Cost-Benefit Analysis of Robotic versus Nonrobotic Minimally Invasive Mitral Valve Surgery

Robotic vs other surgery techniques for mitral valve repair and/or replacement: A systematic review and meta-analysis

OBJECTIVE

Mitral valve repair or replacement (MVr/R) are procedures that aim to correct mitral regurgitation. The three techniques, namely conventional, minimally invasive, and robotic each present their advantages and setbacks. Previous studies had compared each technique with the other but mostly focused on two techniques. In this systematic review and meta-analysis, we attempt to compare all three techniques, to provide a reference for the clinical selection of the best surgical scheme.

METHODS

The literature search was performed in databases including PubMed, Scopus, Google Scholar, EBSCOHost, Wiley, ProQuest, and Embase, up to June 1^st, 2022. Critical appraisal of studies was performed using Newcastle Ottawa Scale converted by Agency for Healthcare Research and Quality (AHRQ). We used bayesian network meta-analysis and conventional meta-analysis (random effects model) to rank and analyze pooled odds ratios (OR) and mean differences (MD) with 95% confidence intervals (CI). Forest plots of pooled effect estimates comparing each treatment and ranking panel using Surface Under the Cumulative Ranking (SUCRA) were used for the intervention measures.

RESULTS

A total of 18 studies with 60,331 patients were included in this systematic review and meta-analysis. Hospital stay was significantly lower in the group with robotic procedure compared to the conventional interventions in terms of ICU stay and overall length of stay. The mean difference of length of hospital stay days of the conventional group was 2.27 (1.31-3.30) days and of the minimally invasive -0.364 (-2.31-1.53) days compared to the robotic group. The robotic procedure was associated with longer cross-clamp and cardiopulmonary bypass (CPB) times. Nevertheless, the robotic procedure was associated with lower infection (OR = 0.60 [95% CI 0.50-0.73)] rates and in-hospital mortality compared to conventional techniques (OR=0.53 [95% CI 0.40-0.70)] but not the minimally invasive techniques (OR = 1.74 [95% CI 0.48-6.31]).

CONCLUSION

Robotic surgery showed more favorable surgical outcomes, including hospital stay, post-operational complications and in-hospital mortality, although it was associated with longer cross-clamp time and CPB time compared to other interventions. However, its high cost is a difficult consideration for its widespread clinical implementation.

Mitral repair and the robot: a revolutionary tool or marketing ploy?

PURPOSE OF REVIEW

In this review, we discuss the current evidence supporting each minimally invasive mitral repair approach and their associated controversies.

RECENT FINDINGS

Current evidence demonstrates that minimally invasive mitral repair techniques yield similar mitral repair results to conventional sternotomy with the benefits of shorter hospital stay, quicker recovery, better cosmesis and improved patient satisfaction. Despite this, broad adoption of minimally invasive mitral repair is still not achieved. Two main approaches of minimally invasive mitral repair exist: endoscopic mini-thoracotomy and robotic-assisted approaches.

SUMMARY

Both minimally invasive approaches share many commonalities; however, most centres are strongly polarized to one approach over another creating controversy and debate about the most effective minimally invasive approach.

Cost effectiveness of robotic mitral valve surgery

Significant technological advances have led to an impressive evolution in mitral valve surgery over the last two decades, allowing surgeons to safely perform less invasive operations through the right chest. Most new technology comes with an increased upfront cost that must be measured against postoperative savings and other advantages such as decreased perioperative complications, faster recovery, and earlier return to preoperative level of functioning. The Da Vinci robot is an example of such a technology, combining the significant benefits of minimally invasive surgery with a "gold standard" valve repair. Although some have reported that robotic surgery is associated with increased overall costs, there is literature suggesting that efficient perioperative care and shorter lengths of stay can offset the increased capital and intraoperative expenses. While data on current cost is important to consider, one must also take into account future potential value resulting from technological advancement when evaluating cost-effectiveness. Future refinements that will facilitate more effective surgery, coupled with declining cost of technology will further increase the value of robotic surgery compared to traditional approaches.