title: Does robotic assistance confer an economic benefit during laparoscopic radical nephrectomy?
abstract: OBJECTIVE
  While robotic assisted radical nephrectomy is safe with outcomes and complication rates comparable to those of the pure laparoscopic approach, there is little evidence of an economic or clinical benefit.
  
  
  METHODS
  From the 2009 to 2011 Nationwide Inpatient Sample database we identified patients 18 years old or older who underwent radical nephrectomy for primary renal malignancy. Robotic assisted and laparoscopic techniques were noted. Patients treated with the open technique and those with evidence of metastatic disease were excluded from analysis. Descriptive statistics were performed using the chi-square and Mann-Whitney tests, and the Student t-test. Multiple linear regression was done to examine factors associated with increased hospital costs and charges.
  
  
  RESULTS
  We identified 24,312 radical nephrectomy cases for study inclusion, of which 7,787 (32%) were performed robotically. There was no demographic difference between robotic assisted and pure laparoscopic radical nephrectomy cases. Median total charges were $47,036 vs $38,068 for robotic assisted vs laparoscopic surgery (p <0.001). Median total hospital costs for robotic assisted surgery were $15,149 compared to $11,735 for laparoscopic surgery (p <0.001). There was no difference in perioperative complications or the incidence of death. Compared to the laparoscopic approach robotic assistance conferred an estimated $4,565 and $11,267 increase in hospital costs and charges, respectively, when adjusted for adapted Charlson comorbidity index score, perioperative complications and length of stay (p <0.001).
  
  
  CONCLUSIONS
  Robotic assisted radical nephrectomy results in increased medical expense without improving patient morbidity. Assuming surgeon proficiency with pure laparoscopy, robotic technology should be reserved primarily for complex surgeries requiring reconstruction. Traditional laparoscopic techniques should continue to be used for routine radical nephrectomy.
authors.affiliation: Department of Urology, Indiana University School of Medicine, Indianapolis, Indiana.
authors.forename: David Y
authors.initials: DY
authors.lastname: Yang
authors.affiliation: Department of Urology, Indiana University School of Medicine, Indianapolis, Indiana.
authors.forename: M Francesca
authors.initials: MF
authors.lastname: Monn
authors.affiliation: Department of Urology, Indiana University School of Medicine, Indianapolis, Indiana.
authors.forename: Clinton D
authors.initials: CD
authors.lastname: Bahler
authors.affiliation: Department of Urology, Indiana University School of Medicine, Indianapolis, Indiana. Electronic address: sundaram@iupui.edu.
authors.forename: Chandru P
authors.initials: CP
authors.lastname: Sundaram
mesh_terms: D003362:Cost-Benefit Analysis; D005260:Female; D006801:Humans; D010535:Laparoscopy / Q000191:economics*; D008297:Male; D008875:Middle Aged; D009392:Nephrectomy / Q000191:economics* / Q000379:methods*; D012189:Retrospective Studies; D012371:Robotics / Q000191:economics*
keywords: cost-benefit analysis; kidney; laparoscopy; nephrectomy; robotics