Is robotic surgery cost-effective: yes. Curr Opin Urol. 2012;22:61-65. [PMID: 22037320 DOI: 10.1097/mou.0b013e32834d543f]

Robotic Surgery in Gynecologic Oncology-A Bibliometric Study

STUDY OBJECTIVE

To characterize robotic surgery publications in gynecologic oncology, and to identify factors associated with high citation metrics.

DESIGN

A cross-sectional study SETTING: Original articles on robotic surgery in gynecologic oncology.

PATIENTS

No patients involved.

INTERVENTIONS

Robotic surgeries in gynecologic oncology.

MEASUREMENTS AND MAIN RESULTS

We performed PubMed Medical Subject Headings search for original articles on robotic surgery in gynecologic oncology. We analyzed citation scores and income level of country of publication, as well as factors associated with high citation metrics. Overall, 566 studies during 2005 to 2023 were included. Of those 292, 51.6% were from North America, and 182 32.2% from Europe. The leading tumor site studied was endometrial cancer (57.4%). The majority (87.6%) of studies were retrospective and 13 (2.3%) were randomized controlled trials. Most studies (94.2%) originated in high-income countries. Articles from middle-income countries had lower citations per year as compared to high-income countries (median 1.6 vs 2.5, p =.002) and were published in lower-impact factor journals (median 2.6 vs 4.3, p < .001) when compared with high-income countries. Cervical cancer studies had higher representation in middle-income countries than in high-income countries (48.5% vs 18.4%, p < .001). In a multivariable regression analysis, journal's impact factor [aOR 95% CI 1.26 (1.12-1.40)], cervical cancer topic [aOR 95% CI 3.0 (1.58-5.91)], and North American publications [aOR 95% CI 2.07 (1.08-3.97)] were independently associated with higher number of citations per year.

CONCLUSION

The majority of robotic surgery research in gynecologic oncology is retrospective and from high-income countries. Middle-income countries are not as frequently cited and are predominantly in lower-impact factor journals.

Internal validation of the Tampa Robotic Difficulty Scoring System: real-time assessment of the novel robotic scoring system in predicting clinical outcomes after hepatectomy

INTRODUCTION

As the robotic approach in hepatectomy gains prominence, the need to establish a robotic-specific difficulty scoring system (DSS) is evident. The Tampa Difficulty Score was conceived to bridge this gap, offering a novel and dedicated robotic DSS aimed at improving preoperative surgical planning and predicting potential clinical challenges in robotic hepatectomies. In this study, we internally validated the recently published Tampa DSS by applying the scoring system to our most recent cohort of patients.

METHODS

The Tampa Difficulty Score was applied to 170 recent patients who underwent robotic hepatectomy in our center. Patients were classified into: Group 1 (score 1-8, n = 23), Group 2 (score 9-24, n = 120), Group 3 (score 25-32, n = 20), and Group 4 (score 33-49, n = 7). Key variables for each of the groups were analyzed and compared. Statistical significance was accepted at p ≤ 0.05.

RESULTS

Notable correlations were found between the Tampa Difficulty Score and key clinical parameters such as operative duration (p < 0.0001), estimated blood loss (p < 0.0001), and percentage of major resection (p = 0.00007), affirming the score's predictive capacity for operative technical complexity. The Tampa Difficulty Score also correlated with major complications (Clavien-Dindo ≥ III) (p < 0.0001), length of stay (p = 0.011), and 30-day readmission (p = 0.046) after robotic hepatectomy.

CONCLUSIONS

The Tampa Difficulty Score, through the internal validation process, has confirmed its effectiveness in predicting intra- and postoperative outcomes in patients undergoing robotic hepatectomy. The predictive capacity of this system is useful in preoperative surgical planning and risk categorization. External validation is necessary to further explore the accuracy of this robotic DSS.

