Reduced pancreatic fistula rates and comprehensive cost analysis of robotic versus open pancreaticoduodenectomy
- Open Access
- 12.05.2025
Erschienen in:
Abstract
While robotic pancreaticoduodenectomy (RPD) has gained increasing adoption for patients with periampullary neoplasms in recent years, it has not yet become the universal standard. The initial report by Prof. Giulianotti in 2003 [1, 2] marked the beginning of this approach, and subsequent studies have confirmed its feasibility and safety in selected patient cohorts, comparing it to open pancreaticoduodenectomy (OPD) [3‐5]. Although RPD adoption is expanding, its role as a standard of care remains under discussion, and further evidence is needed to establish its superiority over OPD.
While RPD may entail longer operative times, we hypothesized that the high level of precision offered by the robotic platform during the reconstruction phase, especially concerning the pancreaticojejunostomy (PJ), may reduce clinically relevant pancreatic fistula (CR-PF), offering benefits such as a shorter hospital stay without increasing the total in-hospital charges. Previous studies have suggested that RPD may reduce the incidence of CR-PF, but solid empirical evidence remains limited [6]. Inconsistent pancreaticoenteric reconstruction techniques across studies, often due to multicenter designs or variability among surgeons, further complicate comparisons.
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At our institution, the RPD program began in 2017 under the proctorship of Prof. Giulianotti [7‐9]. Since then, we have consistently used a standardized robotic pancreaticojejunostomy (PJ) with a modified Blumgart anastomosis (MBA) for over eight years [10, 11]. This single-center approach helps reduce variability in perioperative care and allows for a more direct comparison with OPD. We hypothesize that the precision of robotic techniques may contribute to lower CR-PF rates.
Furthermore, in recent years, a common belief has emerged within the surgical community that RPD is more expensive than open surgery due to the use of multiple robotic and laparoscopic instruments. However, the economic implications of these two techniques (RPD vs. OPD) remain underexplored. Previous investigations have been limited, including a small retrospective cohort study with fewer than 100 cases and a systematic review with meta-analysis, which was hindered by significant heterogeneity in the included studies that grouped laparoscopic and robotic procedures under the broad term "minimally invasive surgery" [12, 13]. Therefore, another key aim of the present study was to provide a direct cost comparison of RPD and OPD within the context of high-volume centers in regions where healthcare systems and resource utilization may differ from Western models.
Materials and methods
Study design and setting
This was a retrospective single-center study of consecutive patients underwent RPD or OPD, between January 2017, when our RPD program begun, and December 2023. Clinical data were retrospectively collected from the prospective database at our center. This study was approved by the institutional review board of Ageo Central General Hospital and followed the principles of the Declaration of Helsinki. Due to the retrospective design of the study, patient consent requirements were waived.
Surgical technique
RPD setup and procedure
RPD was performed under the supervision of a single proctor using a dual-console system. Patients were placed in lithotomy position, pneumoperitoneum was established via a Veress needle, and robotic ports were positioned accordingly. The da Vinci Surgical System™ was used, and the resection phase mirrored the OPD technique (Online Video 1). Hemostasis was primarily achieved through suturing and coagulation; however, SURGICE NU-KNIT™ (Ethicon, Inc., Raritan, NJ, USA) was occasionally used when necessary.
Reconstruction
PJ, hepaticojejunostomy (HJ), and gastrojejunostomy (GJ) were performed using a standardized approach. PJ was performed using an MBA technique (Online Video 2). HJ was sutured with 5/0 PDS, and GJ was stapled with the entry hole closed by barbed suture.
