Propensity-Matched Comparison of Morbidity and Costs of Open and Robot-Assisted Radical Cystectomies: A Contemporary Population-Based Analysis in the United States

doi:10.1016/j.eururo.2014.01.029

European Urology

Volume 66, Issue 3, September 2014, Pages 569-576

https://doi.org/10.1016/j.eururo.2014.01.029 Get rights and content

Abstract

Background

Radical cystectomy (RC) is a morbid procedure associated with high costs. Limited population-based data exist on the complication profile and costs of robot-assisted RC (RARC) compared with open RC (ORC).

Objective

To evaluate morbidity and cost differences between ORC and RARC.

Design, setting, and participants

We conducted a population-based, retrospective cohort study of patients who underwent RC at 279 hospitals across the United States between 2004 and 2010.

Outcome measurements and statistical analysis

Multivariable logistic and median regression was performed to evaluate 90-d mortality, postoperative complications (Clavien classification), readmission rates, length of stay (LOS), and direct costs. To reduce selection bias, we used propensity weighting with survey weighting to obtain nationally representative estimates.

Results and limitations

The final weighted cohort included 34 672 ORC and 2101 RARC patients. RARC use increased from 0.6% in 2004 to 12.8% in 2010. Major complication rates (Clavien grade ≥3; 17.0% vs 19.8%, p = 0.2) were similar between ORC and RARC (odds ratio [OR]: 1.32; p = 0.42). RARC had 46% decreased odds of minor complications (Clavien grade 1–2; OR: 0.54; p = 0.03). RARC had $4326 higher adjusted 90-d median direct costs (p = 0.004). Although RARC had a significantly shorter LOS (11.8 d vs 10.2 d; p = 0.008), no significant differences in room and board costs existed (p = 0.20). Supply costs for RARC were significantly higher ($6041 vs $3638; p < 0.0001). Morbidity and cost differences were not present among the highest-volume surgeons (≥7 cases per year) and hospitals (≥19 cases per year). Limitations include use of an administrative database and lack of oncologic characteristics.

Conclusions

The use of RARC has increased between 2004 and 2010. Compared with ORC, RARC was associated with decreased odds of minor but not major complications and with increased expenditures attributed primarily to higher supply costs. Centralization of ORC and RARC to high-volume providers may minimize these morbidity and cost differences.

Patient summary

Using a US population–based cohort, we found that robotic surgery for bladder cancer decreased minor complications, had no impact on major complications and was more costly than open surgery.

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

References (30)

H.Y. Yu et al.
Comparative analysis of outcomes and costs following open radical cystectomy versus robot-assisted laparoscopic radical cystectomy: results from the US Nationwide Inpatient Sample
Eur Urol
(2012)
A. Shabsigh et al.
Defining early morbidity of radical cystectomy for patients with bladder cancer using a standardized reporting methodology
Eur Urol
(2009)
A. Simonato et al.
Laparoscopic radical cystoprostatectomy: a technique illustrated step by step
Eur Urol
(2003)
C.J. Stimson et al.
Early and late perioperative outcomes following radical cystectomy: 90-day readmissions, morbidity and mortality in a contemporary series
J Urol
(2010)
G. Gakis et al.
ICUD-EAU International Consultation on Bladder Cancer 2012: radical cystectomy and bladder preservation for muscle-invasive urothelial carcinoma of the bladder
Eur Urol
(2013)
D. Mitropoulos et al.
European Association of Urology Guidelines Panel. Reporting and grading of complications after urologic surgical procedures: an ad hoc EAU guidelines panel assessment and recommendations
Eur Urol
(2012)
W. D’Hoore et al.
Practical considerations on the use of the Charlson comorbidity index with administrative databases
J Clin Epidemiol
(1996)
A. Smith et al.
Cost analysis of robotic versus open radical cystectomy for bladder cancer
J Urol
(2010)
M. Sun et al.
Is there a relationship between leapfrog volume thresholds and perioperative outcomes after radical cystectomy?
Urol Oncol
(2014)
M.S. Khan et al.
Long-term outcomes of robot-assisted radical cystectomy for bladder cancer
Eur Urol
(2013)

D.C. Snow-Lisy et al.

Robotic and laparoscopic radical cystectomy for bladder cancer: long-term oncologic outcomes

Eur Urol

(2014)

C.T. Lee et al.

Bladder cancer: diagnosis, therapeutics, and management

(2011)

E. Sanchez de Badajoz et al.

Radical cystectomy and laparoscopic ileal conduit [in Spanish]

Arch Esp Urol

(1993)

M. Menon et al.

Nerve-sparing robot-assisted radical cystoprostatectomy and urinary diversion

BJU Int

(2003)

A.K. Kader et al.

