Long term COST-minimization analysis of robot-assisted hysterectomy versus conventional laparoscopic hysterectomy

Cost-effectiveness of robotic surgery compared to conventional laparoscopy for the management of early-stage cervical cancer: a model-based economic evaluation in China

OBJECTIVES

The aim of this study is to assess cost-effectiveness of robotic radical hysterectomy (RRH) vs laparoscopic radical hysterectomy (LRH) in early-stage cervical cancer (ECC).

DESIGN

Model-based cost-effectiveness analysis.

SETTING

Based on long-term survival data, a three-state Markov model was constructed using TreeAge Pro 2022 to simulate the possible recurrence of ECC. Data on clinical efficacy and costs were derived from published literature and local databases.

PARTICIPANTS

A hypothetical cohort of 1000 individuals diagnosed with early-stage cervical cancer (FIGO 2009 stages

OUTCOME MEASURES

The study endpoints were quality-adjusted life years (QALYs), total costs (in Chinese renminbi (RMB) adjusted to 2023-year values using the Consumer Price Index) and incremental cost-effectiveness ratio (ICER). A willingness-to-pay threshold of 268 074 RMB per QALY was used to assess cost-effectiveness.

RESULTS

Robotic group gained more 4.84 QALYs than the laparoscopic group, but total costs for robotic strategy are substantially higher, with the incremental costs of 1 031 108 RMB. The ICER of robotic strategy is 213 054 RMB per QALY. Outcomes were robust in most one-way sensitivity and probabilistic sensitivity analyses.

CONCLUSIONS

Robotic strategy is on the efficient frontier but incurs substantial initial cost. Our findings indicated that this strategy is a cost-effective treatment option for ECC patients if assessed over a time horizon of patients' lifetime. This study underscores the need for long-term clinical trials in early-stage cervical cancer patients with follow-up data that capture financial and quality-of-life end points.

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Key Words

• China
• Gynaecological oncology
• Health economics
• Minimally invasive surgery

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MESH Headings

• Humans
• Female
• Uterine Cervical Neoplasms/surgery
• Uterine Cervical Neoplasms/economics
• Uterine Cervical Neoplasms/pathology
• Cost-Benefit Analysis
• Laparoscopy/economics
• Laparoscopy/methods
• Robotic Surgical Procedures/economics
• Robotic Surgical Procedures/methods
• China
• Hysterectomy/methods
• Hysterectomy/economics
• Quality-Adjusted Life Years
• Markov Chains
• Neoplasm Staging
• Middle Aged
• Models, Economic
• Adult

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Grants

• the National Natural Science Foundation of China
• the Future Medical Research Innovation Team Project of Chongqing Medical University

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Affiliation(s)

Chunlan Chen School of Medical Informatics, Chongqing Medical University, Chongqing, China
Min Zhang School of Medical Informatics, Chongqing Medical University, Chongqing, China
Junying Tang Department of Gynecology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
Kexue Pu School of Medical Informatics, Chongqing Medical University, Chongqing, China

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Collaborators Collapse

Multi-Institutional Trends in Gynecological Robotic Surgery in India: A Real-World Scenario

Background Robot-assisted laparoscopic surgery in gynecology has grown exponentially compared to laparoscopic surgery. The probable reasons for the increased uptake of robotics are a shorter learning curve, three-dimensional vision, and increased dexterity compared to laparoscopic surgery, and precise surgery as compared to open surgery. This study compares the time trends of various parameters in robotic gynecological surgery in India over a decade. Material and methods In India, a retrospective analysis of all robot-assisted laparoscopic surgery for gynecologic diseases in five tertiary care hospitals was conducted between July 2011 and June 2021. Data were collected regarding demographic profiles, clinical and disease characteristics, and indications for surgery. Details related to surgery were collected, such as the number of ports, console and docking time, the procedure performed, total operative time, average blood loss, blood transfusion, and length of hospital stay. All the parameters collected were grouped into five years, and a comparison was made between the first five years (2011-2015) and the second five years (2016-2021). Statistical analysis, including descriptive statistics and trend analysis, was performed. Results During the 10 years, the total number of cases included was 1,501, out of which 764 were benign cases and 737 were pre-malignant/malignant cases. The common indications were uterine leiomyoma (31.2%) and carcinoma endometrium (28%). The mean age for benign cases was significantly lower than that for malignant cases (40.84 years and 55.42 years, respectively). Mean blood loss was significantly lower for benign indications (97.48 mL) than for oncological surgery (184.67 mL) and needed fewer transfusions. The mean length of stay (LOS) for benign (2.07 days) and malignant/ pre-malignant cases (2.32 days) and the mean BMI for benign (28.40) and for oncological patients (28.47) were similar in both groups. The docking time reduced significantly in the last five years. Conclusion The current retrospective study demonstrates an increasing uptake of robotic technology in gynecological surgery in India. Of the total cohort of cases, 70.9% of patients underwent gynecological robotic surgery in the last five years. A burst of adaptability happened for malignant cases in 2017 and benign cases in 2018, probably due to the increased availability of robotic platforms and improved awareness of technology and training among medical professionals. The number of cases has grown exponentially over the last five years in both benign and malignant/ pre-malignant scenarios; however, there has been a downward trend in the robotic surgery performed in the previous couple of years due to the uncertainty of the COVID pandemic.

