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Cost-effectiveness of robot-assisted radical cystectomy vs open radical cystectomy for patients with bladder cancer

  • Simon Dixon,
  • Harry Hill,
  • Laura Flight,
  • Pramit Khetrapal,
  • Gareth Ambler,
  • Norman R. Williams,
  • Chris Brew-Graves,
  • John D. Kelly,
  • James W. F. Catto,
  • for the iROC Study Team


The value to payers of robot-assisted radical cystectomy with intracorporeal urinary diversion (iRARC) when compared with open radical cystectomy (ORC) for patients with bladder cancer is unclear.


To compare the cost-effectiveness of iRARC with that of ORC.

Design, Setting, and Participants

This economic evaluation used individual patient data from a randomized clinical trial at 9 surgical centers in the United Kingdom. Patients with nonmetastatic bladder cancer were recruited from March 20, 2017, to January 29, 2020. The analysis used a health service perspective and a 90-day time horizon, with supplementary analyses exploring patient benefits up to 1 year. Deterministic and probabilistic sensitivity analyses were undertaken. Data were analyzed from January 13, 2022, to March 10, 2023.


Patients were randomized to receive either iRARC (n = 169) or ORC (n = 169).

Main Outcomes and Measures

Costs of surgery were calculated using surgery timings and equipment costs, with other hospital data based on counts of activity. Quality-adjusted life-years were calculated from European Quality of Life 5-Dimension 5-Level instrument responses. Prespecified subgroup analyses were undertaken based on patient characteristics and type of diversion.


A total of 305 patients with available outcome data were included in the analysis, with a mean (SD) age of 68.3 (8.1) years, and of whom 241 (79.0%) were men. Robot-assisted radical cystectomy was associated with statistically significant reductions in admissions to intensive therapy (6.35% [95% CI, 0.42%-12.28%]), and readmissions to hospital (14.56% [95% CI, 5.00%-24.11%]), but increases in theater time (31.35 [95% CI, 13.67-49.02] minutes). The additional cost of iRARC per patient was £1124 (95% CI, −£576 to £2824 [US $1622 (95% CI, −$831 to $4075)]) with an associated gain in quality-adjusted life-years of 0.01124 (95% CI, 0.00391-0.01857). The incremental cost-effectiveness ratio was £100 008 (US $144 312) per quality-adjusted life-year gained. Robot-assisted radical cystectomy had a much higher probability of being cost-effective for subgroups defined by age, tumor stage, and performance status.

Conclusions and Relevance

In this economic evaluation of surgery for patients with bladder cancer, iRARC reduced short-term morbidity and some associated costs. While the resulting cost-effectiveness ratio was in excess of thresholds used by many publicly funded health systems, patient subgroups were identified for which iRARC had a high probability of being cost-effective.

Trial Registration

ClinicalTrials.gov Identifier: NCT03049410

Commentary by Dr. Francesco Del Giudice

Muscle-invasive bladder cancer (MIBC) is a significant health concern worldwide, with a substantial number of cases eligible for radical interventions such as perioperative systemic regimens followed by radical cystectomy (RC). While robot-assisted radical cystectomy (RARC) has shown promising perspectives in reducing morbidity associated with the procedure, its cost-effectiveness compared to open radical cystectomy (ORC) has been unclear with low level of evidence (LE) supporting the superiority of one approach over the other. In this secondary analysis from the Intracorporeal Robot-Assisted Radical Cystectomy vs Open Radical Cystectomy (iROC) trial, Dixon et al. [1] conducted a comprehensive cost-effectiveness analysis to evaluate the economic implications of RARC for patients with MIBC who are eligible for curative interventions.

The impact of the economic assessment of this secondary analysis is of paramount importance as it sheds light on the financial implications of implementing RARC for patients with MIBC eligible for curative interventions. The value of the findings is timely due to the need for informed decisions on allocating resources and funding treatments in the race for technological exploit in a competitive oncological environment. Understanding the cost-effectiveness of RARC may ultimately lead the training and healthcare orientation towards a challenging yet significantly less invasive surgical procedure. Thus, the growing emphasis on efficient allocation of healthcare resources could translate to tangible value-based care improvement. This article explores the methodology and results presented by Dixon and colleagues in detail.

iROC trial is a multicentre, randomised clinical trial conducted in the UK from March 2017 to January 2020 [2]. The trial’s primary objective was to specifically investigate the effects of RARC and ORC on patient recovery outcomes. According to its original publication, patients with nonmetastatic urothelial or variant histology MIBC were eligible for recruitment. In total, n=317 underwent RC (n=169 in the RARC group and n=169 in the ORC group). The primary analysis focused on a time horizon of 90 days post-surgery to align with available trial evidence, while secondary analyses projected patient recovery up to 180, 270, and 360 days.

