1. Weill Cornell Robotic Cystectomy Costing Study Douglas S. Scherr, MD Department of Urology The New York Presbyterian Hospital Weill Medical College of Cornell University

2. Weill Cornell Background l Objective: to measure the economic impact of open vs. robotic cystectomy with urinary diversion –Urinary diversions: ileal conduit, Indiana pouch, ileal neobladder

3. Weill Cornell Methods l Methods –Costing − Direct: surgeon’s fee, OR fee, anesthesia fee, PACU cost, inpatient hospital cost, cost of equipment (da Vinci Surgical System, Intuitive Surgical, Inc.) –Procedural costs: defined by 50th percentile of Medicare Resource Based Relative Value Scale (RBRVS) − Indirect: cost of complications –Complication rates derived from Cornell prospectively maintained database –Procedural costs derived from Medicare RBRVS

4. Weill Cornell Methods l Assumptions –Cost of da Vinci Surgical System: $1M –Cost of da Vinci Surgical System service contract: $100k per year –7 year depreciation for da Vinci Surgical System –Assume equal robotic cost overhead between all robotic cases − 3 year avg Cornell robotic case volume: 269 cases − Robotic cost burden per case: $904 ($3488 for all robotic case-associated materials)

5. Weill Cornell Methods l Assumptions –Any readmission over any of time after cystectomy and urinary diversion counted as complication (WORST CASE scenario)

6. Weill Cornell Data Data Category OpenRobotic Surgeon Fee ($) Ileal conduit $5248$5248 Indiana pouch $7694$7694 Neobladder$8449$8449 Anesthesia Time (hr) Ileal conduit 6.426.74 Indiana pouch 7.999.15 Neobladder7.579.26

7. Weill Cornell Data Data Category OpenRobotic PACU Time (hr) Ileal conduit 9.8416.49 Indiana pouch 16.4115.33 Neobladder9.7216.33 Length of Stay (d) Ileal conduit 10.577.50 Indiana pouch 15.598.58 Neobladder10.036.11

8. Weill Cornell Data Data Category OpenRobotic OR Time (hr) Ileal conduit 7.126.84 Indiana pouch 89.18 Neobladder7.589.26

9. Weill Cornell Data Data Category OpenRobotic Avg Complication Rate (%) Ileal conduit 54.5%16.7% Indiana pouch 58.3%50.0% Neobladder47.1%46.2% Complication Length of Stay (d) Ileal conduit 8.273.37 Indiana pouch 9.502.75 Neobladder8.595.31

10. Weill Cornell Data Data Category OpenRobotic Avg Cost of Complication ($) Ileal conduit $1307$3523 Indiana pouch $2341$1108 Neobladder$2805$2689

11. Weill Cornell Results Urinary Diversion OpenRobotic Ileal conduit $130,460$81,363 Indiana pouch $180,982$100,328 Neobladder$127,826$92,406

12. Weill Cornell Sensitivity Analysis l Breakeven condition: How few robotic cases would need to be done per annum to make the cost of robotic cystectomy equal to open cystectomy, ceteris paribus? –Ileal conduit: 5 cases ($130,460) –Indiana pouch: 3 cases ($180,982) –Ileal neobladder: 7 cases ($127,826)

13. Weill Cornell Sensitivity Analysis l Breakeven condition: How few robotic cases would need to be done per annum to make the cost of robotic cystectomy equal to open cystectomy, assuming a 25% complication rate in each group? –Ileal conduit: 8 cases ($111,793) –Indiana pouch: 4 cases ($156,518) –Ileal neobladder: 8 cases ($113,039)

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

15. Weill Cornell Caveats l Small surgical series: results need to be re- examined in the context of greater surgical volume l Tertiary care, academic referral center: results may not be generalizable l Complications data may be undercaptured

16. Weill Cornell