Assessing the cost effectiveness of robotics in urological surgery – a systematic review

BJUIB J U I N T E R N A T I O N A L

© 2 0 1 2 T H E A U T H O R S

B J U I N T E R N A T I O N A L © 2 0 1 2 B J U I N T E R N A T I O N A L | doi:10.1111/j.1464-410X.2012.11015.x 1

What ’ s known on the subject? and What does the study add? Research on the subject has shown that robotic surgery is more costly than both laparoscopic and open approaches due to the initial cost of purchase, annual maintenance and disposable instruments. However, both robotic and laparoscopic approaches have reduced blood loss and hospital stay and robotic procedures have better short term post-operative outcomes such as continence and sexual function. Some studies indicate that the robotic approach may have a shorter learning curve. However, factors such as reduced learning curve, shorter hospital stay and reduced length of surgery are currently unable to compensate for the excess costs of robotic surgery.

This review concludes that robotic surgery should be targeted for cost effi ciency in order to fully reap the benefi ts of this advanced technology. The excess cost of robotic surgery may be compensated by improved training of surgeons and therefore a shorter learning curve; and minimising costs of initial purchase and maintenance. The review fi nds that only a few studies gave an itemised breakdown of costs for each procedure, making accurate comparison of costs diffi cult. Furthermore, there is a lack of long term follow up of clinical outcomes, making it diffi cult to accurately assess long term post-operative outcomes. A breakdown of costs and studies of long term outcomes are needed to accurately assess the effectiveness of robotic surgery in urology.

OBJECTIVES

• Although robotic technology is becoming increasingly popular for urological procedures, barriers to its widespread dissemination include cost and the lack of long term outcomes. This systematic review analyzed studies comparing the use of robotic with laparoscopic and open urological surgery. • These three procedures were assessed for cost effi ciency in the form of direct as well as indirect costs that could arise from length of surgery, hospital stay, complications, learning curve and postoperative outcomes.

METHODS

• A systematic review was performed searching Medline, Embase and Web of Science databases. Two reviewers identifi ed abstracts using online databases and independently reviewed full length papers suitable for inclusion in the study.

RESULTS

• Laparoscopic and robot assisted radical prostatectomy are superior with respect to reduced hospital stay (range 1 – 1.76 days and 1 – 5.5 days, respectively) and blood loss (range 482 – 780 mL and 227 – 234 mL,

respectively) when compared with the open approach (range 2 – 8 days and 1015 mL). Robot assisted radical prostatectomy remains more expensive (total cost ranging from US $2000 – $39 215) than both laparoscopic (range US $740 – $29 771) and open radical prostatectomy (range US $1870 – $31 518). • This difference is due to the cost of robot purchase, maintenance and instruments. The reduced length of stay in hospital (range 1 – 1.5 days) and length of surgery (range 102 – 360 min) are unable to compensate for the excess costs. • Robotic surgery may require a smaller learning curve (20 – 40 cases) although the evidence is inconclusive.

CONCLUSIONS

• Robotic surgery provides similar postoperative outcomes to laparoscopic surgery but a reduced learning curve. • Although costs are currently high, increased competition from manufacturers and wider dissemination of the technology could drive down costs. • Further trials are needed to evaluate long term outcomes in order to evaluate fully the value of all three procedures in urological surgery.

KEYWORDS

robotics , urology , healthcare economics , training , outcomes

Study Type – Therapy (systematic review)

Level of Evidence 1a

Assessing the cost effectiveness of robotics in urological surgery – a systematic review Kamran Ahmed , Amel Ibrahim , Tim T. Wang , Nuzhath Khan , Ben Challacombe , Muhammed Shamim Khan and Prokar Dasgupta MRC Centre for Transplantation, King ’ s College London, King ’ s Health Partners, Department of Urology, Guy ’ s Hospital, London, UK Accepted for publication 10 November 2011

A H M E D E T A L .

© 2 0 1 2 T H E A U T H O R S

2 B J U I N T E R N A T I O N A L © 2 0 1 2 B J U I N T E R N A T I O N A L

INTRODUCTION

Robotic surgery is becoming increasingly common in pelvic urological procedures such as radical prostatectomy and cystectomy [ 1 ] . Barriers to widespread dissemination include cost and the lack of long term outcomes. Despite this, robotic technology is gradually becoming popular due to a reduced learning curve, shorter hospital stay, comparable clinical outcomes and demand from patients [ 1,2 ] . Therefore the overall economic impact of robotic technology is considerable. Surgical departments need to use this concept of healthcare economics to see if services can be optimized in a cost effi cient manner [ 3 ] . Health economics, that aim to provide maximum value for money without impacting quality, need to be appropriately researched and implemented for emerging technology such as robotics [ 4 ] .

Urological conditions such as prostate cancer are often detected at an early stage (due to PSA screening) and radical prostatectomy can be an effective treatment option. Open radical prostatectomy may be associated with higher complications, increased hospital stay and postoperative morbidity [ 5 ] . Laparoscopic radical prostatectomy has been widely used to overcome these challenges. However, this technique has a steep learning curve and technological drawbacks including two-dimensional images, limited degrees of freedom for movement of instruments and increased operative times [ 6 ] .

Since 2000, the da Vinci system (Intuitive Surgical, Sunnyvale, CA, USA) has been increasingly employed to provide an alternative for certain procedures such as radical prostatectomy. It may reduce hospital stay, improve postoperative outcomes and decrease the learning curve [ 2,7 ] . The major challenge at present is high operative costs with some studies claiming that robot assisted surgery adds US $1000 – 2500 to a procedure [ 8 ] . Robotic technology in surgery has enjoyed rapid expansion since its inception. There still remains a great deal of uncertainty over its viability with sceptics citing cost effi ciency as its major shortfall. Indeed, the recent global economic diffi culties have meant a desire by governments to implement defi cit-reducing measures which have placed health organizations under increased

pressure to justify its expenditure. Some argue that robotics may not be a fi nancially viable option in comparison with laparoscopic and open techniques [ 9 ] .

This article reviews systematically the evidence to analyze the concept and trends of cost effectiveness in relation to robotic urological surgery.

METHODS

This systematic review was conducted according to the PRISMA guidelines (Preferred Reporting Items for Systematic reviews and Meta-Analyses) [ 10 ] .

Studies comparing cost of urological robotic procedures with other types of operation were included. Case reports, case series and empirical studies which did not report cost, procedural outcomes, technical and clinical challenges and training issues related to robotic urological surgery were excluded. We also excluded reviews, editorials, letters and studies not directly related to robotic surgery.

Relevant studies were identifi ed by searching the following databases: (i) Ovid Medline (1950 – May 2010), (ii) Ovid MEDLINE(R) In-Process & Other Non-Indexed Citations 1950 – May 2010), (iii) Ovid EMBASE (1980 – 2010) and (iv) Ovid PsychINFO (1967 – 2010). We also searched the Cochrane database to look for any reviews on this subject.

The search was performed using free text terms describing cost effectiveness in urological surgery in relation to the outcomes. The search terms included a combination of: ‘ robotics ’ or ‘ minimally invasive ’ or ‘ surgery ’ and ‘ urology ’ or ‘ cost ’ or ‘ healthcare economics ’ or ‘ robot ’ or ‘ learning curve ’ . Reference checks of published review articles were performed to supplement the aforementioned searches.

