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doi:10.1111/jog.12507
J. Obstet. Gynaecol. Res. Vol. 40, No. 11: 2125–2134, November 2014
Cost assessment of robotics in gynecologic surgery: A systematic review Christos Iavazzo1, Eleni K. Papadopoulou2 and Ioannis D. Gkegkes3 1
Robotic Gynaecology and Gynaecological Oncology Department, Christie Hospital, Manchester, UK; and 2Department of Economics, Democritus University of Thrace, Komotini and 3First Department of Surgery, General Hospital of Attica ‘KAT’, Athens, Greece
Abstract Aim: The application of robotics is an innovation in the field of gynecologic surgery. Our objective was to evaluate the currently available literature on the cost assessment of robotic surgery of various operations in the field of gynecologic surgery. Material and Methods: PubMed and Scopus databases were systematically searched in order to retrieve the included studies in our review. Results: We retrieved 23 studies on a variety of gynecologic operations. The mean cost for robotic, open and laparoscopic surgery ranged from 1731 to 48 769, 894 to 20 277 and 411 to 41 836 Euros, respectively. Operative charges, in hysterectomy, for robotic, open and laparoscopic technique ranged from 936 to 33 920, 684 to 25 616 and 858 to 25 578 Euros, respectively. In sacrocolpopexy, these costs ranged from 2067 to 7275, 2904 to 69 792 and 1482 to 2000 Euros, respectively. Non-operative charges ranged from 467 to 39 121 Euros. The mean total costs for myomectomy ranged from 27 342 to 42 497 and 13 709 to 20 277 Euros, respectively, for the robotic and open methods, while the mean total cost of the laparoscopic technique was 26 181 Euros. Conversions to laparotomy were present in 79/36 185 (0.2%) cases of laparoscopic surgery and in 21/3345 (0.62%) cases of robotic technique. Duration of robotic, open and laparoscopic surgery ranged from 50 to 445, 83.7 to 701 and 74 to 330 min, respectively. Conclusion: Robotic surgery has the potential to become cost-effective in centers with many patients while industry competition could reduce the cost of the robotic instrumentation, making robotic technology more affordable and cost-effective. Key words: cost, gynecology, health-care economics, outcome, robotics, training.
Introduction During the last decade, robotically assisted surgery has made great progress and has become popular in various surgical fields, such as urology, general surgery, head/neck surgery, thoracic surgery and gynecology.1 Smaller incisions, shorter length of hospital stay, lower intraoperative blood loss and decreased postoperative pain are some of the major advantages of
robotically assisted surgery over open surgical technique.1,2 In addition, robotic surgery may improve the surgical time compared with laparoscopy as it allows a 3-D view of the operating field, eliminating surgeon tremor, permitting more precise movements while the use of wristed instruments improves dexterity and facilitates easier suturing into the abdominal cavity.3 On the other hand, the lack of tactile feedback and the difficulty in operating in anatomically limited places,
Received: December 26 2013. Accepted: May 22 2014. Reprint request to: Dr Christos Iavazzo, Robotic Gynaecology and Gynaecological Oncology Department, Christie Hospital, Wilmslow Road, Manchester M20 4BX, UK. Email: [email protected]
© 2014 The Authors Journal of Obstetrics and Gynaecology Research © 2014 Japan Society of Obstetrics and Gynecology
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C. Iavazzo et al.
such as the lower abdomen, due to instrument crowding, are some of the drawbacks of robotic surgery. Nevertheless, the elevated cost of acquisition as well as of maintenance of the robotic system (necessitating an annual service contract, 10% of the initial cost) represents the most important factor that causes drawbacks in the dissemination of robotically assisted surgery.3 The current cost of the da Vinci robotic equipment is relatively high and includes the acquisition, training and equipment-instrument cost. The initial capital for the acquisition of robotic devices can be amortized over a period of more than 7 years, which would amount to more than 1000 Euros per patient, if it is used for 300 or more procedures per year.3 If it were used for fewer patients, this would result in higher per-case charges. The robotic instruments have a limited number of uses (10 uses per instrument), and the charges per instrument are more than 1500 Euros.4 Nevertheless, the reimbursement to the hospital for utilization of the robot depends on the type of health insurance and on the health system. The aim of the present study was to evaluate the currently available literature on the cost assessment of robotic gynecologic surgery.
Methods Data sources A systematic search was performed in PubMed (2 September 2013) and Scopus (2 September 2013) and the search strategy used included a combination of the key words: robotic AND (gynecology OR endometrial OR cervical OR ovarian OR tubal OR sacrocolpopexy OR vaginal OR endometriosis OR fibroids OR myomectomy OR hysterectomy) AND (cost OR cost analysis). The references of the included articles were also hand searched. Study selection criteria The included studies reporting data on the cost assessment of robotic technology in gynecologic surgery were considered as admissible for this review. Abstracts, reviews, letters to the editor, short surveys, commentaries, editorials as well as studies published in languages other than English, German, French, Italian, Spanish, and Greek were not included in this review. Definitions Operative charges are defined as all the medical costs related with the operation itself (e.g. operating room,
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anesthesia, surgical supply). Non-operative charges are defined as all the costs not related with the operation itself but with the preoperative preparation and postoperative convalescence (e.g. postoperative medication, hospital stay, laboratory, radiology). Maintenance costs are included in the robot costs. Total costs are the sum of operative and non-operative charges. All costs are referred to hospital charges and estimated in Euros.