Patient selection and variables
Prior to insurance coverage in 2020, RPD was indicated for distal cholangiocarcinoma, ampulla of Vater carcinoma, IPMN, and similar conditions. After 2020, pancreatic ductal adenocarcinoma (PDAC) was also included. As our surgical team gained experience, the selection criteria for RPD evolved. Initially, RPD was limited to low-risk cases, but over time, it was expanded to include more complex cases. Patients requiring vascular resection were primarily treated with OPD, while other cases were managed with RPD. While vascular resection cases are still preferentially treated with OPD, some are now selectively considered for RPD. Additionally, tumors with significant fibrosis or adhesion risks are carefully evaluated for feasibility. The RPD group included conversions to open surgery due to factors like vascular resection, multivisceral resection, or limited workspace. The indication for resection as the preferred treatment approach for each patient was based on established Japanese clinical guidelines [14]. Preoperative diagnoses were classified as PDAC, pancreatitis (low risk of fistula), or other conditions. CR-PF was defined as grade B or C pancreatic fistula based on the International Study Group of Pancreatic Fistula (ISGPF) criteria [15, 16]. Surgical procedures were categorized into four groups following Büchler's classification [17]. Pancreatic duct diameter was measured intraoperatively and classified as > 5 mm (low risk of fistula) or ≤ 5 mm. Lymph nodes were classified according to the Japan Pancreas Society's 7th/8th edition [14]. Postoperative morbidity within 30 days was graded using the Clavien-Dindo system (CD ≥ 3 for severe complications) [18]. Mortality was recorded at 30 and 90 days. Pancreas-specific complications, including CR-PF, delayed gastric emptying (DGE), and postpancreatectomy hemorrhage (PPH), were graded per ISGPS criteria. Biliary fistula was defined using ISGLS criteria [15, 16, 19‐21]. The primary endpoint was CR-PF incidence. Secondary endpoints included surgical outcomes, 30- and 90-day mortality, pathological data, and operative and total hospital costs.
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Charges for pancreaticoduodenectomy recording
We analyzed cost data from consecutive patients treated between April 2020 and December 2023, after the implementation of insurance coverage for RPD in Japan. This study aimed to compare total charges and operating room costs between RPD and OPD, with a detailed breakdown of operative and non-operative costs.
Operative costs
Operative costs encompassed all expenses directly related to the surgical procedure. Surgical equipment costs included both disposable and reusable instruments. Disposable instruments were priced based on market rates, while reusable instruments were calculated by dividing their original purchase price by the expected number of uses. Personnel costs were determined using the average hourly wages of attending surgeons and nurses, multiplied by the total operative time. Operating room maintenance expenses were primarily calculated from electricity costs, which were estimated based on per-minute usage during surgeries. This data was derived from a two-week observation of operating room electricity consumption and scaled to the duration of each procedure. Robotic platform costs included the acquisition, maintenance, and depreciation of the robotic system. These costs were combined and divided by the average monthly usage across all departments to calculate the per-case expense.
Non-operative costs
Non-operative costs included all charges associated with hospitalization, covering both pre- and postoperative care. Personnel costs were calculated by multiplying the daily wages of nutritionists, pharmacists, two attending physicians, nurses, and radiology technicians by the patient’s length of stay. Physician costs were further refined by dividing daily compensation by the average number of patients managed by each doctor. Hospital fees encompassed bed charges, utilities, and general inpatient services, which were calculated based on standard daily inpatient costs. Medical services, including diagnostic tests, therapeutic procedures, and postoperative care, were factored into the total hospitalization charges. These services covered a range of activities such as drug administration, laboratory tests, imaging, and any necessary interventions for postoperative complications.
Special considerations for comprehensive cost analysis
Electricity costs were derived from the average electricity usage of an operating room over a two-week period and scaled to reflect the surgical durations. Additionally, certain costs, such as bed charges and facility fees, were calculated based on billed amounts (equivalent to reimbursement rates) rather than direct expenses, aligning with the reimbursement structure of the Japanese healthcare system. This cost analysis provides a detailed comparison of operative and non-operative expenses for RPD and OPD. By incorporating surgical equipment, personnel costs, robotic system expenses, and hospitalization-related charges, this study offers valuable insights into the economic implications of these surgical approaches in Japan.
Statistical analysis
Patients were stratified into two groups based on surgical technique (RPD vs. OPD), and baseline characteristics and outcomes were compared before and after propensity score matching (PSM). Subgroup analysis was performed using PSM after excluding converted cases in the RPD group. Normality of continuous variables was assessed by visually inspecting histograms and Q-Q plots. Non-normally distributed continuous data were expressed as medians with interquartile ranges (IQR) and compared using the Mann–Whitney U test. Categorical data were expressed as percentages and compared using the chi-square test or Fisher’s exact test, as appropriate.
To minimize potential confounders, covariates for PSM included age, American Society of Anesthesiologists (ASA) classification, type of pancreaticoduodenectomy, pathology, preoperative albumin level, and blood loss. The diameter of the main pancreatic duct was categorized as < 5 mm or ≥ 5 mm [17]. Patients in the RPD group were matched to OPD patients using 1:1 nearest-neighbor matching without replacement and a caliper width of 0.2. Balance between groups was assessed using standardized differences (SD), with SD < 0.1 indicating optimal balance. After matching, categorical data were compared using McNemar's test, and continuous data were compared using the Wilcoxon signed-rank test.
