Although minimally invasive prostate removal aided by a robot can leadto less blood loss, shorter hospital stays and fewer complications,there is no evidence that the procedure improves cure rates, accordingto a new technology assessment.
In addition, robotic surgery, in high demand among patients, canlose money for hospitals because of its expense and special trainingrequired, according to the new review of studies by ECRI.
ECRI is a nonprofit health services research agency thatproduces systematic evidence reviews on medical devices, drugs,biotechnologies, procedures and behavioral health services.
The review of 625 cases looks at two studies that compared thethree procedures available to patients: traditional open surgery,laparoscopic (also known as minimally invasive) surgery androbotic-assisted laparoscopic surgery.
In the review, average blood loss was significantly lower forpatients who underwent either of the two minimally invasive procedures:less than 150 ml for robotic-assisted and 382 ml for non-robotic, whilethe average blood loss for open radical surgery in the two studies was418 ml and 910 ml.
Cancer cure rate, measured by presence of cancerous cells atthe surface of the removed prostate, and by PSA levels followingsurgery, was nearly identical for all three procedures.
Hospital stay was significantly shorter with robotic-assistedprostatectomy compared to open surgery in both studies, 25.9 hoursversus 52.8 hours in one study.
One study reported significant difference in catheterizationtime: 7 days for robotic-assisted patients, 7.9 days for non-roboticlaparoscopy patients and 15.8 days for open surgery patients.
Open prostatectomy had a significantly higher overallcomplication rate of 15 percent, while non-robotic laparoscopicprostatectomy had a rate of 10 percent and robotic-assisted had acomplication rate of 5 percent.
Prostate cancer patients' biggest concerns -- after cure -- are thepossible side effects of surgery, including urinary incontinence andsexual impotency. Data on these side effects from robotically assistedprostatectomy were sketchy at best, and no evidence was available toindicate that any surgical method emerged as better than another forthese side effects.
So far, patient demand, not evidence, is the driving forcebehind the rise in robotic-assisted prostatectomy, according to reportco-author Diane Robertson, director of Health Technology AssessmentServices for ECRI.
Robertson says that the concept of minimally invasive surgeryis highly attractive to patients, with many willing to travel for therobotic procedure, but she cautions that patients should choose basedon surgeon experience and evidence on efficacy rather than just pickingthe latest technology.
"If you have to choose between someone who hasn't performedmany robotic surgeries and a person who has performed many openprocedures -- take the open procedure," says Peter G. Schulam, M.D.,Ph.D., a urology professor at the David Geffen School of Medicine atUCLA.
Schulam routinely performs non-robotic laparoscopy, the more technically difficult of the minimally invasive surgeries.
Michael Esposito, M.D., a surgeon in Hackensack, N.J., who hasperformed about 425 robot-assisted surgeries, explains, "Robotics is amodification tool that further refines laparoscopy." Esposito says thatrobotics offers a three-dimensional view with much greater clarity,made possible with a binocular telescope held by one of the roboticarms.
Robotics allows surgeons to work seated at a console a few feetaway from the operating table, pushing a joystick and pressing footcontrols to remotely manipulate the three robotic arms at the bedside.
One arm positions a high-resolution camera, while the othertwo arms control the surgical instruments. "Robotic [hands] are wristedinstrument that can open, close, flex and rotate 170 degrees," Espositosays. "They're so small and meticulous that you can scale movements anddo extremely fine work."
Robotics is meant to eliminate hand tremors, but some surgeonsfind the lack of contact with instruments disconcerting. Esposito saysthat, once experienced with robotics, "your vision becomes a surrogatefor tactile feedback."
Schulam says that both forms of minimally invasive surgery leadto shorter recovery and less pain "because there's no stretching ofmuscle, and possibly, less blood loss." Also, "patients prefer the fivesmaller holes over a larger midline incision."
Cost was the one area in which the older open surgery was theclear winner: Open radical prostatectomy costs $487 less a case thannon-robotic laparoscopy and $1,726 less than robot-assistedprostatectomy.
According to the review, "Shorter operative time and decreasedhospital stays associated with the robotic procedure did not make upfor the cost of the additional equipment expenditure." Estimated costsof the robotic system to a provider run about $1.2 million a year, withmaintenance costs of $120,000 a year and one-time costs of $1,500 acase.
"Hospitals have to consider whether they can use the system formore than one type of procedure to make it worth the capital equipmentinvestment, if the institute can use it for many applications," saysRobertson. She adds that many operating rooms are not big enough toaccommodate the robotic system.
ECRI is a nonprofit international health services research agencythat provides information and technical assistance to the health carecommunity.
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