1096 TRENDS AND OUTCOMES OF PEDIATRIC PYELOPLASTY

EDITORIAL COMMENT

The authors have examined real-world experience bedside assistant costs. It is unclear on what basis

for pediatric pyeloplasty. While there are a myriadof potentially problematic issues with the approach(eg the fairly opaque proprietary billing databasewhose validity cannot be readily assessed and thelack of capture of subsequent outpatient treatmentand patient outcome in the data set), the studyleverages “big data” to compare 3 approaches toureteropelvic junction obstruction repair, and thedatabase is, despite flaws, considered robust at costcomparison. This strategy meaningfully augmentsthe case series information that has been publishedto date and through large numbers achieves arandomization of sorts. This fact is germane in thatthe ideal studyda randomized blinded trial withpractitioners of representative proficiency usingindependent criterion based subsequent manage-ment and assessmentdwill simply not be conduct-ed. Furthermore, the relevance of such an idealstudy, beyond benchmarking to particular pediatricurologists who are possessed of varying, likelyasymmetrical proficiencies, is unclear. However, weneed to understand the comparative value of thediffering surgical approaches, identify particularstrengths and pitfalls, and build a data drivenrationale to select and modify our approach asindividuals and in the profession through time. Theauthors achieve this goal.

This series raises a significant question regardingthe added costs of robotics. The study identifies asignificant increased cost of the robotic approach($2,500 per case) that is entirely exclusive of theconsiderable capital expenditure, maintenance ofthe platform and, besides training programs, the

there would ultimately be any substantive differencein morbidity profile (hence equivalent LOS, pain,scar, etc) between the 2 minimally invasive ap-proaches. Admirable efficacy and minimal compli-cations associated with all approaches providedlimited potential for savings from improvement inthese areas. Thus, assuming equivalence of outcome,laparoscopy would be the preferred minimallyinvasive approach. Given purely the added supplycost associated with robotics, the increased RP costwould remain even in the unlikely event that oper-ating room use were cut in half (and hence broughtwell below open and laparoscopic approaches).

Finally, the subset analysis of the more recentyears in this data set challenges the perception thatthe technical difficulty of a laparoscopic approachlimits its potential. Laparoscopic operative timesappear to be moving toward parity with the openapproach in later years, and laparoscopy hasachieved the goal of cost savings through decreasedLOS in this broad survey compared to traditionalopen surgery. While it is true that significantreduction in the cost of robotic technology throughcompetition, for instance, will decrease the roboticpremium, the choice offered by the current plat-forms to replace discipline driven adroitness even at$1,000 a case should be suspect.

Lars J. CisekDivision of Urologic Surgery

University of Minnesota Medical School

Minneapolis, Minnesota

e-mail: ljcisek@umn.edu