Cost effectiveness and Robot-assisted urologic surgery: Does it make dollars and

sense?

Ryan W. Dobbs1, Brenden P. Magnan1, Nikita Abhyankar1, Ashok K. Hemal2, Ben

Challacombe, 3, Jim Hu4, Prokar Dasgupta3, Francesco Porpiglia5 and Simone
Crivellaro1

1 Department of Urology, University of Illinois at Chicago, Chicago, Illinois; 2.

Department of Urology, Wake Forest University, Winston-Salem, North Carolina; 3.
Department of Urology, Guy's and Thomas' NHS Foundation Trust and KCL, London,
UK; 4. Lefrak Center for Robotic Surgery, Department of Urology, Presbyterian Weill
Cornell Medical Center, New York, NY, USA; 5. Division of Urology, Department of Oncology,
University of Turin "San Luigi" Hospital, Orbassano, Italy.

Word count: 4,394

Abstract count: Not applicable

Source of Funding: None

Key Words: Cost Effectiveness - Robotic Surgery - New Technology Minimally

Invasive Surgery Cost Control

Corresponding Author:
Ryan Dobbs, MD
Urology Resident
University of Illinois-Chicago
820 S. Wood Street Suite 515
Chicago, Illinois 60612
rdobbs@uic.edu
(312) 996-1545 (telephone)
(773) 257-6226 (fax)
Abstract:

INTRODUCTION: The introduction of the robotic surgical platform has led to distinct
changes in practice patterns and the utilization of minimally invasive surgery in
urology. While use of the robotic system is associated with improvements in
perioperative outcomes such as estimated blood loss and hospital stay, there are
significant fixed and variable costs with the purchase, maintenance and use of the
robotics system that has led many authors to investigate the cost effectiveness of
robotic urologic surgery. We sought to examine the best current available evidence
for the cost effectiveness of robotic urologic surgery.

EVIDENCE ACQUISITION: Comprehensive electronic literature searches were

conducted without language restriction to identify reports of published studies
within PubMed/Medline, SCOPUS and Web of Science. Relevant articles were
examined and reference lists cross referenced to find additional pertinent
publications.

EVIDENCE SYNTHESIS: PubMed literature searches of robot urology cost (304

articles) robotic prostatectomy cost (215 articles), robotic nephrectomy cost (87
articles), robotic cystectomy cost (44 articles) and robotic pyeloplasty cost (41
articles) were initially reviewed in abstract form to find appropriate articles for
inclusion. Given that robotic cystectomy (559 articles), robotic pyeloplasty (344
articles) robotic retroperitoneal lymph node dissection (59 articles) are less
frequently performed than robotic prostatectomy, all available articles published
from January 1st 2000 until July 31st 2016 were reviewed for potential inclusion.
After excluding duplicates, appropriate articles were pulled for full text review. 49
articles were used for the final analysis.

CONCLUSIONS: The available literature on the cost effectiveness of robotic urologic

surgery is somewhat limited by heterogeneity of research methods, local cost
variations and methods for determining costs associated with surgical outcomes.
The introduction of the robotic surgical platform has led to a dramatic change in the
availability and utilization of laparoscopic surgery and is associated with both
favorable perioperative outcomes as well as significantly greater fixed costs related
to instrumentation and equipment expenses. Well-designed trials comparing open
and robotic approaches in the contemporary era of widespread robotic adoption
with quality of life and validated economic metrics will be necessary to provide
evidence for continued use of this valuable technology.
INTRODUCTION