Results In total, 141 and 108 studies were retrieved, respectively, from PubMed and Scopus among which 23 studies met the inclusion criteria of our systematic review.5–27 Only one additional study was included through hand-searching of references.28 The utilized search strategy is represented in Figure 1 (flow diagram). The main characteristics of the included studies in our review (demographics, type of operation, number of patients, total costs, operative charges, nonoperative charges, robot charges included in the total costs, professionals’ costs, surgical equipment costs, operating room costs, length of hospital stay, number of conversions to laparotomy, duration of the operation, blood loss) are presented in Tables 1 and 2. Among the 24 studies, 15 referred to hysterectomy, three to myomectomy, four to sacrocolpopexy and two to tubal anastomosis. Two studies had four arms comparing robotic to open to laparoscopic to vaginal procedures; five studies had three arms comparing robotic to open to laparoscopic procedures; while 17 studies compared robotic with either an open or laparoscopic technique. Of the 23 studies listed, 14 had no surgical equipment or operating room costs. Of these 14, a further 11 had no operative charges or non-operative charges but only total costs. Among the 15 studies referring to the costs of hysterectomy, only three of them neglected to clarify whether the operation was combined with lymphadenectomy. A total of 4150 patients underwent the open method, 36 185 underwent the laparoscopic method and 3345 underwent the robotic method. The mean cost for robotic, open and laparoscopic methods ranged from 1731 to 48 769, 894 to 20 277 and 411 to 41 836 Euros, respectively. Operative charges ranged from 684 to 69 792 Euros. In hysterectomy, costs for robotic, open and laparoscopic procedures ranged from 936 to 33 920, 684 to 25 616 and 858 to 25 578 Euros, respectively. In sacrocolpopexy, costs ranged from 2067 to 7275, 2904 to
© 2014 The Authors Journal of Obstetrics and Gynaecology Research © 2014 Japan Society of Obstetrics and Gynecology
Robotics in gynecologic surgery
Potentially relevant articles retrieved from Pubmed and Scopus database (N = 249) 130 studies were excluded as irrelevant to the review based on their title or abstract* Articles selected for further evaluation after first screening of title and abstract (N = 119) One additional study identified through handsearching bibliographies of relevant articles
Articles excluded after detailed screening according to specific criteria (N = 95) • Review articles (n = 61) • Studies did not refer to cost analysis of robotic surgery (n = 20) • Commentaries /editorials (n = 6) • Letters to the editor (n = 4) • Short surveys (n = 3) • Studies written in excluded languages (n = 1)
24 individual articles qualifying for inclusion in our review
Figure 1 Flow diagram of the detailed process of selection of articles for inclusion in the review. *Most of the articles were retrieved from both databases.
69 792 and 1482 to 2000 Euros, respectively. The operative costs of myomectomies were not mentioned in any of the included studies. Non-operative charges ranged from 467 to 39 121 Euros. In hysterectomy, costs for robotic, open and laparoscopic procedures ranged from 492 to 39 121, 2260 to 41 062 and 467 to 29 874 Euros, respectively. In the included studies, the nonoperative charges for myomectomy were not mentioned. In sacrocolpopexy, costs ranged from 331 to 3546, 1617 to 19 190 and 251 to 431 Euros, respectively. The mean total costs for myomectomy ranged from 27 342 to 42 497 and 13 709 to 20 277 Euros, respectively, for the robotic and open methods while the mean total cost of the laparoscopic technique was 26 181 Euros. Regarding tubal anastomosis, operative and non-operative charges were not mentioned while the mean total costs of the robotic and open methods were 10 452 and 8911, respectively. In 15 studies, the robotic costs were included in the estimation of operative charges. The professional cost ranged from 499 to 5178 Euros. Surgical equipment costs ranged from 25 to 3014 Euros. Operating room costs ranged from 48 to 28 762 Euros. Mean hospital stay (in days) for robotic, open and laparoscopic procedures ranged from 0.7 to 6, from 1 to 8.1 and from 0 to 42, respectively. Specifically, in hysterectomy, hospital stay for robotic, open and laparoscopic procedures ranged from 1 to 5.5, 2.7 to 8.1 and 1 to 4.6 days, respectively. In myomectomy, hospital stay ranged from 0.7 to 1.48, 2.3 to 3.62 and 1 to 3 days, respectively. In sacrocolpopexy, hospital stay
ranged from 0 to 5, 1 to 25 and 0 to 42, respectively. Conversions to laparotomy were present in 79/36 185 (0.2%) cases of the laparoscopic procedure and in 21/3345 (0.62%) cases of the robotic technique. Duration of robotic, open and laparoscopic surgery ranged from 50 to 445, 83.7 to 701 and from 74 to 330 min, respectively. Blood loss in robotic, open and laparoscopic surgeries ranged from 20 to 2900, from 25 to 1300 and from 25 to 750 mL, respectively.
