The Association of Robot-assisted Versus Pure Laparoscopic Radical Nephrectomy with Perioperative Outcomes and Hospital Costs

Background: Although robot assistance can facilitate the advantages of minimally invasive surgery, it is unclear whether it offers benefits in settings in which laparoscopic surgery has been established as the standard of care. Objective: To examine the comparative effectiveness of robot-assisted laparoscopic radical nephrectomy (RALRN) and laparoscopic radical nephrectomy (LRN) using a nationwide data set. Design, setting, and participants: 8316 adults who underwent RALRN or LRN for non- urothelial renal cancer from the Nationwide Inpatient Sample from 2010 to 2013. Intervention: RALRN and LRN. Outcome measurements and statistical analysis: The associations of surgical approach with perioperative outcomes and total hospital costs were evaluated using multivariable logistic regression. Results and limitations: Over the study period, utilization of RALRN increased from 46% to 69%. Compared to LRN, RALRN was associated with lower rates of intraoperative (0.9% vs 1.8%; p <0.001) and postoperative complications (20.4% vs 27.2%; p <0.001), but there were no differences in perioperative blood transfusion (5.6% vs 6.2%; p = 0.27) and prolonged hospitalization (7.2% vs 7.1%; p = 0.81). RALRN was also significantly associated with higher total hospital costs (median $16 207 vs $15 037; p < 0.001). In multivariable analyses, RALRN remained independently associated with a lower risk of intraoperative (odds ratio [OR] 0.50; p = 0.001) and postoperative complications (OR 0.72; p < 0.001) but not perioperative blood transfusion (OR 1.10; p = 0.34), and with a higher risk of prolonged hospitalization (OR 1.29; p = 0.007) and higher mean total hospital costs (+$1468; p < 0.001). There was no effect modification by hospital volume. Conclusions: Although RALRN was independently associated with a reduction in perioperative complications compared to LRN, it was associated with prolonged hospitalization and higher total hospital costs. These relationships must be interpreted in light of potential differences in case mix. Patient summary: Although robot-assisted laparoscopic radical nephrectomy was independently associated with a reduction in perioperative complications compared to laparoscopic radical nephrectomy, it was associated with prolonged hospitalization and higher total hospital costs. (C) 2018 European Association of Urology. Published by Elsevier B.V. All rights reserved.