Temporal and institutional trends in robotic surgery

Robotic surgery has become increasingly prevalent in general surgery practice. While previous studies have shown the safety and efficacy of robotic assistance in laparoscopic general surgery procedures, few studies have evaluated the temporal and regional trends in implementation. In our retrospective population-based study, we aim to evaluate the national trends in robotic surgery. National Inpatient Database (NIS 2009-2014) was used to identify adults who underwent robotic assisted surgery (ICD 9 codes 17.41 to 17.49). Robotic procedures related to seven abdominal organ systems were compared against the trends of Urology, Gynaecologic, and Orthopedic robotic procedures. Discharge weights were applied to calculate National temporal trends separated by hospital size, teaching status and US geographic region. 894,163 patients received a robotic assisted procedure between 2009 and 2014 with 64% increase in utilization. The largest percent change was witnessed in biliary robotic procedures with 2984% change in utilization, followed by hernia (1376%). Lowest percent change was witnessed in esophageal procedures with 114% increase. Medium sized hospitals had the largest change in robotic utilization (41%), with large institutions seeing 18% decrease. Gastric procedures were the most common robotic procedure performed at small institutions (7917 total cases; 316%). Large institutions saw an overall decrease in gastric (- 47%), esophageal (- 17%), small and large intestinal (-16%), and hepatic (- 7%) robotic procedures. Rural non-teaching hospitals saw the largest increase in robotic surgery (274%). Urban non-teaching hospitals saw a decrease of 29%. While urban teaching institutions saw a 20% and 6% increase in gynecological and urological procedures, an overall decrease was seen in esophageal (- 10%), gastric (- 12%), intestinal (- 11%), hepatic (- 17%), biliary (- 10%), pancreatic (- 11%) and hernia procedures (- 14%). Biliary procedures saw the largest increase in rural institutions (740 cases; 392%), followed by hernia (144% increase). South region of the nation had the largest increase in robotic procedures (23%). No change was seen in the use of robotic surgery in the northeast region with the midwest and west seeing an overall decrease (- 4% and - 22%, respectively). Our study highlights the increase in use of robotics for both general and specialty surgery, with an increase in utilization over time. Increased incidence of robotic surgery in smaller, rural institutions with overall decrease in larger, urban teaching hospitals suggests increasing comfort in robotic surgery in the community setting. Further studies are necessary to evaluate the factors associated with increased utilization in smaller institutions.

Influence of Otolaryngological Subspecialties on Perception of Transoral Robotic Surgery: An International YO-IFOS Survey

BACKGROUND

To investigate perception, adoption, and awareness on the part of otolaryngology and head and neck surgeons (OTO-HNS) of transoral robotic surgery (TORS).

METHODS

Several items assessed: awareness/perception; access to TORS; training; indications and advantages/hurdles to TORS practice. A subanalysis was performed to assess differences according to the identified otolaryngological subspecialties.

RESULTS

A total of 359 people completed the survey. Among subspecialties, while for otolaryngologists 30/359 (8.4%) and H&N surgeons 100/359 (27.9%) TORS plays an effective role in hospital stay, laryngologists frequently disagreed (54.3%). There was a lower incidence among rhinologists and otologists (1.9%). Pediatric surgeons (0.8%) reported a positive response regarding the adoption of robotic surgery, and head and neck specialists expressed an even greater response (14.2%). Low adherence was related to perceived cost-prohibitive TORS, by 50% of H&N surgeons.

CONCLUSIONS

Perception, adoption, and knowledge about TORS play a key role in the application of the robotic system, significantly varying across subspecialties.

Robotic surgery in obstetrics and gynecology: a bibliometric study

We aimed to identify the trends and patterns of robotic surgery research in obstetrics and gynecology since its implementation. We used data from Clarivate's Web of Science platform to identify all articles published on robotic surgery in obstetrics and gynecology. A total of 838 publications were included in the analysis. Of these, 485 (57.9%) were from North America and 281 (26.0%) from Europe. 788 (94.0%) articles originated in high-income countries and none from low-income countries. The number of publications per year reached a peak of 69 articles in 2014. The subject of 344 (41.1%) of articles was gynecologic oncology, followed by benign gynecology (n = 176, 21.0%) and urogynecology (n = 156, 18.6%). Articles discussing gynecologic oncology had lower representation in low- and middle-income countries (LMIC) (32.0% vs. 41.6%, p < 0.001) compared with high income countries. After 2015 there has been a higher representation of publications from Asia (19.7% vs. 7.7%) and from LMIC (8.4% vs. 2.6%), compared to the preceding years. In a multivariable regression analysis, journal's impact factor [aOR 95% CI 1.30 (1.16-1.41)], gynecologic oncology subject [aOR 95% CI 1.73 (1.06-2.81)] and randomized controlled trials [aOR 95% CI 3.67 (1.47-9.16)] were associated with higher number of citations per year. In conclusion, robotic surgery research in obstetrics & gynecology is dominated by research in gynecologic oncology and reached a peak nearly a decade ago. The disparity in the quantity and quality of robotic research between high income countries and LMIC raises concerns regarding the access of the latter to high quality healthcare resources such as robotic surgery.

Crossover-effects in technical skills between laparoscopy and robot-assisted surgery

INTRODUCTION

Robot-assisted surgery is often performed by experienced laparoscopic surgeons. However, this technique requires a different set of technical skills and surgeons are expected to alternate between these approaches. The aim of this study is to investigate the crossover effects when switching between laparoscopic and robot-assisted surgery.

