Robotics in Gynecologic Oncology Surgery: Justified or Just Great Marketing?
Special Feature
Robotics in Gynecologic Oncology Surgery: Justified or Just Great Marketing?
By Robert L. Coleman, MD, Professor, University of Texas; M.D. Anderson Cancer Center, Houston, is Associate Editor for OB/GYN Clinical Alert.
Dr. Coleman reports no financial relationships relevant to this field of study.
Synopsis: Robotic-assisted hysterectomy is increasing in prevalence without clear evidence that the modality is cost effective. This population-based analysis found that compared to standard laparoscopy, robotic hysterectomy was no safer but more expensive.
Source: Wright JD, et al. Comparative effectiveness of robotic versus laparoscopic hysterectomy for endometrial cancer. J Clin Oncol 2012;30:783-791.
Endoscopic hysterectomy and staging has proved to be equivalent to open laparotomy in reference to survival for selected women with endometrial cancer. Increasingly, endoscopic procedures are being performed with robotic assistance under the claim of improved safety and efficacy. The objective of this analysis was to compare laparoscopic and robotic hysterectomy by interrogating the Perspective Database.
This fee-supported database collects inpatient information from more than 500 private and academic facilities throughout the United States and represents approximately 15% of hospitalizations. The authors identified 2464 women, including 1027 (42%) who underwent laparoscopic hysterectomy and 1437 (58%) who underwent robotic hysterectomy from 2008 to 2010. Women treated at larger hospitals, nonteaching hospitals, and centers outside of the northeast were significantly (P < 0.05) more likely to undergo a robotic hysterectomy procedure, whereas black women, those without insurance, and women in rural areas were less likely to undergo a robotic hysterectomy procedure. Overall complication rates were similar (10% for laparoscopic hysterectomy vs 8% for robotic hysterectomy). The adjusted odds ratio (OR) for any morbidity for robotic hysterectomy was 0.76 (95% confidence interval [CI], 0.56 to 1.03). After adjusting for patient, surgeon, and hospital characteristics, there were no significant differences in the rates of intraoperative complications, surgical site complications, medical complications, or prolonged hospitalization between the procedures. The mean cost for robotic hysterectomy was $10,618 vs $8996 for laparoscopic hysterectomy (P < 0.001) and was significantly more costly in a multivariable model ($1291; 95% CI, $985 to $1597). The authors concluded that despite claims of decreased complications, robotic hysterectomy had morbidity and increased cost compared with laparoscopic hysterectomy. Comparative long-term efficacy data are needed to justify its widespread use.
Commentary
Aligned with the advances in endoscopic surgery, the adoption of robotics has accelerated in many medical specialties.1-10 Their widespread availability in academic and private institutions despite the upfront and maintenance costs would suggest there is documented utility across multiple specialties. Indeed, claims of reduced morbidity, mortality, and expansion of an individual's surgical repertoire have permeated the dialogue of those who see robotic surgery as the next iteration in surgical innovation. And hospitals eager to attract patients are actively involved in direct-to-patient marketing, including utilization of unaltered industry advertising platforms.11 However, much of the published experience with the device comes from highly experienced surgeons and centers of endoscopic excellence. To provide some clarity on the application of the technology in a more general population, Wright and colleagues performed a comparative effectiveness study of robotic and traditional laparoscopic hysterectomy for women with endometrial cancer.12 Somewhat not surprising, claims previously touted (and marketed) as clear benefits for robotics were not supported, noting that morbidity and mortality rates were similar and costs were greater when hysterectomy was performed robotically.
Although the paper raises several important considerations and potential problems emblematic of technological innovation, it is clear that "snapshot" studies during widespread adaptation lose precision in validity. This is because the collected data from a database such as Perspective represent two different spectra of surgical experience with regard to the procedure. Endoscopic hysterectomy was largely rolled out into clinical practice for this disease in the late 1980s.13 Initial reports of the utility of the "new" procedure were countered with claims that open laparotomy for the similar cohort of patients was unfairly compared as more difficult cases would be preferentially performed by the open approach.14 However, after a randomized trial demonstrated the safety and lack of efficacy differences between the two approaches, it has increasingly become the approach of choice for uncomplicated patients needing oncologic evaluation.15,16 Intriguing in the current paper was the higher rate of lymphadenectomy for patients undergoing robotic hysterectomy. This might reflect case selection and ability to perform procedures for which the surgeon may not be comfortable performing via standard laparoscopy. This was the trend seen with radical prostatectomy when the procedure was adopted for robotics.
For those of us who have experience with the robot and were trained in an era of surgical staging via laparoscopy, there are real and tangible differences the technology brings to the experience. The optics and hand agility, while able to be learned in straight laparoscopy, are a refreshing advance, which no doubt lowers the amount of instruction and learning curve in becoming facile with a variety of procedures, particularly those requiring more difficult hand positioning. This is easily illustrated in recounting the vast array of suturing and knot-tying devices (e.g., all-in-one needle and thread endoscopic instruments, barbed and loop-holed sutures, knot-pushing devices, and intracorporeal knot-tying maneuvers), as compared to natural suture and knot-tying hand positioning in the context of three-dimensional visualization. In addition, surgeon comfort and injury should not be underestimated, as these issues have become significant as complexity and operation times increase.17,18 It would be an interesting experiment to evaluate proficiency between the two techniques in trainees with experience in neither technology.
