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Cover of Systematic Review and Economic Modelling of the Relative Clinical Benefit and Cost-Effectiveness of Laparoscopic Surgery and Robotic Surgery for Removal of the Prostate in Men with Localised Prostate Cancer

Systematic Review and Economic Modelling of the Relative Clinical Benefit and Cost-Effectiveness of Laparoscopic Surgery and Robotic Surgery for Removal of the Prostate in Men with Localised Prostate Cancer

Health Technology Assessment, No. 16.41

C Ramsay, R Pickard, C Robertson, A Close, L Vale, N Armstrong, DA Barocas, CG Eden, C Fraser, T Gurung, D Jenkinson, X Jia, TB Lam, G Mowatt, DE Neal, MC Robinson, J Royle, SP Rushton, P Sharma, MDF Shirley, and N Soomro.

Author Information

C Ramsay,1,* R Pickard,2 C Robertson,1 A Close,3 L Vale,1,4 N Armstrong,5 DA Barocas,6 CG Eden,7 C Fraser,1 T Gurung,1 D Jenkinson,1 X Jia,1 TB Lam,9 G Mowatt,1 DE Neal,10 MC Robinson,11 J Royle,8 SP Rushton,3 P Sharma,1 MDF Shirley,3 and N Soomro12.

1 Health Services Research Unit, University of Aberdeen, Aberdeen, UK
2 Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, UK
3 School of Biology, Newcastle University, Newcastle upon Tyne, UK
4 Health Economics Group, Institute of Health and Society, Newcastle University, Newcastle upon Tyne, UK
5 Kleijnen Systematic Reviews Ltd, York, UK
6 Department of Urologic Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
7 Royal Surrey County Hospital NHS Foundation Trust, Guildford, UK
8 Department of Urology, Aberdeen Royal Infirmary, Grampian NHS Trust, Aberdeen, UK
9 Academic Urology Unit, University of Aberdeen, Aberdeen, UK
10 Department of Oncology, University of Cambridge, Cambridge, UK
11 Department of Cellular Pathology, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
12 Freeman Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
* Corresponding author
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Complete surgical removal of the prostate, radical prostatectomy, is the most frequently used treatment option for men with localised prostate cancer. The use of laparoscopic (keyhole) and robot-assisted surgery has improved operative safety but the comparative effectiveness and cost-effectiveness of these options remains uncertain.


This study aimed to determine the relative clinical effectiveness and cost-effectiveness of robotic radical prostatectomy compared with laparoscopic radical prostatectomy in the treatment of localised prostate cancer within the UK NHS.

Data sources:

MEDLINE, MEDLINE In-Process & Other Non-Indexed Citations, EMBASE, BIOSIS, Science Citation Index and Cochrane Central Register of Controlled Trials were searched from January 1995 until October 2010 for primary studies. Conference abstracts from meetings of the European, American and British Urological Associations were also searched. Costs were obtained from NHS sources and the manufacturer of the robotic system. Economic model parameters and distributions not obtained in the systematic review were derived from other literature sources and an advisory expert panel.

Review methods:

Evidence was considered from randomised controlled trials (RCTs) and non-randomised comparative studies of men with clinically localised prostate cancer (cT1 or cT2); outcome measures included adverse events, cancer related, functional, patient driven and descriptors of care. Two reviewers abstracted data and assessed the risk of bias of the included studies. For meta-analyses, a Bayesian indirect mixed-treatment comparison was used. Cost-effectiveness was assessed using a discrete-event simulation model.


The searches identified 2722 potentially relevant titles and abstracts, from which 914 reports were selected for full-text eligibility screening. Of these, data were included from 19,064 patients across one RCT and 57 non-randomised comparative studies, with very few studies considered at low risk of bias. The results of this study, although associated with some uncertainty, demonstrated that the outcomes were generally better for robotic than for laparoscopic surgery for major adverse events such as blood transfusion and organ injury rates and for rate of failure to remove the cancer (positive margin) (odds ratio 0.69; 95% credible interval 0.51 to 0.96; probability outcome favours robotic prostatectomy = 0.987). The predicted probability of a positive margin was 17.6% following robotic prostatectomy compared with 23.6% for laparoscopic prostatectomy. Restriction of the meta-analysis to studies at low risk of bias did not change the direction of effect but did decrease the precision of the effect size. There was no evidence of differences in cancer-related, patient-driven or dysfunction outcomes. The results of the economic evaluation suggested that when the difference in positive margins is equivalent to the estimates in the meta-analysis of all included studies, robotic radical prostatectomy was on average associated with an incremental cost per quality-adjusted life-year that is less than threshold values typically adopted by the NHS (£30,000) and becomes further reduced when the surgical capacity is high.


The main limitations were the quantity and quality of the data available on cancer-related outcomes and dysfunction.


This study demonstrated that robotic prostatectomy had lower perioperative morbidity and a reduced risk of a positive surgical margin compared with laparoscopic prostatectomy although there was considerable uncertainty. Robotic prostatectomy will always be more costly to the NHS because of the fixed capital and maintenance charges for the robotic system. Our modelling showed that this excess cost can be reduced if capital costs of equipment are minimised and by maintaining a high case volume for each robotic system of at least 100–150 procedures per year. This finding was primarily driven by a difference in positive margin rate. There is a need for further research to establish how positive margin rates impact on long-term outcomes.


The National Institute for Health Research Health Technology Assessment programme.


Suggested citation:

Ramsay C, Pickard R, Robertson C, Close A, Vale L, Armstrong N, et al. Systematic review and economic modelling of the relative clinical benefit and cost-effectiveness of laparoscopic surgery and robotic surgery for removal of the prostate in men with localised prostate cancer. Health Technol Assess 2012;16(41).

Declared competing interests of authors: none

The research reported in this issue of the journal was commissioned by the HTA programme as project number 09/14/02. The contractual start date was in March 2011. The draft report began editorial review in July 2011 and was accepted for publication in February 2012. As the funder, by devising a commissioning brief, the HTA programme specified the research question and study design.The authors have been wholly responsible for all data collection, analysis and interpretation, and for writing up their work. The HTA editors and publisher have tried to ensure the accuracy of the authors' report and would like to thank the referees for their constructive comments on the draft document. However, they do not accept liability for damages or losses arising from material published in this report.

The views expressed in this publication are those of the authors and not necessarily those of the HTA programme or the Department of Health.

© 2012, Crown Copyright.

Included under terms of UK Non-commercial Government License.

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