Robot-assisted laparoscopic vs open radical cystectomy: comparison of complications and perioperative oncological outcomes in 200 patients

BJU Int

(2013)

Cited by (205)

Cost-analysis of robot-assisted radical cystectomy in Europe: A cross-country comparison
2023, European Journal of Surgical Oncology
Robotic-assisted radical cystectomy (RARC) with intracorporeal urinary diversion (ICUD) is surging worldwide. Aim of the study was to perform a multicentric cost-analysis of RARC by comparing the gross cost of the intervention across hospitals in four different European countries.
Patients who underwent RARC + ICUD were recruited from eleven European centers in four European countries (Belgium, France, Netherlands, and UK) between 2015 and 2020. Costs were divided into six parts: cost for hospital stay, cost for ICU stay, cost for surgical theater occupation, cost for transfusion, cost for robotic instruments, and cost for stapling instruments. These costs were individually assessed for each patient.
A total of 490 patients were included. Median operative time was 300(270–360) minutes and median hospital length-of-stay was 11(8–15) days. The average total cost of RARC was 14.794€ (95%CI 14.300–15.200€). A significant difference was found for the total cost, as well as the various subcosts abovementioned, between the four included countries. Different sets and types of robotic instruments were used by each center, leading to a difference in cost of robotic instrumentation. Nearly 84% of costs of RARC were due to hospital stay (42%), ICU stay (3%) and operative time (39%), while 16% of costs were due to robotic (8%) and stapling (8%) instruments.
Costs and subcosts of RARC + ICUD vary significantly across European countries and are mainly dependent of hospital length-of-stay and operative time rather than robotic instrumentation. Decreasing length-of-stay and reducing operative time could help to decrease the cost of RARC and make it more widely accessible.
Cost-Effectiveness of Nadofaragene Firadenovec and Pembrolizumab in Bacillus Calmette-Guérin Immunotherapy Unresponsive Non–Muscle Invasive Bladder Cancer
2023, Value in Health
Nadofaragene firadenovec is a gene therapy for bacillus Calmette-Guérin (BCG)–unresponsive non–muscle-invasive bladder cancer (NMIBC) undergoing Food and Drug Administration review. Pembrolizumab is approved for treating patients with BCG-unresponsive NMIBC with carcinoma in situ (CIS). We evaluated the cost-effectiveness of these treatments compared with a hypothetical therapeutic alternative, at a willingness-to-pay threshold of $150 000 per quality-adjusted life-year (QALY) gained, in CIS and non-CIS BCG-unresponsive NMIBC populations.
We developed a Markov cohort simulation model with a 3-month cycle length and lifetime horizon to estimate the total costs, QALYs, and cost per additional QALY from the health sector perspective. Clinical inputs were informed by results of single-arm clinical trials evaluating the treatments, and systematic literature reviews were conducted to obtain other model inputs. Sensitivity analyses were conducted to assess uncertainty in model results.
Nadofaragene firadenovec, at a placeholder price 10% higher than the price of pembrolizumab, had an incremental cost-effectiveness ratio of $263 000 and $145 000 per QALY gained in CIS and non-CIS populations, respectively. Pembrolizumab had an incremental cost-effectiveness ratio of $168 000 per QALY gained for CIS. A 5.4% reduction in pembrolizumab’s price would make it cost-effective. The model was sensitive to many inputs, especially to the probabilities of disease progression, initial treatment response and durability, and drug price.
The cost-effectiveness of nadofaragene firadenovec will depend upon its price. Pembrolizumab, although not cost-effective in our base-case analysis, is an important alternative in this population with an unmet medical need. Comparative trials of these treatments are warranted to better estimate cost-effectiveness.
Comparative Effectiveness of Radiation Versus Radical Cystectomy for Localized Muscle-Invasive Bladder Cancer
2023, Advances in Radiation Oncology
Radical cystectomy (RC) with neoadjuvant chemotherapy is the most commonly recommended treatment for muscle-invasive bladder cancer (MIBC), yet RC with urinary diversion remains an invasive treatment. Although some patients with MIBC gain good cancer control with radiation therapy (RT), its effectiveness remains under discussion. Therefore, we aimed to reveal the effectiveness of RT compared with RC for MIBC.
Using cancer registry and administrative data from 31 hospitals in our prefecture, we recruited patients with bladder cancer (BC) initially registered between January 2013 and December 2015. All patients received RC or RT, and none had metastases. Prognostic factors for overall survival (OS) were analyzed by Cox proportional hazards model and log-rank test. Propensity score matching between the RC and RT groups was performed to examine the association of each factor with OS.
Among the patients with BC, 241 received RC and 92 received RT. Median ages of the patients receiving RC and RT were 71.0 and 76.5 years, respectively. Five-year OS rates were 44.8% for patients receiving RC and 27.6% for patients receiving RT (P < .001). Multivariate analysis for OS showed that older age, poorer functional disability, clinical node positive, and pathology of nonurothelial carcinoma were significantly associated with worse prognosis. A propensity score-matching model identified 77 patients with RC and 77 with RT. In this arranged cohort, there were no significant differences in OS between the RC and RT groups (P = .982).
