Validation of the pediatric surgical risk assessment scoring system.

BACKGROUND: Within the adult population, there exist numerous validated risk stratification tools aimed at predicting postoperative outcomes using preoperative and intraoperative parameters. However, similar tools for the pediatric population are scarce. We previously developed and reported on a scoring system to predict postoperative complications in children undergoing surgery at Boston Children's Hospital. The objective of this study was to validate our scoring system to determine its effectiveness in identifying children at risk for major complications or death within 30 days following surgery. STUDY DESIGN: A computer program randomly selected 2015 out of 11,734 patients who underwent surgery at our institution in 2009. The severity of the complications was graded based on the Clavien classification system, with major complications being a grade III or higher. The Preoperative Complication Score (PCS) and the Overall Complication Score (OCS) were calculated for all patients, and Receiver Operating Characteristic (ROC) curves were generated for each scoring system. RESULTS: The overall incidence of major complications was 3.9% (79 patients). Proportionally, cardiac surgery had the highest percentage of major complications (20% of the performed surgeries). Both PCS and OCS demonstrated excellent correlation with postoperative outcomes with c-statistic values of 0.740 (CI 0.682-0.800, p < 0.001) and 0.767 (CI 0.712-0.822, p < 0.001) respectively. CONCLUSIONS: We determined that both the PCS and OCS are effective in identifying children at risk for major complications and death following surgery. Further studies will be needed to determine if these scoring systems are applicable to children undergoing surgery at other institutions and if the use of the scoring systems would result in improved clinical outcomes and reduced costs.

The feasibility of robotic urologic surgery in infants and toddlers.

OBJECTIVE: To determine the feasibility and safety of performing robotic-assisted laparoscopic urological surgery (RALS) in infants and young children, highlighting technical challenges posed by the smaller body size and their potential solutions. PATIENTS AND METHODS: We retrospectively reviewed perioperative records of all patients less than 3 years of age who underwent RALS at our institution between January 2006 and October 2012. Intraoperative data included difficulties with the robotic instruments or surgical procedure. Post-operative data included length of hospital stay and any complications. RESULTS: A total of 65 children less than 3 years underwent RALS. The average patient age was 1.6 years ± 0.7, with 14 patients under 1 year of age. Median patient weight was 11.6 kg ± 2.5 kg. Mean operative time was 153.3 ± 57 min. No conversions to open technique or intra-operative complications were reported. A total of 12 post-operative complications were identified after a mean follow-up of 13.6 months: 7 early complications and 5 late complications. Smaller children did not have more complications than larger children. CONCLUSION: There are inherent challenges with performing RALS in infants and young children. However, they may be overcome with specific technical maneuvers and through understanding of the limitations of the robotic system.

Parent and patient perceptions of robotic vs open urological surgery scars in children.

PURPOSE: Cumulative evidence shows that robot-assisted laparoscopic surgery is safe and at least as efficacious as open surgery for several pediatric urological procedures. Scars resulting from robotic surgery are often assumed to have a cosmetic advantage. However, no study has clearly demonstrated that parents and patients consistently prefer such scars. MATERIALS AND METHODS: We developed 3 distinct surveys consisting of photographs and diagrams of scars resulting from open and robot-assisted laparoscopic surgery for ureteral reimplantation, pyeloplasty and bladder augmentation. Surveys were distributed to parents of patients being evaluated for 1 of the 3 procedures. The surveys evaluated information such as scar preference, reason for preference and demographics. Patients older than 7 years also completed surveys. RESULTS: Robot-assisted laparoscopic surgical scars were preferred by parents for all procedures studied (85% for ureteral reimplant, 63% for pyeloplasty and 93% for bladder augmentation). Patients also preferred the robotic scars (76%, 62% and 91%, respectively). Patients and parents did not differ significantly in scar preference or in rating of factors affecting decision. Scar size was important or very important to 80% of parents for reimplant, 83% for pyeloplasty and 86% for bladder augmentation. However, the majority of parents would ultimately base their choice of surgical approach on clinical efficacy rather than scar preference. CONCLUSIONS: Parents and patients prefer robot-assisted laparoscopic surgical scars to open surgical scars for pediatric ureteral reimplantation, pyeloplasty and bladder augmentation. Scar appearance is an important influence on the decisions of parents and patients, and should be discussed when surgical treatment is presented.