Robotic lobectomy costs and quality of life

Introduction

The surgical approach for pulmonary lobectomy has significantly changed over time. Two decades ago, the majority of lobectomies were performed via thoracotomy. Over time, surgeons began to adopt video-assisted thoracoscopic surgery (VATS) and an increased proportion of lobectomies were performed using this minimally invasive approach. The da Vinci Surgical System (Intuitive Surgical; Sunnyvale, California, USA) later provided an alternative platform. The proportion of lobectomies after introduction of this system performed by thoracotomy continued to decline. One study showed that, in 2008, 76.2% of lobectomies were performed using the open approach, compared with 23.4% and < 1.0% for VATS and robotic approaches, respectively^[1]. In 2014, the majority of lobectomies was no longer performed via the open approach, and VATS and robotic approaches comprised 31.6% and 25.0% of lobectomies, respectively^[1]. Another study demonstrated that, from 2011 to 2015, lobectomies performed by thoracotomy had an absolute decline of 11.5%^[2]. Lobectomies performed using the robotic approach had an absolute increase of 10%, yet VATS only had an absolute increase of 1.5%^[2].

While the use of the robotic platform for lobectomy is growing and its safety has been evaluated and found to be acceptable^[2-5], additional considerations for utilizing the robotic approach over other techniques and starting a robotic lobectomy program are still under evaluation, including costs and patient reported outcomes (PRO). A systematic review of the literature on the cost of robotic-assisted lobectomy that was performed by Singer et al.^[6] from our institution, which included six observational studies published before 1 December 2017, found that, in general, the costs of robotic lobectomy exceed those of VATS. The studies that they reviewed were primarily based on early experiences, with the study period ranging from 2007 to 2013, and were only from the USA.

In this article, an updated review of the literature of the cost of robotic lobectomy is presented and the quality of life in these patients is reviewed.

Methods

Results

The literature search for costs associated with robotic lobectomy and review of its references resulted in 16 relevant articles [Table 1] from five different countries (Canada, 1; China, 2; France, 1; Italy, 1; and USA, 11)^[1,7-21]. These articles were published from 2008 to 2019 with the study period ranging from 2008 to 2017. The number of patients undergoing robotic lobectomy ranged from 12 to 2498. All studies were observational. The majority of studies were retrospective analyses of prospectively collected data from a single institution. Other studies included one prospective observational study^[7] and four population-based cohort studies^[1,8-10]. In addition to analyzing costs of patients undergoing robotic lobectomy, seven of these studies also included patients who underwent robotic segmentectomy or wedge resection^{[7,9,11,13-15,18]}. The majority of studies reported using the da Vinci Si system. Only two studies noted the use of the Xi^[16,17]. Both four-arm^{[11,13,14,17,18,20]} and three-arm^{[7,12,15,19,21]} techniques were reported. There were three relevant articles identified that studied quality of life in patients undergoing robotic lobectomy^[21-23].

Robotic lobectomy cost

Quality of life

Lacroix et al.^[22] presented a single-center, retrospective analysis of 61 consecutive patients who underwent robotic lobectomy during its introduction to their unit from December 2012 to August 2015. They defined the learning period as their first 22 lobectomies and assessed quality of life (QOL) using the 36-Item Short Form Survey (SF-36) at midterm follow-up for the remaining 39 patients in their study. The mean physical component scale (PCS) score was 64.3 ± 17.6 and the mean mental component scale (MCS) score was 62.6 ± 19.6. The SF-36 was previously used at their institution to assess QOL for chest wall resection surgery, resulting in a mean PCS score of 40 and MCS score of 44. They found an association between pain and PCS scores, where PCS scores were significantly lower in patients with moderate pain (51.6 ± 14.2) than those with mild (69.4 ± 17.7) or no pain (67.8 ± 16.1) (P = 0.05). They concluded that QOL was satisfactory in their early experience for robotic lobectomy and was related to the pain level.

In the study by Worrell et al.^[21], costs and quality of life outcomes were evaluated during the initiation of their robotic lobectomy program. They compared their first 25 robotic assisted lobectomies with 73 VATS lobectomies, which were performed from 2010 to 2012. The European Organization for Research and Treatment of Cancer quality of life questionnaire (QLQ-30) was used to assess QOL with responses from 29 of the 98 patients, 9 robotic and 20 VATS, at a median follow-up of 65 months. This study found no significant difference between the robotic and VATS groups in their global health status and symptom scale median scores.

In a retrospective study, Cerfolio et al.^[23] reported a consecutive series of patients with clinically apparent resectable non-small cell lung cancer (NSCLC) from February 2010 to April 2011 who underwent attempted completely portal robot lobectomy using the four-arm technique. This group was compared against propensity-matched controls who underwent nerve- and rib-sparing thoracotomy. The study was performed by a single surgeon at a single institution. Quality of life information was obtained at two time points, three weeks and four months after surgery, and was measured by the Short Form Health Survey (SF-12) with supplemental questions about pain control. The robotic lobectomy group had a significantly higher average mental quality of life (MCS) score at three weeks when compared with the thoracotomy controls (53.5 vs. 40.3; P < 0.001). A trend for higher physical quality of life (PCS) score at three weeks was observed with the robotic group, although it was not of statistical significance (40.3 vs. 43.1; P = 0.07). There was no significant difference observed for mental or physical quality of life at four months. The authors in this study noted that there may have been bias introduced in the surveys since the patients were informed that the robotic approach was a new and “less invasive” technique.

