title: Comparison of clinical and economic outcomes between robotic, laparoscopic, and open rectal cancer surgery: early experience at a tertiary care center.
abstract: BACKGROUND
  Robotic surgery has gained popularity in surgical oncology. Rectal cancer surgery, known to be technically challenging, may benefit from robotics in achieving better mesorectal dissection and may contribute to improved perioperative outcomes. The objective of this study was to compare early experience in robotic surgery to conventional approaches with regard to clinicopathologic and economic parameters.
  
  
  METHODS
  A retrospective review using a prospectively maintained database of rectal cancer surgeries performed at a tertiary cancer center from 2007 to 2013 was conducted. These resections included those performed via laparotomy, laparoscopy, and robotic-assisted operations. Perioperative demographic and tumor characteristics were collected, and short-term clinicopathologic outcomes were compared. Additionally, economic variables were evaluated for each patient's episode of care.
  
  
  RESULTS
  Seventy-nine cases were identified. Twenty-six were completed via open approach, 27 laparoscopically, and 26 via robotic assistance. Demographic characteristics were similar between all groups including age, gender, BMI, and Charlson score. Comparison of intraoperative characteristics showed a lower rate of conversion to laparotomy (12 vs. 37%, p = 0.05), and lower estimated blood loss (mean 296 vs. 524 cc, p = 0.04), in the robotic group compared to laparoscopy or open resection. There was no significant difference in quality of total mesorectal excision and number of lymph nodes harvested between the three cohorts. Postoperative complication rate, mean length of stay, 30-day readmission, and 30-day mortality were comparable among the cohorts. Median cost per episode of care was lower in laparoscopic surgery ($11,493), compared to open ($12,558) and robotic approach ($18,273); p = 0.029.
  
  
  CONCLUSIONS
  The findings demonstrate similar perioperative and short-term outcomes between robotic surgery and conventional approaches. Robotic assistance is associated with decreased intraoperative blood loss and fewer conversions, albeit at an increased overall cost. Given these benefits, and as data and experience mature, future study is needed to fully define the value of the robotic approach.
authors.affiliation: Department of Surgery, University of Toronto, Toronto, ON, Canada.
authors.forename: Karim M
authors.initials: KM
authors.lastname: Ramji
authors.affiliation: Division of General Surgery, University Health Network - Toronto Western Hospital, 399 Bathurst Street, Room 8MP-320, Toronto, ON, M5T 2S8, Canada.
authors.forename: Michelle C
authors.initials: MC
authors.lastname: Cleghorn
authors.affiliation: Department of Surgery, University of Toronto, Toronto, ON, Canada.
authors.forename: Jonathan M
authors.initials: JM
authors.lastname: Josse
authors.affiliation: Department of Surgical Oncology, University of Toronto, Toronto, ON, Canada.
authors.forename: Andrea
authors.initials: A
authors.lastname: MacNeill
authors.affiliation: Department of Surgery, University of Toronto, Toronto, ON, Canada.|Division of General Surgery, University Health Network - Toronto Western Hospital, 399 Bathurst Street, Room 8MP-320, Toronto, ON, M5T 2S8, Canada.|Department of Surgical Oncology, University of Toronto, Toronto, ON, Canada.
authors.forename: Catherine
authors.initials: C
authors.lastname: O'Brien
authors.affiliation: Department of Surgery, University of Toronto, Toronto, ON, Canada.|Division of General Surgery, University Health Network - Toronto Western Hospital, 399 Bathurst Street, Room 8MP-320, Toronto, ON, M5T 2S8, Canada.
authors.forename: David
authors.initials: D
authors.lastname: Urbach
authors.affiliation: Department of Surgery, University of Toronto, Toronto, ON, Canada. Fayez.Quereshy@uhn.ca.|Division of General Surgery, University Health Network - Toronto Western Hospital, 399 Bathurst Street, Room 8MP-320, Toronto, ON, M5T 2S8, Canada. Fayez.Quereshy@uhn.ca.|Department of Surgical Oncology, University of Toronto, Toronto, ON, Canada. Fayez.Quereshy@uhn.ca.
authors.forename: Fayez A
authors.initials: FA
authors.lastname: Quereshy
mesh_terms: D000368:Aged; D003082:Colectomy / Q000379:methods*; D005260:Female; D006801:Humans; D010535:Laparoscopy / Q000379:methods*; D007813:Laparotomy / Q000379:methods*; D008297:Male; D008875:Middle Aged; D011183:Postoperative Complications / Q000601:surgery; D012004:Rectal Neoplasms / Q000601:surgery*; D012189:Retrospective Studies; D065287:Robotic Surgical Procedures / Q000379:methods*; D062606:Tertiary Care Centers; D013997:Time Factors; D016896:Treatment Outcome
keywords: Cost; Laparoscopy; Rectal cancer; Robotics