Open versus minimally invasive surgical approaches in pediatric urology: Trends in utilization and complications

Abstract

Summary Objective Minimally invasive surgery (MIS) techniques are anecdotally reported to be increasingly used, but little objective data supports this. Our objective was to assess trends in MIS utilization across various procedures in pediatric urology and to compare postoperative complication rates between MIS and open procedures. Methods We analyzed the 1998–2012 Nationwide Inpatient Sample. We identified children (<18 years old) undergoing open and MIS inpatient procedures and any in-hospital postoperative complications that occurred during that postoperative hospitalization. We utilized propensity score matching and multivariable logistic regression to adjust for confounding factors. Results We identified 163,838 weighted encounters in the “overall cohort,” 70,273 of which were at centers performing more than five MIS procedures over the years studied. Use of MIS techniques increased significantly over time for several procedures, most prominently for nephrectomy (Figure). The overall rate of complications was lower in patients undergoing MIS compared with open surgery (6% vs. 11%, p<0.001). Specialized centers had a significantly lower overall rate of complications than unspecialized centers (9% vs. 12%, p<0.001). Within specialized centers, MIS had lower complication rates than open procedures (7% vs. 9%, p<0.001); this finding was consistent even after adjusting for other factors (OR 0.71, p=0.02). Discussion Limitations include that these data may not be generalizable to encounters not in the sample pool. As a large, retrospective, administrative database, NIS may be affected by miscoding bias – rendering our analysis sensitive to the accuracy of procedure coding in NIS. Although the accuracy level of NIS is high for an administrative database, it is possible at least some portion of our cohort may be incorrectly coded. Further, the NSQIP complications we identified may represent associated comorbidities and not true postoperative complications, as NIS does not provide temporal relationships between different diagnosis codes. Despite these limitations, we note that the NIS database is rigorously monitored and audited for coding accuracy and, therefore, represents a reasonably reliable panorama of the characteristics of an inpatient surgical cohort. However, it is important to note that the choice of operative modality is, undoubtedly, multifactorial and patient/setting-specific. Conclusions There is increasing use of MIS for pediatric urology procedures, although utilization rates vary among procedures. MIS was associated with a lower postoperative complication rate than for open procedures. Higher-volume MIS centers have a lower complication rate than lower-volume centers.

Relative to open surgery, minimally-invasive renal and ureteral pediatric surgery offers no improvement in 30-day complications, yet requires longer operative time: Data from the National Surgical Quality Improvement Program Pediatrics

“…It was previously shown that increased specialization results in lower rates of complications and mortality [ 1 9 ]. While rates of overall 30-day complications following urologic surgery in children have been reported as low as 5.9%, cases involving urinary diversion and incorporation of bowel have been associated with rates as high as 27.8% [ 10 12 16 ].…”

“…Trends in utilization of minimally-invasive pediatric urologic surgery are an ever-growing area of interest [ 1 ]. In 2005, the American College of Surgeons (ACS) collaborated with the American Pediatric Surgical Association to develop the ACS National Surgical Quality Improvement Program Pediatrics (NSQIP Peds) [ 2 3 ].…”

“…Such trends would be interesting to show how MIS vs. open surgery changed over time. A bibliometric analysis showed a progressive trend of increasing volume of reported procedures annually [ 1 ]. From an identified 780 MIS procedures and 75,976 open UR surgeries (NSQIP, 1998–2012), patients who underwent MIS were significantly older (6.2 vs. 4.8 years), more likely to be publicly insured (43% vs. 26%), and more likely to be treated in recent years (90% vs. 46%) compared with patients who underwent open surgery [ 2 ].…”

Pediatric Challenges in Robot-Assisted Kidney Transplantation

“…Minimally invasive surgery such as laparoscopic surgery or RALS has consistently shown to produce improved clinical outcomes as compared to open surgery equivalents. These outcomes include fewer complications, reduced length of hospital stay, reduced need for blood transfusion, less postoperative pain, shorter convalescence period, fewer surgical site infections, and better cosmetic results (10)(11)(12).…”

For Whom the Bubble Grows: Physical Principles of Bubble Nucleation and Dynamics in Histotripsy Ultrasound Therapy

“…Surgery is not well tolerated in elderly or comorbid patients (Turrentine et al 2006). The development of new surgical techniques or instrumentation focuses on reducing procedural complications, incisions, scarring and recovery time (Jaffray 2005;Tejwani et al 2017). Minimally invasive techniques such as laparoscopy and endoscopy achieve these goals, and are now standard procedure over open surgeries for many indications.…”