Robotic-assisted surgical removal of the bladder is becoming increasingly popular for treating bladder cancer, despite being more expensive than traditional surgery. Benefits of the robotic approach include smaller incisions and less blood loss for patients. In addition, surgeons have a better three-dimensional view and more freedom of wrist movement when compared with conventional laparoscopy. The procedure eliminates hand tremors, making tasks like suturing easier. However, robotic surgery for this patient group is fairly new. We’re only now beginning to gather larger, more comprehensive studies comparing outcomes of traditional open surgeries with robot-assisted procedures.
A New Analysis: Robotic Surgery
In the March 30, 2012 issue of European Urology, my colleagues and I had a study published that compared perioperative outcomes and costs of open robot-assisted laparoscopic radical cystectomy. Previous comparisons have been limited to reports from high-volume referral centers and have not made direct comparisons with regard to inpatient morbidity and mortality, lengths of stay, and costs.
Using a national database of in-patient information from 1,050 hospitals in 44 states, our research team examined 1,444 traditional open surgeries and 224 robotic-assisted laparoscopic procedures in 2009. Robotic surgery for bladder cancer resulted in fewer deaths during hospitalization (0% vs 2.5%) and fewer in-patient complications (49.1% vs 63.8%) when compared with open surgery. It also reduced the need for intravenous nutrition after the procedure (6.4% vs 13.3%). Patients who underwent both types of surgery spent about 8 days in the hospital.
Costs of Robot-Assisted Cystectomy
The costs for robot-assisted laparoscopic radical cystectomy were significantly higher, amounting to nearly $3,800 more than traditional open surgery. This may be due to longer operation times and more use of disposable instruments that are necessary with robotics. In addition, women were less likely to undergo a robotic procedure. This may be the result of gender-based differences in anatomy that make robotic procedures more difficult. Plus, men are three times more likely to be diagnosed with the disease.
Future Research On Robotic Surgery
Overall, we expected to see greater expenses associated with the robotic procedure for bladder cancer, but we were surprised that there was such a significant reduction in deaths and complications, particularly this early in the adoption of robotic-assisted laparoscopic procedures. There are still opportunities for even better outcomes with the robotic procedure since many patients in our analysis didn’t undergo lymph node removal.
While robotic surgery has certain advantages over the traditional open approach, it should be noted that surgeons play the most important role in bladder cancer surgery outcomes. Future investigations should follow patients beyond their hospitalization and look more closely at the severity of surgical complications, tumor characteristics, and other factors that may also play a role in outcomes.
Readings & Resources (click to view)
Yu HY, Hevelone ND, Lipsitz SR, 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 Mar 30. [Epub ahead of print]. Available at: http://www.sciencedirect.com/science/article/pii/S0302283812003533.
Choudhury SM, Mahesan NM, Elhage O, Khan MS, Dasgupta P. Oncological outcomes of robot-assisted radical cystectomy. BJU Int. 2011;108:1679-1680.
Warde N. Bladder cancer: robot-assisted laparoscopic radical cystectomy: a single-center experience. Nat Rev Urol. 2011;8:472.
Orvieto MA, DeCastro GJ, Trinh QD, et al. Oncological and functional outcomes after robot-assisted radical cystectomy: critical review of current status. Urology. 2011;78:977-984.
Challacombe BJ, Bochner BH, Dasgupta P, et al. The role of laparoscopic and robotic cystectomy in the management of muscle-invasive bladder cancer with special emphasis on cancer control and complications. Eur Urol. 2011;60:767-775.
Morgan TM, Keegan KA, Clark PE. Bladder cancer. Curr Opin Oncol. 2011;23:275-282.