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 "The rapid increase in costly robot surgery in lieu of laparoscopic
surgery without a definite advantage for the patient is a problem
that can be applied not only to the urological field but also to the
entire surgical field,” Dr. In Gab Jeong from University of Ulsan
College of Medicine, Seoul, Korea told Reuters Health by email.
“This may lead to a huge increase in the cost of medical care that
can be a significant burden on the healthcare system.”
In robotic-assisted surgery, the same instruments used in
laparoscopic surgery are connected to a robotic device that allows
for 3-dimensional visualization, greater range of motion of the
instruments, and improved ergonomics for the surgeon.
Extensive marketing and competition among hospitals have led to
widespread use of robotic surgery for a broad range of procedures,
but it remains controversial because of its increased costs and lack
of evidence of improved outcomes compared with non-robotic minimally
invasive approaches.
In a study reported in the Journal of the American Medical
Association, Jeong's team used a U.S. database to compare outcomes
and costs of robotic-assisted surgery versus laparoscopic surgery
for extensive kidney surgery.
In 2003, robotic-assisted surgery accounted for 1.5 percent of
operations in this setting; by 2015, it accounted for 27 percent of
surgeries. Laparoscopic surgeries declined in parallel during that
period.
After taking a variety of factors into account, robotic-assisted
surgery had similar rates of major complications, blood
transfusions, and prolonged hospital stays as laparoscopic surgery.
But robotic-assisted surgery costs averaged US$2678 (2272.67 euros)
more than those associated with laparoscopic surgery, mainly as a
result of longer operating room times and higher supply costs.
“The development and use of robotic platforms might be helpful in
patient care,” Jeong said. “However, scientific research on
cost-effectiveness and safety has sometimes not been sufficiently
conducted, and it is rapidly spreading in the medical field due to
various reasons, such as marketing of the company, patient's
preference for the latest technology, and recommendations of the
hospital/doctors.”
In a second study in the same issue of the journal, Dr. David Jayne
from St. James's University Hospital, Leeds, UK and colleagues from
29 centers in 10 countries investigated whether robotic-assisted
surgery was less likely to require conversion to open surgery,
compared with conventional laparoscopic surgery, in 471 patients who
were having rectal cancers removed.
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The average surgery time was 37.5 minutes longer in the
robotic-assisted group than in the conventional laparoscopic group,
but the robotic devices didn’t reduce the need to convert some of
the operations to open surgery.
Nor did the robotic devices reduce complication rates, either during
the procedure or within 30 days after the procedure.
As in the kidney surgery study, healthcare costs were significantly
higher with robotic-assisted surgery than with conventional
laparoscopic surgery, by an average US$1132 (961.32 euros).
“Robotic surgery is a technical advance in minimally invasive
surgery, but the current robotic system is too expensive to justify
its unselected use in rectal cancer,” Jayne told Reuters Health by
email. “There is a need for robotic systems to be competitively
priced to enable advanced surgeries, such as rectal cancer surgery,
to be cost-effective.”
“The area of robotic surgery will change appreciably in the near
future as other manufacturers bring robotic surgical systems onto
the market,” he said. “This will open up competition and should push
costs down.”
“Whether robotic-assisted surgery for some procedures represents
‘value’ for either the individual patient or the health care system
is unlikely,” writes Dr. Jason D. Wright from Columbia University
College of Physicians and Surgeons, New York in a related editorial.
“From a policy perspective, robotic-assisted surgery exemplifies the
difficulty of balancing surgical innovation with evidence-based
medicine,” he concludes. “Both the generation of high-quality
evidence evaluating new procedures and then the utilization of this
evidence to guide practice should remain priorities for surgical
disciplines.”
SOURCES: http://bit.ly/2y3SzSf, http://bit.ly/2y30AXO and http://bit.ly/2y1JE3P
JAMA, October 24, 2017.
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