- Email: [email protected]
Reducing Costs for Robotic Radical Prostatectomy: Three-instrument Technique
Accepted Manuscript Title: Reducing Costs for Robotic Radical Prostatectomy: Three-Instrument Technique Author: Daniel Ramirez, Vishnu Ganesan, Ryan J. Nelson, Georges-Pascal Haber PII: DOI: Reference:
S0090-4295(16)30296-5 http://dx.doi.org/doi: 10.1016/j.urology.2016.03.067 URL 19855
To appear in:
Urology
Received date: Accepted date:
18-9-2015 30-3-2016
Please cite this article as: Daniel Ramirez, Vishnu Ganesan, Ryan J. Nelson, Georges-Pascal Haber, Reducing Costs for Robotic Radical Prostatectomy: Three-Instrument Technique, Urology (2016), http://dx.doi.org/doi: 10.1016/j.urology.2016.03.067. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
Reducing Costs for Robotic Radical Prostatectomy: Three-Instrument Technique Daniel Ramireza, Vishnu Ganesan, Ryan J. Nelson, Georges-Pascal Haber Keywords: Cost efficiency, robotic surgery, robotic prostatectomy, cost reduction in robotics Acknowledgements: No sources of funding were used in the creation of this manuscript Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH, USA; a
Corresponding author: Daniel Ramirez, MD Glickman Urology and Kidney Institute, Cleveland Clinic 9500 Euclid Ave, Q10 Cleveland, OH 44195, USA Tel: (216) 445-4781 ABSTRACT Objectives: To describe our technique for performing robotic-assisted radical prostatectomy (RALP) and pelvic lymph node dissection (PLND) using only 3 robotic instruments in order to reduce disposable costs associated with the robotic surgical platform. Methods: The financial impact of robotic surgery is real. While the initial capital investment of the robotic platform (including the cost of the device itself and the maintenance contract) is largely fixed, the cost of disposable instrumentation can vary depending on utilization. Herein we describe our technique for 3-instrument robotic radical prostatectomy which may decrease costs by limiting the use of disposable instruments. Results: Exclusion of the high cost energy instruments may reduce operative costs by up to 40%. In addition, using one robotic needle driver versus two may decrease overall costs by another 12%. At our institution, we have adopted these techniques in cost efficiency and have gone further by only using 3 instruments during robotic radical prostatectomy. The only three instruments necessary to perform a successful RALP are a robotic needle driver, prograsp forceps, and monopolar scissors. Conclusions: In order to improve the value of care while utilizing robotic technology, we must be cognizant of keeping operative costs to a minimum while maintaining positive patient outcomes. We demonstrate here a method to decrease disposable operating room costs while preserving the ability to successfully perform a RALP.
1 Page 1 of 11
From 2007 to 2010 the volume of robotic-assisted laparoscopic prostatectomies (RALP) performed globally has tripled.1 Since 2008, 80% of the radical prostatectomies performed in the United States have been done robotically.2 The acceptance and utilization of the robot for management of prostate cancer is likely to continue to grow. Encouraging perioperative outcomes3-7 and increasing market forces8 will continue to facilitate this rise. One of the major barriers to widespread adoption includes increased associated costs. The economic footprint of surgical robotic technology is considerable and its application should be carefully appraised to guarantee that the platform is used in the most cost-effective manner.9 The present cost of a robotic platform is approximately $2 million dollars with a $150,000 annual maintenance contract. These costs do not encompass the price of individual robotic instruments, which are approximately $2,500 per instrument for 10 uses, averaging $250 per instrument per case.10 The initial capital investment for a robotic platform may be mitigated by increase in its utilization, ultimately decreasing expenditure on a per-case basis. Nevertheless, increase in utilization does not decrease the per-case cost of disposable instruments. Thorough evaluation of intraoperative instrument utilization has been shown to decrease overall costs.11,12 Our center has adopted a three instrument technique for RALP to further decrease operative cost associated with disposable devices. Previous publications have described methods for saving money in the operative room during robotic urology procedures. Recently, Delto et al demonstrated that exclusion of the high cost energy instruments (such as a PK
2 Page 2 of 11
