Background: Robotic surgery is increasingly used to resect lung cancer. However costs are high. We compared costs and outcomes for robotic surgery, video-assisted thoracic surgery (VATS), and open surgery, to treat non-small cell lung cancer (NSCLC). Methods: We retrospectively assessed 103 consecutive patients given lobectomy or segmentectomy for clinical stage I or II NSCLC. Three surgeons could choose VATS or open, the fourth could choose between all three techniques. Between-group differences were assessed by Fisher’s exact, two-way analysis of variance (ANOVA), and Wilcoxon-Mann-Whitney test. P values <0.05 were considered significant. Results: Twenty-three patients were treated by robot, 41 by VATS, and 39 by open surgery. Age, physical status, pulmonary function, comorbidities, stage, and perioperative complications did not differ between the groups. Pathological tumor size was greater in the open than VATS and robotic groups (P=0.025). Duration of surgery was 150, 191 and 116 minutes, by robotic, VATS and open approaches, respectively (P<0.001). Significantly more lymph node stations were removed (P<0.001), and median length of stay was shorter (4, 5 and 6 days, respectively; P<0.001) in the robotic than VATS and open groups. Estimated costs were 82%, 68% and 69%, respectively, of the regional health service reimbursement for robotic, VATS and open approaches. Discussion: Robotic surgery for early lung cancer was associated with shorter stay and more extensive lymph node dissection than VATS and open surgery. Duration of surgery was shorter for robotic than VATS. Although the cost of robotic thoracic surgery is high, the hospital makes a profit.

We investigated predictive factors of failure and performed a resource consumption analysis in patients who underwent active surveillance for nonmuscle invasive bladder cancer. This prospective observational study monitored patients with a history of pathologically confirmed stage pTa (grade 1-2) or pT1a (grade 2) nonmuscle invasive bladder cancer, and recurrent small size and number of tumors without hematuria and positive urine cytology. The primary end point was the failure rate of active surveillance. Assessment of failure predictive variables and per year direct hospital resource consumption analysis were secondary outcomes. Descriptive statistical analysis and Cox regression with univariable and multivariable analysis were done. Of 625 patients with nonmuscle invasive bladder cancer 122 with a total of 146 active surveillance events were included in the protocol. Of the events 59 (40.4%) were deemed to require treatment after entering active surveillance. Median time on active surveillance was 11 months (IQR 5-26). Currently 76 patients (62.3%) remain under observation. On univariable analysis only time from the first transurethral resection to the start of active surveillance seemed to be inversely associated with recurrence-free survival (HR 0.99, 95% CI 0.98-1.00, p = 0.027). Multivariable analysis also revealed an association with age at active surveillance start (HR 0.97, 95% CI 0.94-1.00, p = 0.031) and the size of the lesion at the first transurethral resection (HR 1.55, 95% CI 1.06-2.27, p = 0.025). The average specific annual resource consumption savings for each avoided transurethral bladder tumor resection was €1,378 for each intervention avoided. Active surveillance might be a reasonable clinical and cost-effective strategy in patients who present with small, low grade pTa/pT1a recurrent papillary bladder tumors.

Background: Bariatric surgery is the most effective treatment for patients affected by morbid obesity. The Enhanced Recovery After Surgery (ERAS) protocol increases clinical outcomes, but the most recent literature shows incomplete patients’ adherence. This study aims to demonstrate the feasibility of applying a Value-Based Healthcare (VBHC) strategy associated with ERAS to increase patients’ engagement and outcomes. Method: A multiprofessional team redesigned the process considering ERAS recommendations and patients’ feedbacks. Outcomes that matter to patients were defined with structured patients’ interviews and collected in the electronic clinical record. Adherence to the pathway and the cost of the cycle of care were measured to demonstrate sustainability. A model was developed to grant its replicability. Results: A total of 2.122 patients were included. The lowest adherence to the protocol for a single item was 82%. 74% of excess weight loss; 90% better comorbidities control; 77.5% had no pain after surgery; 61% no postoperative nausea and vomiting. Zero mortality; 1.8% overall morbidity; 0.4% readmission and reoperation rate within 30 days. The average length of stay is 2.1 days. Patient-Reported Outcome Measures (PROMs) documented increased productivity and quality of life. Conclusion: Building a caring relationship by a multidisciplinary team, adding patient wellness in a VBHC framework on top of ERAS as a patient-centered approach, increases patients’ engagement and adherence to the pathway of care, resulting in better health outcomes (clinical and PROMs). The Value-Based Model is sustainable and replicable; it represents the prototype for redesigning other pathways and may become a model for other organizations.

Use of robot-assisted techniques is growing fast in several surgical disciplines, now including thoracic surgery. The paper reviews experience of robotic surgery to resect lung cancer and in particular analyzes data on the costs of these procedures in comparison to open surgery and video-assisted thoracoscopic surgery (VATS). Retrospective studies published over 14 years show that robotic surgery for lung cancer has the advantages of minimally invasive surgery for patients, and some advantages over VATS for the surgeon. Limited data indicate that oncological outcomes are comparable with those of VATS and open surgery, while lymph node dissection may be more radical. Other studies indicate that robotic surgery for lung cancer offers no advantages either in terms of costs or outcomes. The high costs of purchase, maintenance and consumables are a concern and continue to limit uptake of robot systems in thoracic surgery. Most studies—but not all—indicate that robotic surgery for lung cancer is more expensive than VATS and open surgery. However limited data also indicate that hospitals can make a profit from robotic thoracic surgery, as costs seem to be lower than reimbursements from paying bodies. Nevertheless robotic thoracic surgery is still too expensive for many public hospitals, particularly in low income countries. Entry of new surgical robot manufacturers onto the market will bring much-needed competition that may also lead to cost reduction.