Reviewers (KA and AI) independently identifi ed potentially relevant articles. The full text of the article was obtained and further screened for inclusion if it had at least one of the following categories of information: robotic urological surgery, surgical outcomes (including cost, effi cacy and safety), guidelines, health care economics or disease impact (use of

resources, re-admissions and quality of life). Confl icts between the reviewers were subsequently discussed until there was 100% agreement on the fi nal studies to be included.

Two independent investigators (KA and AI) assessed each study for inclusion and quality assessment. The inter-rater agreement for inclusion was satisfactory with inter-rater reliability of 0.93.

An electronic data collection form (Microsoft Excel 2007) was used to extract data according to the outcome measures. Where applicable, for each item the statistical method used in the study was recorded. Disagreement in the assessment and data extraction were resolved by consensus.

Due to heterogeneous study designs and a learning curve effect, direct comparisons or meta-analysis of data were not feasible. However, the framework from similar studies has been summarized. In the body of this article we review comparative studies to compare robotic surgery with laparoscopic and open approaches for the main urological procedures. In our analysis of each individual study, we discuss the following: (i) postoperative outcomes, (ii) training and learning curve and (iii) cost effi ciency

The quality of each study included in the analysis was assessed using variables based on existing stratifi cation tools such as the Jadad ’ s, MINORS (Methodological index for non-randomized studies) and Oxford EBM and the Grade system [ 11 – 13 ] ( Table 1 ). Six dimensions were used to evaluate the quality of the individual studies: (i) Title: whether the study clearly identifi es itself as comparative of costs associated with robotic, laparoscopic and/or open urological surgery, (ii) Abstract: whether there is a structured format which outlines comparative groups and summarizes results, (iii) Introduction: whether the clinical problem is described and background information given, (iv) Methods: whether it explains measures taken to optimize study quality, defi nes groups and outcomes measured, (v) Results: whether outcomes are reported accurately and clearly and (vi) Discussion: if key fi ndings are analyzed and limitations mentioned.

E C O N O M I C I M P A C T O F R O B O T I C S U R G E R Y I N U R O L O G Y

© 2 0 1 2 T H E A U T H O R S

B J U I N T E R N A T I O N A L © 2 0 1 2 B J U I N T E R N A T I O N A L 3

TABL

E 1

Qual

ity o

f the

incl

uded

stud

ies

Auth

ors

Lota

n et

al .

[ 19 ]

Scal

es

et a

l . [ 3

1 ]

Burg

ess

et a

l . [ 2

0 ]

Link

et

al .

[ 35 ]

M

oura

viev

et

al .

[ 32 ]

Cace

res

et a

l . [ 1

8 ]

Jose

ph

et a

l . [ 3

3 ]

Lota

n et

al .

[ 41 ]

Bole

nz

et a

l . [ 2

]

Smith

et

al .

[ 24 ]

Lee

et a

l . [ 2

7 ]

Low

ranc

e et

al .

[ 22 ]

Hu

et a

l . [ 2

3 ]

Qua

lity

crite

ria

Title

Iden

tify

the

stud

y as

a c

ompa

rativ

e an

alys

is o

f co

st b

etw

een

open

vro

botic

pro

stat

ecto

my/

cyst

ecto

my

10

10

11

11

11

10

0 Ab

stra

ct

U

ses

a st

ruct

ured

for

mat

11

11

11

11

11

11

1

Clea

rly s

tate

s th

e ob

ject

ives

11

11

11

11

11

11

1

Outli

nes

com

para

tive

grou

ps a

nd w

hich

cos

ts w

ere

anal

yzed

11

11

11

11

11

11

1

Sum

mar

izes

the

mai

n re

sults

11

11

11

11

11

11

1 In

trod

uctio

n

Desc

ribes

the

clin

ical

pro

blem

, rat

iona

le f

or c

ompa

rativ

e an

alys

is1

11

11

11

11

11

11

Met

hods

Prov

ides

a s

peci

fi c t

imel

ine

over

whi

ch d

ata

wer

e co

llect

ed0

01

11

00

11

11

11

Cl

early

out

lines

com

para

tive

grou

ps a

nd n

umbe

rs in

eac

h1

01

11

11

11

11

11

De

scrib

es h

ow c

ost

data

wer

e ob

tain

ed1

11

10

11

11

10

0

Subd

ivid

es c

osts

into

ope

rativ

e/no

nope

rativ

e1

11

11

11

11

00

0

Furt

her

subd

ivid

es o

pera

tive/

nono

pera

tive

cost

into

spe

cifi c

s1

10

11

11

11

00

0

Expl

icitl

y st

ates

cos

t of

rob

ot /

whe

ther

cos

t of

the

rob

ot is

incl

uded

11

01

01

11

11

00

Ac

coun

ts f

or le

arni

ng c

urve

by

sepa

rate

ly c

ompa

ring

cost

of

the

initi

al c

ases

vs

late

r ca

ses

00

10

00

00

00

00

0

Prov

ides

sel

ecte

d m

etric

s of

out

com

e (o

pera

tive

time,

blo

od lo

ss, l

engt

h of

hos

pita

l sta

y, po

sitiv

e m

argi

n %

, PSA

rec

urre

nce

%)

11

11

11

10

11

11

1

De

scrib

es a

val

id m

etho

d an

d so

ftw

are

of s

tatis

tical

ana

lysi

s1

11

11

11

11

11

11

Resu

lts

Ac

cura

tely

sum

mar

izes

res

ults

in s

tudy

11

11

11

11

11

11

1

Prov

ides

sta

tistic

al a

naly

sis

of c

ompa

rison

gro

ups

11

11

11

11

11

11

1

Gra

phic

al/S

umm

ary

tabl

e re

pres

enta

tion

of r

esul

ts1

11

11

11

11

11

11

Disc

ussi

on

Su

mm

ariz

es a

nd in

terp

rets

key

fi nd

ings

11

11

11

11

11

11

1

Disc

usse

s re

sults

of

stud

y in

vie

w o

f to

talit

y of

evi

denc

e av

aila

ble

11

11

11

11

11

11

1

Disc

usse

s lim

itatio

ns o

f st

udy

11

11

11

11

11

11

1 To

tal:

21

19

17

19

19

18

19

19

20

20

18

15

15

RESULTS

Six hundred and nine potentially relevant publications were identifi ed by the search. Five hundred and eighty were excluded following the abstract review. Of the remaining 29 studies, we excluded a further 21 after reviewing the full text. Five additional studies were identifi ed after reviewing references from relevant studies. Thirteen studies were fi nally included in the systematic review ( Fig. 1 ).

The selected studies consisted of case series and a limited number of case-control studies ( Table 2 ). The evidence was primarily level 2 in the form of systematic reviews as well as non-randomized comparative studies based on the Oxford Centre for Evidence-based Medicine [ 14 ] . Information from these studies was categorized under the headings of (i) postoperative outcomes, (ii) training and learning curve and (iii) cost effi ciency ( Figs 2 and 3 ).

POSTOPERATIVE OUTCOMES

A systematic review by Ficarra et al . [ 15 ] analyzed studies comparing robot assisted with open radical prostatectomy. They found that robot-assisted prostatectomy had a shorter hospital stay (1 – 17 days, median = 1.5 days), limited blood loss (145 – 570 mL, median = 329 mL), short learning curve (40 – 60 cases) and promising outcomes at follow-up in terms of erectile function (20 – 79%, median = 72%), urinary continence (82 – 96%, median = 91.6%) as well as similar positive surgical margins (2 – 59% median = 13%) to laparoscopic and open approaches [ 15 ] . Although promising, the authors acknowledged that further data were needed to establish signifi cance of long term oncological and sexual potency outcomes.