METHODS

An international multicentre crossover study was conducted. Trainees with distinctly different levels of experience were divided into three groups (novice, intermediate, expert). Each trainee performed six trials of a standardized suturing task using a laparoscopic box trainer and six trials using the da Vinci surgical robot. Both systems were equipped with the ForceSense system, measuring five force-based parameters for objective assessment of tissue handling skills. Statistical comparison was done between the sixth and seventh trial to identify transition effects. Unexpected changes in parameter outcomes after the seventh trial were further investigated.

RESULTS

A total of 720 trials, performed by 60 participants, were analysed. The expert group increased their tissue handling forces with 46% (maximum impulse 11.5 N/s to 16.8 N/s, p = 0.05), when switching from robot-assisted surgery to laparoscopy. When switching from laparoscopy to robot-assisted surgery, intermediates and experts significantly decreased in motion efficiency (time (sec), resp. 68 vs. 100, p = 0.05, and 44 vs. 84, p = 0.05). Further investigation between the seventh and ninth trial showed that the intermediate group increased their force exertion with 78% (5.1 N vs. 9.1 N, p = 0.04), when switching to robot-assisted surgery.

CONCLUSION

The crossover effects in technical skills between laparoscopic and robot-assisted surgery are highly depended on the prior experience with laparoscopic surgery. Where experts can alternate between approaches without impairment of technical skills, novices and intermediates should be aware of decay in efficiency of movement and tissue handling skills that could impact patient safety. Therefore, additional simulation training is advised to prevent from undesired events.

Robot-assisted and conventional urology surgical procedures: comparison of average length of stay, economic status, operative time and patient's expenditure in a tertiary care hospital of North India

Robot-assisted surgeries allows the surgeons to operate using remote-controlled robotic arms that are more effective in comparison to conventional (open/laparoscopic) surgeries. However, there is substantial lack of evidence on the effectiveness of robot-assisted surgeries in low to middle income countries (LMICs) like India. A study was conducted with an aim to evaluate the average length of stay (ALOS), Operative time, economic status (patient's) and cost borne by the patient (patient's expenditure) for undergoing robot-assisted surgeries and conventional surgeries. Grouping of the surgical procedures was done wherein patients who were treated with robot-assisted surgical procedures were placed in Group-01 whereas those treated with conventional surgical procedures were placed under Group-02. Comparative evaluation of the two surgical groups revealed that in robot-assisted surgical procedure, the ALOS was less (18.43 vs. 23.14 days, p = 0.06) whereas operative time (316.7 vs. 252.63 min, p = 0.05) and patient's expenditure were more (INR 70,654.29 vs. INR 41,314.73, p = 0.00). However, there was no significant difference between the economic statuses of patients in both groups. The study concluded that in this era of rapidly expanding health care scenario; targeted, regular, rigorous and repeated training programmes in future may shorten the learning curve thereby paving a way to reduce the cost as well as the operative time of robot-assisted surgeries in LMICs.

Aligning Incentives for Surgical Innovation: Review of the Literature and Best Practices

Background: Innovation in the clinical surgical space is often generated by the insight and ideas of practicing surgeons whose ideas solve direct and relevant clinical problems with both novel products and reimagined processes. Despite some successes in both product and process development, innovation in the practicing surgical space does not occur with the frequency one might expect and does not consistently result in adoption of profitable or health-improving new products or processes. One barrier to successful innovation is the misalignment of incentives for early-stage innovation in the clinical surgical enterprise. This project was undertaken to determine best innovation practices for clinical Divisions and Departments. Methods: Best practices for innovation in industry were determined by company-specific examples, as well as literature review in the business and medical literature. Concepts were then integrated to determine a viable model that aligns incentives to encourage early-stage innovation. Proposal: The centralized Moderated Innovation Database (MID) of early-stage exploratory ideas integrates best practices of innovation in a low-cost, sustainable model. The MID must be executed in 3 phases to ensure viability in implementation. This model is likely to encourage innovation by both improving stakeholder satisfaction with and engagement in the process, and by increasing capture of early-stage innovation. Conclusion: Infrastructure for early-stage ideas will help align incentives for early-stage innovation, and the MID is consistent with best practices for innovation.

Robotic surgery costs: Revealing the real villains

BACKGROUND

This study aimed to evaluate the main drivers of robot assisted radical prostatectomy (RARP) hospitalization costs, in addition to assess perioperative predictors that impact costs.

METHODS

Overall, 474 RARP were analyzed between February 2018 and December 2019. The association between perioperative variables and total direct costs was analyzed by simple and multiple linear regression.

DISCUSSION

The main drivers of RARP hospitalization costs were robotic surgical supplies. Costs increased with American Society of Anesthesiologists score 3, a one-hour increase in OR time, increased utilization of polymeric clip packs and longer length of hospital stay. There was a 11.5% reduction in costs with the use of four robotic instruments instead of five.

CONCLUSION

Costs of hospitalization were mainly influenced by the OR time, use of surgical supplies and length of hospital stay. Reducing the number of robotic instruments used in RARP represented the potentially modifiable factor with the greatest impact on cost reduction.

