Minimally invasive cystectomy linked with shorter hospital stay

Compared to an open approach, minimally invasive radical cystectomy was associated with a near 2-day shorter hospital stay in bladder cancer patients treated at diverse institutions across the United States, according to authors of a recent retrospective analysis of Medicare claims.

There was no difference in readmission rates for minimally invasive versus open radical cystectomy, while the cost to Medicare was nearly $4,000 less for the minimally invasive procedure, according to the analysis, which was presented at the 2018 Society of Urologic Oncology annual meeting in Phoenix and published in Urology (2019; 125:86-91).

“The real-world practice of robotic cystectomy appears to line up with that in high-volume centers in randomized trials, which is reassuring for us,” said researcher Parth K. Modi, MD, MS, a urologic oncology and health services research fellow at the University of Michigan, Ann Arbor, working with Chad Ellimoottil, MD, MS, and colleagues.

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Specifically, these findings confirm and extend those of the randomized RAZOR trial, Dr. Modi told Urology Times. In that phase III, non-inferiority study, which included 350 patients treated at 15 high-volume, specialized centers, median length of stay was significantly shorter for those patients who underwent robot-assisted radical cystectomy versus those who underwent an open procedure (Lancet 2018; 391:2525-36).

However, cost data in RAZOR were unsuitable for analysis, according to investigators, who cited “considerable heterogeneity” in data among centers and an inability to collect data from all participating centers due to proprietary concerns.

For the analysis presented at the SUO annual meeting, Dr. Modi and colleagues looked at 4,760 Medicare patients with bladder cancer who underwent radical cystectomy between 2008 and 2015. Of those patients, 693 (14.6%) underwent a minimally invasive procedure, while the remaining 4,067 (85.4%) were open.

Length of stay was a median 10.1 days for the minimally invasive procedure versus 11.9 days for the open procedure (p<.001) after adjusting for patient, hospital, and surgeon factors, Dr. Modi and colleagues reported. By contrast, 30-day readmission rates were not significantly different, at 27.4% and 26.8% for the minimally invasive and open approach, respectively (p=.77).

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Total Medicare payments within 90 days of surgery were significantly lower for minimally invasive versus open radical cystectomy, at $34,369 and $38,071, respectively, in adjusted multiple regression analysis (p<.001).

Dr. Modi said it was somewhat surprising that 90-day episode spending was lower for the minimally invasive approach, given a previous analysis showing the opposite-that the minimally invasive approach was associated with higher 90-day spending (Eur Urol 2016; 70:195-202).

That previous analysis focused on an earlier time period, 2002-2012-earlier in the adoption of minimally invasive technology-which could mean that higher spending was due to inexperience or more “cautious” postoperative management, Dr. Modi said.

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Mortality outcomes of minimally invasive versus open radical cystectomy were not analyzed in the current study due to the short time frame evaluated, and oncologic outcomes were not available in the Medicare data, according to Dr. Modi.

“It’s possible that there are patient factors that we were unable to account for in our analysis, and so we wouldn’t make any strong claims about the effectiveness of robotic cystectomy based on this data,” he said. “A randomized trial really is the best way to answer those types of questions.”

Effectiveness of robotic cystectomy was the main focus of the randomized, phase III RAZOR trial. In the Lancet report on the study, RAZOR investigators said robot-assisted radical cystectomy was noninferior to open radical cystectomy with regard to the clinical primary endpoint of progression-free survival.