Robotic roundup: Useful? Or little clinical value?…”robotic invasion”…outpaces evidence

Here’s another of our periodic roundups of robotic surgery news, some of which doesn’t get much attention in the mainstream news media.

Forbes has hosted a little back-and-forth about robotic surgery in recent weeks.  First, Robert Pearl, MD, chief executive of the Permanente Medical Group, included a discussion of robotic surgery in his piece, “America’s Broken Health Care System: The Role of Drug, Device Manufacturers.” Excerpt:

Laparoscopic surgery was a miracle advancement. Hardly the same story as the prostate surgery robot.

Mention “robot” to most patients and they’ll assume it’s a space-age advancement with major clinical benefits. It sounds sexy and, intuitively, its approach to prostate surgery makes sense. After all, the robot has steady hands and requires a smaller incision.

The problem is the outcome data doesn’t support the hype or the cost. The results – in terms of both cancer eradication and surgical complications – are similar to traditional alternatives, according to most studies. And for most surgeons, the robot-assisted procedure takes longer.

The price tag for this device is over $1 million, but that’s just the beginning. The company behind the robot designed it with disposable “arms” and built in an obsolescence factor that forces the hospital to replace each arm after 10 uses. The motivation isn’t safety. It’s profit. The manufacturer could have built a robot that could complete 100 procedures. But that would reduce profits dramatically.

If the robots add little clinical value yet significantly increase costs, why do so many hospitals tout them? The answer: Aggressive advertising.

By simultaneously marketing to consumers and hospitals, these devices were strategically positioned to help hospitals lure patients from their competitors. And, of course, it worked. Big billboards helped early adopting hospitals attract patients with the promise of a new “high-tech wonder.” Once a few hospitals jumped on board, others had no choice but to follow.

Since the robot’s introduction, academic medical centers (university hospitals) train their surgical residents almost exclusively in its use. Gone or going are the more traditional methods. Unless patient expectations change or expanded competition is permitted, this will ensure that the manufacturer sees a large revenue stream for decades to come.

The result: This device will drive up health care costs significantly in the future, while clinical outcomes remain relatively unchanged.

Then, Dr. Catherine Mohr, senior director of medical research at Intuitive Surgical, makers of the DaVinci robotic surgical system, countered on Forbes.com, “Here is Why Robotic Surgery Is Useful.” Excerpt:

One important aspect in this debate that skeptics often ignore is that use of the da Vinci Surgical System is compatible with, and complementary to, laparoscopy. If laparoscopy is available or feasible for a particular patient, the surgery should be performed laparoscopically. But, where laparoscopy isn’t feasible or appropriate for a particular patient, a surgeon may use the da Vinci Surgical System to offer that patient a minimally invasive option – and a chance at a faster return to their daily activities.

An example of this is hysterectomy. The introduction of the da Vinci Surgical System into gynecologic surgery in the past 10 years has resulted in a significant decrease in the number of open incision hysterectomies performed in the United States. At the same time, the percentage performed laparoscopically has continued to rise. These two techniques are currently taught side by side, and many surgeons do both. As with any treatment decision, doctors are driven to select the most appropriate technique based on the patient’s specific needs, not clever marketing.

In raising these issues, Dr. Mohr didn’t discuss:

• how often is laparoscopy not feasible or appropriate?
• the American College of Obstetricians and Gynecologists made a strong statement: “Robotic surgery is not the only or the best minimally invasive approach for hysterectomy. Nor is it the most cost-efficient. It is important to separate the marketing hype from the reality when considering the best surgical approach for hysterectomies.”

Meantime, an associate editor of the Canadian Urological Association Journal recently wrote about  “The robotic invasion of Canada.”  Excerpts:

The benefits of robotic surgery include magnified, high definition visualization, excellent range of motion and elimination of tremor, and surgeon comfort at a seated console. Having performed a number of robotic surgeries, I can attest to these benefits. …

At what cost? In Canada, the initial purchase price is $2.8 million, with annual maintenance costs of $180 000, and cost per case of $3500. Currently, outside of Alberta and Quebec, these costs in most provinces are covered through philanthropy. The University of British Columbia experience published last month showed similar outcomes in hospital length of stay, transfusion rates, and positive surgical margin rates, but an additional cost of $5629 per robotic case over open surgery. With surgical robots popping up all over Ontario and other provinces, eventually the public will be asked to cover the costs of these robotic surgeries. Perhaps these robots should be regionalized to maximize efficiencies and thereby lower operating costs? However, every institution wants to be on the cutting edge and have their own robot. Currently in Ontario there are daVinci robots in London, Ottawa, Hamilton and at 5 sites in Toronto. A number of high-volume community hospitals have successfully raised funds to purchase a robot in the near future. With the proliferation of robots, individual institutional volumes will be lower, driving up costs per case. Perhaps regional robotic centres of excellence in each province would be more efficient and cost effective.

And Managed Care magazine published an article of more than 3,500 words: Rush to robotic surgery outpaces medical evidence, critics say.

Addendum on July 25:

“Study Shows Robotic Surgery Holds No Major Advantages for Bladder Cancer Patients” – Memorial Sloan Kettering Cancer Center blog.

Addendum on August 3:

“Keeping up with the Joneses,” by former hospital exec Paul Levy about robotic surgery systems in the medical arms race.  About a study also discussed in the Washington Post.

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