Retrograde stent with external string for pediatric robotic pyeloplasty: does it reduce cost and complications?

Robotic-assisted pyeloplasty (RAP) is a mainstay in the treatment of ureteropelvic junction obstruction (UPJO) in children. At our institution, to limit planned operating rooms visits we have placed a ureteral stent with an external string (SWES) immediately prior to RAP. In this study, we sought to quantify the operative time, complications, and costs associated with this approach compared to the traditional approach, requiring subsequent stent removal in the operating room. We hypothesized the SWES cohort would have decreased cost, yet with similar operative time and complications. We retrospectively collected all RAPs performed at our institution using the SWES approach (Aug 2012-July 2017). We excluded those with a redo pyeloplasty, and/or a percutaneous nephrostomy tube for post-operative drainage. We collected 30-day costs linked to the patients' MRN using the Pediatric Health Information System (PHIS) database. We compared 30-day healthare costs for all patients following RAP. We compared our SWES group to a national cohort of all pediatric RAP during the same time period. Lastly, we sent an anonymous, electronic survey to urologists of all PHIS institutions to identify the predominant postoperative drainage, nationally. Within our institution, we reviewed all those treated with SWES (n = 85) (Table 1). The median 30-day cost was $10,548 among those with SWES (Table 2). This was significantly less than the overall, national cohort of all pediatric RAP during the same period ($14,119, p < 0.001). There was a 15.5 % rate of unplanned return to the hospital in the SWES group. Of those unplanned returns, 8.2 % (7/85) had unplanned return for a procedure (3 for unplanned stent removal, 2 for nephrostomy tube for persistent obstruction, 1 for omental hernia, and 1 for stent replacement). With a 42.5 % (37/87) response rate, our nationwide survey found 84.6 % primarily leave stents WITHOUT a string, 7.7 % left nephrostomy tubes, and 7.7 % stents with strings. During pediatric RAP, placement of a SWES takes little time, carries a risk of unplanned visit to the operating room, saves the patient a certain, second anesthetic for stent removal, and amounts to a cost savings of approximately 25 %.

Single Port Robotic Surgery in Urology.

PURPOSE: To provide a comprehensive review on the new da Vinci SP (single port) robotic surgical system. The published literature to date within urology and a description of the new system will be discussed. FINDINGS: There are currently no high-quality published studies with the SP robotic system. All studies are case series, many with 10 or fewer patients. However, all studies have found the SP system to be safe and feasible in performing most urological procedures. Renal and pelvic surgery using the SP robotic system is safe and feasible in the hands of expert robotic surgeons. Long-term, high-quality data is lacking. While the current high price and the learning curve will limit the SP systems' use in many health care systems, new updates and the release of robotic surgical systems from other developers may help drive down costs and encourage uptake.

Outcomes and costs analysis of Externalized PyeloUreteral versus internal Double-J ureteral stents after paediatric laparoscopic Anderson-Hynes pyeloplasty.

BACKGROUND: The gold standard treatment for Uretero-Pelvic Junction Obstruction (UPJO) is laparoscopic dismembered pyeloplasty according to the Anderson-Hynes technique. The internal Double-J ureteral (DJ) and the Externalized PyeloUreteral (EPU) stents are usually the drainage of choice. Only a few articles have compared the clinical impact of the different drainage techniques on the perioperative morbidity and none presented a cost analysis of the incurred hospital stay. OBJECTIVE: To present the clinical outcome and financial analysis of a cohort of children who underwent a laparoscopic pyeloplasty comparing the use of the DJ versus EPU stent. STUDY DESIGN: Retrospective study of consecutives children who underwent laparoscopic Anderson-Hynes pyeloplasty in a single tertiary paediatric referral centre from January 2017 to March 2020. Patients were grouped according to the type of stent used: DJ stent vs EPU stent. RESULTS: Fifty-three laparoscopic pyeloplasties were performed on 51 patients: 27 (50.9%) had an EPU stent and 26 (49.1%) a DJ stent. There was no statistically significant difference between the two patient groups with regards to surgical time, hospital stay, stent-related complications or the need for re-do surgery. All the EPU stents were removed with an outpatient admission 8.1 days ± 3.1 after surgery while the DJ stents were removed with a cystoscopy 61.6 days ± 30.2 after surgery (p value < 0.001). On a financial analysis (Figure), the hospital costs for stent removal were significantly lower for the EPU stent group (£ 686.7 ± 263.4 vs £ 1425 ± 299.5, p value < 0.01). DISCUSSION: Both drainage methods have some disadvantages. Possible complications associated with DJ stents include migration and artificial vesicoureteral reflux which may lead to higher incidence of Urinary Tract Infections. Possible disadvantages of the EPU stent insertion are related to the damage of the renal parenchyma and to the risk of developing skin site infections and urinary leaks. However, in our series the EPU stent has not been associated with a higher incidence of bleeding, leakage or discomfort. In addition to clinical considerations, there is a financial implication to be considered. With this regard, the EPU stent was associated with a significant reduction in the incurred hospital costs. CONCLUSIONS: The use of DJ and EPU stents is equivalent in regards of overall complications and success rates. DJ and EPU stents provided comparable success and complication rates, however the latter avoids the need of an additional general anaesthesia and reduces the overall incurred hospital costs.

