A fool with a tool is still a fool

Robotic prostate surgery rises, but results unclear

New York Times

Published Saturday, February 13, 2010

Dr. Jeffrey Cadeddu was trained to take out cancerous prostates by laparoscopy: making small incisions in the abdomen and inserting tools with his own hands to slice out the organ.

“Patients interview you,” said Cadeddu, a urologist at the University of Texas Southwestern Medical Center at Dallas. “They say: ‘Do you use the robot? Okay, well, thank you.’ ” And they leave.

Those patients want surgery by a robot, controlled by a physician not necessarily even in the operating room.

On one level, robot-assisted surgery makes sense. A robot’s slender arms can reach places human hands cannot. But robot-assisted prostate surgery costs more — about $1,500 to $2,000 more per patient. And it is not clear whether its outcomes are better, worse or the same.

One large national study, which compared outcomes among Medicare patients, indicated that surgery with a robot might lead to fewer in-hospital complications, but that it might also lead to more impotence and incontinence. But the study included conventional laparoscopic surgery patients among the ones who had robot-assisted surgery, making it difficult to assess its conclusions.

It is also not known whether robot-assisted prostate surgery gives better, worse or equivalent long-term cancer control than the traditional methods, either with a 4-inch incision or with smaller incisions and a laparoscope.

Meanwhile, marketing has moved into the breach, with hospitals and surgeons advertising their services with claims that make critics raise their eyebrows.

Robot-assisted prostate surgery has grown at a nearly unprecedented rate. Last year, 73,000 American men — 86 percent of the 85,000 who had prostate cancer surgery — had robot-assisted operations, according to the robot’s maker, Intuitive Surgical. Eight years ago there were fewer than 5,000, Intuitive says.

Dr. Sean Tunis, director of the Center for Medical Technology Policy, a nonprofit group that evaluates medical technology, said few other procedures had made such rapid inroads in medicine.

Still, a situation like robot-assisted surgery illustrates how patients may end up making what can be life-changing decisions based on little more than assertive marketing or the personal prejudices of their surgeon.

“There is no question there is a lot of marketing hype,” said Dr. Gerald Andriole Jr., chief of urologic surgery at Washington University. Andriole performs laparoscopic prostate surgery, and although he tried the robot, he went back to the old ways.

“I just think that in this particular instance, with this particular robot,” he said, “there hasn’t been a quantum leap in anything.”

But Cadeddu has now begun offering robot-assisted surgery to those who want it. “The battle is lost,” Cadeddu said. “Marketing is driving the case here.”

My thoughts_

I really don’t have a feel for which way this trend will go long term.  The inference is that it will continue on and that the only prostatectomies done will be with the robot. Unless….patients begin to see the limited long term advantage of the robot vs. the open method and hospitals/insurance companies begin to look more closely at the costs. As a rule, not true for all but for most, the robotic method takes longer to perform, meaning more operating room time, more anesthesia time and more other associated expenses. Another thing is happening and this has happened in other specialties and other organs as well. As more and more urologists are trained on the robot and use it exclusively, they will be come less experienced in performing the open method. So the new urologists won’t be able to do the open, the old guys can’t do the robot. It is a “brer rabbit” scenario for both. The very thing that the robotic surgeon doesn’t want is to have to open the patient for whatever reason during a robotic case, leaving what he is comfortable with to doing something he is not. I was speaking to a urologic resident that is interviewing for jobs and he told me that in his four years at his resident program he’d only seen four open prostatectomies. All the young guy’s coming out will need an old guy somewhere nearby, I would think, to be available if a robotic case converts to open. Curious times- all the patients want something that costs more and does not impact what is really important in the surgical management of prostate cancer,that is, cure, potency and continence.

Remember an experienced open guy is better than an inexperienced robotic guy… and vice versa.  A fool with a tool is still a fool.


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