A cost-effectiveness modeling study of robot-assisted (RARC) versus open radical cystectomy (ORC) for bladder cancer to inform future research

Abstract

Background: Open radical cystectomy (ORC) is regarded the standard treatment for muscle-invasive bladder cancer, but robot-assisted radical cystectomy (RARC) is increasingly used in practice. However, it is unclear whether RARC provides value for money.

Objective: To identify the main evidence gaps and main drivers of cost-effectiveness, comparing RARC to ORC.

Design, setting, and participants: A decision analytical model was developed to study the 30d and 90d postoperative complications with RARC versus ORC and their related cost in bladder cancer patients. Input data were derived from systematic literature searches, meta-analyses, internal databases and expert opinion.

Outcome measurements and statistical analysis: Cost per saved complication (in Clavien-Dindo grading) was determined. Deterministic sensitivity analyses was performed to search for threshold values for RARC to become cost saving. Uncertainty was addressed using probabilistic sensitivity analyses.

Results: The expected 30d and 90d risk for a minor complication was lower for RARC than ORC (37% vs. 45% and 32% vs. 36%). The expected 30d and 90d risk of RARC versus ORC for a major complication was 18% vs. 23% and 16% vs. 25%. The 30d and 90d extra costs needed to prevent one major complication were €62,582 and €37,007, respectively. Data on the impact of complications on quality of life were lacking. Three scenarios resulted in cost savings for RARC: operating time (threshold: ≤175min), length of stay (≤4d), and RARC equipment (≤€281).

Conclusion: Current evidence suggests that it is unlikely that RARC will become less expensive than ORC. However, RARC might result in fewer complications. To determine value for money, research is needed into the consequences of these complications in terms of quality of life.

Patient summary: Economic modeling showed that RARC might result in fewer complications, but is more expensive than ORC. Future research should focus on the impact on quality of life.

Keywords: Bladder cancer; cost-effectiveness; radical cystectomy; robot-assisted.