Discussion

The hospital cost of robotic lobectomy during initiation of a robotic lobectomy program and/or early experiences at an institution has consistently been shown to be higher when compared to VATS lobectomy^{[11,18,20,21]}. There were many factors observed to affect total hospital cost, one of which was intraoperative cost. Studies that disclosed OR time during early experiences reported a significantly longer time for robotic lobectomies when compared to VATS [Table 3]^{[11,18,20,21]}. Two of these studies observed a decrease in operating time with more experience, which translated into a difference in intraoperative cost^[11,20]. Kaur et al.^[11] found that, based on their micro-costing analysis, anatomic resections using the robotic approach cost more than VATS by $3116 per case. They considered significantly higher intraoperative times to be a main contributor to this difference, and reported that OR time using the robotic platform decreased over time. There was a mean difference of 71 min (P = 0.004) when comparing the first 20 robotic resections with the remaining 22 robotic resections, which resulted in an intraoperative cost difference of $883.38, reducing the total hospital cost. In their study, Spillane et al.^[20] attributed higher associated hospital charges for robotic-assisted lobectomies to increased cost of OR time. They also found a trend in a decrease in intraoperative duration with the robotic approach over time. In their study, Bao et al.^[18] noted that longer operative time for the robotic group may be due to the limited robotic experience of the surgeon.

This review also includes studies performed at centers with established robotic programs with high robotic surgical case volume. Case volume and surgeon experience may influence hospital costs. The amortized cost of robotic equipment is directly dependent on the number of cases performed, with higher volume resulting in lower costs. The two studies that unexpectedly demonstrated no significant difference in adjusted cost of robotic lobectomy compared to VATS were performed at high-volume surgical centers experienced in robotic surgery. These studies also found no significant difference in cost when comparing robotic to open lobectomy. Both Si and Xi systems were used and both reported on a more recent study period with patients evaluated into the year 2017.

There are also non-operating room costs to take into consideration. Postoperative complications have been shown to increase costs^[16,24]. In Nelson’s^[16] study, they reported an association between pulmonary and cardiovascular complications with increase in mean costs for all approaches. While the majority of studies in this review did not find a significant difference in overall postoperative major or minor complications between robotic and VATS or open groups^{[7,8,11,14-19,21]}, this is a potential area for cost reduction. Kneuertz et al.^[24] performed a retrospective review of patients at our institution who underwent robotic-assisted lobectomy for NSCLC and evaluated postoperative outcomes on cost. Postoperative complications and prolonged hospital stay added considerable hospital expenses, which was the largest variability in total cost in the study.

The studies in this review that reported a difference in postoperative complications between groups were multi-institutional database studies^[1,9]. Swanson et al.^[9] reported that patients undergoing lobectomy via robotic approach from 2009 to 2011 were 4.24 times more likely to have a minor event than those undergoing VATS. In contrast, the study by Subramanian et al.^[1] found that, from 2009 to 2014, robotic lobectomy compared with VATS was associated with decreased adjusted risk of any minor postoperative complication, and, when compared with the open approach, had a decreased risk of any major or minor postoperative complication. Glenn et al.^[8] found no significant difference in overall morbidity between the robotic group and VATS group from 2010 to 2013; however, they observed that, in the earlier period of the study (2010-2011), morbidity was significantly higher in the robotic group when compared with VATS (robotic 42.9% vs. VATS 36.3%, P = 0.004). From 2012 to 2013, there was no longer a significant difference. Findings in these studies suggest, but do not confirm, that postoperative complications may be higher in earlier experiences of robotic lobectomy.

Based on the literature comparing all three approaches at single institutions, the cost of robotic lobectomy appears to be comparable if not less costly than open lobectomy and/or profitable. While OR time was significantly longer in the robotic group in these studies, length of stay was shorter or similar. The reduction in length of stay was noted by some authors to account for their findings. From the three studies that evaluated quality of life in their early experience, it appears that the robotic approach has acceptable results, although the number of studies and patients evaluated are limited^[21-23].

Many studies in our review compared robotic approach to VATS only, with results consistently demonstrating higher costs for robotic lobectomy. Interestingly, no study was identified during our literature search that compared costs for robotic approach to thoracotomy only even when the data suggest that the continued decline in thoracotomy for lobectomies appears mainly a result from increased adoption of the robotic platform not from increased use of VATS^[1,2]. While the majority of studies show that robotic lobectomy has higher hospital costs than VATS, the significance of this finding is unclear. The difference in index hospital cost is of statistical significance, but its overall impact on patient outcomes and health economics has not been elucidated and the value of using the robotic platform has not been defined. Further studies on patient outcomes such as quality of life, recovery time, and morbidity, as well as surgeon factors, are needed.

Conclusion

Developing a robotic lobectomy program may be associated with relatively higher index hospital costs when compared to VATS approach. With increased experience and volume of robotic cases, this difference may no longer be of significance, but additional defining of costs versus charges is needed as a surgical society. As an overall review, the cost of robotic lobectomy is comparable if not less costly than open lobectomy based on single institution studies and may be profitable for the hospital, if we can better understand the operational costs needed to care for these patients. Quality of life appears to be acceptable in the early experience of robotic lobectomy.