Cost-Benefit Analysis of Robotic vs. Laparoscopic Hepatectomy: A Propensity-Matched Retrospective Cohort Study of American College of Surgeons National Surgical Quality Improvement Program Database

BACKGROUND

Robotic and laparoscopic hepatectomies having increased utilization as minimally invasive techniques are explored for hepatobiliary malignancies. Although the data on outcomes from these 2 approaches are emerging, the cost-benefit analysis of these approaches remains sparse. This study compares the costs associated with robotic vs. laparoscopic liver resections, taking into account 30-day complications.

METHODS

Using the American College of Surgeons National Surgical Quality Improvement Program database, a propensity-matched cohort of patients with laparoscopic or robotic liver resections between 2014 and 2017 was identified. Costs were assigned to perioperative variables, including operating room (OR) time, length of stay, blood transfusions, and 30-day complications. Cost estimates were obtained from the Centers for Medicare and Medicaid Services billing data (2017), American Hospital Association data (2017), relevant literature, and local institutional cost data.

RESULTS

In our matched cohort of 454 patients (227 per group), total costs associated with laparoscopic liver resections were estimated at $5.5 M ($24 K per patient) vs. $6.8 M ($29.8 K per patient) for robotic liver resections (21.3% difference, P < .001). The higher cost associated with robotic hepatectomies was related to blood transfusions ($22.0 K vs. $12.1 K, P = .02), length of stay ($2.05 M vs. $1.76 M, P = .046), and OR time ($4.01 M vs. $3.24 M, P < .0001).

DISCUSSION

Robotic hepatectomies were associated with higher costs compared to laparoscopic hepatectomies. The 2 major contributors to the cost disparity were increased OR time and increased length of stay. Future studies are warranted to analyze high-volume Minimally Invasive Surgery surgeons' impact in specialty centers on potentially mitigating this current cost disparity.

National Use and Short-term Outcomes of Video and Robot-Assisted Thoracoscopic Thymectomies

BACKGROUND

Transsternal open thymectomy has long been the most widely used approach for thymectomy, but recent decades have seen the introduction of minimally invasive surgery (MIS), such as video-assisted thoracoscopic surgery (VATS) and robot-assisted thoracoscopic surgery (RATS) thymectomy. This retrospective cohort study provides a national comparison of trends, outcomes, and resource utilization of open, VATS, and RATS thymectomy.

METHODS

Admissions for thymectomies from 2008 to 2014 were identified in the National Inpatient Sample. Patients were identified as undergoing open, VATS, or RATS thymectomy. Propensity score-matched analyses were used to compare overall complication rates, length of stay (LOS), and cost of VATS and RATS thymectomies.

RESULTS

An estimated 23,087 patients underwent thymectomy during the study period: open in 16,025 (69%) and MIS in 7217 (31%). Of the MIS cohort, 4119 (18%) underwent VATS and 3097 (13%) underwent RATS. Performance of RATS and VATS thymectomy increased while that of open thymectomy declined. Baseline characteristics between VATS and RATS were similar, except more women underwent VATS thymectomy. No differences in LOS or overall complication rates were appreciable in this study. VATS was associated with the lowest cost of the 3 approaches.

CONCLUSIONS

Our findings demonstrate the increasing adoption of MIS and declining use of the open surgical approach for thymectomy. There are no differences in overall complication rates between RATS and VATS thymectomy, but RATS is associated with greater cost and lower cardiac complication rates.

Proposed training pathway with initial experience to set up robotic hepatobiliary and pancreatic service

Although robot-assisted hepatobiliary and pancreatic (HPB) surgery has gained momentum over the last 2 decades, only a handful of units in the world perform major robotic resections. Adaptation of robotic surgery in the UK lags behind its European counterparts and this is mainly because of cost implications in a publicly funded National Health Service (NHS). We describe our experience of setting up a robotic HPB programme with clinical outcomes and propose a training pathway that would help prospective centres in setting up their own robotic HPB service with robust clinical governance oversight. After gaining colleagues' and departmental support, approval from the hospital clinical governance, finance department and new intervention procedure committee was sought. A team of two consultant surgeons, three assistants and three theatre staff went through a structured training programme sponsored mainly by the industry. Surgeon training consisted of online modules, simulation, wet lab, cadaveric training, case observations, proctored procedures followed by independent practice. All major cases were recorded and videos reviewed to improve performance. A total of 111 procedures were successfully completed with robotic assistance between April 2018 and March 2020. The programme started with robot-assisted cholecystectomy as index procedure and progressed on to more complex liver and pancreatic resections including major hepatectomy and Whipple's procedure. The training pathway followed by our team has been effective in setting up a safe robotic HPB programme and could be considered as a roadmap to start new Robotic HPB services.

