RALP Costs More, But Advantages Questionable

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ORLANDO – Robotic-assisted laparoscopic prostatectomy (RALP) is associated with significantly higher costs than laparoscopic prostatectomy (LRP) or open radical retropubic prostatectomy (RRP), yet the clinical advantages of RALP are unproven, according to researchers.

One the first studies of its kind comparing the costs of the three surgeries has been conducted by Amit Gupta, MD, MPH, chief resident, and Yair Lotan, MD, Associate Professor, both in the Department of Urology at the University of Texas Southwestern Medical Center in Dallas, and collaborators. RALP, they found, is associated with higher costs, predominantly due to increased operating room, anesthesia, and surgical supply costs.

“Robotic-assisted prostatectomies have been growing in popularity over the past several years, and now more than 50% of prostatectomies across the country are being done robotically,” said Dr. Gupta, who led the study. “We quantified what exactly the increased costs are with the robot.”

He and his colleagues analyzed data from 645 men who underwent radical prostatectomy (263 RALP, 220 LRP, and 162 open RRP). The median age was similar for all three groups (61, 59, and 61 years, respectively). The groups also had similar mean BMI (28, 27, and 27 kg/m2) and preoperative PSA values (5.3, 5.0, and 5.3 ng/mL, respectively).  The median prostate size was 46 cc for both RALP and LRP and 45 cc for open RRP.

Nerve-sparing surgery was performed in 85% of RALP procedures, 96% of LRP procedures, and 90% of open RRP procedures. Lymph node dissection was more common with RRP (100%) than LRP (22%) and RALP (11%).

The length of hospital stay was higher for RRP, and 21% of patients who underwent RRP received blood transfusions compared with 4.6% for RALP and 1.8% for LRP. The median direct cost was higher for RALP as compared with LRP or RRP.

The main differences were in operating room (OR) costs, even without incorporating the purchase and maintenance costs of the robot into the analysis. Direct costs were $6,752 for RALP, $5,687 for LRP, and $4,437 for RRP, respectively. Surgical supply costs were $2,015 for RALP, $725 for LRP, and $185 for RRP. OR service costs were $2,798 for RALP, $2,453 for LRP, and $1,611 for RRP.

The study concluded that RALP is not a cost-effective way of performing prostatectomies. “We have adopted technology without really looking at the socioeconomic effect of the technology,” said Dr. Gupta, who presented findings here at the 2009 Genitourinary Cancers Symposium.

“Known benefits of RALP and LRP, such as reduced length of stay and decreased blood loss, do not translate into cost benefits. To answer this question definitively, we need a clinical trial to compare outcomes like cancer control, continence, potency, and the cost-effectiveness of the three prostatectomy approaches.

“To our knowledge this is among the first studies to quantify the costs of these three approaches,” Dr. Gupta told Renal & Urology News. “The robotic technology is expensive, but it has equal results.”

With respect to surgery-related morbidity, Dr. Gupta pointed out that some well- conducted studies have not demonstrated improvement in length of stay or pain with RALP compared with RRP or LRP approaches. 

In a study at Vanderbilt University Medical Center in Nashville, researchers compared 374 patients who underwent RRP and 629 who underwent RALP. Overall 94.3% of patients in the RRP group and 97.5% of the RALP group were discharged home on or before postoperative day 1, according to findings published in The Journal of Urology (2007;177:929-931).

Mean length of stay in the RRP and RALP groups were 1.25 and 1.17 days, respectively, a nonsignificant difference. Readmission rates also were similar (7% and 5%, respectively). Unscheduled clinic or emergency room visits were the same (10% in both groups). In a separate study, another team at the same institution concluded that RALP did not provide “a clinically meaningful decrease in pain compared with RRP, primarily because of the low pain scores reported in each group,” according to a report in The Journal of Urology (2005;174:912-914).

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