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Original Investigation
October 24/31, 2017

Association of Robotic-Assisted vs Laparoscopic Radical Nephrectomy With Perioperative Outcomes and Health Care Costs, 2003 to 2015

Author Affiliations
  • 1Department of Urology, Stanford University Medical Center, Stanford, California
  • 2Department of Urology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
  • 3University of California, San Diego School of Medicine
  • 4Department of Urology and Dermatology, Stanford University Medical Center, Stanford, California
  • 5Center for Surgery and Public Health, Brigham and Women’s Hospital, Boston, Massachusetts
  • 6Division of Urology, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
JAMA. 2017;318(16):1561-1568. doi:10.1001/jama.2017.14586
Key Points

Questions  Has the use of robotic-assisted vs laparoscopic radical nephrectomy changed from 2003 to 2015?

Findings  The proportion of radical nephrectomies using robotic-assisted operations increased from 1.5% in 2003 to 27.0% in 2015. Although there was no significant difference between robotic-assisted vs laparoscopic radical nephrectomy in major postoperative complications, robotic-assisted procedures were associated with longer operating time and higher direct hospital costs.

Meaning  The use of robotic-assisted radical nephrectomy increased substantially from 2003 to 2015 and was associated with prolonged operating time and increased costs.

Abstract

Importance  Use of robotic surgery has increased in urological practice over the last decade. However, the use, outcomes, and costs of robotic nephrectomy are unknown.

Objectives  To examine the trend in use of robotic-assisted operations for radical nephrectomy in the United States and to compare the perioperative outcomes and costs with laparoscopic radical nephrectomy.

Design, Setting, and Participants  This retrospective cohort study used the Premier Healthcare database to evaluate outcomes of patients who had undergone robotic-assisted or laparoscopic radical nephrectomy for renal mass at 416 US hospitals between January 2003 and September 2015. Multivariable regression modeling was used to assess outcomes.

Exposures  Robotic-assisted vs laparoscopic radical nephrectomy.

Main Outcomes and Measures  The primary outcome of the study was the trend in use of robotic-assisted radical nephrectomy. The secondary outcomes were perioperative complications, based on the Clavien classification system, and defined as any complication (Clavien grades 1-5) or major complications (Clavien grades 3-5, for which grade 5 results in death); resource use (operating time, blood transfusion, length of hospital stay); and direct hospital cost.

Results  Among 23 753 patients included in the study (mean age, 61.4 years; men, 13 792 [58.1%]), 18 573 underwent laparoscopic radical nephrectomy and 5180 underwent robotic-assisted radical nephrectomy. Use of robotic-assisted surgery increased from 1.5% (39 of 2676 radical nephrectomy procedures in 2003) to 27.0% (862 of 3194 radical nephrectomy procedures) in 2015 (P for trend <.001). In the weighted-adjusted analysis, there were no significant differences between robotic-assisted and laparoscopic radical nephrectomy in the incidence of any (Clavien grades 1-5) postoperative complications (adjusted rates, 22.2% vs 23.4%, difference, −1.2%; 95% CI, −5.4 to 3.0%) or major (Clavien grades 3-5) complications (adjusted rates, 3.5% vs 3.8%, difference, −0.3%; 95% CI, −1.0% to 0.5%). The rate of prolonged operating time (>4 hours) for patients undergoing the robotic-assisted procedure was higher than for patients receiving the laparoscopic procedure in the adjusted analysis (46.3% vs 25.8%; risk difference, 20.5%; 95% CI, 14.2% to 26.8%). Robotic-assisted radical nephrectomy was associated with higher mean 90-day direct hospital costs ($19 530 vs $16 851; difference, $2678; 95% CI, $838 to $4519), mainly accounted for operating room ($7217 vs $5378; difference, $1839; 95% CI, $1050 to $2628) and supply costs ($4876 vs $3891; difference, $985; 95% CI, $473 to $1498).

Conclusions and Relevance  Among patients undergoing radical nephrectomy for renal mass between 2003 and 2015, the use of robotic-assisted surgery increased substantially. The use of robotic-assistance was not associated with increased risk of any or major complications but was associated with prolonged operating time and higher hospital costs compared with laparoscopic surgery.

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