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Thakker PU, Mithal P, Dutta R, Carreno G, Gutierrez-Aceves J. Comparative outcomes and cost of ambulatory PCNL in select kidney stone patients. Urolithiasis 2022; 51:22. [PMID: 36571653 PMCID: PMC9791625 DOI: 10.1007/s00240-022-01392-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2022] [Accepted: 12/02/2022] [Indexed: 12/27/2022]
Abstract
Limited hospital resources and access to care during the COVID-19 pandemic led us to implement a quality-improvement study investigating the feasibility, safety, and costs of same-day discharge after PCNL. The outcomes of 53 consecutive first-look PCNL patients included in a same-day discharge protocol during COVID-19 were compared to 54 first-look PCNL patients admitted for overnight observation. Control group had a similar comorbidity profile. Demographics, operative details, 30 day outcomes and readmissions, complications, and cost were compared between the two groups. Same-day discharge and one-day admission post-PCNL patients did not have significantly different baseline characteristics. The study group were more likely to have mini-PCNL (81% vs 50%, p < 0.01). Operative characteristics including median pre-operative stone burden (1.4 vs 1.7 cm3, p = 0.47) and post-operative stone burden (0.14 vs 0.18 cm3, p = 0.061) were similar between the two groups. Clavien-Dindo complication rates were lower in the study group compared to controls (0 vs 7%, p = 0.045). Readmission rates (2 vs 4%, p = 0.569) and ED visits (4 vs 6%, p = 0.662) were similar between the two groups. Total cost ($6,648.92 vs $9,466.07, p < 0.01) was significantly lower and operating margin ($4,475.96 vs $1,742.16, p < 0.01) was significantly higher for the same-day discharge group. Percutaneous nephrolithotomy may be performed in select patients without an increase in short-term complications, ED visits, or readmissions. Patients undergoing mini-PCNL are particularly amenable to same-day discharge, however, standard PCNL patients should not be excluded from consideration. Avoiding overnight admission decreases total cost and increased hospital operating margin.
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Affiliation(s)
- Parth U. Thakker
- Atrium Health Wake Forest Baptist Medical Center, Winston-Salem, NC 27101 USA
| | - Prabhakar Mithal
- Atrium Health Wake Forest Baptist Medical Center, Winston-Salem, NC 27101 USA
| | - Rahul Dutta
- Atrium Health Wake Forest Baptist Medical Center, Winston-Salem, NC 27101 USA
| | - Gabriel Carreno
- Atrium Health Wake Forest Baptist Medical Center, Winston-Salem, NC 27101 USA
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Lee MS, Assmus MA, Agarwal D, Rivera ME, Large T, Krambeck A. Ambulatory PCNL may be cost-effective compared to Standard PCNL. J Endourol 2021; 36:176-182. [PMID: 34663076 DOI: 10.1089/end.2021.0482] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background COVID-19 changed the practice of medicine in America. During the March 2020 lockdown, elective cases were cancelled to conserve hospital beds/resources resulting in financial losses for health systems and delayed surgical care. Ambulatory percutaneous nephrolithotomy (aPCNL) has been shown to be safe and could be a strategy to: ensure patients receive care that has been delayed, conserve hospital resources, and maximize cost-effectiveness. We aimed to compare the safety and cost-effectiveness of patients undergoing ambulatory percutaneous nephrolithotomy (aPCNL) against standard PCNL (sPCNL). Materials and Methods 98 patients underwent PCNL at Indiana University Methodist hospital, a tertiary referral center, by three expert surgeons from January 2020 to September 2020. The primary outcome of the study was to compare the 30-day rates of ED-visits, readmissions, and complications between sPCNL and aPCNL. Secondary outcomes included: cost analysis and stone free rates (SFRs). Prospensity-score matching was performed to ensure the groups were balanced. Statistical analyses were performed using SAS 9.4 using independent t-tests for continuous variables and chi-square analyses for categorical variables. Results 98 patients underwent PCNL during the study period (sPCNL=75 and aPCNL=23). After propensity-score matching, 42 patients were available for comparison (sPCNL=19 and aPCNL=23). We found no difference in 30-day ED-visits, readmissions, or complications between the two groups. aPCNL resulted in cost savings of $5327±442 per case. Stone free rates were higher for aPCNL compared to sPCNL. Conclusions aPCNL appears safe to perform and does not have a higher rate of ED-visits or readmissions compare to sPCNL. aPCNL may also be cost-effective compared to sPCNL.