Point-of-care ultrasound is an accurate, time-saving, and cost-effective modality for post-operative imaging after pyeloplasty.

BACKGROUND: Dismembered pyeloplasty is considered the gold standard treatment for ureteropelvic junction obstruction (UPJO). Although the frequency and timing of follow up imaging after pyeloplasty is variable, renal ultrasound (RUS) is commonly utilized. With minimal training, point-of-care ultrasound (POCUS) can be easily performed by a urologist during a post-operative visit. OBJECTIVE: Our hypothesis is that POCUS is an accurate, time-saving, and cost-effective alternative to a complete retroperitoneal ultrasound (CRUS) performed by the Radiology Department after pyeloplasty. STUDY DESIGN: The clinical records of all children who underwent pyeloplasty (by any method) over a 12 month period at our institution were retrospectively reviewed. The exact timing and method (POCUS vs. CRUS) of follow up imaging was surgeon-dependent. Statistical analysis was performed to compare the time and cost of POCUS vs. CRUS. The clinical course of each patient who had each type of imaging was assessed. RESULTS: A total 45 patients were included in this analysis. Over a mean follow up period of 29 months, a total of 73 CRUS and 67 POCUS were performed. Each CRUS on average added 2 h to each patient's healthcare encounter. Had the 73 CRUS been performed as POCUS instead, this would have corresponded to $83,751 less charges to payers. There was no difference in the rate of the detection of worsening, stable, or improved hydronephrosis (HN) between either modality (p > 0.05). The recommended follow up time for observed HN was no different between CRUS and POCUS (p > 0.05). Children with worsening HN on POCUS underwent functional studies without confirmatory CRUS. Interestingly, two patients had metachronous, contralateral UPJO discovered during post-operative imaging. These were both discovered by POCUS. Nineteen (42%) patients who had attended at least one post-operative visit were eventually loss to follow-up. This occurred exclusively in those who did not have worsening ultrasound (p < 0.01). There was no difference in the loss to follow-up after POCUS (8) or CRUS (12) (p > 0.05). CONCLUSIONS: POCUS performed by a urologist is an accurate assessment of HN after pyeloplasty with time and cost savings to compared to a CRUS performed by a radiologist. POCUS is not associated with any difference in rate of detection of worsening HN or rate of loss to follow up.

Learning robotic pyeloplasty without simulators: an assessment of the learning curve in the early robotic era.

OBJECTIVE: To analyze our experience and learning curve for robotic pyeloplasty during this robotic procedure. METHODS: Ninety-nine patients underwent 100 consecutive procedures. Cases were divided into 4 groups of 25 consecutive procedures to analyze the learning curve. RESULTS: The median anastomosis times were 50.0, 36.8, 34.2 and 29.0 minutes (p=0.137) in the sequential groups, respectively. The median operative times were 144.6, 119.2, 114.5 and 94.6 minutes, with a significant difference between groups 1 and 2 (p=0.015), 1 and 3 (p=0.002), 1 and 4 (p<0.001) and 2 and 4 (p=0.022). The mean hospital stay was 7.08, 4.76, 4.88 and 4.20 days, with a difference between groups 1 and 2 (p<0.001), 1 and 3 (p<0.001) and 1 and 4 (p<0.001). Clinical and radiological improvements were observed in 98.9% of patients. One patient presented with recurrent obstruction. CONCLUSIONS: Our results demonstrate a high success rate with low complication rates. A significant decrease in hospital stay and surgical time was evident after 25 cases.