Prognostic analysis with matched characteristics showed that patients with BC receiving RT were not significantly different from those receiving RC. These findings could contribute to proper treatment strategies for MIBC.
The Impact of Venous Thromboembolism on Mortality and Morbidity During Nephrectomy for Renal Mass
2022, Urology
To determine the morbidity, mortality, and costs associated with having concurrent venous thromboembolism (VTE) at the time of surgical resection of a renal mass.
We identified 108,430 patients undergoing elective partial or radical nephrectomy for a renal mass from 2013 to 2017 using the Premier Healthcare database. The association of VTE with 90-day complication rates, mortality, ICU admission, readmission, and direct hospital costs (2019 US dollars) was determined with multivariable logistic regression and quantile regression models, respectively.
Of the 108,430 patients who underwent elective partial or radical nephrectomy, 1.2% (n = 1301) of patients were diagnosed with a preoperative VTE. Patients with preoperative VTE have higher rates of minor (odds ratio [OR] 1.47, 95% confidence inteval [CI] 1.34-1.62, P < .0001) and major complications (OR 2.53, 95% CI 2.23-2.86, P < .0001), mortality (OR 2.03, 95% CI 1.6-2.57, P < .0001), and readmissions (OR 1.73, 95% CI 1.57-1.90, P < .0001) compared to patients without preoperative VTE at the time of nephrectomy. Notably, the predicted probability for a major complication was significantly higher among patients with preoperative VTE who underwent either partial or radical nephrectomy, irrespective of the surgical approach utilized. Furthermore, rates of all types of complications except endocrine and soft tissue were significantly increased in patients undergoing nephrectomy with preoperative VTE compared to those without VTE.
VTE at the time of nephrectomy is associated with significantly higher rates of major complications, increased mortality, and higher overall costs. Taken together, these findings have important implications for the counseling and management of renal masses in presence of VTE.
The Association of Trainee Involvement in Radical Cystectomy With Perioperative and Oncologic Outcomes
2022, Urology
To assess the impact of trainee involvement in surgery on perioperative and oncological outcomes of patients undergoing radical cystectomy (RC).
We reviewed the records of patients undergoing RC for urothelial carcinoma between 2000 and 2015 at our institution. Trainee level was categorized as fellow, chief, senior and junior residents. Demographic, perioperative and oncological outcomes were recorded and compared between the groups. Specifically, operative time, 30-day complications, severe complications (Clavien III-V) and oncological outcomes (overall, cancer-specific and recurrence-free survival) were assessed.
A total of 895 patients were included for study. On multivariable analysis, operative times were 30-40 minutes longer in procedures assisted by junior residents as compared to more senior trainees. Notably, trainee level was not associated with overall or severe complications on multivariable analyses. Similarly, trainee level was not associated with oncologic outcomes.
While cases assisted by junior residents had longer operative times, complication rates and oncological outcomes were comparable across trainee groups. Trainee level does not appear to have an impact on perioperative and oncological outcomes of RC for urothelial carcinoma.
Robotic-assisted radical cystectomy is associated with lower perioperative mortality in octogenarians
2022, Urologic Oncology: Seminars and Original Investigations
To compare perioperative outcomes between robotic and open radical cystectomy in octogenarians using real-world data
Using the Premier Healthcare Database, we found 13,127 patients who underwent robotic-assisted radical cystectomy (RARC) between 2008 and 2017, of which 15.1% were ≥80 years old. Perioperative mortality was the primary outcome of interest. Secondary outcomes include complications, hospital length of stay, readmission rates, and disposition after discharge. Multivariable regression analysis was used to adjust for patient and hospital characteristics.
In octogenarians, mortality at the index admission was 2.2% in those who underwent RARC, compared to 4.6% in those who underwent open surgery (P = 0.027). On multivariable analysis, robotic surgery was associated with lower in-hospital mortality in octogenarians (OR 0.46, 95% CI 0.22–0.99, P = 0.047) even after controlling for patient, and hospital characteristics.
RARC is safe and feasible in octogenarians. Elderly patients may derive more benefit from minimally invasive radical cystectomy compared to a younger cohort.

View all citing articles on Scopus

View full text

Bladder CancerPropensity-Matched Comparison of Morbidity and Costs of Open and Robot-Assisted Radical Cystectomies: A Contemporary Population-Based Analysis in the United States

Abstract

Background

Objective

Design, setting, and participants

Outcome measurements and statistical analysis

Results and limitations

Conclusions

Patient summary

Introduction

Section snippets

Data source

Study cohort

Discussion

Conclusions

Eur Urol

Eur Urol

Eur Urol

J Urol

Eur Urol

Eur Urol

J Clin Epidemiol

J Urol

Urol Oncol

Eur Urol

Eur Urol

Bladder cancer: diagnosis, therapeutics, and management

Radical cystectomy and laparoscopic ileal conduit [in Spanish]

Arch Esp Urol

Nerve-sparing robot-assisted radical cystoprostatectomy and urinary diversion

BJU Int

Robot-assisted laparoscopic vs open radical cystectomy: comparison of complications and perioperative oncological outcomes in 200 patients

BJU Int

Bladder Cancer
Propensity-Matched Comparison of Morbidity and Costs of Open and Robot-Assisted Radical Cystectomies: A Contemporary Population-Based Analysis in the United States