Learning curves for operative time and robotic PJ in RPD were evaluated using Cumulative Sum (CUSUM) analysis. CUSUM analysis calculated cumulative deviations from the cohort mean, and a pooled CUSUM plot illustrated the performance trends to determine the number of procedures required to achieve proficiency.
Single imputation based on the median was used to address missing data for blood loss, as this was not a primary outcome measure. Main outcome data were not imputed. Statistical analyses were performed using SPSS Statistics® version 28.0 (IBM, Armonk, NY, USA) and R for Mac OS X version 4.2.1, with the MatchIt package for PSM [22]. CUSUM analysis was conducted using JMP version 11 (SAS Institute, Cary, NC, USA). Statistical significance was set at a two-tailed p value of < 0.05.
Results
A total of 193 patients were included, with 112 undergoing OPD and 81 undergoing RPD.
Patient demographics and perioperative outcomes before PSM
The RPD group had a lower incidence of PDAC compared to the OPD group (23.5% vs. 46.9%, p < 0.001). Concomitant vascular or multivisceral resection was less frequent in the RPD group (8.6% vs. 29.5%, p < 0.001). Other demographic characteristics were comparable between the groups (Table 1).
Table 1
Baseline, intraoperative and oncological characteristics of patients undergoing robotic and open pancreatoduodenectomy
Overall | After PSM | |||||
|---|---|---|---|---|---|---|
RPD | OPD | p | RPD | OPD | p | |
n = 81 | n = 112 | n = 60 | n = 60 | |||
Baseline patient characteristics | ||||||
Age, years | 73 [13] | 75 [9] | 0.175 | 73 [13] | 76 [10] | 0.063 |
Sex, male | 54 (66.7) | 74 (66.1) | 0.931 | 37 (61.6) | 40 (66.7) | 0.703 |
BMI, kg/m2 | 22.9 [3.6] | 22.1[4.05] | 0.050 | 22.8 [3.3] | 22.2 [4.02] | 0.210 |
ASA grade | ||||||
ASA 1 | 6 (7.4) | 3 (2.7) | 4 (6.6) | 2 (3.4) | ||
ASA 2 | 69 (85.2) | 92 (82.1) | 51 (85) | 54 (90) | ||
ASA 3 | 6 (7.4) | 17 (15.2) | 5 (8.4) | 4 (6.6) | ||
ASA 4 | 0 (0) | 0 (0) | 0.095 | 0 (0) | 0 (0) | 0.713 |
Preoperative diagnosis† | ||||||
PDAC | 19 (23.5) | 53 (47.4) | 17 (28.3) | 23 (38.3) | 0.332 | |
Other | 62 (76.5) | 59 (52.6) | < 0.001* | 43(71.7) | 37 (61.7) | |
Distal CCa | 28 (34.6) | 25 (22.3) | 16 (26.7) | 14 (23.3) | ||
Vater Ca | 13 (16.0) | 10 (8.9) | 9 (15) | 7 (11.7) | ||
IPMN/C | 10 (12.3) | 10 (8.9) | 8 (13.3) | 5 (8.4) | ||
Others | 11 (13.6) | 14 (12.5) | 10 (16.7) | 11(18.3) | ||
Tumor size, (millimeters) | 29 [24.5] | 27.5 [16.5] | 0.544 | 29 [21.5] | 25 [13] | 0.426 |
Neoadjuvant chemotherapy for PDAC | 13 (16) | 23 (20.5) | 0.547 | 11 (18.3) | 9 (15) | 0.806 |
Adjuvant chemotherapy | 30 (37) | 44 (39.3) | 0.751 | 21 (35) | 17 (28.3) | 0.431 |
Previous abdominal surgery | 5 (6.2) | 7 (6.3) | 1 | 4(6.6) | 4 (6.6) | 1 |
Pancreaticoduodenectomy type ** | ||||||
Type1 | 74 (91.4) | 70 (70.5) | 54 (90) | 53 (88.4) | ||
Type2 | 1 (1.2) | 18 (16.1) | 1 (1.6) | 0 (0) | ||
Type3 | 6 (7.4) | 15 (13.4) | 5 (8.4) | 7 (11.6) | ||
Type4 | 0 | 0 | < 0.001* | 0 (0) | 0 (0) | 0.762 |
Albumin, mg/dl | 3.8 [0.6] | 3.7 [0.73] | 0.377 | 3.8 [0.6] | 3.8 [0.7] | 0.555 |
Intraoperative and oncological outcome | ||||||
Diameter of Wirsung duct (> 5 mm) | 18 (22.2) | 42 (37.5) | 0.035* | 13 (21.7) | 14(23.3) | 1 |
