Assessing the cost effectiveness of robotics in urological surgery – a systematic review

Study Type – Therapy (systematic review) Level of Evidence 1a What's known on the subject? and What does the study add? Research on the subject has shown that robotic surgery is more costly than both laparoscopic and open approaches due to the initial cost of purchase, annual maintenance and disposable instruments. However, both robotic and laparoscopic approaches have reduced blood loss and hospital stay and robotic procedures have better short term post‐operative outcomes such as continence and sexual function. Some studies indicate that the robotic approach may have a shorter learning curve. However, factors such as reduced learning curve, shorter hospital stay and reduced length of surgery are currently unable to compensate for the excess costs of robotic surgery. This review concludes that robotic surgery should be targeted for cost efficiency in order to fully reap the benefits of this advanced technology. The excess cost of robotic surgery may be compensated by improved training of surgeons and therefore a shorter learning curve; and minimising costs of initial purchase and maintenance. The review finds that only a few studies gave an itemised breakdown of costs for each procedure, making accurate comparison of costs difficult. Furthermore, there is a lack of long term follow up of clinical outcomes, making it difficult to accurately assess long term post‐operative outcomes. A breakdown of costs and studies of long term outcomes are needed to accurately assess the effectiveness of robotic surgery in urology.

OBJECTIVES

• ? Although robotic technology is becoming increasingly popular for urological procedures, barriers to its widespread dissemination include cost and the lack of long term outcomes. This systematic review analyzed studies comparing the use of robotic with laparoscopic and open urological surgery.
• ? These three procedures were assessed for cost efficiency in the form of direct as well as indirect costs that could arise from length of surgery, hospital stay, complications, learning curve and postoperative outcomes.

METHODS

• ? A systematic review was performed searching Medline, Embase and Web of Science databases. Two reviewers identified abstracts using online databases and independently reviewed full length papers suitable for inclusion in the study.

RESULTS

• ? Laparoscopic and robot assisted radical prostatectomy are superior with respect to reduced hospital stay (range 1–1.76 days and 1–5.5 days, respectively) and blood loss (range 482–780 mL and 227–234 mL, respectively) when compared with the open approach (range 2–8 days and 1015 mL). Robot assisted radical prostatectomy remains more expensive (total cost ranging from US $2000–$39 215) than both laparoscopic (range US $740–$29 771) and open radical prostatectomy (range US $1870–$31 518).
• ? This difference is due to the cost of robot purchase, maintenance and instruments. The reduced length of stay in hospital (range 1–1.5 days) and length of surgery (range 102–360 min) are unable to compensate for the excess costs.
• ? Robotic surgery may require a smaller learning curve (20–40 cases) although the evidence is inconclusive.

CONCLUSIONS

• ? Robotic surgery provides similar postoperative outcomes to laparoscopic surgery but a reduced learning curve.
• ? Although costs are currently high, increased competition from manufacturers and wider dissemination of the technology could drive down costs.
• ? Further trials are needed to evaluate long term outcomes in order to evaluate fully the value of all three procedures in urological surgery.