Robotic radical nephrectomy sees steady increase in use

“Journal Article of the Month” is a new Urology Times section in which Badar M. Mian, MD (left), offers perspective on noteworthy research in the peer-reviewed literature.  Dr. Mian is associate professor of surgery in the division of urology at Albany Medical College, Albany, NY. 

Robot-assisted radical nephrectomy is now performed more frequently than laparoscopic radical nephrectomy. According to a recently published study in JAMA (2017; 318:1561-8), there has been a steady increase in the rate of the robot-assisted procedure throughout the period covered in the study.

Jeong et al performed a retrospective cohort analysis using a health care database that captures 20% of all hospital admissions from over 700 acute care hospitals in the United States. They identified a cohort of 23,753 patients undergoing elective laparoscopic radical nephrectomy (18,573) or robot-assisted radical nephrectomy (5,180) between 2003 and 2015 at 413 U.S. hospitals. They performed propensity score weighted adjustment to determine the outcomes such as perioperative complications, resource utilization (long operative time, hospital stay, blood transfusion), and direct hospital cost for each group.

The study authors indicated that there had been a steady increase in the proportion of radical nephrectomies performed using the robot-assisted technique, from 1.5% in 2003 to 27% in 2015. Further, they noted that by 2015, the robot-assisted technique for radical nephrectomy had outpaced the laparoscopic cases.

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There was no difference in the minor or major postoperative complications, blood transfusion rate, and hospital length of stay between the two techniques. However, the total cost to the hospital was significantly higher for the robot-assisted procedures. The increased cost of robot-assisted cases by nearly $2,700 was mostly due to prolonged operative time and increased use of supplies. Prolonged surgery time, defined as greater than 4 hours, was reported in nearly 44% of robot-assisted cases compared to 26% of laparoscopic cases.

Clearly, the disposable instruments for robotic procedures could result in an increased cost of the procedure, but the prolonged surgical time reported for robotic cases is less clear since port placement and positioning are similar for both techniques except for the few additional minutes required for docking and undocking the robot. The authors mentioned the possible increase in the attempted robotic partial nephrectomy procedures being converted to radical nephrectomy. This may be one of the reasons for the prolonged surgical time and related cost.

Next: "One of the potentially significant confounding factors for the cost analysis is the issue of the study period and learning curve"

One of the potentially significant confounding factors for the cost analysis is the issue of the study period and learning curve. It is encouraging to note that there were no differences in complications between the two procedures. One might speculate that due to the learning curve, a slow or cautious approach may have resulted in prolonged surgical time and increased cost. The study period for this report (2003-2015) includes essentially the entire learning curve for the robot-assisted technique, whereas the laparoscopic technique had been well established by that time. A more meaningful comparison would be to analyze the data at the beginning of the study (eg, 2003-2005) and at the end of the study period (eg, 2013-2015) to determine whether the differences in outcomes, resources utilization, and cost still exist.

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In general, there is no increased payment by third-party payers to the hospitals and surgeons for performing robot-assisted radical nephrectomy, and the difference in cost is typically absorbed by the hospital. At least for now, we cannot automatically assume that increased cost of robotic nephrectomy results in increased cost for the insurers and/or the patients, or a net loss for the hospital. The issues surrounding hospital charges, payments, costs, and perceived value are not linear and often quite opaque.

Clearly, robotic surgery, as with other technological advances, is associated with increased cost. Practicing cost-effective medicine is a collective responsibility. A team approach to reducing resource utilization and cost can be implemented to include the surgeon, anesthesiologist, OR staff, and postoperative early recovery pathways. Sharing the resource utilization and cost data with the robotic surgical team will create awareness of the problem and facilitate, with or without additional incentives, reduction in the total cost the procedure. In the end, it is up to the surgeons who wish to continue to perform these robotic procedure to demonstrate their cost-effectiveness.

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