Robot-assisted Versus Open Radical Cystectomy in Bladder Cancer: An Economic Evaluation Alongside a Multicentre Comparative Effectiveness Study



      Open radical cystectomy (ORC) is regarded as the standard treatment for muscle-invasive bladder cancer, but robot-assisted radical cystectomy (RARC) is increasingly used in practice. A recent study showed that RARC resulted in slightly fewer minor but slightly more major complications, although the difference was not statistically significant. Some differences were found in secondary outcomes favouring either RARC or ORC. RARC use is expected to increase in coming years, which fuels the debate about whether RARC provides value for money.


      To assess the cost-effectiveness of RARC compared to ORC in bladder cancer.

      Design, setting, and participants

      This economic evaluation was performed alongside a prospective multicentre comparative effectiveness study. We included 348 bladder cancer patients (ORC, n = 168; RARC, n = 180) from 19 Dutch hospitals.

      Outcome measurements and statistical analysis

      Over 1 yr, we assessed the incremental cost per quality-adjusted life year (QALY) gained from both healthcare and societal perspectives. We used single imputation nested in the bootstrap percentile method to assess missing data and uncertainty, and inverse probability of treatment weighting to control for potential bias. Deterministic sensitivity analyses were performed to explore the impact of various parameters on the cost difference.

      Results and limitations

      The mean healthcare cost per patient was €17 141 (95% confidence interval [CI] €15 791–€18 720) for ORC and €21 266 (95% CI €19 163–€23 650) for RARC. The mean societal cost per patient was €18 926 (95% CI €17 431–€22 642) for ORC and €24 896 (95% CI €21 925–€31 888) for RARC. On average, RARC patients gained 0.79 QALYs (95% CI 0.74–0.85) compared to 0.81 QALYs (95% CI 0.77–0.85) for ORC patients, resulting in a mean QALY difference of −0.02 (95% CI −0.05 to 0.02). Using a cost-effectiveness threshold of €80 000, RARC was cost-effective in 0.6% and 0.2% of the replications for the healthcare and societal perspectives, respectively.


      RARC shows no difference in terms of QALYs, but is more expensive than ORC. Hence, RARC does not seem to provide value for money in comparison to ORC.

      Patient summary

      This study assessed the relation between costs and effects of robot-assisted surgery compared to open surgery for removal of the bladder in 348 Dutch patients with bladder cancer. We found that after 1 year, the two approaches were similarly effective according to a measure called quality-adjusted life years, but robot-assisted surgery was much more expensive.
      This trial was prospectively registered in the Netherlands Trial Register as NTR5362 (


      To read this article in full you will need to make a payment


        • Witjes J.A.
        • Bruins H.M.
        • Cathomas R.
        • et al.
        EAU guidelines on muscle-invasive and metastatic bladder cancer.
        European Association of Urology, Arnhem, The Netherlands2020
        • Novara G.
        • Catto J.W.
        • Wilson T.
        • et al.
        Systematic review and cumulative analysis of perioperative outcomes and complications after robot-assisted radical cystectomy.
        Eur Urol. 2015; 67: 376-401
        • Satkunasivam R.
        • Tallman C.T.
        • Taylor J.M.
        • Miles B.J.
        • Klaassen Z.
        • Wallis C.J.D.
        Robot-assisted radical cystectomy versus open radical cystectomy: a meta-analysis of oncologic, perioperative, and complication-related outcomes.
        Eur Urol Oncol. 2019; 2: 443-447
        • Yuh B.
        • Wilson T.
        • Bochner B.
        • et al.
        Systematic review and cumulative analysis of oncologic and functional outcomes after robot-assisted radical cystectomy.
        Eur Urol. 2015; 67: 402-422
        • Wijburg C.J.
        • Michels C.T.J.
        • Hannink G.
        • et al.
        Robot-assisted radical cystectomy versus open radical cystectomy in bladder cancer patients: a multicentre comparative effectiveness study.
        Eur Urol. 2021; 79: 609-618
        • Husereau D.
        • Drummond M.
        • Petrou S.
        • et al.
        Consolidated Health Economic Evaluation Reporting Standards (CHEERS) statement.
        BMJ. 2013; 346: f1049
        • Wijburg C.J.
        • Michels C.T.J.
        • Oddens J.R.
        • Grutters J.P.C.
        • Witjes J.A.
        • Rovers M.M.
        Robot assisted radical cystectomy versus open radical cystectomy in bladder cancer (RACE): study protocol of a non-randomized comparative effectiveness study.
        BMC Cancer. 2018; 18: 861
        • Dindo D.
        • Demartines N.
        • Clavien P.A.
        Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey.
        Ann Surg. 2004; 240: 205-213
        • Herdman M.
        • Gudex C.
        • Lloyd A.
        • et al.
        Development and preliminary testing of the new five-level version of EQ-5D (EQ-5D-5L).
        Qual Life Res. 2011; 20: 1727-1736
        • Versteegh M.M.
        • Vermeulen K.M.
        • Evers S.M.A.A.
        • de Wit G.A.
        • Prenger R.
        • Stolk E.A.
        Dutch tariff for the five-level version of EQ-5D.
        Value Health. 2016; 19: 343-352
        • Drummond M.F.
        • Drummond M.F.
        • Sculpher M.J.
        • Torrance G.W.
        • O’Brien B.J.
        • Stoddart G.L.
        Methods for the economic evaluation of health care programmes.
        Oxford University Press, Oxford, UK2005
        • Hakkaart-van Roijen L.
        • Van der Linden N.
        • Bouwmans C.
        • Kanters T.
        • Tan S.S.
        Costing manual: methodology of research costs and reference prices for economic evaluations in health care.
        Zorginstituut Nederland, Diemen, The Netherlands2016
        • Bouwmans C.
        • Hakkaart-van Roijen L.
        • Koopmanschap M.
        • Krol M.
        • Severens H.
        • Brouwer W.
        Instruction manual: iMTA Medical Consumption Questionnaire (iMTA MCQ).
        Institute for Medical Technology Assessment, Erasmus Universiteit, Rotterdam, The Netherlands2013
        • Bouwmans C.
        • Krol M.
        • Severens H.
        • Koopmanschap M.
        • Brouwer W.
        • Hakkaart-van Roijen L.
        The iMTA productivity cost questionnaire: a standardized instrument for measuring and valuing health-related productivity losses.
        Value Health. 2015; 18: 753-758
        • Intuitive Surgical Inc
        Expert opinion from the clinical sales representative for The Netherlands.
      1. Zorginstituut Nederland. Farmacotherapeutisch Kompas.