The cost-effectiveness analysis focused on quality-adjusted life-years (QALYs) based on patient responses to the EQ-5D-5L questionnaire. Cost data were collected from various sources, which included equipment costs, theatre time, ward stay, and postoperative care.

The results of this specific economic evaluation indicated that RARC incurred higher costs per procedure compared to ORC. The additional cost of RARC was primarily driven by the expenses associated with robotic equipment. Specifically, the cost of the surgical robot, including its purchase, maintenance, simulator, instruments, and staff training, amounted to £2,638 per patient. In contrast, the equipment costs for ORC were estimated to be £1,514 per patient.

Despite the higher upfront costs of RARC, the analysis revealed certain advantages of the robotic approach. Patients who underwent RARC had 6.35% fewer admissions to intensive therapy units and 14.56% fewer readmissions to the hospital after discharge compared to patients who underwent ORC. While the differences in ward days and admissions to high-dependency care were not statistically significant, there were trends suggesting potential benefits associated with RARC which included reduction in the length of hospital stay.

The incremental cost-effectiveness ratio (ICER), which represents the additional cost per QALY gained with RARC compared to ORC, was calculated to be £100,008 per QALY gained. This ICER indicates that the cost of gaining one additional QALY with RARC compared to ORC exceeded the usual funding thresholds commonly used by publicly funded health systems in the UK. Typically, a threshold of £20,000 per QALY gained is indeed considered acceptable for cost-effective interventions.

At sensitivity analysis, shorter surgical times for RARC compared to the observed times in the study had a significant impact on the ICER. A 10% reduction in surgical times rendered RARC dominant and increased the probability of cost-effectiveness to 61.9% at a threshold of £20,000 per QALY gained. On the other hand, changes in robot life expectancy and throughput had only a marginal role on the ICER, similarly to lower ward costs which resulted in only minimal influence. This means that reducing surgical times and optimising cost components could enhance the cost-effectiveness of RARC in the future.

More interestingly were the results from cost-effectiveness of RARC among patients older than 70 years: those with more locally advance disease (i.e., ≥pT3) and those with a worse performance status (i.e., 0 vs 1 or greater on the ECOG Performance Status Scale). The probabilities of RARC being cost-effective at the £20,000 per QALY threshold were 82.2%, 77.6%, and 84.7%, respectively. Furthermore, moderate improvements in cost-effectiveness were observed in patients undergoing an ileal conduit diversion, with an ICER of £58,101 per QALY gained and a probability of cost-effectiveness of 32.9%. Similarly, patients with a body mass index (BMI) of 25 or above had an ICER of £66,656 per QALY gained and a probability of cost-effectiveness of 34.1%.

While the study provided valuable insights into the cost-effectiveness of RARC, several limitations should be considered. The short follow-up period of 90 days may have underestimated the full health benefits of RARC. Generalizability beyond the UK may also be limited due to variations in cost structures and surgical practices in different healthcare systems. Additionally, the funding thresholds used in the analysis may not be applicable to other countries.

In conclusion, this study contributes to our understanding of the cost-effectiveness of RARC compared to ORC for bladder cancer (BCa) treatment. Although RARC demonstrated advantages in terms of reduced morbidity, the higher costs associated with robotic equipment resulted in an ICER that exceeded typical funding thresholds. However, patient subgroups were identified for whom RARC may be more cost-effective. Future research should further investigate these subgroups and assess the economic implications in different healthcare settings. Moreover, evaluating long-term outcomes and patient-reported outcome measures would enhance our understanding of the overall value of RARC in BCa treatment.


  1. Dixon S, Hill H, Flight L, Khetrapal P, Ambler G, Williams NR, Brew-Graves C, Kelly JD, Catto JWF; iROC Study Team. Cost-Effectiveness of Robot-Assisted Radical Cystectomy vs Open Radical Cystectomy for Patients With Bladder Cancer. JAMA Netw Open. 2023 Jun 1;6(6):e2317255. doi: 10.1001/jamanetworkopen.2023.17255. PMID: 37389878; PMCID: PMC10314306.
  2. Catto JWF, Khetrapal P, Ricciardi F, Ambler G, Williams NR, Al-Hammouri T, Khan MS, Thurairaja R, Nair R, Feber A, Dixon S, Nathan S, Briggs T, Sridhar A, Ahmad I, Bhatt J, Charlesworth P, Blick C, Cumberbatch MG, Hussain SA, Kotwal S, Koupparis A, McGrath J, Noon AP, Rowe E, Vasdev N, Hanchanale V, Hagan D, Brew-Graves C, Kelly JD; iROC Study Team. Effect of Robot-Assisted Radical Cystectomy With Intracorporeal Urinary Diversion vs Open Radical Cystectomy on 90-Day Morbidity and Mortality Among Patients With Bladder Cancer: A Randomized Clinical Trial. JAMA. 2022 Jun 7;327(21):2092-2103. doi: 10.1001/jama.2022.7393. PMID: 35569079; PMCID: PMC9109000.