Assessment of Out-of-Pocket Costs for Robotic Cancer Surgery in US Adults

IMPORTANCE

Expensive technologies-including robotic surgery-experience rapid adoption without evidence of superior outcomes. Although previous studies have examined perioperative outcomes and costs, differences in out-of-pocket costs for patients undergoing robotic surgery are not well understood.

OBJECTIVE

To assess out-of-pocket costs and total payments for 5 types of common oncologic procedures that can be performed using an open or robotic approach.

DESIGN, SETTING, AND PARTICIPANTS

A retrospective, cross-sectional, propensity score-weighted analysis was performed using deidentified insurance claims for 1.9 million enrollees from the MarketScan database from January 1, 2012, to December 31, 2017. The final study sample comprised 15 893 US adults aged 18 to 64 years who were enrolled in an employer-sponsored health plan. Patients underwent either an open or robotic radical prostatectomy, hysterectomy, partial colectomy, radical nephrectomy, or partial nephrectomy for a solid-organ malignant neoplasm. Statistical analysis was performed from December 18, 2018, to June 5, 2019.

EXPOSURES

Type of surgical procedure-robotic vs open.

MAIN OUTCOMES AND MEASURES

The primary outcome of interest was out-of-pocket costs associated with robotic and open surgery. The secondary outcome of interest was associated total payments.

RESULTS

Among 15 893 patients (11 102 men; mean [SD] age, 55.4 [6.6] years), 8260 underwent robotic and 7633 underwent open procedures; patients undergoing robotic hysterectomy were older than those undergoing open hysterectomy (mean [SD] age, 55.7 [6.7] vs 54.6 [7.2] years), and patients undergoing open radical nephrectomy had more comorbidities than those undergoing robotic radical nephrectomy (≥2 comorbidities, 658 of 861 [76.4%] vs 244 of 347 [70.3%]). After adjustment for baseline characteristics, the robotic approach was associated with lower out-of-pocket costs for all procedures: -$137.75 (95% CI, -$240.24 to -$38.63) for radical prostatectomy (P = .006); -$640.63 (95% CI, -$933.62 to -$368.79) for hysterectomy (P < .001); -$1140.54 (95% CI, -$1397.79 to -$896.54) for partial colectomy (P < .001); -$728.32 (95% CI, -$1126.90 to -$366.08) for radical nephrectomy (P < .001); and -$302.74 (95% CI, -$523.14 to -$97.10) for partial nephrectomy (P = .003). The robotic approach was similarly associated with lower adjusted total payments: -$3872.62 (95% CI, -$5385.49 to -$2399.04) for radical prostatectomy (P < .001); -$29 640.69 (95% CI, -$36 243.82 to -$23 465.94) for hysterectomy (P < .001); -$38 151.74 (95% CI, -$46 386.16 to -$30 346.22) for partial colectomy; (P < .001); -$33 394.15 (95% CI, -$42 603.03 to -$24 955.20) for radical nephrectomy (P < .001); and -$9162.52 (95% CI, -$12 728.33 to -$5781.99) for partial nephrectomy (P < .001).

CONCLUSIONS AND RELEVANCE

This study found significant variation in perioperative costs according to surgical technique for both patients (out-of-pocket costs) and payers (total payments); the robotic approach was associated with lower out-of-pocket costs for all studied oncologic procedures.

Robotic-assisted gastrectomy for gastric cancer: a European perspective

Gastrectomy is the mainstay treatment for gastric cancer. To reduce the associated patient burden, minimally invasive gastrectomy was introduced in almost 30 years ago. The increase in the availability of surgical robotic systems led to the first robotic-assisted gastrectomy to be performed in 2002 in Japan. Robotic gastrectomy however, particularly in Europe, has not yet gained significant traction. Most reports to date are from Asia, predominantly containing observational studies. These cohorts are commonly different in the tumour stage, location (particularly with regards to gastroesophageal junctional tumours) and patient BMI compared to those encountered in Europe. To date, no randomised clinical trials have been performed comparing robotic gastrectomy to either laparoscopic or open equivalent. Cohort studies show that robotic gastrectomy is equal oncological outcomes in terms of survival and lymph node yield. Operative times in the robotic group are consistently longer compared to laparoscopic or open gastrectomy, although evidence is emerging that resectional surgical time is equal. The only reproducibly significant difference in favour of robot-assisted gastrectomy is a reduction in intra-operative blood loss and some studies show a reduction in the risk of pancreatic fistula formation.

The age of robotic surgery - Is laparoscopy dead?

Introduction

Robot-assisted laparoscopic surgery (RALS) has become a widely used technology in urology. Urological procedures that are now being routinely performed robotically are: radical prostatectomy (RP), radical cystectomy (RC), renal procedures - mainly partial nephrectomy (PN), and pyeloplasty, as well as ureteric re-implantation and adrenalectomy.

