Pathologic Specimens at Time of Pyeloplasty: Frequency and Practice Patterns.

OBJECTIVE: To assess national and regional practice patterns and rates of pathologic specimen identification sent at time of pyeloplasty, as well as project associated costs, we used a national administrative database. The rate at which the excised ureteropelvic junction obstruction (UPJO) is sent for pathologic identification is variable, arguably without a clear clinical purpose. MATERIALS / METHODS: Utilizing a national administrative database of privately insured patients, 1496 individual cases were identified using international classification of diseases (ICD) and Current Procedural Terminology (CPT) coding. Patients from 0-18 years of age were included whose pyeloplasty was performed during 2010-2014. Patients who were and were not billed for pathologic identification at time of surgery were identified. Regional practice patterns and associated costs were determined. RESULTS: One thousand four hundred and ninety-six pyeloplasty cases were identified (68.2% males). Specimens were sent for pathologic identification in 827 cases (55%). Average age was 5.8 years for those without pathology and 4.6 years for those in whom a specimen was billed. Regionally, the Western United States was least likely to bill for surgical pathology (49%). The parental out-of-pocket payment for the encounter was on average $1518 for cases in which pathology was sent and $1398 for those cases for which no pathology bill was identified. CONCLUSION: Pediatric pyeloplasty is a common surgical procedure for which a pathologic specimen is sent in as many as 55% of cases in this cohort. Regional differences exist across the country and there is an associated slightly higher out-of-pocket cost in cases for which pathologic specimens are sent at time of pyeloplasty.

The Memokath-051 Stent for the Treatment of Ureteric Obstruction: A NICE Medical Technology Guidance.

Memokath-051 is a thermo-expandable, nickel-titanium alloy spiral stent used to treat ureteric obstruction resulting from malignant or benign strictures. The National Institute for Health and Care Excellence (NICE) selected Memokath-051 for evaluation. The company, PNN Medical, claimed Memokath-051 has clinical superiority and cost savings compared with double-J stents. It identified five studies reporting clinical evidence on Memokath-051 and constructed a de novo cost model comparing Memokath-051 to double-J stents. Results indicated that Memokath-051 generated cost savings of £4156 per patient over 2.5 years. The External Assessment Centre (EAC) critiqued the company's submission and completed substantial additional work. Sixteen studies were identified assessing Memokath-051 and all listed comparators in the scope (double-J stents, reconstructive surgery and metallic and alloy stents) except nephrostomy. Similar success rates were reported for Memokath-051 compared with double-J and Resonance stents and worse outcomes compared with other options with evidence available. The EAC updated the company's cost model structure and modified several inputs. The EAC's model estimated that Memokath-051 generated savings of at least £1619 per patient over 5 years compared with double-J stents, was cost neutral compared with other metallic stents and was cost saving compared with surgery up to month 55. Overall, Memokath-051 is likely to be cost saving in patients not indicated for reconstructive surgery and those expected to require a ureteral stent for at least 30 months. The Medical Technologies Advisory Committee (MTAC) reviewed the evidence and supported the case for adoption, issuing partially supportive recommendations published after public consultation as Medical Technologies Guidance 35.

Robot-assisted laparoendoscopic single-site versus mini-laparoscopic pyeloplasty: a comparison of perioperative, functional and cosmetic results.

BACKGROUND: New approaches have been developed to further reduce the invasiveness of laparoscopic pyeloplasty (P) as treatment for uretero-pelvic junction obstruction (UPJO). Aim of the study was to compare perioperative, functional and cosmetic results of mini-laparoscopic (mL-P) versus robot-assisted laparoendoscopic single-site P (rLESS-P). METHODS: Since April 2009 to June 2010, 12 adult patients with primary UPJO, BMI<25 and no previous abdominal surgeries were enrolled undergoing mLP (3-mm instruments only). With the same indications since February 2012 to October 2013, 15 patients underwent rLESS-P with "single site"® platform (Intuitive Surgery Inc, Sunnyvale, CA, USA). Success of surgeries was determined by clinical parameters and renal scan (success if T 1/2<20 min) at 12 months postoperatively. Demographics and perioperative results were analyzed. Cosmetic results were assessed by using the Patient Scar Assessment Questionnaire (PSAQ). RESULTS: Groups were comparable at baseline. No differences were found in perioperative variables except for a longer operative time in rLESS-P group (128 vs. 190, P<0.001). Postoperative complications rate, analgesic consumption, pain visual analogue scale scores, hospital stay and success rate of surgeries were not significantly different between the groups. PSAQ revealed that in both the groups patients were satisfied with the cosmetic result. At one-year follow-up no recurrences were observed. Semiquantitative analysis of costs revealed an extra-cost for rLESS-P of € 3410 per procedure. CONCLUSIONS: In our experience, both mLP and rLESS-P appeared to be feasible and safe in the treatment of UPJO and allowed for excellent cosmetic results. r-LESS required longer operative times and higher costs.

