The Economics of Robotic Cystectomy: Cost Comparison of Open versus Robotic Cystectomy Douglas Scherr, MD

Background Treatment for recurrent CIS, high grade T1, or muscle invasive bladder carcinoma includes radical cystectomy with extended pelvic lymph node dissection and urinary diversion

Background What is the economic impact of open vs. robotic cystectomy with urinary diversion? Peri- and postoperative cost outcome data from prospectively maintained database of consecutive radical cystectomies (62 open, 41 robotic)

Methods Methods Costing Direct: professional, facility, and anesthesia fees Procedural costs: defined by 50th percentile of Medicare Resource Based Relative Value Scale (RBRVS) Cost of equipment ($1M) and annual service contract ($100k) (da Vinci Surgical System, Intuitive Surgical, Inc.) amortized over 7 years with Cornell 3 year avg case volume (269 cases per year) → robotic cost burden of $3,488 per case Indirect: cost of complications Complication rates derived from Cornell prospectively maintained database for any readmission or treatment during 90 day global period

Data Data Category Open Robotic Surgeon Fee ($) Ileal conduit $7,694 Continent cutaneous diversion Neobladder $8,449 Anesthesia Time (hr) 7.0 7.8 6.4 6.7 8.0 9.2 Neobladder* 7.6 9.3 * denotes p < 0.05

Data Data Category Open Robotic PACU Time (hr) 11.1 16.3 Ileal conduit* 9.8 16.5 Continent cutaneous diversion 16.4 15.3 Neobladder 9.7 Length of Stay (d) 11.4 7.2 10.6 7.5 15.6 8.6 Neobladder* 10.0 6.2 * denotes p < 0.05

Data Data Category Open Robotic Avg Complication Rate (%)* 30.6% 19.5% Ileal conduit* 42.4% 8.3% Continent cutaneous diversion 16.7% 25.0% Neobladder 17.6% 38.5% Complication Length of Stay (d) 17.2 13.8 17.5 18.0 13.0 8.0 Neobladder* 18.3 13.2 * denotes p < 0.05

Results Urinary Diversion Open Robotic Ileal conduit $154,276 $90,472 Direct $98,445 $79,015 Indirect $55,831 $11,457 Continent cutaneous diversion $155,222 $105,203 $138,925 $90,245 $16,297 $14,958 Neobladder $120,601 $111,111 $96,820 $72,843 $24,321 $38,267

Results The impact of decreased length of stay (LOS) with robotic cystectomy outweighs the marginal cost impact of a da Vinci robotic system!

Sensitivity Analysis Minimum number of annual robotic cases to maintain cost equivalence to open cystectomy? Ileal conduit: 4 cases ($150,282) Continent cutaneous diversion: 5 cases ($152,870) Orthotopic neobladder: 23 cases ($120,766) Maximum LOS for open cystectomy to achieve cost equivalence to robotic cystectomy? Ileal conduit: 2.0 days Continent cutaneous diversion: 8.9 days Orthotopic neobladder: 8.8 days

Conclusions Robotic cystectomy appears more cost-effective than open cystectomy for treatment of bladder cancer Majority of improvement driven by lower LOS High initial materials cost of robotic surgery defrayed by subsequent cost savings during hospitalization Annual robotic volume does not need to be high (<25 cases per year) to justify use of robotic cystectomy Cost savings of robotic cystectomy however is diminished with decreased open cystectomy LOS (2 to 9 days)