Learning robotic pyeloplasty without simulators: an assessment of the learning curve in the early robotic era

OBJECTIVE: To analyze our experience and learning curve for robotic pyeloplasty during this robotic procedure. METHODS: Ninety-nine patients underwent 100 consecutive procedures. Cases were divided into 4 groups of 25 consecutive procedures to analyze the learning curve. RESULTS: The median anastomosis times were 50.0, 36.8, 34.2 and 29.0 minutes (p=0.137) in the sequential groups, respectively. The median operative times were 144.6, 119.2, 114.5 and 94.6 minutes, with a significant difference between groups 1 and 2 (p=0.015), 1 and 3 (p=0.002), 1 and 4 (p<0.001) and 2 and 4 (p=0.022). The mean hospital stay was 7.08, 4.76, 4.88 and 4.20 days, with a difference between groups 1 and 2 (p<0.001), 1 and 3 (p<0.001) and 1 and 4 (p<0.001). Clinical and radiological improvements were observed in 98.9% of patients. One patient presented with recurrent obstruction. CONCLUSIONS: Our results demonstrate a high success rate with low complication rates. A significant decrease in hospital stay and surgical time was evident after 25 cases.

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.

Has the robot caught up? National trends in utilization, perioperative outcomes, and cost for open, laparoscopic, and robotic pediatric pyeloplasty in the United States from 2003 to 2015.

INTRODUCTION: Since 2010, there have been few new data comparing perioperative outcomes and cost between open (OP) and robotic pyeloplasty (RP). In a post-adoption era, the value of RP may be converging with that of OP. OBJECTIVE: To 1) characterize national trends in pyeloplasty utilization through 2015, 2) compare adjusted outcomes and median costs between OP and RP, and 3) determine the primary cost drivers for each procedure. STUDY DESIGN: We performed a retrospective cohort study using the Premier database, which provides a nationally representative sample of U.S. hospitalizations between 2003 and 2015. ICD9 codes and itemized billing were used to abstract our cohorts. Trends in utilization and cost were calculated and then stratified by age. We used propensity scores to weight our cohorts and then applied regression models to measure differences in the probability of prolonged operative time (pOT), prolonged length of stay (pLOS), complications, and cost. RESULTS: During the study period 11,899 pyeloplasties were performed: 75% open, 10% laparoscopic, and 15% robotic. The total number of pyeloplasty cases decreased by 7% annually; OP decreased by a rate of 10% while RP grew by 29% annually. In 2015, RP accounted for 40% of cases. The largest growth in RPs was among children and adolescents. The average annual rate of change in cost for RP and OP was near stagnant: -0.5% for open and -0.2% for robotic. The summary table provides results from our regression analyses. RP conferred an increased likelihood of pOT, but a reduced likelihood of pLOS. The odds of complications were equivalent. RP was associated with a significantly higher median cost, but the absolute difference per case was $1060. DISCUSSION: Despite advantages in room and board costs for RP, we found that the cost of equipment and OR time continue to make it more expensive. Although the absolute difference may be nominal, we likely underestimate the true cost because we did not capture amortization, hidden or down-stream costs. In addition, we did not measure patient satisfaction and pain control, which may provide the non-monetary data needed for comparative value. CONCLUSION: Despite an overall decline in pyeloplasties, RP utilization continues to increase. There has been little change in cost over time, and RP remains more expensive because of equipment and OR costs. The robotic approach confers a reduced likelihood of pLOS, but an increased likelihood of pOT. Complication rates are low and similar in each cohort.

Low-Cost Training Simulator for Open Dismembered Pyeloplasty: Development and Face Validation.

PURPOSE: Surgical simulation has benefited from a surge in interest over the last decade because of the increasing need for a change in the traditional apprenticeship model of teaching surgery. Open surgery for ureteropelvic junction (UPJ) poses unique training challenges owing to smaller workspaces, and finer sutures used that require increased surgical dexterity when compared with adult analogues. We describe the development and face validation of a low-cost training simulator for open dismembered pyeloplasty. MATERIALS AND METHODS: The simulator is built with A4 Kraft envelopes, catheter tip syringe filled with 30mL of air, tape, 260 modeling balloon, and 11-in party balloon. Evaluation of the device is based on an evaluation form including 11 items on a 5-point Likert-type scale. Thirty-one departments of pediatric surgery in France were contacted and received a pack containing 4 to 10 devices, already set up and ready for use, a tutorial and an evaluation form. Candidates were stratified according to their level of expertise. RESULTS: A total of 180 devices were sent. Procedures on the device were performed 118 times (65%) by expert surgeons (n = 44), fellows (n = 25), and residents (n = 49). Statistically significant difference was noted for 4 items (anatomy, model exposition, UPJ resection, and difficulty) for the 3 levels of expertise. The global score evaluation for realistic items, face validity, and usability was 4.2 (range: 1-5). CONCLUSION: This low-cost model is evaluated as an efficient tool for UPJ teaching and training. It shows promise as an educational tool.

Robotic surgery start-up with a fellow as the console surgeon.

OBJECTIVE: Owing to the encouraging data on fellowship training in robotic pyeloplasty and the documented benefits of robotic pyeloplasty, the aim of this study was to test the feasibility of starting up pediatric urological robotic surgery in a center with a limited case volume. MATERIALS AND METHODS: The operative parameters and clinical outcome of the first 25 robotic pyeloplasties performed were compared to data on open and laparoscopic procedures from the previous 5 year period. The fellow was the only console surgeon. An experienced non-robotic pediatric urologist was supervising at the patient site. RESULTS: The learning curve was in accordance with previously published data on fellows. The median operating time in robotic surgery was 182 min and was significantly shorter than in laparoscopic surgery (median 250 min) and the postoperative inpatient length of stay was significantly shorter after robotic surgery (median 1 day) than after both laparoscopic (median 2 days) and open surgery (median 3.5 days). For robotic cases, postoperative renography showed either stable or increased function of the hydronephrotic kidney. The only complication was in one case with ureteral orifice edema after JJ-stent removal, requiring nephrostomy for 6 weeks. CONCLUSIONS: The benefits of overall shorter postoperative hospital stay after robotic pyeloplasty and faster operating time compared to the laparoscopic procedure are clearly in accordance with data from the recent literature. The fast learning curve for robotic pyeloplasty will allow pediatric urology fellowship programs to be integrated in the start-up phase of a pediatric robotic program even though the case material is limited. Operative success rates were in accordance with the gold standard of open surgery.

Cost Analysis of Treatments for Ureteropelvic Junction Obstruction.

BACKGROUND AND PURPOSE: Ureteropelvic junction obstruction is a common urologic condition that accounts for approximately $12 million in inpatient spending annually. Few studies have assessed the costs related to treatment. We sought to examine the cost of care for patients treated for ureteropelvic junction obstruction. PATIENTS AND METHODS: We used the MarketScan® database to identify adults from 18 to 64 years old treated with minimally invasive pyeloplasty, open pyeloplasty, and endopyelotomy for ureteropelvic junction obstruction between 2002 and 2010. Our primary outcome was total expenditures related to the surgical episode, defined as the period from 30 days prior until 30 days after the index surgery. We fit a multinomial linear regression model to evaluate cost of the surgical episode, adjusting for age, gender, comorbidity, benefit plan type, and region of residence. RESULTS: We identified 1251 endopyelotomies, 717 open pyeloplasties, and 1048 minimally invasive pyeloplasties. The adjusted mean costs were $16,379 for endopyelotomy, $22,421 for open pyeloplasty, and $22,843 for minimally invasive pyeloplasty (p < 0.0001, ANCOVA). Both open and minimally invasive pyeloplasties were more costly than endopyelotomy (both p < 0.0001, comparison between groups). However, the cost of open and minimally invasive pyeloplasties was similar (p = 0.57, comparison between groups). CONCLUSIONS: Among the three treatments, endopyelotomy was the least expensive in the immediate perioperative period. Open and minimally invasive pyeloplasties were similar in cost, but both more expensive than endopyelotomies. The similar cost between the two pyeloplasty approaches provides additional evidence that minimally invasive pyeloplasty should be considered the standard treatment for ureteropelvic junction obstruction.

Epidemiology, diagnosis, preoperative evaluation and prognostic assessment of upper-tract urothelial carcinoma (UTUC).

