title: Perioperative Outcomes, Health Care Costs, and Survival After Robotic-assisted Versus Open Radical Cystectomy: A National Comparative Effectiveness Study.
abstract: Radical cystectomy is the gold-standard management for muscle-invasive bladder cancer, and there is debate concerning the comparative effectiveness of robotic-assisted (RARC) versus open radical cystectomy (ORC).
  
  
  
  To compare utilization, perioperative, cost, and survival outcomes of RARC versus ORC.
  
  
  
  We identified bladder urothelial carcinoma treated with RARC (n=439) or ORC (n=7308) during 2002-2012 using the Surveillance, Epidemiology, and End Results Program-Medicare linked data.
  
  
  
  Comparison of RARC versus ORC.
  
  
  
  We used propensity score matching to compare perioperative and survival outcomes, including lymph node yield, perioperative complications, and healthcare costs.
  
  
  
  Utilization of RARC increased from 0.7% of radical cystectomies in 2002 to 18.5% in 2012 (p<0.001). Women comprised 13.9% versus 18.1% (p=0.007) of RARC versus ORC, respectively. RARC was associated with greater lymph node yield with 41.5% versus 34.9% having ≥10 lymph nodes removed (relative risk 1.1, 95% confidence interval [CI] 1.01-1.22, p=0.03) and shorter mean length of hospitalization at 10.1 (± standard deviation 7.1) d versus 11.2 (± 8.6) d (p=0.004). While inpatient costs were similar, RARC was associated with increased home healthcare utilization (relative risk 1.14, 95% CI 1.04-1.26, p=0.009) and higher 30-d (p<0.01) and 90-d (p<0.01) costs. With a median follow-up of 44 mo (interquartile range 16-78), overall survival (hazard ratio 0.88, 95% CI 0.74-1.05) and cancer-specific survival (hazard ratio 0.91, 95% CI 0.66-1.26) were similar.
  
  
  
  RARC provides equivalent perioperative and intermediate term outcomes to ORC. Additional long-term and randomized studies are needed for continued comparative effectiveness assessment of RARC versus ORC.
  
  
  
  Our population-based US study demonstrates that robotic-assisted radical cystectomy has similar perioperative and survival outcomes albeit at higher costs.
authors.affiliation: Department of Urology, Weill Cornell Medical College, New York, NY, USA. Electronic address: jch9011@med.cornell.edu.
authors.forename: Jim C
authors.initials: JC
authors.lastname: Hu
authors.affiliation: Department of Urology, Weill Cornell Medical College, New York, NY, USA.
authors.forename: Bilal
authors.initials: B
authors.lastname: Chughtai
authors.affiliation: Department of Urology, Weill Cornell Medical College, New York, NY, USA.
authors.forename: Padraic
authors.initials: P
authors.lastname: O'Malley
authors.affiliation: Department of Urology, Weill Cornell Medical College, New York, NY, USA.
authors.forename: Joshua A
authors.initials: JA
authors.lastname: Halpern
authors.affiliation: Department of Healthcare Policy and Research, Weill Cornell Medical College, New York, NY, USA.
authors.forename: Jialin
authors.initials: J
authors.lastname: Mao
authors.affiliation: Department of Urology, Weill Cornell Medical College, New York, NY, USA.
authors.forename: Douglas S
authors.initials: DS
authors.lastname: Scherr
authors.affiliation: Herbert Irving Comprehensive Cancer Center, Columbia University College of Physicians and Surgeons, New York, NY, USA.
authors.forename: Dawn L
authors.initials: DL
authors.lastname: Hershman
authors.affiliation: Herbert Irving Comprehensive Cancer Center, Columbia University College of Physicians and Surgeons, New York, NY, USA.
authors.forename: Jason D
authors.initials: JD
authors.lastname: Wright
authors.affiliation: Department of Healthcare Policy and Research, Weill Cornell Medical College, New York, NY, USA.
authors.forename: Art
authors.initials: A
authors.lastname: Sedrakyan
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D002295:Carcinoma, Transitional Cell / Q000601:surgery*; D015653:Cystectomy / Q000009:adverse effects / Q000191:economics / Q000379:methods*; D005260:Female; D017048:Health Care Costs; D006699:Home Care Services / Q000706:statistics & numerical data; D006801:Humans; D007902:Length of Stay; D008197:Lymph Node Excision / Q000379:methods*; D008297:Male; D059035:Perioperative Period; D011183:Postoperative Complications / Q000209:etiology; D065287:Robotic Surgical Procedures / Q000009:adverse effects / Q000191:economics / Q000706:statistics & numerical data; D018426:SEER Program; D015996:Survival Rate; D013997:Time Factors; D016896:Treatment Outcome; D001749:Urinary Bladder Neoplasms / Q000601:surgery*
keywords: Bladder cancer; Costs and cost analysis; Cystectomy; Lymph node excision; Robotic surgical procedures