Long learning curve for robotic prostate surgery: why not more stories on this? What are the human costs?

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If my Google search can be trusted at this moment, very few mainstream news organizations have reported on new robotic prostate surgery data presented at a cancer meeting in Florida this week.

MedPageToday had the best story I’ve seen, “Long Learning Curve for Robotic Prostate Removal.” Excerpts:

“Three experienced surgeons needed more than 1,600 cases to achieve acceptable outcomes with robotic-assisted laparoscopic prostatectomy (RALP), data from a retrospective chart review showed.

The results suggest that proficiency in RALP involves a much longer learning curve than previously recognized.

“Robotic prostatectomy is gaining in popularity and being done by a large number of surgeons who thus do a relatively few number of cases…We thus recommend that this operation should not be done by all urologists in small community hospitals,” Prasanna Sooriakumaran, MD, of Weill Cornell Medical College in New York said.

“It should be concentrated into those high-volume centers of excellence, where the operation can be done by surgeons who do a large number of cases very frequently, in order that they can achieve the best possible cancer-control results for their patients,” he said.

Of the estimated 90,000 radical prostatectomies performed in the U.S. each year, robotics is used in more than 70,000 cases. More than 70% of RALP procedures are performed by surgeons who do fewer than 100 cases a year, according to Sooriakumaran.

Studies suggest urologic surgeons require only 25 to 40 cases to master the safety of RALP, he continued. However, the learning curve to achieve expert-level results has not been established.

“I think this data will make everyone pause and say, ‘maybe it’s time to go a little bit farther before we rush into this surgery,'” said Nicholas Vogelzang, MD, of Comprehensive Cancers Centers of Nevada in Las Vegas.

The take-home message from the study, according to Sooriakumaran is that RALP is “indeed a simple procedure, in terms of the safety aspect. In terms of achieving the best possible results, it is not a simple procedure, and it takes a lot of skill and experience.”

Because I was curious, I found an Oncology Times article from more than 5 years ago that raised questions about the “learning curve remains steep” from this procedure, and quoted one expert questioning “whether the procedure’s benefits outweighed the human costs of the learning curve.”

Of course, questions about a learning curve 5 years later – today – are much more concerning.

A cancer specialist wrote to me this week after checking the fourth quarter results for the companhy that makes the robotic surgery system. He wrote:

“For the year their revenue was 1.4 billion dollars. That is 1.4 billion dollars drained from the health care system with little proof that it saves lives, while it is now being marketed to everyone under the sun.

What could we do with $1.4 billion–and climbing?????

While we try to move the system to a more rational process, others are trumpeting irrationality. And they have more money and more influence than we will ever have.”

Meantime, medical centers promote their robots like crazy. One staffer from a robot-using medical center even urged me to promote the out-takes of a TV commercial they produced about their robot. And he posted the comment in response to an article I wrote about robot hype! See the comments section. (I can still remember my instructor from my single PR class in college saying, “It doesn’t matter what you say about me as long as you spell my name correctly.”)

Isn’t it nice that medical centers have budgets to not only produce commercials about their robots, but budgets to pay people to put out-takes on YouTube?

Let me be clear: this technology will undoubtedly offer some benefit to some patients with some conditions. I’m not a doctor. I am choosing to reflect on the public messages and news coverage about new technologies. I’ve witnessed an imbalance in the public discussion and in the news coverage of robotic prostate surgery. (I did a search on this blog just to get some indication of how often I’ve written about such imbalanced news coverage in the past. See the search results.) I wish that every news organization that has hyped robots had given equal weight this week to the study about longer than expected learning curves.

What are the human costs of this finding?

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Please note, comments are no longer published through this website. All previously made comments are still archived and available for viewing through select posts.

Gregory D. Pawelski

February 17, 2011 at 3:48 pm

I do understand the problem a lot of patients have with being unfamiliar with their doctors cancer treatment options. I understand what a learning curve there is and a limited amount of time to get up to speed. The bottom line is there is a steep learning curve with respect to this treatment protocol and to get to the top of the curve, you have to do a lot of them, and the only way to do that is to be in a big, busy center, not your local community hospital. I think this website has been an enormous help in getting the word out to people about public messages and news coverage on newer technologies. These points need to be stressed more often.

Michael Kirsch, M.D.

February 18, 2011 at 6:52 am

While your posts asks if robotic prostate surgery is ready for prime time, the fundamental question is if the surgery is needed for the particular patient. New and futuristic technology should not be a seduction to do procedures that are unnecessary.

Gary Schwitzer

February 18, 2011 at 7:41 am

Thanks for your note.
At the risk of appearing to quibble, I really didn’t ask if the surgery is ready for prime time. That’s why I emphasize that I’m not a doctor. And that “this technology will undoubtedly offer some benefit to some patients with some conditions.”
What I question – and have questioned consistently on this blog – is whether the NEWS about such technologies – often reported in an imbalanced discussion of benefits AND harms – is ready for prime time.
And when a study suggests that a surgeon might need more than 1,600 cases to achieve acceptable outcomes with this approach, I think journalists should be helping their readers/viewers think about whether they want to be first – or even 1,599th – in line.