A later systematic review by Ficarra et al . [ 16 ] analyzed studies which compared robotic ( n = 14 studies), laparoscopic ( n = 27 studies) and open prostatectomy ( n = 33 studies). They found that length of surgery was increased by both laparoscopic (weighted mean difference (WMD) – 71.20 min, 95% confi dence interval (CI) – 97.35, – 45.05, P < 0.001) and robotic approaches (median 231 min, range 160 – 288 min) when compared with open (median 204 min, range 127 – 214 min). Laparoscopic prostatectomy appeared

A H M E D E T A L .

© 2 0 1 2 T H E A U T H O R S


superior in comparison with open with respect to blood loss (WMD 557.43, 95% CI of WMD 277.01, 837.85, P < 0001), transfusion rates (relative risk (RR) 4.72, 95% CI of RR 2.2, 10.14, P < 0.001), catheterization times (WMD 6.18, 95% CI of WMD 0.46, 11.91, P = 0.03), length of hospital stay (WMD 2.46, 95% CI of WMD 1.54, 3.37, P < 0.001) and postoperative complications. Both laparoscopic and robotic approaches showed similar outcomes of potency and incontinence ( P = 0.16) (both superior to open approach). Oncological outcomes in the form of positive margins were similar for all three techniques. However, the authors report that the quality of the included studies was not ‘ excellent ’ and thus recommended further prospective, multicentre studies of high quality to improve the accuracy of the data.

Postoperative outcomes have also been shown to improve in a study by Menon et al . [ 17 ] . They used a cohort of over 2600 patients and showed that with experienced surgeons robotic prostatectomy yielded 0.8% frequency of incontinence at 12 months. In patients undergoing bilateral Veil nerve sparing procedures, 70% sexual potency was achieved at 12 months and 100% in 48 months. However, only half of these patients described this return to sexual function as normal compared with pre-operatively.

A review by Caceres et al . [ 18 ] suggested that robot assisted prostatectomy may be associated with reduced incidence of sexual dysfunction (22 – 85%, median 61%) ( Table 2 ) compared with laparoscopic prostatectomy. They also show similar rates for positive surgical margins.

Lotan et al . [ 19 ] compared open, laparoscopic and robot assisted prostatectomy with respect to postoperative outcomes. They found that length of stay was the same for laparoscopic and robotic surgery (1 day) which were both less than open prostatectomy (3 days). Meanwhile length of surgery was reduced in robot assisted approaches (140 min) compared with laparoscopic (160 min) and open (200 min).

The study by Burgess et al . [ 20 ] reported that length of stay was the same for robot assisted as well as open perineal prostatectomy (1 day). It was increased for

the open retropubic approach (2 days). They suggested that operative time was highest for robotic surgery (262 min) compared with open retropubic (202 min) and perineal (196 min). However, blood loss was less in robotic prostatectomy (227 mL) compared with open perineal (1015 mL) and retroperitoneal prostatectomy (780 mL).

The work of Bolenz et al . [ 2 ] found that length of hospital stay was higher in open prostatectomy (2.51 days) compared with laparoscopic (1.76 days) and robotic surgery (1.56 days). They also showed that nerve sparing occurred in 85% of robot assisted procedures compared with 96% of laparoscopic and 90% of open ( P < 0.001). Lymph node dissection was most likely to be performed in open prostatectomy (100%) in contrast with laparoscopic (22%) and robotic approaches (11%) ( P < 0.01). This difference in lymphadenectomy and nerve sparing procedures was not correlated with medium term outcomes.

Lowrance et al . [ 21,22 ] used the SEER-medicare dataset to analyze postoperative outcomes at 90 days as well as 365 days for genitourinary complications and bowel disorders. They compared patients receiving

open radical prostatecetomy ( n = 4697 patients) with those undergoing minimally invasive prostatectomy ( n = 1006). They did not fi nd a signifi cant difference in postoperative complications between the two groups (OR 0.93, 95% CI 0.77, 1.14, P = 0.49). They also did not fi nd a difference in development of bladder neck obstruction or urethral contracture between the groups (OR 0.96, 95% CI 0.76, 1.22, P = 0.74). The authors however, grouped robot assisted prostatectomy with laparascopic prostatectomy. Median length of stay (2 vs 3 days, P < 0.001) was on average 35% shorter in minimally invasive procedures when patient and tumour characteristics are controlled for. They explain, in a later review, that the majority of minimally invasive procedures are robot assisted [ 21 ] and thus these data represents a comparison of robotic with open prostatectomy.

Hu et al . [ 23 ] also used the SEERS-medicare dataset to compare minimally invasive radical prostatectomy (MIRP) ( n = 1938) with the open approach ( n = 6899). They compared 30 day postoperative complications, anastomotic stricture up to 365 days post-procedure, as well as incontinence and erectile dysfunction more

FIG. 1. Search study for study selection. Titles/abstracts reviewed (based on search terms)

609 articles identified and screened fromMedline EMBASE PsycINFO

29 Retrieved for full text evaluation

580 articles excluded after reviewsbased on abstract and title

8 articles identified for inclusion in the study

Thirteen articles included in final analysis

21 excluded after full text search(Articles using virtual reality,motion analysis devices)

Five articles identified from crossreferencing


© 2 0 1 2 T H E A U T H O R S


than 18 months postoperatively. They also identifi ed the need for further postoperative cancer therapies to determine indirectly cancer control. Using propensity score-adjusted analyses, Hu et al . [ 23 ] found that MIRP was associated with reduced length of stay (median, 2.0 vs 3.0 days, P < 0.001) and less need for blood transfusion (2.7% vs 20.8%, P < 0.001) when compared with open radical prostatectomy. MIRP was also superior with respect to fewer postoperative respiratory complications (4.3% vs 6.6%, P = 0.004), miscellaneous surgical complications (4.3% vs 5.6%, P = 0.03) and anastomotic stricture (5.8% vs 14.0%, P < 0.001) [ 23 ] . However, MIRP was associated with worse long term complications in the form of genitourinary complications (4.7% vs 2.1%, P = 0.001) such as incontinence (15.9 vs 12.2 per 100 person-years, P = 0.02) and erectile dysfunction (26.8 vs 19.2 per 100 person-years, P = 0.009). There was no difference in use of additional cancer therapies between the two approaches (8.2 vs 6.9 per 100 person-years, P = 0.35) [ 23 ] .

Cystectomy is another procedure that we tried to review. Table 5 shows an overview of postoperative outcomes of cystectomy. Smith et al . [ 24 ] revealed that the average length of hospital stay was the same for open and robotic cystectomy (5 days) whilst length of surgery was longer for robotic cystectomy (246 min) compared with open (228 min). Nix et al . [ 25 ] conducted a randomized controlled trail (RCT) which showed the robotic approach to be equivalent to the open with respect to radical cystectomy with pelvic lymph node clearance and negative margins. Ahlering et al . [ 26 ] also found that robotic surgery had signifi cantly better outcomes such as blood loss, length of stay and return of bowel function. Lee et al . [ 27 ] found that the median length of stay was lower for robotic cystectomy (5.5 days) than open cystectomy (8 days). The mean complication rate was slightly lower for robotic cystectomy (49.4%) compared with open cystectomy (61%) and the mean cost of complications was signifi cantly lower for robotic cystectomy (US $1624) compared with open cystectomy (US $7202).

Whilst robotic surgery appears to offer benefi ts over open approaches in terms of reducing post-operative complications and length of stay (range 1 – 5.5 days vs 2 – 8 days) ( Table 2 ), there have not been any

FIG. 2. An overview of cost comparison of robotic surgery with the other modalities.

