Journal of Endourology Reducing Robotic Prostatectomy Costs by Minimizing Instrumentation (doi: 10.1089/end.2014.0533) This article has been peer-reviewed and accepted for publication, but has yet to undergo copyediting and proof correction. The final published version may differ from this proof.
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Reducing Robotic Prostatectomy Costs by Minimizing Instrumentation
Joan C. Delto MD Department of Urology, Mount Sinai Medical Center, Miami Beach FL George Wayne BS College of Medicine, Florida International University, Miami FL Rafael Yanes MD Department of Urology, Mount Sinai Medical Center, Miami Beach FL Alan M. Nieder MD Department of Urology, Mount Sinai Medical Center, Miami Beach FL Akshay Bhandari MD Department of Urology, Mount Sinai Medical Center, Miami Beach FL
Journal of Endourology Reducing Robotic Prostatectomy Costs by Minimizing Instrumentation (doi: 10.1089/end.2014.0533) This article has been peer-reviewed and accepted for publication, but has yet to undergo copyediting and proof correction. The final published version may differ from this proof.
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ABSTRACT:
Introduction and Objective:
Since the introduction of robotic surgery for radical prostatectomy, the cost-benefit of this technology has been under scrutiny. While robotic surgery professes to offer multiple advantages including reduced blood loss, reduced length of stay, and expedient recovery, the associated costs tend to be significantly higher, secondary to the fixed cost of the robot as well as the variable costs associated with instrumentation. This study provides a simple framework for the careful consideration of costs during the selection of equipment and materials.
Methods:
Two experienced robotic surgeons at our institution as well as several at other institutions were queried about their preferred instrument usage for robotically assisted prostatectomy. Costs of instruments and materials were obtained and clustered by type and price. A minimal set of instruments was identified and compared against alternative instrumentation. A retrospective review of 125 patients who underwent RALP for prostate cancer at our institution was performed to compare estimated blood loss, operative times, and intraoperative complications for both surgeons. Our surgeons now conceptualize instrument costs as proportional changes to the cost of the baseline, minimal combination.
Results:
Robotic costs at our institution were reduced by eliminating an energy source like the ligasure or vessel sealer, exploiting instruments’ versatility, and utilizing inexpensive tools such as hemolok
Journal of Endourology Reducing Robotic Prostatectomy Costs by Minimizing Instrumentation (doi: 10.1089/end.2014.0533) This article has been peer-reviewed and accepted for publication, but has yet to undergo copyediting and proof correction. The final published version may differ from this proof.
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3 clips. Such modifications reduced surgeon 1’s cost of instrumentation to approximately 40% less than that of surgeon 2 and up to 32% less than instrumentation used by surgeons at other institutions. Surgeon 1’s combination may not be optimal for all robotic surgeons; however, it establishes a minimally viable toolbox for our institution through a rudimentary cost analysis. A similar analysis may aid others in better conceptualizing long-term costs not as nominal, often unwieldy prices, but as percent changes in spending. In regards to intraoperative outcomes, the use of a minimally viable toolbox did not result in increased estimated blood loss (EBL), operative time, or intraoperative complications.
Conclusion: Simple changes to surgeon preference and creative utilization of instruments can eliminate 40% of costs incurred on robotic instruments alone. Moreover, EBL, operative times, and intraoperative complications are not compromised as a result of cost reduction. Our process of identifying such improvements is straightforward and may be replicated by other robotic surgeons. Further prospective, multicenter trials should be initiated to assess other methods of cost-reduction.
Introduction Following a quarter century of experimental, widely unadapted predecessors, the Da Vinci surgical system is the first robotic surgical assistant to achieve broad utilization [1, 2]. Adoption has been rapid, despite high costs and only recently emerging long-term outcomes. Between 2007 and 2010, the number of robotically assisted procedures worldwide tripled [3], and, since 2008, robotically assisted laparoscopic prostatectomies (RALP) accounted for almost 80% of all radical prostatectomies performed in the United States [4, 5]. Analysis of outcomes has shown
Journal of Endourology Reducing Robotic Prostatectomy Costs by Minimizing Instrumentation (doi: 10.1089/end.2014.0533) This article has been peer-reviewed and accepted for publication, but has yet to undergo copyediting and proof correction. The final published version may differ from this proof.
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4 reduced hospital stays, reduced blood loss, comparable postsurgical margin rates, and higher survival in experienced hands as compared to past laparoscopic or open procedures [4, 6, 7, 8, 9]. Given such patient safety, wide physician acceptance, a yearly influx of almost 240,000 new prostate cancer diagnoses [10], and recent trends towards direct-to-consumer advertising [11], demand for RALP will likely continue to rise. As such, reigning in procedural cost becomes an increasingly important consideration. At a fixed cost of $1-2.5 million per da Vinci system [3, 12], and a variable cost per procedure estimated to range between $2,000 and $40,000, a complete substitution of conventional surgery by robotics would bloat national health spending by an estimated $2.5 billion annually [3]. Furthermore, although many industries witness falling prices as new technologies age, it is yet unclear whether the da Vinci surgical system will follow suit, or at what rate, given its lack of and high regulatory barriers to competition – qualities which dampen such cost reduction [13]. Eventually, competing and novel robotic surgery platforms will arrive and will likely lead to reduced costs [7, 14]. Until then, procedural changes can be made to improve cost effectiveness. Specifically, OR supplies have been identified in the literature as primary cost drivers [15, 16]. As such, our institution aimed to not only eliminate unused equipment but to also replace unnecessary equipment with more cost-effective alternatives. This paper summarizes our approach to considering instrumentation costs, not to validate any specific set of instruments, but to share with surgeons a novel way of thinking about the costs of their preference cards. Methods
Journal of Endourology Reducing Robotic Prostatectomy Costs by Minimizing Instrumentation (doi: 10.1089/end.2014.0533) This article has been peer-reviewed and accepted for publication, but has yet to undergo copyediting and proof correction. The final published version may differ from this proof.
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5 We studied improved surgical materials selection as one possible method of cost reduction. Two experienced robotic surgeons at our institution were queried about their preferred instrument usage for RALP. Surgical supply preference cards were compared and an exhaustive list of supplies enumerated. Costs of instruments and all materials were obtained from various internet retailers, tabulated, and sorted to identify prominent cost drivers (Figure 1). Finally, high-volume surgeons at three other institutions were consulted to explore possible and novel combinations of surgical supplies, and a minimally viable toolbox was identified. This minimally viable toolbox represents the bare, essential combination of RALP instruments: it minimizes the set of recognized cost-drivers by eliminating or replacing underutilized equipment with the highest impact to cost. The total price of our minimally viable toolbox – consisting, in our case, of monopolar shears, a prograsp, a fenestrated bipolar, one needle driver, and hemolok clips was then compared to more conventional alternatives, and relative cost improvements were calculated. Thereafter, our surgeons have been encouraged to consider the minimally viable toolbox as a baseline for selecting instruments, keeping in mind the percent change in cost due to various choices. Our institution-specific pricing data is restricted, but online retailer pricing serves effectively as a frame of reference for calculating these proportional changes. Of course, retail data should be substituted – when possible – by any specific cost schedule being analyzed. We performed a retrospective review of 125 patients who underwent RALP for prostate cancer from January 2012 to August 2013 by these two surgeons. We compared estimated blood loss, operative times, and intraoperative complications. Results
Journal of Endourology Reducing Robotic Prostatectomy Costs by Minimizing Instrumentation (doi: 10.1089/end.2014.0533) This article has been peer-reviewed and accepted for publication, but has yet to undergo copyediting and proof correction. The final published version may differ from this proof.
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6 The two surgeons queried for materials utilization each performed 64 and 61 RALP procedures in the 20 month period. Their use of surgical supplies is summarized in Figure 1. Four categories of supplies emerge: (1) energy-requiring vessel sealing instruments, comprising 28% of expenditures, (2) forceps and shears instruments, making up 27% of spending, and (3) expensive and (4) inexpensive miscellaneous equipment, comprising 29% and 16% of spending, respectively. Miscellaneous equipment consists of sutures, clips, draping, various trocars and specimen pouches, as well as other items whose use varies by procedure and may be difficult to predict. The two most expensive (by item) categories, consisting of far fewer, more predictably and consistently used items – e.g. Ligasure, monopolar shears, needle drivers, etc. – together make up 55% of operating room supply expenditures. Hence, we predicted that it would be easier to find savings by streamlining these two top-priced categories. Both surgeons use monopolar shears and a prograsp. In addition to these instruments, surgeon 1 utilizes a fenestrated bipolar, doubling as a forceps grasper, and thus he uses only 1 needle driver. Surgeon 1 does not use an energy source (e.g., ligasure or vessel sealer), and instead utilizes hemolok clips. Thus, surgeon 1 utilizes what we have dubbed the minimally viable toolbox for RALP. Alternatively, surgeon 2 utilizes two needle drivers, and either a fenestrated bipolar or PK dissector. In addition to this, surgeon 2 also uses a ligasure that is operated by a bedside assistant. As a result of the above modifications, the cost of the minimally viable toolbox was approximately 40% less than that of the second surgeon’s. The largest cost savings is through the elimination of an energy source and the usage of hemolok clips, which are inexpensive, retailing near two dollars each (Figure 1 and Figure 2). An energy source accounts for 25-30% of the cost of total robotic instruments. Utilizing the fenestrated bipolar as forceps can eliminate
Journal of Endourology Reducing Robotic Prostatectomy Costs by Minimizing Instrumentation (doi: 10.1089/end.2014.0533) This article has been peer-reviewed and accepted for publication, but has yet to undergo copyediting and proof correction. The final published version may differ from this proof.
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7 the need for a second needle driver, saving 12.5% of total instrument costs for surgeon 2. There is no significant cost savings when utilizing the bipolar over the PK dissector (1.2%). In assembling our minimally viable toolbox, surgeons at three other institutions were consulted, and some of their preferred instrumentation is compared in Figure 3. Again, sacrificing a needle driver and making do with as few instruments as possible accounts for significant savings, ranging between 16% and 32%. In addition to promising cost reductions, our records indicate a potential improvement in both average blood loss (148 v. 265 mL; p = 0.045) and operative time (132 v. 158 minutes; p = 0.001) associated with our adoption of the minimally viable toolbox and an overall absence of intraoperative complications in the 20 month period. Discussion: Robotic surgery is becoming more widely used for prostatectomy [17, 18]. The benefits of minimally invasive surgery – including decreased operative time, blood loss, length of hospital stay, and postoperative pain – have overcome the choice of open prostatectomy [19, 20]; however, the costs incurred by robotic surgery can be overwhelmingly expensive, compared to open or pure laparoscopic prostatectomy [21, 22, 23]. Several studies have attempted to identify and understand the predominant drivers of robotic surgery costs. Rebuck et al. reported that direct costs (surgical supplies, OR time, room, hospital stay) of robotic surgery are significant [16]. Tomaszewski et al. compared the cost of open versus RALP among four experienced surgeons in one institution. They reported that robotic surgery was more expensive than the traditional method. They demonstrated that cost
Journal of Endourology Reducing Robotic Prostatectomy Costs by Minimizing Instrumentation (doi: 10.1089/end.2014.0533) This article has been peer-reviewed and accepted for publication, but has yet to undergo copyediting and proof correction. The final published version may differ from this proof.
