Health News Review

Robotic prostatectomy has spread all over the US despite the fact that we don’t have clinical trial data to show that it’s better than traditional open surgery.  The marketing of the new, the high-tech, is amplified by news coverage that uses headlines such as the following:

  • Robot doctor – surgery of tomorrow
  • Da Vinci puts magical touch on the prostate
  • Cancer survivors meet lifesaving surgical robot
  • Robotic surgeon’s hands never tremble
  • Da Vinci is code for faster recovery
  • Da Vinci robot is surgery work of art

The company marketing the robotic surgery systems boasts on its website about news coverage from ABC’s Good Morning America and from CNN’s Dr. Sanjay Gupta.  And, under a picture of a couple dancing, the manufacturer claims:

“Studies show patients who undergo a da Vinci Prostatectomy may experience a faster return of urinary continence following surgery…Several studies also show that patients who are potent prior to surgery have experienced a high level of recovery of sexual function (defined as an erection for intercourse) within a year following da Vinci Surgery.”

But a paper published by the Journal of Clinical Oncology concludes that:

Risks of problems with continence and sexual function are high after both (robotic and open prostatectomy). Medicare-age men should not expect fewer adverse effects following robotic prostatectomy.

A population-based random sample was drawn from Medicare claims files – with surveys of 406 men who had robotic prostatectomy and 220 who had open surgery.  Here’s a simple breakdown of the comparison of side effects reported:

Open surgery Robotic surgery
Continence 

No problem

Very small problem

Small problem

Moderate problem

Big problem

 

41 (19.2%)

63 (29.4%)

52 (24.3%)

39 (18.2%)

19 (8.9%)

 

52 (13.2%)

117 (29.8%)

93 (23.7%)

85 (21.6%)

46 (11.7%)

Sexual Function 

No problem

Very small problem

Small problem

Moderate problem

Big problem

 

6 (2.9%)

8 (3.8%)

9 (4.3%)

37 (17.6%)

150 (71.4%)

 

9 (2.3%)

11 (2.0%)

28 (7.3%)

83 (21.7%)

252 (65.8%)

The authors write that the reasons for the rapid spread of robotic prostatectomy are unclear, given the lack of randomized trials and few comparative studies, given that it’s more expensive and appears to have a long learning curve to achieve optimal outcomes.  They note that some have suggested that “gizmo idolatry” is at play. The authors’ summary:

Our results do not show lower risks of problems with continence of sexual function after (robotic prostatectomy), a finding consistent with the earlier study by Hu and colleagues. … The apparent lack of better outcomes associated with (robotic prostatectomy) also calls into question whether Medicare should pay more for this procedure until prospective large-scale outcome studies from the typical sites performing these procedures demonstrate better results in terms of side effects and cancer control.”

Disclosure:  Two of the authors – Michael Barry and Floyd J. Fowler, Jr. – are with the Foundation for Informed Medical Decision Making, which supports my web publishing efforts.  No one, however, has any influence on what I publish.

Addendum:  See my additional post about the accompanying editorial in the Journal of Clinical Oncology and the opinion piece in the New York Times, both of which raise parallel questions about the evidence for high-tech, high-cost cancer radiation treatments like intensity modulated radiation treatments (IMRT) and proton beam therapy as well.  One of them describes the “medical arms race” as “crazy medicine and unsustainable public policy.”

Comments

Jenny R posted on January 5, 2012 at 10:36 am

If the claim about shorter recovery is true, providers might push for robotic because of pressure on bed utilization? Did the review you mention go into that claim? (reading from a location where I can’t access the journal).

    Gary Schwitzer posted on January 5, 2012 at 10:44 am

    No, it did not.

    Providers who are looking for ways to increase market share and justify their capital expenditures could find (and have found) many ways to promote this technology.

Mike Lemonick posted on January 9, 2012 at 1:44 pm

Anecdotal evidence is to be taken with a huge grain of salt, but I’m going to offer it anyway. Having had a robotic prostatectomy, and having been out of bed walking with little discomfort the day of surgery and discharged with even less the next day (as of the day after surgery, I needed essentially no painkillers), I find it hard to imagine anyone arguing that the recovery time isn’t shorter than it would have been for conventional, open surgery. How could it conceivably NOT be shorter?

The questions about comparative lingering side effects remain, of course. But

Paul McGhee posted on May 16, 2012 at 6:56 pm

I recently chose open RRP over the robot, in part because I couldn’t find any good trials or studies that showed that robotic-assisted surgery showed better outcomes. I did find a surgeon that was convinced that open surgery was more appropriate for my cancer.

On the radiation side, we’re about to see the same phenomenon as the new proton beam treatment facilities now being built replace the existing IMRT devices, with almost no science to show that proton beam radiation produces improved mortality, or creates fewer complications.