Discussion In eras of economic recession, the strength of healthcare systems is tested. With the intention to maintain the basic structure and function of a health-care system, the costs usually undergo substantial cuts. The adjustment of a health-care system to new financial conditions necessitates also a cost-analysis of the various techniques and procedures, especially in surgical fields. Although cost studies are difficult to accomplish, it is imperative that physicians and society as a whole understand the impact of the cost of robotics. The comparison of innovative minimally invasive methods and standard surgical techniques therefore is essential. Furthermore, the operative costs among the different surgical approaches are influenced by the necessity of specialized equipment. In particular, robotically assisted surgery uses equipment of elevated cost due to the innovation of the technique and the high specialization of the equipment, which does not have a
© 2014 The Authors Journal of Obstetrics and Gynaecology Research © 2014 Japan Society of Obstetrics and Gynecology
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201015
Pasic,
Sarlos
Bell, 200816
201028
Holtz, 201014
Shah, 201113
Landeen, 201112
Jonsdottir, 201111
Wright, 201210
Scribner, 201226 Venkat, 20129
Lau 20128
Dennis, 20127
Reynisson, 20135 Coronado, 20126
Hysterectomy DesilleGbaguidi, 201327
First author, year [ref]
OP LA RO
RO††
LA††
RO
OP†† LA†† RO†† VA OP LA RO LA RO LA
VA
RO††
40/110 (36.4) 30/110 (27.2) 40/110 (36.4)
40/80 (50)
48/76 (63.2) 28/76 (36.8) 27/54 (50) 27/54 (50) 1610/1894 (85) 217/1894 (11.5) 67/1894 (3.5) In 2006: 682/1054 (64.7) In 2009: 386/1079 (35.7) In 2006: 187/1054 (17.7) In 2009: 496/1079 (46) In 2006: 22/1054 (2) In 2009: 63/1079 (5.8) In 2006: 163/1054 (15.5) In 2009: 134/1079 (12.4) 274/1474 (18.6) 230/1474 (15.6) 569/1474 (38.6) 401/1474 (27.2) 73/234 (31.2) 118/234 (50.4) 43/234 (18.4) 20/33 (60.6) 13/33 (39.4) Inpatient 25 789/36 188 (71) Outpatient 8738/36 188 (24) Inpatient 1282/36 188 (4) Outpatient 379/36 188 (1) 40/80 (50)
LA RO LA RO OP LA RO OP††
LA††
143/303 (47.2)
Endometrium cancer group: 15/57 (26) Cervix cancer group: 12/57 (21) Endometrium cancer group: 20/57 (35) Cervix cancer group: 10/57 (18) 51/231 (22.1) 180/231 (77.9) 192/347 (55.3) 84/347 (24.2) 71/347 (20.5) NR NR In 2008: 13 In 2009: 24 160/303 (52.8)
Number of patients (%)
RO
OP
OP RO OP LA RO OP LA RO
RO
LA
Type of operation
Mean: 9822 Mean: 5744 Mean: 6231
NR
Mean (±SD): 684 (215) Mean (±SD): 858 (139) Mean (±SD): 936 (157)
NR
NR
NR NR
Mean (95%CI): 5568, P < 0.001
Mean: 4066, P < 0.05
Mean (±SD): 8501 (1451), P < 0.0001 NR NR Mean (±SD): 1144.5 (206.3) Mean (±SD): 2334.5 (334.1) Mean (±SD): 3018.4 (500.5) NR NR NR
Mean (±SD): 12 211 (3252), P = 0.001 Mean: 9854 Mean range: 9682–13 949 Mean (±SD): 4680.7 (1860.3) Mean (±SD): 4594.3 (1447.8) Mean (±SD): 5048.3 (2370.1) In 2006: mean: 894 In 2006: mean: 411 In 2008: mean: 2207 In 2009: mean: 1731 Mean (95%CI): 7553
Median (range): 2181 (12 159–25 813) Median (range): 3617 (2477–9085), P < 0.001 NR NR NR NR NR In 2006: mean (±SD): 3783 (1486) In 2009: mean (±SD): 4715 (1540), P < 0.001 In 2006: mean (±SD): 4396 (1695) In 2009: mean (±SD): 5850 (1491), P < 0.001 In 2006: mean (±SD): 8593 (1302) In 2009: mean (±SD): 7989 (2252), P < 0.084 In 2006: mean (±SD): 3002 (931) In 2009: mean (±SD): 3194 (947), P < 0.002 Mean (±SD): 3054 (1708), P < 0.0001 Mean (±SD): 3395 (1435), P < 0.0001 Mean (±SD): 4651 (1042) Mean (±SD): 2511 (871), P < 0.0001 Mean: 25 616 Mean: 25 578 Mean: 33 920, P < 0.01 Median: 1555 Median: 2521 NR
Mean (±SD): 3239 (542) Mean (±SD): 7402 (1733), P < 0.0001
Median (range): 17 094 (12 159–25 813) Median (range): 23 316 (16 988–41 182), P < 0.001 Mean: 41 836 Mean: 48 769, P = 0.04 Median: 7298 Median: 8934 Median: 7722, P < 0.0001 In 2006: mean (±SD): 10 128 (7478) In 2009: mean (±SD): 9621 (5669), P < 0.147 In 2006: mean (±SD): 7048 (3073) In 2009: mean (±SD): 9356 (4793), P < 0.001 In 2006: mean (±SD): 12 145 (1819) In 2009: mean (±SD): 11 004 (3193), P < 0.001 In 2006: mean (±SD): 5838 (1804) In 2009: mean (±SD): 8969 (4553), P < 0.001 Mean (±SD): 5315 (2855), P < 0.0001 Mean (±SD): 5236 (2309), P < 0.0001 Mean (±SD): 6173 (1347) Mean (±SD): 4177 (1256), P < 0.0001 NR NR NR Median: 2743 Median: 3858 Mean (±SD): Inpatient§ 5291 (885) Outpatient‡ 4514 (616) Mean (±SD): Inpatient§ 7315 (1224), P < 0.01 Outpatient‡ 6010 (821), P < 0.01 Mean: 2150
Mean (±SD): 2733 (735)
Mean (±SD): 7803 (2130) Mean (±SD): 10 816 (1935), P < 0.0001
Operative charges
Mean (±SD): 6666 (1963)
Total costs
Mean (±SD): 4204 (1964) Mean (±SD): 1522 (188) Mean (±SD): 1677 (316)
NR
NR
NR
NR
Y
NR
Y
Y
Mean (range): 1329 (1160–1707) Mean (range): 1770 (1194–2288), P > 0.05 NR NR NR
NR
NR NR NR NR NR NR NR NR NR NR
Mean (±SD): 2260 (1187), P < 0.0001 Mean (±SD): 1840 (919), P < 0.0001 Mean (±SD): 1522 (437) Mean (±SD): 1666 (467), P < 0.0001 Mean: 41 062, P < 0.01 Mean: 29 874 Mean: 39 121, P < 0.01 NR NR NR
NR
NR
Mean (95%CI): 504 (499–511) Mean (95%CI): 598 (598–598), P < 0.001 NR NR Mean: 4801 Mean: 5178, P = 0.033 NR NR NR NR
NR NR NR NR NR NR NR NR NR
NR NR
NR
Professionals’ costs
NR Y
Y
NR
NR
Y
Y
Y
Y
Y
Y
Robot cost included (Y/N)
NR
NR
NR
Mean (95%CI): 2658 (1814–3503), P < 0.001 Median (range): 692 (467–1428) Median (range): 692 (492–3389), P = 0.4 NR NR NR NR NR NR
Mean (95%CI): 4826 (4284–5367)
Mean (±SD): 3362 (2287), P = 0.07 NR NR Mean (±SD): 4384.5 (2932.9) Mean (±SD): 2694.3 (2547.5) Mean (±SD): 2045.2 (2019.6) NR NR NR
Mean (±SD): 3879 (1456) Mean (±SD): 3435 (989), P = 0.39
Mean (±SD): 4142 (1550)
Non-operative charges
Table 1 Robotic surgery in gynecology: costs related to equipment and peri-operative outcomes, regarding hysterectomy†
