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Rethinking robotic surgery

As surgeons and finance leaders consider adopting robotic technology, more information on costs and benefits makes the decisions more complex

Among a variety of high-risk, high-reward investments for health systems, robotic surgery is emerging as a technology with lots of promise as well as conflicting evidence.

Now that the Great Recession is behind and fears of the Affordable Care Act have eased, some clinical and finance leaders are ready to make big investments, including in robotic surgery, which since its inception with prostate cancer treatment has been expanded to other areas of oncology, as well as gynecology and cardiology.

Two CFOs at academic health systems in New York City, for instance, are in the midst of adding more robotic surgery systems, according to a briefing by BTIG Equity Research. At a recent meeting, the two officers said they’re finding that the da Vinci Surgical System, the widely-used robotic system made by Intuitive Surgical, is helping extend the careers of older surgeons and shorten the learning curve for younger ones. More surgeons are also asking about using robots in general surgery, they said.

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But the evidence remains mixed on robotic surgery’s long-term effectiveness — the rationale for charging and paying extra for it. The robotic surgery movement has also drawn a range of skepticism and marketing controversies, like a da Vinci endorsement ad by University of Illinois surgeons who were later found to have violated internal policy.

Now, there are new findings that robotically-assisted gynecological surgeries may be riskier, costlier and no more effective than minimally-invasive laparoscopic surgery.

Jason Wright, MD, chief of gynecologic oncology at Columbia University College of Physicians and Surgeons, and colleagues followed 52,000 women who received ovary removal surgery and 34,900 who received bladder cyst removal between 2009 and 2012, either through robotic or laparoscopic procedures.

“Of concern, we found that the intraoperative complication rate of robotically assisted adnexal surgery was higher than for laparoscopy,” the researchers wrote in Obstetrics & Gynecology, the journal of the American College of Obstetricians and Gynecologists.

The overall complication rate in robotically-assisted ovary removal procedures was 7.1 percent, compared to 6 percent in those done laparoscopically; intraoperative complications, occurring in the course of surgery, occurred at a rate of 3.4 percent in robotic surgeries and 2.1 percent in laparoscopic surgeries.

For cystectomy, the researchers found, robotic procedures had an overall complication rate of 3.7 percent, compared to 2.7 percent in laparoscopic procedures. Surgery-related complications were higher in robotic cystectomy procedures as well, at 2 percent compared to 0.9 percent.

The increased intraoperative complications with robotic surgery was largely associated with ureteral and bladder injuries, Wright and colleagues found. Part of that may be the result of “gynecologic surgeons gaining experience on a new technology.” Or, “surgeons may be attempting to perform more technically challenging cases through a minimally invasive approach,” Wright and colleagues wrote.

“If this is indeed the case, our data raise an important concern from a patient perspective; that is, whether the potential benefits of undergoing a minimally invasive procedure outweigh the increased risk of intraoperative complications.”

Overall, the two different types of robotic gynecological surgeries they studied also came with increases costs of between $2,300 and $3,500 relative to the laparoscopic methods.

After the da Vinci system was approved by the FDA in 2000, robotic surgery was mostly used in prostatectomy; it’s only more recently been applied to other clinical areas.

“Unlike prostatectomy, however, laparoscopic alternatives were already in use for many of these operations,” Wright and colleagues noted.

Laparoscopic gynecological surgery has been an alternative to open-abdomen surgery since the mid-1990s, and research reviews have found that laparoscopic adnexal surgery for benign ovarian masses was associated with decreased morbidity, decreased pain, shorter hospital stays and cost savings of around $1,000 per case.

“Given the favorable outcomes of laparoscopy,” Wright and colleagues wrote, the technology is the considered a standard of care for benign adnexal surgery.

One of the main uncertainties with robotic surgery, they argue, is whether it will afford more access to “access to minimally invasive surgery for a greater number of patients.” One way to find out perhaps could be reference pricing, as two large Philadelphia institutions are doing to learn about the effectiveness of proton-beam radiation therapy.