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.