Pricey surgery robots lack clear benefits: study
NEW YORK (Reuters Health) - As robots march into operating rooms across the nation, some doctors are getting worried that patients might not be better off with the costly machines.
In the latest study to cast doubt on the technology, researchers found similar complication rates among women treated for endometrial cancer whether or not surgeons got help from a robot.
Yet robotic surgery costs about $1,300 more than the low-tech approach, called laparoscopy, in addition to the upfront cost to the hospital of the machine itself.
"Robotic surgery is clearly associated with higher costs, without any clear advantages," Dr. Jason Wright, a gynecologic surgeon at Columbia University in New York, told Reuters Health.
In a report in the Journal of Clinical Oncology, he and his colleagues say millions of dollars could be saved by switching from robotic surgery to traditional laparoscopy, adding that official regulation might be needed.
"Surgeons need to keep in mind all of the modalities that are available to them," said Wright. "The newer, more technologically advanced ones aren't always better."
The results fuel concerns that robotic surgery has been hyped unduly by manufacturers and hospitals wishing to justify purchasing the expensive machines, which cost between $1 million and $2.25 million each.
Earlier this year, a study showed men who had their prostate removed due to cancer complained just as frequently about sexual problems and urinary leakage after robotic surgery as when they'd had the traditional surgery.
Other researchers have found that hospitals that invest in robots see spikes in the number of surgeries they do, raising concerns that the technology could lead to unnecessary treatments.
ROBOT SURGERY NO SAFER
Wright's team tapped into data from hospitals across the U.S., including nearly 2,500 women who had had their uterus removed due to endometrial cancer.
More than 40,000 women are diagnosed with endometrial cancer in the U.S. every year. The standard treatment is removal of the uterus, or hysterectomy.
Nearly 60 percent of the women in the new study had robotic surgery, during which the surgeon sits at a console, operating robotic "arms" that use fine tools to extract the uterus through small cuts in the abdomen.
The remainder had a similar procedure, laparoscopic surgery, without assistance from robots.
Overall, 9.8 percent of the patients who had laparoscopic surgery suffered complications, such as bladder injuries, wound infections or kidney failure. For patients who got robotic surgery, that number was 8.1 percent.
Wright called the gap "pretty small," and noted that it disappeared after accounting for differences in race, insurance status and hospital location.
The robotic operation racked up hospital costs of some $10,600 on average, compared to about $9,000 for laparoscopic surgery. Taking other factors into account, the difference came out to about $1,300 per procedure.
"The bottom line is that there is really no difference in the complication rate between robotic and laparoscopic surgery, but robotic is much more expensive," said Wright.
HYPE AND REGULATION
Intuitive Surgical Inc, which sells a robot system called da Vinci, said patients don't bear the extra cost of robot surgery.
"Over the past 6 years the number of women receiving a less invasive approach to treating endometrial cancer has risen from approximately 14% to 65%," Intuitive Surgical's Chris Simmonds told Reuters Health by email.
"This has been achieved at no extra cost to the patient as reimbursement codes for robotic and standard laparoscopy are the same, yet numerous peer reviewed articles have documented clear improvements in many quality of life measures associated with surgery."
In an editorial on the new findings, Dr. Mario Leitao criticizes the new study, noting that robotic surgery means more patients have access to minimally invasive surgery since relatively few doctors are skilled enough to do laparoscopies.
Leitao, of Memorial Sloan-Kettering Cancer Center in New York and a consultant to Intuitive Surgical, adds that doctors shouldn't give up on robots.
"How will we ever advance innovative technology in surgery if we cannot understand and accept the associated start-up costs?" he writes.
So far, there are no randomized controlled trials -- the gold-standard test in medicine -- comparing robotic hysterectomy to alternative procedures. The same goes for prostate cancer surgery, which is now mainly done robotically.
As a result, Wright's team writes, "there is increasing recognition that more formal regulation is needed."
"Given our findings, systems to monitor the trends in utilization of robotic surgery would help to further define patterns of use," Dr. Dawn Hershman, who also worked on the study, added in an email to Reuters Health.
Dr. Herbert Gretz, who heads the Gynecologic Minimally Invasive Surgery Division at the Mount Sinai Hospital in New York, said the new results might not be representative of other women in the U.S.
Still, he said, most experts agree there is little difference between robotic surgery and laparoscopic.
Although Gretz is a proctor for Intuitive Surgical and trains surgeons to use the company's system, he nonetheless prefers laparoscopy, which is a faster procedure for him and his colleagues.
"What has happened over time to physicians is, once they go down the path of robotic surgery they lose some of the traditional laparoscopy skills," he told Reuters Health.
Gretz said patients might have unrealistic expectations of robotic surgery, and should focus less on technology and more on surgeon skill and experience.
"A lot of that hype is coming out of the company," he said. "For the majority of patients, it could be done either way."
SOURCE: bit.ly/aaGhWR Journal of Clinical Oncology, online January 30, 2012.
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