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

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. (C) 2016 European Association of Urology. Published by Elsevier B.V. All rights reserved.