Being medtech fans we’re rarely unenthusiastic about new technologies and have eulogised about such as home patient monitoring, simply because it ticks all the right boxes in an era where old ideas need to be challenged and new approaches embraced, especially when there is an economic as well as patient benefit.
And so, we thought, was the the robot. We have posted several times on Intuitive’s da Vinci system and watch with interest for the next application. Yet now, Reuters Health has published an interesting appraisal of “robots in surgery” which rather pours water on things.
The article can be found here and in it the author claims that surgical outcomes are little improved and the cost of the procedure is significantly greater even without accounting for the capital outlay on the big grey box.
Insufficient patient benefit?
Forgetting the cost for a minute, let’s look at the data put forward:
- Earlier this year, a US study showed men who had their prostate removed due to cancer complained just as frequently about sexual problems and urinary leakage after robotic surgery as when they’d had the traditional surgery.
- Data from hospitals across the U.S., including nearly 2,500 women who had had their uterus removed due to endometrial cancer showed that nearly 60 percent of the women had robotic surgery, during which the surgeon sits at a console, operating robotic “arms” that use fine tools to extract the uterus through small cuts in the abdomen. The remainder had a similar procedure, laparoscopic surgery, without assistance from robots. Overall, 9.8 percent of the patients who had laparoscopic surgery suffered complications, such as bladder injuries, wound infections or kidney failure. For patients who got robotic surgery, that number was 8.1 percent. The researchers considered the gap to be “pretty small,” and noted that it disappeared after accounting for differences in race, insurance status and hospital location.
- Other researchers have found that hospitals that invest in robots see spikes in the number of surgeries they do, raising concerns that the technology could lead to unnecessary treatments.
Undoubtedly yes. The robotic operation in the hysterectomy study racked up hospital costs of some $10,600 on average, compared to about $9,000 for laparoscopic surgery. Taking other factors into account, the difference came out to about $1,300 per procedure.
Do Surgeons lose key skills?
Dr. Herbert Gretz, who heads the Gynecologic Minimally Invasive Surgery Division at the Mount Sinai Hospital in New York, said most experts agree there is little difference between robotic surgery and laparoscopic.
“What has happened over time to physicians is, once they go down the path of robotic surgery they lose some of the traditional laparoscopy skills,” he told Reuters Health.
Although Gretz is a proctor for Intuitive Surgical and trains surgeons to use the company’s system, he nonetheless prefers laparoscopy, which is a faster procedure for him and his colleagues.
So what do we conclude?
Well clearly, like all new technologies, the jury will remain out for years yet, although adoption in USA at least appears to be rapid. According to Intuitive Surgical, “Over the past 6 years the number of women receiving a less invasive approach to treating endometrial cancer has risen from approximately 14% to 65%.”
In USA at least the train is in motion and anyone who doesn’t jump aboard may be feeling left behind. That’s a slightly dangerous view though isn’t it? While surgeons are well characterised as making evidence-based decisions there is no doubt that a new technology is always appealing, especially when patients have a choice of clinician and are likely to choose the guy with the latest gear.
The main point however seems to be that robots have not exactly snuck in the back door. Clinicians simply must be getting benefits from using these things. In fact the article quotes Intuitive as saying “numerous peer reviewed articles have documented clear improvements in many quality of life measures associated with surgery.”
Furthermore Dr. Mario Leitao of Memorial Sloan-Kettering Cancer Center in New York criticizes the new study, noting that robotic surgery means more patients have access to minimally invasive surgery since relatively few doctors are skilled enough to do laparoscopies. Leitao is a consultant to Intuitive Surgical.
Back to Dr. Herbert Gretz, his conclusion is that; “most experts agree there is little difference between robotic surgery and laparoscopic”…. which might be a key determinant if you’re a decision-maker in a European hospital.
What’s clearly needed to drive home the technology is more definitive randomised clinical studies if, as it seems, there is an ongoing debate about whether expensive surgical robot technology is to become truly a supportable investment, especially in the public sector.
Source: Reuters Health