dissector, bipolar graspers or robotic Ligasure) may reduce operative costs by up to 40%.12 They also demonstrate that using one robotic needle driver versus two may decrease overall costs by another 12%. At our institutions, we have adopted these techniques in cost efficiency and have gone further by only using 3 instruments during robotic radical prostatectomy. None of our robotic surgeons use high cost vessel sealants, and instead rely on low cost Hem-o-lok Weck clips (Teleflex, Morrisville, NC) for control of the prostatic pedicle and other vessels. The only three instruments needed are a robotic needle driver, prograsp forceps, and monopolar scissors. During initial dissection, the needle driver is used in the third robotic arm to assist with retraction of the bowel cranially. The bowel is never grasped with the jaws of the needle driver. Instead, the wrist and arm of the instrument are used to gently retract the bowel out of the pelvis. Table 1 outlines the location of each robotic instrument relative to each of the three robotic ports during each major step of the procedure. The needle driver is maintained on the 3rd robotic arm for the entire case, except for during the vesicourethral anastomosis. During the mobilization of the bladder, and opening of the bladder neck, the needle driver remains in a cranial position maintaining the small bowel out of the pelvis. Neither the small bowel nor the mesentery is ever grasped with the jaws of the needle driver. Once the bladder neck is open, a 3-0 vicryl suture on an SH needle is used to secure the Foley catheter to the anterior abdominal wall with a Hem-o-lok clip and placed on traction outside of the body to elevated the prostate. This allows for counter-traction during the posterior dissection. Once the vas deferens and seminal 3 Page 3 of 11
vesicles are freed, the needle driver is used to suspend them anteriorly, allowing for development of the plane between the prostate and rectum with the monopolar scissor and prograsp forceps on robotic arms 1 and 2, respectively. The needle driver is used from this point until the anastomosis to provide traction on the prostate itself, and can also be used during the lymph node dissection to adjust the position of the bladder. At the time of the vesicourethral anastomosis, the scissors are removed and the needle driver is placed onto the first robotic arm. The anastomosis is performed with two 2-0 monocryl suture on GU needles, tied at the ends in a double arm configuration. The Prograsp forceps is kept in the second robotic port while the needle driver is used to handle the needle on the first robotic arm. The third arm is left empty during this portion of the procedure. In order to facilitate keeping the small bowel out of the pelvis, the patient must be placed in full Trendelenburg prior to docking the robot. All of our patients receive a preoperative bowel preparation of 20 ounces of magnesium citrate. This also facilitates exposure and mobilization of the small bowel, though bowel preparation is not mandatory. Prior to adopting an alternative approach for cost saving methods, the surgeon should be beyond their learning curve and should be comfortable with troubleshooting any intraoperative difficulties that may arise. Before adopting a 3instrument technique, RALP has been routinely performed at our institution using only 4 instruments including two Prograsp forceps, one mono-polar curved scissors, and only one large needle driver, thus facilitating the transition to 3 instruments by eliminating the extra Prograsp forceps. The senior author had experience with over 1,000 robotic procedures prior to developing the 3-instrument technique. 4 Page 4 of 11
Assessing minute-to-minute intraoperative costs associated with operative time and anesthesia is difficult to assess and depends heavily on the complexity of the case, need for invasive monitoring and patient co-morbidities and American Society of Anesthesiologists (ASA) score.13 With employment of this novel 3instrument technique, we saw no significant differences in regards to operative time, blood loss, post-operative complications or post-operative functional outcomes compared to our standard 4-instrument approach. The primary drawbacks of using 3 instruments during RALP is performing the anastomosis with a single robotic needle driver in the right hand and a Prograsp forceps in the left, though this is how we performed out anastomosis even when 4 instruments are used. Additionally, the large robotic needle driver does not have the same grasping ability the Prograsp when handling soft tissue and this may cause some difficulty during cephlad retraction on the prostate during apical dissection. Technological evolution is inherent to minimally invasive surgery and should advance the quality of patient care. There are real, financial implications as robotic urologic procedures continue to be adopted. In order to improve the value of care while utilizing robotic technology, we must be cognizant of keeping operative costs to a minimum while maintaining positive patient outcomes. We demonstrate here a method to decrease disposable operating room costs while preserving the ability to successfully performed a RALP.