45000

Total Price Comparison of Open,Robotic and Laparoscopic Surgery

Lotan

(200

4)

Lotan

(201

0)

Josep

h

Bolen

zSm

ith

Cace

res Link

Lee

Scale

s

Burge

ss

Mourav

iev

400003500030000

US

Dolla

rs, $

250002000015000100005000

Open Robotic Laproscopic

0

Operating Cost Comparison of Open,Robotic and Laparoscopic Surgery

Lotan

(200

4)

Lotan

(201

0)

Josep

h

Bolen

zSm

ith

Cace

res Link

Lee

Scale

s

Burge

ss

Mourav

iev

30000

US

Dolla

rs, $ 25000

2000015000100005000


0

Non-Operating Cost Comparison of Open,Robotic and Laparoscopic Surgery

Lotan

(200

4)

Lotan

(201

0)

Josep

h

Bolen

zSm

ith

Cace

res Link

Lee

Scale

s

Burge

ss

Mourav

iev

160001400012000

US

Dolla

rs, $

100008000600040002000


0

Professionals’ Cost-Comparison of Open,Robotic and Laparoscopic Surgery

Lotan

(200

4)

Lotan

(201

0)

Josep

h

Bolen

zSm

ith

Cace

res Link

Lee

Scale

s

Burge

ss

Mourav

iev

35003000

US

Dolla

rs, $

2500200015001000500


0

Equipment Cost Comparison of Open,Robotic and Laparoscopic Surgery

Lotan

(200

4)

Lotan

(201

0)

Josep

h

Bolen

zSm

ith

Cace

res Link

Lee

Scale

s

Burge

ss

Mourav

iev

6000

US

Dolla

rs, $ 5000

4000300020001000

600050004000300020001000


0

Operating Room Cost Comparison of Open,Robotic and Laparoscopic Surgery

Lotan

(200

4)

Lotan

(201

0)

Josep

h

Bolen

zSm

ith

Cace

res Link

Lee

Scale

s

Burge

ss

Mourav

iev

US

Dolla

rs, $


0

Anaesthetic Cost Comparison of Open,Robotic and Laparoscopic Surgery

Lotan

(200

4)

Lotan

(201

0)

Josep

h

Bolen

zSm

ith

Cace

res Link

Lee

Scale

s

Burge

ss

Mourav

iev

800700600

US

Dolla

rs, $

500400300200100

700600500400300200100


0

Medication Cost Comparison of Open,Robotic and Laparoscopic Surgery

Lotan

(200

4)

Lotan

(201

0)

Josep

h

Bolen

zSm

ith

Cace

res Link

Lee

Scale

s

Burge

ss

Mourav

iev

US

Dolla

rs, $


0

Laboratory Cost Comparison of Open,Robotic and Laparoscopic Surgery

Lotan

(200

4)

Lotan

(201

0)

Josep

h

Bolen

zSm

ith

Cace

res Link

Lee

Scale

s

Burge

ss

Mourav

iev

US

Dolla

rs, $

600050004000300020001000


0

Room and Board Cost Comparison of Open,Robotic and Laparoscopic Surgery

Lotan

(200

4)

Lotan

(201

0)

Josep

h

Bolen

zSm

ith

Cace

res Link

Lee

Scale

s

Burge

ss

Mourav

iev

US

Dolla

rs, $


0

700600500400300200100

Lenght of Stay Comparison of Open,Robotic and Laparoscopic Surgery

Lotan

(200

4)

Lotan

(201

0)

Josep

h

Bolen

zSm

ith

Cace

res Link

Lee

Scale

s

Burge

ss

Mourav

iev

1086

US

Dolla

rs, $

42

40035030025020015010050


0

Length of Surgery Comparison of Open,Robotic and Laparoscopic Surgery

Lotan

(200

4)

Lotan

(201

0)

Josep

h

Bolen

zSm

ith

Cace

res Link

Lee

Scale

s

Burge

ss

Mourav

iev

Tim

e in

Min


0

A H M E D E T A L .

© 2 0 1 2 T H E A U T H O R S


TABLE 2 Cost related equipment and peri-operative outcomes of robotic prostatectomy

Authors Type of surgeryTotal cost (US $)

Robot cost included Y/N

Operative charges

Nonoperative charges

Number of patients

Peri-operative outcomes

Professionals ’ (US $)

Surgical equipment (US $)

Operating room (US $)

Lotan et al . [ 19 ]

LRP 6 041 Y x x 898 1688 1705 2876

RARP 7 280 x x 403 1688 533 2204

ORP 5 554 x x 923 1594 75 2428

Scales et al . [ 31 ]

RARP 8 929 N x x x 2173 1704 2183

ORP – Specialist setting 8 146 x x x 1787 575 8929

ORP – Community setting 8 734 x x x 1787 575 2316

Burgess et al . [ 20 ]

ORP 31 518 N 16 522 14 663 16 x x X

LRP 29 771 16 320 13 451 16 x x X

RARP 39 315 25 443 13 782 78 x x X

Mouraviev et al . [ 32 ]

ORP 10 704 x x 197 x 2471

LRP 10 536 x x 60 x 2788

RARP 10 047 N x x 137 x 3441

CAP 9 195 X x 58 x 5702


LRP 8 557 N 4 021 2 452 157 2250 X X

RARP 10 269 5 670 2 887 214 2662 x X

ORP 6 473 6 988 3 281 246 3007 x X

Joseph et al . [ 33 ]

LRP 3 876 X X x 57 832 2933 x

ORP 1 870 X x x 70 330 1429 x

RARP 5 410 X x x 106 494 4805 x

Bolenz et al . [ 2 ]

LRP 5 687 X x x 220 330 725 2453

RARP 6 752 Y x x 262 x 2015 2798

ORP 4 437 x x 161 x 185 1611

Caceres et al . [ 18 ]

RARPS x Y x x x x 1705 x

LRP x x x x x 533.0 x

RALP 2 000 Y X x 10 X x X

Link et al . [ 35 ] LP 740 X x X 10 x X x

Lowrance et al . [ 22 ]

LRP x x x x 1065 x x x

ORP x x x x 4858 x x x

Hu et al . [ 23 ] MIRP x x x x 1938 x x x

RRP x x x x 6899 x x x

Blood Loss Comparison of Open,Robotic and Laparoscopic Surgery

Lotan

(200

4)

Lotan

(201

0)

Josep

h

Bolen

zSm

ith

Cace

res Link

Lee

Scale

s

Burge

ss

Mourav

iev

Volu

me

in m

l


0

Number of Cases Comparison of Open,Robotic and Laparoscopic Surgery

Lotan

(200

4)

Lotan

(201

0)

Josep

h

Bolen

zSm

ith

Cace

res Link

Lee

Scale

s

Burge

ss

Mourav

iev

No.

of C

ases


0

Lenght of Stay Comparison of Open,Robotic and Laparoscopic Surgery

Lotan

(200

4)

Lotan

(201

0)

Josep

h

Bolen

zSm

ith

Cace

res Link

Lee

Lowran

ce HuSc

ales

Burge

ss

Mourav

iev

109

78

56

No.

