Does Robotic Surgery Make the Cut?

September 2010, Vol 1, No 4

Over the past decade, polarized opinion has abounded regarding robot-assisted laparoscopy. On one side, many of the surgeons who pioneered the use of the da Vinci surgical robot (Intuitive Surgical, Sunnyvale, CA) in Germany and the United States described it as “revolutionary,” heralding “a new era,” and creating a “paradigm shift.”1-3 “We are convinced that it will totally change the future of urological surgery,” researchers at the University of Heidelberg, Germany, wrote in May 2001.3 The technology was rapidly adopted—it went from being used in 2648 radical prostatectomies in 2003 to 73,000 in 2009—about 85% of the total performed in the United States, according to an article in the New York Times.4

Some urologists, however, were deeply skeptical about the da Vinci robot’s benefits. Some surgeons take issue with the robot’s high costs—as much as $1.4 million for the unit, several hundred thousand dollars annually for maintenance contracts, and nearly $2000 per procedure for consumables. Others question the comparative effectiveness of robot-assisted surgery and are frustrated with what they view as the slow pace of improvement in the technology. To bolster their views, they point to studies indicating that robot-assisted surgery is no more effective than well-established open procedures and standard laparoscopy.

The Pennsylvania Hospital Experience

A recent media seminar and expert panel convened at Pennsylvania Hospital, Philadelphia, to help assess whether robotic surgery is an advance in modern medicine or just effective marketing. Although the seminar did not necessarily provide the answer to this question, it did provide a background as to how the technology works and the experiences of the institution and the surgical teams in employing it.

Laparoscopy, whether robotic or standard, results in smaller incisions; less pain and blood loss; fewer transfusions; and faster discharge and recovery times, said Daniel Eun, MD, assistant professor of urology in surgery and director of minimally invasive and robotic urologic oncology and recon struction at the University of Penn sylvania School of Medicine, Philadel phia. The drawbacks of laparoscopic procedures include less surgical dexterity, limitations on the kinds of procedures that can be performed, and generally longer times in the operating room, he said.

During standard laparoscopy, the surgeon must stand over the patient but look at a 2-dimensional image on a monitor, usually located overhead. The instruments are long and awkward, with no “wristed” movement. “It’s counterintuitive,” Dr Eun said. “It’s like operating with chopsticks.” The instruments also amplify movement and are more likely to cause “instrument tremor.” Ergonomically, standard laparoscopy results in greater surgeon fatigue than open or robot-assisted surgeries.

In contrast, the da Vinci surgical robot offers a 3-dimensional vision system, computerized tremor filtering, and automatic scaling down of large motions of the surgeon’s hand to the confined surgical domain. The surgeon sits at a console, using a foot-operated clutch that supplements the hand controls to conduct the operation. Even though members of his team are qualified, Dr Eun makes all incisions. Robot-assisted procedures performed by Dr Eun rarely have to be converted to open surgical techniques. “The open incision is a thing of the past in my care,” he said. Although Dr Eun is an advocate of robot-assisted procedures, having performed 4500 during his career, he does not perform them unless, based on previous experience, the expected “outcome [will be] at least equal to an open operation.”

“The robot is a tool,” Dr Eun concluded. “The surgeon is the one who selects the patients and produces the results.” Jonathan D. Moreno, MD, David and Lyn Silfen University Professor of Medical Ethics, University of Pennsylvania School of Medicine, seconded this conclusion. “Perhaps it’s better to think of this as device-assisted surgery, an extension of the kinds of tools surgeons have used for a long time,” he said. “A true robot is autonomous.”

Despite the state of the US economy, Dr Moreno said he expects that plenty of money will be invested in new medical technology, including enhancements to the da Vinci robot and the development of new robotic systems. “In 25 years, we’ll have a device that will be able to interact with [the surgeon],” he said.

Other panelists were enthusiastic about robot-assisted surgery. “The robot can work in places you can’t get your hands in. This technology is really in its infancy,” said William Welch, MD, professor of neurosurgery at the University of Pennsylvania School of Medicine.

Use Ahead of the Evidence

Despite the generally positive reaction to the technology at Pennsylvania Hospital, at least one cautionary note was struck. John Y.K. Lee, MD, assistant professor of neurosurgery at the University of Pennsylvania School of Medicine and medical director of the Gamma Knife Center at Pennsylvania Hospital, remarked on the difficulties of performing comparative effectiveness studies. “How do we get randomized studies? It’s very difficult,” he said, pointing out that this is particularly the case for the rare tumors seen in neurology. “The patient doesn’t want to be randomized to open or endoscopic [surgery]. They want the least invasive or maximally effective [procedure]. We’ll never have comparative effectiveness studies for these types of tumors.”

Outside of the institution, studies of the merits of robot-assisted surgery have emerged, and although some have been inconclusive, some researchers have taken definite stands on the comparative effectiveness of the technology. Hu and colleagues performed a population-based observational cohort study using information from a national cancer database.5 They determined that patients who underwent minimally invasive radical prostatectomy (standard and robot-assisted) experienced shorter length of stay and fewer miscellaneous surgical complications and strictures than patients in the open prostatectomy group, but experienced more genitourinary complications, incontinence, and erectile dysfunction. The researchers concluded that patients “had been enamored of new technology” in choosing minimally invasive surgery instead of the established gold standard of open radical prostatectomy.4

When Breitenstein and colleagues conducted a case-matched study of robot-assisted versus standard laparoscopic cholecystectomy, they found similar outcomes, but hospital costs were 28% higher for the robot-assisted cholecystectomies.6 “Costs of robots…are high and do not justify the use of this technology considering the lack of benefits for patients,” the authors concluded.

The debate will certainly continue. When more experience is gained with robotic technology, outcomes should improve and costs should drop as the technology improves and competitors enter the field. In the meantime, the da Vinci robot should not be seen as a miraculous device that can overcome the limitations of an inexperienced surgeon, according to Vipul Patel, MD, medical director of the Global Robotics Institute at Florida Hospital, Orlando. Dr Patel, who did not attend the meeting, commented in a separate interview that “the robot is an enabling technology. It makes a good surgeon better; it doesn’t make a bad surgeon good.”

References

  1. Bräutigam WM, Engl T, Bentas W, et al. Robotic-assisted laparoscopic radical prostatectomy: the Frankfurt technique. World J Urol. 2003;21(3):128-132.
  2. Bentas W, Wolfram M, Jones J, et al. Robotic technology and the translation of open radical prostatectomy to laparoscopy: the early Frankfurt experience with robotic radical prostatectomy and 1-year follow-up. Eur Urol. 2003;44(2):175-181.
  3. Rassweiler J, Binder J, Frede I. Robotic and telesurgery: will they change our future? Curr Opin Urol. 2001;11(3):309-320.
  4. Kolata G. Results unproven, robotic surgery wins converts. New York Times. February 14, 2010;A1.
  5. Hu JC, Gu X, Lipsitz SR, et al. Comparative effectiveness of minimally invasive vs open radical prostatectomy. JAMA. 2009;302(14):1557-1564.
  6. Breitenstein S, Nocito A, Puhan M, et al. Robotic-assisted versus laparoscopic cholecystectomy: outcome and cost analyses of a case-matched control study. Ann Surg. 2008;247(6):987-993.