PRECISION PROSTATECTOMY Robot-assisted prostatectomy is a cleaner, safer, more pleasant operation than open radical prostatectomy.

Robotic surgery has had a major impact on the surgical management of prostate cancer in the United States. A new study found that more surgeons are performing their prostatectomies robotically. Authors of the study, published in BJU International, looked at the cases of nearly 490,000 men who had their prostates removed between 2003 and 2010. During that time, researchers say that there was a dramatic increase in the number of U.S. surgeons who did at least half of their prostate removals with robotic help, from 0.7% in 2003 to 42% by 2010.

However, during that time, the actual number of surgeons performing prostate removals decreased from 10,000 to 8,200. The authors suggested that as more high-volume surgeons adopted the technology, those who performed only a few cases a year stopped altogether. Mani Menon, MD, director of the Vattikuti Urology Institute at Henry Ford Health System in Detroit, is one such surgeon. “We did 40 consecutive cases over 10 years ago, but we had to discontinue, because insurance companies would not cover it,” he says.

Urology’s great debate
Robotically assisted radical prostatectomy, also known as RARP, aims to eliminate cancer and preserve function. It is associated with minimal bleeding, minimal pain and quick recovery.

The emerging standard for RARP is a 23-hour stay, as Elizabeth Wein, MPS, RN, CNOR, director of surgical services at St. Clare’s Health System in New Jersey explains. “The post-operative care is rather routine in these patients,” she says. “It is considered ambulatory surgery from a reimbursement standpoint, but we do keep the patients overnight.”

Robert Reiter, MD, director of the UCLA Prostate Cancer Treatment and Research Center, is one of the few doctors who will do same-day RARP. He says a patient well suited to the procedure is highly motivated to not spend a night in the hospital and to comply with post-operative instructions. He’s relatively young (40s) and his prostate cancer is in the early stages. Even at that, as an outpatient procedure RARP requires one extra pre-operative step: a magnetic resonance imaging (MRI) the day before the surgery to pinpoint the exact location of the cancer.

BELIEVER Robert Reiter, MD, of the UCLA Prostate Cancer Treatment and Research Center, is one of the few surgeons who performs same-day robotically assisted radical prostatectomy.

A few years ago, surgeons at the Mayo Clinic in Arizona performed a series of same-day RARP operations, although they’ve since stopped doing the procedure, explains Erik Castle, MD, director of urologic research. “The reason we were doing it is because so many people looked so good the morning after surgery that there didn’t seem to be a real need for them to stay in the hospital,” he says. The facility’s protocol was to limit the same-day option to only the first case of the day; all other cases had to stay overnight.

Dr. Castle notes a few barriers to getting wider acceptance of same-day RARP:

• Getting patients and their families comfortable with the concept. “A patient who would feel more comfortable being in the hospital would not be a good candidate,” he says.
• The surgical and post-operative care teams must also buy into the concept. “They have to be primed for it,” says Dr. Castle.
• Medicare requires a full hospital admission to reimburse for the procedure. That meant after recovery, patients went onto the floor, where a nurse had to admit them — a process that takes an hour or so; then a few hours later, the same nurses had to process a full discharge. It became a logistical nuisance for the floor nurses, says Dr. Castle.

“From a purely medical need and feasibility standpoint, same-day robotic-assisted radical prostatectomy is very easy to perform,” says Dr. Castle. “As far as procedural issues and dealing with paperwork — that’s the challenge.”

Post-operative challenges
One challenge to sending these patients home so early is management of the Foley catheter. “You have to look at the potential complication rate of sending a patient home with a Foley catheter, but it’s not just any Foley catheter: it’s holding together the anastomosis,” says Rajesh Laungani, MD, a high-volume urological surgeon in Atlanta. “It plays a huge role in healing and maintaining good urine output, to make sure the wound is draining well and to make sure it doesn’t cause post-operative bowel issues. These are all things we monitor during that 24-hour hospital stay.”

On top of that, the center has to have contingencies for an intraoperative or post-operative emergency. “If a patient has acute bleeding, that’s a life-and-death situation; and you have to have the ability in surgery to convert to an open procedure,” says Dr. Laungani. “One complication in an outpatient setting could be disastrous.”

Besides the hurdles of patient care, other logistical issues must be resolved before RARP can be a truly common, same-day procedure. Robotic procedures require longer operative and turnaround times than non-robotic laparoscopic surgery, and finding skilled physicians and OR staff can be a challenge, according to Lori-Lynne A. Webb, CPC, an independent coding specialist who’s lectured on robotic surgery. Also, as Dr. Laungani points out, “Having a patient sit in a recovery room for 6 hours is not productive for an ASC.”

The da Vinci surgical robot, the standard equipment for RARP, costs up to $2 million to purchase, and then needs a dedicated surgical suite. On top of that comes the maintenance contract, which can run another $200,000 a year. The costs of disposables can add up to $250 per case as well. “All the money a surgery center makes on gall bladders would go to the cost of a robot,” says Dr. Laungani.

To justify the investment, the procedure needs to turn a profit. At Emory St. Joseph’s Hospital in Atlanta, Dr. Laungani has calculated it takes 269 RARP cases a year to turn a profit. In his facility, the cost of RARP is about $14,000 compared to $17,000 for an open radical prostatectomy. However, in many facilities, RARP is more expensive than open surgery.

Yet payers don’t reimburse robot-assisted surgery at a higher rate. At one time, plans covered robotic surgery with an add-on code, but that changed about 7 years ago, says Julie Kessel, MD, senior medical director for coverage policies at Cigna. “We decided that because the robotic approach was now a widely accepted standard in surgery, we would no longer consider separate reimbursement for it,” she says. “We came to consider the robotic assist integral to the surgery itself,” a determination she says is typical among commercial payers. Medicare employs a similar reimbursement policy: no premium for robotic assist, says Ms. Webb.

Hospitals have an internal conflict when it comes to embracing same-day robot-assisted surgery. “Hospitals are incentivized to bill out the highest level of care while getting the patient out the door as quickly as possible,” says Ms. Webb. For hospitals, the highest level of care includes an overnight admission.