REFERENCES 1.
Barbash GI, Glied SA. New technology and health care costs – the case of robot-assisted surgery. N Engl J Med 2010;363:701-704
5 Page 5 of 11
2. 3. 4. 5. 6.
7. 8. 9.
10. 11. 12. 13.
Jacobs EF, Boris R, Masterson TA. Advances in robotic-assisted radical prostatectomy over time. Prostate Cancer 2013;2013:902686 Cozzi G, Lorenzis ED, Palumbo C, Acquati P, Albo G, Dell’orto P, Grasso A, Rocco B. Robotic prostatectomy: an update on functional and oncologic out comes. E Cancer Medical Science. 2013;7:355 (p 1-6) De Lorenzis E, Palumbo C, Cozzi G, Talso M, Rosso M, Costa B, Gadda F, Rocco B. Robotics in uro-oncologic surgery. E Cancer Medical Science. 2013:7:354 (p 1-11) Ahmed K, Ibrahim A, Wang TT, Khan N, Challacombe B, Khan MS, Dasgupta P. Assessing the cost effectivenss of robotics in urologic surgery – a systematic review. BJU Int. 2012;110:1544-1556 Ramsay C, Pickard R, Robertson C, et al. Systemic review and economic modeling of the relative clinical benefit an cost-effectiveness of laparoscopic surgery and robotic surgery for removal of the prostate in men with localized prostate cancer. Health Technol Assess 2012;16:1313 Lowrance WT, Tarin TV, Shariat SF. Evidence-based comparison of robotic and open radical prostatectomy. Scientific World Journal. 2010;10:2228-2237 Mirkin JN, Lowrance WT, Feifer AH, Mulhall JP, Eastham JE, Elkin EB. Direct-to-consumer internet promotion of robotic prostatectomy exhibits varying quality of information. Health Aff (Millwood) 2012;31:760-769 Becker C. Nowhere to run, or hide. Current economic downturn may exacerbate hospitals’ weakness with buildings, technology, costs, reimbursements. Mod Healthc. 2008;38(16): 6-7,16. Retrieved from http://search.proquest.com/docview/211952914?accountid=50452 Ramirez D, Lotan Y. Cost-effectiveness is minimally invasive urologic surgery. Minimally Invasive Urology. Springer. 2015 Tabib CH, Bahler CD, Hardacker TJ, Ball KM, Sundaram CP. Reducing operating room costs through real-time cost information feedback: a pilot study. J Endourol 2015;29:963-8 Delto JC, Wayne G, Yanes R, Nieder AM, Bhandari A. Reducing robotic prostatectomy cost by minimizing instrumentation. J Endourol 2014;29(5):556-60 Shuster M, Standl T, Wagner JA, Berger J, Reimann H, Esch JS. Effect of different cost drivers on cost per anesthesia minute in difference anesthesia subspecialties. Anesthesia 2004;101(6):1435-1443
6 Page 6 of 11
Table 1. Location of robotic instruments during major steps of RALP Step Dropping bladder Opening of endopelvic fascia Ligation of DVC Bladder neck Posterior dissection Release of NVB Vascular prostatic pedicles Apical dissection Lymph node dissection Vesicourethral anastomosis
Arm #1 Monopolar scissors Monopolar scissors Needle driver Monopolar scissors Monopolar scissors Monopolar scissors Monopolar scissors Monopolar scissors Monopolar scissors Needle driver
Arm #2 Prograsp Prograsp Prograsp Prograsp Prograsp Prograsp Prograsp Prograsp Prograsp Prograsp
Arm #3 Needle driver Needle driver Empty Needle driver Needle driver Needle driver Needle driver Needle driver Needle driver Empty
7 Page 7 of 11
RE: Reducing Costs for Robotic Radical Prostatectomy: Three-Instrument Technique Wesley M. White, MD1 Christopher A. Winter, MD1
1Division
of Urologic Surgery, The University of Tennessee Medical Center, Knoxville
Corresponding Author: Wesley M. White M.D. Director of Laparoscopic and Robotic Urologic Surgery The University of Tennessee Medical Center, Knoxville 1928 Alcoa Highway B-222 Knoxville, TN 37920 [email protected] 865-305-9254 865-305-9716 (fax)
8 Page 8 of 11
