Hospital marketing departments love new technology – the latest imaging, diagnostic or surgical equipment offers a point of differentiation from the competition. This is particularly important in the United States where patients have a choice of hospital and surgeon. Advertisements highlighting new technology are common, and patients actively seek out the “latest” option.
Today at the European Association of Urology (EAU) annual congress in Vienna, Associate Professsor Axel Merseburger from Hannover in Germany discussed some of the challenges with robotic surgery for prostatectomy or partial nepthrectomy.
- Lack of data showing an improved functional outcome compared to single port laparascopy or open surgery. I was surprised that there are no comparative clinical trials that show robotic surgery to be better/worse than other surgical techniques. Complication rates remain inconclusive and urinary function is comparable. What is more, the panel of leading urologists concluded that high quality clinical trials would be difficult to design and enroll. One challenge in any surgical technique clinical trial is controlling for surgical experience; an important factor in determining outcome.
- The need for licensing of robotic surgeons. In the same way that airline pilots need to renew their licence every year and show they are competent in the skills required to fly a plane, there seemed to be concensus by the EAU panel that some form of “licensing” for robotic surgery should be required. However, as one member of the panel pointed out, it takes 250 patients to become proficient in new technology, which raises the issue of how that skill is obtained and if you were a patient, would you like to be one of those initial 250?
- The cost/benefit trade-off for robotic surgery remains unclear. Robotic surgery takes longer, but is associated with shorter hospital stays, reduced blood loss and distinct cosmetic benefits. The fact that so much can be done through a small incision through the belly button is quite impressive. However, the higher cost associated with the robotic procedures in terms of time, equipment and training has to be considered when there is no evidence of better functional outcome. Do the benefits outweigh the costs? The answer to that is not yet clear.
The take home that I took from the presentation by Dr Merseburger is that choice of surgeon is the key factor when facing any urology surgical procedure. As Dr Merseburger stated in one of his slides, “The risk of complication is related to the surgeons experience regardless of the surgical approach.”
Those patients who are interested in robotic surgery should carefully consider the surgeon’s experience, with that particular equipment. I expect we will see an ongoing debate about how innovations in surgical technology should be evaluated.