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Randomized Controlled Trial
. 2023 Jun 1;6(6):e2317255.
doi: 10.1001/jamanetworkopen.2023.17255.

Cost-Effectiveness of Robot-Assisted Radical Cystectomy vs Open Radical Cystectomy for Patients With Bladder Cancer

Simon Dixon  1   2 , Harry Hill  1 , Laura Flight  1   3 , Pramit Khetrapal  4 , Gareth Ambler  5 , Norman R Williams  6 , Chris Brew-Graves  5 , John D Kelly  4 , James W F Catto  1   7   8 ; iROC Study Team
Collaborators, Affiliations
Randomized Controlled Trial

Cost-Effectiveness of Robot-Assisted Radical Cystectomy vs Open Radical Cystectomy for Patients With Bladder Cancer

Simon Dixon et al. JAMA Netw Open. .

Abstract

Importance: The value to payers of robot-assisted radical cystectomy with intracorporeal urinary diversion (iRARC) when compared with open radical cystectomy (ORC) for patients with bladder cancer is unclear.

Objectives: To compare the cost-effectiveness of iRARC with that of ORC.

Design, setting, and participants: This economic evaluation used individual patient data from a randomized clinical trial at 9 surgical centers in the United Kingdom. Patients with nonmetastatic bladder cancer were recruited from March 20, 2017, to January 29, 2020. The analysis used a health service perspective and a 90-day time horizon, with supplementary analyses exploring patient benefits up to 1 year. Deterministic and probabilistic sensitivity analyses were undertaken. Data were analyzed from January 13, 2022, to March 10, 2023.

Interventions: Patients were randomized to receive either iRARC (n = 169) or ORC (n = 169).

Main outcomes and measures: Costs of surgery were calculated using surgery timings and equipment costs, with other hospital data based on counts of activity. Quality-adjusted life-years were calculated from European Quality of Life 5-Dimension 5-Level instrument responses. Prespecified subgroup analyses were undertaken based on patient characteristics and type of diversion.

Results: A total of 305 patients with available outcome data were included in the analysis, with a mean (SD) age of 68.3 (8.1) years, and of whom 241 (79.0%) were men. Robot-assisted radical cystectomy was associated with statistically significant reductions in admissions to intensive therapy (6.35% [95% CI, 0.42%-12.28%]), and readmissions to hospital (14.56% [95% CI, 5.00%-24.11%]), but increases in theater time (31.35 [95% CI, 13.67-49.02] minutes). The additional cost of iRARC per patient was £1124 (95% CI, -£576 to £2824 [US $1622 (95% CI, -$831 to $4075)]) with an associated gain in quality-adjusted life-years of 0.01124 (95% CI, 0.00391-0.01857). The incremental cost-effectiveness ratio was £100 008 (US $144 312) per quality-adjusted life-year gained. Robot-assisted radical cystectomy had a much higher probability of being cost-effective for subgroups defined by age, tumor stage, and performance status.

Conclusions and relevance: In this economic evaluation of surgery for patients with bladder cancer, iRARC reduced short-term morbidity and some associated costs. While the resulting cost-effectiveness ratio was in excess of thresholds used by many publicly funded health systems, patient subgroups were identified for which iRARC had a high probability of being cost-effective.

Trial registration: ClinicalTrials.gov Identifier: NCT03049410.

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Conflict of interest statement

Conflict of Interest Disclosures: Professor Dixon reported receiving grant funding from the Urology Foundation and the Champniss Foundation for the University of Sheffield for undertaking the analysis presented during the conduct of the study. Dr Hill reported receiving grant funding from the Urology Foundation and the Champniss Foundation during the conduct of the study. Dr Flight reported receiving grant funding from the Urology Foundation and the Champniss Foundation during the conduct of the study. Professor Kelly reported receiving grant funding from the Urology Foundation during the conduct of the study. Professor Catto reported receiving personal fees from F. Hoffmann–La Roche AG, AstraZeneca, Bristol-Myers Squibb, Janssen Pharmaceuticals, and Ferring Pharmaceuticals outside the submitted work. No other disclosures were reported.

Figures

Figure 1.
Figure 1.. Breakdown of Total Costs by Treatment and Cost Component
Treatment groups include intracorporeal robot-assisted radical cystectomy (iRARC) and open radical cystectomy (ORC). Error bars indicate 95% CIs.
Figure 2.
Figure 2.. European Quality of Life 5-Dimension 5-Level Instrument (EQ-5D-5L) Responses to 90 Days, Including Day 5 Imputation
When analyzed as described, EQ-5D-5L scores range from 1.00 (perfect health) through 0 (a health state equivalent to death) to −0.594 (the worst possible health classified by the instrument). iRARC indicates robot-assisted radical cystectomy with intracorporeal urinary diversion; ORC, open radical cystectomy.
See this image and copyright information in PMC

References

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