Combined robotic approach and enhanced recovery after surgery pathway for optimization of costs in patients undergoing proctectomy.

BACKGROUND: Enhanced recovery after surgery (ERAS) pathways are beneficial in proctocolectomy, but their impact on robotic low rectal proctectomy is not fully investigated. This study assessed the impact of an ERAS pathway on the outcomes and cost of robotic (RTME) versus laparoscopic (LTME) total mesorectal excision. METHODS: A retrospective review was performed of patients with rectal cancer in a single French tertiary centre for three yearly periods: 2011, LTME; 2015, RTME; and 2018, RTME with ERAS. Patient characteristics, operative and postoperative data, and costs were compared among the groups. RESULTS: A total of 220 consecutive proctectomies were analysed (71 LTME, 58 RTME and 91 RTME with ERAS). A prevalence of lower and locally advanced tumours was observed with RTME. The median duration of surgery increased with the introduction of RTME, but became shorter than that for LTME with greater robotic experience (226, 233 and 180 min for 2011, 2015 and 2018 respectively; P < 0·001). The median duration of hospital stay decreased significantly for RTME with ERAS (11, 10 and 8 days respectively; P = 0·011), as did the overall morbidity rate (39, 38 and 16 per cent; P = 0·002). Pathology results, conversion and defunctioning stoma rates remained stable. RTME alone increased the total cost by €2348 compared with LTME. The introduction of ERAS and improved robotic experience decreased costs by €1960, compared with RTME performed in 2015 without ERAS implementation. In patients with no co-morbidity, costs decreased by €596 for RTME with ERAS versus LTME alone. CONCLUSION: ERAS is associated with cost reductions in patients undergoing robotic proctectomy.

ANTECEDENTES: Las vías clínicas ERAS son beneficiosas en la proctocolectomía, pero su impacto en la proctectomía rectal baja robótica no se ha investigado exhaustivamente. El objetivo de este estudio fue evaluar el impacto de la vía clínica ERAS sobre los resultados y el coste de la proctectomía robótica (resección total del mesorrecto robótica, robotic total mesorectal excision, RTME) versus procedimientos laparoscópicos de resección total del mesorrecto (laparoscopic total mesorectal excision, LTME). MÉTODOS: Revisión retrospectiva de pacientes con cáncer de recto tratados en un único centro terciario francés durante un periodo de tres años: 1) 2011: resección total del mesorrecto laparoscópica (LTME); 2) 2015: TME robótica y 3) 2018: TME robótica plus ERAS. Se compararon las características de los pacientes, los datos operatorios y postoperatorios, y los costes entre subgrupos utilizando análisis estadísticos. RESULTADOS: Se analizaron 220 proctectomías consecutivas que incluían 71 LTME, 58 RTME y 91 RTME plus ERAS. Se observó un predominio de tumores inferiores y localmente avanzados en la RTME. La mediana del tiempo operatorio aumentó con la introducción de RTME, pero llegó a ser inferior que en la LTME con una mayor experiencia robótica (226, 233 y 180 minutos para los periodos 1, 2 y 3, respectivamente; P = 0,0001). La mediana de la estancia hospitalaria disminuyó significativamente con la RTME plus ERAS (11, 10 y 8 días; P = 0,01), así como la morbilidad global (40%, 38% y 16%; P = 0,002). Los resultados de la anatomía patológica, las tasas de conversión y de estomas de protección permanecieron estables. La RTME sola aumentó el coste total en €2.348 comparado con la LTME. La introducción de ERAS y una mejora en la experiencia robótica disminuyeron los costes en €1.960 versus RTME realizada en 2015 sin la implementación de ERAS. En pacientes sin comorbilidades, los costes disminuyeron en €1.196 con RTME plus ERAS versus LTME sola. CONCLUSIÓN: ERAS se asocia con reducciones de coste en la proctectomía robótica.

Cost of ownership assessment for a da Vinci robot based on US real-world data.

