Use of robotic-assisted surgery for radical nephrectomy (RN) has increased substantially, and while the modality is not associated with an increased risk of any or major complications compared with conventional laparoscopic RN, it is associated with prolonged operating times and higher hospital costs, new study findings suggest.
In a retrospective study of patients who underwent robotic-assisted and laparoscopic RN at 416 US hospitals from 2003 to 2015, In Gab Jeong, MD, PhD, of the University of Ulsan College of Medicine in Seoul, Korea, and colleagues found that use of robotic-assisted RN grew from 39 (1.5%) of 2676 RN procedures in 2003 to 862 (27%) of 3194 RN procedures in 2015, according to a report published in JAMA (2017;318:1561-1568). In the robotic-assisted and laparoscopic RN groups, the incidence of any postoperative complications (Clavien 1-5) was 22.2% and 23.4%, respectively, and the incidence of major complications (Clavien 3-5) was 3.5% and 3.8%. The differences between the groups were not significant.
The rate of prolonged operating time (defined as longer than 4 hours) was significantly greater for the robotic-assisted than laparoscopic procedure (46.3% vs 25.8%). The mean 90-day direct hospital costs were significantly higher for robotic-assisted than laparoscopic RN ($19,530 vs $16,851), which included higher operating room costs ($7217 vs $5378) and higher supply costs ($4876 vs $3891).
“It remains unclear why the use of robotic-assistance has increased substantially and has been steadily replacing laparoscopic radical nephrectomies,” Dr Jeong’s team wrote. “One possibility is the financial viability of the robotic system in relatively small hospitals.”
The investigators reported that the costs of purchasing and maintaining a robotic system range from $0.5 million to $2.5 million and $80,000 to $170,000 per year, respectively. “Surgeons have to perform at least 100 to 150 procedures annually to offset the upfront and ongoing costs of its acquisition,” Dr Jeong and colleagues noted.
For the study, the researchers used the Premier Healthcare dataset, an all-payer, fee-supported database that captures about 20% of all hospitalizations from more than 700 acute care hospitals in the United States.
With respect to study limitations, the authors noted that their study is subject to potential misclassification bias because they used billing codes and ICD-9 procedural codes to capture robotic-assisted surgeries. Second, the Premier Healthcare database does not publish information regarding tumor characteristics, which could affect the risk of perioperative outcomes. Third, the rates of conversion to open RN between robotic-assisted and laparoscopic RN could not be compared.
In an editorial accompanying the new study, Jason D. Wright, MD, of Columbia University College of Physicians and Surgeons in New York, commented, “From a policy perspective, robotic-assisted surgery exemplifies the difficulty of balancing surgical innovation with evidence-based medicine. Both the generation of high-quality evidence evaluating new procedures and then the utilization of these evidence to guide practice should remain priorities for surgical disciplines.”
Dr Wright summarized some of the nonclinical factors influencing the dissemination of robotic-assisted surgery, including intense marketing to physicians, hospitals, and patients and competition among hospitals. “Currently, much of the increased cost associated with robotic-assisted surgery is underwritten by hospitals,” he wrote. “Hospitals are willing to bear these costs in the hope of increasing market share and remaining competitive in their regional markets.”
Jeong IG, Khandwala YS, Kim JH, et al. Association of robotic-assisted vs laparoscopic radical nephrectomy with perioperative outcomes and health care costs, 2003 to 2015. JAMA 2017;318:1561-1568.
Wright JD. Robotic-assisted surgery – Balancing evidence and implementation. JAMA 2017;318:1545-1547.