Despite the current concerns regarding its cost, RALS continues to grow. Therefore, it is necessary to change the paradigm to make RALS cost-effective. The best clinical model for effective integration of RALS into practice is in urology. Recognizing a need, with the large amount of suturing required and the lack of progression to laparoscopy, there was wide and rapid adoption of robotic surgery in urology [43]. Robot-assisted radical prostatectomy increased from 1% in 2001 to more than 50% of all prostatectomies performed in the United States in 2009 and is currently recognized as the gold standard [44]. Even in this optimal model, robotics is associated with higher costs than open and laparoscopic prostatectomy, predominantly from higher surgical supply and OR cost due to increased operative time [45]. The value comes from reducing the length of stay, with cost savings realized when enough nights in the hospital are saved to overcome the increased cost of the robotic procedure [46]. The shorter length of stay and faster recovery when transitioning from open to robotic models has been proven in multiple studies [47–51]. Study has found the length of stay for RALS was 1 day shorter than laparoscopic and 2 days shorter than open prostatectomy [45]. When determining if there is a value in integrating RALS into clinical practice, a break-even analysis is beneficial. An example of the cost–benefit analysis for integration of RALS is shown in Fig. 16.1.

Minimally invasive procedures are the most overall cost effective. Most reports on the cost concerns of RALS compare laparoscopic and robotic colorectal resections [14, 32, 41, 42]. However, these comparisons are short sighted. RALS is a minimally invasive tool; it is not intended to steal market share from laparoscopic surgery. Despite proven benefits of minimally invasive rectal cancer surgery, its use is still estimated at 10% nationwide; 90% of rectal cancer cases are still performed open [10]. The value of RALS is in converting open to robotic surgery and expanding the use of minimally invasive procedures in general. National studies on robotic trends further that benefits are most pronounced when robotics is used in procedures previously performed open [15, 52]. For all common general surgery procedures, length of stay was shorter, with fewer complications and lower or equivalent mortality in the RALS compared to open cases [52]. The trends of shorter length of stay with lower complication and mortality rates were also seen in RALS versus open surgery in colorectal procedures specifically [15]. Compared to open surgery, the improved functional outcomes, reduction in postoperative pain, faster time to recover normal bowel function, and shorter length of stay make the value proposition against the cost for purchasing and integrating RALS in colorectal surgery [53]. When overall costs were considered, RALS appears more cost-effective than open surgery for colorectal procedures [15]; this same value proposition was seen during the evolution from open to laparoscopic surgery. As RALS enables open surgeons to perform more minimally invasive procedures, it can follow the model of urology, reaching overall cost reductions in length of stay and faster recovery.

Recognizing laparoscopic surgery for rectal cancer continues to be associated with low national adaption rates, RALS may be positioned as tool for increasing minimally invasive rectal cancer resections [10, 28, 41, 54]. RALS has definite advantages over open TME for rectal cancer, including significantly more lymph nodes harvested, less estimated blood loss, a shorter length of stay, faster postoperative recovery, and a significantly lower local recurrence rate [39, 55]. The robot system may overcome challenges associated with difficult pelvic anatomy, which could increase the percent of patients that undergo a minimally invasive resection [38]. The RALS approach even has benefits over laparoscopy for TME including lower conversion rates, better quality of the TME specimen, and faster recovery of urinary and sexual function, increasing the value proposition [27, 56–58]. Several characteristics have been defined as selection criteria for robotic surgery to justify its increased cost, including obesity, male sex, preoperative radiotherapy, and tumors in the lower two-thirds of the rectum [59]; rectal cancer patients with these characteristics should be considered prime candidates for RALS. RALS may be the means to increase MIS for rectal procedures. Using the platform to allow a skilled laparoscopic surgeon to overcome the barriers of pelvic surgery and offer a minimally invasive approach to rectal cancer patients is a true benefit of RALS. RALS could feasibly transition a 10% increase in utilization of minimally invasive surgery for rectal cancer cases. At 20%, the paradigm shift from open to minimally invasive surgery occurs, and true economic benefits are realized.

