COMMENTARY

A Closer Look at Robotic Surgery Cost, Use, and Trends

Albert B. Lowenfels, MD

Disclosures

January 05, 2018

About a quarter of a century has elapsed since the first publications about robotic surgery appeared.[1] Since then, approximately 14,000 reports containing the term "robotic surgery" have been published, largely focusing on costs and short-term results.

Although the volume of publications has increased exponentially, there is a scarcity of randomized trials. A recent randomized trial published in the Lancet comparing robotic surgery versus suprapubic open conventional surgery for prostate cancer found no difference in early results.[2] Few reports provide information about long-term results.

Which Patients Are Most Suitable for Robotic Surgery?

What are the main questions patients (rather than physicians or hospitals) are likely to ask about robotic surgery? Patients want a firm answer to the straightforward question, "Is robotic surgery safer and better than conventional surgery?" And cancer patients want to know, "If I have robotic surgery, will my survival be significantly improved compared with other types of surgery?" With currently available data, it is difficult to give an unequivocal answer to either question.

At present, about 4000 surgical robots are in current use, mostly using a patented system that has been approved by the US Food and Drug Administration.[3] Although these machines perform well, robotic surgery may or may not be superior to operations using existing laparoscopic techniques.[4]

What is the real potential for robotic surgery? Could it be better suited to pediatric patients than to adult patients? Robotic surgery is increasingly being used in pediatric conditions, especially for pyeloplasty and urologic procedures.[5] The design of new, miniaturized equipment offers the promise of tremor-free surgery when operating in the confined spaces of newborn infants or when performing fetal surgery.

Let us review three recent articles that provide insight into the current use, costs, and results reported for patients operated with robotic surgery.

Outlining the Costs of Robotic Surgery

How do costs of robotic surgery compare with costs of similar procedures performed with a laparoscopic technique? To compare the financial aspects of these alternative surgical approaches, the authors of a paper published in the Journal of the American College of Surgeons reviewed results from 92,835 patients in the National Inpatient Sample that used different surgical approaches.[6]

Of this sample, 4% had robotic surgery, whereas 96% of the procedures were performed with a laparoscopic approach. Types of operations performed were cholecystectomy, incisional hernia repair, colorectal surgery, and total abdominal hysterectomy. For all of the different surgical procedures, costs were significantly higher for robotic surgery than for laparoscopic surgery (P < .001), with the lowest cost increase for hysterectomy (6.4%) versus an increase of 28% for left hemicolectomy.

This report from the 2017 meeting of the American College of Surgeons focuses solely on the cost aspects of robotic versus laparoscopic surgery for several of the most common surgical procedures. Because the report is based on administrative data from many different types of hospitals, it is likely to be representative of results throughout the United States. The authors present only cost data, so we cannot say whether or not the extra costs associated with robotic surgery were counterbalanced by better results or reduced readmission rates.

In another study using the same database, robotic surgery resulted in a threefold to fourfold increase in costs compared with other approaches for patients undergoing bariatric surgery-another commonly performed operation.[7]

Ten-Year Review of Robotic Surgery Use

In a paper also presented at the 2017 American College of Surgeons meeting, the authors report on time trends for the use of robotic surgery at the University of California, San Diego.[8] During the decade from 2005 to 2015, a total of 3203 robotic procedures were performed by 45 different staff surgeons, with about a fourfold increased use of this procedure during the period. Robotic surgery increased for general, urologic, and gynecologic procedures, but not for cardiovascular surgery.

The increased use of robotic surgery was associated with a reduction of 1.8 days for length of stay, but an increase in costs. After 2009, readmission rates were 15% for robotic procedures compared with 23% for open procedures (P < .001).

This single-center report documents a steady increase in the use of robotic surgery for common procedures performed by general surgeons, urologists, and gynecologists over a 10-year period. Although length of stay after robotic surgery was shorter than for open surgery, costs did not decrease—implying that costs associated with robotic equipment must have increased. There was a gratifying reduction in patient readmission rate, which reduces overall patient care costs and may be an indicator of quality of care.

What Are the Long-Term Outcomes of Robotic Surgery?

During the 10-year period from 2002 to 2012, the authors of a single-center report published in Annals of Surgery[9] compare three different surgical approaches for managing early lung cancer: robotic (n = 172), video-assisted thoracic surgery (n = 141), and thoracotomy lobectomy (n = 157).

When patients were matched by propensity score (age, sex, smoking, clinical stage, and so on), postoperative mortality was similar (P = .30), as was complication rate (P = .55), and completeness of resection (P = .99). Robotic surgery yielded more lymph nodes (P < .001) and a shorter length of stay (P < .001). After follow-up ranging from 0.3 to 148 months, overall survival rates in robotic (78%), video-assisted (74%), or open surgery (78%) were similar.

This single-institution study found little difference in survival rates for groups with early lung cancer treated with three contrasting surgical approaches: robotic, video-assisted surgery, or open lobectomy. As the authors mention, this was not a truly randomized trial, only a matched trial based on initial patient characteristics. With true randomization at the onset, the results may have revealed significant between-group differences during the follow-up period.

The authors do point out that robotic surgery increases the lymph node yield, allowing for better staging. A true randomized trial with longer follow-up would be necessary to reveal survival differences.

What are your thoughts and experiences with robotic surgery? Please leave a comment below in the comment section.

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