C. Iavazzo et al.
© 2014 The Authors Journal of Obstetrics and Gynaecology Research © 2014 Japan Society of Obstetrics and Gynecology
© 2014 The Authors Journal of Obstetrics and Gynaecology Research © 2014 Japan Society of Obstetrics and Gynecology NR NR NR NR NR
NR
NR
Mean: 821 Mean: 2296 Mean (±SD): 684 (215) Mean (±SD): 858 (138) Mean (±SD): 936 (157)
NR NR NR Median: 1013 Median: 1175 NR
Mean: 3.84 Mean: 1.44, P < 0.001 Mean: 1.3, P < 0.001 Mean (±SD): 1.7 (1.2) Mean (±SD): 1.7 (0.6) Mean (±SD): Inpatient§ 1.49 (0.2) Outpatient‡ Mean (±SD): Inpatient§ 1.37 (0.18), P < 0.01 Outpatient‡ Mean (range): 3.9 (2–7) Mean (range): 3.3 (2–6), P = 0.924 Mean (±SD): 4 (1.5) Mean (±SD): 2 (1.2) Mean (±SD): 2.3 (1.3)
Mean (±SD): 1.3 (0.6) Mean (±SD): 1.9 (0.8), P < 0.0001
— 0/40 — NR NR
NR
— 6/118 (5.1) 0/43 2/20 (10) 0/13 NR
5/569 (0.9) 4/401 (1), P = 1
9/230 (3.9), P = 0.013
Mean (±SD): 1.8 (1.5), P < 0.0001
Mean (±SD): 118 (150), P < 0.0001 Mean (±SD): 675 (336), P < 0.0001 Mean (±SD): 1409 (412) Mean (±SD): 214 (325), P < 0.0001 NR NR NR Median: 527 Median: 1197 NR
NR
NR NR
NR
NR
NR
NR
NR
In 2006: 28/187 (15) In 2009: 22/496 (4.4), P < 0.0001 In 2006: 3/22 (13.6) In 2009: 0/63, P < 0.05 In 2006: 1/163 (0.6) In 2009: 2/134 (1.5) —
NR
NR
NR NR — NR NR —
0/28
1.3, P = 0.005 Mean: 1.8 Mean: 1.7, P = 0.63 Median (IQR): 3 (3–4) Median (IQR): 2 (1–2) Median (IQR): 1 (1–2), P < 0.0001 In 2006: mean (±SD): 4.1 (3.4) In 2009: mean (±SD): 3.5 (2.3), P < 0.05 In 2006: mean (±SD): 1.3 (1.5) In 2009: mean (±SD): 1.3 (0.9)
0/48
— 3/303 (4.2)
— 2/180 (1.1) — 7/84 (8.3) 3/71 (4.2) NR NR NR
3/57 (5.3)
5/57 (8.7)
Conversion to laparotomy (%)
1
Mean (IQR): 5.5 (4–6) Mean (IQR): 2.2 (1–2), P < 0.001
Mean (±SD): 5.27 (2.12) Mean (±SD): 5.83 (1.99) Mean (±SD): 4.60 (1.35), P = 0.39 Mean (±SD): 4.70 (3.13), P = 0.07 Mean: 7.3 Mean range: 2.4–5.5 Mean (±SD): 8.1 (4.8) Mean (±SD): 4.6 (4) Mean (±SD): 3.5 (3.4) NR NR NR
Length of hospital stay (days)
In 2006: mean (±SD): 1.2 (0.7) In 2009: mean (±SD): 1.4 (0.9) In 2006: mean (±SD): 1.7 (0.8) In 2009: mean (±SD): 1.4 (0.83), P < 0.001 Mean (±SD): 2.7 (1.4), P < 0.0001
Median (range): 2001 (950–6181), P < 0.001 Mean: 18 886 Mean: 24 891, P < 0.001 NR NR NR NR
43 363/h 43 363/h 84 921/h 84 921/h NR NR NR NR NR NR NR In 2008: mean: 51 In 2009: mean: 48 Mean (95%CI): 172 (147–197) Mean (95%CI): 2168 (2168–2168), P < 0.001 Median (range): 1052 (353–1443)
Operating room costs
Median (range): 109 (25–220) Median (range): 145 (48–220), P = 0.001 NR NR NR NR NR NR
Mean: 91 393 Mean: 91 393 Mean: 148 308 Mean: 148 308 NR NR NR NR NR NR NR In 2008: mean: 1856 In 2009: mean: 1440 NR NR
Surgical equipment costs
Mean: 192.28 Mean: 186.8, P < 0.001 Mean: 252.6, P < 0.001 Mean (±SD): 156.2 (49) Mean (±SD): 192.5 (38) Mean (±SD): Inpatient§ 2.82 (0.46)¶ Outpatient‡ 2.46 (0.4)¶ Mean (±SD): Inpatient§ 3.22 (0.52)¶, P < 0.01 Outpatient‡ 2.99 (0.48)¶, P < 0.01 Mean (range): 82.9 (55–165) Mean (range): 108.9 (50–180), P < 0.001 Mean (±SD): 108.6 (41.4) Mean (±SD): 171.1 (36.2) Mean (±SD): 184 (41.3)
Mean (±SD): 117.2 (59.4) Mean (±SD): 99.2 (45.2), P < 0.0001
Mean:
doi:10.1111/jog.12507
J. Obstet. Gynaecol. Res. Vol. 40, No. 11: 2125–2134, November 2014
Cost assessment of robotics in gynecologic surgery: A systematic review Christos Iavazzo1, Eleni K. Papadopoulou2 and Ioannis D. Gkegkes3 1
Robotic Gynaecology and Gynaecological Oncology Department, Christie Hospital, Manchester, UK; and 2Department of Economics, Democritus University of Thrace, Komotini and 3First Department of Surgery, General Hospital of Attica ‘KAT’, Athens, Greece
Abstract Aim: The application of robotics is an innovation in the field of gynecologic surgery. Our objective was to evaluate the currently available literature on the cost assessment of robotic surgery of various operations in the field of gynecologic surgery. Material and Methods: PubMed and Scopus databases were systematically searched in order to retrieve the included studies in our review. Results: We retrieved 23 studies on a variety of gynecologic operations. The mean cost for robotic, open and laparoscopic surgery ranged from 1731 to 48 769, 894 to 20 277 and 411 to 41 836 Euros, respectively. Operative charges, in hysterectomy, for robotic, open and laparoscopic technique ranged from 936 to 33 920, 684 to 25 616 and 858 to 25 578 Euros, respectively. In sacrocolpopexy, these costs ranged from 2067 to 7275, 2904 to 69 792 and 1482 to 2000 Euros, respectively. Non-operative charges ranged from 467 to 39 121 Euros. The mean total costs for myomectomy ranged from 27 342 to 42 497 and 13 709 to 20 277 Euros, respectively, for the robotic and open methods, while the mean total cost of the laparoscopic technique was 26 181 Euros. Conversions to laparotomy were present in 79/36 185 (0.2%) cases of laparoscopic surgery and in 21/3345 (0.62%) cases of robotic technique. Duration of robotic, open and laparoscopic surgery ranged from 50 to 445, 83.7 to 701 and 74 to 330 min, respectively. Conclusion: Robotic surgery has the potential to become cost-effective in centers with many patients while industry competition could reduce the cost of the robotic instrumentation, making robotic technology more affordable and cost-effective. Key words: cost, gynecology, health-care economics, outcome, robotics, training.
