EURURO Vol. 72 No. 5

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not feasible. Established methods apply mainly to quanti-
tative meta-analyses (eg, funnel plots) or focus on
comparing trial protocols with published results
neither of which was applicable here. Finally, we assessed
the quality of the cumulative evidence according to the
Grades of Recommendation, Assessment, Development and
Evaluation approach .
3. Evidence synthesis
Many of the studies referred to in the following sections
evaluated cost effectiveness by estimating the incremental
cost effectiveness ratio (ICER), expressed as cost per quality-
adjusted life year (QALY) gained. To do this, they compare
the cost of the new technology (RARP, IMRT, or proton beam
therapy) with that of the standard treatment. Next, they
compare outcomes and express them as QALY gained—the
arithmetic product of quantity and quality of life that allows
for assessment of outcomes that affect quality of life, such as
urinary or sexual side effects of treatment . Lastly, they
calculate the ICER as the increase in cost per QALY gained. In
these analyses, an intervention with an ICER of <$50 000/
QALY is generally considered cost effective, indicating that
most experts agree that such interventions should be
implemented . However, there is considerable debate
about the $50 000 threshold as it dates back to at least
1982. Some suggest that this threshold is much too low, and
one may wish to implement treatments with higher ICERs
depending upon one’s willingness to pay . Some authors
have suggested that the ICER is country specific based on
the individual country’s gross domestic product, the
available budget for health interventions, or the country-
specific willingness to pay .
3.1. Robotic prostatectomy versus RRP
3.1.1. RARP versus RRP from the hospital’s perspective
Between 2004 and 2016, 18 studies were published
comparing the cost of RARP and RRP from the hospital’s
perspective ). Most studies were from the USA, with
two studies from Australia and one each from Canada and
Italy. The vast majority of studies (17 of 18) found an
increased cost for RARP, ranging from $195 to over $6000
more per case. Only one study found a decreased cost for
RARP, but did not adjust for patient differences that may
have accounted for this finding In fact, many studies
did not adjust cost for patient differences such as age,
comorbidity, and socioeconomic factors. RARP patients
tended to be younger and healthier than RRP patients; thus,
the increased cost of RARP was likely underestimated in
these studies. The magnitude of the increased cost for RARP
varied substantially from study to study, likely because of
different methodologies used. The most common method-
ologies included cost comparisons based on local hospital
accounting data (n = 7), use of population-based data and
cost-to-charge ratios (n = 5), and cost modeling including
institutional data and data from the literature (n = 4).
Limitations of these methodologies include the following:
(1) cost comparison based on local hospital data is not
generalizable; (2) cost-to-charge ratios likely do not lead to
an accurate estimate of cost—especially for new technolo-
gies—because they are aggregated at the hospital level and
can vary widely across hospital departments ; and (3)
cost modeling is highly dependent on assumptions that go
into the model. In addition, there was variation across
studies in whether they included or did not include the cost
of robot acquisition. Among the 11 studies that either
included local hospital accounting data or used cost
modeling, seven accounted for the cost of robot acquisition
and four did not. Nevertheless, the cumulative evidence
supports the fact that RARP is costlier than RRP for hospitals,
but the exact difference likely varies from hospital to
hospital. RARP costs appear to be lower with increasing
hospital volume and decreasing length of stay and
operating room time
3.1.2. RARP versus RRP from the payer’s perspective
There were 16 studies comparing the cost of RARP and RRP
from the payer’s perspective ). These studies
examined data from 2002 through 2014 and came from
three different countries, including the USA ( n = 14),
Germany (n = 1), and the UK (n = 1). Twelve of the 16 studies
found an increased cost for RARP, ranging from $293 to
$7797 more per case. Larger absolute differences in cost
were found in (1) studies that examined charges and
(2) studies that did not adjust for patient differences,
contributing to this wide range of estimates. Four studies
found a reduced cost for the payer when comparing RARP
with RRP. Their results were likely affected by high case
volumes for RARP , lack of adjustment for patients’
general health status and socioeconomic status , and
assumptions that went into cost modeling
There was substantial heterogeneity across studies,
likely because of variations in the methodologies. Three
of the four studies examining Medicare payments found
fairly small differences in cost to the payer between RARP
and RRP. All four studies did not take steps to adjust for
intentional differences in Medicare payments that may
have affected the results. Medicare payments vary by many
intentional factors other than the type of treatment,
including price differences based on regional wage dispar-
ities, cost of living, illness severity, and the expense of caring
for underinsured patients Hospital reimbursement by
other US health plans was examined in three studies, two of
which found significantly higher reimbursement for RARP
in adjusted analyses .
Five studies examined hospital charges. However,
charges are unlikely to be meaningful because hospitals
can freely set charge master rates. While most markups fall
into the 1.5–4 range relative to Medicare allowable cost, the
markup may be more than 10 times that cost . Finally,
three studies constructed models to estimate cost, based on
data from the literature and reimbursement rates
. Two of these studies did not perform sensitivity
analyses to test how the assumptions would affect cost from
the payer’s perspective .
In summary, from the payer’s perspective, RARP is likely
somewhat more expensive than RRP. However, RARP has
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