Long-Term Percutaneous Nephrostomy Management of Malignant Urinary Obstruction: Estimation of Optimal Exchange Frequency and Estimation of the Financial Impact of Patient Compliance.

PURPOSE: To estimate the least costly routine exchange frequency for percutaneous nephrostomies (PCNs) placed for malignant urinary obstruction, as measured by annual hospital charges, and to estimate the financial impact of patient compliance. MATERIALS AND METHODS: Patients with PCNs placed for malignant urinary obstruction were studied from 2011 to 2013. Exchanges were classified as routine or due to 1 of 3 complication types: mechanical (tube dislodgment), obstruction, or infection. Representative cases were identified, and median representative charges were used as inputs for the model. Accelerated failure time and Markov chain Monte Carlo models were used to estimate distribution of exchange types and annual hospital charges under different routine exchange frequency and compliance scenarios. RESULTS: Long-term PCN management was required in 57 patients, with 87 total exchange encounters. Median representative hospital charges for pyelonephritis and obstruction were 11.8 and 9.3 times greater, respectively, than a routine exchange. The projected proportion of routine exchanges increased and the projected proportion of infection-related exchanges decreased when moving from a 90-day exchange with 50% compliance to a 60-day exchange with 75% compliance, and this was associated with a projected reduction in annual charges. Projected cost reductions resulting from increased compliance were generally greater than reductions resulting from changes in exchange frequency. CONCLUSIONS: This simulation model suggests that the optimal routine exchange interval for PCN exchange in patients with malignant urinary obstruction is approximately 60 days and that the degree of reduction in charges likely depends more on patient compliance than exact exchange interval.

Contemporary national comparison of open, laparoscopic, and robotic-assisted laparoscopic pediatric pyeloplasty.

OBJECTIVE: We sought to determine current and longitudinal trends in the usage of open (OP), laparoscopic (LP), and robotic pyeloplasties. (RALP) Furthermore, we aimed to describe patient and hospital level characteristics associated with the use of minimally invasive pyeloplasties (MIP) and to compare basic utilization metrics for each approach. MATERIALS/METHODS: The 2000, 2003, 2006, and 2009 Kid's Inpatient Databases (KID) were used to determine current and longitudinal trends. As a result of a specific billing code for robotic surgery introduced in 2008, the 2009 KID database was used for analysis of RALP. Patient and hospital characteristics examined included: age, gender, race, insurance status, hospital location, and academic status. Utilization metrics of length of stay (LOS) and cost were determined from each modality. RESULTS: In 2009, there were 3354 pediatric pyeloplasties performed in the USA (85% OP, 3% LP, 12% RP). Compared with 2000, this represents an 11.7% decrease in the overall number of pyeloplasties but a progressive increase in MIP from 0.34% in 2000 to 11.7%. Mean patient age was 3.7 years for OP, 9.3 years for LP and 9.9 years for RALP. MIP was more commonly performed in females, Caucasians, patients with private insurance, at urban hospitals and at teaching hospitals. Although length of stay (LOS) in days was statistically lower for MIP (3.46 OP, 2.86 LP, 1.96 RP, p < 0.001), total cost between the groups was not statistically different. On multivariable logistic regression analysis, age (OR 1.17, p < 0.001) increased the odds of MIP whereas lack of private insurance decreased the odds of MIP (OR 0.62, p = 0.002). CONCLUSION: Although utilization of MIP is increasing in the USA, especially in older children, OP remains predominant. MIP was associated with a decrease in LOS. The odds of MIP were higher in older children, whereas the lack of private insurance decreased the odds of MIP.