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8 differences were rooted in OR supplies and indirect costs, such as the purchase and maintenance of the robot [15]. A study by Bolenz et. al. aimed to predict factors responsible for direct costs associated with RALP using preoperative, intraoperative, and postoperative variables. They demonstrated that higher costs are driven by events occurring during the procedure (increased operating room time, use of a pelvic drain) or by those occurring postoperatively (transfusion, complications, length of hospital stay). Thus, although many of these higher costs could not be predicted preoperatively, the authors hypothesized that RALP cost reduction may be achieved by decreasing operative times and complications [12]. Other studies have tried to minimize costs of robotic surgery. Rebuck [16] also found significant improvements in both cost and time by using a dedicated nursing and anesthesia team familiar with RALP, by scheduling tasks in parallel (e.g. opening equipment while bringing the patient into the O.R. instead of in series), by setting time goals for trainees for each step of surgery, and by eliminating unused supplies - i.e. an extra needle driver, an extra stapler, unused irrigation fluid. They reported a cost reduction of 28% [16]. In fact, other studies have identified surgical instruments as primary RALP cost drivers, ripe for reductions [7, 25, 26]. Similarly, we attempted to improve our conceptualization of costs, which we hope will translate to sustained cost reductions. We surveyed two surgeons at our institution to better understand the minimum instruments required to successfully perform RALP. We report a simple method of identifying an institution’s instrumentation cost drivers and establishing a minimally viable toolbox of instruments for performing the procedure. This toolbox can then be compared to more traditional combinations of instruments. Notably, our analysis relies in part on the gathering of retail price information because medical supply price negotiations are
Journal of Endourology Reducing Robotic Prostatectomy Costs by Minimizing Instrumentation (doi: 10.1089/end.2014.0533) This article has been peer-reviewed and accepted for publication, but has yet to undergo copyediting and proof correction. The final published version may differ from this proof.
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9 contractually sealed and unpublishable at our institution. Nonetheless, assuming similar retail markups on all supplies, an analysis which compares product prices proportionally would not change at a different scale – i.e. 40% calculated savings would still be 40%, regardless of the nominal price. Undoubtedly, however, any use of this analysis procedure would be greatly improved with access to exact prices, avoiding such assumptions. To summarize, our analysis led us to eliminate a second needle driver with a fenestrated bipolar used in its place, reducing overall equipment costs and, possibly, operating room time. The fenestrated bipolar is able to both cauterize and grasp, thus theoretically reducing the time required for multiple instrument exchanges when hemostasis is desired. Further observations would need to be carried out to determine if this is, in fact, the case, however. Furthermore, obtaining hemostasis with inexpensive, yet effective hemolok clips virtually eliminates the cost of an extra hemostatic instrument. Of course, these specific changes may not be readily adoptable by all surgeons, but the process of identifying a comfortable, minimum instrumentation can provide surgeons with an easy and effective method of viewing their instruments as proportional expenditures, rather than as any specific dollar value without the context of a baseline minimal instrumentation. Again, our specific adjustments may not suit all surgeons, who should use our analysis to guide only their perceptions of cost, still considering other variables vital to selecting instruments: operative time, complications and blood loss, etc. Our study did not aim to validate our own minimally viable toolbox in this context, but nonetheless analyzed these factors. Blood loss and operative time were sampled by convenience, and an independent sample t-test was used to compare means in these metrics. Interestingly, surgeon 1, using the minimally viable toolbox, had a statistically significant improvement in both blood loss (148 v. 265 mL; p = 0.045) and operative
Journal of Endourology Reducing Robotic Prostatectomy Costs by Minimizing Instrumentation (doi: 10.1089/end.2014.0533) This article has been peer-reviewed and accepted for publication, but has yet to undergo copyediting and proof correction. The final published version may differ from this proof.
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10 time (132 v. 158 minutes; p = 0.001) over surgeon 2. Surgeon 1 did not have any intraoperative complications, while surgeon 2 reported one rectal enterotomy that was simply repaired. Such results, however, again only aim to report a cognizance of costs: reporting of blood loss is subjective, and operating time may depend more on surgeon and bedside assistance than on tools. Factors for intraoperative complications can be multifactorial, including difficulty of the case, patient anatomy, and surgeon and assistant skill. Moreover, our study is by no means a well-controlled, randomized experiment. Nonetheless, our results demonstrate that supply costs may be reconsidered and contained without compromising important metrics of efficiency and patient safety. Future studies should be undertaken to include such variables in the process for choosing a minimally viable toolbox, or to ever validate a universal one. Still, surgeons seeking to establish their own minimally viable toolbox should take these variables into consideration. Instrumentation is only one aspect of robotic prostatectomy cost. In a review, Bolenz concluded that, over all, RALP has not been shown to be cost effective in the perioperative period; however, long-term follow-up should consider the cost of future, derivative procedures (salvage therapy, stricture dilations, procedures for incontinence and erectile dysfunction), which may significantly impact a true assessment of costs [27]. Until long-term data for oncologic, continent, and potency outcomes of robotic surgery demonstrate superiority over conventional prostatectomy, it may be difficult to economically justify the use of robotics. Furthermore, even if RALP costs could be reduced, passage of savings to patients and in what ratio could not be guaranteed [15]. Nonetheless, Steinberg et al. postulates that a significant increase in caseloads can be profitable for high-volume, non-academic (no residents or fellows) institutions [28]. One can hope that the patient will eventually share in the benefits of said profitability. Despite such
Journal of Endourology Reducing Robotic Prostatectomy Costs by Minimizing Instrumentation (doi: 10.1089/end.2014.0533) This article has been peer-reviewed and accepted for publication, but has yet to undergo copyediting and proof correction. The final published version may differ from this proof.
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11 uncertainty, RALP continues to gain favor and is likely to remain a staple for prostatectomy, and, as such, cost reduction should continue to be explored, particularly on an individual level.
Conclusion: Robotic surgery costs can be minimized by identifying a minimally viable toolbox of instruments, eliminating the use of an energy source like the ligasure or vessel sealer, and utilizing an inexpensive tool such as hemolok clips. Additionally, the use of the fenestrated bipolar as forceps eliminates the need for a second needle driver. These changes can reduce costs incurred on robotic instruments alone by 40% or greater. Moreover, EBL, operative times, and intraoperative complications were not compromised as a result of cost reduction. Further prospective, multicenter trials should be initiated to assess other methods of cost-reduction. Although such changes may not be suitable to all surgeons, our straightforward process of identifying a minimally viable toolbox allows one to view costs not as nominal prices but as proportional deviations from a baseline. Thus, one can more fluidly remain cognizant of longterm costs before they accumulate.
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12 References 1. Kalan S, Chauhan S, Coelho RF, Orvieto MA, Camacho IR, Palmer KJ, Patel VR. History of robotic surgery. Journal of Robotic Surgery. 2010 July 22; 4:141-147. 2. Lanfranco AR, Castellanos AE, Desai JP, Meyers WC. Robotic surgery: a current perspective.Ann Surg. 2004 Jan;239(1):14-21. PubMed [citation] PMID: 14685095, PMCID: PMC1356187 3. Barbash GI, Glied SA. New technology and health care costs--the case of robotassisted surgery. N Engl J Med. 2010 Aug 19;363(8):701-4. doi: 10.1056/NEJMp1006602. PubMed [citation] PMID: 20818872 4. Cozzi G, Lorenzis ED, Palumbo C, Acquati P, Albo G, Dell'orto P, Grasso A, Rocco B. Robotic prostatectomy: an update on functional and oncologic outcomes. Ecancermedicalscience. 2013;7:355. PubMed [citation] PMID: 24101944, PMCID: PMC3788169 5. Jacobs EF, Boris R, Masterson TA. Advances in Robotic-Assisted Radical Prostatectomy over Time. Prostate Cancer. 2013;2013:902686. Epub 2013 Nov 12. PubMed [citation] PMID: 24327925, PMCID: PMC3845837 6. De Lorenzis E, Palumbo C, Cozzi G, Talso M, Rosso M, Costa B, Gadda F, Rocco B. Robotics in uro-oncologic surgery. Ecancermedicalscience. 2013;7:354. PubMed [citation] PMID: 24101943, PMCID: PMC3788173 7. Ahmed K, Ibrahim A, Wang TT, Khan N, Challacombe B, Khan MS, Dasgupta P. Assessing the cost effectiveness of robotics in urological surgery - a systematic review. BJU Int. 2012 Nov;110(10):1544-56. doi: 10.1111/j.1464410X.2012.11015.x. Epub 2012 Mar 22. PubMed [citation] PMID: 22443296 8. Ramsay C, Pickard R, Robertson C, Close A, Vale L, Armstrong N, Barocas DA, Eden CG, Fraser C, Gurung T, Jenkinson D, Jia X, Lam TB, Mowatt G, Neal DE, Robinson MC, Royle J, Rushton SP, Sharma P, Shirley MD, Soomro N. Systematic review and economic modeling of the relative clinical benefit and cost-effectiveness of laparoscopic surgery and robotic surgery for removal of the prostate in men with localised prostate cancer. Health Technol Assess. 2012;16(41):1-313. doi: 10.3310/hta16410. PubMed [citation] PMID: 23127367 9. Lowrance WT, Tarin TV, Shariat SF. Evidence-based comparison of robotic and open radical prostatectomy. ScientificWorldJournal. 2010 Nov 16;10:2228-37. doi: 10.1100/tsw.2010.218. PubMed [citation] PMID: 21103791 10. American Cancer Society. Cancer Facts & Figures 2013. Atlanta: American Cancer Society, 2013. 11. Mirkin JN, Lowrance WT, Feifer AH, Mulhall JP, Eastham JE, Elkin EB. Direct-toconsumer Internet promotion of robotic prostatectomy exhibits varying quality of information. Health Aff (Millwood). 2012 Apr;31(4):760-9. doi: 10.1377/hlthaff.2011.0329.PubMed [citation] PMID: 22492893, PMCID: PMC3897330
Journal of Endourology Reducing Robotic Prostatectomy Costs by Minimizing Instrumentation (doi: 10.1089/end.2014.0533) This article has been peer-reviewed and accepted for publication, but has yet to undergo copyediting and proof correction. The final published version may differ from this proof.
