Over the past decade, the use of minimally invasive pyeloplasty has dramatically increased, largely replacing open pyeloplasty, while the use of endopyelotomy, albeit significantly more common than the other two approaches, has remained relatively stable. The total rate of surgery for ureteropelvic junction obstruction has remained stable during this time. The surgical approach is influenced by several patient, provider, and hospital factors. We found that patients with private insurance, patients treated by high-volume surgeons, and patients treated at teaching hospitals receive minimally invasive pyeloplasties more frequently than either open pyeloplasties or endopyelotomies.
Although the rate of minimally invasive pyeloplasty has substantially increased, its dissemination varies, depending on patient, surgeon, and hospital factors. Adjusting for other covariates, patients undergoing minimally invasive pyeloplasty tended to be younger than patients undergoing endopyelotomy. Although not as effective,5
endopyelotomy is an attractive option for older patients who may benefit from the least invasive approach.22
A more concerning finding, however, is that patients with private insurance are more likely than patients without private insurance to receive minimally invasive pyeloplasties relative to open pyeloplasties or endopyelotomies. This finding may stem from the increasing number of robotic platforms in recent years23
and the subsequent increase in the use of robot-assisted laparoscopic pyeloplasties.24
Robotic equipment requires a substantial initial investment.10
To recoup those costs, hospitals may preferentially treat patients who have a favorable payer-mix with this expensive technology. For instance, a single-institutional study found that robot-assisted laparoscopic prostatectomy was a money-losing proposition across all payers, but it incurred the least debt when performed on patients with private insurance.25
Alternatively, payer status may relate to patient access to hospitals that provide new technologies. In light of the advantages of minimally invasive pyeloplasty, this disparity in utilization based on payer status has quality-of-care implications for patients without private insurance.
Along these same lines, the disproportionate use of minimally invasive pyeloplasty by teaching hospitals has implications for patients as well. Our study supports previous findings that physicians in academic settings are more likely to perform minimally invasive pyeloplasties.6–8
In part, this reflects the higher proportion of surgeons at academic centers who are laparoscopically trained and the types of hospitals investing in new, expensive technologies.8
The estimated effect of teaching vs
a nonteaching hospital does not appear to be explained by differences in surgeon volume.
Nonetheless, regardless of the setting, minimally invasive pyeloplasties are performed primarily by high-volume surgeons. Forty-three percent of high-volume surgeons used the minimally invasive approach, compared with only 14% and 10% of intermediate- and low-volume surgeons. This finding underscores the technical demands and learning curve associated with minimally invasive pyeloplasty.5,6
Further, pyeloplasties are not common procedures, and surgeons who do not see a large volume of these patients may be less inclined to learn new and challenging techniques.26
At the same time, the ability of robotic surgery to reduce the learning curve9
may help the diffusion of minimally invasive pyeloplasties by attracting lower-volume surgeons. Conversely, endopyelotomies represent the predominant procedure performed by lower volume surgeons, largely because they are technically easier and less morbid compared with pyeloplasties.22
These findings, along with endopyelotomy's inferior success rates to both open and minimally invasive pyeloplasty,22
suggest that endopyelotomy may be overused. Although there is a definite role for endopyelotomies among a specific patient population and for secondary repairs,27
64% of patients in our study were younger than 65 years, 80% had no comorbidities, and the rates of endopyelotomy were often twice as high as those for either of the pyeloplasty approaches. Similarly, even though the rate of minimally invasive pyeloplasty has increased over the past 10 years, its utilization compared with other treatments for ureteropelvic junction obstruction appears to be affected by the patient's primary payer, the teaching status of the hospital, and the annual number of cases performed by the surgeon.
These findings should be interpreted in the context of several limitations. First, for the study period, patient information was available only at the discharge level. Thus, we could not follow patients over time and assess long-term outcomes. Further, the context of the procedure (eg, a primary or secondary repair) could not be determined. Given the high success rates of both minimally invasive5
and open pyeloplasties,28
however, the number of secondary repairs (eg, endopyelotomies) will be relatively low. Despite the inability to track patients longitudinally, this study provides a population-based assessment of the trends in treatment of ureteropelvic junction obstruction repair and factors associated with surgical approach. Second, our study is limited by the lack of a specific procedure code for minimally invasive pyeloplasty. Given the advent of the robot-assisted laparoscopic pyeloplasty at the turn of the century, however, the simultaneous decline in the rate of open pyeloplasties, and the relative stability in the total number of procedures, we believe our results accurately depict a substantial, yet uneven, dissemination of minimally invasive pyeloplasty. Third, we do not know the extent to which our findings from Florida can be generalized to other states or the entire country. Although Florida has a large, diverse population and numerous hospitals and ambulatory surgery centers, our findings will need to be replicated in other populations.
Over the past decade, the rates of minimally invasive pyeloplasty have risen dramatically, surpassing the rates of open pyeloplasty. Reasons for this may include the improved technical feasibility with robot-assisted surgery compared with laparoscopy, the greater comfort in performing minimally invasive pyeloplasties among the younger generation of urologists, or the conviction that minimally invasive pyeloplasties produce better outcomes. Regardless of the reasons, its dissemination is not occurring uniformly in the general population; minimally invasive pyeloplasties are performed more frequently among patients with private insurance, those treated at teaching hospitals, and those cared for by high-volume surgeons. Future studies are warranted to evaluate how the expense of robotic technology, in particular, influences the treatment pattern of minimally invasive pyeloplasty.