      2. Nederlandse Zorgautoriteit. NZa zorgproductapplicatie.

      3. Centraal Bureau voor Statistiek. Prijsindexcijfers consumentenprijzen:

        • Ramsey S.D.
        • Willke R.J.
        • Glick H.
        • et al.
        Cost-effectiveness analysis alongside clinical trials II—an ISPOR Good Research Practices Task Force report.
        Value Health. 2015; 18: 161-172
        • Brand J.
        • van Buuren S.
        • le Cessie S.
        • van den Hout W.
        Combining multiple imputation and bootstrap in the analysis of cost-effectiveness trial data.
        Stat Med. 2019; 38: 210-220
        • Austin P.C.
        An introduction to propensity score methods for reducing the effects of confounding in observational studies.
        Multivariate Behav Res. 2011; 46: 399-424
        • Briggs A.H.
        • Weinstein M.C.
        • Fenwick E.A.
        • Karnon J.
        • Sculpher M.J.
        • Paltiel A.D.
        Model parameter estimation and uncertainty: a report of the ISPOR-SMDM Modeling Good Research Practices Task Force-6.
        Value Health. 2012; 15: 835-842
        • Bansal S.S.
        • Dogra T.
        • Smith P.W.
        • et al.
        Cost analysis of open radical cystectomy versus robot-assisted radical cystectomy.
        BJU Int. 2018; 121: 437-444
        • Bochner B.H.
        • Dalbagni G.
        • Sjoberg D.D.
        • et al.
        Comparing open radical cystectomy and robot-assisted laparoscopic radical cystectomy: a randomized clinical trial.
        Eur Urol. 2015; 67: 1042-1050
        • Hu J.C.
        • Chughtai B.
        • O’Malley P.
        • et al.
        Perioperative outcomes, health care costs, and survival after robotic-assisted versus open radical cystectomy: a national comparative effectiveness study.
        Eur Urol. 2016; 70: 195-202
        • Kukreja J.B.
        • Metcalfe M.J.
        • Qiao W.
        • Kamat A.M.
        • Dinney C.P.N.
        • Navai N.
        Cost-effectiveness of robot-assisted radical cystectomy using a propensity-matched cohort.
        Eur Urol Focus. 2020; 6: 88-94
        • Michels C.T.J.
        • Wijburg C.J.
        • Leijte E.
        • Witjes J.A.
        • Rovers M.M.
        • Grutters J.P.C.
        A cost-effectiveness modeling study of robot-assisted (RARC) versus open radical cystectomy (ORC) for bladder cancer to inform future research.
        Eur Urol Focus. 2019; 5: 1058-1065
        • Yu H.Y.
        • Hevelone N.D.
        • Lipsitz S.R.
        • et al.
        Comparative analysis of outcomes and costs following open radical cystectomy versus robot-assisted laparoscopic radical cystectomy: results from the US Nationwide Inpatient Sample.
        Eur Urol. 2012; 61: 1239-1244
        • van der Poel H.
        • de Jong I.-J.
        Werkgroep oncologische urologie van de NVU. Jaarverslag cystectomieregistratie NVU 2017.
        Tijdschr Urol. 2019; 9: 56-67
      4. ZonMw. Budget Impact Analyses in de praktijk: Leidraad en rekentool.

        • Abrishami P.
        • Boer A.
        • Horstman K.
        When the evidence basis breeds controversies: exploring the value profile of robotic surgery beyond the early introduction phase.
        Med Care Res Rev. 2020; 77: 596-608