Robotic surgery is gaining in popularity; two new studies have reported that the procedure is safer (i.e., fewer deaths and complications); however, it comes with a higher price tag. Robotic surgery is laparoscopic surgery in which the surgeon indirectly controls surgical instruments via a robot. During a robotic procedure, rather than crouching over an operating table, the surgeon sits comfortably at a console several feet from the patient and uses joysticks and foot pedals to control the robot; robotic arms hold and manipulate small surgical instruments, which are inserted through small incisions in the abdomen. On April 2, UCLA Health System researchers reported the results of a study on robotic cancer surgery. Their study was published in the current online edition of the journal European Urology.
“While we expected to see greater expenses associated with the robotic procedure for bladder cancer, we were surprised to see the significant reduction in deaths and complications, particularly this early in its adoption,” noted senior author, Dr. Jim Hu, director of minimally invasive surgery in the urology department at the David Geffen School of Medicine at UCLA. He explained that previous reports of outcomes from robotic-assisted surgery were derived from single medical centers and did not include direct comparisons to traditional surgery. He added that the study marked one of the first national population-based studies comparing robotic and traditional surgery outcomes for bladder cancer. In addition, it is one of the first studies to compare the procedures in a variety of hospital settings across the nation.
The UCLA researchers collaborated with colleagues at Harvard Medical School and Georgetown University Hospital; they reviewed the U.S. Nationwide Inpatient Sample, which is a national government database of hospital in-patient information that includes data from 1,050 hospitals in 44 states. They specifically reviewed data from 2009, which is the most recent date currently available on radical cystectomy for bladder cancer. They reviewed 1,444 traditional open surgeries and 224 robotic-assisted laparoscopic procedures. In 2009, robotic-assisted surgeries accounted for 13% of all radical cystectomies. Via statistical analysis, the researchers compared hospital-level information, including in-patient deaths, complications, length of hospital stays, and costs for the procedures.
A significant finding of the study was that one in 100 patients who underwent the standard surgical procedure (2.5%) died during hospitalization; however, there were no in-hospital deaths for patients who underwent a robotic-assisted cystectomy. Another important finding was that patients who underwent robotic-assisted laparoscopic surgery experienced fewer in-patient complications than those who had the traditional procedure (robotic: 49.1%; traditional: 63.8%). Delayed bowel function often occurs following major surgical procedures; patients with this complication require parenteral feeding (intravenous fluids) to supply nourishment. The patients who underwent the robotic procedure had less need of parenteral nutrition than those that underwent the open procedure (robotic: 6.4%; traditional: 13.3%). The length of hospital stay was similar for both groups: approximately eight days.
The total costs for robotic surgery significantly higher; the increase was in excess of $3,000. The investigators attributed this difference to a longer surgery time as well as the greater use of disposable instruments with the robot. Dr. Hu noted that the study did not include expenses for the purchase of the robot and its maintenance; thus. The actual cost to the hospital is likely to be even higher.
Other findings of the study found differences in gender and hospital type. Women were less likely to undergo a robotic procedure; the researchers suspected that this was due to gender-based differences in anatomy, which make robotic procedures more difficult. In addition, bladder cancer is rarer in women; men are three times more likely to be diagnosed with the disease. The investigators found that 95.7% of the robotic procedures were performed in teaching hospitals such as UCLA and Harvard.
Bladder cancer is the fourth most commonly diagnosed cancer in men, and the American Cancer Society estimates that 73,500 people will be diagnosed with bladder cancer in 2012. A third of those will require a radical cystectomy.
The most commonly employed surgical system is the da Vinci Surgical System. It costs on the average $1.3 million plus several hundred thousand dollars of annual maintenance fees. It is a sophisticated robotic platform, which is designed to expand the surgeon’s capabilities and offer a minimally invasive option for major surgery. For a robotic procedure, small incisions are used to introduce miniaturized wristed instruments and a high-definition 3D camera. The surgeon sits comfortably at a console and views a magnified, high-resolution 3D image of the surgical site. At the same time, the robotic and computer technologies scale, filter, and seamlessly translate the surgeon’s hand movements into precise micro-movements of the da Vinci instruments. In other words, hand motions of the surgeon are scaled down to very precise motions of the robotic arms. The manufacturer notes that the system cannot be programmed and it cannot make decisions on its own; the da Vinci System requires that every surgical maneuver be performed with direct input from the surgeon.