NSQIP Data Comparing 30-Day Outcomes between Open and Minimally Invasive Ureteral Reimplantation
Michael P. Kurtz, MD, MPH, Briony K. Varda, MD, Caleb P. Nelson, MD, MPH.
Boston Children's Hospital, Boston, MA, USA.
BACKGROUND: There has been substantial variation in the reported comparative postoperative outcomes of minimally invasive surgical (MIS) versus open pediatric ureteral reimplantation (OUR) with some studies finding no difference and others reporting higher rates of complications with MIS. The American College of Surgeons National Surgical Quality Improvement Program (NSQIP) created Pediatric NSQIP with the goal of prospectively tracking cases and rigorously analyzing 30-day outcomes in children. Unlike other national data sets, inpatient and outpatient encounters are tracked for complications whether they occur at the hospital of origin or elsewhere, and the outcomes are collected in all NSQIP hospitals regardless of the program's willingness to put forward their results. We hypothesized that 30-day outcomes (complications, reoperations, and readmissions) would differ between MIS and OUR.
METHODS: We analyzed the 2015 NISQIP file, including all OUR (CPT 50780, 50782) and MIS (CPT 50947, 50948) procedures, and confirming the modality of surgery by the NSQIP description. A single year was selected as this allowed the most precise determination of procedure modality and represents the most recent time point in technology dissemination. Demographic factors, operative times, LOS, readmissions, complications, and reoperations were tabulated. Descriptive statistics were generated, Wilcoxon rank-sum tests were used for continuous variables, and Fisher's exact test for categorical variables.
RESULTS: 1,175 subjects underwent ureteral reimplantation. We excluded 161 patients undergoing other major operations simultaneously, 116 cases of ureteral tapering, and another 130 cases in which the modality of surgery was ambiguous. This yielded 80 MIS cases and 688 open cases. The groups were comparable in gender, and the MIS group was substantially older (Table 1). There were no differences between MIS and OUR in the rates of non-operative 30-day complication, readmissions, or LOS. However, unplanned reoperations within 30 days were more common in the MIS group (5% vs 1.3%, p=0.037). Operative times were longer in MIS despite similar use of cystoscopy, and anesthetic time was longer by a median of 70 minutes (p<0.0001). Limitations include anonymized data restricting the ability to analyze hospital or surgeon factors. Surgical technical details are absent; most notably bilaterally of procedure, and efficacy (reflux resolution) is not analyzed. The cohort size did not permit multivariable analysis regarding complications.
CONCLUSIONS: In prospectively accrued data, there was no difference between OUR and MIS in non-operative 30-day complications, but reoperations within 30 days were more common in the MIS group, and the MIS procedures were substantially longer. Longer term data to define differences in these approaches and multi-institutional collaboration to refine techniques are currently ongoing.
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