An Economic Analysis of Robotic-Assisted Radical Prostatectomy

Robotic-assisted radical prostatectomy (RARP) was first used in Germany in 2000,1 and started to be implemented in the United States around two years later.1 It is now estimated that more than 90% of all RPs in the United States are performed robotically.2 As RARP has become established as the “gold standard” for RP over the past two decades, associated with less blood loss, shorter hospital stays, fewer complications, and better functional outcomes, attention has turned to an evaluation of the costs of RARP compared with other techniques.

A 2014 systematic review3 identified 11 prior studies that analyzed direct costs of different RP techniques, only seven of which compared costs associated with the different approaches. Minimally invasive RP, including RARP, was found to be more expensive than open retro-pubic RP (RRP) in most studies, mainly due to costs of surgical supplies and longer operating room time. Among the cost-comparison studies, for minimally invasive RP costs ranged from $5058 to $11,806, while for RRP costs spanned $4075 to $6296. One study found RARP not to be cost-effective from a health-economic standpoint.

However, a recent economic analysis4 concluded that despite differences in upfront costs, patients with prostate cancer who underwent in-hospital RARP compared with open radical prostatectomy (ORP) had similar health care costs one year after discharge.

US researchers retrospectively reviewed data from around 11,500 men aged 18-64 years with prostate cancer who underwent radical prostatectomy, all identified from a large national private insurance database for January 2013 through December 2018. All patients were continuously enrolled with medical and prescription drug coverage from 180 days before to one year after surgery. Costs and use of health care services were compared between patients who underwent ORP (n=1604) versus RARP (n=9853).

Primary outcomes assessed at one-year post-discharge were total health care costs, including reimbursement paid by insurers and patients’ out-of-pocket costs; health care use, including inpatient readmission as well as emergency department (ED), hospital outpatient, and office visits; and estimated days missed from work due to health care use.

Compared with patients who underwent ORP, costs at the index hospitalization were higher for patients who underwent RARP. However cumulative costs did not differ between the groups at 180 days or at one year. At one year, health care use in patients in the RARP group was significantly lower compared with the ORP group, with significantly fewer ED visits (–0.09 visits; 95% CI, −0.11 to −0.07; P<0.001) and hospital outpatient visits (−1.5 visits; 95% CI, −1.63 to −1.36; P<0.001). This produced additional savings of $2929 and resulted in around 169 fewer days missed from work for health care visits. The researchers also found that the use of RARP was associated with $2000 less postoperative outpatient therapeutic radiologic expenditure than ORP.

A 2020 study5 reported that, like other robotic cancer surgeries compared with open surgery, RARP was more cost-effective for patients with prostate cancer. Among 5869 patients who underwent RARP, out-of-pocket costs were reduced by $137.75 (adjusted difference) compared with 1652 patients who underwent open prostatectomy. Adjusted total costs were also lower with RARP, with a $3872.62 reduction versus open prostatectomy.

The role of surgeons and hospitals in RARP costs was highlighted in a 2016 study,6 in which US researchers used a weighted sample of nearly 300,000 men with prostate cancer who received RARP performed by 667 surgeons between 2003 and 2013 at 197 hospitals, nationwide, analyzing 90-day hospital costs. High and low costs per procedure were defined as above the 90th percentile and below the 10th percentile, respectively.

Each RARP resulted in an average hospital cost of $11,878 (2014 US dollar value), ranging from an average of $2837 in the low-cost group to an average of $25,906 in the high-cost group. Hospital and surgeon characteristics appeared accountable for about one-third and one-fifth of RARP cost, respectively. The odds of high-cost surgery were lower among both high-volume surgeons (OR 0.24) and high-volume hospitals (OR 0.105). The investigators also noted an increased likelihood of low-cost RARP at high-volume hospitals (OR 839).

Despite initial high costs, RARP shows long-term ad- vantages in cost-effectiveness and cost-utility that justify its implementation, according to a recent Brazilian report.7 A retrospective analysis of outcomes in 56 patients who underwent RARP and 149 who underwent RRP at a single cancer center during 2013 were used to simulate 1000-patient hypothetical cohorts for both groups. The average cost was higher in the RARP group than the RRP group ($24,535.49 vs $12,776.32, respectively), but the total cost was lower ($1373,987 vs $1903,671.93).

Treating the hypothetical cohorts was estimated to cost $19,224,195.90 and $10,010,582.35, respectively. Using Incremental Cost-Effectiveness Ratios calculations, the between-group difference was $9213,613.55, and the Incremental Cost-Utility Ratio was $22,690.83 per quality-adjusted life-year (QALY) saved.

References

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  7. de Oliveira RAR, Guimarães GC, Mourão TC, et al. Cost-effectiveness analysis of robotic-assisted versus retropubic radical prostatectomy: a single cancer center experience . J Robot Surg. Published online January 8, 2021.doi: 10.1007/s11701-020-01179-z