of D

ays

4321

12001000

600800

400200

1000

600800

400200

Open

Robotic

Laproscopic

0

KEY

RARP – robot assisted radical prostatectomyLRP – laparoscopic radical prostatectomyORP – open radical prostatectomyMIRP: Minimally Invasive Radical ProstatectomyCAP: Cryosurgical AblationRARC – robot assisted radical cystectomyLRC – laparoscopic radical cystectomyORC – open radical cystectomyRALP – robot assisted laparoscopic pyeloplastyLP – laparoscopic pyeloplastyRC - Robotic cystectomyOC - Open cystectomyIC - Ileal conduitCCD - Continent cutaneous diversionOC ON - Orthotopic neobladder

FIG. 2. Continued


© 2 0 1 2 T H E A U T H O R S


Anaesthetic (US $)

Medication (US $)

Laboratory (US $)

Room and board (US $)

Length of stay (days)

Nerve sparing % n

Lymphadenectomy % n

Conversion to open/laparoscopic/robot

Length of surgery (min)

Blood loss (mL)

x 78 x 514 1 x x x 200 x

x 72 x 514 1 x x x 140 x

x 150 x 988 3 x x x 160 x

578 x 168 1092 x x x x x x

620 x 329 2100 x x x x x x

620 x 329 2688 x x x x x x

x x x x 2 x x x 202 1015

x x x x 1 x x x 196 780

x x x x 1 x x x 262 227

x 593 620 x x x x x x x

x 578 609 x x x x x x x

x 570 345 x x x x x x x

x 199 204 x x x x x x x

x x x x x x x x x x

x x x x x x x x x x

x x x x x x x x x x

111 x x x 1.06 x x x x x

111 x x x 2.73 x x x x x

111 x x x x x x x x x

365 271 386 873 (409) 1.76 (0.83) 96 22 x x x

419 297 295 778 (758) 1.56 (1.53) 85 11 x x x

234 272 659 1242 (678) 2.51 (1.37) 90 100 x x x

x x x x 1 – 5 x x x 182 234

x x x x 6 – 12 x x x 234.0 482.0

x x x x x x x x 100.2 x

x x x x x x x x 80.7 x

x x x x 2.0 x x x x x




RCTs comparing postoperative as well as long term functional outcomes following robotic surgery compared with laparoscopic approaches.

TRAINING AND LEARNING CURVE

There is no overall consensus on the learning curve of robotic prostatectomy. Some studies, suggest that robotic prostatectomy may have a shorter learning curve than laparoscopic [ 18 ] ( Table 3 ).

The da Vinci robot was embraced by urologists particularly in the USA as it allowed substantial magnifi cation ( × 10 – 20), 3-D HD vision, 6 degrees of movement of the instruments and modulation of movement (i.e. can downscale movement to eliminate a tremor or increase precision) [ 8 ] . The learning curve was also reduced as it allowed surgeons to transfer skills used during open surgery to the robotic approach

in 10 – 12 cases vs the 80 – 100 needed for laparoscopic transition [ 8 ] . This is supported by Caceres et al . [ 18 ] who suggested that the learning curve for robotic prostatectomy was 10 – 20 cases compared with 50 – 60 for laparoscopic. However, Steinberg et al . [ 28 ] devised a theoretical model which approximated an average learning curve of 77 cases (range 24 – 360) at an average cost of US $217 034 (range $95 000 – $1.5 million). Limitations highlighted by the authors were a lack of differentiation between learning curves for individual surgeons vs teams working together and the use of charge data rather than direct costs. They did, however, analyze published series which gave a learning curve ranging from 13 to 200 cases at a cost ranging from US $49 613 – 554 694. They also did not assess clinical outcomes such as erectile function.

Ahlering and colleagues [ 26 ] showed that after a learning curve of 40 procedures, both

open and robotic radical prostatectomy had equivalent outcomes but robotic surgery led to signifi cantly reduced length of stay (1.02 (0.75 – 4) vs 2.12 (2 – 8) days, P < 0.001) as well as blood loss (103 mL (25 – 400 mL) vs 418 mL (150 – 1200 mL), P < 0.01).

Further attempts to reduce the learning curve associated with robotic surgery have included the use of live animal models and virtual reality simulators [ 29 ] . Ethical issues surround the former in some countries and thus research is currently being undertaken to establish methods which can deliver surgical training in robotic surgery that meet ethical standards [ 1 ] .

COST EFFICIENCY

Lotan et al . [ 19 ] devised a model using cost data from a large county hospital as well as

A H M E D E T A L .

© 2 0 1 2 T H E A U T H O R S


a literature search to assess robot purchase costs, length of stay and operating time. They compared robot-assisted, laparoscopic and open prostatectomy. The fi ndings suggested that open radical prostatectomy was the least expensive procedure [ US $6473 (range $3677 – 16 490) ] , whilst robotic prostatectomy was the most expensive [ US $10 269 (range $5494 – 40 401) ] . The cost of purchase and maintenance of the robot was $857 per day [ 19 ] . Length of surgery (140 vs 160 min) was shortest in robotic surgery as was length of stay (1.2 vs 2.5 days) ( Table 2 ) [ 30 ] . This study identifi ed the price for the robot (US $1.4 million), maintenance cost ($150 000/year) and equipment prices ($533) as areas to target for cost effi ciency [ 19 ] . They stated that if the cost of robotic equipment was similar to laparoscopic, then due to the reduced length of operation as well as hospital stay, robotic surgery would be cost equivalent to open surgery [ 19 ] . Limitations of this study include that the cost of the learning curve was not assessed (it was eliminated as a variable by using experienced surgeons) and nor were long term complications or recurrence. They also assumed that a minimum of one robot-assisted procedure was performed per week.

Scales et al . [ 31 ] compared robot assisted prostatectomy with open prostatectomy in the general hospital and specialist urology centre settings. Their base case model revealed a cost premium of US $783 when comparing robotic with open surgery at the specialist level (the premium dropped to US $195 when comparing robotic with open surgery in the general setting). However, based on this model robot assisted prostatectomy could be as cost effective (US $8929 vs $8734) as open in the specialist setting if case volume was increased to 10/week. Robot assisted prostatectomy may be even less expensive (as cost of maintenance would decrease from US $1200 to $500 for each case) in the general setting if length of stay was 1.5 days and case volume increased to 14/week [ 31 ] . Again, a limitation of this model was that it requires a high case load which is not necessarily refl ective of all centres. The cost of the learning curve was also not discussed.

Bolenz et al . [ 2 ] compared robot assisted prostatectomy with laparoscopic and open prostatectomy (643 patients). They found

that even when the cost of purchasing and maintaining the robot were excluded, the cost of each operation was over $1000 more than the laparoscopic procedure whilst open prostatectomy was the cheapest. The operating room costs [ US $2798 (range 2493 – 3175) ] contributed to the increased cost of robot assisted procedures as these took longer to perform than the other two types of procedure. The equipment (US $2015 fi xed cost) necessary to perform robotic prostatectomy also increased the cost of the procedure [ 2 ] . A limitation of this study was that postoperative complications and long term follow-up were not measured. The study also did not give any measure of cost effectiveness ratios and cost per quality of life.

Mouraviev et al . [ 32 ] suggested that costs associated with robotic and laparoscopic surgery were greater than those of using an open approach ( P < 0.05). This was supported by Burgess et al . [ 20 ] who reported a difference of almost US $10 000 [ mean cost is US $39 315 ($25 281 – 81 263) ] between robot assisted and open retropubic prostatectomy. However, Burgess et al . [ 20 ] used charge rather than direct costs. The

former are higher as profi t margins are included. Like Mouraviev et al . [ 32 ] , others have reported that a similar increased cost of instruments accounts for most of the increased charges associated with robotic surgery. This is supported by Caceres et al . [ 18 ] and Joseph et al . [ 33 ] who showed that the increased cost of laparoscopic surgery could be largely attributed to the cost of the instruments. It is reasonable to conclude that the main barriers to cost effi ciency in robotic surgery include the high initial cost, annual maintenance fee and limited number of uses per instrument. There is some evidence that the price of laparoscopic instruments is rising [ 30 ] . This may allow robotic surgery to become a viable alternative if simultaneously the above costs can be reduced.

