Laparoscopy versus Robotics
Currently, traditional laparoscopy, robotic-assisted laparoscopy and LESS are used for primary surgical management of women with endometrial cancer. Debate is ongoing regarding which choice of minimally invasive technique has the most benefit to the patient, the surgeon and the healthcare system as a whole. In addition to improving patient outcomes in the short and long term, cost effects of the various modalities have become a research interest.
As previously mentioned, there have been several cohort studies that have compared laparoscopy with robotic surgery (Table 1). In studies by Boggess et al. and Seamon et al., many outcomes comparing laparoscopic surgery with robotic-assisted surgery significantly favored the patients who underwent robotic surgery. Results included shorter length of hospital stay, shorter operative time, decreased blood loss and lower transfusion rate in the robotics group when compared with the laparoscopic group. Also, a lower conversion rate to laparotomy was noted for the robotic group compared with laparoscopy. These factors, in addition to improved surgical field visualization, improved ergononomics, instrument articulation, decreased tremor and shortened learning curve all point to the potential advantages of robotic-assisted surgery for endometrial cancer.
As more physicians begin to adopt the robotic platform as the basis for the surgical treatment of choice for the management of women with endometrial cancer, the economic impact of this technology becomes an important factor given the ever-changing healthcare industry. The debate will continue regarding the economic impacts of robotic surgery in terms of healthcare costs, reimbursements and utilization of resources. A population-based analysis was conducted in 2012, which compared laparoscopic hysterectomy and robotic hysterectomy for endometrial cancer. Over 2400 women were included in this analysis. Patient outcomes studied included intraoperative complications, surgical site and medical complications. Resource utilization factors such as hospital stay, mean hospital cost, transfusion and reoperation were also compared between the two modalities of surgery. In addition to demonstrating the feasibility of both laparoscopic and robotic approaches to surgery for endometrial cancer, the study concluded that these procedures are well tolerated and have similar morbidity. In the multivariate analysis, controlling for patient characteristics, surgeon factors and hospital characteristics, the cost per robotic hysterectomy was US$1291 more than for a comparable laparoscopic procedure. Since there was no difference in short-term morbidity for the two surgery modalities, these results do demonstrate higher hospital resource utilization and increased direct hospital costs associated with the robotic procedure.
Another study by Venkat et al. emphasized the differences in costs, charges and actual reimbursements between laparoscopic and robotic surgery for endometrial cancer. Various economic aspects of each surgery type were analyzed, including operating room, anesthesia, room and board, and post-anesthesia charges. The authors concluded that even though robotic surgery increases hospital charges, due to robotic suite costs and time in the operating room, the actual reimbursement to the hospital, surgeon and anesthesia did not differ between the surgery types. This was the first study conducted that included reimbursement differences in the comparative cost analysis of laparoscopy and robotics. A larger multi-institution study may be required to confirm these results.
A study by Barnett et al., utilized decision modeling to look into the societal and hospital cost perspectives between robotic, laparoscopic and open hysterectomy for the treatment of women with endometrial cancer. The societal aspects of the study looked at the economic impact of the different surgery modalities on hospitalization, costs of the robot, as well as lost wages including postoperative care. The hospital perspective model analyzed all the above except for lost wages and caregiver costs. Results in the societal model demonstrated that the laparoscopic approach is the least costly mode of surgery over the robotic and open approach. Laparoscopic procedure cost was US$1347 less than robotic hysterectomy and US$2719 cheaper than the open approach. The minimally invasive approaches, both laparoscopic and robotic, demonstrate a shorter hospital stay and quicker return to daily activities when compared with laparotomy. In both the societal and hospital models, it was shown that the robotic approach can be the most cost-effective modality if the expense of the disposable instrumentation would decrease from baseline estimates by at least US$1200.