The introduction of the da Vinci robotic surgical platform (Intuitive Surgical,

Sunnyvale, CA) in 1997 marked a transformative moment in surgical technology. 1
Since its first use for a robotic assisted laparoscopic cholecystectomy, the da Vinci
system has been widely adopted by patients and clinicians alike, particularly in
urologic field for the surgical treatment of prostate cancer. 2 Since its Food and Drug
Administration (FDA) approval in 2001 for radical prostatectomy, robotic assisted
radical prostatectomy has become the preferred technique replacing the open
retropubic radical prostatectomy.3 While per capita utilization of prostate cancer
surgery has remained stable from 1998 to 2011, the annual rate of minimally
invasive prostatectomy has sharply increased from less than 1 per million to 895
per million while open radical prostatectomy declined from 1424 per million to 435
per million.4 This trend has continued and by 2013, 85% of prostatectomies were
performed robotically.5 While robotic assistance is often utilized for prostatectomy, it
has also been adopted for use for other common urologic operations including
cystectomy6, 7, retroperitoneal lymph node dissection (RPLND) 8, nephrectomy9 &
partial nephrectomy10, pyeloplasty11 and urolithiasis.12

While the da Vinci system has been widely adopted in the field of urologic
surgery, there remain significant questions regarding the clinical benefit and cost
effectiveness of the robotic surgical platform. The initial cost of the platform can be
significant and there have been concerns regarding the robustness of cost
effectiveness analyses performed during the era of early adoption of robotic surgery
13
Beyond the initial expense of purchasing a robotic surgical platform which costs
14
between 1 and 2.5 million dollars there are also a significant costs associated with
yearly maintenance costs as well as specialized disposable surgical instruments.
One study determined that including amortized costs, the use of robotic platforms
may cost 2.5 billion dollars annually in the United States. 14 These increased upfront
costs are balanced by research which have suggested that robotic surgery may
have improved oncological outcomes such as reduced positive surgical margins as
well as decreased perioperative complications such as a reduction in hospital stay
and blood transfusion requirements.15 Additionally, the advantages of the robotic
platform extend to the surgeon as the shorter learning curve than laparoscopic
techniques and increased surgeon comfort with robotics has led to increased
availability for patients for minimally invasive approaches. The goal of this review is
to critically evaluate the current evidence related to cost effectiveness in robotic
urologic surgery for prostatectomy, cystectomy, RPLND, and pyeloplasty as well as
to investigate potential mechanisms for cost containment that clinicians are
investigating to reduce costs and improve cost effectiveness for robotic surgery.

EVIDENCE ACQUISITION
Comprehensive electronic literature searches were conducted to identify
reports of published studies. Highly sensitive search strategies were designed
including appropriate subject headings and text word terms, interventions under
consideration and specific study designs. There was no language restriction,
literature searches were limited from the year 2000 given the introduction of the
robotic surgical platform with particular focus in contemporary years given the
widespread adoption of the technology. PubMed/Medline, SCOPUS, and Web of
Science databases were searched for primary studies using as keywords cost and
robotic surgery. Conference abstracts from meetings of the European, American
and British Urological Associations were searched through Google Scholar. The
obtained reference lists was scanned to identify relevant reports on the specific
cost control factors of robotic surgery topic and used for this review.

EVIDENCE SYNTHESIS
PubMed literature searches of robot urology cost (304 articles) robotic
prostatectomy cost (215 articles), robotic cystectomy cost (44 articles) robotic
nephrectomy cost (87 articles) and robotic pyeloplasty cost (41 articles) were
initially reviewed in abstract form to find appropriate articles for inclusion. Given
that robotic cystectomy (559 articles), robotic pyeloplasty (344 articles) robotic
retroperitoneal lymph node dissection (59 articles) are less frequently performed
than robotic prostatectomy, all available articles published from January 1 st 2000
until July 31st 2016 were reviewed for potential inclusion. After excluding duplicates,
appropriate articles were pulled for full text review. 49 articles were used in the final
analysis.

ROBOTIC PROSTATECTOMY
 Discussions of cost and cost effectiveness for robotic assisted laparoscopic
prostatectomy (RALP) have been one of the most contentious debates in urology.
Since the introduction of the Da Vinci robotic system, RALP has been rapidly
adopted and is now utilized for the majority of prostatectomies in the United
States.4 The robotic platform is well suited for RALP given the anatomical location
deep in the pelvis and attractive to surgeons given a shorter learning curve than the
technically demanding pure laparoscopic prostatectomy, improved operative view
with magnification for careful dissection of the neurovascular bundles and carbon
dioxide insufflation to reduce the risk of significant bleeding. While these
advantages perhaps allow less experienced surgeons to comfortably perform
prostatectomy, RALP is the most commonly performed robotic procedure that
urologists perform and the fixed costs of the robotic system represent a substantial
economic outlay for healthcare systems.

