The financial impact of robotic technology for partial and radical nephrectomy

One-year healthcare costs after robotic-assisted and laparoscopic partial and radical nephrectomy: a cohort study

OBJECTIVE

Despite the wide-spread adoption of robotic-assisted surgery (RAS), the cost-benefit implications for partial (PN) and radical nephrectomy (RN) versus laparoscopic surgery (Lap) is not well established. We sought to examine the trend of adoption and 1-year healthcare expenditure of PN and RN, and compare 1-year expenditures of RAS versus Lap for PN and RN.

PATIENTS AND METHODS

This cohort study used the MerativeTM MarketScan® Databases between 2013 and 2020. A total of 5,353 patients with kidney cancer undergoing PN (2,980, 55.7%) or RN (2,373, 44.3%). We compared open-conversion, length of stay (LOS), index expenditure, 1-year healthcare expenditure and utilization, and missed work-days between RAS and Lap for PN and RN.

RESULTS

Adoption of PN increased overtime (47.0% to 55.8%), mainly driven by robotic PN increase. Among PN, RAS had lower open-conversion, shorter LOS and lower index expenditure than Lap. Among RN, RAS had shorter LOS, and similar open-conversion and index expenditures. During 1-year post-discharge, RAS had lower hospital outpatient visits (IRR = 0.92, 95% CI = 0.85, 0.99, p = 0.029) and office-based visits (IRR = 0.91, 95% CI = 0.86, 0.96, p = 0.002) for PN, translating to a 1-day less (95% CI = 0.25, 1.75, p = 0.008) missed from work for RAS. Following RN, RAS had lower 1-year readmission than Lap (O.R = 0.72, 95% CI = 0.55, 0.94, p = 0.018). RAS and Lap had comparable 1-year post-discharge expenditures for both PN (mean difference, MD = -$475, 95% CI = -$4362, $3412, p = 0.810) and RN (MD = -$4,204, 95% CI = -$13,837, $5430, p = 0.404).

CONCLUSION

At index surgery, RAS was associated with shorter LOS for both PN and RN, and lower open-conversion and expenditures for PN. RAS and Lap had comparable 1-year total expenditures, despite lower healthcare visits for RAS.

Surgical Complications Requiring Reoperation in Open Versus Minimally Invasive Radical Nephrectomy: A Contemporary Analysis of the National Surgical Quality Improvement Program

BACKGROUND

To explore reoperation rates for different radical nephrectomy (RN) approaches that are experiencing a shift from open radical nephrectomy (ORN) toward minimally invasive surgery (MIS), we aimed to compare reoperation rates along with their culprit etiologies between the different types of surgical approaches for RN.

METHODS

The national surgical quality improvement program dataset was used to select patients who underwent RN between the years 2012-2019. A 1:1 propensity score matched analysis was used. Reoperation rates and causes were then compared between open and MIS approach.

RESULTS

The propensity matched cohort included 15,294 patients. Reoperation rates due to large bowel injury (0.01 vs. 0.14%), vascular injury (0.07 vs. 0.22%), and other abdominal (0.5 vs. 0.77%) were more common in ORN as compared to MIS (MIS vs. ORN, respectively, p < 0.034). Reoperation due to hernia (0.14 vs. 0.03%) was more common in MIS as compared to ORN (p = 0.027). No difference was seen for small bowel injury and incision/wound debridement. General reoperation (1.61 vs. 2.22%) and mortality (0.57 vs. 1.47%) were also more common in ORN as compared to MIS (p < 0.008).

CONCLUSION

Reoperation due to large bowel injury, vascular injury, and other abdominal was more likely to occur in ORN. Whereas reoperation due to hernia was more likely to occur in MIS. Surgical approach was an independent risk factor for immediate and early reoperation rates in RN patients. These results could be used to counsel patients pre-operatively on possible surgical approaches and complications.

Does size matter? Comparing robotic versus open radical nephrectomy for very large renal masses

INTRODUCTION

We evaluated perioperative and mortality outcomes of robotic-assisted radical nephrectomy (RRN) vs. open radical nephrectomy (ORN) for very large renal cell carcinomas (RCC).

