European Journal of Obstetrics & Gynecology and Reproductive Biology 171 (2013) 348–352
Contents lists available at ScienceDirect
European Journal of Obstetrics & Gynecology and Reproductive Biology journal homepage: www.elsevier.com/locate/ejogrb
Overall care cost comparison between robotic and laparoscopic surgery for endometrial and cervical cancer H. Desille-Gbaguidi a,*, T. Hebert a, J. Paternotte-Villemagne a, C. Gaborit b, E. Rush b, G. Body a a b
Department of Gynecology and Obstetric, Bretonneau Hospital, Franc¸ois-Rabelais University, Tours, France Department of Public Health, Bretonneau Hospital, Franc¸ois-Rabelais University, Tours, France
A R T I C L E I N F O
A B S T R A C T
Article history: Received 17 December 2012 Received in revised form 5 June 2013 Accepted 21 September 2013
Objective: The aim of our medico-economic study was to compare robotic surgery cost with conventional laparoscopic cost in endometrial and cervical cancer. Study design: Our study included laparoscopic and robot-assisted procedures (radical hysterectomies and lymphadenectomies) for endometrial or cervical cancer ever since first using the Da Vinci1 in 2008 within a hospital setting. In the hospital perspective, direct costs were determined by examining the overall medical pathway for each type of intervention. Actual costs were calculated for 27 conventional laparoscopic procedures and for 30 robot-assisted procedures including initial cost of the robot and its maintenance. We estimated the complete medical ‘‘overall care’’ costs by adding the costs of consultations, surgery and post-operative hospital stay to the costs of any eventual emergency consultation and/or hospitalisation within the two months that followed surgery. A sensitivity analysis was performed to evaluate the effects of variable modulations. Results: For endometrial cancer, surgical procedure cost for robotic-assisted surgery was s7402 compared to s2733 for conventional laparoscopic surgery. When considering overall medical care, the patient treatment average cost was s6666 for the laparoscopic group (with an average length of stay of 5.27 days) as compared to s10,816 for robotic group (with an average hospital stay of 4.60 days), p = 0.39. For cervical cancer, average surgical cost with robotic-assisted surgery was s8501 compared to conventional laparoscopic surgery at s3239. For cervical cancer, overall care average cost was s7803 for the laparoscopic group (with an average length of stay of 5.83 days) as compared to s12,211 for the robotic group (with an average hospital stay of 4.70 days) p = 0.07. Sensitivity analysis results confirmed the cost overrun with the use of robotic assisted surgery. Conclusions: Conventional laparoscopy was less expensive in our institution than robotic-assisted surgery for the surgery of endometrial (1:2.7) and cervical (1:2.6) cancers. When considering overall medical care, the use of robotic-assisted surgery was found to be 1.6 times more expensive than conventional surgery. ß 2013 Elsevier Ireland Ltd. All rights reserved.
Keywords: Cost analysis Robotic assistance Robotic versus laparoscopic Robotic hysterectomy Laparoscopic hysterectomy
1. Introduction According to the World Health Organisation [1], cancer of the cervix is the second most common cancer in women worldwide, with about 500,000 new cases and 250,000 deaths each year. Endometrial cancer was estimated to account for 189,000 cases and 45,000 deaths in women [2]. The superiority of laparoscopy compared to laparotomy has already been demonstrated for these gynecologic malignancies
* Corresponding author at: Hoˆpital Bretonneau, 2 boulevard Tonnelle´, 37044 Tours cedex 1, France. Tel.: +33 06 65 21 99 52; fax: +33 0247 47 38 01. E-mail address: [email protected] (H. Desille-Gbaguidi). 0301-2115/$ – see front matter ß 2013 Elsevier Ireland Ltd. All rights reserved. http://dx.doi.org/10.1016/j.ejogrb.2013.09.025
[3–5]. It is currently recommended in the early stages for curative treatment. In April 2005, the US Food and Drug Administration (FDA) authorised the use of the Da Vinci1 system for gynecologic surgery. This system has several advantages compared to conventional laparoscopic surgery, including three-dimensional vision and a higher degree of forceps freedom. Unfortunately, the cost of the Da Vinci1 system does little to favour its use, but most of the studies have been made in the USA where the health system and robotic costs are different. No study has compared postoperative cost after laparoscopic versus robotic assisted surgery. The aim of the present study was to assess the use of roboticassisted surgery from a medico-economic perspective. First we compared only the surgical procedure cost, and then we evaluated the overall cost of the patient’s treatment in order to determine the
H. Desille-Gbaguidi et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology 171 (2013) 348–352
effect of robotic-assisted surgery on postoperative costs. Additionally, a sensitivity analysis was performed to evaluate the effects of variable modulations. 2. Material and methods We conducted a retrospective study that compared the cost of conventional to that of robotic-assisted laparoscopy for patients suffering from endometrial or cervical cancer. This review was performed in a single institution (University Hospital of Tours in France) from 2008 (purchase year of the Da Vinci1 system) to December 2011. All patients who had one of the aforementioned pathologies and who were operated with the robotic assistance were compared to those treated using conventional laparoscopy over the same period. Eligible patients were women suffering from either endometrial cancer requiring hysterectomy or cervical cancer requiring radical hysterectomy. We included surgery with or without lymphadenectomy. The four-armed Da Vinci1 surgical robot was shared by a number of surgical teams in a specific operation room where all the robotic-assisted surgery was performed by an experienced medical and paramedical team. Robotic-assisted surgery was programmed according to operation room availability (2 days per month). Patients were included consecutively. When the Da Vinci1 system was available, patients were operated with robotic assistance. If not (remaining patients), conventional laparoscopy was chosen. Since 2010, our institution was involved