National trends of perioperative outcomes and costs for open, laparoscopic and robotic pediatric pyeloplasty.

PURPOSE: We performed a population based study comparing trends in perioperative outcomes and costs for open, laparoscopic and robotic pediatric pyeloplasty. Specific billing items contributing to cost were also investigated. MATERIALS AND METHODS: Using the Perspective database (Premier, Inc., Charlotte, North Carolina), we identified 12,662 pediatric patients who underwent open, laparoscopic and robotic pyeloplasty (ICD-9 55.87) in the United States from 2003 to 2010. Univariate and multivariate statistics were used to evaluate perioperative outcomes, complications and costs for the competing surgical approaches. Propensity weighting was used to minimize selection bias. Sampling weights were used to yield a nationally representative sample. RESULTS: A decrease in open pyeloplasty and an increase in minimally invasive pyeloplasty were observed. All procedures had low complication rates. Compared to open pyeloplasty, laparoscopic and robotic pyeloplasty had longer median operative times (240 minutes, p <0.0001 and 270 minutes, p <0.0001, respectively). There was no difference in median length of stay. Median total cost was lower among patients undergoing open vs robotic pyeloplasty ($7,221 vs $10,780, p <0.001). This cost difference was largely attributable to robotic supply costs. CONCLUSIONS: During the study period open pyeloplasty made up a declining majority of cases. Use of laparoscopic pyeloplasty plateaued, while robotic pyeloplasty increased. Operative time was longer for minimally invasive pyeloplasty, while length of stay was equivalent across all procedures. A higher cost associated with robotic pyeloplasty was driven by operating room use and robotic equipment costs, which nullified low room and board cost. This study reflects an adoption period for robotic pyeloplasty. With time, perioperative outcomes and cost may improve.

Population-based comparison of laparoscopic and open pyeloplasty in paediatric pelvi-ureteric junction obstruction.

OBJECTIVE: To describe the extent of use and in-hospital outcomes of open and laparoscopic pyeloplasty for paediatric pelvi-ureteric junction (PUJ) obstruction in the USA. PATIENTS AND METHODS: Using the 2004-2008 Nationwide Inpatient Sample, we identified 4590 paediatric patients (≤18 years old) who underwent open or laparoscopic pyeloplasty for PUJ obstruction at 195 hospitals. Multivariable regression models were used to test the associations between hospital and patient covariates (age, gender, race, primary health insurance), type of admission (emergent vs elective), and hospital characteristics (teaching vs non-teaching status; rural vs urban location) with complications, length of stay (LOS), and total hospitalization costs. RESULTS: During the 5-year study interval, 4426 (96.4%) and 164 (3.6%) paediatric patients diagnosed with PUJ obstruction underwent open and laparoscopic pyeloplasty, respectively. The proportion of patients undergoing laparoscopic pyeloplasty gradually increased from 2.4% in 2004 to 4.4% in 2008, but this increase was not significant (P = 0.22 for trend). On multivariable analysis, laparoscopic pyeloplasty was observed to have rates of postoperative complications (2.51 vs 5.00; P = 0.67), LOS (2.42 vs 2.75; P = 0.33) and total hospitalization cost ($9755 vs $8537; P = 0.24) similar to those of open pyeloplasty. CONCLUSIONS: While laparoscopic pyeloplasty was generally an infrequent operation performed for paediatric PUJ obstruction during the period studied, this minimally invasive surgery provided similar outcomes in terms of in-hospital complications, LOS and total hospitalization costs. The results of this study inform policymakers about the comparative effectiveness of laparoscopic and open pyeloplasty.

How much is a kidney worth? Cost-effectiveness of routine imaging after ureteroscopy to prevent silent obstruction.