In initial modelling examinations of the costs of RALP, the cost was estimated
as $1,726 greater than open retropubic prostatectomy (RRP) due to increased
equipment costs and increased operative times (200 minutes versus 160 minutes)
with savings for inpatient LOS (1.3 versus 2.5 days) favoring RALP. 16 While these
authors had stated that costs of new technology are typically higher in their first
years of use due to the learning curve for the technology, a follow up study 6 years
later by the same group found that between 2003 and 2008, the costs associated
with RALP considering purchase and maintenance of the robot were still $2,698
greater for RALP as compared to RRP.17 As data matured, cost effectiveness studies
were able to transition from models to actual costs. Mouraviev et al 18 were the first
group to compare direct costs of RALP and found that while direct surgical costs
were significantly higher for RALP, gains in length of stay meant that total hospital
costs were less for RALP compared to RRP. While there are intrinsic costs associated
with robotic surgery, several studies have demonstrated that surgeon experience
and hospital volume are both related to improved complication rates and lower
overall costs. Leow et al 5 found that RALP patients experienced less morbidity at a
higher expense than RRP, but that this cost difference was not observed for high
19
volume surgeons or hospitals. Hyams et al evaluated the relationship between
surgical volume and cost of RALP and found that RALP was associated with
significantly greater total costs ($14,000 vs 10,100 for RALP and RRP respectively)
but that higher volume surgeons had a significantly lower costs for both RALP and
RRP and higher volume hospitals had significantly lower costs for RALP. Similarly, Yu
20
et al found that hospitals in the lowest RALP volume quartile (1 to 15 annual
cases) incurred significantly higher costs ($12,754 vs $8,623, p<0.01) than median
highest quartile for RALP volume (55 to 166 annual cases) as well as significantly
more complications than high volume centers. These results are in line with health
technology assessment (HTA) analysis in the United Kingdom 21 that found that RALP
was cost effective at centers performing > 150 cases annually while a Canadian HTA
found that incremental costs fell significantly during the first 200 robotic
procedures.22 The reason for improved cost efficiency with experienced surgeons
23, 24
and hospitals is likely multifactorial including reduced operative time , reduced
20
complication rates , greater familiarity with enhanced recovery after surgery
25
protocols and utilization of dedicated and experienced robotics team to streamline
intraoperative room turnover.26

While it is clear that several perioperative outcomes such as transfusion

requirements and length of stay are improved with RALP 17, the amount of
improvement in perioperative outcomes is not as striking as the differences that
robotic technology may provide with cystectomy or RPLND. Thus, improvements in
variable inpatient costs that are seen with these procedures are less likely to
outweigh the fixed costs associated with the robotic platform.