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12. Turchetti G, Palla I, Pierotti F, Cuschieri A. Economic evaluation of da Vinci-assisted robotic surgery: a systematic review. Surg Endosc. 2012 Mar;26(3):598-606. doi: 10.1007/s00464-011-1936-2. Epub 2011 Oct 13. PubMed [citation] PMID: 21993935 13. Brown A, Meenan BJ, Dixon D, Young TP, Brennan M. Application of the Experience Curve to Price Trends in Medical Devices: Implications for Product Development and Marketing Strategies. Journal of Medical Marketing: Device, Diagnostic, and Pharmaceutical Marketing. 2008; 8:241. 14. Shah BC, Buettner SL, Lehman AC, Farritor SM, Oleynikov D. Miniature in vivo robotics and novel robotic surgical platforms. Urol Clin North Am. 2009 May;36(2):251-63, x. doi: 10.1016/j.ucl.2009.02.013. PubMed [citation] PMID: 19406325 15. Tomaszewski JJ, Matchett JC, Davies BJ, Jackman SV, Hrebinko RL, Nelson JB. Comparative hospital cost-analysis of open and robotic-assisted radical prostatectomy. Urology. 2012 Jul;80(1):126-9. doi: 10.1016/j.urology.2012.03.020. Epub 2012 May 16.PubMed [citation] PMID: 22608294 16. Rebuck DA, Zhao LC, Helfand BT, Casey JT, Navai N, Perry KT, Nadler RB. Simple modifications in operating room processes to reduce the times and costs associated with robot-assisted laparoscopic radical prostatectomy. J Endourol. 2011 Jun;25(6):955-60. doi: 10.1089/end.2010.0534. Epub 2011 Apr 2. PubMed[citation] PMID: 21457071 17. Box GN, Ahlering TE. Robotic radical prostatectomy: long-term outcomes. Curr Opin Urol. 2008 Mar;18(2):173-9. doi: 10.1097/MOU.0b013e3282f517d6. PubMed [citation] PMID: 18303539 18. Hu JC, Wang Q, Pashos CL, Lipsitz SR, Keating NL. Utilization and outcomes of minimally invasive radical prostatectomy. J Clin Oncol. 2008 May 10;26(14):227884. doi: 10.1200/JCO.2007.13.4528.PubMed [citation] PMID: 18467718 19. Coelho RF, Chauhan S, Palmer KJ, Rocco B, Patel MB, Patel VR. Robotic-assisted radical prostatectomy: a review of current outcomes. BJU Int. 2009 Nov;104(10):1428-35. doi: 10.1111/j.1464-410X.2009.08895.x. Epub 2009 Oct 5. PubMed [citation] PMID: 19804427 20. Ficarra V, Novara G, Artibani W, Cestari A, Galfano A, Graefen M, Guazzoni G, Guillonneau B, Menon M, Montorsi F, Patel V, Rassweiler J, Van Poppel H. Retropubic, laparoscopic, and robot-assisted radical prostatectomy: a systematic review and cumulative analysis of comparative studies. Eur Urol. 2009 May;55(5):1037-63. doi: 10.1016/j.eururo.2009.01.036. Epub 2009 Jan 25. PubMed [citation] PMID: 19185977 21. Bolenz C, Gupta A, Hotze T, Ho R, Cadeddu JA, Roehrborn CG, Lotan Y. Cost comparison of robotic, laparoscopic, and open radical prostatectomy for prostate cancer. Eur Urol. 2010 Mar;57(3):453-8. doi: 10.1016/j.eururo.2009.11.008. Epub 2009 Nov 11.PubMed [citation] PMID: 19931979
Journal of Endourology Reducing Robotic Prostatectomy Costs by Minimizing Instrumentation (doi: 10.1089/end.2014.0533) This article has been peer-reviewed and accepted for publication, but has yet to undergo copyediting and proof correction. The final published version may differ from this proof.
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22. Murphy DG, Bjartell A, Ficarra V, Graefen M, Haese A, Montironi R, Montorsi F, Moul JW, Novara G, Sauter G, Sulser T, van der Poel H. Downsides of robot-assisted laparoscopic radical prostatectomy: limitations and complications. Eur Urol. 2010 May;57(5):735-46. doi: 10.1016/j.eururo.2009.12.021. Epub 2009 Dec 28. PubMed [citation] PMID: 20036784 23. Lotan Y, Cadeddu JA, Gettman MT. The new economics of radical prostatectomy: cost comparison of open, laparoscopic and robot assisted techniques. J Urol. 2004 Oct;172(4 Pt 1):1431-5.PubMed [citation] PMID: 15371862 24. Bolenz C, Gupta A, Roehrborn CG, Lotan Y. Predictors of costs for robotic-assisted laparoscopic radical prostatectomy. Urol Oncol. 2011 May-Jun;29(3):325-9. doi: 10.1016/j.urolonc.2011.01.016. PubMed [citation] PMID: 21555102 25. Joseph, J., Leonhardt, A., Patel, Hitendra. "The cost of radical prostatectomy: retrospective comparison of open, laparoscopic, and robot-assisted approached." Journal of robotic Surgery, 2008: 21-24. 26. Mouraviev V, Nosnik I, Sun L, Robertson CN, Walther P, Albala D, Moul JW, Polascik TJ. Financial comparative analysis of minimally invasive surgery to open surgery for localized prostate cancer: a single-institution experience. Urology. 2007 Feb;69(2):311-4.PubMed [citation] PMID: 17320670 27. Bolenz C, Freedland SJ, Hollenbeck BK, Lotan Y, Lowrance WT, Nelson JB, Hu JC. Costs of radical prostatectomy for prostate cancer: a systematic review. Eur Urol. 2013 Feb;65(2):316-24. doi: 10.1016/j.eururo.2012.08.059. Epub 2012 Sep 5. PubMed [citation] PMID: 22981673 28. Steinberg PL, Merguerian PA, Bihrle W 3rd, Heaney JA, Seigne JD. A da Vinci robot system can make sense for a mature laparoscopic prostatectomy program. JSLS. 2008 Jan-Mar;12(1):9-12.PubMed [citation] PMID: 18402732, PMCID: PMC3016020
Abbreviations Used RALP = Robotically Assisted Laparoscopic Prostatectomy OR = Operating Room EBL = Estimated Blood Loss
Journal of Endourology Reducing Robotic Prostatectomy Costs by Minimizing Instrumentation (doi: 10.1089/end.2014.0533) This article has been peer-reviewed and accepted for publication, but has yet to undergo copyediting and proof correction. The final published version may differ from this proof. Page 15 of 22
15
Journal of Endourology Reducing Robotic Prostatectomy Costs by Minimizing Instrumentation (doi: 10.1089/end.2014.0533) This article has been peer-reviewed and accepted for publication, but has yet to undergo copyediting and proof correction. The final published version may differ from this proof.
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16
Figure 1.The bar graph ranks 20 months’ supply prices per-use, divided into four categories and compared by proportion of spending in the overlying pie chart.
Journal of Endourology Reducing Robotic Prostatectomy Costs by Minimizing Instrumentation (doi: 10.1089/end.2014.0533) This article has been peer-reviewed and accepted for publication, but has yet to undergo copyediting and proof correction. The final published version may differ from this proof. Page 17 of 22
17
Figure 2. The minimally viable toolbox uses no Ligasure and one needle-driver, leading to a 40% cost reduction compared to instrumentation combinations within our institution.
18 Manufacturer Number
Unit Price
Retailer
HANDPIECE LIGASURE LAP SEALER DIV DISP 5MM HANDPIECE LIGASURE VESSEL SEALER/DIV DISP 5MM SEALANT FIBRIN HUMAN TISSEEL PRE-FILL 10ML ENDO STITCH 10M 173016 KIT FLOSEAL HEMOSTATIC MATRIX 5ML
LF1537 LF1537 1501238 173016 1501825
$ $ $ $ $
762.01 762.01 698.92 487.84 429.00
ciamedical.com ciamedical.com ecomm.baxter.com ciamedical.com medexsupply.com
ENDO CATCH II 15M Monopolar Shears ENDO CLIP III MED-LRG 5MM ENDO GIA STAPLER THICK 60 MED PK Dissector Fenestrated Bipolar SEALER VESSEL ENDOWRIST ONE DISP ENDO GIA STAPLER VASCULAR 60 MED Needle Driver Prograsp ENDO CLIP APPLIER MD/LG 5M
173049
335.51 320.00 300.00 295.00 290.00 270.00 250.00 235.00 220.00 220.00 216.67
medequipdepot.com
EL5ML
$ $ $ $ $ $ $ $ $ $ $
NB15STF EGIA45AVM 30403 176674PF G11327 16400 POUCH 173050G tlc75 b12L 1946 52306 00496-0523-06 B12 B12 B12 us349sp 2216 176626P G14813 b12lt 6640 tcr75 VS101012P
$ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $
186.43 180.00 169.00 168.01 144.08 140.77 140.00 100.00 100.00 100.00 100.00 100.00 100.00 100.00 100.00 100.00 97.07 96.04 95.00 92.75 91.67 86.75 80.00 75.00
Category 3
Category 1
Tool
Category 2
Journal of Endourology Reducing Robotic Prostatectomy Costs by Minimizing Instrumentation (doi: 10.1089/end.2014.0533) This article has been peer-reviewed and accepted for publication, but has yet to undergo copyediting and proof correction. The final published version may differ from this proof.
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ENDO TROCAR VPORT+ BL STD FIXN 15MM ENDO GIA STAPLER VASCULAR 45 MED HANDLE ENDO GIA UNIV 12M ENDO TROCAR VISIPORT+ OPT FIXN 5-12MM LSCP LAPSAC SURG TISSUE POUCH 10 X 8 PLEUROVAC EXPRESS CHEST DRAIN ADULT ENDO CATCH POUCH ENDO CATCH POUCH GOLD 10MM ENDO STAPLER LNR CUTTER BLUE 75MM TLC75 ENDO TROCAR BLADELESS W/STAB SLEEVE 10/12MM HEMOSTAT SURGICEL NUKNIT 6X9 ADHESIVE MASTISOL STRL 4OZ ADHESIVE MASTISOL STRL 4OZ ENDO TROCAR BLADELESS W/STAB SLEEVE 10/12MM ENDO TROCAR BLADELESS W/STAB SLEEVE 10/12MM ENDO TROCAR BLADELESS W/STAB SLEEVE 10/12MM CORD BOVIE BIPOLAR STRL DISP DRAIN BLAKE FLAT FLUTD 3/4 19F ENDO TROCAR BLUNTPORT PLUS 5-12MM CATH SUPRAPUBIC PERC STAMEY ENDO TROCAR XCEL 12 X 100 B12LT DRAPE STERI IOBAN 6640 13X13 ENDO RELOAD BLUE 75MM TCR75 ENDO VERSASTEP PLUS TROCAR 12MM
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right: surgeons from other institutions would save 18%, 16%, and 32% if using our minimally viable toolbox; identifying one’s own minimally viable toolbox may yield similar savings.
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Journal of Endourology Reducing Robotic Prostatectomy Costs by Minimizing Instrumentation (doi: 10.1089/end.2014.0533) This article has been peer-reviewed and accepted for publication, but has yet to undergo copyediting and proof correction. The final published version may differ from this proof. Category 4
Page 19 of 22 ENDO TROCAR XCEL 5 X 100 B5LT (R) DRAIN BLAKE ROUND 1/4' TROCAR 19FR CATH FOLEY HEMATURIA 3-WAY 24FR 30ML ENDO TROCAR VPORT+ BL STD FIXN 12MM ENDO TROCAR VPORT+ BL STD FIXN 5MM SURGICLIP II PREM TI M-11.5 ENDO STAPLER LNR BLUE 60 X 3.5 TX60B DRAIN BLAKE ROUND 3/16" TROCAR 15F SURGICLIP II PREM TI M-9.75 TUBING SURGICAL SUCT DEVICE DISP TIP DRAPE WARMING SYSTEM DISP 66 X 66 TISSEEL ACCESORY DUPLOCAT # 25 HEMOSTAT GELDOAM SPONZE SZ100 HEMOSTAT GELFOAM SPONGE SZ 100 BOVIE CORD BIPOLAR DISP SUT MONOCRYL 3-0 UR-6 D9503 HEMOSTAT SURGICEL STRL 2X14 HEMOSTAT SURGICEL STRL 4X8 CATH FOLEY COUNCILL 20FR 5ML SUT V-LOC 180 CLOS DEVIC 0 GR 12 GS-21 SUT V-LOC 180 CLOS DEVIC 2-0 GR 12 GS-21 CATH FOLEY 3-WAY 24FR 30ML SUT V-LOC 180 ABS CLOS DEVIC 3-0 GR 6 CV-23 ENDO TROCAR VPORT+ V2 FIXN 5MM CATH FOLEY COUDE 2-WAY 22FR 5ML TRAY CATH FOLEY LUBRI W/URINE METER 16FR STAPLER SKIN MULTI PREM 35W PRW35 ENDO CLIP LAPRA-TY XC200 DERMABOND SKIN ADHESIVE TOPICAL HI VISCOSITY PAD DEFIB HP CODEMASTER DISP DRAPE ROBOT CAMERA ARM DISP SEAL ROBOT CANNULA DISP TRAY URINE METER LF 16FR DRAIN JP RESERVOIR 400CC LUBRICANT ELECTROLUBE ENDO SURGINEEDLE 120MM PN120 COVER ROBOT TIP ACCESSORY DISP HC CATH SWAN GANZ W/COAT 7.5FR CLOSESURE CARTER-THOMASON SYSTEM (R) TUBING INSUFFLATOR HEATED HIGH FLOW SUT QUILL MONODERM 2-0 18MM DMND PNT 3/8C YA-1012Q OVERLAY EGGCRATE OVERLAY EGGCRATE HC GWIRE ARROW DUOFLX.025 X 17 3/4 SUT QUILL PDO 1 14 X 14 36MM TAPER 1/2 CRCL RA-1003Q CATH FOLEY 3-WAY 22FR 30ML DRAPE ROBOT S INSTRUMENT ARM DISP ENDO SCISSOR DISP PACK BASIN DOUBLE TRAY URINE METER 200ML CATH FOLEY 2-WAY 18FR 30ML CATH FOLEY 2-WAY 20FR 30ML CATH FOLEY 2-WAY 24FR 30ML DRAIN JP RESERVOIR 100CC CATH FOLEY 2-WAY 22FR 5ML CATH FOLEY 2-WAY 20FR 5ML CATH FOLEY 2-WAY 18FR 5ML CATH FOLEY 2-WAY 24FR 5ML
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Journal of Endourology Reducing Robotic Prostatectomy Costs by Minimizing Instrumentation (doi: 10.1089/end.2014.0533) This article has been peer-reviewed and accepted for publication, but has yet to undergo copyediting and proof correction. The final published version may differ from this proof.