BACKGROUND: Despite growth of robotic surgery, published literature lacks assessment of the cost of ownership (CoO) of a da Vinci robot by surgical service line and the associated benefit such data provides. METHODS: Based on real-world data (RWD) from 14 US hospitals and ≈6000 da Vinci robotic cases, CoO was assessed using all relevant fixed and variable cost components, calculated by surgical service line. RESULTS: At a representative hospital with an efficient robotic program (n = 424 cases), the weighted average fixed cost per case was $984. Weighted average variable cost per case was $8025 (range: $3325 for Cholecystectomy-multiport, to $16 986 for Rectal Resection). Assessing weighted average by case, main variable cost drivers were non-da Vinci supplies (49.5%), staff costs (28.6%), and da Vinci supplies (21.9%). CONCLUSIONS: Case mix, annual robotic case volumes, and cut-to-close/patient-in-room time by surgical service line represent core variables influencing robotic program CoO, which help drive profitable program management.

Implementation and evaluation of a sterile compounding robot in a satellite oncology pharmacy.

PURPOSE: The purpose of this study was to quantify the impact of robotic technology on efficiency, accuracy, and cost in a satellite oncology pharmacy. METHODS: A 33-week quasi-experimental study was conducted at an academic, quaternary care institution with 1,119 licensed beds from June 2016 to February 2017 to evaluate the turnaround time (TAT) for preparations compounded by automated robotic compounding technology (ARCT) versus historical procedures. Secondary endpoints included mean preparation time and percentage of doses with a TAT of <30 minutes before and after the implementation of ARCT and were evaluated using time-segmented regression analysis. The cost savings in the satellite oncology pharmacy was determined by comparing usage of closed-system transfer devices (CSTDs) and labor costs between study phases. Accuracy of the intervention was expressed through a descriptive analysis of mean ARCT dose preparation deviations and preparation failures. RESULTS: Data for 1,453 preparations were included for analysis. The mean ± S.D. preimplementation TAT was 64.1 ± 27.9 minutes, which decreased to 53.2 ± 32.2 minutes after ARCT implementation (p < 0.01). Financial benefit was demonstrated through supply cost savings. Breakeven was estimated at 8.6 years after capital expenditure, with an annualized projected savings of $129,477. The mean ± S.D. deviation of the doses compounded using ARCT was -0.58% ± 0.01% from the ordered dosage. CONCLUSION: Adoption of ARCT for compounding of admixtures containing 4 oncology agents reduced TAT and preparation time and led to lower expenditures for CSTDs.

Robotics in Orthopedics: A Brave New World.

Future health-care projection projects a significant growth in population by 2020. Health care has seen an exponential growth in technology to address the growing population with the decreasing number of physicians and health-care workers. Robotics in health care has been introduced to address this growing need. Early adoption of robotics was limited because of the limited application of the technology, the cumbersome nature of the equipment, and technical complications. A continued improvement in efficacy, adaptability, and cost reduction has stimulated increased interest in robotic-assisted surgery. The evolution in orthopedic surgery has allowed for advanced surgical planning, precision robotic machining of bone, improved implant-bone contact, optimization of implant placement, and optimization of the mechanical alignment. The potential benefits of robotic surgery include improved surgical work flow, improvements in efficacy and reduction in surgical time. Robotic-assisted surgery will continue to evolve in the orthopedic field.

Updates in Urologic Robot Assisted Surgery.

Modern robotics is an advanced minimally invasive technology with the advantages of wristed capability, three-dimensional optics, and tremor filtration compared with conventional laparoscopy. Urologists have been early adopters of robotic surgical technology: robotics have been used in urologic oncology for more than 20 years and there has been an increasing trend for utilization in benign urologic pathology in the last couple of years. The continuing development and interest in robotics are aimed at surgical efficiency as well as patient outcomes. However, despite its advantages, improvements in haptics, system size, and cost are still desired. This article explores the current use of robotics in urology as well as future improvements on the horizon.

Robot-assisted surgery in a broader healthcare perspective: a difference-in-difference-based cost analysis of a national prostatectomy cohort.

