More work is needed on cost-utility analyses of robotic-assisted surgery

Economic Evaluations of Robotic-Assisted Surgery: Methods, Challenges and Opportunities

BACKGROUND

The use of robotic-assisted surgery (RAS) is growing rapidly. However, economic evaluation of this technology is challenging. This study aims to identify and discuss the different economic evaluation methods which have been used to evaluate RAS.

METHOD

This scoping review systematically searched PubMed and Embase from 2015 to 2023. We included economic evaluation studies comparing RAS versus laparoscopic or open surgery. The Consolidated Health Economic Evaluation Reporting Standards (CHEERS) checklist was used to aid data extraction and was extended to cover additional features relevant to RAS, including learning curve, organisational impact, incremental innovation and dynamic pricing.

RESULTS

A total of 50 economic evaluations of RAS were included. Cost-utility analysis (46%) was the most commonly applied economic evaluation method, followed by cost-consequence analysis (32%). The studies focused on the specialties of urology (42%), hepato-pancreato-biliary (20%), colorectal (14%) and gynaecology (6%). Distinctive features related to the assessment of RAS were under-addressed in economic evaluations. Only 40% of the included studies considered learning curve and organisational impact and less than 12% of the included studies reflected on incremental innovation and dynamic pricing.

CONCLUSIONS

This review found that some studies have incorporated challenges specific to RAS in their evaluations. However, most studies still lack key aspects of importance. In particular, studies rarely considered the ability of RAS platforms to be shared across multiple specialities. Incorporating these distinctive features offers an opportunity for economic evaluation to provide decision-makers with a more realistic assessment of the cost-effectiveness of this technology and to ensure its optimal utilisation in clinical practice.

First worldwide report on rectal resections with Hugo™ surgical system: description of docking angles and tips for an effective setup

BACKGROUNDS

Rectal robotic surgery gained momentum in the last decade, but it is still associated with not-negligible costs. In order to reduce costs, recently different robotic systems have received approval for clinical use. This study aims to present the first case series of rectal resection with the novel cost-effective platform Robotic Assisted Surgery (RAS) Hugo™. Tips for effective set up of the system and detailed configuration of tilt and docking angles are also provided.

METHODS

Three cases of rectal resection with Hugo RAS™ system are reported. After the first two cases of resection with partial mesorectal excision in which surgeries were performed with the setup proposed by the vendor company, in the third case we tested a novel setup that allowed a full robotic low rectal resection performing vascular ligations, TME and colonic splenic flexure mobilization without the need of any de-docking.

RESULTS

Our first three robotic rectal resections with the Hugo RAS™ system were completed without complications with a median docking time of 12 min (range 8-15) and a median console time of 345 minutes (range 271-475). In the first two cases, hybrid robotic and laparoscopic surgeries were performed to obtain an adequate haemostasis and traction during the pelvic phase. In the third case, a full robotic TME was successfully accomplished.

CONCLUSION

Our experience demonstrates that a full robotic low rectal resection with TME with Hugo™ RAS system is feasible, safe and associated with satisfactory postoperative outcomes.

Looking to the Future; Veterinary Robotic Surgery

This article details the rise of surgical robots in the human surgical sphere as well as their use in veterinary medicine. Sections will describe in detail the equipment required for these procedures and the advantages and disadvantages of their use. Specific attention is given to the articulated instrumentation, which affords psychomotor benefits not only for surgical precision but also for surgeon ergonomics. A discussion of the possible indications and current use of robotics in veterinary medicine and the challenges to integrating robotics is also provided.

Full robotic cholecystectomy: first worldwide experiences with HUGO RAS surgical platform

BACKGROUND

The Hugo RAS™ system (Medtronic, Minneapolis, MN, USA), approved for gynaecological and urological procedures, has been recently certified for the use in few general surgeries. Only bariatric and colorectal procedures have been described so far.

METHODS

Here, we report the first worldwide experience with three cases of full-robotic cholecystectomies with the Hugo RAS™ system.

RESULTS

A description of the operative room setup, of the docking angles and details of the procedures is reported. Docking time was 12, 10, and 6 min, respectively. The total operative time was 105 min in the first case, 100 min in the second and 88 in the third case. Intra- and post-operative courses were uneventful.