Operative time, minutes | 639 [181] | 419 [128] | < 0.001* | 633[187] | 395 [77.5] | < 0.001* |
Estimated blood loss, (mL) | 175 [285] | 386 [408] | < 0.001* | 210 [333] | 303 [284] | 0.178 |
Blood transfusions | 6 (7.4) | 21 (18.8) | 0.042* | 6 (10) | 8 (13.3) | 0.776 |
Number of harvested lymph nodes | 24 [11.5] | 23.5 [16.2] | 0.224 | 24 [11.5] | 23 [18.5] | 0.439 |
Concomitant vascular resection | 1 (1.2) | 25 (22.3) | < 0.001* | 1 (1.6) | 4 (6.6) | 0.364 |
Radical resection margin (R0) | 78 (96.3) | 111 (99.1) | 0.400 | 58 (96.6) | 59 (98.4) | 1 |
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Regarding perioperative outcomes, the RPD group had significantly less blood loss (median 175 vs. 386 ml, p < 0.001) but longer operative time (median 639 vs. 419 min, p < 0.001). The length of hospital stay was shorter in the RPD group (median 14.5 vs. 21 days, p < 0.001). The RPD group also had lower rates of major complications (19.8% vs. 35.7%, p = 0.024) and CR-PF rates (8.6% vs. 32.1%, p < 0.001) (Table 2).
Table 2
Postoperative and complications of patients undergoing robotic and open pancreatoduodenectomy
Before PSM | After PSM | |||||
|---|---|---|---|---|---|---|
RPD | OPD | p | RPD | OPD | p | |
n = 81 | n = 112 | n = 60 | n = 60 | |||
Postoperative outcomes | ||||||
ICU stay, days | 1 [0] | 1 [1] | 0.745 | 1 [0.25] | 1 [1] | 0.858 |
Hospital LOS, days | 14.5 [8.25] | 21 [21] | < 0.001* | 15 [9.5] | 22.5 [25.5] | < 0.001* |
30-day mortality | 1 (1.2) | 0 (0) | 0.419 | 1 (1.6) | 0 (0) | 1 |
90-day mortality | 2 (2.5) | 4 (3.6) | 1 | 1 (1.6) | 1 (1.6) | 1 |
90-day readmission | 13 (16.0) | 22 (19.6) | 0.652 | 10 (16.7) | 12 (20) | 0.813 |
Complications | ||||||
Overall complication | 39 (48.1) | 63 (56.2) | 0.333 | 31 (51.6) | 35 (58.4) | 0.581 |
Major complication (CD ≥ 3) | 16 (19.8) | 40 (35.7) | 0.024* | 13 (21.6) | 22 (36.6) | 0.108 |
Reoperation | 3 (3.7) | 1 (0.9) | 0.311 | 3 (5) | 0 (0) | 0.243 |
Biliary Fistula | 1 (1.2) | 7 (6.3) | 0.141 | 1 (1.6) | 5 (8.4) | 0.206 |
Pancreas-specific complications | ||||||
CR-PF (ISGPS grade ≥ B) | 7 (8.6) | 36 (32.1) | < 0.001* | 6 (10) | 20 (33.3) | 0.003* |
PPH | 5 (6.2) | 12 (10.7) | 0.400 | 5 (8.4) | 7 (11.6) | 0.760 |
DGE | 5 (6.2) | 8 (7.1) | 1 | 4 (6.6) | 4 (6.6) | 1 |
Two cases in the RPD group required conversion to open surgery: one due to the need for portal vein resection and the other due to limited workspace. Although not statistically significant, the converted cases had higher rates of major complications (50% vs. 18.9%, p = 0.358) and longer hospital stays (median 29.5 vs. 14 days, p = 0.266) (Table S1).
Patient demographics and perioperative outcomes after PSM
After propensity score matching (PSM), 60 RPD cases were matched with 60 OPD cases, achieving well-balanced covariates (Fig. S1). Operative time remained longer in the RPD group (median 633 vs. 395 min, p < 0.001). Postoperative length of stay was still shorter for RPD (median 15 vs. 22.5 days, p < 0.001). Although major complication rates were similar between groups, the CR-PF rate remained significantly lower in the RPD group (10% vs. 33.3%, p < 0.001) (Table 2).