Outcomes of robotic and laparoscopic surgery for benign gynaecological disease: a systematic review

Benign gynaecological diseases are usually treated with minimally invasive approaches. Robotic surgery seems an alternative to laparoscopic surgery. No definitive conclusions have yet been made regarding comparison of robotic versus laparoscopic surgery for benign diseases. In this scenario, we performed a systematic review in order to assess the advantages and disadvantages of laparoscopy versus robotic surgery and conclude whether laparoscopy should be replaced by robotic surgery for the treatment of benign gynaecological conditions, following the Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) Statement. We included 64 studies: no significant difference was observed regarding overall complication rate; no significant benefit of robotic approach was demonstrated regarding length of hospital stay and conversion to laparotomy; furthermore, robotic surgery is more easily used by non-experienced surgeons, while it is more expensive and characterised by longer operative time. In conclusion, current evidence indicates neither statistically significant nor clinically meaningful differences in surgical outcomes between robotic and laparoscopic surgeries for benign gynaecological diseases. Impact statementWhat is already known on this subject? Benign gynaecological diseases are usually treated with minimally invasive approaches. Nevertheless, no definitive conclusions have yet been made regarding comparison of robotic versus laparoscopic surgery for benign diseases.What do the results of this study add? No significant difference was observed regarding overall complication rate; no significant benefit of robotic approach was demonstrated regarding length of hospital stay and conversion to laparotomy; furthermore, robotic surgery is more easily used by non-experienced surgeon, while it is more expensive and characterised by longer operative time.What are the implications of these findings for clinical practice and/or further research? Robotic surgery should not replace laparoscopy for the treatment of benign gynaecological conditions; in addition, gynaecologic surgeon should offer robotic surgery for benign diseases only after a proper counselling and a balanced decision-making process involving the patient.

Healthcare and Indirect Cost of the Laparoscopic vs. Vaginal Approach in Benign Hysterectomy

Background and Objectives:

The aim of this study was to analyze indirect costs of vaginal and laparoscopic routes for hysterectomy to determine whether this makes a difference in total costs when considering route for surgery.

Methods:

A five-year observational retrospective cohort study was conducted in an academic tertiary care center. A total of 517 patients scheduled for total laparoscopic hysterectomy (n = 137) and vaginal hysterectomy (n = 380) for benign conditions between January 1, 2008 and December 31, 2012 meeting inclusion criteria were reviewed.

Results:

Indirect costs were higher in the vaginal hysterectomy group compared to the laparoscopic hysterectomy group (mean cost €3,239.86 vs. €1,371.58; cost increase of €1,868.28; p < .001). Indirect costs due to lost-work-productivity were the most important, represented by 97.7% in the vaginal group and 93.6% in the laparoscopic group.

Conclusion:

Among women undergoing hysterectomy for benign disease, laparoscopic hysterectomy appears to be superior to vaginal hysterectomy when indirect costs are analyzed in a five-year temporal horizon. Laparoscopic hysterectomy is a good alternative to vaginal hysterectomy when technically feasible as both present comparable advantages. The surgical approach to hysterectomy should be decided in light of the relative benefits and hazards, which will depend on clinical circumstances and surgical expertise.

Decline in surgeon volume after successful implementation of advanced laparoscopic surgery in gynecology: An undesired side effect?

INTRODUCTION

The implementation of advanced minimally invasive surgical (MIS) techniques has broadened. An extensive body of literature shows that high hospital and surgeon volumes lead to better patient outcomes. However, no information is available regarding volume trends in the post-implementation phase of MIS. This study investigated these trends and poses suggestions to adjust these developments. This knowledge can provide guidance to optimize patient safe performance of new surgical techniques.