The authors report on the use of limited instrumentation during robotic assisted laparoscopic prostatectomy. More specifically, the lead surgeon has adopted a technique in which one pair of monopolar scissors, one standard needle driver and one ProGrasp forcep is used during the entirety of the operation. While the intent of the manuscript was neither to demonstrate superiority of the approach nor to offer a radical new surgical technique, the authors do an effective job of enunciating the increasingly important aspect of surgical stewardship. Robotics is a frequent economic target due to its considerable initial capital outlay. However, disposable robotic instruments are not inexpensive and when taken as a whole, can add several thousands of dollars to every procedure. With most nonprofit hospitals struggling to achieve a 1-2% operating margin, every dollar indeed matters. However magnanimous surgical stewardship may be, we must remain ever cognizant of the careful balance between cost containment and patient safety. It is certainly reasonable for highly skilled surgeons, such as the authors, to use instrumentation that is not purpose-built for its designated task (i.e. using a ProGrasp forcep as a needle driver or using standard needle drivers with comparatively greater crushing force for retraction). On the other hand, for the novice surgeon, the decision to follow the lead of the authors must be judicious as the use of limited instrumentation adds potential complexity to the procedure. Moreover, in certain difficult cases, even the best surgeons may need to abandon their pride and concern for cost when the surgical circumstances prescribe. Context should always dictate prudence. Ultimately, Jordan Spieth has the ability to shoot par using nothing but a 7-iron and a putter. Less polished professionals may require more clubs in their bag to achieve an equally good result. Regardless, each shot and club choice must be individualized. You will not see Spieth play a major tournament with just three instruments, regardless of costs.
9 Page 9 of 11
RE: Reducing Costs for Robotic Radical Prostatectomy: ThreeInstrument Technique Daniel Ramireza, Georges-Pascal Habera* Article Type: Response to editorial comment (Invited) Keywords: Robotics; Costs; Outcomes; Surgical technique Word count: 182 aAffiliation:
Cleveland Clinic Glickman Urological and Kidney Institute Cleveland, OH 44195 *Corresponding author: Georges-Pascal Haber, MD, PhD Center for Laparoscopic and Robotic Surgery Cleveland Clinic Glickman Urological and Kidney Institute 9500 Euclid Ave. Q10-1 Cleveland, OH 44195 Attaining the best possible quality by optimizing surgical outcomes is paramount. We agree with the comments outlined above, the primary objective of delivering care at its highest quality is to optimize outcomes. Reducing costs should only be pursued when those savings do not negatively influence outcomes. From a surgical improvement standpoint, it is imperative to use what instruments we have at our disposal, even if we use them unconventionally. Employment of instruments to perform tasks for which they were not purposefully designed is an important aspect of furthering what can be accomplished with available technology, and could ultimately play a role in decreasing disposable costs in robotic surgery.1 We have been able to reduce our disposable costs for robotic radical prostatectomy while maintaining comparable outcomes, though larger clinical studies are still needed to justify these cost-saving maneuvers across practice 10 Page 10 of 11
settings. We do not recommend that robotic surgeons perform radical prostatectomies with limited instrumentation unless they feel that they are able to do so effectively. If Jorden Spieth is unable to win the tournament with 3 clubs alone, he should not attempt it. References 1. Ludwig WW, Gorin MA, Allaf ME. Reducing the cost of robotic partial nephrectomy through innovative instrument use. Eur Urol. 2015; 67:594-5.