Nearly 600 cases of robotic cystectomy have been performed world wide [ 24 ] and the International Robotic Cystectomy Consortium has collected data on over 1000 patients. Smith et al . [ 24 ] recently published a study comparing open radical cystectomy with robotic surgery. They found that after adjusting for variable operating room and hospitalization costs, the fi xed costs of

FIG. 3. Fallacies in assessment of robotic technology [ 7 ] .

Technologyspecific

questions?Parameters

TechnologyAssessment

Fallacies in assessmentof Robotic technology

Clinical Outcome ‘ONLY’fallacy

Is robotics overcomingthe problems related to

reduced dexterity &impaired visual control?

Reduction in postsurgical pain levels?

Availability of long-termsurvival/quality of life

parameters?

Learning curve ‘FORALL’fallacy

Do we know factorsaffecting learning curve(for surgeons with open

and laparoscopicexperience)?


© 2 0 1 2 T H E A U T H O R S


robotic surgery are US $1634 higher. Lee et al . [ 34 ] , on the other hand, suggest that the higher fees for robotic cystectomy were offset by the reduced length of stay. Lee et al . [ 27 ] found that the direct relative cost performance of robotic cystectomy was US $13 – 1085 higher than open cystectomy. However, the reduced median length of stay with robotic cystectomy (5.5 days) compared with open cystectomy (8 days), most signifi cantly contributed to lowering costs and, coupled with lower complication rates, resulted in robotic cystectomy being more cost effi cient for some procedures, such as continent cutaneous diversion and ileal conduit.

Other operations where robotic surgery is gaining popularity are partial nephrectomy, pyeloplasty and paediatric urological procedures [ 7 ] . For instance, Link et al . [ 35 ] compared laparoscopic with robotic pyeloplasty and found that the latter demonstrated no improvement in clinical outcomes but was 2.7 times more expensive. Based on their fi ndings, the laparoscopic procedure must take up to 6.5 h longer in order for the cost to become comparable with the robotic pyeloplasty approach. However as with prostatectomy and cystectomy, long term follow-up is critical in evaluating robotic surgery.

So far all the studies suggest that robotic prostatectomy is more expensive than laparoscopic and open equivalents ( Tables 2 and 4 ). Breakdown of these costs suggests that expense is incurred in the cost of purchasing the robot, maintenance and instruments. At present, reduced length of stay in hospital and length of surgery are unable to compensate for the excess costs of robotic surgery. There is a lack of studies describing cost effectiveness ratios or cost per quality of life. An attempt has been made by Qing-Wang et al . [ 36 ] from the London School of Economics and King ’ s College London to suggest a solution. As there have been very few RCTs comparing

TABLE 3 An overview of postoperative outcomes in prostate surgery

Authors Type of surgery

Postoperative outcomes

Learning curve (cases)

Post-anaesthetic care costs (US $)

Mean blood transfusion (units)

Oncological margins (%)

Sexual dysfunction (%)

Urinary symptoms (%)

Other outcomes


LRP x x x x x x xRARP x x x x x x xORP x x x x x x x

Scales et al . [ 31 ]

RARP 295 x x x x x xORP – Specialist setting 419 x x x x x xORP – Community setting 419 x x x x x x

Burgess et al . [ 20 ]

ORP- Retropubic x x x x x x xORP- Perineal x x x x x x RARP x x x x x x x

Mouraviev et al . [ 32 ]

ORP- Retropubic x x x x x x xORP- Perineal x x x x x x xRARP x x x x x x xCAP x x x x x x x


ORP x x 11 – 37 x x x xLRP x x 11 – 30 x x x 100RARP x x 9.6 – 26 20 – 30 x x 13 – 200

Joseph et al . [ 33 ]

ORP x x x x x x xLRP x x x x x x xRARP x x x x x x x

Bolenz et al . [ 2 ]

LRP x x x x x x xRARP x x x x x x xORP x x x x x x x

Caceres et al . [ 18 ]

RARP x x 19.2 0 – 21 0 – 44 x 10 – 20LRP x x 20.6 18 – 75 2 – 30 x 50 – 60

Link et al . [ 35 ]

RALP x x x x x 1 urinary leak

x

LP x x x x x x xLowrance

et al . [ 22 ] LRP x x 11.6 x 35.4 x xORP x x 9.2 x 40.3 x x

Hu et al . [ 23 ]

MIRP x x x 26.8 15.9 x x

RRP x x x 19.2 12.2 x x

A H M E D E T A L .

© 2 0 1 2 T H E A U T H O R S

1 0 B J U I N T E R N A T I O N A L © 2 0 1 2 B J U I N T E R N A T I O N A L

robotic pelvic surgery with other approaches with respect to costs, quality of life, immediate and long term outcomes, it is important to devise a method to ascertain the overall value of robotic surgery. Decision analytic modelling can provide this solution but there must be clear outcome measures and suitable comparators [ 36 ] . A ‘ decision tree ’ can then be made to assist in analyzing and processing data. However, for models to be accurate the best evidence on clinical pathways, possibility of decline in cost of technology and long term outcomes need to be known. Two studies included in this review which utilized decision tree analysis are those of Lotan et al . [ 19 ] and Lee et al . [ 27 ] . However these were limited by the lack of higher level studies, data on long term outcomes as well as quality of life indicators.

DISCUSSION

Both robotic and laparoscopic urological surgery appear to be superior to open surgery with respect to blood loss and hospital stay. However, robotic surgery is currently more expensive than the other two approaches due to capital cost, maintenance of the robot and limited life of the instruments. This cost may be offset by a shorter learning curve and competition for purchase contracts once the patents limited to the sole manufacturer expire. However this is not guaranteed. In addition, the operating theatre cost can add to the expense, although, experienced robotic teams are often quicker than their laparoscopic and open counterparts, thus compensating for the initial increase in operating room time and set-up costs.

Although the cost analyses differ across various studies, hospital and health systems, the fact that robotic procedures are more expensive than open will not change, regardless of how the calculations are designed [ 9,37 ] . As questioned by Graefen, ‘ are these extra costs justifi ed? ’ [ 9 ] The answer is possibly yes. First, if long term advantages for robotic procedures are reported; but this is the not currently the case. Second, if an improved learning curve is established by long term, multicentre studies then more urologists will acquire high quality skills rapidly and patient outcomes will improve. Third, if the cost of the operating theatre equipment and robots can be reduced. Finally, a prospective analysis of outcomes needs to be carried out in RCTs.

Most of the existing trials have not included long term follow-up of clinical outcomes, have failed to mention additional costs associated with conversion of laparoscopic to open procedures (occurs in up to 14%), the huge costs of individual disasters requiring prolonged ITU and hospital stays and the key issue of training ( Fig. 3 ). This combined with reduced length of stay, postoperative complications as well as easier training in robotic surgery may provide an advanced, cost effective surgical tool.

Accurate comparison of cost was diffi cult to assess as few studies gave itemized details of expenditure for each operative technique.