Page 20 of 22 PACK LAPAROSCOPY SUT PROLENE 4-0 RB-1 DA 36 8557H HC SOL GLYCINE 1.5% 3000ML 2B7317 SUT MONOCRYL 4-0 PS-2 27 Y426H TAPE MEDIPORE H 4 X 10 YD PACK BASIN SINGLE HC SOL NACL IRR 0.9%3000ML 2B7127 ENDO SLEEVE VSEAL+ FIXN 5-12MM HC CATH ARTERY RADIAL 20 X 1 3/4 NEEDLE MACROPLASTIQUE ENDOSCOPIC DRAPE COVER MAYO STAND 23" WATER IRRIG BAG 3000ML 2B7117 HC SOL NACL IRR 0.9%3000ML 2B7127 SUT VICRYL 4-0 PS-2 18 J496H SUT SILK 2-0 PS 18 1588H DRAPE ROBOT CAMERA DISP SUT ETHILON 2-0 PS 18 585H ENDO CLIP HEM-O-LOK LRG ENDO CLIP HEM-O-LOK MED LRG ENDO CLIP HEM-O-LOK XLG ENDO CLIP HEM-O-LOK LRG ENDO CLIP HEM-O-LOK MED LRG ENDO CLIP HEM-O-LOK XLG GOWN SURG IMPERVIOUS SLEEVE XXL DRAPE ENDOSCOPIC GENERAL 98X77 CATH THORACIC STRT 32FR 20IN DRAPE LEGGINGS PACK IN VIEW CLEAR 30 X 55 BAG DRAIN URINARY 4000ML ANCHOR FOLEY CATH PE FOAM BOVIE HANDSWITCH W/HOLSTER ENDO REDUCER CAP TROCAR 5-12M OBTURATOR ROBOT BLADELESS 8MM BOVIE GROUND PAD POLYHESIVE RED SUT PROLENE 2-0 KS 30 8623H SUT MONOCRYL 3-0 27IN RB-1 Y305H GOWN SURG IMPERVIOUS SLEEVE XLG GOWN SURG IMPERVIOUS SLEEVE LRG BUTTON STRL ORTHO ETHCON 520G SUT PDS II 1 CT-1 27 Z341H BOVIE ELECTRODE BLADE EXT 6" SUT MONOCRYL 2-0 CP-1 27 Y266H SUT MONOCRYL 2-0 CT-1 36 Y945H SUT MONOCRYL 2-0 CT-2 27 Y333H SUT MONOCRYL 2-0 SH 27 Y317H SEAL SCOPE WARMER DISP SET CYSTO BLADDER IRRIG LIGHT HANDLE STRL DISP 1 PK SUT MONOCRYL 0 CT-1 36 Y946H BLANKET WARM BAIR HUGGER UPPER SUT MONOCRYL 0 CT-1 CR 8-18 Y740D BAG DRAIN URINARY 2000ML RETRACTOR ABD FISH VISCERA DISP SUT VICRYL 0 UR-6 27 J603H DRAPE XRAY CASSETTE 20X23" SUT VICRYL 0 CT-2 27 J334H HC SOL PLASMA LYT INJ PH7.4 1000M 2B2544X SUT VICRYL 0 CT-1 27 J340H TAPE 3M CLOTH ADHESIVE 3 X 10 WATER IRRIG BTL 1500ML 2F7115 SUT VICRYL 0 CT-1 36 J946H SUT VICRYL 2-0 CT-2 27 J333H SUT VICRYL 2-0 SH 27 J417H SET TUR CYSTO UROMATIC IRRIG HC SOL NACL INJ 0.9%500ML 2B1323Q TRAY SKIN SCRUB W/GEL HC SOL NACL INJ 0.9% 1000M 2B1324X DRSG TEGADERM TRANSP STRL 6 X 8 GLOVE SURG LF PF DERMAPRENE 7.0 HC CATH IV AUTOGUARD INSYTE W/WING 16 X 1.16 HC CATH IV AUTOGUARD INSYTE W/WING 18 X 1.16 HC CATH IV AUTOGUARD INSYTE W/WING 22 X 1 TAPE DURAPORE SILK 3 X 10YD SUT VICRYL 3-0 SH CR 8-18 J774D DRAPE SHEET 3/4 REINF 56X77" SOL NACL IRR POUR 0.9%1000CC 2F7124 POUR BOTTLE HC CATH IV AUTOGUARD INSYTE W/WING 20 X 1 HC SOL NACL INJ 0.9% 1000M 2B1324X SYRINGE DISP TOOMEY CATH LUER TIP 70ML HEMOCLIP WECK DISP LRG HEMOCLIP WECK DISP LRG
29242 8557h 2B7317 y426h 2864 13752-624 2b7127 175772p RA-04020 MRN-420 8337 2b7117 2b7127 j496h 1588h 400027 585h 544240 544230 544250 544240 544230 544250 9071 DYNJP2492 8888570556 8430 153509 FCS200XT ESP1H 1seal 420023 A1202 8623h y305h 9041 9011 520g z341h ES04T y266h y945h y333h y317h c3101 2c4040 31140257 y946h 522 y740d 154002 3204 j603h 1009 j334h 2b2544x j340h 2950-3 2f7115 j946h j333h j417h 2C4006 2b1323q DYND70356 2b1324x 1628 8514 BD381454 BD381444 BD381423 1538-3 j774d 9349CE 2f7124 BD381433 2b1324x BRD0038460 523370 523370
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12.40 12.00 11.80 11.25 11.05 10.78 10.10 10.00 9.99 9.99 9.80 9.75 9.36 9.17 8.00 8.00 7.75 7.44 7.44 7.44 7.44 7.44 7.44 7.27 7.10 7.10 6.88 6.71 6.37 6.05 6.00 6.00 5.80 5.75 5.56 5.28 5.26 5.25 5.25 5.17 5.00 5.00 5.00 5.00 5.00 4.99 4.91 4.50 4.50 4.38 4.22 4.19 4.00 3.96 3.83 3.81 3.78 3.78 3.77 3.50 3.50 3.50 3.32 3.25 3.20 3.18 3.16 3.05 3.01 2.86 2.86 2.84 2.81 2.79 2.69 2.62 2.61 2.40 2.31 2.31
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Journal of Endourology Reducing Robotic Prostatectomy Costs by Minimizing Instrumentation (doi: 10.1089/end.2014.0533) This article has been peer-reviewed and accepted for publication, but has yet to undergo copyediting and proof correction. The final published version may differ from this proof.
Page 21 of 22 TUBE SALEM SUMP 18FX48" SUT SILK 3-0 SH CR 8-18 C013D DRSG MEDIPORE + PAD ADH STRL 3.5 X 13.75 GLOVE SURG LTX PF BRWN MICROPTIC 8.0 GLOVE SURG LTX PF BRWN MICROPTIC 8.5 GLOVE SURG LTX PF BRWN MICROPTIC 6.5 GLOVE SURG LTX PF BRWN MICROPTIC 7.5 GLOVE SURG LTX PF WHT ACCLAIM 7.5 HC SOL NACL INJ 45% 1000CC 2B1314X HC DEX 5% AND .45% NACL 1000ML 2B1074X HC SOL NACL INJ 0.9%500ML 2B1323Q HEMOCLIP WECK DISP LRG SYRINGE DISP LL CONTROL 10ML SUCTION YANKAUER STR DISP BLADE SURGICAL SS 11 PATTIE SURG COTTONOID 1/2X3 SPONGE LAP PREWASHED 18 X 18 5 PK HEMOCLIP WECK DISP MED HEMOCLIP WECK DISP SML SYRINGE DISP TOOMEY DR TORUFF 60ML GLOVE SURG LTX PWD WHT MICRO-TOUCH 7.5 GLOVE SURG LTX PWD WHT MICRO-TOUCH 8.5 SYRINGE DISP LL 20ML STRIP SURGICAL 1/2 X 6 STRIP SURGICAL 1.5 X 6 NEEDLE HYPO SAFETYGLIDE 25 X 1 CONTAINER SPEC STRL SCRTOP 7OZ STERI STRIP 3M SKIN CLOSURE REINFORCED 1/2 X 4 CONTAINER SPEC STRL SCRTOP 4OZ DRSG TELFA ISLAND ADH 2 X 3.50 DRSG KERLIX SPONGE NSTRL 6 X 6.75 LINER CLEAR 24 X 32 LINER CLEAR 24 X 32 DRSG TELFA NON ADH STRL 4 X 3 DRSG SPONGE GAUZE STRL 4 X 4 12-PLY PK/2 DRSG CURITY SPONGE STRL 12-PLY 4 X 4 LUBRICANT JELLY MEDICHOICE STRL 3GR BAG SPEC BIOHAZARD 6 X 9 DRSG SPONGE STRL 8-PLY 2 X 2 PK/2
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Journal of Endourology Reducing Robotic Prostatectomy Costs by Minimizing Instrumentation (doi: 10.1089/end.2014.0533) This article has been peer-reviewed and accepted for publication, but has yet to undergo copyediting and proof correction. The final published version may differ from this proof.
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1
Reducing Robotic Prostatectomy Costs by Minimizing Instrumentation
Joan C. Delto MD Department of Urology, Mount Sinai Medical Center, Miami Beach FL George Wayne BS College of Medicine, Florida International University, Miami FL Rafael Yanes MD Department of Urology, Mount Sinai Medical Center, Miami Beach FL Alan M. Nieder MD Department of Urology, Mount Sinai Medical Center, Miami Beach FL Akshay Bhandari MD Department of Urology, Mount Sinai Medical Center, Miami Beach FL
Journal of Endourology Reducing Robotic Prostatectomy Costs by Minimizing Instrumentation (doi: 10.1089/end.2014.0533) This article has been peer-reviewed and accepted for publication, but has yet to undergo copyediting and proof correction. The final published version may differ from this proof.
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2
ABSTRACT:
Introduction and Objective:
Since the introduction of robotic surgery for radical prostatectomy, the cost-benefit of this technology has been under scrutiny. While robotic surgery professes to offer multiple advantages including reduced blood loss, reduced length of stay, and expedient recovery, the associated costs tend to be significantly higher, secondary to the fixed cost of the robot as well as the variable costs associated with instrumentation. This study provides a simple framework for the careful consideration of costs during the selection of equipment and materials.