Some authors have argued that assessing the true economic impact of RALP
requires a comprehensive approach, factoring in Quality Adjusted Life Years (QALY)
to account for functional outcomes, namely incontinence and erectile dysfunction.
Hohwu et al27 performed a short term cost effectiveness study between RALP and
RRP in a cohort of 231 Danish men and found higher direct and indirect costs for
RALP patients. In their study, patients treated with RRP had more gained QALYs
(0.0116 for RRP, 0.0103 for RALP) and thus they concluded that RALP was not cost
effective given increased costs without concurrent improvement in QALY outcomes.
21
Conversely in a modelling experiment, Close et al found that over a 10 year
period that while RALP was more costly than laparoscopic prostatectomy, it was
more effective with a mean gain in QALY of 0.08. They determined that given an
annual surgical volume of 200 cases, the incremental cost effectiveness ratio (ICER)
was 18,329 with an 80% probability that RALP was cost effective at the standard
30,000 per QALY threshold recommendation. Given the discrepancy in findings in
European studies, it is clear that a comprehensive economic study including
functional outcomes and QALY between RALP and RRP in the United States would
provide crucial data towards assessing the cost effectiveness of RALP. Cost
effectiveness studies comparing RALP and RRP are summarized in Table 1.
In addition to QALY, another emerging model for determining the
comprehensive costs associated with treatment is the use of time driven activity-
based costing (TDABC) analyses. This approach uses a multidisciplinary team to
create a comprehensive process map with associated costs for treatment. In a
recent study of low risk men with prostate cancer, Laviana et al 28 found that RALP
was the second most expensive treatment option over a 5 year period with
only intensity-modulated radiation therapy with higher associated costs.
Given the trends in both resident training and RALP utilization 4, it is clear that
RALP will continue to be the dominant surgical technique in the future. Thus, it has
29-31
been a target of several studies to reduce costs which will be further discussed
in the cost containment section. Reported improvements in functional outcomes
32 33
such as erectile dysfunction and urinary incontinence as well as oncological
outcomes such as a reduction in positive surgical margins 34, 35
will be necessary
factors to consider for a comprehensive cost effectiveness analysis.

ROBOTIC CYSTECTOMY

Currently, bladder cancer has the highest lifetime treatment costs per patient
of all malignancies.36 Given the morbidity associated with open radical cystectomy
(ORC), the robotic assisted radical cystectomy (RARC) has been an appealing, albeit
technically demanding procedure. As long term functional and oncologic results are
still maturing, the available studies on costs for RARC are limited to cost-
identification analyses which assumes equivalent outcomes between RARC and
37
ORC. An initial cost analysis of the robotic approach by Smith et al concluded that
mean fixed operating room costs for robotic cases were $1,634 higher for robotic
cases as well as $570 greater for variable operating room costs directly related to
increased operative time. These increased costs were somewhat counterbalanced
by lower transfusion requirements and a shorter length of stay (0.6 days mean
difference) for RARC patients whose variable inpatient costs were $564 less than the
open approach for a total financial cost difference of $1,640. While this analysis did
not include amortized costs associated with the purchase and maintenance of the
robotic platform, other studies have included these variables.

38
Martin et al performed a complete cost analysis between ORC and RARC
and found that at their institution, RARC had a 38% total cost advantage as
compared to ORC. Based on their historical data, this cost savings for the robotic
approach was due to a 5 day difference in mean LOS (5 days for RARC, 10 days for
ORC), decreased mean operative time (280 minutes for RARC versus 320 minutes
for ORC) as well as a striking difference in transfusion rates (57% of ORC patients
required 2 units packed red blood cells as compared to 8% for RARC patients). In
their analysis, RARC became more expensive than ORC if the OR time was greater
than 361 minutes, LOS was greater than 6.6 days or if the fixed operative room
39
costs exceeded $5,853. Similarly, Lee et al compared 103 ORC and 83 RARC
patients between 2002 and 2009 and found a difference of LOS of 2.2 to 3.5 days
depending on type of diversion. In their analysis, the cost effectiveness of RARC
varied on the type of diversion. Including complications data, RARC was most cost
effective by $4,846 for ileal conduits and $596 more favorable for continent
cutaneous diversion but ORC was favored by $1,966 for orthotopic neobladder. This
study suggests that the complexity of the urinary diversion may be a key driver for
costs associated with RARC, as for both ileal conduits and continent cutaneous
diversion there were significantly less costs associated with complications, while
this advantage was not seen with orthotopic neobladder. Thus, somewhat
contradictory, younger healthier patients who are good candidates for orthotopic
neobladder may benefit from an open approach due to the technical challenge and
increased complicated associated with robotic orthoptopic neobladder, while for
older patients with more comorbidities in a high volume center it may be more cost
effective for ileal conduit RARC.