MATERIALS AND METHODS

Adult patients with non-metastatic RCC >10 cm in size (pT2b) were identified from the National Cancer Database (2010-2017). Mixed-effects multivariable logistic regression adjusting for patient, tumor, and facility characteristics were used to evaluate rates of positive margin, prolonged length of stay (LOS) (>75th percentile), 30-day readmission, and 30-day and 90-day mortality for RRN vs. ORN. Overall survival (OS) was evaluated using the Kaplan-Meier method and adjusted Cox proportional hazard modeling.

RESULTS

Of the 2,977 patients who underwent radical nephrectomy, 492 (16.5%) underwent RRN. Factors associated with RRN included male gender, metro or urban locations, academic facilities, Charlson-Deyo score >2, private or Medicaid insurance, and surgery in a later year (all P < 0.05). Tumors ≥15.1cm in size were associated with a higher rate of conversion to open surgery (P < 0.001). ORN was associated with increased median postoperative LOS (4d [interquartile range; IQR 3-6] vs. 3d, [IQR 2-4]; P < 0.01). RRN demonstrated no significant difference in the risk of positive margin, 30-day readmission, 30-day mortality, or 90-day mortality. RRN was associated with a decreased risk of prolonged LOS (OR 0.38; 95%CI [0.28-0.53]). There was no difference in long-term OS observed in patients treated with ORN vs. RRN.

CONCLUSIONS

Very large, non-metastatic RCC can be safely and effectively treated with RRN. Rates of conversion to open were higher for tumors ≥15.1 cm. RRN has comparable long-term OS and improved LOS compared to ORN.

Initial experience of robot-assisted radical nephrectomy in Japan: Single institutional study of 12 cases

INTRODUCTION

To evaluate the initial experience of robot-assisted radical nephrectomy (RARN) in a single institution in Japan.

METHODS

This study included a total of 12 patients with renal tumors who were not preoperatively regarded as optimal candidates for robot-assisted partial nephrectomy (RAPN) and subsequently treated with RARN between April 2019 and June 2021 at our institution. Comprehensive perioperative outcomes in these patients were retrospectively analyzed.

RESULTS

Of the 12 included patients, 10 and two were male and female, respectively, and the median age was 66 years. The median tumor diameter was 44 mm, and four, four and four patients were classified into cT1a, cT1b and cT3a, respectively. There was no patient requiring open conversion, and the median operative and console times were 167 and 79 minutes, respectively. The median estimated blood loss was 42 cc, and no patient required blood transfusion. During the perioperative period, no major complication corresponding to Clavien-Dindo grade ≥3 occurred. Nine, two and one patient were pathologically diagnosed with clear cell carcinoma (CCC), non-CCC and benign cyst, respectively, and there was no patient who developed recurrent diseases.

CONCLUSIONS

Considering complicated tumor characteristics not amenable to RAPN in this series, such as an intravenous tumor thrombus or previous history of open partial nephrectomy, perioperative outcomes of initial experience with RARN in Japan could be considered favorable. Collectively, these findings suggest that RARN may be a promising alternative to laparoscopic radical nephrectomy for patients with complicated renal tumors, contraindicated for RAPN.

Comparison of Perioperative Outcomes of Robot-Assisted vs. Laparoscopic Radical Nephrectomy: A Systematic Review and Meta-Analysis

Background: The use of robot-assisted radical nephrectomy (RARN) for renal cell carcinoma (RCC) has increased in recent years, but the advantages of RARN over laparoscopic radical nephrectomy (LRN) remain controversial. This study aimed to compare the perioperative outcomes between RARN and LRN. Methods: We systematically searched the EMBASE, PubMed, Web of Science, and CNKI databases to identify eligible comparative studies. The parameters were perioperative outcomes including operating time (OT), estimated blood loss (EBL), length of stay (LOS), conversion rate, and complications. Stata 15.0 software was used for the meta-analysis. Results: Seven studies with 1,832 patients were included in the analysis. Among them, 532 underwent RARN and 840 underwent LRN for RCC. There were no significant differences in OT (weighted mean difference [WMD], 29.05; 95% confidence interval [CI], -0.31, 58.41; p = 0.05), EBL (WMD, -4.56; 95% CI, -29.79, 20.67; p = 0.72), LOS (WMD, -0.34; 95% CI, -0.68, 0.00; p = 0.05), conversion rate (WMD, 2.67; 95% CI, 0.68, 10.46; p = 0.05), transfusion rate (odds ratio [OR], 1.30; 95% CI, 0.74, 2.27; p = 0.36), intraoperative complications (OR, 1.13; 95% CI, 0.61, 2.12; p = 0.62), and postoperative complications (OR, 1.07; 95% CI, 0.68, 1.67; p = 0.62) between the two groups. Conclusion: RARN was not superior to LRN in patients with RCC in terms of perioperative outcomes. Before establishing conclusive clinical recommendations, high-quality prospective large-scale randomized controlled trials with long-term follow-up are needed.

