“Gizmo idolatry,” robotic prostatectomy, and real data

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.”