As we work to change the paradigm from open to robotic colorectal surgery, there are methods to streamline costs now. Standardizing and reducing instrumentation is a way to reduce the unnecessary costs. The Da Vinci surgical system has no third-party disposables available, offering an ability to standardize equipment that laparoscopic surgery could never offer. For example, the proprietary EndoWrist 45 (Intuitive Surgical, Inc.) robotic stapler may be more cost-effective than a separate laparoscopic instrument. Holzmacher et al. retrospectively compared the EndoWrist 45 to laparoscopic staplers in patients who underwent RALS colorectal procedures [60]. The laparoscopic stapler group required significantly more fires per patient than the robotic stapler group (2.69 vs. 1.86; p = 0.001) and had significantly higher stapler cost per patient ($631.45 vs. $473.28; p = 0.001), demonstrating the cost- effectiveness of the robotic accessory [60]. Delto et al. demonstrated the impact of streamlining equipment to optimize the cost–benefit of robotic technology without negatively impacting operative time, blood loss, or intra-operative complications [47]. By eliminating a laparoscopic energy source in lieu of inexpensive tools (such as Hem-o-lock clips), instrumentation costs were reduced by approximately 40% [47]. Each robotic case across all service lines uses the same basic instruments, so a standardized peel pack and instrument table can reduce unnecessary equipment costs. An example of a standardized and non-standardized equipment table, and the contents of a standardized peel pack for RALS are seen in Fig. 16.2 and Table 16.2. The robotic instruments are also highly multi-functional and can be exploited to perform more tasks and contain costs. For example, using the hook instead of monopolar shears will save $120 per procedure. At a hospital that performs 100 colorectal procedures annually, this change on just 50% of the procedures will save $6000. Utilizing the suturing capabilities of the robot instead of a laparoscopic tacker in cases that use mesh fixation, such as a rectopexy, will save $500–700 per procedure. Depending on the volume of the institution, streamlining and maximizing the capabilities of the robotic instruments can result in significant cost savings.

The cost of each RALS case is determined by robotic system value/ the number of cases performed. Therefore, increasing the number of cases is a method to reduce the cost per case and make the tool more cost-effective. A recent review of the Premier Persepectives® database found only 13% of hospitals and 4.4% of surgeons performed a high volume of robotic colorectal cases [61]. The majority of colorectal RALS were performed by low volume surgeons (less than or equal to five cases) at low volume hospitals (less than or equal to ten cases). Furthermore, low volume providers were associated with significantly more overall complications, longer length of stay, and higher costs at both the hospital and surgeon level [61]. In addition, increasing use of robotics in other service lines will increase the total case numbers and ability to profit through economies of scale. A study has shown the technology can become cost-effective in high-volume centers with high-volume surgeons [62]. Thus, increasing individual case volumes and/or regionalizing RALS cases to a high volume center could reduce the individual cost per procedure and increase the overall revenue.

Facility costs can be impacted by shorter console/operative times. The attenuated learning curve with RALS has already been discussed. Another way to reduce the operative times and realize cost savings is to institute quality control measures around docking time. Docking times have been reported as a median of 10 min, but with a wide variation (range: 2–70 minutes) [63]. Docking should be a 3–5 min drill regardless of the case. Establishing docking time as a best practice, and tracking docking times against the benchmark has the potential to dramatically reduce costs. For example, if docking currently takes 15 min, at an average cost of $60 per operating room minute, in a practice that performs 2 RALS cases per operating day, and operates 100 days a year, the cost is: 15 min × ($60/min) × 2 cases/operative day × 100 operative days = 180,000. By reducing the docking time to an average of 3 minutes, the costs are reduced to $36,000, for a cost savings of $144,000.

To reduce the capital cost, advances in robotic technology and competition in the marketplace to reduce the cost of the surgical robotic and its equipment are needed. Although costs are currently high, increased competition from manufacturers and wider dissemination of the technology could drive down the costs [64]. Intuitive Surgical’s robotic system currently dominates the market, but Titan Medical (Toronto, Ontario) has an alternative, the Single Port Orifice Robotic Technology (SPORT™) Surgical System , in clinical trials.

In sum, understanding the cost model is paramount to making RALS a cost-efficient tool in every institution. The key to a profitable program is the contribution margin. The contribution margin is defined as the net revenue minus the direct costs (Table 16.3). To increase the contribution margin, RALS can increase reimbursement by improving the payor mix and the related reimbursement. RALS may have higher costs, but there is the ability to improve other variables in the cost model to make RALS more cost-effective. Variables to factor into the cost model include:

Fixed capital and maintenance costs can be addressed with advances in robotic technology and increased competition. Streamlining instrumentation can optimize the cost of consumables. Reducing operative and docking times to increase the number of total cases performed can reduce the facility costs. In addition, increasing use of robotics in other service lines will increase the total case numbers and ability to profit through economies of scale.