Bladder CancerPropensity-Matched Comparison of Morbidity and Costs of Open and Robot-Assisted Radical Cystectomies: A Contemporary Population-Based Analysis in the United States
Introduction
Bladder cancer (BCa) imposes a significant burden on the health care system, with approximately $3 billion in annual expenditures in the United States [1]. Patients who have muscle-invasive BCa contribute substantially to this economic burden, because the gold-standard therapy—radical cystectomy (RC)—is a complex surgical procedure with a high surgical complication rate [2], [3]. These postoperative complications frequently increase hospital length of stay (LOS) and use of hospital resources, thereby raising medical expenditures.
Since the 1990s, minimally invasive surgery (MIS) has gained popularity because of its potential to reduce surgical morbidity and shorten LOS. Laparoscopic RC was first described in 1993 [4] but was not widely adopted, likely because of the demand for advanced laparoscopic skills [5]. Since robot-assisted RC (RARC) was first reported in 2003 [6], there has been renewed optimism for reducing the morbidity of RC with MIS.
The investigations directly comparing the outcomes of RARC with open RC (ORC) are primarily single-institution studies [7], [8], [9] or without a standardized 90-d measure for complications [2], as recommended by the European Association of Urology (EAU) [10], [11]. Herein, we performed a contemporary population-based analysis to examine utilization rates, associated morbidity with the Clavien classification system, and costs of RARC compared with ORC.
Section snippets
Data source
Premier Perspective Database (Premier, Inc., Charlotte, NC, USA) is an all-payer hospital discharge database developed for quality and utilization benchmarking in the United States [12]. It includes more than 45 million inpatient discharges (about 20% of total discharges) from approximately 600 hospitals, capturing all hospital costs and charges. Each patient has a unique identifier, permitting longitudinal analysis. All data are de-identified, and we received institutional review board
Study cohort
The study cohort consisted of 6195 patients, equaling a survey-weighted cohort of 43 647 and a survey- and propensity-weighted cohort of 36 773, who underwent either ORC or RARC. After propensity weighting, all characteristics were comparable (p > 0.05; Table 1). Patients tended to be male (83.0%), white (76.5%), and married (59.7%). The mean and median age was 68.7 and 70.0 yr of age, respectively. Over the course of the study, 2101 (5.7%) RCs were performed with robotic assistance. The
Discussion
Our contemporary population-based study shows progressive RARC adoption between 2004 and 2010 in the United States, which was associated with similar morbidity compared with ORC while having significantly higher costs. The current study expands on the findings of a population-based study using the Nationwide Inpatient Sample (NIS) by Yu et al., which reported that RARC was associated with fewer overall inpatient complications than ORC (49.1% and 63.8%; p = 0.035) [2]. Unlike the prior study, we
Conclusions
Our contemporary, population-based evaluation shows a gradual adoption of RARC between 2004 and 2010 in the United States, with robot-assisted surgery currently involved in one out of every nine RC cases. The advent of RARC has not improved the morbidity profile of RC while simultaneously increasing expenditures, primarily because of the costly supplies associated with the robotic platform. Despite the apparent lack of benefit for robotic surgery, the current study demonstrates that RARC can
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