Robotic Gastrectomy No Better, but More Costly, than Laparoscopic Surgery

Charles Bankhead

March 2013, Vol 4, No 3 - Health Economics

San Francisco, CA—Patient survival after minimally invasive gastrectomy was identical with robotic-assisted and conventional laparoscopic surgery, according to data from a large patient series that was presented at the 2013 Gastrointestinal Cancers Symposium.

Similar Outcomes
Both techniques led to 5-year 94% overall survival and 92% disease-free survival rates. Disease stage did not significantly alter survival results.

“Robotic assistance in gastrectomy for gastric cancer is associated with acceptable long-term and oncologic outcomes and is an effective alternative [to conventional laparoscopic surgery] with satisfactory short-term outcomes,” said Woo Jin Hyung, MD, PhD, Department of Surgery, Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Korea. “Robotic surgery might help expand the indication for minimally invasive surgery in gastric cancer.”

Dr Hyung reported findings from a review of 313 patients who underwent robotic gastrectomies and 524 patients who underwent conventional laparoscopic gastrectomies for nonmetastatic gastric cancer between 2004 and 2009. Patients with stage ≥II disease received adjuvant chemotherapy.

The patients who opted for robotic surgery were younger (54.5 years vs 59.3 years, respectively; P <.001) and more often had total gastrectomies (27% vs 20%, respectively; P = .016).

On average, robotic procedures required significantly more overall recovery time (219 minutes vs 149 minutes, respectively; P <.001). Blood loss did not differ significantly with robotic procedures nor did the length of hospital stays. Patients regained bowel function slightly faster with robotic surgery (2.8 days vs 3.0 days, respectively). The disease recurrence rates were 5.4% after robotic surgery and 3.6% after standard laparoscopic gastrectomy.

This study did not involve an analysis of functional outcomes or costs associated with the 2 surgical techniques. Those factors cannot be ignored in contemporary comparisons of robotic and conventional laparoscopic surgery, said Donald E. Low, MD, FACS, Director, Esophageal Center of Excellence, Head of Thoracic Surgery and Thoracic Oncology, Fellowship Director, Ryan Hill Re­search Foundation, and Codirector, Digestive Disease Institute, Virginia Mason Medical Center, Seattle, WA.

Cost is an especially contentious issue regarding robotics, and would likely become even more so if the United States were to adopt reimbursement policies such as those in South Korea; patients who opt for robotic surgical procedures versus conventional laparoscopy have to pay the difference in cost, which can be substantial, said Dr Low.

Cost Implications
In the absence of cost-related data specific to gastrectomy, Dr Low referenced a recent study of 300 rectal surgery procedures (Baek SJ, et al. World J Surg. 2012;36:2722-2729). Robotic-assisted procedures cost approximately $5000 more than laparoscopic surgeries, and patients’ out-of-pocket costs for robotic procedures averaged $11,500. Hospitals netted $689 per robotic procedure and $1671 per standard laparoscopic surgery.

The Korean clinical experience is consistent with other recent comparisons of robotic and conventional laparoscopic surgery, according to Dr Low. In general, comparative studies have shown similar patient outcomes with the 2 surgical approaches and substantially higher costs associated with robotic-assisted procedures, including system acquisition, instrumentation, and maintenance costs.

“Robotic surgery is equivalent to—but not better than—laparoscopic surgery for major cancer procedures,” said Dr Low. “Robotic gastrectomy currently provides no measurable outcome benefits and is likely significantly more expensive.”

Future randomized studies of robotic surgery must focus on identifying advantages of robotic techniques rather than on demonstrating equivalence to conventional laparoscopic surgery, he added.