PURPOSE: The 2012 American Urological Association (AUA) Clinical Effectiveness Protocols for Imaging in the Management of Ureteral Calculous Disease recommends routine postoperative imaging after ureteroscopy. We evaluated the cost-effectiveness of routine postoperative imaging after ureteroscopy. MATERIALS AND METHODS: We searched the literature to determine the risk of complications after routine ureteroscopy for stones, including the incidence of postoperative pain, stricture and silent obstruction. Sequelae of renal loss due to undiagnosed silent obstruction may include chronic kidney disease, end stage renal disease and cardiovascular disease. Imaging and procedure costs were obtained from Medicare reimbursement rates and the literature. The costs and prevalence of lifetime complications associated with silent loss of 1 kidney were obtained from the renal donor transplant literature. A decision tree was constructed to calculate the cost of a strategy of routinely imaging all patients after ureteroscopy vs selective imaging based on postoperative pain. We performed 1-way and 2-way sensitivity analyses. RESULTS: The average cost per patient of a strategy of routine imaging after ureteroscopy in all patients was $5,326 vs $5,196 for a strategy of selective imaging based on postoperative pain. Assuming a 2% rate of silent obstruction, the cost per kidney saved would be $6,262. CONCLUSIONS: While routine postoperative imaging carries a $130 per patient incrementally higher cost over that of a strategy of selective imaging in patients with postoperative pain, preventing renal loss and its attendant morbidity justifies the additional modest cost.

Cost analysis of pediatric robot-assisted and laparoscopic pyeloplasty.

PURPOSE: An increasing percentage of pediatric pyeloplasties are being performed with assistance of the da Vinci® Surgical System. A review of the recent literature shows decreased operative times and length of hospital stays when robotic procedures are performed, although there are few published data comparing the cost of pediatric robotic and pure laparoscopic pyeloplasty. We reviewed a representative sample of pyeloplasties performed at our institution and performed a cost analysis. MATERIALS AND METHODS: We retrospectively identified 23 robot-assisted and 23 laparoscopic pyeloplasties performed at our institution between August 2008 and April 2012. Total cost was calculated from direct and indirect costs provided by our billing department. RESULTS: Robotic procedures were shorter than pure laparoscopic procedures (200 vs 265 minutes, p <0.001) but there was no significant difference in the total cost of the 2 procedures ($15,337 vs $16,067, p <0.46). When compared to laparoscopic cases, subgroup analysis demonstrated decreased operative times (140 vs 265 minutes, p <0.00001) and total cost ($11,949 vs $16,067, p <0.0001) in robotic cases where stents were placed in an antegrade fashion. CONCLUSIONS: With widespread use the cost of robotic instrumentation may decrease, and experience may further shorten operative times. However, it currently remains to be seen whether robotic technology will become a cost-effective replacement for pure laparoscopy in the management of pediatric ureteropelvic junction obstruction.

Cost analysis of metallic ureteral stents with 12 months of follow-up.

BACKGROUND AND PURPOSE: The metallic ureteral stent was first developed for patients with ureteral obstruction related to malignant disease, but it can be used in all patients needing chronic indwelling ureteral stents, including those with benign disease. The traditional method of polymer stent management often necessitates multiple exchanges per year depending on patient and logistical factors. This has significant direct financial cost and likely a negative effect on patients' overall health. The objective was to analyze and compare the costs associated with chronic indwelling metal and silicone-based ureteral stents. PATIENTS AND METHODS: A prospective database of patients undergoing metal stent placement from February 2008 to June 2010 was reviewed. Mean charges for a single traditional nonmetal and metal stent insertion were calculated. Charges were based on direct hospital charges related to stent cost and surgery. Cost data were based on the fiscal year 2010 cost for polymer or metal stent insertions. RESULTS: Twenty-one patients underwent metal stent placement at our institution. Of these, three traditional stent placements were omitted from analysis because of bundled charges for ureteroscopy at the same setting. Mean charges per single traditional and metal stent placement were $6072.75 and $9469.50, respectively. The estimated annual charges for traditional stents (3-6 exchanges) would be $18,218.25 to $36,436.50. Compared with metal stents, this is a potential financial savings of 48% to 74%. The mean direct cost to patients was 21.6% and 25.4% of the charges for metal and polymer stents, respectively. No patient needed early discontinuation of his or her metal stent because of lower urinary tract symptoms or gross hematuria. CONCLUSIONS: Metal stents are well tolerated by patients with ureteral obstruction of various etiologies and provide a significant financial benefit compared with polymer ureteral stents. For patients who are not fit for surgical intervention regarding their ureteral occlusive disease, the metal Resonance stent is a financially advantageous and well-tolerated option.

