ORLANDO—Robot-assisted partial nephrectomy (RAPN) has more upfront costs than laparoscopic partial nephrectomy (LPN), but these costs may decrease with time as surgeon and operating room staff experience increase, according to a new study.

In recent years, nephron-sparing surgery has become the standard of care for the treatment of small renal masses. However, partial nephrectomy remains underused. It is theorized that this underuse is due to a number of factors, one of which is the limitation of advanced laparoscopic techniques needed to perform partial nephrectomy. Robot-assisted surgery has eased the transition to minimally invasive surgery in the setting of prostate cancer and may also do so for partial nephrectomy, the researchers noted. But the cost of robotic techniques is an important barrier.

“If you are an experienced laparoscopic surgeon, you will not need the robot,” said study investigator Thomas Schwaab, MD, PhD, Assistant Professor of Urology/Immunology. “If you are an inexperienced surgeon who wants to tackle complex partial nephrectomy, the robot may make it easier and we simply wanted to look at whether it costs more money.”

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To quantify the costs associated with RAPN and LPN (excluding the cost of the robot), researchers identified 35 consecutive patients with normal renal function who underwent RAPN for a localized renal mass by a single surgeon who had performed fewer than 25 RAPN. The 35 RAPN patients were compared to the last 35 similar patients who underwent LPN by a surgeon who had performed more than 150 previous LPNs. The team analyzed surgical outcomes and compared room time, length of stay, and total operating room charges (ORC). The total ORC included surgeon and anesthesia fees, as well as labor and supply costs. The depreciation of the robot is factored into the ORC as a higher per unit time charge for LPN. 

The researchers had complete data on charges for the first 29 RAPN patients. These charges were compared to the last 29 LPN patients. The procedures were conducted from October 2008 to July of 2009 for LPN and January 2010 to August 2010 for RAPN. Patient and tumor characteristics were similar between groups, except for larger tumor sizes in the RAPN group (3.6 vs. 2.7 cm). 

The findings, presented at the Genitourinary Cancers Symposium, suggest that surgical and oncologic outcomes were similar. However, the mean ORC for the LPN group was $28,606 compared with $30,874 for the RAPN group, a difference of $2,268

“The cost difference between the two procedures is there and it is distinct, but hopefully over time will ameliorate. We plan on a re-analysis in about another year,” Dr. Schwaab said.

Lead investigator Rebecca O’Malley, MD, a urology fellow, said it is important to note that the tumors were larger in the RAPN group. “Our outcomes were comparable, but the tumors were actually larger in the robotic series. So, it may be that robotic surgery will allow you to do larger and more complex tumors with less experience. Right now, we don’t know that but that is where we are going with it. In terms of the cost difference, we expected it to be more. We expect with more experience the operating time will go down and that will mean the costs will go down.”