Methods:
Two experienced robotic surgeons at our institution as well as several at other institutions were queried about their preferred instrument usage for robotically assisted prostatectomy. Costs of instruments and materials were obtained and clustered by type and price. A minimal set of instruments was identified and compared against alternative instrumentation. A retrospective review of 125 patients who underwent RALP for prostate cancer at our institution was performed to compare estimated blood loss, operative times, and intraoperative complications for both surgeons. Our surgeons now conceptualize instrument costs as proportional changes to the cost of the baseline, minimal combination.
Results:
Robotic costs at our institution were reduced by eliminating an energy source like the ligasure or vessel sealer, exploiting instruments’ versatility, and utilizing inexpensive tools such as hemolok
Journal of Endourology Reducing Robotic Prostatectomy Costs by Minimizing Instrumentation (doi: 10.1089/end.2014.0533) This article has been peer-reviewed and accepted for publication, but has yet to undergo copyediting and proof correction. The final published version may differ from this proof.
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3 clips. Such modifications reduced surgeon 1’s cost of instrumentation to approximately 40% less than that of surgeon 2 and up to 32% less than instrumentation used by surgeons at other institutions. Surgeon 1’s combination may not be optimal for all robotic surgeons; however, it establishes a minimally viable toolbox for our institution through a rudimentary cost analysis. A similar analysis may aid others in better conceptualizing long-term costs not as nominal, often unwieldy prices, but as percent changes in spending. In regards to intraoperative outcomes, the use of a minimally viable toolbox did not result in increased estimated blood loss (EBL), operative time, or intraoperative complications.
Conclusion: Simple changes to surgeon preference and creative utilization of instruments can eliminate 40% of costs incurred on robotic instruments alone. Moreover, EBL, operative times, and intraoperative complications are not compromised as a result of cost reduction. Our process of identifying such improvements is straightforward and may be replicated by other robotic surgeons. Further prospective, multicenter trials should be initiated to assess other methods of cost-reduction.
Introduction Following a quarter century of experimental, widely unadapted predecessors, the Da Vinci surgical system is the first robotic surgical assistant to achieve broad utilization [1, 2]. Adoption has been rapid, despite high costs and only recently emerging long-term outcomes. Between 2007 and 2010, the number of robotically assisted procedures worldwide tripled [3], and, since 2008, robotically assisted laparoscopic prostatectomies (RALP) accounted for almost 80% of all radical prostatectomies performed in the United States [4, 5]. Analysis of outcomes has shown
Journal of Endourology Reducing Robotic Prostatectomy Costs by Minimizing Instrumentation (doi: 10.1089/end.2014.0533) This article has been peer-reviewed and accepted for publication, but has yet to undergo copyediting and proof correction. The final published version may differ from this proof.
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4 reduced hospital stays, reduced blood loss, comparable postsurgical margin rates, and higher survival in experienced hands as compared to past laparoscopic or open procedures [4, 6, 7, 8, 9]. Given such patient safety, wide physician acceptance, a yearly influx of almost 240,000 new prostate cancer diagnoses [10], and recent trends towards direct-to-consumer advertising [11], demand for RALP will likely continue to rise. As such, reigning in procedural cost becomes an increasingly important consideration. At a fixed cost of $1-2.5 million per da Vinci system [3, 12], and a variable cost per procedure estimated to range between $2,000 and $40,000, a complete substitution of conventional surgery by robotics would bloat national health spending by an estimated $2.5 billion annually [3]. Furthermore, although many industries witness falling prices as new technologies age, it is yet unclear whether the da Vinci surgical system will follow suit, or at what rate, given its lack of and high regulatory barriers to competition – qualities which dampen such cost reduction [13]. Eventually, competing and novel robotic surgery platforms will arrive and will likely lead to reduced costs [7, 14]. Until then, procedural changes can be made to improve cost effectiveness. Specifically, OR supplies have been identified in the literature as primary cost drivers [15, 16]. As such, our institution aimed to not only eliminate unused equipment but to also replace unnecessary equipment with more cost-effective alternatives. This paper summarizes our approach to considering instrumentation costs, not to validate any specific set of instruments, but to share with surgeons a novel way of thinking about the costs of their preference cards. Methods
Journal of Endourology Reducing Robotic Prostatectomy Costs by Minimizing Instrumentation (doi: 10.1089/end.2014.0533) This article has been peer-reviewed and accepted for publication, but has yet to undergo copyediting and proof correction. The final published version may differ from this proof.
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5 We studied improved surgical materials selection as one possible method of cost reduction. Two experienced robotic surgeons at our institution were queried about their preferred instrument usage for RALP. Surgical supply preference cards were compared and an exhaustive list of supplies enumerated. Costs of instruments and all materials were obtained from various internet retailers, tabulated, and sorted to identify prominent cost drivers (Figure 1). Finally, high-volume surgeons at three other institutions were consulted to explore possible and novel combinations of surgical supplies, and a minimally viable toolbox was identified. This minimally viable toolbox represents the bare, essential combination of RALP instruments: it minimizes the set of recognized cost-drivers by eliminating or replacing underutilized equipment with the highest impact to cost. The total price of our minimally viable toolbox – consisting, in our case, of monopolar shears, a prograsp, a fenestrated bipolar, one needle driver, and hemolok clips was then compared to more conventional alternatives, and relative cost improvements were calculated. Thereafter, our surgeons have been encouraged to consider the minimally viable toolbox as a baseline for selecting instruments, keeping in mind the percent change in cost due to various choices. Our institution-specific pricing data is restricted, but online retailer pricing serves effectively as a frame of reference for calculating these proportional changes. Of course, retail data should be substituted – when possible – by any specific cost schedule being analyzed. We performed a retrospective review of 125 patients who underwent RALP for prostate cancer from January 2012 to August 2013 by these two surgeons. We compared estimated blood loss, operative times, and intraoperative complications. Results
Journal of Endourology Reducing Robotic Prostatectomy Costs by Minimizing Instrumentation (doi: 10.1089/end.2014.0533) This article has been peer-reviewed and accepted for publication, but has yet to undergo copyediting and proof correction. The final published version may differ from this proof.
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6 The two surgeons queried for materials utilization each performed 64 and 61 RALP procedures in the 20 month period. Their use of surgical supplies is summarized in Figure 1. Four categories of supplies emerge: (1) energy-requiring vessel sealing instruments, comprising 28% of expenditures, (2) forceps and shears instruments, making up 27% of spending, and (3) expensive and (4) inexpensive miscellaneous equipment, comprising 29% and 16% of spending, respectively. Miscellaneous equipment consists of sutures, clips, draping, various trocars and specimen pouches, as well as other items whose use varies by procedure and may be difficult to predict. The two most expensive (by item) categories, consisting of far fewer, more predictably and consistently used items – e.g. Ligasure, monopolar shears, needle drivers, etc. – together make up 55% of operating room supply expenditures. Hence, we predicted that it would be easier to find savings by streamlining these two top-priced categories. Both surgeons use monopolar shears and a prograsp. In addition to these instruments, surgeon 1 utilizes a fenestrated bipolar, doubling as a forceps grasper, and thus he uses only 1 needle driver. Surgeon 1 does not use an energy source (e.g., ligasure or vessel sealer), and instead utilizes hemolok clips. Thus, surgeon 1 utilizes what we have dubbed the minimally viable toolbox for RALP. Alternatively, surgeon 2 utilizes two needle drivers, and either a fenestrated bipolar or PK dissector. In addition to this, surgeon 2 also uses a ligasure that is operated by a bedside assistant. As a result of the above modifications, the cost of the minimally viable toolbox was approximately 40% less than that of the second surgeon’s. The largest cost savings is through the elimination of an energy source and the usage of hemolok clips, which are inexpensive, retailing near two dollars each (Figure 1 and Figure 2). An energy source accounts for 25-30% of the cost of total robotic instruments. Utilizing the fenestrated bipolar as forceps can eliminate
Journal of Endourology Reducing Robotic Prostatectomy Costs by Minimizing Instrumentation (doi: 10.1089/end.2014.0533) This article has been peer-reviewed and accepted for publication, but has yet to undergo copyediting and proof correction. The final published version may differ from this proof.
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7 the need for a second needle driver, saving 12.5% of total instrument costs for surgeon 2. There is no significant cost savings when utilizing the bipolar over the PK dissector (1.2%). In assembling our minimally viable toolbox, surgeons at three other institutions were consulted, and some of their preferred instrumentation is compared in Figure 3. Again, sacrificing a needle driver and making do with as few instruments as possible accounts for significant savings, ranging between 16% and 32%. In addition to promising cost reductions, our records indicate a potential improvement in both average blood loss (148 v. 265 mL; p = 0.045) and operative time (132 v. 158 minutes; p = 0.001) associated with our adoption of the minimally viable toolbox and an overall absence of intraoperative complications in the 20 month period. Discussion: Robotic surgery is becoming more widely used for prostatectomy [17, 18]. The benefits of minimally invasive surgery – including decreased operative time, blood loss, length of hospital stay, and postoperative pain – have overcome the choice of open prostatectomy [19, 20]; however, the costs incurred by robotic surgery can be overwhelmingly expensive, compared to open or pure laparoscopic prostatectomy [21, 22, 23]. Several studies have attempted to identify and understand the predominant drivers of robotic surgery costs. Rebuck et al. reported that direct costs (surgical supplies, OR time, room, hospital stay) of robotic surgery are significant [16]. Tomaszewski et al. compared the cost of open versus RALP among four experienced surgeons in one institution. They reported that robotic surgery was more expensive than the traditional method. They demonstrated that cost
Journal of Endourology Reducing Robotic Prostatectomy Costs by Minimizing Instrumentation (doi: 10.1089/end.2014.0533) This article has been peer-reviewed and accepted for publication, but has yet to undergo copyediting and proof correction. The final published version may differ from this proof.
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8 differences were rooted in OR supplies and indirect costs, such as the purchase and maintenance of the robot [15]. A study by Bolenz et. al. aimed to predict factors responsible for direct costs associated with RALP using preoperative, intraoperative, and postoperative variables. They demonstrated that higher costs are driven by events occurring during the procedure (increased operating room time, use of a pelvic drain) or by those occurring postoperatively (transfusion, complications, length of hospital stay). Thus, although many of these higher costs could not be predicted preoperatively, the authors hypothesized that RALP cost reduction may be achieved by decreasing operative times and complications [12]. Other studies have tried to minimize costs of robotic surgery. Rebuck [16] also found significant improvements in both cost and time by using a dedicated nursing and anesthesia team familiar with RALP, by scheduling tasks in parallel (e.g. opening equipment while bringing the patient into the O.R. instead of in series), by setting time goals for trainees for each step of surgery, and by eliminating unused supplies - i.e. an extra needle driver, an extra stapler, unused irrigation fluid. They reported a cost reduction of 28% [16]. In fact, other studies have identified surgical instruments as primary RALP cost drivers, ripe for reductions [7, 25, 26]. Similarly, we attempted to improve our conceptualization of costs, which we hope will translate to sustained cost reductions. We surveyed two surgeons at our institution to better understand the minimum instruments required to successfully perform RALP. We report a simple method of identifying an institution’s instrumentation cost drivers and establishing a minimally viable toolbox of instruments for performing the procedure. This toolbox can then be compared to more traditional combinations of instruments. Notably, our analysis relies in part on the gathering of retail price information because medical supply price negotiations are
Journal of Endourology Reducing Robotic Prostatectomy Costs by Minimizing Instrumentation (doi: 10.1089/end.2014.0533) This article has been peer-reviewed and accepted for publication, but has yet to undergo copyediting and proof correction. The final published version may differ from this proof.