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Affiliation(s)
- Matthew S Lee
- Northwestern University Feinberg School of Medicine, 12244, Urology, 675 N. St. Clair, STE 20-150, Chicago, Illinois, United States, 60611.,Northwestern University Feinberg School of Medicine;
| | - Mark A Assmus
- Indiana University Department of Urology, 372831, Urology, 1801 Senate Blvd., Suite 220, Indianapolis, Indiana, United States, 46202;
| | - Deepak Agarwal
- Indiana University School of Medicine, Urology, Indianapolis, Indiana, United States;
| | - Marcelino E Rivera
- Indiana University Health Methodist Hospital, 22535, Urology, 1801 Senate Blvd, Ste 220, Indianapolis, Indiana, United States, 46202;
| | - Tim Large
- Indiana University School of Medicine, 12250, Urology, 1801 N Senate Blvd, Suite 220, Indianapolis, Indiana, United States, 46202;
| | - Amy Krambeck
- Indiana University Department of Urology, 372831, Urology, 1801 N Senate Blvd, Ste 220, Indianapolis, Indiana, United States, 46202-5289;
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Sahan A, Cubuk A, Ozkaptan O, Ertas K, Toprak T, Eryildirim B, Sarica K. How does puncture modality affect the risk of intraoperative bleeding during percutaneous nephrolithotomy? A prospective randomized trial. Actas Urol Esp 2021; 45:486-492. [PMID: 34330691 DOI: 10.1016/j.acuroe.2021.06.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2020] [Accepted: 10/26/2020] [Indexed: 11/30/2022]
Abstract
INTRODUCTION AND OBJECTIVES To evaluate the possible effects of two different renal puncture techniques (ultrasound-assisted [US-assisted], fluoroscopic-guided [FG]) on the intraoperative hemorrhage risk during percutaneous nephrolithotomy (PCNL). MATERIAL AND METHODS A total of 130 patients with Guy stone scores of 1-2 were prospectively allocated to US-assisted and FG puncture groups by simple randomization. Patients with intraoperative pelvicalyceal rupture and the ones requiring multiple accesses were excluded from the study. Apart from the puncture steps, all other steps of the PCNL procedure were performed with similar techniques by a single surgeon. Patient characteristics, operative data, and postoperative outcomes were compared. RESULTS A total of 10 patients were excluded from the study due to intraoperative complications after puncture. Patient demographics and stone characteristics were similar between the two groups (p > 0.05). Mean hemoglobin drop was meaningfully greater in the FG group (1.7 g/dL) when compared with US-assisted group (1.3 g/dL) (p < 0.01). The mean duration of radiation exposure was significantly higher for the FG (p < 0.001). Total operative time, number of attempts for a successful puncture, length of hospital stay, and stone free rates were similar between the groups (p > 0.05). In addition, the remaining complications classified according to the modified Clavien-Dindo grading system were similar between groups (p > 0.05). CONCLUSION US-assisted puncture provides significantly decreased level of hemoglobin drop and radiation exposure time when compared with FG.
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Affiliation(s)
- A Sahan
- Department of Urology, Kartal Dr. Lutfi Kirdar Traning and Research Hospital, Estambul, Turkey
| | - A Cubuk
- Department of Urology, Kırklareli University, Faculty of Medicine, Krıklareli, Turkey.
| | - O Ozkaptan
- Department of Urology, Kartal Dr. Lutfi Kirdar Traning and Research Hospital, Estambul, Turkey
| | - K Ertas
- Department of Urology, Van Yüzüncü Yıl University, Faculty of Medicine, Van, Turkey
| | - T Toprak
- Department of Urology, Fatih Sultan Mehmet Traning and Research Hospital, Estambul, Turkey
| | - B Eryildirim
- Department of Urology, Kartal Dr. Lutfi Kirdar Traning and Research Hospital, Estambul, Turkey
| | - K Sarica
- Department of Urology, Biruni University Faculty of Medicine, Estambul, Turkey
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Sahan A, Cubuk A, Ozkaptan O, Ertas K, Toprak T, Eryildirim B, Sarica K. How does puncture modality affect the risk of intraoperative bleeding during percutaneous nephrolithotomy? A prospective randomized trial. Actas Urol Esp 2021. [PMID: 33958219 DOI: 10.1016/j.acuro.2020.10.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
INTRODUCTION AND OBJECTIVES To evaluate the possible effects of two different renal puncture techniques (ultrasound-assisted [US-assisted], fluoroscopic-guided [FG]) on the intraoperative hemorrhage risk during percutaneous nephrolithotomy (PCNL). MATERIAL AND METHODS A total of 130 patients with Guy stone scores of 1-2 were prospectively allocated to US-assisted and FG puncture groups by simple randomization. Patients with intraoperative pelvicalyceal rupture and the ones requiring multiple accesses were excluded from the study. Apart from the puncture steps, all other steps of the PCNL procedure were performed with similar techniques by a single surgeon. Patient characteristics, operative data, and postoperative outcomes were compared. RESULTS A total of 10 patients were excluded from the study due to intraoperative complications after puncture. Patient demographics and stone characteristics were similar between the two groups (P>.05). Mean hemoglobin drop was meaningfully greater in the FG group (1.7g/dL) when compared with US-assisted group (1.3g/dL) (P<.01). The mean duration of radiation exposure was significantly higher for the FG (P<.001). Total operative time, number of attempts for a successful puncture, length of hospital stay, and stone free rates were similar between the groups (P>.05). In addition, the remaining complications classified according to the modified Clavien-Dindo grading system were similar between groups (P>.05). CONCLUSION US-assisted puncture provides significantly decreased level of hemoglobin drop and radiation exposure time when compared with FG.
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