Nevertheless, when asking a question of necessity, it is clear there are few procedures in the sphere of gynecology or gynecologic oncology that mandate the fine motor robotic assistance that appears necessary for procedures involving small vessel or organ manipulation or in confined spaces, such as the neck or mediastinum. As part of the Obama Administration's Affordable Care Act (ACA), various industries in the medical profession were asked to develop cost-cutting measures to curb the burgeoning growth in health care expenditures. A recent response to the "Brody Challenge" in the practice of oncology is relevant to this Special Feature.19 In that challenge, medical specialties were charged with developing a "Top Five" list of procedures and tests that were proven by formal investigation to bring no significant benefit to patients. In their response, Smith and Hillner presented a Top Five list of suggested changes in attitudes and practice to meet this challenge.20 One vital step discussed was the need to conduct cost-effectiveness analyses and to establish and accept some limits on care. It would appear now that this new technology is mainstream; effort as intense as the marketing should be made to measure the value added, if any, to the conduct of gynecologic oncology patient care.
References
- Park BJ, et al. Robotic lobectomy for non-small cell lung cancer (NSCLC): Long-term oncologic results. J Thorac Cardiovasc Surg 2012;143:383-389.
- Thorsteinsdottir T, et al. LAPPRO: A prospective multicentre comparative study of robot-assisted laparoscopic and retropubic radical prostatectomy for prostate cancer. Scand J Urol Nephrol 2011;45:102-112.
- Paley PJ, et al. Surgical outcomes in gynecologic oncology in the era of robotics: Analysis of first 1000 cases. Am J Obstet Gynecol 2011;204:551 e1-9.
- Padavano J, et al. Robotic radical prostatectomy at a teaching community hospital: Outcomes and safety. JSLS 2011;15:193-199.
- Markar SR, et al. Robotic vs. laparoscopic Roux-en-Y gastric bypass in morbidly obese patients: systematic review and pooled analysis. Int J Med Robot 2011;7:393-400.
- Kanji A, et al. Robotic-assisted colon and rectal surgery: A systematic review. Int J Med Robot 2011;7:401-407.
- Challacombe BJ, et al. The role of laparoscopic and robotic cystectomy in the management of muscle-invasive bladder cancer with special emphasis on cancer control and complications. Eur Urol 2011;60:767-775.
- Caruso S, et al. Open vs robot-assisted laparoscopic gastric resection with D2 lymph node dissection for adenocarcinoma: A case-control study. Int J Med Robot2011;7:452-458.
- White HN, et al. Transoral robotic-assisted surgery for head and neck squamous cell carcinoma: one- and 2-year survival analysis. Arch Otolaryngol Head Neck Surg2010;136:1248-1252.
- Lee KE, et al. Outcomes of 109 patients with papillary thyroid carcinoma who underwent robotic total thyroidectomy with central node dissection via the bilateral axillo-breast approach. Surgery 2010;148:1207-1213.
- Alkhateeb S, Lawrentschuk N. Consumerism and its impact on robotic-assisted radical prostatectomy. BJU Int 2011;108:1874-1878.
- Wright JD, et al. Comparative effectiveness of robotic versus laparoscopic hysterectomy for endometrial cancer. J Clin Oncol 2012;30:783-791.
- Kovac SR, et al. Laparoscopy-assisted vaginal hysterectomy. J Gynecol Surg 1990;6:185-193.
- Querleu D, et al. The impact of laparoscopic surgery on vaginal hysterectomy. J Am Assoc Gynecol Laparosc 1994;1(4 Part 2):S29.
- Walker JL, et al. Recurrence and survival after random assignment to laparoscopy versus laparotomy for comprehensive surgical staging of uterine cancer: Gynecologic Oncology Group LAP2 Study. J Clin Oncol 2012;30:695-700.
- Walker JL, et al. Laparoscopy compared with laparotomy for comprehensive surgical staging of uterine cancer: Gynecologic Oncology Group Study LAP2. J Clin Oncol 2009;27:5331-5336.
- Johnston WK, 3rd, et al. Comparison of neuromuscular injuries to the surgeon during hand-assisted and standard laparoscopic urologic surgery. J Endourol 12005 ;9:377-81.
- Wolf JS, Jr, et al. Survey of neuromuscular injuries to the patient and surgeon during urologic laparoscopic surgery. Urology 2000;55:831-836.
- Brody H. Medicine's ethical responsibility for health care reform — the Top Five list. N Engl J Med2010;362:283-285.
- Smith TJ, Hillner BE. Bending the cost curve in cancer care. N Engl J Med 2011;364:2060-2065.
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