Courtney K. Rowe

A Comparative Direct Cost Analysis of Pediatric Urologic Robot-Assisted Laparoscopic Surgery Versus Open Surgery: Could Robot-Assisted Surgery Be Less Expensive?

BACKGROUND AND PURPOSE Cost in healthcare is an increasing and justifiable concern that impacts decisions about the introduction of new devices such as the da Vinci(®) surgical robot. Because equipment expenses represent only a portion of overall medical costs, we set out to make more specific cost comparisons between open and robot-assisted laparoscopic surgery. MATERIALS AND METHODS We performed a retrospective, observational, matched cohort study of 146 pediatric patients undergoing either open or robot-assisted laparoscopic urologic surgery from October 2004 to September 2009 at a single institution. Patients were matched based on surgery type, age, and fiscal year. Direct internal costs from the institution were used to compare the two surgery types across several procedures. RESULTS Robot-assisted surgery direct costs were 11.9% (P=0.03) lower than open surgery. This cost difference was primarily because of the difference in hospital length of stay between patients undergoing open vs robot-assisted surgery (3.8 vs 1.6 days, P<0.001). Maintenance fees and equipment expenses were the primary contributors to robotic surgery costs, while open surgery costs were affected most by room and board expenses. When estimates of the indirect costs of robot purchase and maintenance were included, open surgery had a lower total cost. There were no differences in follow-up times or complication rates. CONCLUSIONS Direct costs for robot-assisted surgery were significantly lower than equivalent open surgery. Factors reducing robot-assisted surgery costs included: A consistent and trained robotic surgery team, an extensive history of performing urologic robotic surgery, selection of patients for robotic surgery who otherwise would have had longer hospital stays after open surgery, and selection of procedures without a laparoscopic alternative. The high indirect costs of robot purchase and maintenance remain major factors, but could be overcome by high surgical volume and reduced prices as competitors enter the market.

Genome gender diversity in affected sib-pairs with familial vesico-ureteric reflux identified by single nucleotide polymorphism linkage analysis.

Study Type – Aetiology (case series)

A Novel Method of Evaluating Ureteropelvic Junction Obstruction: Dynamic Near Infrared Fluorescence Imaging Compared to Standard Modalities to Assess Urinary Obstruction in a Swine Model

PURPOSE Dynamic near infrared fluorescence imaging of the urinary tract provides a promising way to diagnose ureteropelvic junction obstruction. Initial studies demonstrated the ability to visualize urine flow and peristalsis in great detail. We analyzed the efficacy of near infrared imaging in evaluating ureteropelvic junction obstruction, renal involvement and the anatomical detail provided compared to conventional imaging modalities. MATERIALS AND METHODS Ten swine underwent partial or complete unilateral ureteral obstruction. Groups were survived for the short or the long term. Imaging was performed with mercaptoacetyltriglycine diuretic renogram, magnetic resonance urogram, excretory urogram, ultrasound and near infrared imaging. Scoring systems for ureteropelvic junction obstruction were developed for magnetic resonance urogram and near infrared imaging. Physicians and medical students graded ureteropelvic junction obstruction based on magnetic resonance urogram and near infrared imaging results. RESULTS Markers of vascular and urinary dynamics were quantitatively consistent among control renal units. The same markers were abnormal in obstructed renal units with significantly different times of renal phase peak, start of pelvic phase and start of renal uptake. Such parameters were consistent with those obtained with mercaptoacetyltriglycine diuretic renography. Near infrared imaging provided live imaging of urinary flow, which was helpful in identifying the area of obstruction for surgical planning. Physicians and medical students categorized the degree of obstruction appropriately for fluorescence imaging and magnetic resonance urogram. CONCLUSIONS Near infrared imaging offers a feasible way to obtain live, dynamic images of urine flow and ureteral peristalsis. Qualitative and quantitative parameters were comparable to those of conventional imaging. Findings support fluorescence imaging as an accurate, easy to use method of diagnosing ureteropelvic junction obstruction.

Predicting Anatomical Urological Abnormalities in Children Who Present With Their First Urinary Tract Infection

Objectives. Classically, presence of fever ≥38.0°C is used to distinguish pyelonephritis from cystitis. We analyzed whether this is an appropriate marker to initiate further workup and whether temperature is correlated with urological abnormalities and further surgical or pharmacological intervention. Methods. Children who presented for their first workup of urinary tract infection between October 1, 2008, and September 30, 2009 were retrospectively selected from our institution. Demographics and clinical details were correlated with the diagnosis of urological abnormalities and requirement for intervention. Results. Age was the most important variable to predict urological abnormalities. The temperature value of 38.3°C maximized the balance between sensitivity (90%) and specificity (46%) for predicting the need to intervene and the presence of anatomical urological abnormalities. Conclusion. Young age (≤2 years) and temperature are the best factors to predict further intervention and urological abnormalities, with a temperature value of 38.3°C being a better predictive value than the currently used 38.0°C.

MP3-09 NATIONAL TRENDS AND DISPARITIES IN THE UTILIZATION OF INPATIENT HYPOSPADIAS SURGERY

Ariella A. Friedman*, Detroit, MI; Briony Varda, Courtney K. Rowe, Boston, MA; Akshay Sood, Detroit, MI; Marianne Schmid, Hamburg, Germany; Khurshid R. Ghani, Ann Arbor, MI; Jesse D. Sammon, Detroit, MI; Shyam Sukumar, Minneapolis, MN; Jessica Meyers, Detroit, MI; Arun Rai, Steven L. Chang, Adam S. Kibel, Boston, MA; Pierre Karakiewicz, Maxine Sun, Montreal, Canada; Jack S. Elder, Detroit, MI; Quoc-Dien Trinh, Boston, MA

Robotic Intravesical Ureterocele Excision

Abstract Introduction: Ureterocele excision is a procedure that is typically performed in an open fashion. The robotic approach has many challenges associated with it, as well as many advantages. This video will demonstrate a robotic intravesical ureterocele excision, highlighting several novel techniques to aid the procedure, including bladder fixation to the rectus muscle and a unique approach to effective and watertight port closure, which can make a robotic approach a feasible, safe, and effective approach to ureterocele excision. Methods: A suitable patient was selected who had a large enough bladder, clinical indication for ureterocele excision, and interest in a robotic approach. The patient had congenital multicystic kidney without much function, and underwent a right nephroureterectomy previously. He had recurrent episodes of hematuria, and a ureterocele was identified via voiding cystourethrogram (VCUG). The ureterocele was a simple orthotopic stenotic ureterocele, seen on VCUG as a filling defe...

Robot-Assisted Laparoscopic Bilateral Ureteroureterostomies

Abstract Introduction: We demonstrate a technique for robot-assisted laparoscopic bilateral ureterouretero-stomies of upper pole to lower pole ureters through a single approach. The patient is a 2-year-old girl with a history of bilateral reflux who was found to have bilateral ectopic ureters. Historically, repair of these ureters would have required two separate incisions. To our knowledge, this is the first published report describing a single-approach technique. Materials and Methods: The surgery was performed transperitoneally using four ports, approaching the ureters through the broad ligament at the level between the bladder and the uterus. A “hitch stitch” was used to suspend each lower pole ureter to facilitate anastomosis.1 Results and Conclusions: Operative time was 230 min, and there were no major intraoperative or postoperative complications. The patient was doing well at her 2-month follow-up, with no urinary tract infections or other complaints. Follow-up ultrasonography showed resolving hyd...