37-39
These initial cost identification studies were derived from single
40
institution data sets from high volume academic centers. Yu et al performed a
comparative analysis of costs between open and robotic approaches using the US
Nationwide Inpatient Sample and found that RARC was on average $3,797 more
expensive than ORC. In contrast to single center studies, they found that while
RARC patients had a lower requirement for parenteral nutrition use, there was not a
41
significant difference in LOS. Leow et al used a larger US population based cohort
and found a 46% decreased risk of minor complications with similar major
complication rates. In this study, RARC was associated with $4,326 greater 90 day
direct hospital cost, most significantly related to increased cost of supplies. While
RARC LOS was shorter by 1.5 days, there was no significant difference in room and
board costs in this dataset. Most interestingly is that when costs were analyzed by
surgeon and hospital volume, high volume surgeons (7 cases per year) and high
volume hospitals (19 cases per year), these differences in morbidity and cost were
not present. These results suggest that centralization of RARC to high volume
centers may improve outcomes and cost effectiveness. As more hospitals and
surgeons gain experience with RARC, it will be interesting to see if volume related
outcomes present between 2004 and 2010 will continue to be present as RARC data
matures.

Overall, RARC appears to be associated with reduced blood loss, less

transfusion requirements, fewer complications and a reduced LOS as compared to
ORC. Based on available studies, the differences in complication rates and LOS
derived from robotic techniques are the most important overall drivers for cost
effectiveness, while the choice and complexity of urinary diversion may also
contribute towards the overall cost and help determine if RARC is a financially
feasible option. Given the complexity of RARC, centralization of this procedure to
high volume surgeons and hospitals may improve outcomes and cost effectiveness.

ROBOTIC NEPHRECTOMY
One of the most successful application of the robotic surgical system has
been its use with robotic nephrectomy and partial nephrectomy. Laparoscopic
surgery without the need for a significant and painful flank incision has been a key
driver for the reduction of hospitalization times over open renal surgery. In a meta-
analysis of outcomes for partial nephrectomy, Mir et al 42 found that laparoscopic
partial nephrectomy was the most cost effective option compared to open or robotic
approaches due to the improvement in LOS with minimally invasive approaches as
compared to open surgery. Similarly, in a series of 20 consecutive robotic (RPN) and
laparoscopic partial nephrectomies (LPN), it was found that RPN was associated with
an additional $1,066 case premium over LPN although the authors did note there
were theoretical benefits such as decreased warm ischemia time and increased
utilization of nephron-sparing surgery which were not included in their model. 43
These findings were similar to those in several other institutional studies 44-46
although some studies did not find significant differences between laparoscopic
hand assisted and robotic techniques.47
Overall, robotic techniques represent a key option for the treatment of renal
tumors and advantages regarding LOS and complications associated with the
robotic approach make it an appealing and technically feasible option for providers
and patients.

ROBOTIC PYELOPLASTY

One of the most common urologic issues prompting surgical intervention in

children is ureteropelvic junction (UPJ) obstruction. The gold standard operation for
this condition is the open dismembered pyeloplasty (OP), although recent national
surveys have demonstrated a changing practice pattern as minimally invasive
pyeloplasties (MIP) (laparoscopic pyeloplasty LP and robotic pyeloplasty (RP)
increased from 0.34% in 2000 to 11.7% in 2009 with the bulk of these procedures
being performed with robotic assistance. 48 Similarly, a study of the Perspective
database (Premier, Inc., Charlotte, North Carolina) demonstrated that while the total
number of pyeloplasties performed between 2003 and 2010 was relatively stable
(1,634 and 1,542 respectively) the proportion of MIP sharply increased (>30% all
pyeloplasties) while OP decreased, demonstrating a substitution effect. In this
study, a shorter mean hospitalization of 17 hours was observed for RP compared to
OP however, operative times for OP were 55 and 85 minutes shorter than those for
LP and RP respectively and median total cost was lower among patients undergoing
OP v RP ($7,221 vs $10,780, p<0.001)49

