Local cost structures and the economics of robot assisted radical prostatectomy

Open, laparoscopic and robotic radical prostatectomy: optimizing the surgical approach

As advances in the understanding of prostatic anatomy led to improvements in functional and oncologic outcomes after prostatectomy of the past few decades, advances in technology and surgical technique have made minimally-invasive prostate surgery a reality. Today patients diagnosed with clinically localized prostate cancer have more surgical treatment options than in the past including open, laparoscopic and robot-assisted laparoscopic radical prostatectomy. Advantages and disadvantages exist for each modality and lead to subtle differences in the technical execution of the procedure. Evidence from centers of excellence and from experienced surgeons demonstrates that both laparoscopic and robotic-assisted laparoscopic radical prostatectomy appear to be comparable to outcomes achieved with open radical retropubic prostatectomy series. Individual surgeon skill, experience and clinical judgment are likely the stronger predictors of outcome rather than the technique chosen. However, learning curves, oncologic outcomes and cost-efficacy remain important considerations in the dissemination of minimally-invasive prostate surgery. A greater appreciation of the periprostatic anatomy and further modification of surgical technique will result in continued improvement in functional outcomes and oncological control for patients undergoing radical prostatectomy, whether by open or minimally-invasive surgery.

Advances in robotic prostatectomy

Robotic-assisted laparoscopic prostatectomy (RALP) has emerged as an important treatment option for localized prostate cancer. As such, methods to improve instrumentation, technique, outcomes, and cost require continued investigation. For example, a recently introduced four-armed robotic system has limited the need for bedside assistants, while an enhanced understanding of pelvic anatomy as visualized robotically has led to valuable modifications in operative technique. Increased surgeon experience has decreased perioperative morbidity, and has resulted in short-term pathologic and functional outcomes that compare favorably with open radical prostatectomy. Meanwhile, quality-of-life studies using validated instruments are helping to define the time course of patient recovery. Nevertheless, costs associated with robotic surgery remain daunting. As the follow-up of patients treated with RALP matures, future studies, ideally with a prospective, randomized design, will be needed to establish the long-term oncologic efficacy of the procedure and to evaluate the overall advantages of RALP compared with open surgery.

Outcomes after robot-assisted laparoscopic radical prostatectomy

Robot-assisted laparoscopic radical prostatectomy (RALRP) using the da Vinci surgical system is now in widespread use in many countries where economic conditions allow the installation of this expensive technology. Controversy has surrounded the procedure since it was first performed in 2000, with many critics highlighting the lack of evidence to support its use. However, despite the lack of level I evidence, many large studies of patients have confirmed that the procedure is feasible and safe, with low morbidity. Available longer-term oncological data seem to show that outcomes from the robotic approach at least match those of traditional open radical prostatectomy. Functional outcomes also seem satisfactory, although randomized controlled trials are lacking. This paper reviews the current status of RALRP with respect to perioperative data and complications and oncologic and functional outcomes.

Robotic-assisted versus laparoscopic cholecystectomy: outcome and cost analyses of a case-matched control study

OBJECTIVE

To compare safety and costs of robotic-assisted and laparoscopic cholecystectomy in patients with symptomatic cholecystolithiasis.

BACKGROUND

Technical benefits of robotic-assisted surgery are well documented. However, pressure is currently applied to decrease costs, leading to restriction of development, and implementation of new technologies. So far, no convincing data are available comparing outcome or costs between computer assisted and conventional laparoscopic cholecystectomy.

METHODS

A prospective case-matched study was conducted on 50 consecutive patients, who underwent robotic-assisted cholecystectomy (Da Vinci Robot, Intuitive Surgical) between December 2004 and February 2006. These patients were matched 1:1 to 50 patients with conventional laparoscopic cholecystectomy, according to age, gender, American Society of Anesthesiologists score, histology, and surgical experience. Endpoints were complications after surgery (mean follow-up of 12.3 months [SD 1.2]), conversion rates, operative time, and hospital costs (ClinicalTrial.gov ID: NCT00562900).

RESULTS

No minor, but 1 major complication occurred in each group (2%). No conversion to open surgery was needed in either group. Operation time (skin-to-skin, 55 minutes vs. 50 minutes, P < 0.85) and hospital stay (2.6 days vs. 2.8 days) were similar. Overall hospital costs were significantly higher for robotic-assisted cholecystectomy $7985.4 (SD 1760.9) versus $6255.3 (SD 1956.4), P < 0.001, with a raw difference of $1730.1(95% CI 991.4-2468.7) and a difference adjusted for confounders of $1606.4 (95% CI 1076.7-2136.2). This difference was mainly related to the amortization and consumables of the robotic system.