11 Page 11 of 11
S0090-4295(16)30296-5 http://dx.doi.org/doi: 10.1016/j.urology.2016.03.067 URL 19855
To appear in:
Urology
Received date: Accepted date:
18-9-2015 30-3-2016
Please cite this article as: Daniel Ramirez, Vishnu Ganesan, Ryan J. Nelson, Georges-Pascal Haber, Reducing Costs for Robotic Radical Prostatectomy: Three-Instrument Technique, Urology (2016), http://dx.doi.org/doi: 10.1016/j.urology.2016.03.067. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
Reducing Costs for Robotic Radical Prostatectomy: Three-Instrument Technique Daniel Ramireza, Vishnu Ganesan, Ryan J. Nelson, Georges-Pascal Haber Keywords: Cost efficiency, robotic surgery, robotic prostatectomy, cost reduction in robotics Acknowledgements: No sources of funding were used in the creation of this manuscript Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH, USA; a
Corresponding author: Daniel Ramirez, MD Glickman Urology and Kidney Institute, Cleveland Clinic 9500 Euclid Ave, Q10 Cleveland, OH 44195, USA Tel: (216) 445-4781 ABSTRACT Objectives: To describe our technique for performing robotic-assisted radical prostatectomy (RALP) and pelvic lymph node dissection (PLND) using only 3 robotic instruments in order to reduce disposable costs associated with the robotic surgical platform. Methods: The financial impact of robotic surgery is real. While the initial capital investment of the robotic platform (including the cost of the device itself and the maintenance contract) is largely fixed, the cost of disposable instrumentation can vary depending on utilization. Herein we describe our technique for 3-instrument robotic radical prostatectomy which may decrease costs by limiting the use of disposable instruments. Results: Exclusion of the high cost energy instruments may reduce operative costs by up to 40%. In addition, using one robotic needle driver versus two may decrease overall costs by another 12%. At our institution, we have adopted these techniques in cost efficiency and have gone further by only using 3 instruments during robotic radical prostatectomy. The only three instruments necessary to perform a successful RALP are a robotic needle driver, prograsp forceps, and monopolar scissors. Conclusions: In order to improve the value of care while utilizing robotic technology, we must be cognizant of keeping operative costs to a minimum while maintaining positive patient outcomes. We demonstrate here a method to decrease disposable operating room costs while preserving the ability to successfully perform a RALP.
1 Page 1 of 11
From 2007 to 2010 the volume of robotic-assisted laparoscopic prostatectomies (RALP) performed globally has tripled.1 Since 2008, 80% of the radical prostatectomies performed in the United States have been done robotically.2 The acceptance and utilization of the robot for management of prostate cancer is likely to continue to grow. Encouraging perioperative outcomes3-7 and increasing market forces8 will continue to facilitate this rise. One of the major barriers to widespread adoption includes increased associated costs. The economic footprint of surgical robotic technology is considerable and its application should be carefully appraised to guarantee that the platform is used in the most cost-effective manner.9 The present cost of a robotic platform is approximately $2 million dollars with a $150,000 annual maintenance contract. These costs do not encompass the price of individual robotic instruments, which are approximately $2,500 per instrument for 10 uses, averaging $250 per instrument per case.10 The initial capital investment for a robotic platform may be mitigated by increase in its utilization, ultimately decreasing expenditure on a per-case basis. Nevertheless, increase in utilization does not decrease the per-case cost of disposable instruments. Thorough evaluation of intraoperative instrument utilization has been shown to decrease overall costs.11,12 Our center has adopted a three instrument technique for RALP to further decrease operative cost associated with disposable devices. Previous publications have described methods for saving money in the operative room during robotic urology procedures. Recently, Delto et al demonstrated that exclusion of the high cost energy instruments (such as a PK
2 Page 2 of 11
