Original Paper
Urologia Internationalis
Received: March 4, 2015 Accepted after revision: May 3, 2015 Published online: July 9, 2015
Urol Int DOI: 10.1159/000431104
da Vinci and Open Radical Prostatectomy: Comparison of Clinical Outcomes and Analysis of Insurance Costs Christina Niklas Matthias Saar Britta Berg Katrin Steiner Martin Janssen Stefan Siemer Michael Stöckle Carsten-Henning Ohlmann Saarland University Medical Center, Department of Urology and Pediatric Urology, Homburg/Saar, Germany
Abstract Purpose: To assess clinical outcomes and reimbursement costs of open and robotic-assisted radical prostatectomies in Germany. Methods: Perioperative data of 499 open (2003– 2006) and 932 (2008–2010) robotic-assisted radical prostatectomies as well as longitudinal reimbursement costs of an anonymized health insurance research database from Germany containing data of patients who underwent robotic-assisted or open radical prostatectomy were retrospectively analysed in a single-centre study. Results: Significantly better outcomes after robotic-assisted vs. open prostatectomy were observed in regards to positive surgical margins (13.3 vs. 22.4%; p < 0.0001), intraoperative transfusions (0.1 vs. 2.6%; p < 0.0001), hospitalization (8.7 vs. 15.2 days; p < 0.0001) and duration of catheter (6.6 vs. 12.8 days; p < 0.0001). Operating time was significantly longer with robotic-assisted radical prostatectomy when compared to open surgery (184.4 vs. 128.0 min; p < 0.0001), while intraoperative complications showed a similar occurrence between both groups. Significant fewer postoperative complications were observed after robotic-assisted radical prostatectomy (26.5 vs. 42.5%; p < 0.0001) and rate of re-admission was lower for the
© 2015 S. Karger AG, Basel 0042–1138/15/0000–0000$39.50/0 E-Mail [email protected] www.karger.com/uin
robotic patients (13.6 vs. 19.4%; p = 0.0050). While insurance costs were higher in the 2 years before radical prostatectomy for the patients who underwent a robotic procedure (4,241.60 vs. 3,410.23 €; p = 0.202), additive costs of care of the year of surgery plus the 2 following years were less for the robotic cohort when compared to the costs incurred by the open group (21,673.71 vs. 24,512.37 €; p = 0.1676). Conclusions: The observed clinical advantages of robotic-assisted radical prostatectomy seem to result in reduced health insurance cost postoperatively when compared to open surgery. This should be taken into consideration regarding reimbursement and implementation of a clinically superior method. © 2015 S. Karger AG, Basel
Introduction
The main goal in the operative treatment of prostate cancer is optimal tumour control through a radical resection with tumour-free margins, accompanied by minimal perioperative morbidity and best possible preservation of urinary continence and erectile function [1]. However, according to both the international literature as well as German insurance data, radical prostatectomy – traditionally per-
C.N. and M.S. contributed equally to this work.
Christina Niklas Klinik für Urologie und Kinderurologie Universitätsklinikum des Saarlandes Kirrberger Strasse, DE–66421 Homburg/Saar (Germany) E-Mail christina.niklas @ uks.eu
Downloaded by: Stockholms Universitet 198.143.54.1 - 7/13/2015 9:16:55 PM
Key Words da Vinci · Robotic · Prostatectomy · Costs · DRG · Reimbursement
2
Urol Int DOI: 10.1159/000431104
erative complications, is strongly influenced by the robotic experience of the surgeons (learning curve) and there are studies that report similar perioperative complication rates for open and robotic prostatectomy [25]. Therefore, this study was conducted to scientifically assess whether the internationally reported clinical outcomes after robotic-assisted radical prostatectomy can also be achieved within the German healthcare system and to evaluate the total cost over a period of several years posed to health insurers after robotic-assisted vs. open radical prostatectomy. Taking both parameters into account, it was aimed at evaluating whether robotic-assisted radical prostatectomy – despite posing financial challenges to the hospital in the perioperative period – might lead to long-term savings for health insurers and thus represent an economically viable treatment procedure.