CONCLUSIONS

Robotic-assisted cholecystectomy is safe and, therefore, a valuable approach. Costs of robots, however, are high and do not justify the use of this technology considering the lack of benefits for patients. A reduction of acquisition and maintenance costs for the robotic system is a prerequisite for large-scale adoption and implementation.

Utilization and outcomes of minimally invasive radical prostatectomy

PURPOSE

Demand for minimally invasive radical prostatectomy (MIRP) to treat prostate cancer is increasing; however, outcomes remain unclear. We assessed utilization, complications, lengths of stay, and salvage therapy rates for MIRP versus open radical prostatectomy assessed whether MIRP surgeon volume is associated with better outcomes.

METHODS

We identified 2,702 men undergoing MIRP and open radical prostatectomy during 2003 to 2005 from a national 5% sample of Medicare beneficiaries. We assessed the association between surgical approach and outcomes, adjusting for surgeon volume, age, race, comorbidity, and geographic region.

RESULTS

MIRP utilization increased from 12.2% in 2003 to 31.4% in 2005. Men undergoing MIRP versus open radical prostatectomy had fewer perioperative complications (29.8% v 36.4%; P = .002) and shorter lengths of stay (1.4 v 4.4 days; P < .001); however, they were more likely to receive salvage therapy (27.8% v 9.1%, P < .001). In adjusted analyses, MIRP versus open radical prostatectomy was associated with fewer perioperative complications (odds ratio [OR], 0.73; 95% CI, 0.60 to 0.90), shorter lengths of stay (parameter estimate, -2.99; 95% CI, -3.45 to -2.53) but more anastomotic strictures (OR, 1.40; 95% CI, 1.04 to 1.87) and higher rates of salvage therapy (OR, 3.67; 95% CI, 2.81 to 4.81). Patients of high-volume MIRP experienced fewer anastomotic strictures (OR, 0.93; 95% CI, 0.87 to 0.99) and less salvage therapy (OR, 0.92; 95% CI, 0.88 to 0.98).

CONCLUSION

Men undergoing MIRP versus open radical prostatectomy have lower risk for perioperative complications and shorter lengths of stay, but are at higher risk for salvage therapy and anastomotic strictures. However, risk for these unfavorable outcomes decreases with increasing MIRP surgical volume.

The cost of learning robotic-assisted prostatectomy

OBJECTIVES

To describe the costs associated with the learning curve of robotic-assisted prostatectomy (RAP).

METHODS

A theoretical model of the cost of operative time during the learning curve for RAP was constructed. Within the theoretical model varying rates of improvement were considered, and once the learning curve was complete, the total cost of operative time was calculated. This cost was then compared with an actual series of RAP, whose operative time and associated costs during the learning curve were also calculated.

RESULTS

In the theoretical model, surgeons improved at rates of 1, 5, or 10 minutes per case, and began the learning curve that required 8 or 9 hours to perform a single RAP. At the end of the learning curve it took either 3 or 4 hours. The most expensive learning curve was 360 cases long and cost $1.3 million; the least expensive learning curve was 24 cases and cost $95,000. The literature search involved 8 series, with a range of learning curves from 13 to 200 cases. The least expensive learning curve was $49,613 and the most expensive learning curve was $554,694. The average learning curve was 77 cases and cost $217,034.

CONCLUSIONS

Costs associated with operative time while learning RAP are substantial, and should be considered when deciding whether to implement RAP at an individual institution. RAP may best be suited to high volume prostatectomy centers, in which the learning curve can be rapidly traversed, and associated costs minimized.

The cost of radical prostatectomy: retrospective comparison of open, laparoscopic, and robot-assisted approaches

New technologies are regularly being used for surgical treatment of prostate cancer, however the cost associated is often a secondary issue. We assessed the operative costs incurred by using the daVinci robot assisted prostatectomy (RAP) method compared to pure laparoscopic radical prostatectomy (LRP) and open radical prostatectomy (ORP). We retrospectively analyzed three techniques of radical prostatectomies: ORP, LRP, and RAP (n = 70, 57, 106, respectively). The mean patient age was 53.6, 57.6, and 60 with a mean preoperative prostate specific antigen (PSA) of 7.2, 8.4, and 6.6, respectively. The mean Gleason score was 6. Operative cost was measured for each patient. Charts were reviewed to assess individual patients postoperative requirements, and hospital length of stay (LOS). Intraoperative data show costs to be higher with the RAP and LRP compared to open surgery. Average total operating room (OR) costs per case were $5410, $3876, and $1870 for RAP, LRP, and open prostatectomy, respectively. However when comparisons are made in the postoperative period with regard to LOS, there is a significant advantage of the RAP and LRP groups over open surgery (P < 0.05). Intraoperative costs are highest for RAP. Both LRP and RAP are associated with a shorter hospital stay.