Population-based analysis of cost and peri-operative outcomes between open and robotic primary retroperitoneal lymph node dissection for germ cell tumors

PURPOSE

To compare perioperative outcomes and perform the first cost analysis between open retroperitoneal lymph node dissection (O-RPLND) and Robotic-RPLND (R-RPLND) using a national all-payer inpatient care database.

METHODS

Nationwide Inpatient Sample (NIS) was queried between 2013-2016 for primary RPLND and germ cell tumor. We compared cost, length of stay (LOS), and complications between O-RPLND and R-RPLND. Linear regression plots identified point of cost equivalence between R-RPLND and O-RPLND. A multivariable linear regression model was generated to analyze predictors of cost.

RESULTS

44 cases of R-RPLND and 319 cases of O-RPLND were identified. R-RPLND was associated with lower rate of complications (0% vs. 16.6%, p < 0.01) and shorter LOS [Median (IQR): 1.5 (1-3) days vs. 4 (3-6) days, p < 0.01]. Rates of ileus, genitourinary complications, and transfusions were lower with R-RPLND, but did not reach significance. On multivariable analysis, robotic approach independently contributed $4457, while each day of hospitalization contributed to an additional $2,431 to the overall model of cost. Linear regression plots determined point of cost equivalence between an R-RPLND staying a mean of 2 days was 4-5 days for O-RPLND, supporting the multivariable analysis. Total hospitalization cost was equivalent between R-RPLND and O-RPLND [Median (IQR): $15,681($12,735-$21,596) vs $16,718($11,799-$24,403), p = 0.48]-suggesting that the cost equivalency of R-RPLND is, at least in part, attributable to shorter LOS.

CONCLUSION

While O-RPLND remains the gold standard and this study is limited by selection bias of a robotic approach to RPLND, our findings suggest primary R-RPLND may represent a cost-equivalent option with decreased hospital LOS in select cases.

A Review of Outcomes and Technique for the Robotic-Assisted Laparoscopic Retroperitoneal Lymph Node Dissection for Testicular Cancer

Objectives

The robotic-assisted laparoscopic retroperitoneal lymph node dissection (R-RPLND) represents a new frontier in the surgical management of testicular cancer in the realm of minimally invasive urologic oncology. We aimed to review the early outcomes as compared to the laparoscopic and open approaches as well as describe the operative technique for the R-RPLND.

Materials and Methods

We reviewed all the literature related to the R-RPLND based on an electronic PubMed search up until July 2017.

Results and Discussion

Encouraged by favorable early oncologic and safety outcomes for treatment of clinical stage (CS) I nonseminomatous germ cell tumor (NSGCT), the R-RPLND affords the same recovery advantages as the laparoscopic retroperitoneal lymph node dissection (L-RPLND) while offering greater dexterity, superior visualization, and a theoretically shorter learning curve for the surgeon. While R-RPLND has a promising future in the management of patients with primary and postchemotherapy NSGCT, larger and more vigorous prospective studies are needed before supplanting the open RPLND as the gold standard approach for primary low-stage NSGCT or becoming an equivalent surgical modality in the postchemotherapy setting.

Association of Robotic-Assisted vs Laparoscopic Radical Nephrectomy With Perioperative Outcomes and Health Care Costs, 2003 to 2015

IMPORTANCE

Use of robotic surgery has increased in urological practice over the last decade. However, the use, outcomes, and costs of robotic nephrectomy are unknown.

OBJECTIVES

To examine the trend in use of robotic-assisted operations for radical nephrectomy in the United States and to compare the perioperative outcomes and costs with laparoscopic radical nephrectomy.

DESIGN, SETTING, AND PARTICIPANTS

This retrospective cohort study used the Premier Healthcare database to evaluate outcomes of patients who had undergone robotic-assisted or laparoscopic radical nephrectomy for renal mass at 416 US hospitals between January 2003 and September 2015. Multivariable regression modeling was used to assess outcomes.

EXPOSURES

Robotic-assisted vs laparoscopic radical nephrectomy.

