title: Reducing robotic prostatectomy costs by minimizing instrumentation.
abstract: OBJECTIVE
  Since the introduction of robotic surgery for radical prostatectomy, the cost-benefit of this technology has been under scrutiny. While robotic surgery professes to offer multiple advantages, including reduced blood loss, reduced length of stay, and expedient recovery, the associated costs tend to be significantly higher, secondary to the fixed cost of the robot as well as the variable costs associated with instrumentation. This study provides a simple framework for the careful consideration of costs during the selection of equipment and materials.
  
  
  METHODS
  Two experienced robotic surgeons at our institution as well as several at other institutions were queried about their preferred instrument usage for robot-assisted prostatectomy. Costs of instruments and materials were obtained and clustered by type and price. A minimal set of instruments was identified and compared against alternative instrumentation. A retrospective review of 125 patients who underwent robotically assisted laparoscopic prostatectomy for prostate cancer at our institution was performed to compare estimated blood loss (EBL), operative times, and intraoperative complications for both surgeons. Our surgeons now conceptualize instrument costs as proportional changes to the cost of the baseline minimal combination.
  
  
  RESULTS
  Robotic costs at our institution were reduced by eliminating an energy source like the Ligasure or vessel sealer, exploiting instrument versatility, and utilizing inexpensive tools such as Hem-o-lok clips. Such modifications reduced surgeon 1's cost of instrumentation to ∼40% less compared with surgeon 2 and up to 32% less than instrumentation used by surgeons at other institutions. Surgeon 1's combination may not be optimal for all robotic surgeons; however, it establishes a minimally viable toolbox for our institution through a rudimentary cost analysis. A similar analysis may aid others in better conceptualizing long-term costs not as nominal, often unwieldy prices, but as percent changes in spending. With regard to intraoperative outcomes, the use of a minimally viable toolbox did not result in increased EBL, operative time, or intraoperative complications.
  
  
  CONCLUSIONS
  Simple changes to surgeon preference and creative utilization of instruments can eliminate 40% of costs incurred on robotic instruments alone. Moreover, EBL, operative times, and intraoperative complications are not compromised as a result of cost reduction. Our process of identifying such improvements is straightforward and may be replicated by other robotic surgeons. Further prospective multicenter trials should be initiated to assess other methods of cost reduction.
authors.affiliation: 1 Department of Urology, Mount Sinai Medical Center , Miami Beach, Florida.
authors.forename: Joan C
authors.initials: JC
authors.lastname: Delto
authors.forename: George
authors.initials: G
authors.lastname: Wayne
authors.forename: Rafael
authors.initials: R
authors.lastname: Yanes
authors.forename: Alan M
authors.initials: AM
authors.lastname: Nieder
authors.forename: Akshay
authors.initials: A
authors.lastname: Bhandari
mesh_terms: D016063:Blood Loss, Surgical; D015331:Cohort Studies; D003362:Cost-Benefit Analysis; D003365:Costs and Cost Analysis; D006801:Humans; D010535:Laparoscopy / Q000191:economics / Q000295:instrumentation / Q000379:methods; D008297:Male; D061646:Operative Time; D011468:Prostatectomy / Q000191:economics* / Q000295:instrumentation / Q000379:methods; D011471:Prostatic Neoplasms / Q000601:surgery*; D012189:Retrospective Studies; D065287:Robotic Surgical Procedures / Q000191:economics* / Q000295:instrumentation / Q000379:methods; D013525:Surgical Instruments / Q000191:economics*