Excluding converted cases, 57 patients in each group were compared. The RPD group continued to show shorter hospital stays (median 14 vs. 21 days, p < 0.001) and lower rates of major complications (21% vs. 42.2%, p = 0.026) and CR-PF (10.5% vs. 40.4%, p < 0.001).
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Learning curve analysis
In all RPD cases, a chief surgeon (GW), who had surpassed the OPD learning curve, acted as the primary or mentoring console surgeon. CUSUM analysis showed that operative time and robotic pancreaticojejunostomy (PJ) time improved after 18 and 20 cases, respectively (Fig. S2a, 2b). The resection phase demonstrated a bimodal distribution (Fig. S2c).
Comprehensive cost analysis
Cost analysis included 62 RPD patients (76.5%) and 83 OPD patients (74.1%). The in-hospital total charges for RPD and OPD were comparable (median 1,842,642 JPY [~ 12,509 USD, ~ 11,500 EUR] vs. 1,850,656 JPY [~ 12,564 USD, ~ 11,548 EUR], p = 0.376), despite higher operating room costs for RPD (986,472 JPY [~ 6,696 USD, ~ 6,155 EUR] vs. 437,401 JPY [~ 2,969 USD, ~ 2,731 EUR], p < 0.001). After PSM, total in-hospital charges remained similar between RPD and OPD (median 1,876,564 JPY [~ 12,741 USD, ~ 11,726 EUR] vs. 1,850,656 JPY [~ 12,564 USD, ~ 11,548 EUR], p = 0.212) (Table 3). Currency conversion was based on the exchange rates as of March 11, 2025 (1 USD = 147.37 JPY, 1 EUR = 160.85 JPY).
Table 3
Cost analysis of robotic and open pancreatoduodenectomy
Charged amount | Before PSM | After PSM | ||||
|---|---|---|---|---|---|---|
RPD | OPD | p | RPD | OPD | p | |
n = 62 | n = 83 | n = 47 | n = 47 | |||
Operating room cost, (Japanese yen) | 986,472 [80,894] | 437,401 [79,122] | < 0.001* | 992,597 [124,567] | 428,670 [76,740] | < 0.001* |
Non-operative cost, (Japanese yen) | 875,725 [380,325] | 1,447,246 [1,109,381] | < 0.001* | 935,320 [420,298] | 1,431,874 [1,155,966] | < 0.001* |
In-hospital total charge, (Japanese yen) | 1,842,642 [453,292] | 1,850,656 [1,103,516] | 0.376 | 1,876,564 [473,883] | 1,850,656 [1,146,421] | 0.212 |
Discussion
Our retrospective cohort study highlights the advantages of the robotic platform in addressing this traditionally complex surgical procedure. Beyond demonstrating the clinical benefits associated with RPD, our study provides compelling findings from a cost analysis, challenging the widely held belief that RPD is inherently more expensive than OPD. With a cohort comprising 193 patients (RPD and OPD combined), this study represents one of the largest datasets from Japan, contributing valuable insights to the global discourse on robotic surgery. By addressing the current scarcity of cost–benefit analyses in this field, our findings offer meaningful evidence with international relevance, bridging the gap in the literature and informing surgical practices worldwide.
Over the past few decades, studies have explored alternative surgical approaches to the traditional open Whipple procedure due to its significant invasiveness. Laparoscopic surgery was introduced in the late 1980s, but widespread adoption was delayed by technical limitations [23]. Minimally invasive pancreatic surgery (MIPS) faced challenges related to oncological efficacy and the steep learning curve [24, 25]. The advent of robotic platforms has since revived MIPS, offering advantages such as lower conversion rates, reduced blood loss, higher lymph node retrieval, and comparable operative times and complication rates [26]. Additionally, mid-term oncological outcomes appear to be comparable [27].
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Several comparative studies, case-matched studies, and propensity score matched studies have reported comparable or better outcomes for RPD over OPD, including reduced blood loss, fewer complications, and shorter hospital stays [5, 6, 28‐34]. However, many of these studies have been limited by small sample sizes. In our study, the two groups exhibited significant heterogeneity in certain characteristics, particularly the absence of vascular resection in the RPD cohort. To address this, we employed propensity score matching (PSM), facilitating a balanced comparison and robust evaluation of outcomes reflective of real-world practices. In addition, excluding conversion cases—associated with worsened outcomes—more clearly highlights the advantages of RPD (Table S1), including reduced CR-PF rates and fewer major complications, reinforcing its clinical benefits over OPD.
