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1 Introduction

Robotic surgery (RS) has gained popularity since the introduction of da Vinci surgical system (Intuitive Surgical Inc., Sunnyvale, USA) in the year 2000, representing a revolution for surgical practice and minimally invasive surgery. Thanks to their well-known technological improvements [1], robotic systems are being used in a wide variety of procedures including colorectal (CR) surgery. Several studies have been published to describe the safety and efficacy of RS in CR surgery and promising benefits of robotics over other alternative conventional approaches (i.e., laparoscopic or open) have been reported [2,3,4]. Hence, the technical advantages of robotic systems should theoretically allow expansion of the minimally invasive approach in the field of CR surgery. However, some concerns have been raised about the use of this new technology, in particular about its real clinical benefits [2, 5] in comparison with its supposed higher costs.

The aim of this chapter is to analyze the current state of costs in robotic CR surgery using da Vinci surgical system.

2 Preliminary Considerations

Because Intuitive Surgical supplies most robotic technology, current costs in robotic CR surgery are evaluated considering da Vinci system on the market. However, before going into the subject, a few general aspects should be considered.

  • In 2000, the US Food and Drug Administration cleared the da Vinci for general laparoscopic surgery. Currently, the da Vinci surgical system is, with 7135 installed systems worldwide, the most used platform [6]. Intuitive Surgical markets its products through a direct sales force in the United States, Europe (excluding Spain, Portugal, Italy, Greece, and most Eastern European countries), China, Japan, South Korea, India, and Taiwan [7].

    The different mode of distribution of the robotic system among countries (direct vs. indirect) represents itself the first limitation when analyzing RS costs.

  • When a hospital is considering the acquisition of robotic system, an accurate assessment of the total cost of ownership (CoO) should be an integral part of the technology acquisition equation. The CoO assessment should include all relevant fixed and variable cost components:

    • Fixed costs include implementation and maintenance costs. Currently, there are five available versions of the da Vinci, with an average sales price of $1.47 million and a yearly average service contract cost of $154,000 [7]. Moreover, there are different purchasing methods, such as installment and leasing.

    • Variable costs include da Vinci and non-da Vinci supplies; operating room time based on surgical case time, divided into cut-to-close time and patient- in-room time; operating room personnel costs; hospital stay costs, which include length of stay (LoS) in both the intensive care unit and the general ward, costs of reoperation, and postoperative procedures. The impact of surgeon learning curves is another variable cost that should be called out, given that learning curves can lead to a cost per case being overstated together with case mix by service line and annual robotic case volume. Moreover, instrument use and surgeon instrument preferences are another contributor to cost and associated variability.

    Hospitals use a variety of approaches to robotic cost accounting, making it difficult to determine accurate CoO assessments across hospitals [8].

  • Health technology assessment is used when a new technology is being introduced into clinical practice. Economic evaluation should not only consider fixed and variable costs, but also the benefits from the different aspects related to patient treatment, such as LoS, complications, readmission or oncological outcomes. To date, cost-effectiveness analysis (CEA) and cost-utility analysis (CUA) are the most commonly used economic evaluation frameworks for international health technology institutions [9].

    Currently, few studies have performed a complete economic evaluation of robotic CR surgery [10,11,12,13,14,15,16]. There is a role for methodologically sound observational studies that should focus on the development, exploration and assessment [17] of robotic CR procedures to examine clinically relevant patient-important outcomes rather than surrogate measures [5].

  • Reimbursement to the hospital for utilization of the robot and hospitalization expenses are also in straight correlation with the health care system. Since 1978 Italy has a universalistic national health system (NHS). The 1992 reform of the NHS introduced a system of remuneration of prospective hospitals, based on the classification of the Diagnosis-Related Groups (DRG). In 2011 the new It-DRG that includes the Italian Classification of Procedures and Interventions (CIPI) was introduced with the aim of reducing the costs for the NHS [18]. However, to date there are no differences for laparoscopic or RS, although in the proposed new CIPI at least 30 procedures will be classified as robotic-assisted [19]. Currently, only Lombardy, Tuscany and Veneto have approved an additional compensation dedicated to RS with substantial differences.

    Differences between countries, private or public sectors render any approach to evaluate cost data complex. The use of the laparoscopic or robotic approach generates an increase in variable costs mostly without changing revenues.

On this basis, the current evidence of the costs of the application of robotics in CR surgery is reported as follows.