Introduction During the last decade, robotically assisted surgery has made great progress and has become popular in various surgical fields, such as urology, general surgery, head/neck surgery, thoracic surgery and gynecology.1 Smaller incisions, shorter length of hospital stay, lower intraoperative blood loss and decreased postoperative pain are some of the major advantages of
robotically assisted surgery over open surgical technique.1,2 In addition, robotic surgery may improve the surgical time compared with laparoscopy as it allows a 3-D view of the operating field, eliminating surgeon tremor, permitting more precise movements while the use of wristed instruments improves dexterity and facilitates easier suturing into the abdominal cavity.3 On the other hand, the lack of tactile feedback and the difficulty in operating in anatomically limited places,
Received: December 26 2013. Accepted: May 22 2014. Reprint request to: Dr Christos Iavazzo, Robotic Gynaecology and Gynaecological Oncology Department, Christie Hospital, Wilmslow Road, Manchester M20 4BX, UK. Email: [email protected]
© 2014 The Authors Journal of Obstetrics and Gynaecology Research © 2014 Japan Society of Obstetrics and Gynecology
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C. Iavazzo et al.
such as the lower abdomen, due to instrument crowding, are some of the drawbacks of robotic surgery. Nevertheless, the elevated cost of acquisition as well as of maintenance of the robotic system (necessitating an annual service contract, 10% of the initial cost) represents the most important factor that causes drawbacks in the dissemination of robotically assisted surgery.3 The current cost of the da Vinci robotic equipment is relatively high and includes the acquisition, training and equipment-instrument cost. The initial capital for the acquisition of robotic devices can be amortized over a period of more than 7 years, which would amount to more than 1000 Euros per patient, if it is used for 300 or more procedures per year.3 If it were used for fewer patients, this would result in higher per-case charges. The robotic instruments have a limited number of uses (10 uses per instrument), and the charges per instrument are more than 1500 Euros.4 Nevertheless, the reimbursement to the hospital for utilization of the robot depends on the type of health insurance and on the health system. The aim of the present study was to evaluate the currently available literature on the cost assessment of robotic gynecologic surgery.
Methods Data sources A systematic search was performed in PubMed (2 September 2013) and Scopus (2 September 2013) and the search strategy used included a combination of the key words: robotic AND (gynecology OR endometrial OR cervical OR ovarian OR tubal OR sacrocolpopexy OR vaginal OR endometriosis OR fibroids OR myomectomy OR hysterectomy) AND (cost OR cost analysis). The references of the included articles were also hand searched. Study selection criteria The included studies reporting data on the cost assessment of robotic technology in gynecologic surgery were considered as admissible for this review. Abstracts, reviews, letters to the editor, short surveys, commentaries, editorials as well as studies published in languages other than English, German, French, Italian, Spanish, and Greek were not included in this review. Definitions Operative charges are defined as all the medical costs related with the operation itself (e.g. operating room,
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anesthesia, surgical supply). Non-operative charges are defined as all the costs not related with the operation itself but with the preoperative preparation and postoperative convalescence (e.g. postoperative medication, hospital stay, laboratory, radiology). Maintenance costs are included in the robot costs. Total costs are the sum of operative and non-operative charges. All costs are referred to hospital charges and estimated in Euros.