Methods

This non-systematic review of the literature examines the effectiveness of RALS compared with conventional laparoscopic surgery for the most relevant urological procedures.

Results

For robot-assisted RP there seems to be an advantage in terms of continence and potency over laparoscopy. Robot-assisted RC seems equal in terms of oncological outcome but with lower complication rates; however, the effect of intracorporeal urinary diversion has hardly been examined. Robotic PN has proven safe and is most likely superior to conventional laparoscopy, whereas there does not seem to be a real advantage for the robot in radical nephrectomy. For reconstructive procedures, e.g. pyeloplasty and ureteric re-implantation, there seems to be advantages in terms of operating time.

Conclusions

We found substantial, albeit mostly low-quality evidence, that robotic operations can have better outcomes than procedures performed laparoscopically. However, in light of the significant costs and because high-quality data from prospective randomised trials are still missing, conventional urological laparoscopy is certainly not 'dead' yet.

How to set up a robotic-assisted laparoscopic surgery center and training of staff

The use of computers to assist surgeons in the operating room has been an inevitable evolution in the modern practice of surgery. Robotic-assisted surgery has been evolving now for over two decades and has finally matured into a technology that has caused a monumental shift in the way gynecologic surgeries are performed. Prior to robotics, the only minimally invasive options for most Gynecologic (GYN) procedures including hysterectomies were either vaginal or laparoscopic approaches. However, even with over 100 years of vaginal surgery experience and more than 20 years of laparoscopic advancements, most gynecologic surgeries in the United States were still performed through an open incision. However, this changed in 2005 when the FDA approved the da Vinci Surgical Robotic System^tm for use in gynecologic surgery. Over the last decade, the trend for gynecologic surgeries has now dramatically shifted to less open and more minimally invasive procedures. Robotic-assisted surgeries now include not only hysterectomy but also most all other commonly performed gynecologic procedures including myomectomies, pelvic support procedures, and reproductive surgeries. This success, however, has not been without controversies, particularly around costs and complications. The evolution of computers to assist surgeons and make minimally invasive procedures more common is clearly a trend that is not going away. It is now incumbent on surgeons, hospitals, and medical societies to determine the most cost-efficient and productive use for this technology. This process is best accomplished by developing a Robotics Program in each hospital that utilizes robotic surgery.

Robotics in Colorectal Surgery

Over the past few decades, robotic surgery has developed from a futuristic dream to a real, widely used technology. Today, robotic platforms are used for a range of procedures and have added a new facet to the development and implementation of minimally invasive surgeries. The potential advantages are enormous, but the current progress is impeded by high costs and limited technology. However, recent advances in haptic feedback systems and single-port surgical techniques demonstrate a clear role for robotics and are likely to improve surgical outcomes. Although robotic surgeries have become the gold standard for a number of procedures, the research in colorectal surgery is not definitive and more work needs to be done to prove its safety and efficacy to both surgeons and patients.

Preoperative Membranous Urethral Length Measurement and Continence Recovery Following Radical Prostatectomy: A Systematic Review and Meta-analysis

CONTEXT

Membranous urethral length (MUL) measured prior to radical prostatectomy (RP) has been identified as a factor that is associated with the recovery of continence following surgery.

OBJECTIVE

To undertake a systematic review and meta-analysis of all studies reporting the effect of MUL on the recovery of continence following RP.

EVIDENCE ACQUISITION

A comprehensive search of PubMed, EMBASE, and Scopus databases up to September 2015 was performed. Thirteen studies comprising one randomized controlled trial and 12 cohort studies were selected for inclusion.

EVIDENCE SYNTHESIS

Four studies (1738 patients) that reported hazard ratio results. Every extra millimeter (mm) of MUL was associated with a faster return to continence (hazard ratio: 1.05; 95% confidence interval [CI]: 1.02-1.08, p<0.001). Eleven studies (6993 patients) reported the OR (OR) for the return to continence at one or more postoperative time points. MUL had a significant positive effect on continence recovery at 3 mo (OR: 1.08, 95% CI: 1.03-1.14, p=0.004), 6 mo (OR: 1.12, 95% CI: 1.09-1.15, p<0.0001). and 12 mo (OR: 1.12, 95% CI: 1.03-1.22, p=0.006) following surgery. After adjusting for repeated measurements over time and studies with overlapping data, all OR data combined indicated that every extra millimeter of MUL was associated with significantly greater odds for return to continence (OR: 1.09, 95% CI: 1.05-1.15, p<0.001).

CONCLUSIONS

A greater preoperative MUL is significantly and positively associated with a return to continence in men following RP. Magnetic resonance imaging measurement of MUL is recommended prior to RP.