OBJECTIVE: To estimate costs attributable to robot-assisted laparoscopic prostatectomy (RALP) as compared with open prostatectomy (OP) and laparoscopic prostatectomies (LP) in a National Health Service perspective. PATIENTS AND METHODS: Register-based cohort study of 4309 consecutive patients who underwent prostatectomy from 2006 to 2013 (2241 RALP, 1818 OP and 250 LP). Patients were followed from 12 months before to 12 months after prostatectomy with respect to service use in primary care (general practitioners, therapists, specialists etc) and hospitals (inpatient and outpatient activity related to prostatectomy and comorbidity). Tariffs of the activity-based remuneration system for primary care and the Diagnosis-Related Grouping case-mix system for hospital-based care were used to value service use. Costs attributable to RALP were estimated using a difference-in-difference analytical approach and adjusted for patient-level and hospital-level risk selection using multilevel regression. RESULTS: No significant effect of RALP on resource-use was observed except for a marginally lower use of primary care and fewer bed days as compared with OP (not LP). The overall cost consequence of RALP was estimated at an additional €2459 (95% CI 1377 to 3540, p=0.003) as compared with OP and an additional €3860 (95% CI 559 to 7160, p=0.031) as compared with LP, mainly due to higher cost intensity during the index admissions. CONCLUSIONS: In this study from the Danish context, the use of RALP generates a factor 1.3 additional cost when compared with OP and a factor 1.6 additional cost when compared with LP, on average, based on 12 months follow-up. The policy interpretation is that the use of robots for prostatectomy should be driven by clinical superiority and that formal effectiveness analysis is required to determine whether the current and eventual new purchasing of robot capacity is best used for prostatectomy.

The affordability of minimally invasive procedures in major lung resection: a prospective study.

OBJECTIVES: Minimally invasive procedures are used for the surgical treatment of lung cancer. Two techniques are proposed: video-assisted thoracic surgery or robotic-assisted thoracic surgery. Our goal was to study the economic impact of our long-standing program for minimally invasive procedures for major lung resection. METHODS: We conducted a single-centre, 1-year prospective cost study. Patients who underwent lobectomy or segmentectomy were included. Patient characteristics and perioperative outcomes were collected. Medical supply expenses based on the microcosting method and capital depreciation were estimated. Total cost was evaluated using a national French database. RESULTS: One hundred twelve patients were included, 57 with and 55 without robotic assistance. More segmentectomies were performed with robotic assistance. The median length of stay was 5 days for robotic-assisted and 6 days for video-assisted procedures (P = 0.13). The duration of median chest drains (4 days, P = 0.36) and of operating room time (255 min, P = 0.55) was not significantly different between the groups. The overall conversion rate to thoracotomy was 9%, significantly higher in the video-assisted group than in the robotic group (16% vs 2%, P = 0.008). No difference was observed in postoperative complications. The cost of most robotic-assisted procedures ranged from €10 000 to €12 000 (median €10 972) and that of most video-assisted procedures ranged from €8 000 to €10 000 (median €9 637) (P = 0.007); median medical supply expenses were €3 236 and €2 818, respectively (P = 0.004). The overall mean cost of minimally invasive techniques (€11 759) was significantly lower than the mean French cost of lung resection surgical procedures (€13 424) (P = 0.001). CONCLUSIONS: The cost at our centre of performing minimally invasive surgical procedures appeared lower than the cost nationwide. Robotic-assisted thoracic surgery demonstrated acceptable additional costs for a long-standing program.

Introduction of robot-assisted radical hysterectomy for early stage cervical cancer: impact on complications, costs and oncologic outcome.