dissector, bipolar graspers or robotic Ligasure) may reduce operative costs by up to 40%.12 They also demonstrate that using one robotic needle driver versus two may decrease overall costs by another 12%. At our institutions, we have adopted these techniques in cost efficiency and have gone further by only using 3 instruments during robotic radical prostatectomy. None of our robotic surgeons use high cost vessel sealants, and instead rely on low cost Hem-o-lok Weck clips (Teleflex, Morrisville, NC) for control of the prostatic pedicle and other vessels. The only three instruments needed are a robotic needle driver, prograsp forceps, and monopolar scissors. During initial dissection, the needle driver is used in the third robotic arm to assist with retraction of the bowel cranially. The bowel is never grasped with the jaws of the needle driver. Instead, the wrist and arm of the instrument are used to gently retract the bowel out of the pelvis. Table 1 outlines the location of each robotic instrument relative to each of the three robotic ports during each major step of the procedure. The needle driver is maintained on the 3rd robotic arm for the entire case, except for during the vesicourethral anastomosis. During the mobilization of the bladder, and opening of the bladder neck, the needle driver remains in a cranial position maintaining the small bowel out of the pelvis. Neither the small bowel nor the mesentery is ever grasped with the jaws of the needle driver. Once the bladder neck is open, a 3-0 vicryl suture on an SH needle is used to secure the Foley catheter to the anterior abdominal wall with a Hem-o-lok clip and placed on traction outside of the body to elevated the prostate. This allows for counter-traction during the posterior dissection. Once the vas deferens and seminal 3 Page 3 of 11
vesicles are freed, the needle driver is used to suspend them anteriorly, allowing for development of the plane between the prostate and rectum with the monopolar scissor and prograsp forceps on robotic arms 1 and 2, respectively. The needle driver is used from this point until the anastomosis to provide traction on the prostate itself, and can also be used during the lymph node dissection to adjust the position of the bladder. At the time of the vesicourethral anastomosis, the scissors are removed and the needle driver is placed onto the first robotic arm. The anastomosis is performed with two 2-0 monocryl suture on GU needles, tied at the ends in a double arm configuration. The Prograsp forceps is kept in the second robotic port while the needle driver is used to handle the needle on the first robotic arm. The third arm is left empty during this portion of the procedure. In order to facilitate keeping the small bowel out of the pelvis, the patient must be placed in full Trendelenburg prior to docking the robot. All of our patients receive a preoperative bowel preparation of 20 ounces of magnesium citrate. This also facilitates exposure and mobilization of the small bowel, though bowel preparation is not mandatory. Prior to adopting an alternative approach for cost saving methods, the surgeon should be beyond their learning curve and should be comfortable with troubleshooting any intraoperative difficulties that may arise. Before adopting a 3instrument technique, RALP has been routinely performed at our institution using only 4 instruments including two Prograsp forceps, one mono-polar curved scissors, and only one large needle driver, thus facilitating the transition to 3 instruments by eliminating the extra Prograsp forceps. The senior author had experience with over 1,000 robotic procedures prior to developing the 3-instrument technique. 4 Page 4 of 11
Assessing minute-to-minute intraoperative costs associated with operative time and anesthesia is difficult to assess and depends heavily on the complexity of the case, need for invasive monitoring and patient co-morbidities and American Society of Anesthesiologists (ASA) score.13 With employment of this novel 3instrument technique, we saw no significant differences in regards to operative time, blood loss, post-operative complications or post-operative functional outcomes compared to our standard 4-instrument approach. The primary drawbacks of using 3 instruments during RALP is performing the anastomosis with a single robotic needle driver in the right hand and a Prograsp forceps in the left, though this is how we performed out anastomosis even when 4 instruments are used. Additionally, the large robotic needle driver does not have the same grasping ability the Prograsp when handling soft tissue and this may cause some difficulty during cephlad retraction on the prostate during apical dissection. Technological evolution is inherent to minimally invasive surgery and should advance the quality of patient care. There are real, financial implications as robotic urologic procedures continue to be adopted. In order to improve the value of care while utilizing robotic technology, we must be cognizant of keeping operative costs to a minimum while maintaining positive patient outcomes. We demonstrate here a method to decrease disposable operating room costs while preserving the ability to successfully performed a RALP.
