Female Pelvic Medicine & Reconstructive Surgery:
Likes, C.1; Behera, M.1; Judd, J.1; Barnett, J. C.1; Havrilesky, L.1; Wu, J.1
1OB/Gyn, Duke University, Durham, NC
DISCLOSURE OF RELEVANT FINANCIAL RELATIONSHIPS: None.
Uterine myomectomy is becoming a more frequent treatment for those women with symptomatic fibroids who choose to preserve fertility. Currently there are three routes of myomectomy; abdominal, traditional laparoscopy, and robotic assisted laparoscopy. Although robotic-assisted myomectomies are being performed, limited data exist regarding the costs associated with this new technique. Thus, we sought to perform a cost-minimization analysis of these three routes of myomectomy.
MATERIALS AND METHODS:
We developed a decision model to compare the costs (2008 US dollars) of abdominal (AM), laparoscopic (LM), and robotic-assisted myomectomy (RM) from a healthcare system perspective. We assumed equivalent surgical outcomes for all three routes and thus performed a cost-minimization analysis. The model included operative time, conversion risk, transfusion risk, and length of stay (LOS) for each modality. Baseline estimates and ranges were based on an extensive literature search. Baseline estimates for AM, LM, and RM were: OR time (154, 264, 232 min), conversion (0, 8.8, 6.9%), transfusion (6, 0, 0%), and LOS (2, 1.6, 1.5 days) respectively. We analyzed two different models: #1) assumed that the hospital already had the robotic system in place (Existing Robot model) and #2) assumed that the hospital has to purchase a robotic system (Robot Purchase Model). We used a micro-costing approach and costs included operating room, hospital, laboratory, and pharmacy fees. Sensitivity analyses were performed to assess the impact of varying each parameter and most of the costs through their defined ranges.
In the baseline analysis for the Existing Robot model, AM was the least expensive at $4987 compared to LM at $6284 and RM at $7374. The abdominal route remained the least expensive when varying the all parameters and costs except in two cases: 1) If AM LOS was greater than 4.6 days, LM became the least expensive; 2) If the surgeon's fee for AM was greater than $2436, LM became the least expensive and if AM surgeon's fee was greater than $3549, RM cost less than AM but remained more than LM. When comparing the two minimally-invasive options, LM to RM, the cost of the robotic approach was consistently higher unless the robotic disposable equipment costs were less than $1400 while the LM disposable costs remained $1163. In the Robot Purchase model, only the RM costs increased while AM and LM costs remained the same. The robotic cost increased incrementally by $2907, $1938, and $1090 per case when the amortized purchase and maintenance costs were distributed over 12, 18, and 32 cases/month, respectively.
In this cost-minimization analysis, abdominal myomectomy is the least expensive when compared to laparoscopy and robotic-assisted laparoscopy. While this study assumed equivalent surgical effectiveness among the three modalities, further studies evaluating post-operative outcomes of minimally invasive alternatives, such as impact on quality of life and/or impact of the uterine scar in a subsequent pregnancy, are warranted.