INTRODUCTION: The objective was to assess the impact of robot-assisted radical hysterectomy (RRH) on surgical and oncologic outcome and costs compared with open radical hysterectomy (ORH) at a tertiary referral center in Sweden. MATERIAL AND METHODS: In this retrospective analysis all patients treated with radical hysterectomy and pelvic lymphadenectomy for early stage uterine cervical cancer during 2006-2015 were included (n = 304). The patients were divided into two groups, ORH (n = 155) and RRH (n = 149). Patient characteristics, FIGO stage, histology, adjuvant therapy, operation time, length of stay (LOS), lymph node yield, recurrence rate and survival were retrieved from medical records. Complications were graded according to the Clavien-Dindo classification. In addition, costs related to the surgical treatments were calculated. RESULTS: Blood loss, LOS and intraoperative complications were significantly lower as well as lymph node yield after RRH. No differences in postoperative complications or costs were observed between the two groups. Recurrence of disease was detected in 13.4 and 10.3% after RRH and ORH, respectively. Regression analysis demonstrated that histology, tumor size, positive lymph nodes and type of operation (RRH) were significantly associated with recurrence. CONCLUSION: The introduction of RRH was accompanied by similar postoperative complication rates and costs but lower LOS compared with ORH. An initial learning curve may account for the higher recurrence rate observed after RRH. These data reinforce the need for structured training and monitoring of outcomes when novel treatment modalities are introduced.

Robot-assisted surgery in gynecological oncology: current status and controversies on patient benefits, cost and surgeon conditions - a systematic review.

INTRODUCTION: Robot-assisted surgery has become more widespread in gynecological oncology. The purpose of this systematic review is to present current knowledge on robot-assisted surgery, and to clarify and discuss controversies that have arisen alongside the development and deployment. MATERIAL AND METHODS: A database search in PubMed and EMBASE was performed up until 4 March 2016. The search strategy was developed in collaboration with an information specialist, and by application of the PRISMA guidelines. Human participants and English language were the only restrictive filters applied. Selection was performed by screening of titles and abstracts, and by full text scrutiny. From 2001 to 2016, a total of 76 references were included. RESULTS: Robot-assisted surgery in gynecological oncology has increased, and current knowledge supports that the oncological safety is similar, compared with previous surgical methods. Controversies arise because current knowledge does not clearly document the benefit of robot-assisted surgery, on perioperative outcome compared with the increased costs of the acquisition and application. CONCLUSIONS: The rapid development in robot-assisted surgery calls for long-term detailed prospective cohorts or randomized controlled trials. The costs associated with acquisition, application, and maintenance have an unfavorable impact on cost-benefit evaluations, especially when compared with laparoscopy. Future developments in robot-assisted surgery will hopefully lead to competition in the market, which will decrease costs.

Robot-assisted versus laparoscopic rectal resection for cancer in a single surgeon's experience: a cost analysis covering the initial 50 robotic cases with the da Vinci Si.

PURPOSE: The aim of this study is to compare surgical parameters and the costs of robotic surgery with those of laparoscopic approach in rectal cancer based on a single surgeon's early robotic experience. METHODS: Data from 25 laparoscopic (LapTME) and the first 50 robotic (RobTME) rectal resections performed at our institution by an experienced laparoscopic surgeon (>100 procedures) between 2009 and 2014 were retrospectively analyzed and compared. Patient demographic, procedure, and outcome data were gathered. Costs of the two procedures were collected, differentiated into fixed and variable costs, and analyzed against the robotic learning curve according to the cumulative sum (CUSUM) method. RESULTS: Based on CUSUM analysis, RobTME group was divided into three phases (Rob1: 1-19; Rob2: 20-40; Rob3: 41-50). Overall median operative time (OT) was significantly lower in LapTME than in RobTME (270 vs 312.5 min, p = 0.006). A statistically significant change in OT by phase of robotic experience was detected in the RobTME group (p = 0.010). Overall mean costs associated with LapTME procedures were significantly lower than with RobTME (p < 0.001). Statistically significant reductions in variable and overall costs were found between robotic phases (p < 0.009 for both). With fixed costs excluded, the difference between laparoscopic and Rob3 was no longer statistically significant. CONCLUSIONS: Our results suggest a significant optimization of robotic rectal surgery's costs with experience. Efforts to reduce the dominant fixed cost are recommended to maintain the sustainability of the system and benefit from the technical advantages offered by the robot.