MATERIAL AND METHODS

A national retrospective cohort study in the Netherlands. The number of advanced laparoscopic (level 3 and 4) and robotic procedures and the number of gynecologists performing them were collected through a web-based questionnaire to determine hospital and gynecological surgeon volume. These volumes were compared with our previously collected data from 2012.

RESULTS

The response rate was 85%. Hospitals produced larger volumes for advanced laparoscopic and robotic procedures. However, still 63% of the hospitals perform low-volume level 4 laparoscopic procedures. Additionally, gynecological surgeon volumes appeared to decrease for level 3 procedures, as the group of gynecologists performing fewer than 20 procedures expanded (64% vs. 44% in 2012), with 15% of the gynecologists performing fewer than ten procedures. Despite an increase in surgeon volumes for level 4 laparoscopy and robotic surgery, volumes continued to be low, as still 49% of gynecologists performed fewer than 10 level 4 procedures per year and 41% performed fewer than 20 robotic procedures per year.

CONCLUSIONS

The broad implementation of advanced MIS procedures resulted in an increasing number of these procedures with increasing hospital volumes. However, as a side-effect, a disproportionate rise in number of gynecologists performing these procedures was observed. Therefore, surgeon volumes remain low and even decreased for some procedures. Centralization of complex procedures and training of specialized MIS gynecologists could improve surgeon volumes and therefore consequently enhance patient safety.

Training for next generation surgeons: a pilot study of robot-assisted hysterectomy managed by resident using dual console

PURPOSE

To assess feasibility of a standardized robot-assisted hysterectomy managed by resident and supervised by senior surgeon using dual-console on a 21-step grid (max score = 42) assessing resident autonomy.

METHODS

A total of seven patients managed between September 2019 and March 2020 by six residents in gynecology and obstetrics were included. Standardized robot-assisted hysterectomy for endometrial cancer or adenomyosis was performed.

RESULTS

No conversion to laparotomy, no intra- or post-operative incidents were reported. Mean score on the evaluation scale was 29.8 out of 42 (SD = 7.3). Mean operative time was 104 min (SD = 23). Mean average suturing time was, respectively, 335 s (SD = 57 s) and 270 s (SD = 53 s) for the first and the fourth knot. There was a 65 s improvement between the first and the fourth intracorporeal knot (p = 0.043). The perceived workload evaluated with the NASA TLX score showed a low level of stress (Temporal demand = 1.6 /10), and a low level of frustration (Frustration level = 3.6/10). Experience gained during the surgery was felt to be important (Commitment = 8.6/10).

CONCLUSION

Standardized robot-assisted hysterectomy managed by a resident supervised by a senior surgeon using the dual-console seems feasible. This tool could be useful to assess residents' surgical skills.

Robotic-assisted versus conventional laparoscopic hysterectomy for endometrial cancer

Objective

The safety and efficacy of robotic-assisted laparoscopic hysterectomy (RALH) compared with conventional total laparoscopic hysterectomy (TLH) for surgical staging of endometrial cancer has not been clearly established. With the commencement of a robotic program at our institution, our objective was to evaluate and compare the surgical outcomes of RALH with TLH for endometrial cancer.

Methods

A retrospective cohort study was performed on 39 patients who underwent RALH and 41 patients who underwent TLH for endometrial cancer at a tertiary care academic institution.

Results

In the setting of endometrial cancer RALH is significantly longer to perform than TLH (mean operating time 133 min vs 107 min, p = 0.0001). There is higher estimated blood loss in TLH cases than RALH cases (78 mL vs 22 mL, p = 0.015). Women who underwent RALH had a shorter length of stay (1.3 days vs 1.8 days, p = 0.006) than TLH patients, and six cases (15 %) of the RALH group were discharged on the same day of surgery. There were no differences between the RALH and TLH groups in intraoperative or postoperative complications and there were no conversions to laparotomy.

Conclusion

RALH is safe and feasible for the treatment of endometrial cancer, with low morbidity, less blood loss and shorter length of stay than TLH. RALH is associated with longer mean operating times than TLH and this may improve with enlisting a consistent experienced team. Prospective randomised studies which include analysis of quality of life measures and long-term outcomes are required to further establish the role of RALH in the surgical staging of endometrial cancer.