Decision analysis for economic evaluation of the management of chronic obstructive uropathy.

OBJECTIVES: To test which is the best treatment for chronic obstructive uropathy: urinary diversion using a conventional double-J ureteral stent or the metal thermo-expandable MemokathTM 051 prosthesis. METHODS: We collected cost data of the insertion of a double-J stent taking into account preoperative and postoperative visits and surgery. Structural, medical, consumables and the prosthesis costs were considered. The estimated survival of the patient, number of spare stents and cost of each therapeutic measure were computed. Then, a simulation of the cost of inserting a MemokathTM 051 prosthesis was conducted, based on data of ureteral catheterization. We performed a decision tree and Cost Effectiveness economic analysis to measure the effectiveness of both health interventions. RESULTS: Cost data of each procedure were: 1275.44 € for the double J catheter in a program of day case surgery (DCS), 4865.16 € for the metal thermo-expandable prosthesis as DCS, and 1424.52€for the double J stent with 1 day admission and 5014.24 € for the prosthesis with 1 day admission. The cost difference between ureteral stent and metal thermo-expandable prosthesis is 3589.72 € per treatment for the ureteral stent as DCS. CONCLUSIONS: Despite its high initial cost, the metal thermo-expandable prosthesis potentially offers economic advantages over the conventional double-J ureteral stent in the treatment of long evolution ureteral obstruction. After the third change of double-J stent, and if the patient survival is long enough, the metal prosthesis as DCS should be the most cost effective option.

Human capital gains associated with robotic assisted laparoscopic pyeloplasty in children compared to open pyeloplasty.

PURPOSE: Robotic assisted laparoscopic pyeloplasty is an emerging, minimally invasive alternative to open pyeloplasty in children for ureteropelvic junction obstruction. The procedure is associated with smaller incisions and shorter hospital stays. To our knowledge previous outcome analyses have not included human capital calculations, especially regarding loss of parental workdays. We compared perioperative factors in patients who underwent robotic assisted laparoscopic and open pyeloplasty at a single institution, especially in regard to human capital changes, in an institutional cost analysis. MATERIALS AND METHODS: A total of 44 patients 2 years old or older from a single institution underwent robotic assisted (37) or open (7) pyeloplasty from 2008 to 2010. We retrospectively reviewed the charts to collect demographic and perioperative data. The human capital approach was used to calculate parental productivity losses. RESULTS: Patients who underwent robotic assisted laparoscopic pyeloplasty had a significantly shorter average hospital length of stay (1.6 vs 2.8 days, p <0.05). This correlated with an average savings of lost parental wages of $90.01 and hospitalization expenses of $612.80 per patient when excluding amortized robot costs. However, cost savings were not achieved by varying length of stay when amortized costs were included. CONCLUSIONS: Robotic assisted laparoscopic pyeloplasty in children is associated with human capital gains, eg decreased lost parental wages, and lower hospitalization expenses. Future comparative outcome analyses in children should include financial factors such as human capital loss, which can be especially important for families with young children.

Metallic ureteral stents: a cost-effective method of managing benign upper tract obstruction.

INTRODUCTION: The management of patients with upper urinary tract obstruction who are not candidates for definitive reconstruction often presents a challenge. We report our initial experience with the Resonance (Cook Urological, Spencer, IN) metallic ureteral stent for the management of benign ureteral obstruction and present a comparative cost analysis of metallic to standard polymer stent use. METHODS: Data were retrospectively gathered on all patients undergoing metallic ureteral stent placement for benign causes from July 2007 to February 2009. Baseline demographics, previous method of drainage, pre- and postoperative creatinine levels, procedural complications, stent-related side effects, and metallic stent dwell time were recorded. The cost of stent maintenance for polymer and metallic stents for a 12-month interval was calculated for each patient. RESULTS: Fifteen stents were placed in 13 patients to manage obstruction due to a variety of benign etiologies. Metallic stents provided adequate drainage in 12/13 patients, but were discontinued prematurely in 3 patients (2 for voiding symptoms, 1 for hematuria). Eight patients had their metallic stents changed after a mean time of 11.6 months, with no encrustation. The yearly cost associated with polymer and metallic stent use was $23,999 and $11,183, respectively. This amounted to a $10,394 annual cost reduction (43%) for each patient. CONCLUSIONS: Metallic ureteral stents provide effective upper tract drainage for the majority of patients with benign upper tract obstruction, with significant cost benefit, largely because of the shorter exchange interval.