Robotic-Assisted Laparoscopic Radical Cystoprostatectomy

OBJECTIVES

Recent small case series have been reported for robotic-assisted laparoscopic radical cystoprostatectomy. The present literature includes 34 patients who have undergone robotic-assisted cystectomy procedures. We report our initial experience with robotic-assisted laparoscopic radical cystoprostatectomy, describing stepwise the surgical procedure and evaluating perioperative and pathologic outcomes of this novel procedure.

METHODS

Twenty men underwent robotic-assisted laparoscopic radical cystoprostatectomy and extracorporeal urinary diversion for clinically localized bladder cancer. The stepwise operative procedure is described in detail. Outcome measures evaluated included operative variables, hospital recovery, pathologic outcomes, and complication rate. Comparisons were made to these gender-matched 24 men who underwent an open procedure during this same period.

RESULTS

Mean age was 62.3 yr (range: 54-76 yr). Ten patients underwent ileal conduit diversion and 10 patients underwent an orthotopic neobladder. In all cases the urinary diversion was performed extracorporeally. Mean operating room time of all patients was 6.1h (most recent 10 cases, 5.2h). Mean surgical blood loss was 313 ml. On surgical pathology, 14 patients were < or =pT2, 4 patients pT3, and 2 patients N+. In no case was there inadvertent entry into the bladder or positive surgical margins. Mean number of lymph nodes removed was 19 (range: 6-29). Mean time to flatus was 2.1 d and bowel movement 2.8 d. Sixteen patients were discharged on postoperative day (POD) 4, three patients on POD 5, and one on POD 8. There were six postoperative complications (30%) in five patients.

CONCLUSIONS

Our initial experience with robotic-assisted laparoscopic radical cystoprostatectomy appears to be favorable with acceptable operative, pathologic, and short-term clinical outcomes. As our experience increases, we should expect to continue to refine our surgical technique and reduce operating room times. Larger experiences are required to adequately evaluate and validate this procedure as an appropriate surgical and oncologic option for the bladder cancer patient.

Robotic urology in the United Kingdom: experience and overview of robotic-assisted cystectomy

In this article we look at the evolution of robotic technology in operative urology and the significant early contribution of Mr John Wickham. We explore the ergonomics of robotic technology and discuss financial issues from a British perspective. We share our clinical experience, describe the authors’ robotic-assisted cystectomy technique, and conclude by exploring the patients’ perception of this new treatment modality.

Choices for Surgery

Surgical treatment of prostate cancer has seen many improvements in the past two decades, including laparoscopy, robotic surgery, and better assessment of quality of life and functional results. The limits of surgery for locally advanced disease and after failure of radiotherapy have been better defined, together with the roles of neoadjuvant and adjuvant treatment. Patients with clinically organ-confined prostate cancer, reasonable life expectancy, and little or no co-morbidity are the best candidates for radical prostatectomy. This chapter reviews the different technical options for the treatment of prostate cancer, with their respective indications and functional and oncological results.

A selected review and personal experience with robotic prostatectomy: implications for adoption of this new technology in the United Kingdom

Robot-assisted laparoscopic prostatectomy (RALP) is a rapidly evolving technique for the treatment of localized prostate cancer. However, cynics point to the increasing role of market forces in the robotic revolution. As yet, Europe has not taken up RALP in large numbers and this may in part relate to the high level of expertise in laparoscopy previously gained. Furthermore, setting up a robotic programme is a major undertaking for many surgical units. This review discusses some of the challenges in the development of a robotic service drawn from personal experience within the United Kingdom. Furthermore, available data on RALP versus open and laparoscopic approaches are reviewed for surgical and cancer-related outcomes. Preliminary data appear to show an advantage over open prostatectomy with reduced blood loss, decreased pain and early mobilisation and shorter hospital stay. Most intra-institutional studies demonstrate better postoperative continence and potency with RALP; however, this needs to be viewed in the context of a paucity of randomized data available in the literature. There is no definitive data to show an advantage over standard laparoscopic surgery, but the fact that this technique has reached parity with laparoscopy within 5 years is encouraging: with continued experience, the hope is that results will continue to improve.

