BERKELEY, CA (UroToday.com) - The goal of our study was to assess both cost and utilization of robotic assistance during dismembered pyeloplasty. Interestingly, use of the robotic approach surpassed the open approach in 2009, and there was no cost difference between approaches.[1] We used the Nationwide Inpatient Sample (NIS) which provides a 20% capture of all nongovernment hospital inpatient stays in the United States and tracks both hospital charge and reimbursement data, in addition to hospitalization related factors.[2]
There is increasing interest in the effectiveness of robotic assistance and the Institute of Medicine marked this as one of their research priorities in 2009.[3] We believe robotic assistance is advantageous over pure laparoscopy for surgeries involving reconstruction. For example, dismembered pyeloplasty requires reshaping the renal pelvis with sutures after removal of the stenotic segment. Robotic assistance offers improved degrees of freedom, dexterity, and depth perception not seen in pure laparoscopy. In a multi-institutional report, comparing laparoscopic and robotic-assisted primary dismembered pyeloplasties (207 Laparoscopic and 354 Robotic), laparoscopic cases had higher rates of postoperative obstruction (11% vs 3.8%, p < 0.001), pain (5.3% vs 1.7%, p = 0.02) and secondary procedures (7.7% vs 1.8%, p = 0.002).[4] In the hands of experienced laparoscopists there may be little difference between the groups, but current residents are spending less time on pure laparoscopic training as robotic assistance training increases.
The widespread adoption of robotic assistance in pyeloplasty supports our hypothesis that robotic assistance is advantageous for reconstruction. Between 2007 and 2009 NIS showed the number of robotic pyeloplasties more than quadrupled and by 2010 accounted for 52.1% of all pyeloplasties and more than 90% of laparoscopic pyeloplasties.[1] This rate of adoption makes it difficult to conceive of an easy transition back to pure laparoscopic pyeloplasty even if mandated by governing bodies or economic factors. In other words, surgeons without pure laparoscopic experience may choose an open approach over a laparoscopic approach if the robot is not available.
Reimbursed costs in our study were similar between open ($11,240), laparoscopic ($11,464), and robotic ($11,953) pyeloplasties (p = 0.369). The costs of acquiring and maintaining the robot may not be reflected in this number. Future robotic costs may decrease with competition as the da Vinci robot by Intuitive Surgical, Inc. is currently the only system on the market. Titan Medical, Inc. is performing tissue testing and expects to have a robotic system on the market in 2015.[5]
Procedures such as radical nephrectomy, that do not require reconstruction, may not benefit from robotic assistance and appear to have a higher cost. In a recent NIS study (unpublished) we found higher total costs for robotic-assisted radical nephrectomy cases compared with laparoscopic cases ($15,624 vs $11,599, p < 0.001). This analysis also found that robotic assistance was only used in 29% of minimally-invasive nephrectomies with other reports finding greater than 90% utilization of robotic assistance for procedures requiring reconstruction (pyeloplasties and prostatectomies).[6] This differential utilization of robotic-assistance in reconstructive vs. non-reconstructive procedures supports our belief that individual surgeons are shifting priorities toward utilization of robotic-assistance for reconstructive purposes.
Surgeons need to carefully assess whether the robot adds value for both the patient and the health care system. We believe it is most effective to evaluate this on a case-by-case and surgeon-by-surgeon basis. Procedures with reconstructive components benefit from robotic assistance. Surgeons with pure laparoscopic experience may add value to health care systems by performing non-reconstructive procedures such as radical nephrectomies without the added cost of the robot.
References:
- Monn MF, Bahler CD, Schneider EB, Sundaram CP. Emerging trends in robotic pyeloplasty for the management of ureteropelvic junction obstruction in adults. Journal of Urology. Apr 2013;189(4):1352-1357.
- Healthcare Cost and Utilization Project 2007–2010. 2012; http://www.hcup-us.ahrq.gov/nisoverview.jsp. Accessed May 22, 2012.
- Initial Priority Topics for Copmarative Effectiveness Research. 2009; http://www.iom.edu/Reports/2009/ComparativeEffectivenessResearchPriorities.aspx. Accessed June 20, 2012.
- Lucas SM, Sundaram CP, Wolf JS, Jr., et al. Factors that impact the outcome of minimally invasive pyeloplasty: results of the Multi-institutional Laparoscopic and Robotic Pyeloplasty Collaborative Group. Journal of Urology. Feb 2012;187(2):522-527.
- Titan Medical Inc. Confirms No Material Changes to Operations. 2013; http://www.titanmedicalinc.com/titan-medical-inc-confirms-no-material-changes-to-operations/. Accessed December 2, 2013.
- Yu HY, Hevelone ND, Lipsitz SR, Kowalczyk KJ, Hu JC. Use, costs and comparative effectiveness of robotic assisted, laparoscopic and open urological surgery. Journal of Urology. Apr 2012;187(4):1392-1398.
Written by:
Chandru Sundaram, MD; Clint Bahler, MD; and Francesca Monn, MD as part of Beyond the Abstract on UroToday.com. This initiative offers a method of publishing for the professional urology community. Authors are given an opportunity to expand on the circumstances, limitations etc... of their research by referencing the published abstract.
Department of Urology, Indiana University School of Medicine, Indianapolis, Indiana and Center for Surgical Trials and Outcomes Research, The Johns Hopkins School of Medicine (EBS), Baltimore, Maryland
More Information about Beyond the Abstract