Robotic prostatectomy: A debate with a urologist

Robotic prostatectomy: A debate with a urologist

I’m involved in a protracted and good-natured (I hope) debate about the merits of robotic surgery with a University of Pittsburgh urologist named Ben Davies. Today he tweeted the following (with translation for the Twitter averse):

“I would love for a $ISRG [stock symbol for Intuitive, makers of the robot] MD hater (like @Skepticscalpel) to actually watch 10 open RRPs [radical retropubic prostatectomies] then watch a 10 robotic RRP. Call me with results.”

Dr. Davies is a rabid proponent of robotic prostatectomy and by his own admission, is pretty good at it.

I will admit that robotic surgery may indeed be better than open or standard laparoscopic prostatectomy. There is a lot of level 3 evidence to suggest that.

However, a PubMed search fails to reveal any randomized trials of robotic vs. open or laparoscopic prostatectomy. All research on this subject has been retrospective with the potential flaws associated with that type of study, selection bias, unknown confounding variables, unblinded authors, etc.

In Australia, randomized study of sorts is in progress comparing 200 robotic prostatectomies done by a single surgeon to 200 open prostatectomies done by a different surgeon. A search of yields only one other prospective trial in progress. It is a “medico-economic” one from France. There is a trial about whether or not a drain should be used in robotic prostatectomy which assumes that the issue of whether robotic is better than open or standard laparoscopic is settled.

Dr. Davies has a rather narrow view. Although in his field robotic surgery may prove to be better, there is not even anecdotal evidence that it results in improved outcomes for any other type of surgery. Two major gynecologic organizations have recently issued position papers stating that robotic hysterectomy is not indicated for benign disease.

A number of unusual and often devastating complications of robotic surgery are surfacing, which has prompted one state, Massachusetts, to issue an advisory to hospitals.

Defenders of the robot say it’s not the technology itself but rather the surgeons who are at fault.

However, the well-documented intense marketing of the robot by its manufacturer and by hospitals attempting to gain market share is pushing surgeons to adopt the method to stay competitive. The amount of training provided may be inadequate and the learning curve for most procedures is unknown but presumed to be long.

So we have a decidedly more expensive technology which even in its possibly most likely area of success, radical prostatectomy, has never been proven more effective in a well-designed prospective study.

I’m afraid I’m going to have to keep pushing on this.

By the way, I appreciate the offer to watch 20 prostatectomies, but must it be 20? How about 4?

“Skeptical Scalpel” is a surgeon blogs at his self-titled site, Skeptical Scalpel.

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  • doc99

    It took awhile before minimally invasive laparoscopic surgery was shown superior to open, traditional abdominal hysterectomy. Might we not be witnessing the same Infancy phenomenon? Stay tuned.

    • Skeptical Scalpel

      doc99, you may be right, but so far, there’s no evidence that we are seeing a similar phenomenon. I’m sure you are aware of the JAMA paper from 2/13 showing no improved outcomes for robotic hysterectomy with the robot substantially increasing the cost. Here’s the link:

      • Suzi Q 38

        I wish I had seen this website before my hysterectomy.
        I did not have a good outcome.
        I tell my friends: “Buyer, beware.”

      • Craig N

        So cost is the #1 concern for the patient? What about the fact that laparoscopy after 25yrs has limited the penetration of minimally invasive hysterectomy to under 20% because the tools are terrible and the learning curve huge. Robotics has nearly doubled it and will eventually eliminate it if the specialty adopts it like the urologic community has so far. The tools are better. There will always be surgical errors regardless of tools, but how can better vision and better tools cause complications. Look not everyone was created equal. That goes for surgeons as well. Soon you’ll be able to shop for surgeons like you would apps on in the App Store. They’ll be rated with stars. That will reduce surgical errors like we’ve never seen. The less

    • Chris

      It sounds interesting but as with any new technology/processes I am happy to let Other People be the beta testers.

  • southerndoc1

    I’ve never been clear on whether insurers pay more when surgery is done with a robot: anyone know?

    • Suzi Q 38

      I had a hysterectomy due to uterine precancer. there was no cancer found. A borderline proliferating tumor was found in my left ovary.
      After the surgery, I felt tingling and weakness in my inner thighs which has gradually gotten worse. Maybe it triggered something I already had (spinal stenosis) W, cord compression maybe not. Maybe my symptoms and condition were merely coincidental.

      I feel that with all the hype of this machine, we are encouraged to try it. We are not told of the side effects or bad outcomes before the surgery. For my type of surgery, maybe a more open approach, not daVinci, would have been safer and better for me.

      The “jury is still out on this one.” Face it, the medical schools to not spend several months teaching their students this technique.
      Some are taught or coached by the sales reps. I know that my doctor was taught when he was a “fellow.” Not sure how many months he had to practice.

      Still, Picture the procedure with a camera and scissors, unhooking my uterus and ovaries. I am not sure, but he probably has to PULL everything out through the vagina.mNOt sure, I am not a surgeon.

      Is there room for running into other organs or vital nerves in the process?? You bet.

      JMHO from a trusting patient that wich that she had researched it more.

      • Skeptical Scalpel

        I am sorry you had a bad experience. I hope you feel better soon. I’m
        not sure what “uterine precancer” is. Do you recall the medical term
        that was used?

        • Suzi Q 38

          complex atypical hyperplasia, endometriosis.
          thanks for your kind words.
          I walked in without a problem walking, and walked out with a lot of problems in my legs.