in a national study concerning robotic surgery. It observed postoperative outcomes without cost analysis. One group of patients was selected for robotic assistance due to this study. Robotic operations were performed by 4 different surgeons as opposed to 7 surgeons for conventional laparoscopic surgery. We reviewed two pre-operative parameters (age and BMI) followed by five intra-operative parameters (uterine weight, lymphadenectomy and number of nodes obtained, blood loss, surgery time, time of operative room) and complications. This study took into consideration a hospital perspective. We included the cost of purchase of the robot with a five year straightline depreciation as well as the service agreement costs (10% of the purchase price per year). Total and direct costs were evaluated for each pathway. In order to record the actual cost generated in the operation room, the costs of disposable instruments used during each procedure and time of operative room use (preparation and surgery) were estimated. Time-cost of operation room use was evaluated using fixed charges (staff cost, depreciation, administration and logistics) as well as variable charges for the year 2010 (medical, anaesthetic and pharmaceutical) except for disposable instruments and without any database update. If laparotomy was performed because of complications, the additional operative time cost was still considered as that of the cost of the initial procedure. Indeed, for such cases that had initially commenced as robotic assisted surgery, the same specific operative room, staff and material continued to be used. The cost of extra supplies cost was therefore considered as already having been included in the variable charges. Concerning coagulation, we used one disposable thermofusion instrument for each conventional laparoscopy. As for roboticassisted surgery, we only used bipolar and monopolar energy. The cost of each reusable robotic forceps was distributed across ten cases. The complete medical care cost was estimated by adding the cost of outpatient clinics(s), surgery and post-surgical hospital stay to the cost of possible emergency clinics and/or hospitalisations for the two months following surgery. Concerning the cost of clinics,
349
we used the rate of the French National Health and Pension Organisation (Se´curite´ Sociale). For the standard cost of hospital stay, we recorded both direct costs (staff, medical and pharmaceutical supplies, depreciation, room and board) and indirect costs (logistics, administration, radiology, laboratory, and physical therapy). Whenever a patient had to stay in intensive care, we used an estimated cost increase of thirty percent. For statistical analysis, we used the programme R 2.14.1 and the Shapiro–Wilk test for normality. Continuous variables were expressed as mean and standard deviation. All comparisons of continuous variables were analysed using the Mann–Whitney test. Sensitivity analyses were used to assess the effects of varying parameters by decreasing the time spent in the operative room as well as hospital stay. 3. Results We compared the cost for 30 robotic procedures for endometrial or cervical cancer to the cost of 27 conventional laparoscopy procedures for the same pathologies over the same period. Among patients treated for endometrial cancer, 20 were operated using robotic assistance (of which 18 had additional lymphadenectomy) and 15 with conventional laparoscopy (of which 13 had associated lymphadenectomy). Among the patients treated for cervical cancer, 12 were operated with robotic assistance (3 lymphadenectomy-associated) and 10 with conventional laparoscopy (3 lymphadenectomyassociated). For cervical cancer, lymphadenectomy staging was mostly done in a previous surgical procedure. The demographic database indicated that the two groups were not statistically different (Tables 1 and 2) and were roughly comparable. For endometrial cancer, in comparison with the laparoscopic cohort, operative time using robotic-assisted laparoscopy and estimated blood loss were not significantly reduced (239 min vs. 269 min, p = 0.08; 423 mL vs. 376 mL, p = 0.30). The average uterine weight was similar (115 g vs. 116 g, p = 0.46). The average number of nodes was not significantly different: 15.2 for conventional laparoscopy vs. 12.2 for robotic-assisted laparoscopy (p 0.48). Intraoperative characteristics for patients suffering from cervical cancer were not significantly different. Operative time and estimated blood loss in comparison with conventional laparoscopy was not reduced (288 min vs. 291 min, p = 0.71; 477 mL vs. 301 mL, p = 0.48). The average uterine weight was 131 g for conventional laparoscopy and 101 g for robotic-assisted laparoscopy (p = 0.76). The average number of nodes was not significantly different: 11.7 for conventional laparoscopy and 9.7 for robotic-assisted laparoscopy (p = 1). There were five laparotomy conversions for bleeding or dissection difficulties in the conventional laparoscopy group Table 1 Database comparison between conventional laparoscopy and robotic assisted laparoscopy in surgery for endometrial cancer. Conventional laparoscopy (n = 15)
Robotic assisted laparoscopy (n = 20)
p value
Pre-operative characteristics Age BMI
66.2 10.3 29.7 7.9
69 9 27.5 8
0.23 0.26
Per-operative characteristics Operative time (min) Blood loss (mL) Uterus weight (g)
239 101 423 312 115 56
269 74 376 692 116 44
0.08 0.30 0.46
Lymphadenectomy rate Number of nodes
87% 15.2 9.5
90% 12.2 5.8
0.48
Endometrium
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Table 2 Database comparison between conventional laparoscopy and robotic assisted laparoscopy in surgery for cervical cancer. Conventional laparoscopy (n = 12)
Robotic assisted laparoscopy (n = 10)
p value
Pre-operative characteristics Age BMI
45.3 11.1 25.5 4.2
45 15 24.7 7.4
0.67 0.56
Per-operative characteristics Operative time (min) Blood loss (mL) Uterus weight (g)
288 79 477 477 131 74
291 84 301 236 101 41
0.71 0.48 0.76
Lymphadenectomy rate Number of nodes
25.00% 11.7 1.5
30.00% 9.7 4.9
1
Cervix