3 Costs in Robotic Colon Surgery

In agreement with another previous publication [20], a recent study evaluating the cost-effectiveness of open, laparoscopic, and robotic colectomy based on modeled analysis of the published literature found that laparoscopic and robotic colectomy result in more quality-adjusted life years (QALY) and lower cost than the open approach [13]. The authors underline that, with more than 50% of colectomies still being performed using an open approach in the U.S.A., this finding represents an important opportunity for improving the value of colectomy delivered across the country. This consideration might be translated also to Italy’s system where, according to the National Outcomes Programme (Programma Nazionale Esiti, PNE), 46.6% of all colectomies were performed laparoscopically in the period 2015–2020, with a median LoS of 7 days [21].

Robotic colectomy is not currently cost-effective by any of the conventional standards used in cost-effectiveness studies, but it can surpass laparoscopy by achieving better quality of life (QoL) after surgery and lowering disposables costs, LoS, time off work, and hernia rates. However, it remains unclear whether RS can achieve improvements of this magnitude [13].

Focusing on right colectomy, in all [16, 22, 23] but one [24] of the most recent cost analyses comparing robotic and laparoscopic right colectomy, operating time (OT), total operating room and hospital costs were higher for the robotic cases compared with laparoscopy, although the difference was not significant in any of the series. These outcomes are in agreement with those reported by a previous meta-analysis [25].

Currently, robotic right colectomy does not provide any significant clinical advantage likely to justify the additional costs, and should probably be used with appropriate clinical justification in high-volume centers with a standardized surgical protocol [26].

4 Cost in Robotic Rectal Surgery

Robotic rectal surgery is more expensive than laparoscopic surgery especially in terms of its high capital, amortization, recurrent costs and longer OT [11, 12, 27,28,29,30].

Interesting findings have been reported by two recently published papers. A monocentric cost-effectiveness analysis of robotic versus laparoscopic rectal resection showed for the first time an apparent improvement in the QoL of the patients in favor of the robotic group [14]. Simianu et al. have recently examined the cost-effectiveness of open, laparoscopic, and robotic approaches to proctectomy from a societal and healthcare system perspective [15]. One important finding of this study is that an open approach is less cost-effective than both minimally invasive techniques. Since approximately 50% of surgery for rectal cancer continues to be open in Italy [31], the proportion of operations carried out with a minimally invasive approach should be increased.

Robotic proctectomy can be cost-effective if modest differences in costs of the operation (such as OT and use of disposables), LoS and time off work can be achieved [15]. In the societal model, reducing the cost of disposables for RS by as little as $400 or achieving a shorter mean duration of robotic cases (by as little as 20 min) could make robotic proctectomy cost-effective.

Recently, a Chinese trial has reported for the first time advantages of RS in improving the oncological quality of resection for middle and low rectal cancer compared with laparoscopy [4]. The robotic group had significantly higher total hospitalization costs but significantly lower postoperative costs which might be associated with lower postoperative morbidity.

Future studies should be conducted for accurate assessment of the already promising functional outcomes provided by RS. However, in rectal cancer surgery, it is particularly important to put surgery-related costs into perspective considering that the most significant cost drivers are oncological and outpatient workup/follow-up treatments irrespective of surgical approach [32].

5 How Can Robotic Colorectal Surgery Become Cost-Effective?

Several efforts can be made to decrease variable costs:

  • use of the robotic platform in a multidisciplinary high-volume center can reduce the extra costs per procedure [33] and may also help to obtain discounts on the purchase costs of robotic instruments [34];

  • surgeon’s experience and programmatic standardization (technique, case time, team performance metrics) can contribute to reduce the number of disposables used in each operation and the OT [8, 11, 12, 15]. Moreover, since the beginning of 2021 there has been an evolution of robotic instruments that allowed the number of uses to be extended to eighteen times while keeping the price of each instrument unchanged [34];

  • especially for robotic rectal cancer surgery, a decreased conversion rate to open surgery and related morbidity and LoS (linked to an enhanced recovery program) can therefore reduce hospital charges [3, 33, 35].

Since RS has considerable potential to improve and advance surgical care, institutions with the ability to prioritize research over pure cost containment may promptly adopt robotics to improve patient outcomes [36].

Finally, the robotic surgical procedure market is expanding. Outside of the current monopoly system, there are several robotic platforms [37] that are entering the marketplace. Exactly what effect this competition will have on the cost-effectiveness of robotics remains to be determined.