Perioperative Outcomes, Health Care Costs, and Survival After Robotic-assisted Versus Open Radical Cystectomy: A National Comparative Effectiveness Study

Eur Urol. 2016 Jul;70(1):195-202. doi: 10.1016/j.eururo.2016.03.028. Epub 2016 Apr 28.


Background: 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).

Objective: To compare utilization, perioperative, cost, and survival outcomes of RARC versus ORC.

Design, setting, and participants: 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.

Intervention: Comparison of RARC versus ORC.

Outcome measurements and statistical analysis: We used propensity score matching to compare perioperative and survival outcomes, including lymph node yield, perioperative complications, and healthcare costs.

Results and limitations: 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.

Conclusions: 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.

Patient summary: Our population-based US study demonstrates that robotic-assisted radical cystectomy has similar perioperative and survival outcomes albeit at higher costs.

Keywords: Bladder cancer; Costs and cost analysis; Cystectomy; Lymph node excision; Robotic surgical procedures.

Publication types

  • Comparative Study

MeSH terms

  • Aged
  • Aged, 80 and over
  • Carcinoma, Transitional Cell / surgery*
  • Cystectomy / adverse effects
  • Cystectomy / economics
  • Cystectomy / methods*
  • Female
  • Health Care Costs*
  • Home Care Services / statistics & numerical data
  • Humans
  • Length of Stay
  • Lymph Node Excision / methods*
  • Male
  • Perioperative Period
  • Postoperative Complications / etiology
  • Robotic Surgical Procedures* / adverse effects
  • Robotic Surgical Procedures* / economics
  • Robotic Surgical Procedures* / statistics & numerical data
  • SEER Program
  • Survival Rate
  • Time Factors
  • Treatment Outcome
  • Urinary Bladder Neoplasms / surgery*