Robotic Cystectomy Costing Study

1. Robotic Cystectomy Costing Study Douglas S. Scherr, MD Department of Urology The New York Presbyterian Hospital Weill Medical College of Cornell University

2. Background • Objective: to measure the economic impact of open vs. robotic cystectomy with urinary diversion • Urinary diversions: ileal conduit, Indiana pouch, ileal neobladder

3. Methods • Methods • Costing • Direct: surgeon’s fee, OR fee, anesthesia fee, PACU cost, inpatient hospital cost, cost of equipment (da Vinci Surgical System, Intuitive Surgical, Inc.) • Procedural costs: defined by 50th percentile of Medicare Resource Based Relative Value Scale (RBRVS) • Indirect: cost of complications • Complication rates derived from Cornell prospectively maintained database • Procedural costs derived from Medicare RBRVS

4. Methods • Assumptions • Cost of da Vinci Surgical System: $1M • Cost of da Vinci Surgical System service contract: $100k per year • 7 year depreciation for da Vinci Surgical System • Assume equal robotic cost overhead between all robotic cases • 3 year avg Cornell robotic case volume: 269 cases • Robotic cost burden per case: $904 ($3488 for all robotic case-associated materials)

5. Methods • Assumptions • Any readmission over any of time after cystectomy and urinary diversion counted as complication (WORST CASE scenario)

6. Data

7. Data

8. Data

9. Data

10. Data

11. Results

12. Sensitivity Analysis • Breakeven condition: How few robotic cases would need to be done per annum to make the cost of robotic cystectomy equal to open cystectomy, ceteris paribus? • Ileal conduit: 5 cases ($130,460) • Indiana pouch: 3 cases ($180,982) • Ileal neobladder: 7 cases ($127,826)

13. Sensitivity Analysis • Breakeven condition: How few robotic cases would need to be done per annum to make the cost of robotic cystectomy equal to open cystectomy, assuming a 25% complication rate in each group? • Ileal conduit: 8 cases ($111,793) • Indiana pouch: 4 cases ($156,518) • Ileal neobladder: 8 cases ($113,039)

14. Results • The impact of decreased length of stay (LOS) with robotic cystectomy outweighs the marginal cost impact of a da Vinci robotic system!

15. Caveats • Small surgical series: results need to be re-examined in the context of greater surgical volume • Tertiary care, academic referral center: results may not be generalizable • Complications data may be undercaptured