Cost comparison between open radical cystectomy, laparoscopic radical cystectomy, and robot-assisted radical cystectomy for patients with bladder cancer: a systematic review of segmental costs

Abstract

Background: Robot-assisted radical cystectomy is becoming a common treatment for bladder carcinoma. However, in comparison with open radical cystectomy, its cost-effectiveness has not been confirmed. Although few published reviews have compared total costs between the two surgical procedures, no study has compared segmental costs and explained their impact on total costs.

Methods: A systematic review was conducted based on studies on the segmental costs of open, laparoscopic, and robot-assisted radical cystectomy using PubMed, Web of Science, and Cochrane Library databases to provide insight into cost-effective management methods for radical cystectomy. The segmental costs included operating, robot-related, complication, and length of stay costs. A sensitivity analysis was conducted to determine the impact of the annual number of cases on the per-case robot-related costs.

Results: We identified two studies that compared open and laparoscopic surgeries and nine that compared open and robotic surgeries. Open radical cystectomy costs were higher than those of robotic surgeries in two retrospective single-institution studies, while robot-assisted radical cystectomy costs were higher in 1 retrospective single-institution study, 1 randomized controlled trial, and 4 large database studies. Operating costs were higher for robotic surgery, and accounted for 63.1-70.5% of the total robotic surgery cost. Sensitivity analysis revealed that robot-related costs were not a large proportion of total surgery costs in institutions with a large number of cases but accounted for a large proportion of total costs in centers with a small number of cases.

Conclusions: The results show that robot-assisted radical cystectomy is more expensive than open radical cystectomy. The most effective methods to decrease costs associated with robotic surgery include a decrease in operating time and an increase in the number of cases. Further research is required on the cost-effectiveness of surgeries, including quality measures such as quality of life and quality-adjusted life years.

Fig. 1

Flow chart of study selection. Flow chart of study selection. From the databases, 315 studies were identified. After removing duplicates and screening of titles, abstracts, and full texts, 11 studies were included for analysis

Fig. 2

Result of risk of bias evaluation. The results of “risk of bias” assessment conducted using the Cochrane Risk of Bias Tool [18]

Fig. 3

Summary of total costs and segmental costs for ORC and RARC. Summary of segmental and total costs in the included studies. Segmental costs are included whenever available; otherwise, total costs are shown. IC: Ileal conduit; ON: Orthotopic Neobladder

Fig. 4

The effect of the annual number of cases on per-case robot-related costs. The per-case robot-related costs and rate of robot-related costs for the total RARC costs when the annual number of cases was changed from 50 to 400. Amortization periods are similar to those in Table 3. The per-case robot-related costs were calculated by amortizing the robot costs and distributing the costs to each case similar to the studies included in this review