RARP vs. open: Outcomes from 650,000 patients

Orlando, FL-A review of more than 650,000 non-metastatic prostate cancer patients “represents the best available evidence for the morbidity and cost profile” of robot-assisted radical prostatectomy (RARP) versus the open procedure (ORP), according to study author Jeffrey J. Leow, MBBS, MPH.

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RARP is associated with less morbidity but at a higher cost than ORP. The cost efficiency of RARP can be improved by limiting operating room time, most likely achieved by high-volume surgeons, said Dr. Leow, a research fellow at the Center for Surgery and Public Health at Brigham and Women’s Hospital, Boston, who presented the findings at the Genitourinary Cancers Symposium in Orlando, FL.

These findings come from a population-based retrospective cohort study of 654,030 patients with non-metastatic prostate cancer who underwent radical prostatectomy between 2003 and 2013 at 449 hospitals in the United States.

“Our contemporary analysis found that RARP confers a perioperative morbidity advantage over ORP, but at higher costs, which are heavily contributed by supplies and OR costs,” said Dr. Leow, who worked on the study with Steven L. Chang, MD, MS, and colleagues.

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Urology Times Editorial Consultant J. Brantley Thrasher, MD, said the advantages conferred by the robotic procedure in this and other studies must be weighed against its higher costs.

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RARP has been adopted rapidly in the United States over the past decade despite the lack of level 1 evidence, aided initially by results from single-institution studies showing benefits over ORP. Subsequent patient-driven marketing and inter-hospital competition contributed to its emergence, Dr. Leow said. Over the study period, the use of RARP grew from 2% to about 85% of radical prostatectomies.

Using regression analysis, Dr. Leow and colleagues compared 90-day postoperative complications, blood transfusions, operating room time, and direct hospital costs between the two groups, using an all-payer discharge database (Premier Hospital Database).

A unique feature of the study was the use of charge master descriptions to classify RARP by identifying supplies unique to robotic procedures.

90-day hospital costs assessed

The median 90-day direct hospital costs exceeded $14,000 in patients undergoing RARP, with supplies contributing $4,267 of this cost and OR time contributing $7,013. The median 90-day direct hospital costs were a little more than $9,000 in the patients undergoing ORP, with supplies contributing $1,089 and OR time contributing $4,529 of this cost. The excess cost of RARP, therefore, was $5,339 compared with ORP.

The adjusted odds ratio (OR) of any complication with RARP compared with ORP was 0.72 (94% CI, 0.6-0.87). Patients undergoing RARP had a lower risk of blood transfusion (OR: 0.3; 95% CI, 0.14-0.64).

A sub-analysis of the highest volume robotic surgeons found no difference in the rate of complications but a reduced risk of transfusions compared with the entire cohort. The OR of transfusion was 0.11 for the highest volume surgeons performing RARP compared with ORP (95% CI, 0.03 to 0.42).

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The median OR time for the entire cohort was 155 minutes. Highest volume surgeons spent less time in the OR, and in this group, the difference in cost between RARP and ORP was $1,188, but it was no longer significant.

“This suggests that there may be a role for centralization of robotic procedures to high-volume providers in the U.S.,” said Dr. Leow.

“Surgeons need to hit a threshold OR time of about 145 minutes for robotic surgery to be more cost efficient than open surgery,” assuming a 10% complication rate (the average), he added.

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The widespread adoption of RARP for the management of localized prostate cancer implies that a large randomized trial will not likely be conducted, so the current large retrospective study “represents the best available evidence for the morbidity and cost profile of RARP vs. ORP,” according to Dr. Leow.

Dr. ThrasherIn an email to Urology Times, Dr. Thrasher said he found it interesting that the authors found fewer transfusions in patients treated robotically and no significant difference in other 90-day complications but that the robotic procedure’s costs were much higher.

“Ultimately, what needs to be considered here is if fewer transfusions, earlier discharge in some studies, and less pain for the robotic group is enough to justify the higher cost. Other studies have shown that in the hands of expert surgeons, cancer outcomes, incontinence, and erectile function are very similar with both approaches, so the other variables I mention have to be weighed against the extra cost,” said Dr. Thrasher, professor and chair of urology at the University of Kansas, Kansas City, who was not involved with the study.

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