Annual nationwide cost estimation and short-term outcomes after para-aortic lymph node dissection for gynecologic malignancies according to surgical approach (open, laparoscopic, and robotic).

objectiveTo compare direct in-hospital costs and short-term outcomes of para-aortic lymph node dissection (PAL) for gynecologic cancer performed by open laparotomy (OLP), conventional laparoscopy (CLS) and robot-assisted surgery (RAS) in a nationwide French cohort, using a tertiary robotic unit as benchmark.

methodsThe 2023 national hospital registry (PMSI) was filtered for admissions in public and not-for-profit hospitals coded for uterine cancer or ovarian cancer (ICD-10) combined with PAL; pelvic dissection was additionally recorded when the corresponding code was present. Aggregate data (admissions, ward and intensive-care unit bed-days, Severity Index (SI) class) were extracted by surgical approach. Direct hospital costs were calculated by combining national tariffs with approach-specific disposable-instrument charges. The primary endpoint was the direct index-stay cost; secondary endpoints included length of stay (LOS) and severe morbidity (SI 3-4). Design was retrospective and based on approach-level aggregates (no patient-level covariates); administrative-coding constraints were present, and comparative results were interpreted accordingly.

resultsAmong the 1 076 patients who underwent PAL in 2023, the surgical approach was OLP in 69.7% (n = 750), CLS in 20.2% (n = 217), and robot-assisted surgery (RAS) in 10.1% (n = 109). Of these, 30 RAS procedures were performed at Hôpital Européen Georges-Pompidou (RAS-HEGP). Median LOS for uncomplicated cases was 7.3 (OLP), 3.3 (CLS), 3.2 (RAS-PUB) and 4.5 (RAS-HEGP) days, respectively (p < 0.001). Severe morbidity fell from 33.1% (OLP) to 6.0% (CLS), 8.9% (RAS-PUB) and 3.3% (RAS-HEGP). Mean direct costs were €8 823, €3 222, €4 099 and €3 962. Adjusted odds of severe morbidity dropped by 87% with CLS, 80% with RAS-PUB and 93% with RAS-HEGP; cost ratios relative to OLP were 0.37 for CLS, 0.46 for RAS-PUB and 0.45 for RAS-HEGP (all p < 0.001). All between-approach comparisons are descriptive; p values are exploratory.

conclusionsOLP remains predominant yet is clinically and economically inferior. CLS offers the best value where expertise exists, while RAS approximates CLS and markedly outperforms OLP, supporting its use as an alternative to OLP in centres that cannot sustain complex laparoscopy.