REFERENCES 1.
Barbash GI, Glied SA. New technology and health care costs – the case of robot-assisted surgery. N Engl J Med 2010;363:701-704
5 Page 5 of 11
2. 3. 4. 5. 6.
7. 8. 9.
10. 11. 12. 13.
Jacobs EF, Boris R, Masterson TA. Advances in robotic-assisted radical prostatectomy over time. Prostate Cancer 2013;2013:902686 Cozzi G, Lorenzis ED, Palumbo C, Acquati P, Albo G, Dell’orto P, Grasso A, Rocco B. Robotic prostatectomy: an update on functional and oncologic out comes. E Cancer Medical Science. 2013;7:355 (p 1-6) De Lorenzis E, Palumbo C, Cozzi G, Talso M, Rosso M, Costa B, Gadda F, Rocco B. Robotics in uro-oncologic surgery. E Cancer Medical Science. 2013:7:354 (p 1-11) Ahmed K, Ibrahim A, Wang TT, Khan N, Challacombe B, Khan MS, Dasgupta P. Assessing the cost effectivenss of robotics in urologic surgery – a systematic review. BJU Int. 2012;110:1544-1556 Ramsay C, Pickard R, Robertson C, et al. Systemic review and economic modeling of the relative clinical benefit an cost-effectiveness of laparoscopic surgery and robotic surgery for removal of the prostate in men with localized prostate cancer. Health Technol Assess 2012;16:1313 Lowrance WT, Tarin TV, Shariat SF. Evidence-based comparison of robotic and open radical prostatectomy. Scientific World Journal. 2010;10:2228-2237 Mirkin JN, Lowrance WT, Feifer AH, Mulhall JP, Eastham JE, Elkin EB. Direct-to-consumer internet promotion of robotic prostatectomy exhibits varying quality of information. Health Aff (Millwood) 2012;31:760-769 Becker C. Nowhere to run, or hide. Current economic downturn may exacerbate hospitals’ weakness with buildings, technology, costs, reimbursements. Mod Healthc. 2008;38(16): 6-7,16. Retrieved from http://search.proquest.com/docview/211952914?accountid=50452 Ramirez D, Lotan Y. Cost-effectiveness is minimally invasive urologic surgery. Minimally Invasive Urology. Springer. 2015 Tabib CH, Bahler CD, Hardacker TJ, Ball KM, Sundaram CP. Reducing operating room costs through real-time cost information feedback: a pilot study. J Endourol 2015;29:963-8 Delto JC, Wayne G, Yanes R, Nieder AM, Bhandari A. Reducing robotic prostatectomy cost by minimizing instrumentation. J Endourol 2014;29(5):556-60 Shuster M, Standl T, Wagner JA, Berger J, Reimann H, Esch JS. Effect of different cost drivers on cost per anesthesia minute in difference anesthesia subspecialties. Anesthesia 2004;101(6):1435-1443
6 Page 6 of 11
Table 1. Location of robotic instruments during major steps of RALP Step Dropping bladder Opening of endopelvic fascia Ligation of DVC Bladder neck Posterior dissection Release of NVB Vascular prostatic pedicles Apical dissection Lymph node dissection Vesicourethral anastomosis
Arm #1 Monopolar scissors Monopolar scissors Needle driver Monopolar scissors Monopolar scissors Monopolar scissors Monopolar scissors Monopolar scissors Monopolar scissors Needle driver
Arm #2 Prograsp Prograsp Prograsp Prograsp Prograsp Prograsp Prograsp Prograsp Prograsp Prograsp
Arm #3 Needle driver Needle driver Empty Needle driver Needle driver Needle driver Needle driver Needle driver Needle driver Empty
7 Page 7 of 11
RE: Reducing Costs for Robotic Radical Prostatectomy: Three-Instrument Technique Wesley M. White, MD1 Christopher A. Winter, MD1
1Division
of Urologic Surgery, The University of Tennessee Medical Center, Knoxville
Corresponding Author: Wesley M. White M.D. Director of Laparoscopic and Robotic Urologic Surgery The University of Tennessee Medical Center, Knoxville 1928 Alcoa Highway B-222 Knoxville, TN 37920 [email protected] 865-305-9254 865-305-9716 (fax)
8 Page 8 of 11