(18.5%) as opposed to three in the robotic-assisted group (10%). There was one bladder wound in each group. No re-operation for bleeding was observed. Within a hospital setting, conventional laparoscopy proved to be less expensive for endometrial cancer (Table 3), with an average cost of s2733 per case as compared to robotic surgery (s7402), and for cervical cancer as well, at s3239 per case (Table 4) as compared to s8501 as compared to robotic surgery. The difference was statistically significant (p < 0.001). The fixed and variable charges add up to an hourly operative room cost of s463.63 for conventional vs. s849.21 for robotic laparoscopy. Disposable instruments cost per surgery was estimated at s913.93 for conventional vs. s1483.08 for robotic laparoscopy. When
considering overall medical care for endometrial cancer, the patient treatment average cost was s6666 for the laparoscopic group, with an average length of stay of 5.27 days (s731 per hospitalisation day), as compared to s10,816 for the robotic group, with an average hospital stay of 4.60 days (p = 0.39). In both groups, there was neither any emergency consultation nor any rehospitalisation during the two post-operative months. For cervical cancer, the overall care average cost was s7803 for the laparoscopic group, with an average length of stay of 5.83 days, as compared to s12,211 for the robotic group, with an average hospital stay of 4.70 days (p = 0.07). In the conventional laparoscopic group, two patients who had difficulty urinating consulted and were hospitalized respectively for 2 and 4 days, as compared to the robotic-assisted laparoscopy group, in which one patient was hospitalized for 3 days because of vaginal dehiscence. On average, robotic-assisted laparoscopy increased surgery cost by a factor of 2.7 for patients treated for endometrial cancer by that of 2.6 for patients treated for cervical cancer. After having considered overall medical care (hospital stay, consultation and complications within two months) costs, we observed a decrease of additional costs. Global care of patients operated with robotic assistance cost 1.6 times more. In our sensitivity analysis (Table 5), we used the average cost of overall medical care. If the length of stay following robotic surgery is decreased by one day, the additional average cost of this assistance can be shown to decrease from s4342 to s3611 for endometrial cancer and from s3894 to s3163 for cervical cancer. Furthermore, if the operation room time is reduced so as to operate on two patients per day, the total patient time (preparation, docking and surgery) should then be reduced to four hours. The
Table 3 Cost comparison between conventional laparoscopy and robotic assisted laparoscopy in surgery for endometrium cancer. Endometrium
Conventional laparoscopy (n = 15)
Robotic assisted laparoscopy (n = 20)
Hourly cost for operative room Disposable material
43,363 s/h 91,393 s
84,921 s/h 148,308 s
p value
Average difference
Average surgery cost Hospital stay (days) Hospital stay cost Consultation within 2 months Hospitalisation within 2 months
2733 735 s 5.27 2.12 4142 1550 s 0 0
7402 1733 s 4.60 1.35 3435 989 s 0 0
p < 0.0001 0.39 0.39
4607 s
Average Complete care cost
6666 1963 s
10,816 1935 s
p < 0.0001
4343 s
Table 4 Cost comparison between conventional laparoscopy and robotic assisted laparoscopy in surgery for cervix cancer. Cervix
Conventional laparoscopy (n = 12)
Robotic assisted laparoscopy (n = 10)
Hourly cost for operative room Disposable material per intervention
43,363 s/h 91,393 s
84,921 s/h 148,308 s
p value
Average difference
Average surgery cost Average hospital stay (days) Average hospital stay cost Consultation within 2 months Hospitalisation within 2 months Total re-hospitalisation cost
3239 542 s 5.83 1.99 3879 1456 s 2 2 4386 s
8501 1451 s 4.70 3.13 3362 2287 s 1 1 2193 s
p < 0.0001 0.07 0.07 0.70 0.70
5640 s
Average complete care cost
7803 2130 s
12,211 3252 s
0.001
3894 s
Table 5 Potential reduction of complete care cost average difference by hospital stay and operative time decrease.
Endometrium Cervix
Actual cost average difference
Hospital stay (one day less)
Time spent in operative room (4 hours per patient)
After hospital stay + time in operative room potential decrease
4342 s 3894 s
3611 s 3163 s
2456 s 1292 s
1725 s 561 s
H. Desille-Gbaguidi et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology 171 (2013) 348–352
actual average time spent in the operation room is 5h58 for endometrial cancer and 7h04 for cervical cancer. Such a decrease in operative room time use could further decrease the additional average cost of robotic assistance from s4342 to s2456 for endometrial cancer and from s3894 to s1292 for cervical cancer. If these improvements are taken into account, robotic-assisted surgery average additional costs can be calculated to be s1725 for endometrial cancer and s561 for cervical cancer. 4. Comment The aim of this study was to obtain a fair estimation of surgery cost. Robotic surgery is not extensively developed in Europe and even less so in France. Indeed, most of the studies have been made in the USA, where the health system and robotic costs are different. In Europe, two studies have been done thus far. Sarlos et al. [6], in a Swiss institution, evaluated the average surgical cost of robotic-assisted laparoscopic hysterectomy (for a benign indication) at s4067, as compared to s2151 using a conventional laparoscopic procedure. In comparison, in our study robotic-assisted surgery costs were more than twice as expensive (factor of 2.6), but it is noteworthy that acquisition and amortisation of the Da Vinci1 System were not included in the Swiss study. Dennis [7] in Lille, France, aimed to evaluate the surplus cost of robotic assistance for radical hysterectomy but he compared the average cost of disposable material without staff, indirect charges and Da Vinci1 system costs. We chose to evaluate complete care cost up to a two month follow-up period because of the putative decrease in complications using roboticassisted surgery, which can eventually be shown to decrease the burden of initial additional surgery costs. Because of the limited number of patients, our results were not statistically significant. Nevertheless, the surplus cost of robotic assistance for patients operated for cervical cancer seems to have been reduced given the decrease in hospital stay. We did not make any societal evaluation as did Bell et al. [8] or Barnett et al. [9] because, in our point of view, return to normal activity after minimal invasive surgery (laparoscopic or roboticassisted surgery) depends mainly