PATIENT SUMMARY

We examined the effect that the length of a section of the urethra (called the membranous urethra) had on the recovery of continence after radical prostatectomy surgery. Our results indicate that measuring the length of the membranous urethra via magnetic resonance imaging before surgery may be useful to predict a longer period of urinary incontinence after surgery, or to explain a delay in achieving continence after surgery.

Esophageal surgery in minimally invasive era

The widespread popularity of new surgical technologies such as laparoscopy, thoracoscopy and robotics has led many surgeons to treat esophageal diseases with these methods. The expected benefits of minimally invasive surgery (MIS) mainly include reductions of postoperative complications, length of hospital stay, and pain and better cosmetic results. All of these benefits could potentially be of great interest when dealing with the esophagus due to the potentially severe complications that can occur after conventional surgery. Moreover, robotic platforms are expected to reduce many of the difficulties encountered during advanced laparoscopic and thoracoscopic procedures such as anastomotic reconstructions, accurate lymphadenectomies, and vascular sutures. Almost all esophageal diseases are approachable in a minimally invasive way, including diverticula, gastro-esophageal reflux disease, achalasia, perforations and cancer. Nevertheless, while the limits of MIS for benign esophageal diseases are mainly technical issues and costs, oncologic outcomes remain the cornerstone of any procedure to cure malignancies, for which the long-term results are critical. Furthermore, many of the minimally invasive esophageal operations should be compared to pharmacologic interventions and advanced pure endoscopic procedures; such a comparison requires a difficult literature analysis and leads to some confounding results of clinical trials. This review aims to examine the evidence for the use of MIS in both malignancies and more common benign disease of the esophagus, with a particular emphasis on future developments and ongoing areas of research.

Robotic colonic resection

Innovative robotic technologies are aiming to help surgeons overcome the limits of conventional laparoscopic surgery. Recent studies have shown that robotic colorectal surgery is safe and provides favorable results in comparison to conventional laparoscopic techniques. Further studies and long-term follow-up are required to assess the outcomes and potential benefits of robotic colon surgery over laparoscopic surgery.

Cost-Effectiveness of Conventional vs Robotic-Assisted Laparoscopy in Gynecologic Oncologic Indications

Objective

Robotic surgical techniques are known to be expensive, but they can decrease the cost of hospitalization and improve patients’ outcomes. The aim of this study was to compare the costs and clinical outcomes of conventional laparoscopy vs robotic-assisted laparoscopy in the gynecologic oncologic indications.

Methods

Between 2007 and 2010, 312 patients referred for gynecologic oncologic indications (endometrial and cervical cancer), including 226 who underwent conventional laparoscopy and 80 who underwent robot-assisted laparoscopy, were included in this prospective multicenter study. The direct costs, operating theater costs, and hospital costs were calculated for both surgical strategies using the microcosting method.

Results

Based on an average number of 165 surgical cases performed per year with the robot, the total extra cost of using the robot was €1456 per intervention. The robot-specific costs amounted to €2213 per intervention, and the cost of the robot-specific surgical supplies was €957 per intervention. The cost of the surgical supplies specifically required by conventional laparoscopy amounted to €1432, which is significantly higher than that of the robotic supplies (P < 0.001). Hospital costs were lower in the case of the robotic strategy (€2380 vs €2841, P < 0.001) because these patients spent less time in intensive care (0.38 vs 0.85 days). Operating theater costs were higher in the case of the robotic strategy (€1490 vs €1311, P = 0.0004) because the procedure takes longer to perform (4.98 hours vs 4.38 hours).

Conclusions

The main driver of additional costs is the fixed cost of the robot, which is not compensated by the lower hospital room costs. The robot would be more cost-effective if robotic interventions were performed on a larger number of patients per year or if the purchase price of the robot was reduced. A shorter learning curve would also no doubt decrease the operating theater costs, resulting in financial benefits to society.

Robotic-assisted laparoscopic surgery: recent advances in urology

The aim of the present review is to summarize recent developments in the field of urologic robotic surgery. A nonsystematic literature review was performed to retrieve publications related to robotic surgery in urology and evidence-based critical analysis was conducted by focusing on the literature of the past 5 years. The use of the da Vinci Surgical System, a robotic surgical system, has been implemented for the entire spectrum of extirpative and reconstructive laparoscopic kidney procedures. The robotic approach can be applied for a range of adrenal indications as well as for ureteral diseases, including benign and malignant conditions affecting the proximal, mid, and distal ureter. Current evidence suggests that robotic prostatectomy is associated with less blood loss compared with the open surgery. Besides prostate cancer, robotics has been used for simple prostatectomy in patients with symptomatic benign prostatic hyperplasia. Recent studies suggest that minimally invasive radical cystectomy provides encouraging oncologic outcomes mirroring those reported for open surgery. In recent years, the evolution of robotic surgery has enabled urologic surgeons to perform urinary diversions intracorporeally. Robotic vasectomy reversal and several other robotic andrological applications are being explored. In summary, robotic-assisted surgery is an emerging and safe technology for most urologic operations. The acceptance of robotic prostatectomy during the past decade has paved the way for urologists to explore the entire spectrum of extirpative and reconstructive urologic procedures. Cost remains a significant issue that could be solved by wider dissemination of the technology.

