Study Assesses Cost Differences for Robot- vs Video-Assisted Thoracoscopic Surgery in Lung Cancer

Researchers took both the learning curve of the new process and the COVID-19 pandemic into consideration.

A new cost analysis found some evidence that the initial increased costs associated with robot-assisted thoracoscopic surgery (RATS) lung resection may be gradually offset as a program progresses.

Findings were published in Frontiers in Surgery.

“In the 1990s, video-assisted thoracoscopic surgery (VATS) was introduced and became the standard surgical approach offered for the treatment of early-stage lung cancer,” authors wrote.

However, over the last 2 decades, RATS has entered the thoracic surgical practice and several studies have shown this process may have benefits over VATS. These include better lymph node dissection, less blood loss, higher complete resection rate, lower conversion rate, less postoperative complications, and better quality of life.

Still, concerns remain about the increased cost of RATS compared with VATS.

“Due to a lack of randomized trials, there is still an open debate regarding the best and most cost-effective minimally invasive approach in the treatment of lung neoplasms,” the researchers explained.

To better understand the impact of the learning curve on the cost-effectiveness of RATS vs VATS lung resection and analyze the impact of the COVID-19 pandemic on postoperative costs in patients with minimally invasive lung cancer surgery, the investigators assessed 365 consecutive RATS lung resections. They noted that their center is the highest-volume thoracic unit for lung cancer resection in the UK National Health Service.

Of the 365 consecutive RATS lung resections included in this analysis, 36.2% were male patients, and the median age was 71 years. Nearly 98% of patients underwent an anatomical lung resection. All patients underwent RATS between January 2017 and December 2020.

The researchers also analyzed a matched cohort of VATS cases. To assess the learning curve, they compared the first 100 and most recent 100 RATS cases performed at their institution.

Analyses revealed:

  • Median cost per procedure was £7167 ($8944.42) and theatre cost accounted for 70%
  • Major contributing factors to overall cost were operative time and postoperative length of stay
  • Cost per case was £640 ($798.72) less after passing the learning curve (P < .001) largely due to reduced operative time
  • Comparison of a post–learning curve RATS subgroup matched to 101 VATS cases revealed no significant difference in theatre costs between the 2 techniques
  • Overall cost of RATS lung resections performed before and during the COVID-19 pandemic were not significantly different
  • Theatre costs were significantly cheaper (£620 [$773.64]/case; P < .001) and postoperative costs were significantly more expensive (£1221 [$1523.56]/case; P = .018) during the pandemic

Median operating time was 127 minutes for patients undergoing RATS. Just 6 patients required a blood transfusion, and 19 patients required an unplanned intensive care unit admission.

“Passing the learning curve is associated with a significant reduction in the theatre costs associated with RATS lung resection and is comparable with the cost of VATS,” the authors wrote.

However, they noted the current analysis may underestimate the true cost benefit of passing the learning curve thanks to the effect of the pandemic on theatre costs.

“The COVID-19 pandemic made RATS lung resection more expensive due to prolonged hospital stay and increased readmission rate,” researchers wrote.

This study is the first to their knowledge that demonstrates the effect of the learning curve on cost of RATS lung resection.

The observational study included a disproportionately high number of robotic procedures performed during the COVID-19 pandemic, which may have introduced bias and marks a limitation.

“In conclusion, prior to passing the learning curve, RATS lung resection is associated with increased average procedure cost. When the learning curve is passed, theatre costs become significantly lower and are comparable with VATS,” the researchers wrote. “The true postoperative costs of RATS surgery may be similar or even lower than VATS; however, further studies are required to elucidate this.”


Harrison OJ, Maraschi A, Routledge T, Lampridis S, LeReun C, Bille A. A cost analysis of robotic vs. video-assisted thoracic surgery: the impact of the learning curve and the COVID-19 pandemic. Front Surg. Published online April 25, 2023. doi:10.3389/fsurg.2023.1123329

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