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 With the technology being used more widely, fewer doctors are
performing the procedure and the overall cost of prostate removal
has gone up, researchers found.
While studies examining the benefits and potential harms of robotic
surgery have produced mixed results, the researchers write in BJU
International that there is little information on how the innovation
influenced prostate removal in the U.S.
"We knew by anecdotal reports as well as the scientific literature
that it had become relatively widespread but we didn’t know how that
had been done,” said Dr. Steven Chang, the study’s lead author from
Harvard Medical School, Brigham and Women’s Hospital and the
Dana-Farber Cancer Institute in Boston.
Robotic-assisted radical prostatectomy, which is the removal of the
prostate with the help of a robot, began after U.S. regulators
approved Intuitive Surgical, Inc.’s da Vinci Surgical System in
2000.
Before that, surgeons would remove the prostate through a relatively
large incision in so-called open surgery - or through a small
incision with the help of a camera, in laparoscopic surgery.
For the new study, the researchers used data on nearly 490,000 men
who had their prostates removed between 2003 and 2010. Of those,
338,448 had open or laparoscopic surgery and 150,921 had
robotic-assisted surgery.
Overall, there was a dramatic increase in the number of prostate
removals with the new technology. The proportion of surgeons doing
at least half of their prostate removals with the robot increased
from 0.7 percent in 2003 to about 42 percent by 2010.
Surgeons who had been doing more than 24 prostate removals each year
were the most likely to start using the new technology.
The researchers also found that the number of surgeons performing
prostate removals decreased during the study period from about
10,000 to 8,200.
Chang said the finding that fewer surgeons are performing the
procedure is likely because the ones who were only doing a few every
year decided to stop altogether.
“It was fairly obvious that the people who adopted this technology
had a higher volume per year than people who did not adopt this
technology,” he said.
“We have seen a concentration of da Vinci use among high volume
surgeons, which we think is a positive for the healthcare system,”
said Dave Rosa, the executive vice president and chief scientific
officer of Intuitive Surgical, Inc., in a statement emailed to
Reuters Health.
“Da Vinci use for radical prostatectomy has been shown to have
clinical advantages over open prostatectomy in most of the dozens of
comparative clinical studies published,” Rosa added.
The current study was not designed to analyze which type of surgery
is safer or leads to fewer complications, Chang said.
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“I don’t think anyone really knows that answer and I don’t know if
that study will ever be done,” Dr. Jeff Karnes, who was not involved
with the new study, told Reuters Health.
Chang and his colleagues also found that the introduction of the new
technology was tied to an increase in overall U.S. spending on
prostate removals.
They write that the increase in cost is likely related to an
increased number of prostate removals and increased cost for each
procedure.
Robotic-assisted prostate removals cost more than open surgeries
throughout the study but the researchers found that the cost of the
older surgical methods also increased toward the end of the study.
They can’t say, based on their data, why the cost of open or
laparoscopic surgeries began to increase, but they suggest it may be
due to slower surgeons continuing to use open surgeon or innovations
in open surgery that drove the price up.
Alternatively, Karnes said it could also be a result of riskier
prostate removals, which take more time, needing open surgery.
Intuitive Surgical, Inc.’s Rosa said a thorough study would take
into account overall societal costs in an economic analysis. Those
costs include how the patients faired after the procedure.
“Costs can be calculated very differently in economic studies
depending on the methodology used,” he said.
Chang said a goal in the future would be to do a more thorough cost
analysis that includes more indirect costs.
Overall, Karnes said he is not surprised by the results of the
study.
“We know that when a hospital acquires the technology the number of
robot procedures go up in that hospital,” he said.
For patients faced with prostate removal, he said it’s likely best
to make a decision on open or robotic-assisted surgery based on the
surgeon’s experience and performance.
SOURCE: http://bit.ly/1luyDMz
BJU International, online August 26, 2014.
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