Short-term outcomes for robotic colorectal surgery by provider volume

BACKGROUND

There has been a rapid increase in robotic colorectal surgery. Benefits of this technology are unclear and being investigated. However, differences in outcomes between centers have not been evaluated. Our aim was to evaluate outcomes for robotic colorectal procedures by surgeon and hospital volume.

STUDY DESIGN

A national inpatient database was reviewed for robotic colorectal resections performed during an 18-month period. Hospitals and surgeons were stratified into high, average, and low case volumes based on a normal distribution scale. High, average, and low volume was defined as ≤ 10, 11 to 20, and >20, respectively, for hospitals, and ≤ 5, 6 to 15, and >15, respectively, for surgeons. Short-term outcomes and hospital cost were evaluated.

RESULTS

There were 1,428 robotic colorectal cases across 123 hospitals and 411 surgeons evaluated. Only 13% (n = 16) of hospitals and 4.4% (n = 18) of surgeons performed a high volume of robotic colorectal cases. Lower volume was associated with significantly more overall complications (p < 0.001; p < 0.001), longer length of stay (p = 0.005; p < 0.001), and higher cost (p < 0.001; p < 0.001) at the hospital and surgeon level, respectively. High-volume hospitals and surgeons had significantly lower rates of postoperative bleeding (p < 0.001; p < 0.001) and ileus (p = 0.003; p = 0.0014).

CONCLUSIONS

Lower-volume providers, who are performing the majority of procedures, are generating more complications, longer hospital lengths of stay, and higher costs of care. These results have a negative impact on quality outcomes measures for those facilities. Although surgeons and hospitals continue to selectively explore robotics, this should be limited to high volume and interested surgeons and hospitals to offer high-quality outcomes to patients.

Robotic surgery: review of prostate and bladder cancer

Minimally invasive laparoscopic surgery has become to replace many of the open procedures in urology because of the obvious benefits in perioperative morbidity. However, because of the technical challenges and steep learning curve, the adoption of laparoscopy has been limited to only highly skilled laparoscopic surgeons. The introduction of the da Vinci surgical system (Intuitive Surgical Inc, Sunnyvale, Calif) has offered significant technical advantages over laparoscopic surgery. Because of the wide acceptance of robotic-assisted radical prostatectomy over the past decade, it has paved the way for urologists to tackle other complex operations, such as a radical cystectomy to decrease the morbidity of the operation. The goal of this article was to review the history and discuss the application and current status of the robot in both prostate and bladder cancer management. We present our technique of performing a robotic-assisted radical prostatectomy and the application of the robust prostate experience to robotic cystectomy.

A randomised trial of robotic and open prostatectomy in men with localised prostate cancer

BACKGROUND

Prostate cancer is the most common male cancer in the Western world however there is ongoing debate about the optimal treatment strategy for localised disease. While surgery remains the most commonly received treatment for localised disease in Australia more recently a robotic approach has emerged as an alternative to open and laparoscopic surgery. However, high level data is not yet available to support this as a superior approach or to guide treatment decision making between the alternatives. This paper presents the design of a randomised trial of Robotic and Open Prostatectomy for men newly diagnosed with localised prostate cancer that seeks to answer this question.

METHODS/DESIGN

200 men per treatment arm (400 men in total) are being recruited after diagnosis and before treatment through a major public hospital outpatient clinic and randomised to 1) Robotic Prostatectomy or 2) Open Prostatectomy. All robotic prostatectomies are being performed by one surgeon and all open prostatectomies are being performed by one other surgeon. Outcomes are being measured pre-operatively and at 6 weeks and 3, 6, 12 and 24 months post-surgery. Oncological outcomes are being related to positive surgical margins, biochemical recurrence +/- the need for further treatment. Non-oncological outcome measures include: pain, physical and mental functioning, fatigue, summary (preference-based utility scores) and domain-specific QoL (urinary incontinence, bowel function and erectile function), cancer specific distress, psychological distress, decision-related distress and time to return to usual activities. Cost modelling of each approach, as well as full economic appraisal, is also being undertaken.

DISCUSSION

The study will provide recommendations about the relative benefits of Robotic and Open Prostatectomy to support informed patient decision making about treatment for localised prostate cancer; and to assist in treatment services planning for this patient group.

TRIAL REGISTRATION

ACTRN12611000661976.