies of the kidney and/or ureter. While PURO was nearly 10 times more likely to operate on children with renal anomalies (0.95 CI, 7.0-13.8, p<0.001), GPS was more than 20 times more likely to operate on children with malignancies (0.95 CI 16.9-34.4, p<0.001). The children on whom GPS operated had a higher average severity level and higher risk of mortality. After controlling for age, sex, severity level, and risk of mortality, PURO had significantly fewer surgical complications (0.079±0.007 vs 0.128±0.018 percent of cases, p=0.015) and shorter length of stay (3.31±0.11 vs 5.85±0.28 days, p<0.001). There was no difference in medical complications. Children with renal flags who underwent partial nephrectomy with PURO had fewer complications and a shorter length of stay. Children with malignancy flags had similar complications, but a shorter length of stay (Table).
CONCLUSIONS: PURO performed more partial nephrectomies overall, most of which were for renal causes. GPS was more likely to operate for malignancy, likely reflecting referral patterns. Whether the surgery was performed for renal causes or malignancy, children operated on by PURO had a shorter length of stay, and those with renal flags had fewer surgical complications.

Complications and Length of Stay Following Partial Nephrectomy
Complications (% of cases)P-valueLOS (days)P-value
Renal Flag (N=1,017)
PURO (N=965)0.048±0.007<0.0012.612±0.092<0.001
PURO (N=965)0.157±0.0304.286±0.401
Malignancy Flag (N=289)
PURO (N=132)0.239±0.0350.6956.533±0.6410.019
GPS (N=157)0.220±0.0328.635±0.581

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