August 22, 2013
Medscape asks: “Robotic Surgery: Too Much, Too Soon?”
On Medscape, an editor and a surgeon published a slide show series entitled “Robotic Surgery: Too Much, Too Soon?” (You need to register in order to see it). Some excerpts:
- Is Insufficient Training a Serious Problem With Robotic Surgery? Intuitive Surgical is currently facing various lawsuits involving improperly trained surgeons. In a Medscape interview, J. Kellogg Parsons, MD, Associate Professor of Surgery, Department of Urology, Moores Cancer Center, University of California, San Diego, pointed out that “there is no standardized process for credentialing, teaching, proctoring, or obtaining hospital privileges for robotic-assisted surgery.” Both the Institute of Medicine and the FDA have recognized that the process by which new devices enter into practice needs to be revised.
- Robotic Surgery for Hysterectomy In March 2013, James T. Breeden, MD, President of the American Congress of Obstetrics and Gynecology (ACOG), issued a statement that recommended against using robotic devices in routine gynecologic procedures…Studies suggest that robotic and laparoscopic hysterectomy have similar morbidity profiles, but the use of robotics substantially increases costs. In the JAMA study, costs associated with robotically assisted hysterectomy were $2189 more per case than for laparoscopic hysterectomy.
- Robotic Surgery for Prostatectomy The European Association of Urology (EAU) has issued guidelines on robotic and single-site surgery in urology, which conclude: “Robot-assisted urologic surgery is an emerging and safe technology for most urologic operations.” The evidence was best for prostatectomy. Nonetheless, the guideline authors also note that the evidence to support EAU’s conclusions was generally poor and based on expert consensus. Even with prostatectomy, studies are not showing better long-term effects on incontinence and erectile dysfunction than with open prostatectomies. However, perioperative benefits were generally confirmed.
- It is still unclear whether robotic surgery has a superior advantage in most general surgeries.
The major issue in the use of robotics is the price. The machines themselves cost between $1.5 and $2.2 million, and service contracts run from $160,000 to $170,000 per year. Disposable instruments range from $600 to $1000, and each procedure can use 3-8 instruments. It is not yet known whether costs will be recouped downstream. An analysis published in March reported that da Vinci surgeries add incremental costs of 20% per procedure, which are absorbed by the hospitals. There is also some indication that hospitals overmarket their robotic capabilities. In a 2011 study, investigators reported that 41% of hospital Websites described their capabilities; clinical superiority was claimed on 86% of these sites, and none mentioned risks.
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