In order to compare the outcomes of robotic surgery against other techniques we looked at the oncological control, continence and sexual function as these are often considered the most important indicators of

quality of life postoperatively after radical prostatectomy [ 38 ] . However, problems arose in gathering enough data for oncological control in robotic and laparoscopic procedures as long term results are currently lacking or preliminary.

Surgical training constantly has to try and keep abreast of innovation. The reduction of working hours in Europe makes this even more diffi cult to achieve. Thus technological advances such as robotic surgery which have a faster learning curve are more likely to be adapted in the face of limited funding, time and resources. The cost of training a surgeon to perform laparoscopic prostatectomy or cystectomy needs to be compared directly with that of training in robotic surgery in order for the true overall costs to be evaluated [ 39 ] .

We conclude that the three areas where robotic surgery can be targeted for cost effi ciency are cost and maintenance of the robot as well as improving the training of surgeons [ 2 ] . If robotic surgery were to yield better quality of life after discharge from hospital, this can have an impact on cost per quality of life. While this may be of little importance to direct hospital costs, it is highly relevant to society as a whole. A patient who returns to work sooner adds to the cost effectiveness of his or her mode of surgery. Health economic modelling needs to take this into consideration for future studies into this growing area of surgery.

FUTURE PROSPECTS

The main obstacle to wider adoption of robotic surgery is cost. If the initial cost of the robot, maintenance and instruments

TABLE 4 Cost related equipment and peri-operative outcomes of robotic cystectomy

AuthorsType of surgery

Total cost (US $)

Robot cost included Y/N

Operative charges

Nonoperative charges

Number of patients

Peri-operative outcomes

Professionals ’ (US $)

Surgical equipment (US $)

Operating room (US $)

Smith et al . [ 24 ] RARC 1 6248 Y x x 20 x x x

ORC 1 4608 x x 20 x x x

Lee et al . [ 34 ] OC IC 25 505 Y 18 303 7202 103 2271 167 x

OC CCD 22 697 20 178 2520 2442 x

OC ON 20 719 19 057 1663 2442 x

RC IC 20 659 19 034 1624 83.0 2271 3905 x

RC CCD 22 102 20 190 1911 2442 x

RC ON 22 685 20 862 1823 2442 x


© 2 0 1 2 T H E A U T H O R S


were reduced, the da Vinci system could prove to be as cost effective as laparoscopic surgery [ 40 ] . The da Vinci system may also have a shorter learning curve which saves money in terms of training and may reduce complications. Moreover, the patent on the da Vinci system is due to expire in a few years and there are plans to produce alternative technologies in future [ 41 ] . These have the advantages of being less bulky with improved precision and access. They are expected to provide value for money as there will be competition which may act to drive down prices. Further savings can be made as the price of instruments for robots reduces or if the frequency of their replacement is reduced. This is, however, only an assumption based on wider economic theories of competition in the free market, rather than specifi c evidence and thus is merely speculative.

LIMITATIONS

Although the quality scoring of the articles included in this review is within appropriate

Anaesthetic (US $)

Medication (US $)

Laboratory (US $)

Room and board (US $)

Length of stay (days)

Nerve sparing% n

Lymphadenectomy % n

Conversion to open/laparoscopic/robot

Length of surgery (min)

Blood loss (mL)

x x x X 5 x x x 246 x

x x x X 5 x x x 228 x

636 x x X 9 x x x 336.0 x

x x X 8 x x x x

x x X 7.8 x x x x

669 x x X 5.5 x x x 360.0 x

x x X 5.8 x x x x

x x X 5 x x x x

TABLE 5 An overview of postoperative outcomes in bladder surgery

AuthorType of surgery

Postoperative outcomesLearning curve (cases)

Post-anaesthetic care costs ($)

Mean blood transfusion (units)

Oncological margins (%)

Sexual dysfunction (%)

Urinary symptoms (%)

Other outcomes

Smith et al . [ 24 ]

RRC x 0.4 x x x x x

ORC x 1.2 x x x x xLee et al .

[ 27 ] OC IC x x x x x x Cost of robot and

maintenance per case is US $1000

OC CCD x x x x x xOC ON x x x x x xRC IC x x x x x xRC CCD x x x x x xRC ON x x x x x x

limits, there is a paucity of well conducted randomized trials. Of the material that exists, only a few papers provide an itemized breakdown of the costs involved in each of the types of surgical approaches. None of the studies provided long term follow-up and thus it was diffi cult to assess thoroughly postoperative outcomes.

CONCLUSIONS

The increasing cost of robotic surgery is associated with the initial purchase of the robot, its annual maintenance and cost of disposable equipment. The cost of robotic surgery in urology can be minimized by addressing issues such as capital costs, maintenance and the learning curve. Robotic procedures have better short term outcomes in terms of complications and hospital stay. Ever growing demands for robotic surgery should be accompanied with studies looking at the actual cost of the procedures as a whole which includes the patient journey within the hospital. Long term outcomes are

needed to establish the effectiveness of robotic surgery in urology.

ACKNOWLEDGEMENTS

Prokar Dasgupta acknowledges fi nancial support from the Department of Health via the National Institute for Health Research (NIHR) comprehensive Biomedical Research Centre award to Guy ’ s & St Thomas ’ NHS Foundation Trust in partnership with King ’ s College London and King ’ s College Hospital NHS Foundation Trust. He also acknowledges the support of the MRC Centre for Transplantation, London Deanery and Olympus.

CONFLICT OF INTEREST

None declared.

REFERENCES

1 Ahmed K , Khan M , Vats A et al . Current status of robotic assisted pelvic

A H M E D E T A L .

© 2 0 1 2 T H E A U T H O R S

1 2 B J U I N T E R N A T I O N A L © 2 0 1 2 B J U I N T E R N A T I O N A L

surgery and future developments . Int J Surg 2009 ; 7 : 431 – 40

2 Bolenz C , Gupta A , Hotze T et al . Cost comparison of robotic, laparoscopic, and open radical prostatectomy for prostate cancer . Eur Urol 2010 ; 57 : 453 – 8

3 Becker C . Nowhere to run, or hide. Current economic downturn may exacerbate hospitals ’ weakness with buildings, technology costs, reimbursements . Mod Healthc 2008 ; 38 : 6 – 7

4 Haycox A . What is health economics? 2nd edn . London : Hayward Medical Communications , 2009 . Available at: http://www.medicine.ox.ac.uk/bandolier/painres/download/whatis/what_is_health_econ.pdf . Accessed 11 February 2012

5 Hummel S , Paisley S , Morgan A , Currie E , Brewer N . Clinical and cost-effectiveness of new and emerging technologies for early localised prostate cancer: a systematic review . Health Technol Assess 2003 ; 7 : iii, ix-x , 1 – 157

6 Hakimi A , Feder M , Ghavamian R . Minimally invasive approaches to prostate cancer: a review of the current literature . Urol J 2007 ; 4 : 130 – 7

7 Dasgupta P . Urologic Robotic Surgery in Clinical Practice , 1st edn. London : Springer , 2008 : 246

8 Rocco B , Djavan B . Robotic prostatectomy: facts or fi ction? Lancet 2007 ; 369 : 723 – 4

9 Graefen M . Editorial comment on cost comparison of robotic, laparoscopic and open radical prostatectomy for prostate cancer . Eur Urol 2010 ; 57 : 458

10 Moher D , Liberati A , Tetzlaff J , Altman DG . Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement . BMJ 2009 ; 339 : b2535

11 Jadad AR , Moore RA , Carroll D et al . Assessing the quality of reports of randomized clinical trials: is blinding necessary? Control Clin Trials 1996 ; 17 : 1 – 12

