Perioperative Outcomes and Cost of Robotic Versus Open Simple Prostatectomy in the Modern Robotic Era: Results from the National Inpatient Sample.

To perform a comparative analysis of peri-operative outcomes and hospitalization cost between open (OSP) and robotic assisted simple prostatectomy (RASP) for treatment of benign prostatic hyperplasia (BPH) using the National Inpatient Sample (NIS) in the contemporary robotic era.

The NIS was queried for cases of OSP and RASP for the treatment of BPH between 2013-2016. Perioperative complications, unadjusted hospital cost and length of stay (LOS) were compared between RASP and OSP. Smoothed linear regression curves comparing hospitalization cost by increasing LOS was stratified by surgical approach to identify point of cost equivalency between RASP and OSP. Multivariable linear regression analysis was used to construct a hospitalization cost model in order to examine contribution of robotic approach and LOS to hospitalization cost.

The total analytic cohort included 2,551 OSP and 704 RASP procedures. Patients undergoing RASP were younger [Median(IQR): 68(63-73) vs. 71(65-77)], with fewer comorbidities (76.8% vs. 86.5%, p<0.01). RASP was associated with fewer total complications (11.1% vs 29.2%, p<0.01) and greater likelihood of routine discharge to home rather than another facility (88.9% vs 76.7%, p<0.01). While LOS was shorter with RASP [Median(IQR), 2(1-3) vs 4(3-6), p<0.01], total unadjusted hospitalization cost was greater [Median(IQR), $10,855($7,965-$15,675) vs $13,467($10,572-$17,722), p<0.01]. Presence of any complication increased both LOS and hospitalization cost (p<0.01). Linear regression modeling determined the point of cost equivalence between RASP staying a median of 2 days was an OSP case staying between 5-6 days. On multivariable regression analysis, the robotic approach contributed an additional $6,175 (p<0.01) to the cost model, whereas each additional day of hospitalization contributed $1,687 (p<0.01), suggesting LOS would need to be 3 - 4 days shorter with RASP to offset surgical costs of the robot.

While RASP appears to have significantly better perioperative complication rates with shorter LOS and likely discharge to home, total hospitalization cost remained greater, likely related to upfront operative costs. While this retrospective study is limited by selection bias for patients undergoing RASP, the benefits of improved convalescence, discharge to home, and lower rate of perioperative complications appear to justify performance of RASP in an experienced pelvic robotic center despite relatively greater hospitalization cost, if referral to an experienced HoLEP center is not feasible.

BJU international. 2020 Sep 27 [Epub ahead of print]

R Bhanvadia, C Ashbrook, J Gahan, R Mauck, A Bagrodia, V Margulis, Y Lotan, C Roehrborn, S Woldu

University of Texas Southwestern, Department of Urology, 2001 Inwood Road, 4thFloor, WBCE3, Dallas, TX 75390, USA.