on adjuvant treatment. Furthermore, our patients suffering from endometrial cancer were all retired. Unlike other studies, we decided to evaluate separate groups of cervical and endometrial cancer at the expense of reducing the respective sample sizes but with the advantage of obtaining even more homogeneous groups in terms of age and comorbidity. In the future, it would be interesting to evaluate the actual cost for hospital stay instead of standard cost. It is by such means that Martino et al. [10] showed a reduction in pain medication cost for robotic patients, which represented a saving greater than 50%. According to Barbash and Glied [11], additional cost for robotic assistance in minimal surgery is approximately $3200 in all specialities taken together. The review by Sarlos et al. of comparative studies evaluated the cost for robot-assisted hysterectomy as approximately $2600 more than conventional laparoscopic hysterectomy (not including investment and amortisation) [6]. Our results demonstrate a greater difference in our institution. Our operative time is at the upper limits of, but coherent with, the findings in the literature. This may be due to a limited number of patients treated using robotic assistance because of the sparse availability of Da Vinci1 system given its being shared with other specialities. In consequence, the learning curve is probably less progressive than is described in the literature [12]. Moreover, this study began from the first patients operated after acquisition of the Da Vinci1 system. The average cost of procedures is biased due to the incorporation of the first procedures, but the team devoted to surgery with robotic assistance allowed us to decrease
351
the time-cost of operation room use by reducing docking and operating time. Consequently, the latest hysterectomies without lymphadenectomy lasted 150 min in operating room including 90 min of surgery. Considering the hourly cost of robotic assistance (849.21s/h) and the cost of disposable material per intervention (s1483.08), the total cost of each latest procedure was s3606.105, which is just above the cost of conventional laparoscopy. Shah et al. [13] demonstrated that it is feasible for robotic hysterectomy to be less expensive in terms of total in-room to out-of-room time. This corresponds to our ‘‘time-cost of operative room use’’ which included preparation, anaesthesia induction, incubation, equipment setup and docking. It is this factor, which has yet to be optimised, that seems to favour laparoscopic hysterectomy as the least costly method for the time being. Finally, Barnett et al. [9] showed in their sensitivity analysis that robotic surgery became least expensive if the cost of robotic disposable equipment was reduced, but nowadays only one company commercialises both the robotic-assisted surgical system and its supplies. Therefore, exclusive control seems to obstruct cost reduction. 5. Conclusion Conventional laparoscopy was less expensive in our institution as compared to robotic-assisted surgery for the treatment of endometrial (2.7) and cervical (2.6) cancers. When considering overall medical care, the use of robotic assistance costs is increased by a factor of 1.6. Robotic surgery surplus costs could be reduced by optimising ground occupation time as well as by reducing operative time. Robotic surgery benefits for the patient may counterbalance any of its additional costs by reduction of complications and length of hospital stay. Conflict of interest There are no conflicts of interest for this manuscript. Acknowledgment We would like to thank financial department staff of Bretonneau Hospital (Tours, France) for their contribution. References [1] Comprehensive cervical cancer prevention and control: a healthier future for girls and women: http://www.who.int/reproductivehealth/topics/cancers/en/ index.html [2] Parkin DM, Bray F, Ferlay J, Pisani P. Estimating the world cancer burden: Globocan 2000. Int J Cancer 2001;94:153–6. [3] Eltabbakh GH, Shamonki MI, Moody JM, Garafano LL. Laparoscopy as the primary modality for the treatment of women with endometrial carcinoma. Cancer 2001;91:378–87. [4] Querleu D, Papageorgiou T, Lambaudie E, Sonoda Y, Narducci F, LeBlanc E. Laparoscopic restaging of borderline ovarian tumors: results of 30 cases initially presumed as stage IA borderline ovarian tumour. BJOG 2003;110: 201–4. [5] Ghezzi F, Cromi A, Ciravolo G. Surgicopathologic outcome of laparoscopic versus open radical hysterectomy. Gynecol Oncol 2007;106:502–6. [6] Sarlos D, Kots L, Stevanovic N, Schaer G. Robotic hysterectomy versus conventional laparoscopic hysterectomy: outcome and cost analyses of a matched case-control study. Eur J Obstet Gynecol Reprod Biol 2010;150:92–6. [7] Dennis T, Mendonc¸a C, Narducci F, et al. Study of surplus cost of robotic assistance for radical assistance for radical hysterectomy, versus laparotomy and standard laparoscopy. Gynecol Obstet Fertil 2012;40:77–83. [8] Bell MC, Torgerson J, Seshadri-Kreaden U, Suttle AW, Hunt S. Comparison of outcomes and cost for endometrial cancer staging via traditional laparotomy, standard laparoscopy and robotic techniques. Gynecol Oncol 2008;111: 407–11. [9] Barnett JC, Judd JP, Wu JM, Scales CD, Myers ER, Havrilesky LJ. Cost comparison among robotic, laparoscopic, and open hysterectomy for endometrial cancer. Obstet Gynecol 2010;116:685–93.
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[10] Martino MA, Shubella J, Thomas MB, et al. A cost analysis of postoperative management in endometrial cancer patients treated by robotics versus laparoscopic approach. Gynecol Oncol 2011;123:528–31. [11] Barbash G, Glied SA. New technology and health care costs – the case of robotassisted surgery. N Engl J Med 2010;363:701–4. [12] Lim PC, Kang E, Park DH. A comparative detail analysis of the learning curve and surgical outcome for robotic hysterectomy with lymphadenectomy
versus laparoscopic hysterectomy with lymphadenectomy in treatment of endometrial cancer: a case-matched controlled study of the first one hundred twenty two patients. Gynecol Oncol 2011;120:413–8. [13] Shah NT, Wright KN, Jonsdottir GM, Jorgensen S, Einarsson JI, Muto MG. The feasibility of societal cost equivalence between robotic hysterectomy and alternate hysterectomy methods for endometrial cancer. Obstet Gynecol Int 2011;2011:570464.
Contents lists available at ScienceDirect
European Journal of Obstetrics & Gynecology and Reproductive Biology journal homepage: www.elsevier.com/locate/ejogrb
Overall care cost comparison between robotic and laparoscopic surgery for endometrial and cervical cancer H. Desille-Gbaguidi a,*, T. Hebert a, J. Paternotte-Villemagne a, C. Gaborit b, E. Rush b, G. Body a a b
Department of Gynecology and Obstetric, Bretonneau Hospital, Franc¸ois-Rabelais University, Tours, France Department of Public Health, Bretonneau Hospital, Franc¸ois-Rabelais University, Tours, France
A R T I C L E I N F O
A B S T R A C T
Article history: Received 17 December 2012 Received in revised form 5 June 2013 Accepted 21 September 2013
Objective: The aim of our medico-economic study was to compare robotic surgery cost with conventional laparoscopic cost in endometrial and cervical cancer. Study design: Our study included laparoscopic and robot-assisted procedures (radical hysterectomies and lymphadenectomies) for endometrial or cervical cancer ever since first using the Da Vinci1 in 2008 within a hospital setting. In the hospital perspective, direct costs were determined by examining the overall medical pathway for each type of intervention. Actual costs were calculated for 27 conventional laparoscopic procedures and for 30 robot-assisted procedures including initial cost of the robot and its maintenance. We estimated the complete medical ‘‘overall care’’ costs by adding the costs of consultations, surgery and post-operative hospital stay to the costs of any eventual emergency consultation and/or hospitalisation within the two months that followed surgery. A sensitivity analysis was performed to evaluate the effects of variable modulations. Results: For endometrial cancer, surgical procedure cost for robotic-assisted surgery was s7402 compared to s2733 for conventional laparoscopic surgery. When considering overall medical care, the patient treatment average cost was s6666 for the laparoscopic group (with an average length of stay of 5.27 days) as compared to s10,816 for robotic group (with an average hospital stay of 4.60 days), p = 0.39. For cervical cancer, average surgical cost with robotic-assisted surgery was s8501 compared to conventional laparoscopic surgery at s3239. For cervical cancer, overall care average cost was s7803 for the laparoscopic group (with an average length of stay of 5.83 days) as compared to s12,211 for the robotic group (with an average hospital stay of 4.70 days) p = 0.07. Sensitivity analysis results confirmed the cost overrun with the use of robotic assisted surgery. Conclusions: Conventional laparoscopy was less expensive in our institution than robotic-assisted surgery for the surgery of endometrial (1:2.7) and cervical (1:2.6) cancers. When considering overall medical care, the use of robotic-assisted surgery was found to be 1.6 times more expensive than conventional surgery. ß 2013 Elsevier Ireland Ltd. All rights reserved.
Keywords: Cost analysis Robotic assistance Robotic versus laparoscopic Robotic hysterectomy Laparoscopic hysterectomy
1. Introduction According to the World Health Organisation [1], cancer of the cervix is the second most common cancer in women worldwide, with about 500,000 new cases and 250,000 deaths each year. Endometrial cancer was estimated to account for 189,000 cases and 45,000 deaths in women [2]. The superiority of laparoscopy compared to laparotomy has already been demonstrated for these gynecologic malignancies
* Corresponding author at: Hoˆpital Bretonneau, 2 boulevard Tonnelle´, 37044 Tours cedex 1, France. Tel.: +33 06 65 21 99 52; fax: +33 0247 47 38 01. E-mail address: [email protected] (H. Desille-Gbaguidi). 0301-2115/$ – see front matter ß 2013 Elsevier Ireland Ltd. All rights reserved. http://dx.doi.org/10.1016/j.ejogrb.2013.09.025
[3–5]. It is currently recommended in the early stages for curative treatment. In April 2005, the US Food and Drug Administration (FDA) authorised the use of the Da Vinci1 system for gynecologic surgery. This system has several advantages compared to conventional laparoscopic surgery, including three-dimensional vision and a higher degree of forceps freedom. Unfortunately, the cost of the Da Vinci1 system does little to favour its use, but most of the studies have been made in the USA where the health system and robotic costs are different. No study has compared postoperative cost after laparoscopic versus robotic assisted surgery. The aim of the present study was to assess the use of roboticassisted surgery from a medico-economic perspective. First we compared only the surgical procedure cost, and then we evaluated the overall cost of the patient’s treatment in order to determine the
H. Desille-Gbaguidi et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology 171 (2013) 348–352
effect of robotic-assisted surgery on postoperative costs. Additionally, a sensitivity analysis was performed to evaluate the effects of variable modulations. 2. Material and methods We conducted a retrospective study that compared the cost of conventional to that of robotic-assisted laparoscopy for patients suffering from endometrial or cervical cancer. This review was performed in a single institution (University Hospital of Tours in France) from 2008 (purchase year of the Da Vinci1 system) to December 2011. All patients who had one of the aforementioned pathologies and who were operated with the robotic assistance were compared to those treated using conventional laparoscopy over the same period. Eligible patients were women suffering from either endometrial cancer requiring hysterectomy or cervical cancer requiring radical hysterectomy. We included surgery with or without lymphadenectomy. The four-armed Da Vinci1 surgical robot was shared by a number of surgical teams in a specific operation room where all the robotic-assisted surgery was performed by an experienced medical and paramedical team. Robotic-assisted surgery was programmed according to operation room availability (2 days per month). Patients were included consecutively. When the Da Vinci1 system was available, patients were operated with robotic assistance. If not (remaining patients), conventional laparoscopy was chosen. Since 2010, our institution was involved in a national study concerning robotic surgery. It observed postoperative outcomes without cost analysis. One group of patients was selected for robotic assistance due to this study. Robotic operations were performed by 4 different surgeons as opposed to 7 surgeons for conventional laparoscopic surgery. We reviewed two pre-operative parameters (age and BMI) followed by five intra-operative parameters (uterine weight, lymphadenectomy and number of nodes obtained, blood loss, surgery time, time of operative room) and complications. This study took into consideration a hospital perspective. We included the cost of purchase of the robot with a five year straightline depreciation as well as the service agreement costs (10% of the purchase price per year). Total and direct costs were evaluated for each pathway. In order to record the actual cost generated in the operation room, the costs of disposable instruments used during each procedure and time of operative room use (preparation and surgery) were estimated. Time-cost of operation room use was evaluated using fixed charges (staff cost, depreciation, administration and logistics) as well as variable charges for the year 2010 (medical, anaesthetic and pharmaceutical) except for disposable instruments and without any database update. If laparotomy was performed because of complications, the additional operative time cost was still considered as that of the cost of the initial procedure. Indeed, for such cases that had initially commenced as robotic assisted surgery, the same specific operative room, staff and material continued to be used. The cost of extra supplies cost was therefore considered as already having been included in the variable charges. Concerning coagulation, we used one disposable thermofusion instrument for each conventional laparoscopy. As for roboticassisted surgery, we only used bipolar and monopolar energy. The cost of each reusable robotic forceps was distributed across ten cases. The complete medical care cost was estimated by adding the cost of outpatient clinics(s), surgery and post-surgical hospital stay to the cost of possible emergency clinics and/or hospitalisations for the two months following surgery. Concerning the cost of clinics,
349
we used the rate of the French National Health and Pension Organisation (Se´curite´ Sociale). For the standard cost of hospital stay, we recorded both direct costs (staff, medical and pharmaceutical supplies, depreciation, room and board) and indirect costs (logistics, administration, radiology, laboratory, and physical therapy). Whenever a patient had to stay in intensive care, we used an estimated cost increase of thirty percent. For statistical analysis, we used the programme R 2.14.1 and the Shapiro–Wilk test for normality. Continuous variables were expressed as mean and standard deviation. All comparisons of continuous variables were analysed using the Mann–Whitney test. Sensitivity analyses were used to assess the effects of varying parameters by decreasing the time spent in the operative room as well as hospital stay. 3. Results We compared the cost for 30 robotic procedures for endometrial or cervical cancer to the cost of 27 conventional laparoscopy procedures for the same pathologies over the same period. Among patients treated for endometrial cancer, 20 were operated using robotic assistance (of which 18 had additional lymphadenectomy) and 15 with conventional laparoscopy (of which 13 had associated lymphadenectomy). Among the patients treated for cervical cancer, 12 were operated with robotic assistance (3 lymphadenectomy-associated) and 10 with conventional laparoscopy (3 lymphadenectomyassociated). For cervical cancer, lymphadenectomy staging was mostly done in a previous surgical procedure. The demographic database indicated that the two groups were not statistically different (Tables 1 and 2) and were roughly comparable. For endometrial cancer, in comparison with the laparoscopic cohort, operative time using robotic-assisted laparoscopy and estimated blood loss were not significantly reduced (239 min vs. 269 min, p = 0.08; 423 mL vs. 376 mL, p = 0.30). The average uterine weight was similar (115 g vs. 116 g, p = 0.46). The average number of nodes was not significantly different: 15.2 for conventional laparoscopy vs. 12.2 for robotic-assisted laparoscopy (p 0.48). Intraoperative characteristics for patients suffering from cervical cancer were not significantly different. Operative time and estimated blood loss in comparison with conventional laparoscopy was not reduced (288 min vs. 291 min, p = 0.71; 477 mL vs. 301 mL, p = 0.48). The average uterine weight was 131 g for conventional laparoscopy and 101 g for robotic-assisted laparoscopy (p = 0.76). The average number of nodes was not significantly different: 11.7 for conventional laparoscopy and 9.7 for robotic-assisted laparoscopy (p = 1). There were five laparotomy conversions for bleeding or dissection difficulties in the conventional laparoscopy group Table 1 Database comparison between conventional laparoscopy and robotic assisted laparoscopy in surgery for endometrial cancer. Conventional laparoscopy (n = 15)
Robotic assisted laparoscopy (n = 20)
p value
Pre-operative characteristics Age BMI
66.2 10.3 29.7 7.9
69 9 27.5 8
0.23 0.26
Per-operative characteristics Operative time (min) Blood loss (mL) Uterus weight (g)
239 101 423 312 115 56
269 74 376 692 116 44
0.08 0.30 0.46
Lymphadenectomy rate Number of nodes
87% 15.2 9.5
90% 12.2 5.8
0.48
Endometrium
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Table 2 Database comparison between conventional laparoscopy and robotic assisted laparoscopy in surgery for cervical cancer. Conventional laparoscopy (n = 12)
Robotic assisted laparoscopy (n = 10)
p value
Pre-operative characteristics Age BMI
45.3 11.1 25.5 4.2
45 15 24.7 7.4
0.67 0.56
Per-operative characteristics Operative time (min) Blood loss (mL) Uterus weight (g)
288 79 477 477 131 74
291 84 301 236 101 41
0.71 0.48 0.76
Lymphadenectomy rate Number of nodes
25.00% 11.7 1.5
30.00% 9.7 4.9
1
Cervix
(18.5%) as opposed to three in the robotic-assisted group (10%). There was one bladder wound in each group. No re-operation for bleeding was observed. Within a hospital setting, conventional laparoscopy proved to be less expensive for endometrial cancer (Table 3), with an average cost of s2733 per case as compared to robotic surgery (s7402), and for cervical cancer as well, at s3239 per case (Table 4) as compared to s8501 as compared to robotic surgery. The difference was statistically significant (p < 0.001). The fixed and variable charges add up to an hourly operative room cost of s463.63 for conventional vs. s849.21 for robotic laparoscopy. Disposable instruments cost per surgery was estimated at s913.93 for conventional vs. s1483.08 for robotic laparoscopy. When
considering overall medical care for endometrial cancer, the patient treatment average cost was s6666 for the laparoscopic group, with an average length of stay of 5.27 days (s731 per hospitalisation day), as compared to s10,816 for the robotic group, with an average hospital stay of 4.60 days (p = 0.39). In both groups, there was neither any emergency consultation nor any rehospitalisation during the two post-operative months. For cervical cancer, the overall care average cost was s7803 for the laparoscopic group, with an average length of stay of 5.83 days, as compared to s12,211 for the robotic group, with an average hospital stay of 4.70 days (p = 0.07). In the conventional laparoscopic group, two patients who had difficulty urinating consulted and were hospitalized respectively for 2 and 4 days, as compared to the robotic-assisted laparoscopy group, in which one patient was hospitalized for 3 days because of vaginal dehiscence. On average, robotic-assisted laparoscopy increased surgery cost by a factor of 2.7 for patients treated for endometrial cancer by that of 2.6 for patients treated for cervical cancer. After having considered overall medical care (hospital stay, consultation and complications within two months) costs, we observed a decrease of additional costs. Global care of patients operated with robotic assistance cost 1.6 times more. In our sensitivity analysis (Table 5), we used the average cost of overall medical care. If the length of stay following robotic surgery is decreased by one day, the additional average cost of this assistance can be shown to decrease from s4342 to s3611 for endometrial cancer and from s3894 to s3163 for cervical cancer. Furthermore, if the operation room time is reduced so as to operate on two patients per day, the total patient time (preparation, docking and surgery) should then be reduced to four hours. The
Table 3 Cost comparison between conventional laparoscopy and robotic assisted laparoscopy in surgery for endometrium cancer. Endometrium
Conventional laparoscopy (n = 15)
Robotic assisted laparoscopy (n = 20)
Hourly cost for operative room Disposable material
43,363 s/h 91,393 s
84,921 s/h 148,308 s
p value
Average difference
Average surgery cost Hospital stay (days) Hospital stay cost Consultation within 2 months Hospitalisation within 2 months
2733 735 s 5.27 2.12 4142 1550 s 0 0
7402 1733 s 4.60 1.35 3435 989 s 0 0
p < 0.0001 0.39 0.39
4607 s
Average Complete care cost
6666 1963 s
10,816 1935 s
p < 0.0001
4343 s
Table 4 Cost comparison between conventional laparoscopy and robotic assisted laparoscopy in surgery for cervix cancer. Cervix
Conventional laparoscopy (n = 12)
Robotic assisted laparoscopy (n = 10)
Hourly cost for operative room Disposable material per intervention
43,363 s/h 91,393 s
84,921 s/h 148,308 s
p value
Average difference
Average surgery cost Average hospital stay (days) Average hospital stay cost Consultation within 2 months Hospitalisation within 2 months Total re-hospitalisation cost
3239 542 s 5.83 1.99 3879 1456 s 2 2 4386 s
8501 1451 s 4.70 3.13 3362 2287 s 1 1 2193 s
p < 0.0001 0.07 0.07 0.70 0.70
5640 s
Average complete care cost
7803 2130 s
12,211 3252 s
0.001
3894 s
Table 5 Potential reduction of complete care cost average difference by hospital stay and operative time decrease.
Endometrium Cervix
Actual cost average difference
Hospital stay (one day less)
Time spent in operative room (4 hours per patient)
After hospital stay + time in operative room potential decrease
4342 s 3894 s
3611 s 3163 s
2456 s 1292 s
1725 s 561 s
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actual average time spent in the operation room is 5h58 for endometrial cancer and 7h04 for cervical cancer. Such a decrease in operative room time use could further decrease the additional average cost of robotic assistance from s4342 to s2456 for endometrial cancer and from s3894 to s1292 for cervical cancer. If these improvements are taken into account, robotic-assisted surgery average additional costs can be calculated to be s1725 for endometrial cancer and s561 for cervical cancer. 4. Comment The aim of this study was to obtain a fair estimation of surgery cost. Robotic surgery is not extensively developed in Europe and even less so in France. Indeed, most of the studies have been made in the USA, where the health system and robotic costs are different. In Europe, two studies have been done thus far. Sarlos et al. [6], in a Swiss institution, evaluated the average surgical cost of robotic-assisted laparoscopic hysterectomy (for a benign indication) at s4067, as compared to s2151 using a conventional laparoscopic procedure. In comparison, in our study robotic-assisted surgery costs were more than twice as expensive (factor of 2.6), but it is noteworthy that acquisition and amortisation of the Da Vinci1 System were not included in the Swiss study. Dennis [7] in Lille, France, aimed to evaluate the surplus cost of robotic assistance for radical hysterectomy but he compared the average cost of disposable material without staff, indirect charges and Da Vinci1 system costs. We chose to evaluate complete care cost up to a two month follow-up period because of the putative decrease in complications using roboticassisted surgery, which can eventually be shown to decrease the burden of initial additional surgery costs. Because of the limited number of patients, our results were not statistically significant. Nevertheless, the surplus cost of robotic assistance for patients operated for cervical cancer seems to have been reduced given the decrease in hospital stay. We did not make any societal evaluation as did Bell et al. [8] or Barnett et al. [9] because, in our point of view, return to normal activity after minimal invasive surgery (laparoscopic or roboticassisted surgery) depends mainly on adjuvant treatment. Furthermore, our patients suffering from endometrial