MAIN OUTCOMES AND MEASURES

The primary outcome of the study was the trend in use of robotic-assisted radical nephrectomy. The secondary outcomes were perioperative complications, based on the Clavien classification system, and defined as any complication (Clavien grades 1-5) or major complications (Clavien grades 3-5, for which grade 5 results in death); resource use (operating time, blood transfusion, length of hospital stay); and direct hospital cost.

RESULTS

Among 23 753 patients included in the study (mean age, 61.4 years; men, 13 792 [58.1%]), 18 573 underwent laparoscopic radical nephrectomy and 5180 underwent robotic-assisted radical nephrectomy. Use of robotic-assisted surgery increased from 1.5% (39 of 2676 radical nephrectomy procedures in 2003) to 27.0% (862 of 3194 radical nephrectomy procedures) in 2015 (P for trend <.001). In the weighted-adjusted analysis, there were no significant differences between robotic-assisted and laparoscopic radical nephrectomy in the incidence of any (Clavien grades 1-5) postoperative complications (adjusted rates, 22.2% vs 23.4%, difference, -1.2%; 95% CI, -5.4 to 3.0%) or major (Clavien grades 3-5) complications (adjusted rates, 3.5% vs 3.8%, difference, -0.3%; 95% CI, -1.0% to 0.5%). The rate of prolonged operating time (>4 hours) for patients undergoing the robotic-assisted procedure was higher than for patients receiving the laparoscopic procedure in the adjusted analysis (46.3% vs 25.8%; risk difference, 20.5%; 95% CI, 14.2% to 26.8%). Robotic-assisted radical nephrectomy was associated with higher mean 90-day direct hospital costs ($19 530 vs $16 851; difference, $2678; 95% CI, $838 to $4519), mainly accounted for operating room ($7217 vs $5378; difference, $1839; 95% CI, $1050 to $2628) and supply costs ($4876 vs $3891; difference, $985; 95% CI, $473 to $1498).

CONCLUSIONS AND RELEVANCE

Among patients undergoing radical nephrectomy for renal mass between 2003 and 2015, the use of robotic-assisted surgery increased substantially. The use of robotic-assistance was not associated with increased risk of any or major complications but was associated with prolonged operating time and higher hospital costs compared with laparoscopic surgery.

Cost-effectiveness of robot-assisted partial nephrectomy for the prevention of perioperative complications

PURPOSE

To evaluate the cost-effectiveness of robot-assisted partial nephrectomy (RAPN) and secondarily of laparoscopic PN (LPN) compared to the open procedure.

METHODS

Model-based cost-effectiveness analysis: The model was structured as decision tree. The model was populated with published data. We measured intraoperative, postoperative complications, and inhospital deaths. We expressed costs in US dollars ($).The reference analysis calculated the mean cost and the mean number of each endpoint over 5000 iterations using a second-order Monte Carlo simulation. We conducted extensive sensitivity analyses.

RESULTS

The mean inhospital costs were $13,186 for RAPN, $10,782 for LPN, and $12,539 for open partial nephrectomy (OPN), respectively. The incremental cost to prevent an inhospital event amounted to $5005 for RAPN compared to OPN. Lower RENAL scores were associated with lower incremental cost per avoided complications. Under assumption of 55 % higher costs in patients with complications, RAPN dominated OPN. LPN dominated OPN. We are aware of the following limitations: First, cost data for patients with and without complications were not available and we assumed the median cost for all cases, i.e., the analysis overestimated the cost associated with RAPN; second, we focused on inhospital estimates and did not apply a societal perspective.

CONCLUSIONS

RAPN appears to be a cost-effective mean to avoid inhospital complications; however, these results might not apply to low-volume hospitals or to other health care systems.

Robotic adrenalectomy: the jury is still out

A minimally-invasive approach is the gold standard for surgical management of the majority of adrenal masses. While laparoscopy has traditionally been used, robotic adrenalectomy is becoming increasingly utilized. This article discusses a recent systematic review and meta-analysis from European Urology that analyzed evidence comparing laparoscopic and robotic adrenalectomy. Robotic adrenalectomy is associated with lower blood loss, length of stay and fewer complications compared to laparoscopic adrenalectomy; however information on efficacy and cost are not addressed. Ultimately, well-done randomized controlled trials (RCTs) are necessary to determine the benefits and cost of robotics in adrenal surgery.