The most noteworthy findings are that patients undergoing RPD experienced significant reductions in CR-PF rates and total hospital length of stay. ICU stay and overall complication rates did not differ significantly between the RPD and OPD groups. One potential bias to acknowledge is Japan's DPC/PDPS (Diagnosis Procedure Combination/Per-Diem Payment System), which reimburses hospitals with a fixed daily amount rather than a lump sum per admission. This creates an incentive to maintain longer hospital stays to avoid financial losses. In contrast, the American DRG/PPS (Diagnosis-Related Group/Prospective Payment System) reimburses per admission, encouraging shorter hospital stays for financial efficiency. Despite these system differences, since the discharge practice applies to both cohorts in the present study, the comparison remains valid. Moreover, the time to adjuvant chemotherapy after the Whipple procedure is an important factor in evaluating postoperative recovery and oncologic outcomes [35]. Given the observed reduction in total hospital length of stay, the faster recovery associated with RPD may facilitate earlier initiation of adjuvant chemotherapy, potentially contributing to improved long-term survival.
Reported CR-PF rates vary widely due to differences in study design, duration, and procedural parameters. The global incidence of postoperative pancreatic fistula (POPF) ranges from 3 to 41% [36, 37]. Despite this variability, our standardized approach yielded a CR-PF rate of 10% after PSM, supporting our hypothesis. The lower incidence of CR-PF in RPD may be due to the robotic platform’s precise dissection capabilities, improved visualization, and enhanced dexterity, which reduce tissue trauma and infection risk [6, 8].
A major strength of our study is that all procedures were performed under the mentorship of a single senior surgeon who had surpassed the learning curve, ensuring consistency in technique and postoperative care. While RPD is not yet universally recognized as the gold standard, our findings indicate that it has the potential to become a preferred approach in high-volume centers with experienced teams. We also analyzed the learning curve based on team performance. The mean number of cases to proficiency was 18 for RPDs and 20 for robotic PJs, which is lower than previously reported [38, 39]. These findings highlight that beyond individual surgical proficiency, standardizing team performance plays a crucial role in efficiently overcoming the learning curve.
Another notable finding is our direct cost comparison of RPD and OPD in a single high-volume referral center in Japan. As expected, operating room costs were higher for RPD. However, in-hospital total charges did not significantly differ between the cohorts. This equivalence is largely due to the shorter hospital stays for RPD patients. While our findings are significant within Japan’s cost-sharing healthcare system, the present analysis is based on direct costs and may serve as a model applicable to other healthcare systems. This could support efficient hospital management practices internationally. However, it is important to distinguish between costs (actual resource consumption) and charges (insurance reimbursements). Equivalent charges with higher costs may imply revenue loss for the hospital. Therefore, our results should not be interpreted as proof of "cost-effectiveness." Further value-based analyses, such as evaluations of complication rates, patient outcomes, and societal impact (e.g., earlier return to work), are needed to fully understand the economic implications. Previous studies have highlighted the importance of these factors in assessing the broader value of robotic surgery [40].
Despite the limitations of our retrospective design, our study provides valuable insights. Achieving the level of evidence from ongoing randomized controlled trials (RCTs) remains challenging [41‐43]. In experienced centers, the benefits of robotic surgery are well-recognized, making it ethically difficult to assign frail patients to OPD within an RCT framework. Our cost analysis, however, comprehensively includes personnel costs, robot depreciation, maintenance fees, and utilities, providing a thorough evaluation of the financial implications. As surgical robotics patents expire, increased competition may lower purchase and maintenance costs [44]. A comprehensive understanding will further benefit from large, multicenter studies with standardized procedures, long-term follow-up, and careful consideration of ethical constraints.
In conclusion, this study confirms that standardized RPD can overcome the challenges of this complex procedure, particularly by reducing CR-PF rates. These findings challenge the belief that RPD is inherently more expensive than OPD. In high-volume centers with standardized management, RPD offers significant clinical benefits at comparable costs. Further studies with larger cohorts are necessary to explore the economic, quality, and efficiency aspects across different healthcare systems.
Declarations
Disclosures
Taiga Wakabayashi, Federico Gaudenzi, Yusuke Nie, Kohei Mishima, Yoshiki Fujiyama, Kazuharu Igarashi, Yu Teshigahara, Sho Mineta, Emre Bozkurt, Go Wakabayashi have no conflicts of interest or financial ties to disclose.
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