Cost-effectiveness evaluation of robotic-assisted thoracoscopic surgery versus open thoracotomy and video-assisted thoracoscopic surgery for operable non-small cell lung cancer

BACKGROUND

This study aimed to evaluate the cost-effectiveness of robotic-assisted thoracoscopic surgery (RATS) over open thoracotomy (OT) and video-assisted thoracoscopic surgery (VATS) for operable non-small cell lung cancer (NSCLC) from the perspective of Chinese healthcare payer.

METHODS

The Markov decision model was developed to assess the 5-year costs and quality-adjusted life year (QALY) of RATS versus OT and VATS for operable NSCLC patients. The propensity-matched cohorts were generated from our clinical center to determine the surgical costs and complication rates. An individual patient data meta-analysis was conducted to estimate model probabilities of progression and survival risks. Other model inputs were abstracted from available studies. The primary outcome was incremental cost-effectiveness ratios (ICERs).

RESULTS

RATS contributed to an incremental 0.28 QALYs at an additional cost of $3,104.82, making for an ICER of $10,967.41 per QALY versus OT. Robotic approach harvested an incremental 0.05 QALYs at an additional cost of $4006.86, making for an ICER of $80324.98 per QALY over VATS. RATS shown a same cost-effectiveness probability (0.50) versus OT and VATS at a willing-to-pay (WTP) threshold of $12,000 per QALY and $75,800 per QALY, respectively. The probabilities of cost-effectiveness for RATS were 0.64 and 0.21 at a presupposed WTP threshold of $ 30,000 per QALY versus OT and VATS, respectively.

CONCLUSIONS

RATS was evaluated to be cost-effective versus OT for patients with operable NSCLC from the perspective of Chinese healthcare payer. To the contrary, robotic approach was associated with less cost-effective than VATS.

[Robotics in thoracic surgery]

The number of interventions using robot-assisted thoracic surgery (RATS) is increasing in Germany, following the previous international development. Robot-assisted surgery provides some technical advantages and can overcome existing limitations of video-assisted thoracic surgery (VATS), especially in the case of extended resections, thus enabling the proportion of minimally invasive operations to be further increased. The safety of the procedure, even in extended resections, has repeatedly been demonstrated but whether there are clinically relevant benefits from RATS is currently the subject of scientific discussions. In addition, a further technical evolution of the RATS can be postulated by the upcoming market introduction of new robotic systems.

Current status and evolution of robotic-assisted thoracic surgery in Germany-results from a nationwide survey

Background

Robot-assisted surgery has made a significant entry into surgical practice within Germany, including thoracic surgery. As no published data exists regarding robotic-assisted thoracic surgery (RATS), we conducted a survey to investigate its current status.

Methods

We performed a nationwide survey of all centers active in RATS, using a standardized questionnaire. The annual number of operations, mean duration of surgery, docking time, length of hospital stay(s), conversions, chest tube duration, the RATS program start date, robot system used, operating room capacity, and staplers and instruments used were recorded.

Results

Of the 22 centers contacted, 14 responded. In total, 786 RATS interventions were recorded. Most were anatomical lung resections, comprising 372 (bi-) lobectomies and 80 segmentectomies. During the study period, eight bronchoplastic procedures were performed robotically. There were 93 wedge lung resections, 148 thymectomies, 26 sympathectomies, and 59 other RATS procedures, and a single-center series of around 1,000 RATS thymectomies (excluded from statistical analysis). The average incision-suture time of the RATS lobectomy was 245 (range, 80-419) minutes, average residence time seven days. The conversion rate was 6.7% across all interventions, with significant inter-intervention differences. All surveyed centers plan to further expand RATS, with OR capacity being a frequent impediment. Five RATS interventions were performed in Germany in 2013, versus 320 in 2018.

Conclusions

Overall, RATS is becoming more established in everyday clinical practice in Germany. The number of operations, active centers, and trained RATS surgeons has increased steadily since 2013. A German-speaking operation course for entry into RATS already exists. Even extended resections can be carried out safely, and RATS has become standard procedure in some centers.