While these findings question the cost effectiveness of RP, the bulk of the
robotic procedures in this dataset were performed between 2009 and 2010 and the
increased costs associated with increased operative time may reflect a learning
curve with robotic technology. Even small improvements in hospital stay may be
particularly important for the pediatric population as one or both caretakers
50
frequently take time off work while their child convalesces. Behan et al
demonstrated a significantly shorter average hospital length of stay (1.6 vs 2.8
days) for RP versus OP and also reported that parents had significantly less lost
wages for RP which may represent an underreported human capital gain associated
with RP. They concluded that RP and OP have comparable costs when amortized
robot costs were excluded ($6008 vs $5079 for RP and OP respectively, p=0.064)

RP is the most commonly performed robotic surgery in children and is twice

as commonly performed as the next most frequently robotic operation, ureteral
51
reimplantation. Between 2008 and 2013, utilization of robotic urologic surgeries in
pediatric patients increased 17.4% annually (p < 0.001) with significant increases in
RP, as well as robotic ureteroneocystostomy, nephroureterectomy and partial
nephrectomy. Similar to previous results, the robotic cohorts for urologic procedures
demonstrated a significant improvement in length of stay for all procedures
evaluated, however robotic procedures were associated with a significantly higher
total cost of admission than patients undergoing equivalent operations ($14,583 vs
$9,388 respectively).51

The most important criteria for OP v RP are comparative effectiveness

52
studies. In a study of the Nationwide Inpatient Sample, Sukumar et al found that
as compared to OP, RP patients had equivalent risks for intraoperative and
postoperative complications as well as lower risk for greater LOS, but had higher
risks for transfusions and greater hospital charges as well as increased rates of
stent placement which may necessitate a second procedure for removal. This is in
line with meta-analyses which have demonstrated no significant differences
between RP and OP for a number of primary outcomes including operative success,
re-operation, postoperative complications and urinary leakage. 53 Generally, the
preponderance of evidence suggests that RP has comparable and equivalent
operative outcomes to OP, albeit with increased costs.

While many studies have suggested that the improvements in hospital stay
54
and cosmesis associated with minimally invasive surgery could be obtained with
 55
less costly laparoscopic techniques, Casella et al compared a cost analysis of LP v
RP and found that operative times for RP were shorter than for LP (200 vs 265
minutes, p<0.001) and there was no significant difference in the total cost of the
procedures ($15,337 vs $16,067, p<0.46) as increased costs associated with robotic
technology were counterweighed by improvements in operative time.

Ultimately, further cost and comparative effectiveness studies between OP

and RP will be necessary given the maturation and widespread adoption of robotic
techniques. Long term analyses of operative success and need for reoperation
should be considered particularly important given the effectiveness of the gold
standard open approach. Presently available studies for long term outcomes have
demonstrated similar success rates regarding flank pain, resolution of
hydronephrosis and renal function over a mean follow up of greater than two years,
however these long term results will need confirmation in multicenter studies. 56 For
pediatric patients, costs associated with parental time off work, cosmesis, parental
satisfaction as well as risks for additional procedures (ureteral stent removal, risk for
lysis of adhesions for small bowel obstruction) are unique factors to consider for a
long term comprehensive cost analysis.

ROBOTIC RETROPERITONEAL LYMPH NODE DISSECTION

Retroperitoneal lymph node dissection (RPLND) is a developing utilization of

the robotic platform. Traditional RPLND is the gold standard for clinical staging and
is indicated for men with clinical stage (CS) I nonseminomatous germ cell tumor
(NSGCT), low-volume CS II disease, and residual disease after chemotherapy. The
traditional open approach has excellent oncological outcomes but is associated with
significant morbidity and prolonged hospitalization. 57 Laparoscopic RPLND has
improved perioperative outcomes and long term cancer control but is technically
challenging and requires extensive laparoscopic experience. 58

First described in 2006 8, robotic RPLND (R-RPLND) was performed for an 18

year old man with a history of a mixed germ cell tumor and has subsequently been
59 60
shown to be an effective therapeutic option for both adult and adolescent
patient populations with decreased blood loss, shorter hospital stay, reduced
convalescence and comparable oncologic outcomes as compared to an open
approach.

