Should you undergo robotic surgery? Results, cost scrutinized

Should you undergo robotic surgery? Results, cost scrutinized

Doug Belohlavy of McHenry, Ill., says recovery proved swift and side effects minimal after surgery to remove his prostate several years ago to treat the common form of cancer that afflicts men. Instead of performing surgery with a scalpel in hand, highly rated urologist Dr. David Goldrath, president of Comprehensive Urologic Care in Lake Barrington, Ill., conducted the operation to remove the walnut-sized gland, involved in sexual function and urination, by controlling the arms of a robot.

“He saved my life,” Belohlavy says. He chose to undergo robotic surgery in hopes of added surgical precision, and read in a newspaper article that highly rated Advocate Good Shepherd Hospital in Barrington, Ill., offered it. Goldrath heads up the hospital’s robotic surgery program. “There’s a lot of vital stuff down there. You don’t want to be messing up any surgeries, but that one especially,” Belohlavy says.

How common is it?

Surgeons now use the three- or four-armed da Vinci robotic surgery system in about one-quarter of all U.S. hospitals, performing about 400,000 procedures annually. It’s the only robotic system approved for soft tissue surgery, from prostate and gallbladder removal to kidney operations. The robot’s Sunnyvale, Calif.,-based manufacturer Intuitive Surgical owes swift adoption of the system to improvements over conventional surgery, such as faster recovery, as surgeons have performed more than 1.5 million procedures with the device since its introduction to the market in 2000.

What are the complications?

Angie’s List members laud the results in their reviews. But last year the FDA began looking into a spike in reported complications for surgeries performed with the da Vinci, from machines breaking down to a robotic arm hitting a patient in the face. While many surgeons sing da Vinci’s praises, some say it’s no better than traditional surgical options, despite a higher price tag.

“It’s all marketing,” says Dr. Barbara Levy, vice president of health policy for the American Congress of Obstetricians and Gynecologists, which recommends against robotic surgery for routine hysterectomy, or removal of the uterus to treat issues such as fibroids, or benign tumors. ACOG says it staked out a position on the procedure, the most common ob-gyn surgery, with about 600,000 done annually, because of widespread advertising and marketing of robotic hysterectomies, claiming advantages over traditional hysterectomies.

“The complication rate is higher,” Levy says, such as with vaginal cuff dehiscense, a rare, but serious, complication involving a separation of a vaginal incision closed at the time of surgery. “Under the worst of circumstances, it means your small intestine falls out of your vagina. Most [cases of vaginal cuff dehiscense] are not that dramatic but mean bleeding or pain with sex and a return to the operating room.”

Does it cost more?

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Robotic surgery
A seated surgeon views a 3-D image of the inside a patient's body while seated at this console, using the master controls to guide the da Vinci robotic system's surgical instruments. (Photo courtesy of Intuitive Surgical)

ACOG also points to a study published last year in the Journal of the American Medical Association that shows, on average, hospital costs increased $2,000 per hysterectomy when performed by surgeons using the more than $1 million da Vinci robot compared with laparoscopic surgery for similar cases. Levy says that providers pass on added costs in the form of higher charges to private insurers and patients. Another study showed that the robot raised the cost of prostate removal surgery by about $3,200, on average, without clear, large-scale studies to prove it produces superior outcomes to traditional surgery.

Both robotic and laparoscopic hysterectomies involve making tiny incisions in the abdominal wall using a camera inside the patient’s body and typically cost more than vaginal hysterectomies, the preferred method in most cases because it involves the fewest incisions and lowest complication rate, Levy says.

What are the positives?

Intuitive Surgical declined a request from Angie’s List for a phone interview, but responded to written questions, saying that robotic surgery speeds recovery and reduces hospital stays and readmission rates over comparable, traditional surgeries, cutting health care costs in the long run.

The company says research shows robotic hysterectomies are as safe as laparoscopic surgery and reduce the length of hospital stays. “Multiple other studies have found that women with gynecological cancer who had a da Vinci hysterectomy experienced fewer complications, including less blood loss, compared with women who received traditional open surgery,” the company says. Levy contends that not enough credible scientific evidence exists to prove or refute that claim.

Intuitive contends overall complications related to the robot are declining, according to its analysis of FDA data, saying that the agency should focus on the dates complications occur, not when they’re reported. The FDA declined to comment on Intuitive’s assertion but provided a breakdown of reports it received during recent years. That included 3,697 reports related to the da Vinci robotic system that the agency received between Jan. 1 and Nov. 3, 2013, the latest data available. That’s up from 1,595 in 2012. The reports cover everything from perforations of organs or surrounding tissue to mechanical problems.

But the FDA called robotic surgery a useful treatment option for many patients, while emphasizing the importance of proper training for surgeons. “Appropriate and consistent training for clinicians is essential for the safe and effective use of computer-assisted (robotic) surgical devices for all indications,” the agency told Angie’s List. But in the absence of standardized training requirements for robotic surgery, the FDA didn’t elaborate further on what that would include. So what should patients do? “Feel free to inquire about their surgeon’s training and experience with these devices,” the agency says, in addition to considering all treatment options.

But what about the humans?

Amid the debate over robots, many echo the agency’s advice that patients pay attention to the human factor. “There’s a big learning curve [and surgeons] who are dabbling in it are going to have lots of problems,” says Goldrath, who also heads the robotic surgery program at Centegra Hospital-McHenry in McHenry, Ill., near Chicago. “I think some hospitals may be too aggressive in marketing it before a program is established,” he says, adding that some surgeons may begin practicing without adequate training.

Intuitive Surgical - da Vinci robot.jpg

Robotic surgery
The da Vinci system's patient-side cart has three or four robotic arms that carry out the surgeon's precise commands with surgical instruments. (Photo courtesy of Intuitive Surgical)

He declined to name providers, but for his part, Goldrath has performed more than 1,000 robotic surgery procedures and believes in its benefits. “It’s just so much better for patients, the recovery is so much quicker,” Goldrath says, noting that it generally takes two weeks for robotic prostate removal, compared with six weeks for conventional open prostate surgery.

Belohlavy says he returned to work just two weeks after his prostate removal surgery. His cancer now in remission, he no longer requires treatment. “I’ve known people that had surgery the regular way,” he says. “It took them longer to recover. They had more problems than I had, more incontinence and all that.” Goldrath concurs in the short-run, incontinence and impotence rates seem to be lower and recovery faster with robotic prostatectomy, though he adds that long-term outcomes are comparable to open surgery. Experts point out too that results vary and remain very doctor dependent.

Though robotic surgery training varies, it typically involves basic instruction that accustoms surgeons to the da Vinci robot, followed by hands-on practice. Surgeons then perform procedures with the da Vinci system on patients under the supervision of a proctor, or surgeon practiced in robotics, to demonstrate proficiency before advancing to perform the procedures on their own. Some advocate additional training.

What do I need to know?

Before agreeing to undergo any procedure or settling on a surgeon to perform it, experts say patients should ask about their surgeon’s training, and whether they track their outcomes and complication rates. “You want to know: Do you have a surgeon that cares enough about what they do to keep track of what goes on with their patients?” Levy says.

Finally, experts say most patients considering robotic surgery have time to evaluate all their options upfront. So take advantage of that. “I always encourage people to get a second opinion,” Levy says. “Especially for elective surgery.”


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