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9 contractually sealed and unpublishable at our institution. Nonetheless, assuming similar retail markups on all supplies, an analysis which compares product prices proportionally would not change at a different scale – i.e. 40% calculated savings would still be 40%, regardless of the nominal price. Undoubtedly, however, any use of this analysis procedure would be greatly improved with access to exact prices, avoiding such assumptions. To summarize, our analysis led us to eliminate a second needle driver with a fenestrated bipolar used in its place, reducing overall equipment costs and, possibly, operating room time. The fenestrated bipolar is able to both cauterize and grasp, thus theoretically reducing the time required for multiple instrument exchanges when hemostasis is desired. Further observations would need to be carried out to determine if this is, in fact, the case, however. Furthermore, obtaining hemostasis with inexpensive, yet effective hemolok clips virtually eliminates the cost of an extra hemostatic instrument. Of course, these specific changes may not be readily adoptable by all surgeons, but the process of identifying a comfortable, minimum instrumentation can provide surgeons with an easy and effective method of viewing their instruments as proportional expenditures, rather than as any specific dollar value without the context of a baseline minimal instrumentation. Again, our specific adjustments may not suit all surgeons, who should use our analysis to guide only their perceptions of cost, still considering other variables vital to selecting instruments: operative time, complications and blood loss, etc. Our study did not aim to validate our own minimally viable toolbox in this context, but nonetheless analyzed these factors. Blood loss and operative time were sampled by convenience, and an independent sample t-test was used to compare means in these metrics. Interestingly, surgeon 1, using the minimally viable toolbox, had a statistically significant improvement in both blood loss (148 v. 265 mL; p = 0.045) and operative
Journal of Endourology Reducing Robotic Prostatectomy Costs by Minimizing Instrumentation (doi: 10.1089/end.2014.0533) This article has been peer-reviewed and accepted for publication, but has yet to undergo copyediting and proof correction. The final published version may differ from this proof.
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10 time (132 v. 158 minutes; p = 0.001) over surgeon 2. Surgeon 1 did not have any intraoperative complications, while surgeon 2 reported one rectal enterotomy that was simply repaired. Such results, however, again only aim to report a cognizance of costs: reporting of blood loss is subjective, and operating time may depend more on surgeon and bedside assistance than on tools. Factors for intraoperative complications can be multifactorial, including difficulty of the case, patient anatomy, and surgeon and assistant skill. Moreover, our study is by no means a well-controlled, randomized experiment. Nonetheless, our results demonstrate that supply costs may be reconsidered and contained without compromising important metrics of efficiency and patient safety. Future studies should be undertaken to include such variables in the process for choosing a minimally viable toolbox, or to ever validate a universal one. Still, surgeons seeking to establish their own minimally viable toolbox should take these variables into consideration. Instrumentation is only one aspect of robotic prostatectomy cost. In a review, Bolenz concluded that, over all, RALP has not been shown to be cost effective in the perioperative period; however, long-term follow-up should consider the cost of future, derivative procedures (salvage therapy, stricture dilations, procedures for incontinence and erectile dysfunction), which may significantly impact a true assessment of costs [27]. Until long-term data for oncologic, continent, and potency outcomes of robotic surgery demonstrate superiority over conventional prostatectomy, it may be difficult to economically justify the use of robotics. Furthermore, even if RALP costs could be reduced, passage of savings to patients and in what ratio could not be guaranteed [15]. Nonetheless, Steinberg et al. postulates that a significant increase in caseloads can be profitable for high-volume, non-academic (no residents or fellows) institutions [28]. One can hope that the patient will eventually share in the benefits of said profitability. Despite such
Journal of Endourology Reducing Robotic Prostatectomy Costs by Minimizing Instrumentation (doi: 10.1089/end.2014.0533) This article has been peer-reviewed and accepted for publication, but has yet to undergo copyediting and proof correction. The final published version may differ from this proof.
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11 uncertainty, RALP continues to gain favor and is likely to remain a staple for prostatectomy, and, as such, cost reduction should continue to be explored, particularly on an individual level.
Conclusion: Robotic surgery costs can be minimized by identifying a minimally viable toolbox of instruments, eliminating the use of an energy source like the ligasure or vessel sealer, and utilizing an inexpensive tool such as hemolok clips. Additionally, the use of the fenestrated bipolar as forceps eliminates the need for a second needle driver. These changes can reduce costs incurred on robotic instruments alone by 40% or greater. Moreover, EBL, operative times, and intraoperative complications were not compromised as a result of cost reduction. Further prospective, multicenter trials should be initiated to assess other methods of cost-reduction. Although such changes may not be suitable to all surgeons, our straightforward process of identifying a minimally viable toolbox allows one to view costs not as nominal prices but as proportional deviations from a baseline. Thus, one can more fluidly remain cognizant of longterm costs before they accumulate.
Journal of Endourology Reducing Robotic Prostatectomy Costs by Minimizing Instrumentation (doi: 10.1089/end.2014.0533) This article has been peer-reviewed and accepted for publication, but has yet to undergo copyediting and proof correction. The final published version may differ from this proof.
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12 References 1. Kalan S, Chauhan S, Coelho RF, Orvieto MA, Camacho IR, Palmer KJ, Patel VR. History of robotic surgery. Journal of Robotic Surgery. 2010 July 22; 4:141-147. 2. Lanfranco AR, Castellanos AE, Desai JP, Meyers WC. Robotic surgery: a current perspective.Ann Surg. 2004 Jan;239(1):14-21. PubMed [citation] PMID: 14685095, PMCID: PMC1356187 3. Barbash GI, Glied SA. New technology and health care costs--the case of robotassisted surgery. N Engl J Med. 2010 Aug 19;363(8):701-4. doi: 10.1056/NEJMp1006602. PubMed [citation] PMID: 20818872 4. Cozzi G, Lorenzis ED, Palumbo C, Acquati P, Albo G, Dell'orto P, Grasso A, Rocco B. Robotic prostatectomy: an update on functional and oncologic outcomes. Ecancermedicalscience. 2013;7:355. PubMed [citation] PMID: 24101944, PMCID: PMC3788169 5. Jacobs EF, Boris R, Masterson TA. Advances in Robotic-Assisted Radical Prostatectomy over Time. Prostate Cancer. 2013;2013:902686. Epub 2013 Nov 12. PubMed [citation] PMID: 24327925, PMCID: PMC3845837 6. De Lorenzis E, Palumbo C, Cozzi G, Talso M, Rosso M, Costa B, Gadda F, Rocco B. Robotics in uro-oncologic surgery. Ecancermedicalscience. 2013;7:354. PubMed [citation] PMID: 24101943, PMCID: PMC3788173 7. Ahmed K, Ibrahim A, Wang TT, Khan N, Challacombe B, Khan MS, Dasgupta P. Assessing the cost effectiveness of robotics in urological surgery - a systematic review. BJU Int. 2012 Nov;110(10):1544-56. doi: 10.1111/j.1464410X.2012.11015.x. Epub 2012 Mar 22. PubMed [citation] PMID: 22443296 8. Ramsay C, Pickard R, Robertson C, Close A, Vale L, Armstrong N, Barocas DA, Eden CG, Fraser C, Gurung T, Jenkinson D, Jia X, Lam TB, Mowatt G, Neal DE, Robinson MC, Royle J, Rushton SP, Sharma P, Shirley MD, Soomro N. Systematic review and economic modeling of the relative clinical benefit and cost-effectiveness of laparoscopic surgery and robotic surgery for removal of the prostate in men with localised prostate cancer. Health Technol Assess. 2012;16(41):1-313. doi: 10.3310/hta16410. PubMed [citation] PMID: 23127367 9. Lowrance WT, Tarin TV, Shariat SF. Evidence-based comparison of robotic and open radical prostatectomy. ScientificWorldJournal. 2010 Nov 16;10:2228-37. doi: 10.1100/tsw.2010.218. PubMed [citation] PMID: 21103791 10. American Cancer Society. Cancer Facts & Figures 2013. Atlanta: American Cancer Society, 2013. 11. Mirkin JN, Lowrance WT, Feifer AH, Mulhall JP, Eastham JE, Elkin EB. Direct-toconsumer Internet promotion of robotic prostatectomy exhibits varying quality of information. Health Aff (Millwood). 2012 Apr;31(4):760-9. doi: 10.1377/hlthaff.2011.0329.PubMed [citation] PMID: 22492893, PMCID: PMC3897330
Journal of Endourology Reducing Robotic Prostatectomy Costs by Minimizing Instrumentation (doi: 10.1089/end.2014.0533) This article has been peer-reviewed and accepted for publication, but has yet to undergo copyediting and proof correction. The final published version may differ from this proof.
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12. Turchetti G, Palla I, Pierotti F, Cuschieri A. Economic evaluation of da Vinci-assisted robotic surgery: a systematic review. Surg Endosc. 2012 Mar;26(3):598-606. doi: 10.1007/s00464-011-1936-2. Epub 2011 Oct 13. PubMed [citation] PMID: 21993935 13. Brown A, Meenan BJ, Dixon D, Young TP, Brennan M. Application of the Experience Curve to Price Trends in Medical Devices: Implications for Product Development and Marketing Strategies. Journal of Medical Marketing: Device, Diagnostic, and Pharmaceutical Marketing. 2008; 8:241. 14. Shah BC, Buettner SL, Lehman AC, Farritor SM, Oleynikov D. Miniature in vivo robotics and novel robotic surgical platforms. Urol Clin North Am. 2009 May;36(2):251-63, x. doi: 10.1016/j.ucl.2009.02.013. PubMed [citation] PMID: 19406325 15. Tomaszewski JJ, Matchett JC, Davies BJ, Jackman SV, Hrebinko RL, Nelson JB. Comparative hospital cost-analysis of open and robotic-assisted radical prostatectomy. Urology. 2012 Jul;80(1):126-9. doi: 10.1016/j.urology.2012.03.020. Epub 2012 May 16.PubMed [citation] PMID: 22608294 16. Rebuck DA, Zhao LC, Helfand BT, Casey JT, Navai N, Perry KT, Nadler RB. Simple modifications in operating room processes to reduce the times and costs associated with robot-assisted laparoscopic radical prostatectomy. J Endourol. 2011 Jun;25(6):955-60. doi: 10.1089/end.2010.0534. Epub 2011 Apr 2. PubMed[citation] PMID: 21457071 17. Box GN, Ahlering TE. Robotic radical prostatectomy: long-term outcomes. Curr Opin Urol. 2008 Mar;18(2):173-9. doi: 10.1097/MOU.0b013e3282f517d6. PubMed [citation] PMID: 18303539 18. Hu JC, Wang Q, Pashos CL, Lipsitz SR, Keating NL. Utilization and outcomes of minimally invasive radical prostatectomy. J Clin Oncol. 2008 May 10;26(14):227884. doi: 10.1200/JCO.2007.13.4528.PubMed [citation] PMID: 18467718 19. Coelho RF, Chauhan S, Palmer KJ, Rocco B, Patel MB, Patel VR. Robotic-assisted radical prostatectomy: a review of current outcomes. BJU Int. 2009 Nov;104(10):1428-35. doi: 10.1111/j.1464-410X.2009.08895.x. Epub 2009 Oct 5. PubMed [citation] PMID: 19804427 20. Ficarra V, Novara G, Artibani W, Cestari A, Galfano A, Graefen M, Guazzoni G, Guillonneau B, Menon M, Montorsi F, Patel V, Rassweiler J, Van Poppel H. Retropubic, laparoscopic, and robot-assisted radical prostatectomy: a systematic review and cumulative analysis of comparative studies. Eur Urol. 2009 May;55(5):1037-63. doi: 10.1016/j.eururo.2009.01.036. Epub 2009 Jan 25. PubMed [citation] PMID: 19185977 21. Bolenz C, Gupta A, Hotze T, Ho R, Cadeddu JA, Roehrborn CG, Lotan Y. Cost comparison of robotic, laparoscopic, and open radical prostatectomy for prostate cancer. Eur Urol. 2010 Mar;57(3):453-8. doi: 10.1016/j.eururo.2009.11.008. Epub 2009 Nov 11.PubMed [citation] PMID: 19931979
Journal of Endourology Reducing Robotic Prostatectomy Costs by Minimizing Instrumentation (doi: 10.1089/end.2014.0533) This article has been peer-reviewed and accepted for publication, but has yet to undergo copyediting and proof correction. The final published version may differ from this proof.
