Purpose : Radical cystectomy (RC), the gold standard
treatment for invasive bladder cancer, is a morbid procedure associated with
high costs, and the increasing adoption of robotic technology requires
Methods: We captured all who underwent a RC (ICD-9 code 57.71) from 2004 to 2010, from a nationally representative discharge database representing over 600 non-federal hospitals across the United States. Robotic RC (RRC) procedures were classified procedures through a detailed review of the charge description master (CDM) for each patient specifically identifying supplies unique to robotic procedures, as previously described. Given the limited number of non-robotic, laparoscopic RC in the study cohort, we combined these procedures with the open RC and defined this group as "non-robotic." Patient characteristics (age, gender, race, marital status, insurance status, Charlson comorbidity), hospital characteristics (bed size, teaching status, location, region), and surgical characteristics (year of procedure, type of approach and urinary diversion, receipt of pelvic lymphadenectomy) were evaluated. Annual volume was based on the number of cystectomies performed by hospital or surgeon in the year the procedure was performed on a given patient. Multi-variate propensity-weighted regression analyses were performed with clustering by hospitals and survey weighting to ensure nationally representative estimates. The primary outcome was 90-day major complications (Clavien 3-5) as defined by ICD-9 diagnosis codes. Secondary outcomes were inpatient length of stay (LOS) and direct patient costs.
Results: The weighted cohort included 43733 patients who underwent a RC from 2004 to 2010 in the United States with an overall complication rate of 57.0%. Compared to non-robotic RC, RRC was not significantly associated with decreased odds of mortality (p=0.53) or major complication (p=0.43). However, RRC had a 46% decreased odds of minor complications (OR=0.54, 95% CI:0.32-0.94, p=0.03). RRC had $4302 higher adjusted 90-day median direct hospitals (p=0.02). Although RRC had a significantly shorter length of stay (1.5 days, p=0.01), costs breakdowns reveal that there were no significant differences in room and board costs (p=0.18). Supplies costs for RRC were significantly higher ($2396, p<0.0001) (Figure).
Conclusions: Our contemporary evaluation of radical cystectomy suggests there is no significant mortality and morbidity advantage for RRCs. Costs differences can be attributed to supplies, which may decrease with increasing adoption. Long-term oncological and functional outcomes of RRCs remain to be seen.