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

2. 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

3. 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)

4. 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

5. 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

6. 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

7. 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

8. 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

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

10. 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

11. 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)