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14
22. Murphy DG, Bjartell A, Ficarra V, Graefen M, Haese A, Montironi R, Montorsi F, Moul JW, Novara G, Sauter G, Sulser T, van der Poel H. Downsides of robot-assisted laparoscopic radical prostatectomy: limitations and complications. Eur Urol. 2010 May;57(5):735-46. doi: 10.1016/j.eururo.2009.12.021. Epub 2009 Dec 28. PubMed [citation] PMID: 20036784 23. Lotan Y, Cadeddu JA, Gettman MT. The new economics of radical prostatectomy: cost comparison of open, laparoscopic and robot assisted techniques. J Urol. 2004 Oct;172(4 Pt 1):1431-5.PubMed [citation] PMID: 15371862 24. Bolenz C, Gupta A, Roehrborn CG, Lotan Y. Predictors of costs for robotic-assisted laparoscopic radical prostatectomy. Urol Oncol. 2011 May-Jun;29(3):325-9. doi: 10.1016/j.urolonc.2011.01.016. PubMed [citation] PMID: 21555102 25. Joseph, J., Leonhardt, A., Patel, Hitendra. "The cost of radical prostatectomy: retrospective comparison of open, laparoscopic, and robot-assisted approached." Journal of robotic Surgery, 2008: 21-24. 26. Mouraviev V, Nosnik I, Sun L, Robertson CN, Walther P, Albala D, Moul JW, Polascik TJ. Financial comparative analysis of minimally invasive surgery to open surgery for localized prostate cancer: a single-institution experience. Urology. 2007 Feb;69(2):311-4.PubMed [citation] PMID: 17320670 27. Bolenz C, Freedland SJ, Hollenbeck BK, Lotan Y, Lowrance WT, Nelson JB, Hu JC. Costs of radical prostatectomy for prostate cancer: a systematic review. Eur Urol. 2013 Feb;65(2):316-24. doi: 10.1016/j.eururo.2012.08.059. Epub 2012 Sep 5. PubMed [citation] PMID: 22981673 28. Steinberg PL, Merguerian PA, Bihrle W 3rd, Heaney JA, Seigne JD. A da Vinci robot system can make sense for a mature laparoscopic prostatectomy program. JSLS. 2008 Jan-Mar;12(1):9-12.PubMed [citation] PMID: 18402732, PMCID: PMC3016020
Abbreviations Used RALP = Robotically Assisted Laparoscopic Prostatectomy OR = Operating Room EBL = Estimated Blood Loss
Journal of Endourology Reducing Robotic Prostatectomy Costs by Minimizing Instrumentation (doi: 10.1089/end.2014.0533) This article has been peer-reviewed and accepted for publication, but has yet to undergo copyediting and proof correction. The final published version may differ from this proof. Page 15 of 22
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Journal of Endourology Reducing Robotic Prostatectomy Costs by Minimizing Instrumentation (doi: 10.1089/end.2014.0533) This article has been peer-reviewed and accepted for publication, but has yet to undergo copyediting and proof correction. The final published version may differ from this proof.
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16
Figure 1.The bar graph ranks 20 months’ supply prices per-use, divided into four categories and compared by proportion of spending in the overlying pie chart.
Journal of Endourology Reducing Robotic Prostatectomy Costs by Minimizing Instrumentation (doi: 10.1089/end.2014.0533) This article has been peer-reviewed and accepted for publication, but has yet to undergo copyediting and proof correction. The final published version may differ from this proof. Page 17 of 22
17
Figure 2. The minimally viable toolbox uses no Ligasure and one needle-driver, leading to a 40% cost reduction compared to instrumentation combinations within our institution.
18 Manufacturer Number
Unit Price
Retailer
HANDPIECE LIGASURE LAP SEALER DIV DISP 5MM HANDPIECE LIGASURE VESSEL SEALER/DIV DISP 5MM SEALANT FIBRIN HUMAN TISSEEL PRE-FILL 10ML ENDO STITCH 10M 173016 KIT FLOSEAL HEMOSTATIC MATRIX 5ML
LF1537 LF1537 1501238 173016 1501825
$ $ $ $ $
762.01 762.01 698.92 487.84 429.00
ciamedical.com ciamedical.com ecomm.baxter.com ciamedical.com medexsupply.com
ENDO CATCH II 15M Monopolar Shears ENDO CLIP III MED-LRG 5MM ENDO GIA STAPLER THICK 60 MED PK Dissector Fenestrated Bipolar SEALER VESSEL ENDOWRIST ONE DISP ENDO GIA STAPLER VASCULAR 60 MED Needle Driver Prograsp ENDO CLIP APPLIER MD/LG 5M
173049
335.51 320.00 300.00 295.00 290.00 270.00 250.00 235.00 220.00 220.00 216.67
medequipdepot.com
EL5ML
$ $ $ $ $ $ $ $ $ $ $
NB15STF EGIA45AVM 30403 176674PF G11327 16400 POUCH 173050G tlc75 b12L 1946 52306 00496-0523-06 B12 B12 B12 us349sp 2216 176626P G14813 b12lt 6640 tcr75 VS101012P
$ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $
186.43 180.00 169.00 168.01 144.08 140.77 140.00 100.00 100.00 100.00 100.00 100.00 100.00 100.00 100.00 100.00 97.07 96.04 95.00 92.75 91.67 86.75 80.00 75.00
Category 3
Category 1
Tool
Category 2
Journal of Endourology Reducing Robotic Prostatectomy Costs by Minimizing Instrumentation (doi: 10.1089/end.2014.0533) This article has been peer-reviewed and accepted for publication, but has yet to undergo copyediting and proof correction. The final published version may differ from this proof.
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ENDO TROCAR VPORT+ BL STD FIXN 15MM ENDO GIA STAPLER VASCULAR 45 MED HANDLE ENDO GIA UNIV 12M ENDO TROCAR VISIPORT+ OPT FIXN 5-12MM LSCP LAPSAC SURG TISSUE POUCH 10 X 8 PLEUROVAC EXPRESS CHEST DRAIN ADULT ENDO CATCH POUCH ENDO CATCH POUCH GOLD 10MM ENDO STAPLER LNR CUTTER BLUE 75MM TLC75 ENDO TROCAR BLADELESS W/STAB SLEEVE 10/12MM HEMOSTAT SURGICEL NUKNIT 6X9 ADHESIVE MASTISOL STRL 4OZ ADHESIVE MASTISOL STRL 4OZ ENDO TROCAR BLADELESS W/STAB SLEEVE 10/12MM ENDO TROCAR BLADELESS W/STAB SLEEVE 10/12MM ENDO TROCAR BLADELESS W/STAB SLEEVE 10/12MM CORD BOVIE BIPOLAR STRL DISP DRAIN BLAKE FLAT FLUTD 3/4 19F ENDO TROCAR BLUNTPORT PLUS 5-12MM CATH SUPRAPUBIC PERC STAMEY ENDO TROCAR XCEL 12 X 100 B12LT DRAPE STERI IOBAN 6640 13X13 ENDO RELOAD BLUE 75MM TCR75 ENDO VERSASTEP PLUS TROCAR 12MM
176630 EGIA60AMT
410322 EGIA60AVM
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Figure 3. esutures.com Left to esutures.com
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right: surgeons from other institutions would save 18%, 16%, and 32% if using our minimally viable toolbox; identifying one’s own minimally viable toolbox may yield similar savings.
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Journal of Endourology Reducing Robotic Prostatectomy Costs by Minimizing Instrumentation (doi: 10.1089/end.2014.0533) This article has been peer-reviewed and accepted for publication, but has yet to undergo copyediting and proof correction. The final published version may differ from this proof. Category 4
Page 19 of 22 ENDO TROCAR XCEL 5 X 100 B5LT (R) DRAIN BLAKE ROUND 1/4' TROCAR 19FR CATH FOLEY HEMATURIA 3-WAY 24FR 30ML ENDO TROCAR VPORT+ BL STD FIXN 12MM ENDO TROCAR VPORT+ BL STD FIXN 5MM SURGICLIP II PREM TI M-11.5 ENDO STAPLER LNR BLUE 60 X 3.5 TX60B DRAIN BLAKE ROUND 3/16" TROCAR 15F SURGICLIP II PREM TI M-9.75 TUBING SURGICAL SUCT DEVICE DISP TIP DRAPE WARMING SYSTEM DISP 66 X 66 TISSEEL ACCESORY DUPLOCAT # 25 HEMOSTAT GELDOAM SPONZE SZ100 HEMOSTAT GELFOAM SPONGE SZ 100 BOVIE CORD BIPOLAR DISP SUT MONOCRYL 3-0 UR-6 D9503 HEMOSTAT SURGICEL STRL 2X14 HEMOSTAT SURGICEL STRL 4X8 CATH FOLEY COUNCILL 20FR 5ML SUT V-LOC 180 CLOS DEVIC 0 GR 12 GS-21 SUT V-LOC 180 CLOS DEVIC 2-0 GR 12 GS-21 CATH FOLEY 3-WAY 24FR 30ML SUT V-LOC 180 ABS CLOS DEVIC 3-0 GR 6 CV-23 ENDO TROCAR VPORT+ V2 FIXN 5MM CATH FOLEY COUDE 2-WAY 22FR 5ML TRAY CATH FOLEY LUBRI W/URINE METER 16FR STAPLER SKIN MULTI PREM 35W PRW35 ENDO CLIP LAPRA-TY XC200 DERMABOND SKIN ADHESIVE TOPICAL HI VISCOSITY PAD DEFIB HP CODEMASTER DISP DRAPE ROBOT CAMERA ARM DISP SEAL ROBOT CANNULA DISP TRAY URINE METER LF 16FR DRAIN JP RESERVOIR 400CC LUBRICANT ELECTROLUBE ENDO SURGINEEDLE 120MM PN120 COVER ROBOT TIP ACCESSORY DISP HC CATH SWAN GANZ W/COAT 7.5FR CLOSESURE CARTER-THOMASON SYSTEM (R) TUBING INSUFFLATOR HEATED HIGH FLOW SUT QUILL MONODERM 2-0 18MM DMND PNT 3/8C YA-1012Q OVERLAY EGGCRATE OVERLAY EGGCRATE HC GWIRE ARROW DUOFLX.025 X 17 3/4 SUT QUILL PDO 1 14 X 14 36MM TAPER 1/2 CRCL RA-1003Q CATH FOLEY 3-WAY 22FR 30ML DRAPE ROBOT S INSTRUMENT ARM DISP ENDO SCISSOR DISP PACK BASIN DOUBLE TRAY URINE METER 200ML CATH FOLEY 2-WAY 18FR 30ML CATH FOLEY 2-WAY 20FR 30ML CATH FOLEY 2-WAY 24FR 30ML DRAIN JP RESERVOIR 100CC CATH FOLEY 2-WAY 22FR 5ML CATH FOLEY 2-WAY 20FR 5ML CATH FOLEY 2-WAY 18FR 5ML CATH FOLEY 2-WAY 24FR 5ML
b5lt 2231 572551H24 NB12STF NB5STF 134053 tx60b 2229 134051 250-070-520 ORS-300 921022 00009-0342-01 I think this is the same thing. A827EU d9503 1951 1952 570196L20CA gs21 gs21 0167SI24 cv-23 ONBFCA5ST 0102L22 800365 prw35 xc200 DHV12 1210H 400016 420206 800065 SU130-1000 el101 pn120 400180 831HF75 cti512n 620030301 YA1012q 35004300 11760 AW04235 RA1003Q 0167SI22 400015 3142 ssk5001 153202 0166SI18 0166SI20 0166SI24 SU130-1305 0165SI22 0165SI20 0165SI18 0165SI24
$ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $
70.00 65.63 63.62 60.00 60.00 60.00 60.00 59.16 50.00 50.00 49.99 47.41 46.80 46.80 42.50 42.11 41.67 41.67 39.81 38.15 38.15 33.74 33.39 30.00 28.01 26.56 25.00 23.61 23.00 22.75 22.50 22.50 22.05 20.47 20.00 20.00 20.00 20.00 19.80 19.50 17.92 17.75 17.59 16.86 16.00 15.00 15.00 15.00 14.45 14.44 14.01 14.01 14.01 13.98 12.93 12.93 12.85 12.85
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Journal of Endourology Reducing Robotic Prostatectomy Costs by Minimizing Instrumentation (doi: 10.1089/end.2014.0533) This article has been peer-reviewed and accepted for publication, but has yet to undergo copyediting and proof correction. The final published version may differ from this proof.