PURPOSE: Upper-tract urothelial carcinoma (UTUC) is a relatively uncommon disease with limited available evidence on specific topics. The purpose of this article was to review the previous literature to summarize the current knowledge about UTUC epidemiology, diagnosis, preoperative evaluation and prognostic assessment. METHODS: Using MEDLINE, a non-systematic review was performed including articles between January 2000 and February 2016. English language original articles, reviews and editorials were selected based on their clinical relevance. RESULTS: UTUC accounts for 5-10 % of all urothelial cancers, with an increasing incidence. UTUC and bladder cancer share some common risk factors, even if they are two different entities regarding practical, biological and clinical characteristics. Aristolochic acid plays an important role in UTUC pathogenesis in certain regions. It is further estimated that approximately 10 % of UTUC are part of the hereditary non-polyposis colorectal cancer spectrum disease. UTUC diagnosis remains mainly based on imaging and endoscopy, but development of new technologies is rapidly changing the diagnosis algorithm. To help the decision-making process regarding surgical treatment, extent of lymphadenectomy and selection of neoadjuvant systemic therapies, predictive tools based on preoperative patient and tumor characteristics have been developed. CONCLUSIONS: Awareness regarding epidemiology, diagnosis, preoperative evaluation and prognostic assessment changes is essential to correctly diagnose and manage UTUC patients, thereby potentially improving their outcomes.

High-pressure balloon assessment of pelviureteric junction prior to laparoscopic "vascular hitch".

AIM: To assess if calibration of the ureteropelvic junction (UPJ) using a high-pressure balloon inflated at the UPJ level in patients with suspected crossing vessels (CV) could differentiate between intrinsic and extrinsic stenosis prior to laparoscopic vascular hitch (VH). MATERIALS AND METHODS: We reviewed patients with UPJO diagnosed at childhood or adolescence without previous evidence of antenatal or infant hydronephrosis (10 patients). By cystoscopy, a high-pressure balloon is sited at the UPJ and the balloon inflated to 8-12 atm under radiological screening. We considered intrinsic PUJO to be presente where a 'waist' was observed at the PUJ on inflation of the balloon and a laparoscopic dismembered pyeloplasty is performed When no 'waist' is observed we considered this to represent extrinsic stenosis and a laparoscopic VH was performed. Patients with absence of intrinsic PUJ stenosis documented with this method are included for the study. RESULTS: Six patients presented pure extrinsic stenosis. The mean age at presentation was 10.8 years. Mean duration of surgery was 99 min and mean hospital stay was 24 hours in all cases. We found no intraoperative or postoperative complications. All children remain symptoms free at a mean follow up of 14 months. Ultrasound and renogram improved in all cases. CONCLUSION: When no 'waist' is observed we considered this to represent extrinsic stenosis and a laparoscopic VH was performed. In these patients, laparoscopic transposition of lower pole crossing vessels ('vascular hitch') may be a safe and reliable surgical technique.

High-pressure balloon assessment of pelviureteric junction prior to laparoscopic "vascular hitch"

ABSTRACT Aim To assess if calibration of the ureteropelvic junction (UPJ) using a high-pressure balloon inflated at the UPJ level in patients with suspected crossing vessels (CV) could differentiate between intrinsic and extrinsic stenosis prior to laparoscopic vascular hitch (VH). Materials and Methods We reviewed patients with UPJO diagnosed at childhood or adolescence without previous evidence of antenatal or infant hydronephrosis (10 patients). By cystoscopy, a high-pressure balloon is sited at the UPJ and the balloon inflated to 8-12 atm under radiological screening. We considered intrinsic PUJO to be present where a ‘waist’ was observed at the PUJ on inflation of the balloon and a laparoscopic dismembered pyeloplasty is performed When no ‘waist’ is observed we considered this to represent extrinsic stenosis and a laparoscopic VH was performed. Patients with absence of intrinsic PUJ stenosis documented with this method are included for the study. Results Six patients presented pure extrinsic stenosis. The mean age at presentation was 10.8 years. Mean duration of surgery was 99 min and mean hospital stay was 24 hours in all cases. We found no intraoperative or postoperative complications. All children remain symptoms free at a mean follow up of 14 months. Ultrasound and renogram improved in all cases. Conclusion When no ‘waist’ is observed we considered this to represent extrinsic stenosis and a laparoscopic VH was performed. In these patients, laparoscopic transposition of lower pole crossing vessels (‘vascular hitch’) may be a safe and reliable surgical technique.

Three-dimensional Technology Facilitates Surgical Performance of Novice Laparoscopy Surgeons: A Quantitative Assessment on a Porcine Kidney Model.

