Outcome and Cost Comparison between Open and Robotic Ileovesicostomy for the Neurogenic Bladder Patient
Alex J. Vanni, M.D.1, Kevin Bennett, B.A.1, Linda Ng, M.D.2, John T. Stoffel, M.D.1.
1Lahey Clinic, Burlington, MA, USA, 2Boston University, Boston, MA, USA.
BACKGROUND: Our objective was to compare outcomes and cost of open versus robotic Ileovesicostomy for the adult neurogenic bladder patient.
METHODS: Consecutive ileovesicostomy procedures between October 2006 and January 2009 were reviewed for demographic, urodynamic, operative, post operative, and cost data. All robotic surgeries were performed transperitoneal with a DaVinci S robot. Both open and robotic procedures utilized the same surgical template and post operative care plan. Outcome endpoints included operative (procedural time, intraoperative complications), post operative recovery (time to return of bowel function), length of post operative hospital stay), and procedural efficacy (continence per urethra, residual bladder volume, upper tract status). Detailed operative and inpatient costs including room and board, operating room, surgical supplies, professional fees, recovery room, intensive care unit, and robotic maintenance fees were obtained. Total inpatient cost was calculated through summation of operative and inpatient hospital costs.
RESULTS: Seven open and eight robotic procedures were performed by a single surgeon. Mean age was 42 years in the open group vs. 52 in the robotic (p=0.13) and mean BMI was 28.4 vs. 29.2, respectively (p=0.84). There was no difference in pre operative urodynamic data between groups. Mean blood loss was 257 cc in the open and 92 cc in the robotic group (p=0.09). Mean total operative time was 291 minutes in the open and 330 minutes in the robotic group (p=0.24). No intraoperative complications occurred in either group. Bowel function returned after a mean 6.0 post operative days in the open and 4.8 days in the robotic group (p=0.32). Mean length of post operative hospital stay was 10.8 days in the open and 8.2 days in the robotic group (p=0.14). After a median follow-up of 12.5 versus 14.0 months, the mean postoperative bladder volume was 125 cc compared to 36 cc in the open and robotic groups, respectively (p=0.11). Urethral incontinence was noted in 3 (42%) and 2 (25%) patients in the open and robotic groups, respectively (p = 0.60). No patients in either group had postoperative hydronephrosis. Total inpatient procedural cost for the open and robotic groups was $14,356 and $17,344 (p = 0.05). On subgroup cost analysis, only OR supply costs were significantly different between groups ($609 vs. $3770, p<0.001).
CONCLUSIONS: Robotic Ileovesicostomy procedures trended toward a lower intraoperative blood loss, shorter hospital stay, and lower post operative bladder residual compared to open. Total inpatient costs were significantly higher in the robotic group, mostly due to OR supply cost differences. A larger series is needed, with longer follow up, to better assess these observations.