title: Comparative effectiveness of flexible versus rigid neuroendoscopy for endoscopic third ventriculostomy and choroid plexus cauterization: a propensity score-matched cohort and survival analysis.
abstract: OBJECTIVE Endoscopic third ventriculostomy (ETV)/choroid plexus cauterization (CPC) has become an increasingly common technique for the treatment of infant hydrocephalus. Both flexible and rigid neuroendoscopy can be used, with little empirical evidence directly comparing the two. Therefore, the authors used a propensity score-matched cohort and survival analysis to assess the comparative efficacy of flexible and rigid neuroendoscopy. METHODS Individual data were collected through retrospective review of infants younger than 2 years of age, treated at 1 of 2 hospitals: 1) Boston Children's Hospital, exclusively utilizing flexible neuroendoscopy, and 2) Nicklaus Children's Hospital-Jackson Memorial Hospital, exclusively utilizing rigid neuroendoscopy. Patient characteristics and postoperative outcomes were assessed. A propensity score model was developed to balance patient characteristics in the case mix. RESULTS A propensity score model for neuroendoscope type was developed with 5 independent variables: chronological age, sex, hydrocephalus etiology, prior CSF diversion, and prepontine scarring. Propensity score decile-adjusted and 1-to-1 nearest-neighbor matching analysis revealed that compared with flexible neuroendoscopy, rigid neuroendoscopy had an ETV/CPC failure odds ratio (OR) of 1.43 (p = 0.31) and 1.31 (p = 0.47), respectively, compared with an unadjusted OR of 2.40 (p = 0.034). Furthermore, in a Cox regression analysis controlled by propensity score, rigid neuroendoscopy had a hazard ratio (HR) of 1.10 (p = 0.70), compared with an unadjusted HR of 1.61 (p = 0.031). CONCLUSIONS Although unadjusted analysis suggested worse ETV/CPC outcomes for infants treated by rigid neuroendoscopy, much of the difference could be attributed to the case mix and other predictors of outcome. A larger sample observational study or randomized controlled trials are required to provide evidence-based guidelines on ETV/CPC technique.
authors.affiliation: Division of Neurosurgery, Department of Surgery, University of Toronto, Ontario, Canada.|Departments of Biostatistics and Epidemiology, Harvard T. H. Chan School of Public Health, Boston.
authors.forename: Shelly
authors.initials: S
authors.lastname: Wang
authors.affiliation: Department of Neurosurgery, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts.
authors.forename: Scellig
authors.initials: S
authors.lastname: Stone
authors.affiliation: Department of Neurosurgery, Sainte Justine Hospital, University of Montreal, Quebec, Canada.
authors.forename: Alexander G
authors.initials: AG
authors.lastname: Weil
authors.affiliation: Division of Pediatric Neurosurgery, Department of Surgery, David Geffen School of Medicine at University of California, Los Angeles.|Brain Research Institute, University of California, Los Angeles, California.
authors.forename: Aria
authors.initials: A
authors.lastname: Fallah
authors.affiliation: Department of Neurosurgery, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts.
authors.forename: Benjamin C
authors.initials: BC
authors.lastname: Warf
authors.affiliation: Department of Neurosurgery, Nicklaus Children's Hospital-Jackson Memorial Hospital, Miami, Florida; and.
authors.forename: John
authors.initials: J
authors.lastname: Ragheb
authors.affiliation: Department of Neurosurgery, Nicklaus Children's Hospital-Jackson Memorial Hospital, Miami, Florida; and.
authors.forename: Sanjiv
authors.initials: S
authors.lastname: Bhatia
authors.affiliation: Division of Neurosurgery, Department of Surgery, University of Toronto, Ontario, Canada.|Division of Neurosurgery, The Hospital for Sick Children, University of Toronto, Ontario, Canada.
authors.forename: Abhaya V
authors.initials: AV
authors.lastname: Kulkarni
mesh_terms: D002425:Cautery / Q000295:instrumentation*; D002831:Choroid Plexus / Q000601:surgery*; D002921:Cicatrix / Q000209:etiology; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D006849:Hydrocephalus / Q000209:etiology / Q000601:surgery; D007223:Infant; D007231:Infant, Newborn; D053208:Kaplan-Meier Estimate; D008297:Male; D044582:Neuroendoscopes; D044583:Neuroendoscopy / Q000295:instrumentation*; D016017:Odds Ratio; D057216:Propensity Score; D016016:Proportional Hazards Models; D012189:Retrospective Studies; D020542:Third Ventricle / Q000601:surgery; D016896:Treatment Outcome; D014696:Ventriculostomy / Q000295:instrumentation*
keywords: CI = confidence interval; CPC = choroid plexus cauterization; ETV = endoscopic third ventriculostomy; ETVSS = ETV Success Score; HR = hazard ratio; OR = odds ratio; choroid plexus; endoscopic third ventriculostomy; hydrocephalus; neuroendoscope