One-stage tubeless antegrade ureteric stenting: a safe and cost-effective option?

INTRODUCTION: Antegrade insertion of ureteric stent has become an established mode of management of upper tract obstruction secondary to ureteric pathology. It is conventionally performed as a two-stage procedure for various reasons but, more recently, a one-stage approach has been adopted. PATIENTS AND METHODS: We discuss our experience of primary one-stage insertion of antegrade ureteric stent as a safe and cost-effective option for the management of these difficult cases in this retrospective observational case cohort study of patients referred to a radiology department for decompression of obstructed upper tracts. Data were retrieved from case notes and a radiology database for patients undergoing one-stage and two-stage antegrade stenting. It was followed by telephone survey of regional centres about the prevalent local practice for antegrade stenting. Outcome measures like hospital stay, procedural costs, requirement of analgesia/antimicrobials and complication rates were compared for the two approaches. RESULTS: a one-stage approach was found to be suitable in most cases with many advantages over the two-stage approach with comparable or better outcomes at lower costs. Some of the limitations of the study were retrospective data collection, more than one radiologist performing stenting procedures and non-availability of interventional radiologist falsely raising the incidence of two-stage procedures. CONCLUSIONS: In the absence of any clinical contra-indications and subject to availability of an interventional radiologist's support, one-stage antegrade stenting could easily be adopted as a routine approach for the management of benign or malignant ureteric obstruction.

The value of newborn urinary proteome analysis in the evaluation and management of ureteropelvic junction obstruction: a cost-effectiveness study.

PURPOSE: The cornerstone of management in newborns with ureteropelvic junction obstruction (UPJO) is serial imaging over time. Surgery is undertaken for disease progression. A marker of disease progression would select out those likely to progress for early surgery and diminish the intensity of imaging and follow-up in the remainder. Recently, urinary proteome analysis in the newborn has been reported to fulfill this aim. The objective of this study is to quantitatively evaluate the effect of this matrix of protein biomarkers on the overall cost-effectiveness (C-E) of UPJO evaluation and management. METHODS: A Markov process decision tree model (Tree Age Pro software, Boston, MA) is created to compare the current strategy (watchful waiting) to one incorporating a urine proteome analysis at birth as a marker of disease progression. The analysis includes the costs of surgery, imaging and office visits based on hospital charge data. We analyze a total of 53 variables. RESULTS: The incorporation of this marker of progression results on the average, in an incremental C-E gain of 8,000 US dollars per quality adjusted life year (QALY) per patient compared to the current strategy of watchful waiting. The results are not sensitive to variation of any of the probabilities including costs and quality of life parameters used for the base-case analysis. CONCLUSIONS: The incorporation of urinary proteome analysis in the initial evaluation of UPJO significantly reduces costs and increases the QALYs in this patient population. The test increases the odds of detecting UPJO progression from 1:3 to 1:1, while improving the overall C-E. These findings justify continued research in this area which in addition may have important applications in evaluating treatment outcomes.

Surgical management of congenital ureteropelvic junction obstruction: a Pediatric Health Information System database study.

