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

Abstract

<div class="section"> <a class="named-anchor" id="ab-joi170114-1"> <!-- named anchor --> </a> <h5 class="section-title" id="d13196399e323">Questions</h5> <p id="d13196399e325">Has the use of robotic-assisted vs laparoscopic radical nephrectomy changed from 2003 to 2015? </p> </div><div class="section"> <a class="named-anchor" id="ab-joi170114-2"> <!-- named anchor --> </a> <h5 class="section-title" id="d13196399e328">Findings</h5> <p id="d13196399e330">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. </p> </div><div class="section"> <a class="named-anchor" id="ab-joi170114-3"> <!-- named anchor --> </a> <h5 class="section-title" id="d13196399e333">Meaning</h5> <p id="d13196399e335">The use of robotic-assisted radical nephrectomy increased substantially from 2003 to 2015 and was associated with prolonged operating time and increased costs. </p> </div><div class="section"> <a class="named-anchor" id="ab-joi170114-4"> <!-- named anchor --> </a> <h5 class="section-title" id="d13196399e339">Importance</h5> <p id="d13196399e341">Use of robotic surgery has increased in urological practice over the last decade. However, the use, outcomes, and costs of robotic nephrectomy are unknown. </p> </div><div class="section"> <a class="named-anchor" id="ab-joi170114-5"> <!-- named anchor --> </a> <h5 class="section-title" id="d13196399e344">Objectives</h5> <p id="d13196399e346">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. </p> </div><div class="section"> <a class="named-anchor" id="ab-joi170114-6"> <!-- named anchor --> </a> <h5 class="section-title" id="d13196399e349">Design, Setting, and Participants</h5> <p id="d13196399e351">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. </p> </div><div class="section"> <a class="named-anchor" id="ab-joi170114-7"> <!-- named anchor --> </a> <h5 class="section-title" id="d13196399e354">Exposures</h5> <p id="d13196399e356">Robotic-assisted vs laparoscopic radical nephrectomy.</p> </div><div class="section"> <a class="named-anchor" id="ab-joi170114-8"> <!-- named anchor --> </a> <h5 class="section-title" id="d13196399e359">Main Outcomes and Measures</h5> <p id="d13196399e361">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. </p> </div><div class="section"> <a class="named-anchor" id="ab-joi170114-9"> <!-- named anchor --> </a> <h5 class="section-title" id="d13196399e364">Results</h5> <p id="d13196399e366">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 ( <i>P</i> for trend &lt;.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 (&gt;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). </p> </div><div class="section"> <a class="named-anchor" id="ab-joi170114-10"> <!-- named anchor --> </a> <h5 class="section-title" id="d13196399e372">Conclusions and Relevance</h5> <p id="d13196399e374">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. </p> </div><p class="first" id="d13196399e377">This cohort study uses commercially available health care improvement database data to compare trends in the use, outcomes, and costs of robotic-assisted vs laparoscopic nephrectomy in the United States between 2003 and 2015. </p>