CONCLUSIONS

With this pre-defined set up, the innovative conformation of Hugo RAS™ system can safely allow performing full robotic cholecystectomy avoiding the need for additional ports.

Cost Analysis for Robotic and Open Gastrectomy

Objective

To determine the magnitude of the perioperative costs associated with robotic gastrectomy (RG).

Background

A robotic surgery platform has a high implementation cost and requires maintenance costs; however, whether the overall cost of RG, including all perioperative costs, is higher than conventional open gastrectomy (OG) remains unknown.

Methods

Patients who underwent a major gastrectomy during February 2018 through December 2021 were retrospectively identified. We calculated the perioperative costs of RG and OG and compared them overall as well as in different phases, including intraoperative costs and 30-day postsurgery inpatient and outpatient costs. We investigated factors potentially associated with high cost and estimated the likelihood of RG to reduce overall cost under a Bayesian framework. All cost data were converted to ratios to the average cost of all operations performed at our center in year FY2021.

Results

We identified 119 patients who underwent gastrectomy. The incidence of postoperative complications (Clavien-Dindo >IIIa; RG, 10% vs OG, 13%) did not significantly differ between approaches. The median length of stay was 3 days shorter for RG versus OG (4 vs 7 days, P < 0.001). Intraoperative cost ratios were significantly higher for RG (RG, 2.6 vs OG, 1.7; P < 0.001). However, postoperative hospitalization cost ratios were significantly lower for RG (RG, 2.8 vs OG, 3.9; P < 0.001). Total perioperative cost ratios were similar between groups (RG, 6.1 vs OG, 6.4; P = 0.534). The multiple Bayesian generalized linear analysis showed RG had 76.5% posterior probability of overall perioperative cost reduction (adjusted risk ratio of 0.95; 95% credible interval, 0.85-1.07).

Conclusions

Despite increased intraoperative costs, total perioperative costs in the RG group were similar to those in the OG group because of reduced postoperative hospitalization costs.

Robot-assisted pelvic and renal surgery compared with laparoscopic or open surgery: Literature review of cost-effectiveness and clinical outcomes

BACKGROUND AND AIM

The purpose of this study was to evaluate clinical experiences and cost-effectiveness by comparing robot-assisted surgery with laparoscopic- or open surgery for pelvic and renal operations.

METHODS

A narrative review was carried out.

RESULTS

When using robotic-assisted surgery, oncological and functional results are similar to after laparoscopic or open surgery. One exception may be a shorter survival in cancer of the cervix uteri. In addition, postoperative complications after robotic-assisted surgery are similar, bleeding and transfusion needs are less, and the hospital stay is shorter but the preparation of the operating theater before and after surgery and the operation times are longer. Finally, robot-assisted surgery has, in several studies, been reported to be not cost-effective primarily due to high investment costs. However, more recent studies provide improved cost-effectiveness estimates due to more effective preparation of the operating theater before surgery, improved surgeon experience, and decreased investment costs.

CONCLUSIONS

Complications and functional and oncological outcomes after robot-assisted surgery are similar to open surgery and laparoscopic surgery. The cost-effectiveness of robot-assisted surgery is likely to equal or surpass the alternatives.

The IDEAL framework for surgical robotics: development, comparative evaluation and long-term monitoring

The next generation of surgical robotics is poised to disrupt healthcare systems worldwide, requiring new frameworks for evaluation. However, evaluation during a surgical robot's development is challenging due to their complex evolving nature, potential for wider system disruption and integration with complementary technologies like artificial intelligence. Comparative clinical studies require attention to intervention context, learning curves and standardized outcomes. Long-term monitoring needs to transition toward collaborative, transparent and inclusive consortiums for real-world data collection. Here, the Idea, Development, Exploration, Assessment and Long-term monitoring (IDEAL) Robotics Colloquium proposes recommendations for evaluation during development, comparative study and clinical monitoring of surgical robots-providing practical recommendations for developers, clinicians, patients and healthcare systems. Multiple perspectives are considered, including economics, surgical training, human factors, ethics, patient perspectives and sustainability. Further work is needed on standardized metrics, health economic assessment models and global applicability of recommendations.