The authors report on the use of limited instrumentation during robotic assisted laparoscopic prostatectomy. More specifically, the lead surgeon has adopted a technique in which one pair of monopolar scissors, one standard needle driver and one ProGrasp forcep is used during the entirety of the operation. While the intent of the manuscript was neither to demonstrate superiority of the approach nor to offer a radical new surgical technique, the authors do an effective job of enunciating the increasingly important aspect of surgical stewardship. Robotics is a frequent economic target due to its considerable initial capital outlay. However, disposable robotic instruments are not inexpensive and when taken as a whole, can add several thousands of dollars to every procedure. With most nonprofit hospitals struggling to achieve a 1-2% operating margin, every dollar indeed matters. However magnanimous surgical stewardship may be, we must remain ever cognizant of the careful balance between cost containment and patient safety. It is certainly reasonable for highly skilled surgeons, such as the authors, to use instrumentation that is not purpose-built for its designated task (i.e. using a ProGrasp forcep as a needle driver or using standard needle drivers with comparatively greater crushing force for retraction). On the other hand, for the novice surgeon, the decision to follow the lead of the authors must be judicious as the use of limited instrumentation adds potential complexity to the procedure. Moreover, in certain difficult cases, even the best surgeons may need to abandon their pride and concern for cost when the surgical circumstances prescribe. Context should always dictate prudence. Ultimately, Jordan Spieth has the ability to shoot par using nothing but a 7-iron and a putter. Less polished professionals may require more clubs in their bag to achieve an equally good result. Regardless, each shot and club choice must be individualized. You will not see Spieth play a major tournament with just three instruments, regardless of costs.
9 Page 9 of 11
RE: Reducing Costs for Robotic Radical Prostatectomy: ThreeInstrument Technique Daniel Ramireza, Georges-Pascal Habera* Article Type: Response to editorial comment (Invited) Keywords: Robotics; Costs; Outcomes; Surgical technique Word count: 182 aAffiliation:
Cleveland Clinic Glickman Urological and Kidney Institute Cleveland, OH 44195 *Corresponding author: Georges-Pascal Haber, MD, PhD Center for Laparoscopic and Robotic Surgery Cleveland Clinic Glickman Urological and Kidney Institute 9500 Euclid Ave. Q10-1 Cleveland, OH 44195 Attaining the best possible quality by optimizing surgical outcomes is paramount. We agree with the comments outlined above, the primary objective of delivering care at its highest quality is to optimize outcomes. Reducing costs should only be pursued when those savings do not negatively influence outcomes. From a surgical improvement standpoint, it is imperative to use what instruments we have at our disposal, even if we use them unconventionally. Employment of instruments to perform tasks for which they were not purposefully designed is an important aspect of furthering what can be accomplished with available technology, and could ultimately play a role in decreasing disposable costs in robotic surgery.1 We have been able to reduce our disposable costs for robotic radical prostatectomy while maintaining comparable outcomes, though larger clinical studies are still needed to justify these cost-saving maneuvers across practice 10 Page 10 of 11
settings. We do not recommend that robotic surgeons perform radical prostatectomies with limited instrumentation unless they feel that they are able to do so effectively. If Jorden Spieth is unable to win the tournament with 3 clubs alone, he should not attempt it. References 1. Ludwig WW, Gorin MA, Allaf ME. Reducing the cost of robotic partial nephrectomy through innovative instrument use. Eur Urol. 2015; 67:594-5.
11 Page 11 of 11