Robotic Prostate Cancer Surgery Widely Used

Growth in RARP use especially pronounced among surgeons at urban hospitals.
Growth in RARP use especially pronounced among surgeons at urban hospitals.

Robot-assisted radical prostatectomy came into widespread use from 2003 to 2010, especially among surgeons who handle a relatively large number of radical prostatectomy (RP) cases, a new study found.

This widespread adoption of robot-assisted RP (RARP) was associated with an increased economic burden for prostate cancer (PCa) surgery.

In a retrospective study of 489,369 men who underwent open or laparoscopic RP or RARP from 2003 to 2010, Steven L. Chang, MD, of Harvard Medical School in Boston, and colleagues found that RARP adoption increased from 0.7% to 42% of surgeons who perform RP, according to findings published online ahead of print in BJU International. From 2005 to 2007, RARP adoption was more common among surgeons at teaching hospitals and intermediate- and large-sized hospitals. After 2007, adoption was more common among surgeons at urban hospitals.

Additionally, the study showed that the annual number of surgeons performing RP decreased from about 10,000 to 8,200 from 2003 to 2010, with the proportion of cases performed by high-volume surgeons rising from 10% to 45%.

By the end of the study, 73% of high-volume surgeons adopted RARP compared with 45% and 36% of intermediate- and low-volume surgeons, respectively. The investigators defined low-, intermediate, and high-volume surgeons as those performing fewer than 5, 5-24, and more than 24 RPs annually, respectively.

The use of RARP was associated with increased costs.  For RARP, the median 90-day direct hospital costs decreased from $16,388 to $9,234 per case from 2003 to 2005, and then leveled off at slightly more than $10,000 per case. The costs for non-RARP cases remained stable until the final 2 years of the study. The costs from 2003 to 2008 ranged from $7,789 to $7,862. The costs rose to $8,534 and $8,681 in 2009 and 2010. Costs were highly associated with operating room time, the authors noted.

“Given its high costs, RARP adoption seems contradictory to contemporary effects for cost containment,” the researchers wrote. “We suspect that RARP diffusion has remained robust due to an absence of pressures to curtail adoption.”

They noted that patients in the U.S. with insurance typically have identical out-of-pocket costs regardless of the type of RP so patient decisions are driven by non-financial factors. Moreover, surgeons do not generally share in the burden of additional costs for the robotic platform.  “Because RARP adoption was typically associated with increased RP volume, we suspect that there may be provider-induced demand for RARP given the potential financial rewards.”

Citing previous studies, Dr. Chang's group pointed out hospitals, which typically carry the financial responsibility for robotic surgery, may also have encouraged RARP adoption. After spending up to $2.5 million to buy a robotic unit, they noted, there is probably pressure to use the robotic equipment to increase or avoid losing market share for RP.

“Therefore, all key components in the decision for the type of prostate cancer surgery actively led to widespread RARP adoption in the USA despite the consequence of increasing the economic burden of prostate cancer surgery,” they wrote.

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