Financial Comparative Analysis of Minimally Invasive Surgery to Open Surgery for Localized Prostate Cancer: A Single-Institution Experience

OBJECTIVES

To evaluate the financial implications of how the costs of new minimally invasive surgery such as laparoscopic robotic prostatectomy (LRP) and cryosurgical ablation of the prostate (CAP) technologies compare with those of conventional surgery.

METHODS

From January 2002 to July 2005, 452 consecutive patients underwent surgical treatment for clinically localized (Stage T1-T2) prostate cancer. The distribution of patients among the surgical procedures was as follows: group 1, radical retropubic prostatectomy (RRP) (n = 197); group 2, radical perineal prostatectomy (RPP) (n = 60); group 3, LRP (n = 137); and group 4, CAP (n = 58). The total direct hospital costs and grand total hospital costs were analyzed for each type of surgery.

RESULTS

The mean length of stay in the CAP group was significantly lower (0.16 +/- 0.14 days) than that for RRP (2.79 +/- 1.46 days), RPP (2.87 +/- 1.43 days), and LRP (2.15 +/- 1.48 days; P <0.0005). The direct surgical costs were less for the RRP (2471 dollars +/- 636 dollars) and RPP (2788 dollars +/- 762 dollars) groups than for the technology-dependent procedures: LRP (3441 dollars +/- 545 dollars) and CAP (5702 dollars +/- 1606 dollars; P <0.0005). The total hospital cost differences, including pathologic assessment costs, were less for LRP (10,047 dollars +/- 107 dollars, median 9343 dollars) and CAP (9195 dollars +/- 1511 dollars, median 8796 dollars) than for RRP (10,704 dollars +/- 3468 dollars, median 9724 dollars) or RPP (10,536 dollars +/- 3088 dollars, median 9251 dollars), with significant differences (P <0.05) between the minimally invasive technique and open surgery groups.

CONCLUSIONS

In our study, despite the relatively increased surgical expense of CAP compared with conventional surgical prostatectomy (RRP or RPP) and LRP, the overall direct costs were offset by the significantly lower nonoperative hospital costs. The cost advantages associated with CAP included a shorter length of stay in the hospital and the absence of pathologic costs and the need for blood transfusion.

Evidence from Robot-Assisted Laparoscopic Radical Prostatectomy: A Systematic Review

OBJECTIVE

To review the literature available on robot-assisted laparoscopic radical prostatectomy (RALP).

METHODS

A literature search was performed using EMBASE, MEDLINE, and Web Science databases through a "free text" protocol, including the following terms: robotic radical prostatectomy, da Vinci, and radical prostatectomy. Three of the authors separately reviewed the records to select the papers relevant for the topic of the review, with any discrepancies solved by open discussion. The selected articles were recorded in an electronic database and analysed by version 13.0 SPSS software.

RESULTS

We identified 71 manuscripts. Eleven papers focused on surgical technique, and 35 manuscripts reported clinical, pathologic, and/or follow-up data. Seven studies included clinical data concerning surgical series with fewer than 10 patients, whereas the remaining 26 series reported larger surgical series of RALP. RALP turned out to be a feasible procedure, with limited blood loss, favourable complication rates, and short hospital stays. Positive surgical margin rates decreased with the surgeon's experience and technique improving, reaching percentages similar to those of retropubic and laparoscopic series. The available oncologic data are only preliminary. Especially interesting are the data on postoperative continence rates, whereas results on potency, although promising, are based only on a limited number of patients and have to be considered as incomplete and premature.

CONCLUSION

Literature showed that RALP had a short learning curve and interesting postoperative results, especially with regard to continence recovery. The available data on recovery of erectile function and oncologic follow-up are still incomplete.

The radius surgical system - a new device for complex minimally invasive procedures in urology?

OBJECTIVE

Complex laparoscopic procedures in urology are technically demanding with an extended learning curve. Robotic systems add significant cost to laparoscopic procedures. We therefore evaluated the use of the Radius Surgical System (RSS), a mechanical manipulator, for complex laparoscopic cases in urology.