Dr B

June 8, 2011 at 9:46 am

I am a doctor and I have an opinion:
1. Robotic technology is clearly providing benefits to some doctors and to some patients (in good hands). To other doctors this technology will trouble their minds, and in some patients this technology will change their lifes.
2. I will explain you exactly “why” from philosophical stand point of view. You should all go and visit museums, and Museums of TOOLs, or ANTHROPOLOGY and if you do not find one nearby, go to France on romantic vacation, and visit the Museum of Tools in Troyes, France…and you will get the point. The manual work and craft did get better with tools. More sophisticated are the tools, better and more sophisticated work the man can do…; No woman No Cry, No tool No nice work….or you can put in anyway you want.
SURGERY is Craft, Art, Manual Work, Procedure, etc.
Being a surgeon I can testimony that a lot of surgeons are just disabled physically, awkward, with view-problems, arm and finger tremoring, can not feel comfortable doing their surgeries, poor decision makers, and with age they are just like football players, they get experience and they can coach, with difficulties playing the game on professional basis. On top of that the most difficult question to ask a surgeon is “who is next best one”, giving you exactly the picture of surgeon with the embedded “no surgeon with small ego”! Here we come….Surgery which is by definition artisanal occupation, craft, kind of art, which needs innate talent for color perception, manual work, sculpturing, sawing, precise response of the body and exact fine movements when the body is impregnated with adrenalin, plus the abstract thinking integrated to real situation, becomes accessible to all kind of people with no predisposition to such work…; Surgeons are not selected on above criterias or qualities on admission: they are selected on their GMAT, SAT, USMLE Scores, tests correlated with IQ Score; So, you have a lot of smart doctors, unable usualy to perform a simple task as sawing a button in 5 minutes with simple tools as a needle and suture. Smart is not equal to Art-Oriented, or Human, or Manual, or “Gold-Handed”, etc.
The worst Combination of skills in a SURGEON: low IQ, Memory damage, low cogninitive skills, low abstract thinking abilities, physical disability limiting performing in areas as visual, hand coordination, combined with “stupidity” (which needs a good definition), arrogance, immorality, strong ego and libido combined with jealous type of personality and you have all prerogatives for someone to get BAD RESULTS in terms of SURGERY OUTCOMES, with or without TOOLS. Of course, with TOOLS the MAN is more DANGEROUS….
Now we have tools, Robotics which will continue to be more intelligent and help people, doing more precise and accurate work for them, compensating for naturally inborn disabilities…giving the freedom of action to those with free-imagination. Those doctors can practice with robot, button sawing….
For instance, Da-Vinci system, does filter surgeon movements for TREMOR, or Surgeon can do a SCALE work, he moves with his hands 5 cm and the Robot will move the Tool 5 mm….
3. Now-day robotic technology is at the age of beginning, so these are no true robots yet. Medical Robots on the market are tools providing to humans (surgeons) some advantages form technical stand point of view. Lets go another time trough analogy. First cars were built with manual transmission. Then you have a nice TOOL, called AUTOMATIC TRANSMISSION (actually it is Robotic Transmission, as it is more Robotic in terms of Robotics than other Robots); In US Automatic Transmission is STANDART before I was born. In Europe, they are moving TOWARD Automatic Transmission, now , because old people find easier to drive such cars…..I met a lot of people in their 70-80s looking for “AT” Cars in Europe….they did not have a problem before that age; With hip replacements, with knee surgeries, with cataract surgeries, with all other issues….they just found automatic a very good TOOL. And this is true also for healthy, young people….
We have two cars; My wife’s car with AT, and my car with Manual transmission. I am driving a lot, and my wife does not. I end up by driving my wife’s car 90% of the time because it is easier…..more comfortable…..because Robotics does help in driving, giving me the privilege to concentrate on other tasks while driving than shifting the gears. I recently found a case report from UK, doctors describing stress-fracture from clutch pedaling in man who changed from automatic to manual transmission car…
We can take other examples from aviation, and the use of robotics during the flight….; or use of robots in other industries….
4. The man relies on the TOOL form pre-history. The TOOL is essential to human development. Robotics in medicine is a TOOL. Why do we need a discussion about the need of TOOLS?
5. The TOOLS are evolving as MAN does. Most of man’s TOOLS end-up in museums, relating to future generation the “inventivity” of their ancestors. The Time is a BEST JUDGE for the MAN and his TOOLS. The Needle and Suture is still in place, than THESE ARE GOOD TOOLS….THE BEST ROBOT IS THAT YOU HAVE AVAILABLE;
The actual Robotic Medical Devices will be in Museums in 10-20 years…; Is it better to be operated with one tool or another?, by one surgeon or another one?, in one hospital or another?, to have surgery or not at all?, these are good questions….
6. You can not impose to a driver what kind of car should he/she drive. I heard that in France, if you pass your drive-test with AT car, than you will have a permission to drive only Automatic transmission Cars ONLY (Makes sense to me.) It would be ridiculous to impose driving a Manual Transmission Car to ONE who does not feel comfortable with….There are enough AT Cars in this world.
The same way, we should not impose to a surgeon WHAT TOOL to use while making his/her surgeries. It is up to the MAN, what TOOL he needs to obtain the RESULT.
We should not provide dangerous tools to dangerous people: I agree with that. On the other hand, asking to drive Manual Transmission Car to someone who does not have a clue about gears is not good for the passenger…..