Results In total, 141 and 108 studies were retrieved, respectively, from PubMed and Scopus among which 23 studies met the inclusion criteria of our systematic review.5–27 Only one additional study was included through hand-searching of references.28 The utilized search strategy is represented in Figure 1 (flow diagram). The main characteristics of the included studies in our review (demographics, type of operation, number of patients, total costs, operative charges, nonoperative charges, robot charges included in the total costs, professionals’ costs, surgical equipment costs, operating room costs, length of hospital stay, number of conversions to laparotomy, duration of the operation, blood loss) are presented in Tables 1 and 2. Among the 24 studies, 15 referred to hysterectomy, three to myomectomy, four to sacrocolpopexy and two to tubal anastomosis. Two studies had four arms comparing robotic to open to laparoscopic to vaginal procedures; five studies had three arms comparing robotic to open to laparoscopic procedures; while 17 studies compared robotic with either an open or laparoscopic technique. Of the 23 studies listed, 14 had no surgical equipment or operating room costs. Of these 14, a further 11 had no operative charges or non-operative charges but only total costs. Among the 15 studies referring to the costs of hysterectomy, only three of them neglected to clarify whether the operation was combined with lymphadenectomy. A total of 4150 patients underwent the open method, 36 185 underwent the laparoscopic method and 3345 underwent the robotic method. The mean cost for robotic, open and laparoscopic methods ranged from 1731 to 48 769, 894 to 20 277 and 411 to 41 836 Euros, respectively. Operative charges ranged from 684 to 69 792 Euros. In hysterectomy, costs for robotic, open and laparoscopic procedures ranged from 936 to 33 920, 684 to 25 616 and 858 to 25 578 Euros, respectively. In sacrocolpopexy, costs ranged from 2067 to 7275, 2904 to
© 2014 The Authors Journal of Obstetrics and Gynaecology Research © 2014 Japan Society of Obstetrics and Gynecology
Robotics in gynecologic surgery
Potentially relevant articles retrieved from Pubmed and Scopus database (N = 249) 130 studies were excluded as irrelevant to the review based on their title or abstract* Articles selected for further evaluation after first screening of title and abstract (N = 119) One additional study identified through handsearching bibliographies of relevant articles
Articles excluded after detailed screening according to specific criteria (N = 95) • Review articles (n = 61) • Studies did not refer to cost analysis of robotic surgery (n = 20) • Commentaries /editorials (n = 6) • Letters to the editor (n = 4) • Short surveys (n = 3) • Studies written in excluded languages (n = 1)
24 individual articles qualifying for inclusion in our review
Figure 1 Flow diagram of the detailed process of selection of articles for inclusion in the review. *Most of the articles were retrieved from both databases.
69 792 and 1482 to 2000 Euros, respectively. The operative costs of myomectomies were not mentioned in any of the included studies. Non-operative charges ranged from 467 to 39 121 Euros. In hysterectomy, costs for robotic, open and laparoscopic procedures ranged from 492 to 39 121, 2260 to 41 062 and 467 to 29 874 Euros, respectively. In the included studies, the nonoperative charges for myomectomy were not mentioned. In sacrocolpopexy, costs ranged from 331 to 3546, 1617 to 19 190 and 251 to 431 Euros, respectively. The mean total costs for myomectomy ranged from 27 342 to 42 497 and 13 709 to 20 277 Euros, respectively, for the robotic and open methods while the mean total cost of the laparoscopic technique was 26 181 Euros. Regarding tubal anastomosis, operative and non-operative charges were not mentioned while the mean total costs of the robotic and open methods were 10 452 and 8911, respectively. In 15 studies, the robotic costs were included in the estimation of operative charges. The professional cost ranged from 499 to 5178 Euros. Surgical equipment costs ranged from 25 to 3014 Euros. Operating room costs ranged from 48 to 28 762 Euros. Mean hospital stay (in days) for robotic, open and laparoscopic procedures ranged from 0.7 to 6, from 1 to 8.1 and from 0 to 42, respectively. Specifically, in hysterectomy, hospital stay for robotic, open and laparoscopic procedures ranged from 1 to 5.5, 2.7 to 8.1 and 1 to 4.6 days, respectively. In myomectomy, hospital stay ranged from 0.7 to 1.48, 2.3 to 3.62 and 1 to 3 days, respectively. In sacrocolpopexy, hospital stay
ranged from 0 to 5, 1 to 25 and 0 to 42, respectively. Conversions to laparotomy were present in 79/36 185 (0.2%) cases of the laparoscopic procedure and in 21/3345 (0.62%) cases of the robotic technique. Duration of robotic, open and laparoscopic surgery ranged from 50 to 445, 83.7 to 701 and from 74 to 330 min, respectively. Blood loss in robotic, open and laparoscopic surgeries ranged from 20 to 2900, from 25 to 1300 and from 25 to 750 mL, respectively.