12 EBM _ Level _ of _ Evidence . Oxford Centre for Evidence-based Medicine – Levels of Evidence (March 2009) . 2009 . Available at: http://www.cebm.net/index.aspx?o=1025 . Accessed 11 February 2012

13 Slim K , Nini E , Forestier D , Kwiatkowski F , Panis Y , Chipponi J . Methodological index for non-randomized studies (minors):

development and validation of a new instrument . ANZ J Surg 2003 ; 73 : 712 – 6

14 EBM . Oxford Centre for Evidence-based Medicine . 2009 . Available at: http://www.cebm.net/index.aspx?o=1025 . Accessed 19 March 2012

15 Ficarra V , Cavalleri S , Novara G , Aragona M , Artibani W . Evidence from robot-assisted laparoscopic radical prostatectomy: a systematic review . Eur Urol 2007 ; 51 : 45 – 55 , discussion 6

16 Ficarra V , Novara G , Artibani W et al . Retropubic, laparoscopic, and robot-assisted radical prostatectomy: a systematic review and cumulative analysis of comparative studies . Eur Urol 2009 ; 55 : 1037 – 63

17 Menon M , Shrivastava A , Kaul S et al . Vattikuti Institute prostatectomy: contemporary technique and analysis of results . Eur Urol 2007 ; 51 : 648 – 57 , discussion 57 – 8

18 C á ceres F , S á nchez C , Mart í nez-Pi ñ eiro L et al . [ Laparoscopic radical prostatectomy versus robotic ] . Arch Esp Urol 2007 ; 60 : 430 – 8

19 Lotan Y , Cadeddu J , Gettman M . The new economics of radical prostatectomy: cost comparison of open, laparoscopic and robot assisted techniques . J Urol 2004 ; 172 : 1431 – 5

20 Burgess S , Atug F , Castle E , Davis R , Thomas R . Cost analysis of radical retropubic, perineal, and robotic prostatectomy . J Endourol 2006 ; 20 : 827 – 30

21 Lowrance WT , Tarin TV , Shariat SF . Evidence-based comparison of robotic and open radical prostatectomy . Scientifi c World Journal 2010 ; 10 : 2228 – 37

22 Lowrance WT , Elkin EB , Jacks LM et al . Comparative effectiveness of prostate cancer surgical treatments: a population based analysis of postoperative outcomes . J Urol 2010 ; 183 : 1366 – 72

23 Hu JC , Gu X , Lipsitz SR et al . Comparative effectiveness of minimally invasive vs open radical prostatectomy . JAMA 2009 ; 302 : 1557 – 64

24 Smith A , Kurpad R , Lal A , Nielsen M , Wallen E , Pruthi R . Cost analysis of robotic versus open radical cystectomy for bladder cancer . J Urol 2010 ; 183 : 505 – 9

25 Nix J , Smith A , Kurpad R , Nielsen M , Wallen E , Pruthi R . Prospective randomized controlled trial of robotic

versus open radical cystectomy for bladder cancer: perioperative and pathologic results . Eur Urol 2010 ; 57 : 196 – 201

26 Ahlering T , Woo D , Eichel L , Lee D , Edwards R , Skarecky D . Robot-assisted versus open radical prostatectomy: a comparison of one surgeon ’ s outcomes . Urology 2004 ; 63 : 819 – 22

27 Lee R , Ng CK , Shariat SF et al . The economics of robotic cystectomy: cost comparison of open versus robotic cystectomy . BJU Int 2011 ; 108 : 1886 – 92

28 Steinberg PL , Merguerian PA , Bihrle W , Seigne JD . The cost of learning robotic-assisted prostatectomy . Urology 2008 ; 72 : 1068 – 72

29 Pierorazio P , Allaf M . Minimally invasive surgical training: challenges and solutions . Urol Oncol 2009 ; 27 : 208 – 13

30 Lotan Y . Economics of robotics in urology . Curr Opin Urol 2010 ; 20 : 92 – 7

31 Scales CJ , Jones P , Eisenstein E , Preminger G , Albala D . Local cost structures and the economics of robot assisted radical prostatectomy . J Urol 2005 ; 174 : 2323 – 9

32 Mouraviev V , Nosnik I , Sun L et al . Financial comparative analysis of minimally invasive surgery to open surgery for localized prostate cancer: a single-institution experience . Urology 2007 ; 69 : 311 – 4

33 Joseph JV , Leonhardt A , Hitendra R , Patel H . The cost of radical prostatectomy: retrospective comparison of open, laparoscopic, and robot-assisted approaches . J Robotic Surg 2008 ; 2 : 21 – 4

34 Lee R , Ng C , Lee M . Open versus robotic cystectomy: re-examining the cost comparison . J Urol 2009 ; 181 : 197

35 Link RE , Bhayani SB , Kavoussi LR . A prospective comparison of robotic and laparoscopic pyeloplasty . Ann Surg 2006 ; 243 : 486 – 91

36 Wang Q , Armstrong D , McGuire A . Health Economics in Robotic Surgery . In Dasgupta P . Urologic Robotic Surgery in Clinical Practice , 1st edn . London : Springer . 2008 : 195 – 233

37 Barbash GI , Glied SA . New technology and health care costs – the case of robot-assisted surgery . N Engl J Med 2010 ; 363 : 701 – 4

38 Gettman M , Blute M . Critical comparison of laparoscopic, robotic, and


© 2 0 1 2 T H E A U T H O R S

B J U I N T E R N A T I O N A L © 2 0 1 2 B J U I N T E R N A T I O N A L 1 3

open radical prostatectomy: techniques, outcomes, and cost . Curr Urol Rep 2006 ; 7 : 193 – 9

39 Patel H , Linares A , Joseph J . Robotic and laparoscopic surgery: cost and training . Surg Oncol 2009 ; 18 : 242 – 6

40 Link R , Su L , Bhayani S , Pavlovich C . Making ends meet: a cost comparison of laparoscopic and open radical retropubic prostatectomy . J Urol 2004 ; 172 : 269 – 74

41 Shah B , Buettner S , Lehman A , Farritor S , Oleynikov D . Miniature in

vivo robotics and novel robotic surgical platforms . Urol Clin North Am 2009 ; 36 : 251 – 63

42 Lotan Y , Bolenz C , Gupta A et al . The effect of the approach to radical prostatectomy on the profi tability of hospitals and surgeons . BJU Int 2010 ; 105 : 1531 – 5

Correspondence: Kamran Ahmed, Research Registrar, Guy ’ s and St Thomas ’ Hospitals, Urology Centre, 1 st fl oor Southwark Wing, Great Maze Pond, London SE1 9RT e-mail: [email protected]

Abbreviations : CAP , cryosurgical ablation ; CCD , continent cutaneous diversion ; IC , ileal conduit ; LP , laparoscopic pyleoplasty ; LRC , laparoscopic radical cystectomy ; LRP , laparoscopic radical prostatectomy ; MIRP , minimal invasive radical prostatectomy ; OC , open cystectomy ; ON , orthoptic neobladder ; ORC , open radical cysectomy ; ORP , open radical prostatectomy ; RALP , robot assisted laparoscopic pyeloplasty ; RARC , robot assisted radical cystectomy ; RARP , robot assisted radical prostatectomy ; RC , robotic cystectomy ; RRP , radical retropubic prostatectomy .

Assessing the cost effectiveness of robotics in urological surgery – a systematic review

Documents

Transcript of Assessing the cost effectiveness of robotics in urological surgery – a systematic review