MATERIAL AND METHODS

The RSS (Tuebingen Scientific) consists of two hand-guided surgical manipulators and provides a deflectable and rotatable tip allowing six degrees of freedom. We evaluated the system by using a series of standardized models in the pelvitrainer. We analyzed the effectiveness of the system and the learning curve. We then evaluated the system in the clinical setting during laparoscopic radical prostatectomy.

RESULTS

Surgeons with experience on the RSS were compared to surgeons without previous experience on the system. We identified a learning curve in those participants without experience on the system only when performing complete anastomoses in the pelvitrainer. However, this learning curve included less than 10 anastomoses. The first clinical experiences during laparoscopic extraperitoneal radical prostatectomy (n=10) are promising. All anastomoses were patent on routine (X-ray) examination 8 days after surgery.

CONCLUSIONS

The RSS system is easy to use and we identified a very short learning curve. We now optimize the system for use in urology. This device may facilitate complex laparoscopic procedures without the use of costly robotic systems and should be further evaluated in the experimental and clinical setting.

Conducting an economic analysis to assess the electrocardiogram's value

BACKGROUND AND PURPOSE

Health economic analyses seek to assess the relative value (cost vs health benefit trade-offs) of medical technologies. However, these methods have been underused in studies of the electrocardiogram (ECG).

METHODS

We develop a framework for the economic evaluation of the ECG as a decision support tool within broader treatment strategies. We then apply this framework to the development of an economic study protocol for the Prehospital Wireless Transmission of Electrocardiograms to a Cardiologist via a Hand-held Device Multicenter study.

RESULTS

Our framework defines key cost-effectiveness concepts and describes alternative methods for estimating medical costs and health benefits. We demonstrate how this framework has been applied to develop the Prehospital Wireless Transmission of Electrocardiograms to a Cardiologist via a Hand-held Device Multicenter economic protocol.

CONCLUSIONS

The conduct of health economic studies alongside ECG clinical studies could provide important information for those seeking to promote newer ECG applications that require significant financial investments.

Robot-assisted versus pure laparoscopic radical prostatectomy

The aim of this study is to report the relative advantages and disadvantages of the radical prostatectomy with a laparoscopic (LRP) and a robotic (RALP) approach. A medline search was performed. Published data regarding perioperative parameters, complications, oncological results, functional results were analyzed. Shorter learning curves have been reported with the RALP. Intra-operative and post-operative outcomes appear to be comparable between the two approaches. The average time for LRP is 234 min (151-453) versus 182 min (141-250) for RALP. Estimated blood loss for the LRP averages 482 ml (185-850) versus 234 ml (75-500) for the RALP. Complication rates in single institution studies are similar. Long-term outcomes data on PSA progression is not yet available for LRP or RALP due to their relatively short existence. RALP appears to offer a significant benefit to the laparoscopically naïve surgeon with respect to learning curve when compared to LRP. This, however, comes at an increased cost. Intra-operative and post-operative outcomes appear to be similar. Longer follow-up data is necessary to compare oncological and functional outcomes.

Robotic prostatectomy: the first UK experience

BACKGROUND

We describe a teamwork approach to setting up the UK's first clinical programme for robotically assisted laparoscopic radical prostatectomy.

METHODS

On 22 November 2004 the Imperial Robotic Urological Surgery Group performed their first robotically assisted prostatectomy. Robotically assisted prostatectomy lends itself to division into eight definable stages. A team of four consultant urological surgeons utilized a structured rotating system, using these stages, for time at the console and tableside assisting. Fluidity of surgery was maintained by a surgeon acting as the tableside assistant for the stage prior to moving to the console. Data was collected prospectively for the first 50 cases and parameters associated with the learning curve compared to other reported series.

RESULTS

Median operative time of 369.5 mins, median blood loss of 700 ml, with 12% of patients requiring a blood transfusion. Four patients required conversion to an open procedure; one resulting from equipment failure and three due to failure of progression. Four patients had an anastomotic leak with resulting ileus and two patients sustained rectal injuries, which were repaired intraoperatively using the robot. Median hospital stay was 4 days with a 22% positive surgical margin rate.

CONCLUSION

Parameters indicative of the learning curve are comparable to existing published initial series of other robotic centres. The use of teamwork has enabled us to provide safe and time-efficient training for four surgeons simultaneously. The structured approach used in this setting demonstrates that urological surgeons of varying laparoscopic experience can acquire the skills necessary to competently perform laparoscopic radical prostatectomy.