Cost-Effectiveness of Robot-Assisted Radical Cystectomy vs Open Radical Cystectomy for Patients With Bladder Cancer
Authors: Dixon Simon , Hill Harry , Flight Laura , Khetrapal Pramit , Ambler Gareth , Williams Norman R. , Brew-Graves Chris , Kelly John D. , Catto James W. F. ,   iROC Study Team, Groves E Ruth , Goodwin Louise , Willson Jayne , Ravencroft Phillip , Kennish Stephen , Rosario Derek J , Torrington Carol , Nair Rajesh , Thurairaja Ramesh , Amery Sue , Chatterton Kathryn , Broadhead Samantha , Hendry David , Zreik Abdullah , Jain Sunjay , Prescott Steve , Roberts Hannah , Morgan Angela , Main Chris , Bedford Elspeth , Wiseman Lorraine , Mpofu Bernice , Daisey Claire , Donachie Michelle , Aning Jon , Johnson Lyndsey , Brain Carol , Shiridzinomwa Constance , Ebon Martin , Hampson Alexander , Schimmel Roisin , Horsley Scott , Nembhard Sayyida , Collins Clare , Gilmore Jemma , Wilson Faith , Peacock Louise , Lim Sheena , Gabriel Rhosyll , Sarpong Rachael , Tan Melanie 
Published: June 2023

ImportanceThe value to payers of robot-assisted radical cystectomy with intracorporeal urinary diversion (iRARC) when compared with open radical cystectomy (ORC) for patients with bladder cancer is unclear.ObjectivesTo compare the cost-effectiveness of iRARC with that of ORC.Design, Setting, and ParticipantsThis economic evaluation used individual patient data from a randomized clinical trial at 9 surgical centers in the United Kingdom. Patients with nonmetastatic bladder cancer were recruited from March 20, 2017, to January 29, 2020. The analysis used a health service perspective and a 90-day time horizon, with supplementary analyses exploring patient benefits up to 1 year. Deterministic and probabilistic sensitivity analyses were undertaken. Data were analyzed from January 13, 2022, to March 10, 2023.InterventionsPatients were randomized to receive either iRARC (n = 169) or ORC (n = 169).Main Outcomes and MeasuresCosts of surgery were calculated using surgery timings and equipment costs, with other hospital data based on counts of activity. Quality-adjusted life-years were calculated from European Quality of Life 5-Dimension 5-Level instrument responses. Prespecified subgroup analyses were undertaken based on patient characteristics and type of diversion.ResultsA total of 305 patients with available outcome data were included in the analysis, with a mean (SD) age of 68.3 (8.1) years, and of whom 241 (79.0%) were men. Robot-assisted radical cystectomy was associated with statistically significant reductions in admissions to intensive therapy (6.35% [95% CI, 0.42%-12.28%]), and readmissions to hospital (14.56% [95% CI, 5.00%-24.11%]), but increases in theater time (31.35 [95% CI, 13.67-49.02] minutes). The additional cost of iRARC per patient was £1124 (95% CI, −£576 to £2824 [US $1622 (95% CI, −$831 to $4075)]) with an associated gain in quality-adjusted life-years of 0.01124 (95% CI, 0.00391-0.01857). The incremental cost-effectiveness ratio was £100 008 (US $144 312) per quality-adjusted life-year gained. Robot-assisted radical cystectomy had a much higher probability of being cost-effective for subgroups defined by age, tumor stage, and performance status.Conclusions and RelevanceIn this economic evaluation of surgery for patients with bladder cancer, iRARC reduced short-term morbidity and some associated costs. While the resulting cost-effectiveness ratio was in excess of thresholds used by many publicly funded health systems, patient subgroups were identified for which iRARC had a high probability of being cost-effective.Trial RegistrationClinicalTrials.gov Identifier: NCT03049410