PURPOSE: Although laparoscopic pyeloplasty has gained popularity, to our knowledge no multi-institutional study has evaluated the prevalence of this approach in children. We used a multicenter database to determine trends in the treatment of congenital ureteropelvic junction obstruction. MATERIALS AND METHODS: The Pediatric Health Information System database contains data on 37 freestanding hospitals for children across the United States. We extracted data on 0 to 19-year-old patients from 2001 to 2006 with the ICD-9 diagnosis code for congenital ureteropelvic junction obstruction and the procedure code for the correction of ureteropelvic junction obstruction. We identified laparoscopic cases based on hospital charges for 1) laparoscope, 2) trocar, 3) insufflating needle or 4) insufflator and tubing. Data were then analyzed using the chi-square and Student t tests to determine management trends. RESULTS: We identified 2,353 patients, of whom 2,177 (92.5%) underwent open pyeloplasty and 176 (7.5%) underwent laparoscopic pyeloplasty. The percent of pediatric pyeloplasties performed laparoscopically increased from 2001 to 2003 (2.53% to 9.73%) and has since remained stable. Patients undergoing laparoscopic pyeloplasty were significantly older than those in the open group (age 8.2 vs 3.3 years, p <0.0001). Average hospital charges were significantly higher in the laparoscopic group than in the open group ($23,295.71 vs $16,467.49, p <0.05). There was no significant difference in terms of race, gender or length of stay. CONCLUSIONS: The percent of pediatric pyeloplasties performed laparoscopically has increased with time. However, laparoscopic pyeloplasty is associated with higher hospital charges than open surgery without a significant decrease in length of stay.

Outcomes and cost analysis of pyeloplasty for antenatally diagnosed ureteropelvic junction obstruction using Markov models.

OBJECTIVES: The optimal timing of pyeloplasty for children diagnosed with ureteropelvic junction obstruction (UPJO) after workup for antenatal hydronephrosis is disputed. We sought to examine the potential costs and clinical outcomes of treatment protocols featuring different indications for pediatric pyeloplasty using Markov models. METHODS: Cost and outcomes analysis using Markov modeling was performed for three treatment algorithms: medical management, immediate pyeloplasty (during the first year of life), and pyeloplasty after no improvement on imaging. The costs were determined from the perspective of the medical institution. The variables tracked during Markov model simulation included age at resolution of UPJO, the proportion of patients with worsened hydronephrosis, the number of pyeloplasties, the number of pyelonephritis episodes, and costs. Sensitivity analyses were performed to determine which elements affected the model and to determine threshold values. RESULTS: Immediate pyeloplasty and pyeloplasty after no improvement on imaging resulted in rapid resolution of UPJO (mean age at resolution younger than 2 years) with lower rates of worsened hydronephrosis and pyelonephritis compared with observation alone. For the surgical protocols, the costs per resolved case of UPJO were greater than those for medical management alone at the probability values tested in the Markov models. The sensitivity analysis of all variables over realistic ranges demonstrated that the costs of surgery, annual antibiotics and imaging, and the rate of pyelonephritis were critical in determining the costs. CONCLUSIONS: Pediatric urologists should include practice-specific features such as the costs of surgery, annual antibiotics and imaging, and pyelonephritis rates when considering efficacious, yet less costly, treatment protocols for UPJO.

Ureteropelvic junction obstruction.

PURPOSE: We quantified the burden of ureteropelvic junction obstruction in the United States by identifying trends in the use of health care resources and estimating the economic impact of the disease. MATERIALS AND METHODS: The analytical methods used to generate these results were described previously. RESULTS: Inpatient hospitalization rates were highest in children younger than 3 years. Most patients were male and hospitalizations occurred almost exclusively at urban centers. Patients with a primary diagnosis of ureteropelvic junction obstruction between 1994 and 2000 had an overall decrease in the age adjusted rate of inpatient hospitalization from 1.1/100,000 to 0.8/100,000. Physician office visits by Medicare beneficiaries with ureteropelvic junction obstruction as the primary diagnosis showed stable overall age adjusted rates during the reported years. Between 1999 and 2003 mean inpatient length of stay and cost per child hospitalized with the primary diagnosis of ureteropelvic junction obstruction was 2.9 days and $7,728, respectively. Average length of stay decreased more for children than for adults but total inpatient spending remained stable at about $12 million. CONCLUSIONS: The majority of ureteropelvic junction obstructions are diagnosed in the perinatal period. Surgical intervention for pediatric patients has decreased with time, while there has been an increasing trend toward the conservative management of this condition.