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Da Vinci surgeries like this one may not be any more effective than the cheaper traditional surgeries.


Robotic surgery popular, expensive, but is it more effective?

by Lisa Weidenfeld and Joseph Uchill
March 06, 2012


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Joseph Uchill/Medill

Marketing for robotic surgery has been extensive and effective.



Lisa Weidenfeld/MEDILL

Dr. Gerald Chodak has started his own website to help patients navigate through all the stages of prostate disease.


The new Da Vinci surgical robot is a hit with patients, who request it for all kinds of procedures. But is it really more effective than traditional surgery -- or just more expensive? Some doctors argue that without much authoritative research, the Da Vinci robot is more a marketing tool than an improvement to surgery.

Surgeries performed with the new, high-tech, da Vinci robot use a narrower blade and provide greater precision than traditional open surgeries, which are performed with a scalpel. The machines are maneuvered by a surgeon operating the robotic arms from behind a nearby console.

There are 2,132 da Vinci systems world-wide, said Chris Simmonds, senior director of marketing services for manufacturer Intuitive Surgical, Inc. and that number is growing. But they do not come cheap. The machines each cost between $1.1 million and $2 million, with an additional cost of $100 thousand to $180 thousand for maintenance annually.

In a 2011 study from Johns Hopkins University about the marketing of the da Vinci robot, 41 percent of hospital websites included a description of robotic surgery, with 89 percent of those descriptions claiming clinical superiority. Despite this claim, only 2 percent of those hospitals made a specific comparison to open or laparoscopic surgery, which involves inserting a camera through an incision. The marketing for robotic surgery may win over more converts than the results of the surgeries.

“You start to see this is not just a trivial issue of exuberant marketing, but it is in some cases potentially inaccurate and really harmful, potentially harmful information, wrapped in the glitz and the glamor of a new technology,” said Gary Schwitzer, publisher of HealthNewsReview.org, a site devoted to reviewing media coverage of “medical treatments, tests, products and procedures.” Schwitzer has been reporting on health issues for more than 30 years.

He said he first noticed heavy positive media coverage of robotics about three years ago and HealthNewsReview.org has since examined a number of articles about robotic surgery. The site often highlights the lack of critical analysis done by journalists. For example, in a May 2009 post, Schwitzer noted that a Good Morning America episode devoted to robotic surgery did not mention risks, the cost of the technology or treatment, independent research to verify results or other treatment options.

Dr. Enrico Benedetti, head of the department of surgery at University of Illinois Hospital Health and Sciences System called the robot a “tremendous advantage” but said it was a “cosmetic advantage more than anything.” His group recently performed the first single port robotic gallbladder removal in the Midwest.

 

Single port surgery involves making only one incision to reduce scarring. The robotic method gives the surgeon a greater range of motion and increased visibility.

One of the most common uses of the robot is in prostate removal. The prostate cancer support group Us Too estimates every five minutes, two men  are diagnosed with prostate cancer. Of that group, a 2010 New York Times article estimated that 86 percent of the ones who opted for surgery chose to have robot-assisted operations.

Yet despite the procedure's popularity, a 2008 study of Medicare patients found that adverse effects like sexual dysfunction and incontinence were no less frequent than with open surgery.

Prostate cancer survivor Bob Wright, an Us Too volunteer, chose to go through with a robotic procedure after talking to a coworker who had gone through it and recommended an experienced surgeon in San Antonio. Wright highlighted the benefits – a shorter hospital stay and decreased blood loss, as well as the increased range of motion provided by the robot that’s not possible with laparoscopic surgery.

But Schwitzer said greater precision and control were not as important as the long-term results.

“If that doesn’t translate to improved outcomes, then healthcare consumers should be asking, 'well, what do I care about greater precision and control?'”

Simmonds disagreed.

“We do think the surgery is proven,” Simmonds said, pointing out that there have been more than 4,600 peer-reviewed papers published on da Vinci surgery.

Another naysayer of robotic surgery writes a blog called Skeptical Scalpel. The anonymous blogger claims to have been a surgeon for 40 years and a surgical department chairman and residency program director for more than 23 of those years. Skeptical Scalpel publishes an extensive list of studies regarding the effectiveness of robotic surgery.

One 2009 study from the Royal Free Hospital and University College School of Medicine in London claims that robot-assisted gallbladder removal had no significant advantages over traditional laparoscopic ones.

Another report from the Department of Surgery at the Second Hospital of Lanzhou University in China in 2010 reviewed studies of robot-assisted surgery for acid reflux. It concluded that robotic surgery was a “feasible alternative” but that it lacked obvious advantages for extensive clinical application.

The standard of proof in medical research is the control study, which randomly determines the patients who get each treatment, keeping that information secret even from the patients. Robotic surgery lacks the control studies that would comfort doctors such as Dr. Richard Hodin, chief of endocrine surgery at Massachusetts General Hospital in Boston.

Hodin said that “the number of good trials comparing robotic surgery are slim, if any.”

“There have been 25 randomized trials carried out on da Vinci out of the 5,600,” Simmonds said. “There have been attempts to do randomized trials over the years against open, but patients have not been willing to go into the open arm when given a choice.”

Dr. Gerald Chodak, a urologist and prostate disease specialist, agreed that the likelihood of more randomized trials is slim, but argued that they were necessary to reduce biases in data.

“The bottom line is that there is no evidence there are better outcomes, but there is less blood loss and faster time to playing golf,” Chodak said.

Instead of randomized trials, most research has been done through the less effective cohort studies, studies that follow people who chose their own treatment. Because the studies aren’t randomized, it might, for example, turn out that the type of people who request da Vinci surgery are the people who do the most outside research into cancer treatments and are most likely to pursue other effective lifestyle changes. But even the cohort studies do not peg da Vinci as a universal panacea.

“It’s a new technology and there’s certainly surgeons and hospitals that are pushing the technology and describing it in a way to make it sound better. If that’s what people are told, that’s what people believe,” Hodin said.

Some robotic surgeries, such as the cystectomy (the removal of all or part of the bladder) did fare well in these studies. While the cost of a robot based procedure is always more expensive, that cost may be offset by the reduction in the hospital stay and fewer necessary corrective procedures.

A 2011 review study by researchers at the University of Bern in Switzerland and the University of Southern California noted that complications in cystectomies could add as much as $20,000 and that after one month complications were nearly 50 percent more likely in traditional, rather than robotic surgery. The Bern study speculated that cutting the costs of complications could compensate for the high price of the robotic procedure, though evidence of this is still pending.

But reduced complications do not result from all robotic procedures. A 2011 cohort study by the University of Modena and Reggio Emilia in Italy found that average length of hospital stays and number of surgical complications were almost identical in patients receiving traditional and robotic splenectomies (when all or part of the spleen is removed). The study of 90 patients found that the total cost of robotic spleen surgeries was nearly three times as much as conventional surgeries.

Still, it’s difficult to argue with testimonials from people like Wright, who chose to go through with the surgery and was pleased with the results. “There’s no question in my mind that if you’re a surgical candidate, it’s a good alternative if you have a well-trained physician doing it.”

He said to choose the technician -- not the technique, which may ultimately be the main thing fans and detractors of robotic surgery can agree on.