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Open versus robot-assisted radical cystectomy: comparison of early outcomes and cost.
Sheaumei Tsai, M.D., Arthur Mourtzinos, M.D., Andrea Sorcini, M.D., Karim Hamawy, M.D., John A. Libertino, M.D., David Canes, M.D., Ali Moinzadeh, M.D..
Lahey Clinic, Boston, MA, USA.

BACKGROUND: Robot-assisted radical cystectomy (RARC) is an alternative for patients undergoing radical cystectomy. The relative financial burden has yet to be elucidated. We report a retrospective comparison of our early experience with robotic versus open radical cystectomy in terms of early perioperative outcomes and cost.
METHODS: Following IRB approval, a retrospective review of medical and billing records was performed on 64 patients undergoing radical cystectomy (14 robotic, 43 open, 7 incomplete data) between November 2007 and March 2009. The majority of patients underwent concomitant ileal loop urinary diversion. Patients with prior pelvic irradiation who had undergone open surgery were excluded (n=15). After matching for BMI, 13 robotic and 13 open cases were selected for analysis. Perioperative outcomes and early postoperative morbidity were compared. Early postoperative morbidity was defined as a complication occurring within 90 days of surgery, as classified by the Clavien morbidity grading system. Overall cost was calculated by factoring in OR time, instrument and robot costs, ICU care, and length of stay. Student’s t-test, Mann-Whitney U-test, and Fisher’s exact test were used for statistical analysis.
RESULTS:

CharacteristicRobotic (N=13)Open (N=13)P value
Mean Age64.4672.690.016
Mean BMI27.6627.300.739
% Male69920.3217
ASA class 2-3 (%)100100n/a
Urinary DiversionIleal conduit (n)9130.0957
Neobladder (n)40
TNM Stage: organ-confined (%)10061.60.0391
Prior abdominal surgery (%)15.3846.150.1159
Mean operative time(min)5714230.002
Median EBL(mL)2006000.0004
Transfusion rate (%)23.130.81
Mean node yield13.757.10.0057
Positive margin (n)11n/a
Early morbidity (%)< Grade 384.761.50.2016
Grade 315.338.5
Mean hospital stay (days)7.698.920.3346
Mean direct cost ($)17,71011,3570.017

Patients undergoing RARC were significantly younger than their open counterparts. The groups also differed significantly in disease extent, with extravesical extension confirmed on final pathology in 5 open cystectomy patients versus none of the robotic patients. The robotic approach resulted in a reduction in median blood loss (200 mL vs 600 mL, p=0.0004) and higher mean lymph node yield (13.75 vs 7.1, p=0.0057). Mean operative time for RARC was longer (571 min vs. 423 min, p=0.002). Notably, there were 4 concomitant neobladders in the robotic group compared to zero in the open group. The direct cost associated with the robotic approach was significantly higher than the cost for open surgery ($17,710 vs $11,357, p=0.017).
CONCLUSIONS: Our small sample population reveals that the robotic approach affords increased nodal yield and decreased blood loss with comparable perioperative morbidity. The potential benefits of the robotic approach should be balanced against the elevated cost of robotic cystectomy.
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