OBJECTIVE: To determine whether the use of 3-dimensional (3D) imaging translates into a better surgical performance of naïve urologic laparoscopic surgeons during pyeloplasty (PY) and partial nephrectomy (PN) procedures. MATERIALS AND METHODS: Eighteen surgeons without any previous laparoscopic experience were randomly assigned to perform PY and PN in a porcine model using initially 2-dimensional (2D) and 3D laparoscopy. A surgical performance score was rated by an "expert" tutor through a modified 5-item global rating scale contemplating operative field view, bimanual dexterity, efficiency, tissue handling, and autonomy. Overall surgical time, complications, subjective perception of participating surgeons, and inconveniences related to the 3D vision were recorded. RESULTS: No difference in terms if operative time was found between 2D or 3D laparoscopy for both the PY (P = .51) and the PN (P = .28) procedures. A better rate in terms of surgical performance score was noted by the tutors when the study participants were using 3D vs 2D, for both PY (3.6 [0.8] vs 3.0 [0.4]; P = .034) and PN (3.6 [0.51] vs 3.15 [0.63]; P = .001). No complications occurred in any of the procedures. Most (77.2%) of the participating naïve laparoscopic surgeons had the perception that 3D laparoscopy was overall easier than 2D. Headache (18.1%), nausea (18.1%), and visual disturbance (18.1%) were the most common issues reported by the surgeons during 3D procedures. CONCLUSION: Despite the absence of translation in a shorter operative time, the use of 3D technology seems to facilitate the surgical performance of naïve surgeons during laparoscopic kidney procedures on a porcine model.

Contemporary assessment of renal stone complexity using cross-sectional imaging.

Recently, several scoring systems have been proposed to predict outcomes of percutaneous nephrolithotomy, objectively and quantitatively assessing kidney calculi complexity using cross-sectional imaging. These scoring systems are promising new tools that can guide surgical decision making, predict surgical outcomes, counsel patients undergoing stone surgery, and improve standardized academic reporting in percutaneous kidney stone surgery. In this article, we review features of each of these systems, their similarities and differences, and their applicability in clinical practice and relevance in academic reporting.

Comparative study for evaluating the cosmetic outcome of small-incision access retroperitoneoscopic technique (SMART) with standard retroperitoneoscopy using the Observer Scar Assessment Scale: are small incisions a big deal?

AIM: To compare the scars and cosmetic results of trocars of 3, 5, and 10 mm in cases by small-incision access retroperitoneoscopic technique pyeloplasty (SMARTp) and standard laparoscopy pyeloplasty (SLp). METHODS: Between January 2012 and October 2013, 20 pyeloplasties were performed: 12 with SMARTp and 8 with SLp techniques. A 5-mm homemade balloon trocar was used to create the retroperitoneal space. In SMARTp, 3- and 5-mm trocars were used and in SLp, 5- and 10-mm trocars were used. All patients underwent a ureteral (Double-J) stent placement preoperatively. The study included a total of 72 trocar-site scars: 3 mm (24 scars), 5 mm (24 scars), and 10 mm (24 scars). Cosmetic outcome was assessed at the 3rd, 12th, and 24th month of surgeries by the Observer Scar Assessment Scale (OSAS). RESULTS: Mean age was 34.7±10.5 (19-52) years, and mean follow up was 18.7±9.2 months. Fifteen patients (75%) underwent Y-V plasty, and 5 (25%) underwent Anderson-Hynes pyeloplasty. Mean operative time was 125.4±28.7 minutes. There was only minimal blood loss, no need for conversion to standard laparoscopic or open pyeloplasty, no intraoperative complications, and only two postoperative complications were recorded: retroperitoneal hemorrhage and wound infection and both were treated conservatively. There were significant differences between objective questions of "vascularization" in a 3-mm trocar and "thickness" in a 10-mm trocar. Twenty-four months after surgery, the cosmetic data assessed by OSAS showed statistically significant differenecs in favor of the 3-mm trocar sites versus the 10-mm trocar sites (OSAS: 13.8±3.9 vs 24.6±1.7; p=0.006) with no statistically significant difference between 3- and 5-mm port sites. CONCLUSIONS: The SMARTp is proved to be an efficacious and tolerable procedure with better cosmetic results and can be used for the treatment of ureteropelvic junction obstruction (UPJO) in suitable patients. We believe that this technique is likely to become an established procedure.

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.