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

Summary 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.