A systematic review of full economic evaluations of robotic-assisted surgery in thoracic and abdominopelvic procedures

This study aims to conduct a systematic review of full economic analyses of robotic-assisted surgery (RAS) in adults' thoracic and abdominopelvic indications. Authors used Medline, EMBASE, and PubMed to conduct a systematic review following the preferred reporting items for systematic reviews and meta-analyses (PRISMA) 2020 guidelines. Fully published economic articles in English were included. Methodology and reporting quality were assessed using standardized tools. Majority of studies (28/33) were on oncology procedures. Radical prostatectomy was the most reported procedure (16/33). Twenty-eight studies used quality-adjusted life years, and five used complication rates as outcomes. Nine used primary and 24 studies used secondary data. All studies used modeling. In 81% of studies (27/33), RAS was cost-effective or potentially cost-effective compared to comparator procedures, including radical prostatectomy, nephrectomy, and cystectomy. Societal perspective, longer-term time-horizon, and larger volumes favored RAS. Cost-drivers were length of stay and equipment cost. From societal and payer perspectives, robotic-assisted surgery is a cost-effective strategy for thoracic and abdominopelvic procedures.Clinical trial registration This study is a systematic review with no intervention, not a clinical trial.

"Single-Surgeon" versus "Dual-Surgeon" Robot-Assisted Radical Prostatectomy and Pelvic Lymph-nodes Dissection: Comparative Analysis of Perioperative Outcomes

PURPOSE

To compare the perioperative outcomes of robot-assisted radical prostatectomy (RARP) with pelvic lymph-nodes dissection (PLND) when the same surgeon performs RARP and PLND versus one surgeon performs RARP and another surgeon performs PLND.

MATERIALS AND METHODS

From January 2022 to March 2023, data of consecutive patients who underwent RARP with PLND were prospectively collected. The surgeries were performed by two "young" surgeons with detailed profile. Specifically for the study purpose, one surgeon performed RARP, and the other surgeon performed PLND. A set of surgeries performed according to the standard setup (i.e., the same surgeon performing both RARP and PLND) was retrieved from the institutional database and used as comparator arm. To test the study hypothesis, patients were divided into two groups: "dual-surgeon" versus "single-surgeon".

RESULTS

Fifty patients underwent RARP and PLND performed according to dual-surgeon setup and were compared to the last 50 procedures performed according to the standard single-surgeon setup. Patients in the groups had comparable baseline characteristics. Dual-surgeon interventions had significantly shorter median total operative (194 [IQR 178-215] versus 174 [IQR 146-195] minutes, p<0.001) and console time (173 [IQR 158-194] versus 154 [IQR 129-170] minutes, p<0.001). No significant differences were found in terms of blood loss, intraoperative complications, postoperative outcomes, and final pathology results.

CONCLUSIONS

The present analysis found that when RARP and PLND are split onto two surgeons, the operative time is shorter by 20 minutes compared to when a single surgeon performs RARP and PLND. This is an interesting finding that could sponsor further studies.

Endoscopic total thyroidectomy using a unilateral transaxillary approach: A case report

Endoscopic transaxillary thyroidectomy is a common method for remote-access thyroidectomy. The approach typically uses a gasless method, and a long incision to insert a special retractor. In addition, it is considered only suitable for unilateral lobectomy because of problems accessing contralateral parts of the thyroid gland. We describe here, a case of a young woman who had a total thyroidectomy performed using an endoscopic approach. We reduced the non-inflated 4-6 cm incision that is usually required, into three holes, and performed unilateral transaxillary thyroidectomy; this was verified by radioactive iodine uptake and thyroglobulin levels during follow-up. The approach was clinically successful and resulted in minimal scarring. More studies are required to optimize this promising technique.

Robotic Surgery for Male Infertility and Chronic Scrotal Content Pain

Robot-assisted microsurgery is a trending approach for the treatment of male infertility and chronic scrotal pain. The advantages seem to include increased optical magnification, improved surgical efficiency, absent tremor, and similar outcomes with standard methods. This chapter covers robotic microsurgical application and techniques for: robot-assisted vasectomy reversal with vasovasostomy and vasoepididymostomy, varicocelectomy, microsurgical testicular sperm extraction, and targeted denervation of the spermatic cord.