Page 20 of 22 PACK LAPAROSCOPY SUT PROLENE 4-0 RB-1 DA 36 8557H HC SOL GLYCINE 1.5% 3000ML 2B7317 SUT MONOCRYL 4-0 PS-2 27 Y426H TAPE MEDIPORE H 4 X 10 YD PACK BASIN SINGLE HC SOL NACL IRR 0.9%3000ML 2B7127 ENDO SLEEVE VSEAL+ FIXN 5-12MM HC CATH ARTERY RADIAL 20 X 1 3/4 NEEDLE MACROPLASTIQUE ENDOSCOPIC DRAPE COVER MAYO STAND 23" WATER IRRIG BAG 3000ML 2B7117 HC SOL NACL IRR 0.9%3000ML 2B7127 SUT VICRYL 4-0 PS-2 18 J496H SUT SILK 2-0 PS 18 1588H DRAPE ROBOT CAMERA DISP SUT ETHILON 2-0 PS 18 585H ENDO CLIP HEM-O-LOK LRG ENDO CLIP HEM-O-LOK MED LRG ENDO CLIP HEM-O-LOK XLG ENDO CLIP HEM-O-LOK LRG ENDO CLIP HEM-O-LOK MED LRG ENDO CLIP HEM-O-LOK XLG GOWN SURG IMPERVIOUS SLEEVE XXL DRAPE ENDOSCOPIC GENERAL 98X77 CATH THORACIC STRT 32FR 20IN DRAPE LEGGINGS PACK IN VIEW CLEAR 30 X 55 BAG DRAIN URINARY 4000ML ANCHOR FOLEY CATH PE FOAM BOVIE HANDSWITCH W/HOLSTER ENDO REDUCER CAP TROCAR 5-12M OBTURATOR ROBOT BLADELESS 8MM BOVIE GROUND PAD POLYHESIVE RED SUT PROLENE 2-0 KS 30 8623H SUT MONOCRYL 3-0 27IN RB-1 Y305H GOWN SURG IMPERVIOUS SLEEVE XLG GOWN SURG IMPERVIOUS SLEEVE LRG BUTTON STRL ORTHO ETHCON 520G SUT PDS II 1 CT-1 27 Z341H BOVIE ELECTRODE BLADE EXT 6" SUT MONOCRYL 2-0 CP-1 27 Y266H SUT MONOCRYL 2-0 CT-1 36 Y945H SUT MONOCRYL 2-0 CT-2 27 Y333H SUT MONOCRYL 2-0 SH 27 Y317H SEAL SCOPE WARMER DISP SET CYSTO BLADDER IRRIG LIGHT HANDLE STRL DISP 1 PK SUT MONOCRYL 0 CT-1 36 Y946H BLANKET WARM BAIR HUGGER UPPER SUT MONOCRYL 0 CT-1 CR 8-18 Y740D BAG DRAIN URINARY 2000ML RETRACTOR ABD FISH VISCERA DISP SUT VICRYL 0 UR-6 27 J603H DRAPE XRAY CASSETTE 20X23" SUT VICRYL 0 CT-2 27 J334H HC SOL PLASMA LYT INJ PH7.4 1000M 2B2544X SUT VICRYL 0 CT-1 27 J340H TAPE 3M CLOTH ADHESIVE 3 X 10 WATER IRRIG BTL 1500ML 2F7115 SUT VICRYL 0 CT-1 36 J946H SUT VICRYL 2-0 CT-2 27 J333H SUT VICRYL 2-0 SH 27 J417H SET TUR CYSTO UROMATIC IRRIG HC SOL NACL INJ 0.9%500ML 2B1323Q TRAY SKIN SCRUB W/GEL HC SOL NACL INJ 0.9% 1000M 2B1324X DRSG TEGADERM TRANSP STRL 6 X 8 GLOVE SURG LF PF DERMAPRENE 7.0 HC CATH IV AUTOGUARD INSYTE W/WING 16 X 1.16 HC CATH IV AUTOGUARD INSYTE W/WING 18 X 1.16 HC CATH IV AUTOGUARD INSYTE W/WING 22 X 1 TAPE DURAPORE SILK 3 X 10YD SUT VICRYL 3-0 SH CR 8-18 J774D DRAPE SHEET 3/4 REINF 56X77" SOL NACL IRR POUR 0.9%1000CC 2F7124 POUR BOTTLE HC CATH IV AUTOGUARD INSYTE W/WING 20 X 1 HC SOL NACL INJ 0.9% 1000M 2B1324X SYRINGE DISP TOOMEY CATH LUER TIP 70ML HEMOCLIP WECK DISP LRG HEMOCLIP WECK DISP LRG
29242 8557h 2B7317 y426h 2864 13752-624 2b7127 175772p RA-04020 MRN-420 8337 2b7117 2b7127 j496h 1588h 400027 585h 544240 544230 544250 544240 544230 544250 9071 DYNJP2492 8888570556 8430 153509 FCS200XT ESP1H 1seal 420023 A1202 8623h y305h 9041 9011 520g z341h ES04T y266h y945h y333h y317h c3101 2c4040 31140257 y946h 522 y740d 154002 3204 j603h 1009 j334h 2b2544x j340h 2950-3 2f7115 j946h j333h j417h 2C4006 2b1323q DYND70356 2b1324x 1628 8514 BD381454 BD381444 BD381423 1538-3 j774d 9349CE 2f7124 BD381433 2b1324x BRD0038460 523370 523370
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12.40 12.00 11.80 11.25 11.05 10.78 10.10 10.00 9.99 9.99 9.80 9.75 9.36 9.17 8.00 8.00 7.75 7.44 7.44 7.44 7.44 7.44 7.44 7.27 7.10 7.10 6.88 6.71 6.37 6.05 6.00 6.00 5.80 5.75 5.56 5.28 5.26 5.25 5.25 5.17 5.00 5.00 5.00 5.00 5.00 4.99 4.91 4.50 4.50 4.38 4.22 4.19 4.00 3.96 3.83 3.81 3.78 3.78 3.77 3.50 3.50 3.50 3.32 3.25 3.20 3.18 3.16 3.05 3.01 2.86 2.86 2.84 2.81 2.79 2.69 2.62 2.61 2.40 2.31 2.31
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Journal of Endourology Reducing Robotic Prostatectomy Costs by Minimizing Instrumentation (doi: 10.1089/end.2014.0533) This article has been peer-reviewed and accepted for publication, but has yet to undergo copyediting and proof correction. The final published version may differ from this proof.
Page 21 of 22 TUBE SALEM SUMP 18FX48" SUT SILK 3-0 SH CR 8-18 C013D DRSG MEDIPORE + PAD ADH STRL 3.5 X 13.75 GLOVE SURG LTX PF BRWN MICROPTIC 8.0 GLOVE SURG LTX PF BRWN MICROPTIC 8.5 GLOVE SURG LTX PF BRWN MICROPTIC 6.5 GLOVE SURG LTX PF BRWN MICROPTIC 7.5 GLOVE SURG LTX PF WHT ACCLAIM 7.5 HC SOL NACL INJ 45% 1000CC 2B1314X HC DEX 5% AND .45% NACL 1000ML 2B1074X HC SOL NACL INJ 0.9%500ML 2B1323Q HEMOCLIP WECK DISP LRG SYRINGE DISP LL CONTROL 10ML SUCTION YANKAUER STR DISP BLADE SURGICAL SS 11 PATTIE SURG COTTONOID 1/2X3 SPONGE LAP PREWASHED 18 X 18 5 PK HEMOCLIP WECK DISP MED HEMOCLIP WECK DISP SML SYRINGE DISP TOOMEY DR TORUFF 60ML GLOVE SURG LTX PWD WHT MICRO-TOUCH 7.5 GLOVE SURG LTX PWD WHT MICRO-TOUCH 8.5 SYRINGE DISP LL 20ML STRIP SURGICAL 1/2 X 6 STRIP SURGICAL 1.5 X 6 NEEDLE HYPO SAFETYGLIDE 25 X 1 CONTAINER SPEC STRL SCRTOP 7OZ STERI STRIP 3M SKIN CLOSURE REINFORCED 1/2 X 4 CONTAINER SPEC STRL SCRTOP 4OZ DRSG TELFA ISLAND ADH 2 X 3.50 DRSG KERLIX SPONGE NSTRL 6 X 6.75 LINER CLEAR 24 X 32 LINER CLEAR 24 X 32 DRSG TELFA NON ADH STRL 4 X 3 DRSG SPONGE GAUZE STRL 4 X 4 12-PLY PK/2 DRSG CURITY SPONGE STRL 12-PLY 4 X 4 LUBRICANT JELLY MEDICHOICE STRL 3GR BAG SPEC BIOHAZARD 6 X 9 DRSG SPONGE STRL 8-PLY 2 X 2 PK/2
8888264986 c013d 3573 5787005 5787006 5787002 5787004 5795003 2b1314x 2B1074x 2b1323q 523770 309695 8888501007 371611 MTO8004007 23250400 523700 523735 1186000444 5875 5885 305617 80-1451 80-1454 305916 a1847 DYND30385 7539Z 1167 A4832PR A4832PR 1050 3033 3033 40673 SBL2X69B5 NON21420
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2.25 2.22 2.16 2.07 2.07 2.05 2.05 2.05 2.03 1.98 1.97 1.95 1.41 1.15 1.13 1.04 1.02 0.98 0.82 0.69 0.66 0.66 0.66 0.50 0.40 0.38 0.33 0.32 0.28 0.27 0.26 0.21 0.21 0.18 0.15 0.09 0.08 0.07 0.02
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Journal of Endourology Reducing Robotic Prostatectomy Costs by Minimizing Instrumentation (doi: 10.1089/end.2014.0533) This article has been peer-reviewed and accepted for publication, but has yet to undergo copyediting and proof correction. The final published version may differ from this proof.
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