Robotic-assisted laparoscopic hysterectomy for women with endometrial cancer - complications, women´s experiences, quality of life and a health economic evaluation.

This thesis contains four studies all focusing on women with endometrial cancer undergoing robotic-assisted laparoscopic hysterectomy (RALH). Women with endometrial cancer are typically elderly with co-morbidities. RALH is a relatively new treatment option which has been introduced and adopted over the last decade without randomised controlled trials (RCTs) to prove superiority over other surgical alternatives. The purpose of the thesis was to explore and describe patient and health economic outcomes of RALH for women with endometrial cancer using different research approaches. The first study was a retrospective descriptive cohort study with 235 women. The aim was to explore types and incidence of post-operative complications within 12 months after RALH reported with the Clavien-Dindo scale. We found that 6% had severe complications and that women with lymphadenectomy did not have an increased rate of complications. Urinary tract and port site infections were the most frequent complications. The second study was a qualitative interview study where we explored the experience of undergoing RALH. Using content analysis, we analysed semi-structured interviews with 12 women who had undergone RALH on average 12 weeks earlier. The women were positive towards the robotic approach and felt recovered shortly after. They expressed uncertainty with the normal course of bleeding and bowel movement post-operatively as well as with the new anatomy. The third study was an economic evaluation; an activity-based costing study including 360 women comparing total abdominal hysterectomy (TAH) to RALH. This study showed that for women with endometrial cancer, RALH was cheaper compared to TAH, mainly due to fewer complications and shorter length of stay (LOS) that counterbalanced the higher robotic expenses. When including all cost drivers the analysis showed that the RALH procedure was more than 9.000 Danish kroner (DKK) cheaper than the TAH. Increased age and Type 2 diabetes appeared to increase costs. The fourth study was a prospective cohort study of 139 women who were followed four months after surgery with the aim to assess short term changes in health-related quality of life (HRQoL), symptoms and function after RALH. Both a general and an illness specific HRQoL questionnaire were used. The preoperative baseline measurement was compared with measurements at one and five weeks and four months post-operatively. The women also selfreported their level of activity once a week for the first five weeks after surgery. We found that HRQoL was back to baseline level at five weeks post-operatively for the majority of women. Fatigue, constipation, gastrointestinal symptoms, pain, appetite and change of taste were negatively affected short-term. At five weeks the mean level of physical activity resumed was 84%. Together, the studies indicate that RALH is a well-tolerated surgical treatment for women with endometrial cancer, and post-operative complications appear fewer and less severe compared to previous open surgery. This points towards RALH being clinically and economically efficient. The women experienced that RALH was easy to overcome and they felt recovered shortly after. However, they expressed uncertainty about the normal post-operative cause and reported changes in functions and symptoms short term after surgery. These changes should be addressed in the preoperative information and at the post-operative follow-up. It is difficult imagining a RCT of robotic-assisted laparoscopic hysterectomy being conducted in the future due to reluctance towards randomisation to open surgery. However, it would be advisable continuously to monitor relevant surgical and patient-reported outcomes as indications for robotic surgery may alter, experiences may develop and further technical advances may change robotic surgery for women with endometrial cancer in the future.

Robotic hepatectomies: advances and perspectives.

INTRODUCTION: Over recent years, minimally invasive hepatic resections have increasingly been reported in the literature. Even though hepatic surgery is still considered a challenge for surgeons due to its technical difficulties and high morbidity, the development and spread of robotic surgery has highlighted a new interest, which has induced a rapid dissemination of robotic approaches for hepatic pathologies. This article presents a systematic review of the literature regarding robotic hepatectomy in order to assess the safety and feasibility of robotic hepatic surgery. EVIDENCE ACQUISITION: All eligible studies in robotic liver surgery which were published between January 2001 and January 2016 were reviewed systematically. Only series of ten patients and more were chosen in order to consider the experience of high-volume centers. In case of multiple articles on the same centers, the study including the largest number of patients was considered for the study. Overall, 18 studies, involving a total of 572 robotic liver resection (RLR) were finally analyzed. EVIDENCE SYNTHESIS: All articles in this review demonstrate that robotic liver surgery must be performed by surgeons trained in open liver surgery and skilled in minimally invasive techniques. CONCLUSIONS: RLR and laparoscopic liver resection (LLR) were comparable in terms of safety, feasibility, and outcome for hepatectomies. However, RLR is more expensive than LLR. Further studies are required before any final conclusion can be drawn.

