Delto Joan C, Wayne George, Yanes Rafael, Nieder Alan M, Bhandari Akshay
1 Department of Urology, Mount Sinai Medical Center , Miami Beach, Florida.
J Endourol. 2015 May;29(5):556-60. doi: 10.1089/end.2014.0533. Epub 2014 Dec 2.
INTRODUCTION AND OBJECTIVE: Since the introduction of robotic surgery for radical prostatectomy, the cost-benefit of this technology has been under scrutiny. While robotic surgery professes to offer multiple advantages, including reduced blood loss, reduced length of stay, and expedient recovery, the associated costs tend to be significantly higher, secondary to the fixed cost of the robot as well as the variable costs associated with instrumentation. This study provides a simple framework for the careful consideration of costs during the selection of equipment and materials. MATERIALS AND METHODS: Two experienced robotic surgeons at our institution as well as several at other institutions were queried about their preferred instrument usage for robot-assisted prostatectomy. Costs of instruments and materials were obtained and clustered by type and price. A minimal set of instruments was identified and compared against alternative instrumentation. A retrospective review of 125 patients who underwent robotically assisted laparoscopic prostatectomy for prostate cancer at our institution was performed to compare estimated blood loss (EBL), operative times, and intraoperative complications for both surgeons. Our surgeons now conceptualize instrument costs as proportional changes to the cost of the baseline minimal combination. RESULTS: Robotic costs at our institution were reduced by eliminating an energy source like the Ligasure or vessel sealer, exploiting instrument versatility, and utilizing inexpensive tools such as Hem-o-lok clips. Such modifications reduced surgeon 1's cost of instrumentation to ∼40% less compared with surgeon 2 and up to 32% less than instrumentation used by surgeons at other institutions. Surgeon 1's combination may not be optimal for all robotic surgeons; however, it establishes a minimally viable toolbox for our institution through a rudimentary cost analysis. A similar analysis may aid others in better conceptualizing long-term costs not as nominal, often unwieldy prices, but as percent changes in spending. With regard to intraoperative outcomes, the use of a minimally viable toolbox did not result in increased EBL, operative time, or intraoperative complications. CONCLUSION: Simple changes to surgeon preference and creative utilization of instruments can eliminate 40% of costs incurred on robotic instruments alone. Moreover, EBL, operative times, and intraoperative complications are not compromised as a result of cost reduction. Our process of identifying such improvements is straightforward and may be replicated by other robotic surgeons. Further prospective multicenter trials should be initiated to assess other methods of cost reduction.
引言与目的:自从引入机器人手术进行根治性前列腺切除术后,这项技术的成本效益就一直受到审视。虽然机器人手术声称具有多种优势,包括减少失血、缩短住院时间以及快速康复,但由于机器人的固定成本以及与器械相关的可变成本,其相关成本往往显著更高。本研究提供了一个简单框架,用于在选择设备和材料时仔细考虑成本。 材料与方法:我们机构的两名经验丰富的机器人外科医生以及其他机构的几名医生被询问了他们在机器人辅助前列腺切除术中偏爱的器械使用情况。获取了器械和材料的成本,并按类型和价格进行了分类。确定了一套最小化的器械组合,并与替代器械进行了比较。对我们机构125例接受机器人辅助腹腔镜前列腺切除术治疗前列腺癌的患者进行了回顾性研究,以比较两位外科医生的估计失血量(EBL)、手术时间和术中并发症。我们的外科医生现在将器械成本概念化为相对于基线最小组合成本的比例变化。 结果:通过消除像Ligasure或血管封闭器这样的能量源、利用器械的多功能性以及使用诸如Hem-o-lok夹等廉价工具,我们机构的机器人手术成本得以降低。与外科医生2相比,这些改进使外科医生1的器械成本降低了约40%,比其他机构外科医生使用的器械成本降低了多达32%。外科医生1的组合可能并非对所有机器人外科医生都是最优的;然而,通过初步的成本分析,它为我们机构建立了一个最低可行的工具箱。类似的分析可能有助于其他人更好地将长期成本概念化为不是名义上的、通常难以处理的价格,而是支出的百分比变化。关于术中结果,使用最低可行工具箱并未导致EBL增加、手术时间延长或术中并发症增多。 结论:对外科医生偏好进行简单改变并创造性地使用器械,可以仅消除机器人器械成本的40%。此外,降低成本并未影响EBL、手术时间和术中并发症。我们识别此类改进的过程很简单,其他机器人外科医生也可以效仿。应启动进一步的前瞻性多中心试验,以评估其他降低成本的方法。
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