Patients and Methods Clinical Data Data from 499 patients who underwent open surgery and from 932 patients who underwent robotic-assisted radical prostatectomy performed at the Department of Urology and Pediatric Urology at Saarland University Medical Center were collected. Part of this data was already available from a prospective database; missing parameters were collected retrospectively after the local ethics committee approval. Data was acquired in a pseudonymised manner. Patients who underwent open surgery represent the last consecutive open surgery cases at this department (surgeries performed from 2003 to 2006) prior to the complete conversion to the robotic approach to radical prostatectomy. But patients of the robotic-assisted cohort underwent surgery between 2008 and 2010, after it could be assumed that the learning curve was completed. All open radical prostatectomies were performed via retro-pubic access, and all robotic-assisted radical prostatectomies were completed via the trans-peritoneal approach. Patients of both treatment options underwent a pelvic lymphadenectomy. Indication for surgery was established based on preoperative findings as a result of transrectal ultrasound guided punch biopsy of the prostate, staging examinations (bone scintigraphy, CT, MRI) and the patients’ general health status. After the patients were thoroughly informed the day before the surgery, all procedures were performed by experienced surgeons (17 for the open procedure, 3 for the robotic-assisted procedure). The surgeons in both groups were experienced urologists with expertise in open and robotic surgeries for at least 2 years. The 3 surgeons in the robotic group performed open prostatectomy before they began with robotic surgery in the year 2006. Depending on the preoperative findings (punch biopsy: Gleason score
Urologia Internationalis
Received: March 4, 2015 Accepted after revision: May 3, 2015 Published online: July 9, 2015
Urol Int DOI: 10.1159/000431104
da Vinci and Open Radical Prostatectomy: Comparison of Clinical Outcomes and Analysis of Insurance Costs Christina Niklas Matthias Saar Britta Berg Katrin Steiner Martin Janssen Stefan Siemer Michael Stöckle Carsten-Henning Ohlmann Saarland University Medical Center, Department of Urology and Pediatric Urology, Homburg/Saar, Germany
Abstract Purpose: To assess clinical outcomes and reimbursement costs of open and robotic-assisted radical prostatectomies in Germany. Methods: Perioperative data of 499 open (2003– 2006) and 932 (2008–2010) robotic-assisted radical prostatectomies as well as longitudinal reimbursement costs of an anonymized health insurance research database from Germany containing data of patients who underwent robotic-assisted or open radical prostatectomy were retrospectively analysed in a single-centre study. Results: Significantly better outcomes after robotic-assisted vs. open prostatectomy were observed in regards to positive surgical margins (13.3 vs. 22.4%; p < 0.0001), intraoperative transfusions (0.1 vs. 2.6%; p < 0.0001), hospitalization (8.7 vs. 15.2 days; p < 0.0001) and duration of catheter (6.6 vs. 12.8 days; p < 0.0001). Operating time was significantly longer with robotic-assisted radical prostatectomy when compared to open surgery (184.4 vs. 128.0 min; p < 0.0001), while intraoperative complications showed a similar occurrence between both groups. Significant fewer postoperative complications were observed after robotic-assisted radical prostatectomy (26.5 vs. 42.5%; p < 0.0001) and rate of re-admission was lower for the
© 2015 S. Karger AG, Basel 0042–1138/15/0000–0000$39.50/0 E-Mail [email protected] www.karger.com/uin
robotic patients (13.6 vs. 19.4%; p = 0.0050). While insurance costs were higher in the 2 years before radical prostatectomy for the patients who underwent a robotic procedure (4,241.60 vs. 3,410.23 €; p = 0.202), additive costs of care of the year of surgery plus the 2 following years were less for the robotic cohort when compared to the costs incurred by the open group (21,673.71 vs. 24,512.37 €; p = 0.1676). Conclusions: The observed clinical advantages of robotic-assisted radical prostatectomy seem to result in reduced health insurance cost postoperatively when compared to open surgery. This should be taken into consideration regarding reimbursement and implementation of a clinically superior method. © 2015 S. Karger AG, Basel
Introduction
The main goal in the operative treatment of prostate cancer is optimal tumour control through a radical resection with tumour-free margins, accompanied by minimal perioperative morbidity and best possible preservation of urinary continence and erectile function [1]. However, according to both the international literature as well as German insurance data, radical prostatectomy – traditionally per-
C.N. and M.S. contributed equally to this work.
Christina Niklas Klinik für Urologie und Kinderurologie Universitätsklinikum des Saarlandes Kirrberger Strasse, DE–66421 Homburg/Saar (Germany) E-Mail christina.niklas @ uks.eu
Downloaded by: Stockholms Universitet 198.143.54.1 - 7/13/2015 9:16:55 PM
Key Words da Vinci · Robotic · Prostatectomy · Costs · DRG · Reimbursement
2
Urol Int DOI: 10.1159/000431104
erative complications, is strongly influenced by the robotic experience of the surgeons (learning curve) and there are studies that report similar perioperative complication rates for open and robotic prostatectomy [25]. Therefore, this study was conducted to scientifically assess whether the internationally reported clinical outcomes after robotic-assisted radical prostatectomy can also be achieved within the German healthcare system and to evaluate the total cost over a period of several years posed to health insurers after robotic-assisted vs. open radical prostatectomy. Taking both parameters into account, it was aimed at evaluating whether robotic-assisted radical prostatectomy – despite posing financial challenges to the hospital in the perioperative period – might lead to long-term savings for health insurers and thus represent an economically viable treatment procedure.
Patients and Methods Clinical Data Data from 499 patients who underwent open surgery and from 932 patients who underwent robotic-assisted radical prostatectomy performed at the Department of Urology and Pediatric Urology at Saarland University Medical Center were collected. Part of this data was already available from a prospective database; missing parameters were collected retrospectively after the local ethics committee approval. Data was acquired in a pseudonymised manner. Patients who underwent open surgery represent the last consecutive open surgery cases at this department (surgeries performed from 2003 to 2006) prior to the complete conversion to the robotic approach to radical prostatectomy. But patients of the robotic-assisted cohort underwent surgery between 2008 and 2010, after it could be assumed that the learning curve was completed. All open radical prostatectomies were performed via retro-pubic access, and all robotic-assisted radical prostatectomies were completed via the trans-peritoneal approach. Patients of both treatment options underwent a pelvic lymphadenectomy. Indication for surgery was established based on preoperative findings as a result of transrectal ultrasound guided punch biopsy of the prostate, staging examinations (bone scintigraphy, CT, MRI) and the patients’ general health status. After the patients were thoroughly informed the day before the surgery, all procedures were performed by experienced surgeons (17 for the open procedure, 3 for the robotic-assisted procedure). The surgeons in both groups were experienced urologists with expertise in open and robotic surgeries for at least 2 years. The 3 surgeons in the robotic group performed open prostatectomy before they began with robotic surgery in the year 2006. Depending on the preoperative findings (punch biopsy: Gleason score