60
While some authors have briefly alluded to potential economic and cost
61-63
benefits with R-RPLND, the largest available series have not included a formal
evaluation of cost effectiveness. While R-RPLND remains a relatively rare procedure
with a high degree of centralization to a few high volume centers and surgeons, the
lack of evaluation of the economic concerns of R-RPLND represent a potential area
for investigation as oncological and efficacy data matures.

COST CONTROL TECHNIQUES

With recent changes to health care policy and delivery, it is clear that an
increasing focus will be on quality improvement and cost effectiveness of medical
care. While there are unequivocally some advantages to robotic surgery, it is also
clear that there are high fixed costs associated to the technology may make it a
target of future cost containment efforts. In this setting, several investigators have
looked at different approaches to reduce both fixed and variable costs associated
with robotic urologic surgery.

One of the simplest technique to reduce fixed costs is to reduce disposable

costs associated with the robotic surgical platform. Instrument costs represent a
significant aspect of increased costs for robotic surgery compared to the open
approach. Critically evaluating the surgical instrumentation has been shown to be a
30
potential mechanism for cost containment. Delto et al identified a minimally
viable toolbox of a monopolar scissors, a Prograsps forcep, a fenestrated bipolar
and a robotic needle driver and found that using these instruments resulted in an
approximate 40% reduction in instrumentation costs compared to a conventional
31
set. Similarly, Ramirez et al reported on their use of a 3 instrument technique for
RALP using only a single robotic needle driver, a Prograsp forceps and monopolar
scissors. In this study, exclusion of use of higher cost energy instruments (such as a
bipolar graspers or robotic Ligasure) resulted in a 40% improvement in operative
costs while use of a single as opposed to two robotic needle drivers decreased
overall costs another 12% without any significant change in operative time, blood
loss, postoperative complications or functional outcomes.

Presently, disposable robotic instruments have a predetermined 10 uses or

29
lives based on manufacturing specification. Ludwig et al looked at instrument
life for RALP and Robotic partial nephrectomy cases and found that monopolar
curved scissors were only exchanged in 12.4% of cases while other instruments
were exchanged in less than 2% of cases. While these findings are reassuring for
the durability of the robotic instrumentation, the predetermined 10 uses for robotic
instruments represents an area for re-evaluation given the cost of approximately
$2,500 ($250 per usage) for each robotic instrument. 31 This same group also
reported replacement of a grasping tool with a limited number of lives for retraction
during robotic partial nephrectomy with a robotic clip applier which may be used
indefinitely for simple retraction as another potential technical modification to
64
reduce instrumentation costs.

While the idea of an outpatient prostatectomy would have unthinkable prior

to introduction to robotic technology, investigators have performed pilot studies of
outpatient RALP. One study of 30 men meeting inclusion criteria (<65 years old,
American Society of Anesthesiologists score <3, body mass index <35 kg/m 2,
localized prostate cancer, primary treatment) were enrolled in a study of outpatient
RALP compared to a matched inpatient cohort. In this study, 26 of 30 men were
discharged the day of surgery with an average hospital stay of 14 hours compared
to 44 hours for the inpatient group (p<0.01) with comparable continence, narcotic
usage, days to return to work and patient/family satisfaction. 65 This study provides
a basis that for some well selected patients, an outpatient approach to RALP may be
feasible as a potential cost control mechanism.

CONCLUSIONS

The introduction of the robotic surgical platform has led to a dramatic change
in the availability and utilization of laparoscopic surgery and is associated with both
favorable perioperative outcomes as well as significantly greater fixed costs related
to instrumentation and equipment expenses. In the current healthcare delivery
environment, these increased costs make robotic surgery a potential target for cost
containment and practitioners may need additional evidence to justify using this
technology. Centralization of operations to high volume surgeons and centers with
experienced surgical and postoperative teams as well as innovative approaches to
reducing waste and redundancy in surgical instrumentation costs will be essential to
improving the cost effectiveness of robotic surgery. Well-designed trials comparing
open and robotic approaches in the contemporary era of widespread robotic
adoption with quality of life and validated economic metrics will be necessary to
provide evidence for continued use of this valuable technology.
Table 1: Cost comparative studies for RRP versus RALP
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