Discussion In eras of economic recession, the strength of healthcare systems is tested. With the intention to maintain the basic structure and function of a health-care system, the costs usually undergo substantial cuts. The adjustment of a health-care system to new financial conditions necessitates also a cost-analysis of the various techniques and procedures, especially in surgical fields. Although cost studies are difficult to accomplish, it is imperative that physicians and society as a whole understand the impact of the cost of robotics. The comparison of innovative minimally invasive methods and standard surgical techniques therefore is essential. Furthermore, the operative costs among the different surgical approaches are influenced by the necessity of specialized equipment. In particular, robotically assisted surgery uses equipment of elevated cost due to the innovation of the technique and the high specialization of the equipment, which does not have a
© 2014 The Authors Journal of Obstetrics and Gynaecology Research © 2014 Japan Society of Obstetrics and Gynecology
2127
2128
201015
Pasic,
Sarlos
Bell, 200816
201028
Holtz, 201014
Shah, 201113
Landeen, 201112
Jonsdottir, 201111
Wright, 201210
Scribner, 201226 Venkat, 20129
Lau 20128
Dennis, 20127
Reynisson, 20135 Coronado, 20126
Hysterectomy DesilleGbaguidi, 201327
First author, year [ref]
OP LA RO
RO††
LA††
RO
OP†† LA†† RO†† VA OP LA RO LA RO LA
VA
RO††
40/110 (36.4) 30/110 (27.2) 40/110 (36.4)
40/80 (50)
48/76 (63.2) 28/76 (36.8) 27/54 (50) 27/54 (50) 1610/1894 (85) 217/1894 (11.5) 67/1894 (3.5) In 2006: 682/1054 (64.7) In 2009: 386/1079 (35.7) In 2006: 187/1054 (17.7) In 2009: 496/1079 (46) In 2006: 22/1054 (2) In 2009: 63/1079 (5.8) In 2006: 163/1054 (15.5) In 2009: 134/1079 (12.4) 274/1474 (18.6) 230/1474 (15.6) 569/1474 (38.6) 401/1474 (27.2) 73/234 (31.2) 118/234 (50.4) 43/234 (18.4) 20/33 (60.6) 13/33 (39.4) Inpatient 25 789/36 188 (71) Outpatient 8738/36 188 (24) Inpatient 1282/36 188 (4) Outpatient 379/36 188 (1) 40/80 (50)
LA RO LA RO OP LA RO OP††
LA††
143/303 (47.2)
Endometrium cancer group: 15/57 (26) Cervix cancer group: 12/57 (21) Endometrium cancer group: 20/57 (35) Cervix cancer group: 10/57 (18) 51/231 (22.1) 180/231 (77.9) 192/347 (55.3) 84/347 (24.2) 71/347 (20.5) NR NR In 2008: 13 In 2009: 24 160/303 (52.8)
Number of patients (%)
RO
OP
OP RO OP LA RO OP LA RO
RO
LA
Type of operation
Mean: 9822 Mean: 5744 Mean: 6231
NR
Mean (±SD): 684 (215) Mean (±SD): 858 (139) Mean (±SD): 936 (157)
NR
NR
NR NR
Mean (95%CI): 5568, P < 0.001
Mean: 4066, P < 0.05
Mean (±SD): 8501 (1451), P < 0.0001 NR NR Mean (±SD): 1144.5 (206.3) Mean (±SD): 2334.5 (334.1) Mean (±SD): 3018.4 (500.5) NR NR NR
Mean (±SD): 12 211 (3252), P = 0.001 Mean: 9854 Mean range: 9682–13 949 Mean (±SD): 4680.7 (1860.3) Mean (±SD): 4594.3 (1447.8) Mean (±SD): 5048.3 (2370.1) In 2006: mean: 894 In 2006: mean: 411 In 2008: mean: 2207 In 2009: mean: 1731 Mean (95%CI): 7553
Median (range): 2181 (12 159–25 813) Median (range): 3617 (2477–9085), P < 0.001 NR NR NR NR NR In 2006: mean (±SD): 3783 (1486) In 2009: mean (±SD): 4715 (1540), P < 0.001 In 2006: mean (±SD): 4396 (1695) In 2009: mean (±SD): 5850 (1491), P < 0.001 In 2006: mean (±SD): 8593 (1302) In 2009: mean (±SD): 7989 (2252), P < 0.084 In 2006: mean (±SD): 3002 (931) In 2009: mean (±SD): 3194 (947), P < 0.002 Mean (±SD): 3054 (1708), P < 0.0001 Mean (±SD): 3395 (1435), P < 0.0001 Mean (±SD): 4651 (1042) Mean (±SD): 2511 (871), P < 0.0001 Mean: 25 616 Mean: 25 578 Mean: 33 920, P < 0.01 Median: 1555 Median: 2521 NR
Mean (±SD): 3239 (542) Mean (±SD): 7402 (1733), P < 0.0001
Median (range): 17 094 (12 159–25 813) Median (range): 23 316 (16 988–41 182), P < 0.001 Mean: 41 836 Mean: 48 769, P = 0.04 Median: 7298 Median: 8934 Median: 7722, P < 0.0001 In 2006: mean (±SD): 10 128 (7478) In 2009: mean (±SD): 9621 (5669), P < 0.147 In 2006: mean (±SD): 7048 (3073) In 2009: mean (±SD): 9356 (4793), P < 0.001 In 2006: mean (±SD): 12 145 (1819) In 2009: mean (±SD): 11 004 (3193), P < 0.001 In 2006: mean (±SD): 5838 (1804) In 2009: mean (±SD): 8969 (4553), P < 0.001 Mean (±SD): 5315 (2855), P < 0.0001 Mean (±SD): 5236 (2309), P < 0.0001 Mean (±SD): 6173 (1347) Mean (±SD): 4177 (1256), P < 0.0001 NR NR NR Median: 2743 Median: 3858 Mean (±SD): Inpatient§ 5291 (885) Outpatient‡ 4514 (616) Mean (±SD): Inpatient§ 7315 (1224), P < 0.01 Outpatient‡ 6010 (821), P < 0.01 Mean: 2150
Mean (±SD): 2733 (735)
Mean (±SD): 7803 (2130) Mean (±SD): 10 816 (1935), P < 0.0001
Operative charges
Mean (±SD): 6666 (1963)
Total costs
Mean (±SD): 4204 (1964) Mean (±SD): 1522 (188) Mean (±SD): 1677 (316)
NR
NR
NR
NR
Y
NR
Y
Y
Mean (range): 1329 (1160–1707) Mean (range): 1770 (1194–2288), P > 0.05 NR NR NR
NR
NR NR NR NR NR NR NR NR NR NR
Mean (±SD): 2260 (1187), P < 0.0001 Mean (±SD): 1840 (919), P < 0.0001 Mean (±SD): 1522 (437) Mean (±SD): 1666 (467), P < 0.0001 Mean: 41 062, P < 0.01 Mean: 29 874 Mean: 39 121, P < 0.01 NR NR NR
NR
NR
Mean (95%CI): 504 (499–511) Mean (95%CI): 598 (598–598), P < 0.001 NR NR Mean: 4801 Mean: 5178, P = 0.033 NR NR NR NR
NR NR NR NR NR NR NR NR NR
NR NR
NR
Professionals’ costs
NR Y
Y
NR
NR
Y
Y
Y
Y
Y
Y
Robot cost included (Y/N)
NR
NR
NR
Mean (95%CI): 2658 (1814–3503), P < 0.001 Median (range): 692 (467–1428) Median (range): 692 (492–3389), P = 0.4 NR NR NR NR NR NR
Mean (95%CI): 4826 (4284–5367)
Mean (±SD): 3362 (2287), P = 0.07 NR NR Mean (±SD): 4384.5 (2932.9) Mean (±SD): 2694.3 (2547.5) Mean (±SD): 2045.2 (2019.6) NR NR NR
Mean (±SD): 3879 (1456) Mean (±SD): 3435 (989), P = 0.39
Mean (±SD): 4142 (1550)
Non-operative charges
Table 1 Robotic surgery in gynecology: costs related to equipment and peri-operative outcomes, regarding hysterectomy†
