Open versus minimally invasive surgical approaches in pediatric urology: Trends in utilization and complications.
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 post-operative 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 (Fig.). 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).


CONCLUSIONS
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.
Division of Urologic Surgery, Duke University Medical Center, Durham, NC, USA.
Rohit
R
Tejwani
Division of Urologic Surgery, Duke University Medical Center, Durham, NC, USA.
Brian J
BJ
Young
Division of Urologic Surgery, Duke University Medical Center, Durham, NC, USA.
Hsin-Hsiao S
HS
Wang
Dept of Biostatistics and Bioinformatics, Duke University, Durham, NC, USA.
Steven
S
Wolf
Division of Urologic Surgery, Duke University Medical Center, Durham, NC, USA.
J Todd
JT
Purves
Division of Urologic Surgery, Duke University Medical Center, Durham, NC, USA.
John S
JS
Wiener
Division of Urologic Surgery, Duke University Medical Center, Durham, NC, USA. Electronic address: jonathan.routh@duke.edu.
Jonathan C
JC
Routh
D002648:Child; D005260:Female; D006760:Hospitalization / Q000706:statistics & numerical data; D006801:Humans; D008297:Male; D019060:Minimally Invasive Surgical Procedures / Q000009:adverse effects* / Q000706:statistics & numerical data*; D011183:Postoperative Complications / Q000453:epidemiology*; D012189:Retrospective Studies; D014481:United States; D013520:Urologic Surgical Procedures / Q000009:adverse effects* / Q000706:statistics & numerical data*
Complications; Laparoscopic surgery; Minimally invasive surgery; Pediatrics; Urology