Perioperative Outcomes, Health Care Costs, and Survival After Robotic-assisted Versus Open Radical Cystectomy: A National Comparative Effectiveness Study
Menée à partir des données des registres américains des cancers et des données de la base Medicare portant sur 7 747 patients atteints d'un carcinome urothélial de la vessie traité entre 2002 et 2012 (durée médiane de suivi : 44 mois), cette étude analyse l'évolution de l'utilisation de deux modalités de cystectomie radicale, l'une réalisée par voie ouverte et l'autre assistée par robot, puis compare les coûts, les données péri-opératoires et les taux de survie associés
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.
European Urology 2016