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New study reports robotic surgery safer but costlier

Robin Wulffson MD's picture
robotic-assisted surgery, laparoscopic surgery, da Vinci Surgical System

BOSTON, MA - In recent decades, laparoscopic surgery has been increasingly applied to many surgical specialties. This minimally invasive technique was initially employed by gynecologists; then spread to other surgical specialties. More recently, robotic assisted laparoscopic has come into use. Instead of hunching over an operating table, the surgeon sits comfortably at a console and directs a multi-armed robot to perform the procedure.

When any new surgical technique is employed, the issue of safety and cost-effectiveness must be taken into account. Thus, urologic surgeons at Brigham and Women's/Faulkner Hospital, Harvard Medical School, Boston, Massachusetts conducted a study entitled: “Use, Costs and Comparative Effectiveness of Robotic Assisted, Laparoscopic and Open Urological Surgery.”

Their results were published online ahead of print on February 16. The researchers noted that the robotic technique had been aggressively marketed and rapidly adopted; however, they stressed that prior to their evaluation, the medical literature contained few comparative studies that assessed how it compared to standard laparoscopic surgery. They employed a population-based approach to evaluate use, costs, and outcomes of robotic-assisted laparoscopic surgery compared to both traditional laparoscopic surgery and open surgery for common robotic-assisted urological procedures.

The researchers derived their data from the Nationwide Inpatient Sample; they found that the most common urological robotic assisted laparoscopic surgery procedures during the last quarter of 2008 as radical prostatectomy (prostate removal), nephrectomy (kidney removal), partial nephrectomy and pyeloplasty (kidney drainage procedure). They compared these surgeries, which were conducted by robotic assisted laparoscopic surgery, laparoscopic surgery, and open surgery use in regard to costs and patient outcomes.

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The researchers found that robotic assistance was employed for 52.7% of the radical prostatectomies, 27.3% of the pyeloplasties, 11.5% of the partial nephrectomies, and 2.3% of nephrectomies. For radical prostatectomy, robotic-assisted laparoscopic surgery was more common than open surgery among Caucasian patients in high volume, urban hospitals. The researchers also noted that geographic variations were found in the use of robotic-assisted laparoscopic surgery vs. open surgery. More importantly, both robotic-assisted laparoscopic surgery and laparoscopic surgery were associated with a shorter length of hospitalization than open surgery; hospital stays for robotic-assisted laparoscopic surgery employed for radical prostatectomy and partial nephrectomy were the shortest of the three techniques.

Also of importance, for most procedures, compared to open surgery, both robotic-assisted laparoscopic surgery and laparoscopic surgery resulted in fewer deaths, complications, transfusions, as well as more routine discharges. For example, among patients who underwent a prostatectomy, none died from either laparoscopic or robotic surgery; however, two out of every 1,000 died after the open procedure. Approximately 5% of the patients who had open surgery required a blood transfusion, compared to less than 2% of men who underwent the robotic technique. In addition, the open-surgery group also stayed in the hospital about one day longer than the robotic group. The results were similar for nephrectomy patients.

The down-side of robotic surgery was a higher cost than either traditional laparoscopic surgery or open surgery. Robotic prostate removal cost approximately $10,000, which was about $700 more than laparoscopic surgery and $1,100 more than open surgery. For a nephrectomy, robotic surgery cost $13,900; this amount was $2,700 more than traditional laparoscopic surgery and $1,300 more than open surgery.

The authors concluded that despite the fact that robotic-assisted and laparoscopic surgery was associated with fewer deaths, less complications, fewer transfusions, and a shorter length of hospitalization, robotic assisted laparoscopic surgery was more expensive than either traditional laparoscopic or open surgery. They noted that additional studies were indicated to “further delineate the comparative and cost-effectiveness of robotic assisted laparoscopic surgery relative to laparoscopic surgery and open surgery.”

The most commonly employed surgical system is the da Vinci Surgical System. It is a sophisticated robotic platform, which is designed to expand the surgeon’s capabilities and offer a minimally invasive option for major surgery. For a robotic procedure, small incisions are used to introduce miniaturized wristed instruments and a high-definition 3D camera. The surgeon sits comfortably at a console and views a magnified, high-resolution 3D image of the surgical site. At the same time, the robotic and computer technologies scale, filter, and seamlessly translate the surgeon's hand movements into precise micro-movements of the da Vinci instruments. In other words, hand motions of the surgeon are scaled down to very precise motions of the robotic arms. The manufacturer notes that the system cannot be programmed and it cannot make decisions on its own; the da Vinci System requires that every surgical maneuver be performed with direct input from the surgeon.

Reference: Urology