          • Chris

            “Pre-cancerous” ….. If left untreated, complex atypical hyperplasia progresses to endometrial carcinoma in 23%-29% of women. I’m curious as to whether, once they had removed your uterus, they found cancer?

          • Suzi Q 38

            Not in the place that he expected, which was the uterus.
            He talked me into removing my ovaries, but forgot to tell me that HRT was not to be given in my case.
            It was too risky to do so.
            I asked him not to test lymph nodes if the initial pathology during the surgery came back negative for cancer.
            It did, and no lymph nodes were removed or tested.

            Lo and behold, a couple of days later, a final pathology report came back. There was a “borderline proliferating tumor” found in my left ovary. this was an incidental finding, as the surgeon had not ordered any scans whatsoever before my hysterectomy. In fact, he persuaded me to think that the surgery was urgent.

            This ovary has a 50-50% chance of becoming active or remaining dormant, never to be woken up again.
            It is in only 1% of the time, and it is not considered ovarian cancer. The doctor was thinking about going in again to test lymph nodes, but I told him that according to Up TO Date publications that the wait and see approach may be better for me given that my surgery is already done. Moreover, this tumor was not aggressive and was of “low malignant potential.”

            Thank you for you kind interest.
            I feel like I want to stand in front of some of these patient education events with physicians speaking on the positives of robotic surgery. I would stand outside with my sign and table to discuss the negatives of my particular case.

          • Chris

            It sounds like you have had a very frustrating experience. I wish the best for you from here on in.

          • Suzi Q 38

            Thank you.
            I “never say never,” but I am the “poster child” for what can go wrong when utilizing a new machine or technique.
            Maybe my surgeon was not that experienced with the machine.

            i am just hoping that as each day passes, my nerves heal and I can walk again like I used to.

    • Suzi Q 38

      The payment was was not out of the ordinary. I can ask my hospital.
      It probably is more, because the DRG for the hospital stay is less.
      This is how they promote it: Faster healing time, faster hospital stay, back to work faster. Also, any way you look at it, it is still a major surgery. No way should women be going back too early. They may need to heal.
      The surgery itself takes longer! Mine took about 4-5 hours.

      • Craig N

        You witnessed the problem. If you’re going to do something, learn a new technology you can’t dabble. He’s a dabbler. Whether it was laparoscopy, robot, whatever. If he continues to dabble he’ll be dangerous. It’s not the technology, it’s his mindset and his approach. I’m sorry your outcome was not ideal. Next time research and ask how many surgeries they’ve perform annually and with the technique they’re suggesting.

    • Suzi Q 38

      According to the ACOG (American Congress for Obstetrics and Gynecology entitiles Statement on Robotic Surgery by ACOG President James T. Breeden, MD) “…….At the price of more than $1.7 million per robot, $125,000 in annual maintenance costs, and up to $2K per surgery for th ecost of single use instuments, robotic surgery is the most expensive approach…….”
      I guess I can call my PPO insurer and ask.

  • Steven Reznick

    Isn’t there a learning curve for the surgeon with any new procedure. The more they do, the more likely they are to produce a result without a complication ( some of which are not even anticipated until they start performing the procedure in volume?). Isn’t the data just evolving in comparing robotic and traditional prostatectomies? Might Dr Patel’s data based on extensive experience at Ohio State and Central Florida be different than a newcomer to the procedure?

    • Craig N

      The problem is the old regime. If the lap crowd would just admit that having wrist is better than not having them, that have depth perception is better than not having it, that eliminating tremors is better than magnifying them then we’d take a big step forward. Then as a resident, I could stop waisting my time splitting my time training on both lap and robotics. Look at Urology as a model. They’ve reached nearly 90% MIS. They only need to know robot and open. That’s all that should be taught. If gynecologist would adopt this model, 250, 000+ women each year would be spared an open surgery. They’d be out of the hospital quicker freeing up more beds, saving money, reducing infections, reducing cost for transfusions, reducing adhesions so future surgical needs won’t be a nightmare. The list of benefits is endless. Obama care wouldn’t be needed.

  • Paul Dorio

    I believe the comments got side-tracked a bit. As an interventional radiologist, I can verify that uterine fibroid embolization, for example, has been shown to be slightly more expensive than, but just as safe or safer than, hysterectomy. Recovery time is significantly shorter. The fact that the procedure, back to Da Vinci, takes longer, does not equate to longer or equally as long recovery times for patients. What is the issue, here, in my opinion, is whether there is enough learning being done by surgeons who use the Da Vinci compared to surgeons who perform similar surgeries using either laparoscopy or open techniques. Everything takes a learning curve. It is the user who may cause an error, not the device.

  • Jay B. Ham

    A more precise way to still cut the wrong nerve?

  • Craig N

    There no randomized trials because robotics IS the gold standard. Patients don’t want an open incision so who would offer there abdomen up to be part of a trial that no one cares about. Seriously. If you are part of the active surgical community you know what we are hearing now about robotics is partly the “death rattle” of the old school open and laparoscopic surgeons trying to yell as loud as they can for business reasons, putting the patients last behind their concerns about losing surgical volume. They’ve spent years training to do what any surgeon can do with the robot. They’re no longer different. If they were smart they’d apply their “greater skills” to robotics and become the elite again, but most chose to take the low road and shout out at meeting “the robot is not needed” “its too expensive”. Do the forget what the old geesers were yelling when they were first attempting laparoscopy. Same shit different day.

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