COST-EFFECTIVENESS ANALYSIS OF MONEY-SAVING PROCEDURES IN ROBOT-ASSISTED UROLOGIC SURGERY

Objective

In literature it is widely demonstrated the feasibility and safeness of robotic surgery that allows minimally invasive procedures and oncologic and functional results comparable to standard open procedures with fewer major complications and shorter length of hospital stay. On the other hand, the Da Vinci System determines higher costs of each single procedure than the relative open and laparoscopic surgery. The aim of this study is to evaluate the financial implications of minimally invasive surgery such as robotic radical prostatectomy (RRP) and renal robotic tumoral enucleation (RTE) performed as standard techniques or as a money-saving procedures and to compare functional and oncological results.

Methods and results

From April 2011 to January 2014 149 patients underwent robotic surgery for prostate (84 patients) and renal cancer (65 patients). We identified the first set of patients treated after the initial learning curve(Group A) and the latest ones (Group B) of each procedure. The first 8 prostatectomies and the first 5 tumoral enucleations were performed following the standard procedures and adopting the prescribed instrumentation. During our experience we redefine the procedures excluding from operating kits some tools to minimize costs. In the present study we compared costs and surgical outcome of the first set of patients to the latest one. Technical features of prostatic and renal surgery are summarized in table 1 and 2 respectively. Instrumentation costs of both, radical prostatectomy and tumoral enucleation, resulted significantly lower in the last 20 procedures: 2577€ Vs 4961€ for RRP and 2457€ Vs 4836€ for robotic RTE, saving the48% and the 49.2% respectively (Tab 1-2). Mean (range) operating time for RRP in Group A was 208.4(160-265) minutes Vs 168.3 (142-170) minutes of Group B (p=0.0041). Both groups of robotic radical prostatectomies resulted similar in intraoperative blood loss (p=0.482), histopatologically-confirmed positive surgical margins (p=0.089) and hospitalization (p=0.195). Regarding renal tumoral enucleation mean (range) operating time for RTE in Group A was 110.6 (70-165) minutes Vs 98 (80-140) minutes of Group B (p=0.5151); intraoperative blood loss and hospitalization resulted comparable (p=0.487 and p=0.379 respectively). In both groups there were not found positive surgical margins, while in Group B it was discovered a peritumoral pseudocapsule incision.

Discussion

This study should be considered a step in driving down costs of Da Vinci – assisted surgery by reducing the number of laparoscopic and robotic surgical instruments and adjusting the relative passages of each procedures. Technical difficulties in using less tools are resulted limited to the very first interventions. Our instrumentation expedients, compared with conventional robotic radical prostatectomy and robotic nephron sparing surgery, determined a saving up to 49.1% for each single procedure. In our experience intraoperative blood loss, operative time, intra and postoperative complications, hospitalization and the finding of histopatologically positive surgical margins resulted comparable to the standard procedures.