cancer were all retired. Unlike other studies, we decided to evaluate separate groups of cervical and endometrial cancer at the expense of reducing the respective sample sizes but with the advantage of obtaining even more homogeneous groups in terms of age and comorbidity. In the future, it would be interesting to evaluate the actual cost for hospital stay instead of standard cost. It is by such means that Martino et al. [10] showed a reduction in pain medication cost for robotic patients, which represented a saving greater than 50%. According to Barbash and Glied [11], additional cost for robotic assistance in minimal surgery is approximately $3200 in all specialities taken together. The review by Sarlos et al. of comparative studies evaluated the cost for robot-assisted hysterectomy as approximately $2600 more than conventional laparoscopic hysterectomy (not including investment and amortisation) [6]. Our results demonstrate a greater difference in our institution. Our operative time is at the upper limits of, but coherent with, the findings in the literature. This may be due to a limited number of patients treated using robotic assistance because of the sparse availability of Da Vinci1 system given its being shared with other specialities. In consequence, the learning curve is probably less progressive than is described in the literature [12]. Moreover, this study began from the first patients operated after acquisition of the Da Vinci1 system. The average cost of procedures is biased due to the incorporation of the first procedures, but the team devoted to surgery with robotic assistance allowed us to decrease
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the time-cost of operation room use by reducing docking and operating time. Consequently, the latest hysterectomies without lymphadenectomy lasted 150 min in operating room including 90 min of surgery. Considering the hourly cost of robotic assistance (849.21s/h) and the cost of disposable material per intervention (s1483.08), the total cost of each latest procedure was s3606.105, which is just above the cost of conventional laparoscopy. Shah et al. [13] demonstrated that it is feasible for robotic hysterectomy to be less expensive in terms of total in-room to out-of-room time. This corresponds to our ‘‘time-cost of operative room use’’ which included preparation, anaesthesia induction, incubation, equipment setup and docking. It is this factor, which has yet to be optimised, that seems to favour laparoscopic hysterectomy as the least costly method for the time being. Finally, Barnett et al. [9] showed in their sensitivity analysis that robotic surgery became least expensive if the cost of robotic disposable equipment was reduced, but nowadays only one company commercialises both the robotic-assisted surgical system and its supplies. Therefore, exclusive control seems to obstruct cost reduction. 5. Conclusion Conventional laparoscopy was less expensive in our institution as compared to robotic-assisted surgery for the treatment of endometrial (2.7) and cervical (2.6) cancers. When considering overall medical care, the use of robotic assistance costs is increased by a factor of 1.6. Robotic surgery surplus costs could be reduced by optimising ground occupation time as well as by reducing operative time. Robotic surgery benefits for the patient may counterbalance any of its additional costs by reduction of complications and length of hospital stay. Conflict of interest There are no conflicts of interest for this manuscript. Acknowledgment We would like to thank financial department staff of Bretonneau Hospital (Tours, France) for their contribution. References [1] Comprehensive cervical cancer prevention and control: a healthier future for girls and women: http://www.who.int/reproductivehealth/topics/cancers/en/ index.html [2] Parkin DM, Bray F, Ferlay J, Pisani P. Estimating the world cancer burden: Globocan 2000. Int J Cancer 2001;94:153–6. [3] Eltabbakh GH, Shamonki MI, Moody JM, Garafano LL. Laparoscopy as the primary modality for the treatment of women with endometrial carcinoma. Cancer 2001;91:378–87. [4] Querleu D, Papageorgiou T, Lambaudie E, Sonoda Y, Narducci F, LeBlanc E. Laparoscopic restaging of borderline ovarian tumors: results of 30 cases initially presumed as stage IA borderline ovarian tumour. BJOG 2003;110: 201–4. [5] Ghezzi F, Cromi A, Ciravolo G. Surgicopathologic outcome of laparoscopic versus open radical hysterectomy. Gynecol Oncol 2007;106:502–6. [6] Sarlos D, Kots L, Stevanovic N, Schaer G. Robotic hysterectomy versus conventional laparoscopic hysterectomy: outcome and cost analyses of a matched case-control study. Eur J Obstet Gynecol Reprod Biol 2010;150:92–6. [7] Dennis T, Mendonc¸a C, Narducci F, et al. Study of surplus cost of robotic assistance for radical assistance for radical hysterectomy, versus laparotomy and standard laparoscopy. Gynecol Obstet Fertil 2012;40:77–83. [8] Bell MC, Torgerson J, Seshadri-Kreaden U, Suttle AW, Hunt S. Comparison of outcomes and cost for endometrial cancer staging via traditional laparotomy, standard laparoscopy and robotic techniques. Gynecol Oncol 2008;111: 407–11. [9] Barnett JC, Judd JP, Wu JM, Scales CD, Myers ER, Havrilesky LJ. Cost comparison among robotic, laparoscopic, and open hysterectomy for endometrial cancer. Obstet Gynecol 2010;116:685–93.
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[10] Martino MA, Shubella J, Thomas MB, et al. A cost analysis of postoperative management in endometrial cancer patients treated by robotics versus laparoscopic approach. Gynecol Oncol 2011;123:528–31. [11] Barbash G, Glied SA. New technology and health care costs – the case of robotassisted surgery. N Engl J Med 2010;363:701–4. [12] Lim PC, Kang E, Park DH. A comparative detail analysis of the learning curve and surgical outcome for robotic hysterectomy with lymphadenectomy
versus laparoscopic hysterectomy with lymphadenectomy in treatment of endometrial cancer: a case-matched controlled study of the first one hundred twenty two patients. Gynecol Oncol 2011;120:413–8. [13] Shah NT, Wright KN, Jonsdottir GM, Jorgensen S, Einarsson JI, Muto MG. The feasibility of societal cost equivalence between robotic hysterectomy and alternate hysterectomy methods for endometrial cancer. Obstet Gynecol Int 2011;2011:570464.