C. Iavazzo et al.
© 2014 The Authors Journal of Obstetrics and Gynaecology Research © 2014 Japan Society of Obstetrics and Gynecology
© 2014 The Authors Journal of Obstetrics and Gynaecology Research © 2014 Japan Society of Obstetrics and Gynecology NR NR NR NR NR
NR
NR
Mean: 821 Mean: 2296 Mean (±SD): 684 (215) Mean (±SD): 858 (138) Mean (±SD): 936 (157)
NR NR NR Median: 1013 Median: 1175 NR
Mean: 3.84 Mean: 1.44, P < 0.001 Mean: 1.3, P < 0.001 Mean (±SD): 1.7 (1.2) Mean (±SD): 1.7 (0.6) Mean (±SD): Inpatient§ 1.49 (0.2) Outpatient‡ Mean (±SD): Inpatient§ 1.37 (0.18), P < 0.01 Outpatient‡ Mean (range): 3.9 (2–7) Mean (range): 3.3 (2–6), P = 0.924 Mean (±SD): 4 (1.5) Mean (±SD): 2 (1.2) Mean (±SD): 2.3 (1.3)
Mean (±SD): 1.3 (0.6) Mean (±SD): 1.9 (0.8), P < 0.0001
— 0/40 — NR NR
NR
— 6/118 (5.1) 0/43 2/20 (10) 0/13 NR
5/569 (0.9) 4/401 (1), P = 1
9/230 (3.9), P = 0.013
Mean (±SD): 1.8 (1.5), P < 0.0001
Mean (±SD): 118 (150), P < 0.0001 Mean (±SD): 675 (336), P < 0.0001 Mean (±SD): 1409 (412) Mean (±SD): 214 (325), P < 0.0001 NR NR NR Median: 527 Median: 1197 NR
NR
NR NR
NR
NR
NR
NR
NR
In 2006: 28/187 (15) In 2009: 22/496 (4.4), P < 0.0001 In 2006: 3/22 (13.6) In 2009: 0/63, P < 0.05 In 2006: 1/163 (0.6) In 2009: 2/134 (1.5) —
NR
NR
NR NR — NR NR —
0/28
1.3, P = 0.005 Mean: 1.8 Mean: 1.7, P = 0.63 Median (IQR): 3 (3–4) Median (IQR): 2 (1–2) Median (IQR): 1 (1–2), P < 0.0001 In 2006: mean (±SD): 4.1 (3.4) In 2009: mean (±SD): 3.5 (2.3), P < 0.05 In 2006: mean (±SD): 1.3 (1.5) In 2009: mean (±SD): 1.3 (0.9)
0/48
— 3/303 (4.2)
— 2/180 (1.1) — 7/84 (8.3) 3/71 (4.2) NR NR NR
3/57 (5.3)
5/57 (8.7)
Conversion to laparotomy (%)
1
Mean (IQR): 5.5 (4–6) Mean (IQR): 2.2 (1–2), P < 0.001
Mean (±SD): 5.27 (2.12) Mean (±SD): 5.83 (1.99) Mean (±SD): 4.60 (1.35), P = 0.39 Mean (±SD): 4.70 (3.13), P = 0.07 Mean: 7.3 Mean range: 2.4–5.5 Mean (±SD): 8.1 (4.8) Mean (±SD): 4.6 (4) Mean (±SD): 3.5 (3.4) NR NR NR
Length of hospital stay (days)
In 2006: mean (±SD): 1.2 (0.7) In 2009: mean (±SD): 1.4 (0.9) In 2006: mean (±SD): 1.7 (0.8) In 2009: mean (±SD): 1.4 (0.83), P < 0.001 Mean (±SD): 2.7 (1.4), P < 0.0001
Median (range): 2001 (950–6181), P < 0.001 Mean: 18 886 Mean: 24 891, P < 0.001 NR NR NR NR
43 363/h 43 363/h 84 921/h 84 921/h NR NR NR NR NR NR NR In 2008: mean: 51 In 2009: mean: 48 Mean (95%CI): 172 (147–197) Mean (95%CI): 2168 (2168–2168), P < 0.001 Median (range): 1052 (353–1443)
Operating room costs
Median (range): 109 (25–220) Median (range): 145 (48–220), P = 0.001 NR NR NR NR NR NR
Mean: 91 393 Mean: 91 393 Mean: 148 308 Mean: 148 308 NR NR NR NR NR NR NR In 2008: mean: 1856 In 2009: mean: 1440 NR NR
Surgical equipment costs
Mean: 192.28 Mean: 186.8, P < 0.001 Mean: 252.6, P < 0.001 Mean (±SD): 156.2 (49) Mean (±SD): 192.5 (38) Mean (±SD): Inpatient§ 2.82 (0.46)¶ Outpatient‡ 2.46 (0.4)¶ Mean (±SD): Inpatient§ 3.22 (0.52)¶, P < 0.01 Outpatient‡ 2.99 (0.48)¶, P < 0.01 Mean (range): 82.9 (55–165) Mean (range): 108.9 (50–180), P < 0.001 Mean (±SD): 108.6 (41.4) Mean (±SD): 171.1 (36.2) Mean (±SD): 184 (41.3)
Mean (±SD): 117.2 (59.4) Mean (±SD): 99.2 (45.2), P < 0.0001
Mean:
