Incidence and management of BPH surgery-related urethral stricture: results from a large U.S. database.

INTRODUCTION AND OBJECTIVES: Urethral stricture (US) is a well-known complication after surgical treatment of benign prostatic hyperplasia (BPH). This study aimed to evaluate the contemporary incidence of the US after different types of BPH surgery, to identify associated risk factors and to assess its management. METHODS: A retrospective analysis was conducted using the PearlDiver™ Mariner database, containing de-identified patient records compiled between 2011 and 2022. Specific International Classification of Diseases (ICD) and Current Procedural Terminology (CPT) codes were employed to identify population characteristics and outcomes. All the most employed surgical procedures for BPH treatment were considered. Multivariable logistic regression was employed to evaluate factors associated with diagnosis of post-operative US. RESULTS: Among 274,808 patients who underwent BPH surgery, 10,918 developed post-operative US (3.97%) within 12 months. Higher incidence of US was observed following TURP (4.48%), Transurethral Incision of the Prostate (TUIP) (3.67%), Photoselective Vaporization of the Prostate (PVP) (3.92%), HoLEP/ThuLEP (3.85%), and open Simple Prostatectomy (SP) (3.21%). Lower incidence rates were observed after laparoscopic\robot-assisted SP (1.76%), Aquablation (1.59%), Prostatic Urethral Lift (PUL) (1.07%), Rezum (1.05%), and Prostatic Artery Embolization (PAE) (0.65%). Multivariable analysis showed that patients undergoing PUL, Rezum, Aquablation, PAE, and PVP were associated with a reduced likelihood of developing US compared to TURP. US required surgical treatment in 18.95% of patients, with direct visual internal urethrotomy (DVIU) and urethroplasty performed in 14.55% and 4.50% of cases, respectively. Urethral dilatation (UD) in an outpatient setting was the primary management in most cases (76.7%). CONCLUSIONS: The present analysis from a contemporary large dataset suggests that the incidence of US after BPH surgery is relatively low (<5%) and varies among procedures. Around 94% of US cases following BPH surgery are managed using minimally invasive treatment approaches such as UD and DVIU.

Benign Prostatic Hyperplasia Surgery: A Snapshot of Trends, Costs, and Surgical Retreatment Rates in the USA.

BACKGROUND: An increasing number of novel surgical treatments (NSTs) for benign prostatic hyperplasia (BPH) have been proposed over time to achieve similar functional outcomes, but better perioperative and sexual outcomes than traditional procedures. OBJECTIVE: To assess the trends in the utilization and costs of BPH surgical procedures over the past decade, and to analyze the need for surgical retreatment after each procedure. DESIGN, SETTING, AND PARTICIPANTS: A retrospective observational population-based analysis was conducted using the PearlDiver Mariner (PearlDiver Technologies, Colorado Springs, CO, USA) database, including all-payer nationally available claims records collected from 2011 to 2022. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: The number and type of BPH surgical procedures per year, costs associated with each BPH surgical treatment, incidence of BPH surgical retreatment rate, and time to BPH surgical retreatment were assessed. Negative binomial regression and Cochran-Armitage test were used for the temporal trend analysis. A multivariable logistic regression analysis evaluated the predictors of BPH surgical retreatment. RESULTS AND LIMITATIONS: In the study period, 274 808 patients received surgical treatment for BPH. The most common procedure was transurethral resection of the prostate (TURP; 71.7%). The overall utilization of BPH surgical treatment increased over the study period. Traditional surgery remained most performed for the entire period (87.8%), but a statistically significantly rising trend of NSTs was recorded. The mean reimbursements paid per procedure was 1.43 times higher (p < 0.001) for NSTs than for traditional procedures. The surgical retreatment rate was 9.4%. The mean time to surgical retreatment was 25.3 mo, with 85.5% of cases re-treated within 5 yr. At the multivariable analysis, transurethral incision of the prostate, photoselective vaporization of the prostate, prostatic urethral lift, convective water vapor energy, and prostatic artery embolization had a significantly greater likelihood of surgical retreatment than TURP. Holmium/thulium laser enucleation of the prostate (HoLEP/ThuLEP), open simple prostatectomy (SP), and laparoscopic/robot-assisted SP were associated with a lower probability of resurgery than TURP, but a similar probability between these procedures. Retrospective design and a lack of relevant clinical data were the main limitations. CONCLUSIONS: Over the past decade, there has been a progressive increase in the adoption of NSTs. The rate of surgical retreatment appears <10%, with patients undergoing SP and HoLEP/ThuLEP experiencing a statistically significantly lower probability of surgical retreatment. PATIENT SUMMARY: We investigated the trends, costs, and surgical retreatments of benign prostatic hyperplasia surgery. Transurethral resection of the prostate remains the most common procedure. Novel surgical treatments are associated with an upward trend, despite appearing more expensive overall. Retreatment is necessary in <10% of patients and generally within 5 yr.

Trends and Costs of Minimally Invasive Surgery for Kidney Cancer in the US: A Population-based Study.

OBJECTIVE: To analyze temporal trends and costs associated with the use of minimally invasive surgery (MIS) for kidney cancer in the US over the past decade. To examine the impact of social determinants of health (SDOH) on perioperative outcomes. METHODS: The PearlDiver Mariner, a national database of insurance billing records, was queried for this retrospective observational cohort analysis. The MIS population was identified and stratified according to treatment modality, using International Classification of Diseases and current procedural terminology codes. SDOH were assessed using International Classification of Diseases codes. Negative binomial regression was used to evaluate the overall number of renal MIS and Cochran-Armitage tests to compare the utilization of different treatment modalities, over the study period. Multivariable logistic regression analysis identified predictors of perioperative complications. RESULTS: A total of 80,821 MIS for kidney cancer were included. Minimally invasive partial nephrectomy adoption as a fraction of total MIS increased significantly (slope of regression line, reg. = 0.026, P <.001). Minimally invasive radical nephrectomy ($26.9k ± 40.9k) and renal ablation ($18.9k ± 31.6k) were the most expensive and cheapest procedures, respectively. No statistically significant difference was observed in terms of number of complications (P = .06) and presence of SDOH (P = .07) among the treatment groups. At multivariable analysis, patients with SDOH undergoing minimally invasive radical nephrectomy had higher odds of perioperative complications, while renal ablation had a significantly lower probability of perioperative complications. CONCLUSION: This study describes the current management of kidney cancer in the US, offering a socioeconomic perspective on the impact of this disease in everyday clinical practice.

Single port robot-assisted pyeloplasty: An early comparative outcomes analysis.

BACKGROUND: The treatment paradigm for ureteropelvic junction obstruction (UPJO) has shifted towards minimally invasive pyeloplasty. A comparison Single Port (SP) and Multi Port (MP) robot-assisted pyeloplasty (RAP) was performed. METHODS: Data from consecutive patients undergoing SP RAP or MP RAP between January 2021 and September 2023 were collected and analysed. Co-primary outcomes were length of stay (LOS), Defense and Veterans Pain Rating Scale (DVPRS), and narcotic dose. The choice of the robotic system depended on the surgeon's preference and availability of a specific robotic platform. RESULTS: A total of 10 SP RAPs and 12 MP RAPs were identified. SP RAP patients were significantly younger [23 years (20-34)] than MP RAP [42 years (35.5-47.5), p < 0.01]. No difference in terms of OT (p = 0.6), LOS (p = 0.1), DVPRS (p = 0.2) and narcotic dose (p = 0.1) between the two groups was observed. CONCLUSIONS: SP RAP can be implemented without compromising surgical outcomes and potentially offering some clinical advantages.

Single-port vs multi-port robot-assisted partial nephrectomy: A single center propensity score-matched analysis.

INTRODUCTION AND OBJECTIVES: The aim of the study is to compare key outcomes of Single-Port (SP) and Multi-Port (MP) robot-assisted partial nephrectomy (RAPN). METHODS: A retrospective analysis was conducted on our prospectively collected database of patients who underwent SP-RAPN or MP-RAPN at our institution from January 2021 to August 2023. To adjust for potential baseline pre-operative confounders, a 1:1 propensity-score matching analysis (PSMa) was performed. The primary endpoint was to compare perioperative outcomes between the two groups. The secondary endpoint was to compare the achievement of the "Trifecta" outcome (defined as negative surgical margins, absence of high-grade complications and change in eGFR values (ΔeGFR) < 10% at 6 months follow-up) in the matched cohort. RESULTS: After PSMa, 30 SP cases were matched 1:1 to 30 MP cases. In the matched cohort, there were no significant differences between SP and MP approaches in operative time, estimated blood loss, ischemia time, transfusions rate, intraoperative complications, postoperative complications, and positive surgical margin rates. Patients who underwent SP-RAPN had a shorter median length of stay [25 (IQR:24.0-34.5) vs 34 (IQR:30.2-48.0) hours, p < 0.003]. The Trifecta outcome was achieved in 16 (57%) of SP patients and 17 (63%) of MP patients (p = 0.8). CONCLUSIONS: SP-RAPN can be safely implemented in a Center with an established MP-RAPN program. Despite being early in the SP-RAPN experience, key surgical outcomes are not compromised. While offering comparable perioperative and short-term functional outcomes, SP-RAPN can translate into faster recovery and shorter LOS, paving the way for outpatient robotic surgery.

Toll-Like Receptor 4 Induction During Renal Ischemia Correlates with Serum Creatinine in a Pig Model.

Objectives: To determine whether toll-like receptor 4 (TLR4), a mediator of organ ischemia-reperfusion injury, is overexpressed during warm ischemia in a porcine solitary kidney model, and whether its expression correlates with creatinine, a surrogate for kidney function. Materials and Methods: Eight adult Yorkshire pigs underwent initial laparoscopic nephrectomy. After 1 week, animals were randomized into two groups: group 1 underwent laparoscopic renal hilar dissection, renal ischemia by cross-clamping, and reperfusion (ischemia group); group 2 underwent laparoscopic renal hilar dissection alone (sham group). Animals were survived to day 7 postrandomization. Peripheral blood was sampled for serum creatinine (sCr) and TLR4 expression at the following time points or corresponding intervals: prenephrectomy, 1-week postnephrectomy (preischemia), after 90 minutes of ischemia, 30 minutes postreperfusion, and at sacrifice. Intragroup TLR4 expression changes were analyzed using repeated measures ANOVA. Intergroup TLR4 expression was compared using Mann-Whitney's test. Correlation between sCr and TLR4 was assessed using Spearman's test. Results: Seven animals completed the experiment (four ischemia and three sham). Relative TLR4 expression significantly increased from baseline levels during ischemia, reperfusion, and sacrifice time points only in the ischemia group, and was significantly higher for the ischemia group after 90 minutes of ischemia (p = 0.034). sCr was significantly higher for the ischemia group during the reperfusion phase (p = 0.048). Relative TLR4 expression level significantly correlated with sCr in the overall cohort (Spearman's rho = 0.69) and in the ischemia group (Spearman's rho = 0.82; p < 0.0001 for each). Conclusions: Warm ischemia in a porcine solitary kidney induces acute overexpression of TLR4 in peripheral blood leukocytes, which is detectable. Relative TLR4 expression level strongly correlated with sCr but had an observable change sooner than change in sCr. Pending further investigation, TLR4 overexpression during renal ischemia may represent a sensitive quantitative marker of unilateral renal injury sustained during nephron-sparing surgery.

Genital monkeypox superimposed on co-incident sexually transmitted infections in AIDS patient; a case report.

Monkeypox outbreaks were, until recently, mostly confined to Africa but a currently expanding worldwide outbreak has recently been designated a global emergency by the World Health Organization. Genital manifestation is common and can be confused with sexually transmitted infection (STI), posing a diagnostic challenge. We herein report a case of genital monkeypox superimposed on multiple co-incident STIs in a HIV patient and describe characteristic clinical findings and management.

Association Between Mental Health Conditions and Postoperative Complications After Gender-Affirming Surgery.

This cohort study assesses whether postoperative complications are associated with having been diagnosed with a mental health condition in patients who have undergone gender-affirming surgery.

The monetary costs of pediatric upper urinary tract stone disease: Analysis in a contemporary United States cohort.

INTRODUCTION: The prevalence of upper urinary tract stone disease (USD) in the United States is rising among both adults and children. Studies on the contemporary economic burden of USD management in the pediatric population are lacking. OBJECTIVE: To comprehensively analyze the economic impact of USD in a contemporary United States pediatric cohort, and to evaluate drivers of cost. STUDY DESIGN: A retrospective cohort study of pediatric patients (aged 0-17), diagnosed with USD between 2011 and 2018 were identified from PearlDiver-Mariner, an all-payer claims database containing diagnostic, treatment and prescription data provided in all treatment settings. Relevant International Classification of Disease (ICD-9 and ICD-10) and Current Procedural Terminology (CPT) codes were used for identification, and only patients with claims recorded for at least one year before and after entry of a diagnosis code for USD were selected (N = 10,045). Patients were stratified into those undergoing operative vs. non-operative management and for each patient, total 1-year healthcare costs following USD diagnosis, including same day and non-same day encounters, were analyzed. Factors associated with increased spending, as well as economic trends were analyzed. RESULTS: Overall, 8498 (85%) patients were managed non-operatively, while 1547 (15%) underwent a total of 1880 procedural interventions. Total overall cost was $117.1 million, while median annual expenditure was $15.8 million. Proportion of spending for outpatient, inpatient and prescription services was 52%, 32% and 16%, respectively (Table). Outpatient management accounted for 67% of overall spending. The proportion of patients managed non-operatively increased significantly over time, in parallel with spending for non-operative care. Comorbidity burden, treatment year and geographic region were among predictors of costs. DISCUSSION: Our study is the first to report actual insurance reimbursements for pediatric USD management using actual reimbursement data, examined across all treatment settings. We found that majority of the costs were for outpatient services and for non-operative management, with a rising tendency toward non-operative management over time. Regional variation in expenditures was evident. Specific reasons underlying these observed patterns could not directly be discerned from our dataset, but merit further investigation. CONCLUSION: Non-operative and outpatient management for pediatric USD are increasingly common, resulting in parallel shifts in spending. Notably, 52% of overall spending was for outpatient care. These insights into the contemporary economic burden of pediatric USD could provide value in shaping future healthcare policy.

Contemporary Assessment of the Economic Burden of Upper Urinary Tract Stone Disease in the United States: Analysis of One-Year Health Care Costs, 2011-2018.

Background: The U.S. health care landscape has witnessed numerous changes since implementation of the Affordable Care Act coupled with rising prevalence of upper urinary tract stone disease (SD). Data on the economic burden of SD during this period are lacking, providing the objective of our study. Materials and Methods: Adults diagnosed as having SD from 2011 to 2018 were identified from PearlDiver Mariner, a national all-payer database reporting reimbursements and prescription costs for all health care encounters. Patients undergoing operative and nonoperative care were identified. Time trends in annual expenditures were evaluated. Multivariable analysis evaluated determinants of spending. Results: A total of $10 billion were spent on SD management between 2011 and 2018 (median overall annual expenditure = $1.4 billion) among 786,756 patients. Inpatient, prescription, and outpatient costs accounted for 34.7%, 20.7%, and 44.6% of expenditures, respectively. Seventy-eight percent of patients were managed nonoperatively (total cost = $6.9 billion). The average overall cost per encounter was $13,587 ($17,102 for surgical vs $11,174 for nonsurgical care). Expenditures on inpatient care decreased significantly over time, while expenditures on prescriptions and outpatient care increased significantly. On multivariable analysis, a higher Charlson Comorbidity Index (CCI) was associated with higher spending, while associations for age, insurance, and region varied by treatment modality. Conclusions: The economic burden of SD management is substantial, dominated by expenditure on nonoperative management and outpatient care. Expenditures for prescription and outpatient care are rising, with the only consistent predictor of higher spending being CCI. Spending variation according to demographic, clinical, and geographic factors was evident.

Prolieve Transurethral Thermodilatation for Treatment of Symptomatic Benign Prostatic Hyperplasia: 5-Year Results from a Prospective Multicenter Trial.

Introduction and Objective: Prolieve® transurethral thermodilatation (TUTD) is the only third-generation transurethral microwave thermotherapy (TUMT) device that incorporates balloon dilation/compression of the prostatic urethra with cooled TUMT, at ≤50 W power. We evaluated its 5-year efficacy in the treatment of symptomatic benign prostatic hyperplasia (BPH) in an open-label prospective multicenter trial. Methods: Eligible patients with American Urological Association symptom index score (AUASS) ≥9, peak urine flow rate (Qmax) <12 mL/s, and prostate size 20-80 g without obstructing median lobe were enrolled. Prolieve TUTD was delivered in the office setting under local anesthesia. AUASS, quality of life (QOL), BPH impact index (BPHII), Qmax, and other measures were assessed at baseline, and at least annually thereafter to year 5. Adverse events (AEs) were recorded. Treatment success over time was analyzed using the Kaplan-Meier method while changes from baseline were evaluated using paired t-tests. Results: Intention to treat population was 225, of whom 220 with a mean (standard deviation) age of 65 (5.9) completed treatment. 187/220 (85%) did not require urethral catheterization. AUAS, QOL, and BPHII scores significantly improved from baseline in ≤3 months, with sustained improvements to year 5. Qmax also significantly improved from baseline at each annual follow-up evaluation. Cumulative 5-year surgical retreatment rate was 14.2% (95% confidence interval 9.5-20.8). Transient urinary urgency and dysuria were the most reported AEs. Conclusions: Prolieve TUTD is a safe and effective treatment option for BPH, with durable long-term improvements in voiding symptoms and urinary flow rates. It has a low catheterization rate and sexual side effects are rare. Clinical Trials.gov Registration Number: NCT02021032.

Beyond Arthritis: Understanding the Influence of Gout on Erectile Function: A Systematic Review.

OBJECTIVE: To review the evidence suggesting a significant association between gout and erectile dysfunction (ED) and evaluate possible underlying pathways that may explain this relationship. METHODS: English medical literature was searched from January 1, 2010, to January 1, 2020, for randomized or quasi-randomized controlled trials, cross-sectional studies, case-cohort studies, or meta-analysis evaluating the relationship between gout and ED. RESULTS: All nine gout studies included in the study found a significant association between gout and ED. ED pathophysiology in gout involves hyperuricemia, increased reactive oxygen species, decreased nitric oxide synthesis, and low-grade inflammation. CONCLUSION: The findings of this review suggest that the effect of urate-lowering therapy on the incidence of ED in gout patients should be studied. Additionally, we propose that all gout patients should be assessed for ED.

Relationship Between the Wisconsin Stone Quality of Life (WISQOL) and Preference-Based/Health Utility Measures of Health-Related Quality of Life (HRQoL) in Kidney Stone Patients.

OBJECTIVE: To determine preference-based (utility) assessments of health-related quality of life (HRQoL) in kidney stone patients, and evaluate the association between these and disease specific, psychometric health status-based HRQoL scores (obtained via the Wisconsin Stone Quality of Life [WISQOL]). METHODS: One hundred four adults with urolithiasis, as well as 78 young healthy adults without history of urolithiasis (controls) were consecutively enrolled, meeting the predetermined recruitment goal. Each participant completed the SF-36 v2 (from which SF-6D utility is calculated) and EQ-5D questionnaires, while urolithiasis patients additionally completed the WISQOL. Relationship between health utility and WISQOL scores was evaluated using Pearson's test and multivariable linear regression analysis (MVA). Construct validity of the utilities for urolithiasis was assessed by comparing utilities for patients vs controls, and for symptomatic vs asymptomatic patients. RESULTS: Mean (SD) WISQOL standard score, SF-6D, and EQ-5D utilities in stone patients respectively were 63 (29.1), 0.68 (0.16), and 0.83 (0.17). SF-6D and EQ-5D utilities significantly correlated with WISQOL standard score (Pearson's r = 0.87 and 0.58, respectively; each P <.0001). On MVA, WISQOL standard score was a significant predictor of SF-6D and EQ-5D utilities, explaining 72.1% and 33.9% of the respective variances in the utilities. Median SF-6D and EQ-5D utility were significantly lower in patients vs controls (each P ≤.0009), and in symptomatic vs asymptomatic patients (each P ≤ .0002). CONCLUSION: SF-6D, more so than EQ-5D utilities in urolithiasis patients are strongly associated with disease-specific WISQOL scores, suggesting they are optimal for preference-based HRQoL assessment in this population. Construct validity of the utilities in stone disease was demonstrated.

Phyllanthus niruri (stone breaker) herbal therapy for kidney stones; a systematic review and meta-analysis of clinical efficacy, and Google Trends analysis of public interest.

INTRODUCTION: Phyllanthus niruri (P. niruri) is the most commonly listed active ingredient in commercially available herbal therapies for kidney stones, despite limited supporting clinical evidence. We performed a meta-analysis to evaluate its efficacy in reducing stone burden. We used Google Trends to analyze its relative popularity in internet searches relative to conventional stone therapies. MATERIALS AND METHODS: A comprehensive literature search for controlled human studies containing data on the effect of P. niruri treatment on stone size and number was performed. Pooled analysis of change in mean stone size and number with P. niruri was performed using a fixed-effects model. Standardized mean difference (SMD) and 95% CI were reported. Google searches in the United States within the 'Health' category, for topics 'Gale of the wind (P. niruri)', 'Extracorporeal shockwave lithotripsy' (ESWL), 'Ureteroscopy' (URS), 'Laser lithotripsy' (URSL) and 'Percutaneous nephrolithotomy' (PCNL), conducted between January 2014 and December 2018, were quantified. Annual median relative search volumes (RSV; 0-100 scale) were compared using the Kruskal-Wallis test. Post-hoc pairwise comparisons were performed using the Dunn test with Holm-Sidak adjustment. RESULTS: Two studies met inclusion criteria. P. niruri treatment resulted in significant decreases in mean stone size (SMD -0.39 cm, 95% CI = -0.68 to -0.09, p = 0.01) and number (SMD -0.38, 95% CI = -0.68 to -0.09, p = 0.01). Median RSV for P. niruri was similar to that for ESWL, PCNL and URS through 2015, but was significantly higher than for ESWL and PCNL after 2015, and higher than for URS after 2016 (each p value p ≤ 0.0012). CONCLUSIONS: Limited clinical evidence supports modest efficacy of P. niruri in reducing stone burden, pending further study. Public interest in P. niruri is growing within the United States, possibly reflecting a rising demand.

High-flow priapism treated with selective embolization of a helicine branch of the penile artery: A case report and selected review of the literature.

High-flow, or nonischemic, priapism occurs in <5% of observed clinical presentations of all priapism and is characterized by prolonged, painless erection in the context of pelvic and genitourinary trauma. While conservative management can be safely attempted for many cases of high-flow priapism (HFP), selective embolization is becoming the preferred approach as it allows for rapid resolution. We, herein, present a case of a 42-year-old male patient who presented with trauma-induced HFP treated with selective embolization and briefly review the current literature regarding the management of HFP.

Contemporary Analysis of Calculous Nephrectomy Utilization and Outcomes in the United States.

Introduction: Calculous nephrectomy was a mainstay of treatment of complex upper tract stone disease up until the 1970s, but data on its contemporary utilization in the current era of rising rates of stone disease are lacking. We characterized the nationwide utilization and outcomes for calculous nephrectomy in the United States. Patients and Methods: The National/Nationwide Inpatient Sample databases for 2001 to 2014 were queried for adults with a principal diagnosis of upper urinary tract calculi (UUTCs), who underwent nephrectomy as well as other inpatient surgeries for UUTCs. Per-population trend in utilization of calculous nephrectomy was analyzed using negative binomial regression. The proportion of calculous nephrectomy as a fraction of all inpatient surgical procedures for UUTCs was analyzed using the Cochran-Armitage test. Patient demographics, hospital characteristics, perioperative outcomes, and complications were analyzed using appropriate statistical tests. Results: Of almost 1.42 million inpatient UUTC procedures performed over the study period, 9232 (0.65%) were calculous nephrectomies. Per-population utilization rate for calculous nephrectomy decreased significantly over time (incidence rate ratio = 0.82; 95% confidence interval = 0.73-0.91, p < 0.001). The proportion of calculous nephrectomy as a fraction of all inpatient surgical procedures for UUTC also decreased significantly over time (p < 0.0001). Majority of the procedures were performed in females, in urban teaching hospitals, and in the Southern United States. The overall complication rate was 38.3%, most commonly hemorrhage requiring transfusion (15.6%). Older age, female gender, and nonprivate insurance or lack of insurance were significant predictors of increased risk of complications, whereas hospitalization in urban hospitals was a predictor of lower risk. Conclusions: Despite increasing prevalence of stone disease in the United States in the contemporary era, utilization of calculous nephrectomy is low and is declining. Inpatient complication rates are moderately high and influenced by patient sociodemographic and hospital characteristics.

Percutaneous Nephrolithotomy in Children: Analysis of Nationwide Hospitalizations and Short-Term Outcomes for the United States, 2001-2014.

OBJECTIVE: To describe population-wide utilization rates and outcomes of percutaneous nephrolithotomy (PCNL) in the management of pediatric upper urinary tract calculi (UUTC). PATIENTS AND METHODS: Patients <18 years with a diagnosis of UUTC, who underwent PCNL between 2001 and 2014 were identified from the National Inpatient Sample database. Annual PCNL rates, based on the at-risk population for each year, were estimated, and change in utilization rate was analyzed using negative binomial regression. Perioperative outcomes, hospital length of stay (LOS), and costs were determined; continuous and categorical variables were analyzed using nonparametric tests and Chi-squared tests, respectively. Trends tests and multivariable analyses (MVAs) were also performed where appropriate. RESULTS: An estimated 3206 pediatric PCNL procedures were performed. Mean annual PCNL rate increased significantly relative to 2001 (incidence rate ratio = 1.40; 95% confidence interval 1.15-1.71, p = 0.001). Proportion of PCNL as a fraction of all inpatient surgical procedures for UUTC also significantly increased over time, from 15.7% in 2001 to 26.4% in 2014 (p < 0.0001). Complications overall occurred in 20.7% of cases, with a significantly rising rate over time period (p < 0.0001). Complication rates were similar across hospital types and geographic regions. Median hospitalization cost was significantly higher for the West than for each of the other regions (p < 0.05 in each case). Median LOS was also highest for the West (4 days vs 3 days for each of the other regions). In MVA, significant predictors of both increased LOS and costs included black race, comorbidities of hypertension, diabetes, coagulopathy and neurologic disease, hospitalization in the South, and presence of complications. Race, gender, comorbidities, and treatment year were among the predictors of complications. CONCLUSIONS: PCNL utilization in the management of pediatric UUTC has significantly increased since 2001, with an associated increase in complication rates, although major complications were uncommon. Regional variations in costs and LOS were evident.