Can Robot-Assisted Unicompartmental Knee Arthroplasty Be Cost-Effective? A Markov Decision Analysis.

BACKGROUND: Unicompartmental knee arthroplasty (UKA) is a treatment option for single-compartment knee osteoarthritis. Robotic assistance may improve survival rates of UKA, but the cost-effectiveness of robot-assisted UKA is unknown. The purpose of this study was to delineate the revision rate, hospital volume, and robotic system costs for which this technology would be cost-effective. METHODS: We created a Markov decision analysis to evaluate the costs, outcomes, and incremental cost-effectiveness of robot-assisted UKA in 64-year-old patients with end-stage unicompartmental knee osteoarthritis. RESULTS: Robot-assisted UKA was more costly than traditional UKA, but offered a slightly better outcome with 0.06 additional quality-adjusted life-years at an incremental cost of $47,180 per quality-adjusted life-years, given a case volume of 100 cases annually. The system was cost-effective when case volume exceeded 94 cases per year, 2-year failure rates were below 1.2%, and total system costs were <$1.426 million. CONCLUSION: Robot-assisted UKA is cost-effective compared with traditional UKA when annual case volume exceeds 94 cases per year. It is not cost-effective at low-volume or medium-volume arthroplasty centers.

Resident education in robotic-assisted vertical sleeve gastrectomy: outcomes and cost-analysis of 411 consecutive cases.

BACKGROUND: Robotic technology is increasingly prevalent in bariatric surgery, yet there are national deficiencies in exposure of surgical residents to robotic techniques. OBJECTIVES: The purpose of this study is to accurately characterize the perioperative outcomes of a resident teaching model using the robotic-assisted sleeve gastrectomy. SETTING: University Hospital. METHODS: We identified 411 consecutive patients who underwent robotic sleeve gastrectomy at our institution from a prospectively maintained administrative database. Perioperative morbidity, operative time, and supply cost of the procedure were analyzed. RESULTS: Mean operative time was 96.4±24.9 minutes; mean robot usage time was 63.9 minutes (range 30.0-122.0 min). Ninety-day morbidities included reoperation (0.72%), major bleeding complications (0.48%), staple line leak (0.24%), stricture (0.97%), need for blood transfusion (3.86%), surgical site infection (1.69%), deep vein thrombosis (0.48%), and pulmonary embolism (0.48%). Mortality was nil. The resident cohort achieved operative time plateaus after five consecutive cases. Subset analysis for fiscal year 2014 demonstrated significantly increased supply cost for robotic sleeve gastrectomy compared with its laparoscopic equivalent. CONCLUSION: Robotic-assisted sleeve gastrectomy can be instituted as a model for resident robotic education with rates of morbidity and operative times equivalent to historical laparoscopic controls. The robot's enhanced ergonomics and its opportunity for resident education must be weighed against its increased supply cost.

Transareolar Robotic-Assisted Access to the Mitral Valve.

During the past years, a rapid development and refinements of robotic heart valve techniques have led to consider robotic mitral valve (MV) surgery safe, effective, and durable. Robotic MV surgery has proven to be a cost-effective and cost-saving strategy in MV operations, being associated with reduced morbidity and mortality rates. We present a novel video-assisted transareolar approach to access the MV using the da Vinci Si HD telemanipulation system (Intuitive Surgical, Inc, Sunnyvale, CA USA). This technique is effective and reproducible, providing maximum patient satisfaction from both the clinical and cosmetic points of view.