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Do ‘Robots’ Offer Any Clear Surgical Advantage?

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A new meta-analysis in the Annals of Internal Medicine assessed the quality of evidence and outcomes of robot-assisted surgery compared with laparoscopy and open surgery in adults.

In this exclusive video, Vinay Prasad, MD, MPH, breaks down the study and explains why he believes our technological advances need to actually improve patient outcomes in order to outweigh the current costs.

Following is a transcript of his remarks:

Dr. Vinay Prasad here for MedPage Today, and I’m back with a new video, these are “Articles You Will Definitely Read (Later).”

On today’s video we have a new paper out now in the Annals of Internal Medicine, it’s entitled “The Evidence Behind Robot-Assisted Abdominal Pelvic Surgery.” Now that’s a mouthful, but basically the authors look at the da Vinci robot and other robots that have been heavily marketed over the last 30 years to doctors [compared] to surgeons. I remember when I was a medical student, I would drive to Chicago from northwest Indiana and along the way, I’d see billboards advertising robotic surgery. Who wouldn’t want a robot? Why would you want a regular old surgery when you can get the robotic surgery? And in fact, many hospitals used it as a marketing tactic to bring in patients.

Well, now the verdict is in. We have a systematic review of all randomized controlled trials in abdominal pelvic surgery. And it’s a sobering look.

The authors looked at every single randomized controlled trial study for mostly gynecologic, gastrointestinal, and urologic procedures. Things in the abdomen and pelvis, which is the bulk of robotic surgery. And what they found was notable. They found just over 40 trials, and not all of them but most of them reported the rates of complications, something over 30. And when they reported complications, sometimes the robot came out ahead, but sometimes the robot didn’t and laparoscopic or even open surgery did just about the same. There appeared to be much more cost if you use the robot. And you were in the OR just as long as you were if you had an open surgery by using the robot. Only laparoscopic surgery saved time.

The authors conclude this: “There is currently no clear advantage with existing robotic platforms, which are costly and increase operative duration. With refinement, competition, and cost reduction, future versions may have potential to improve clinical outcomes without the existing disadvantages.” That’s a very negative conclusion about what’s been going on for over 30 years. A widespread and expensive robot that’s being used all over America to perform these surgeries. And the authors here look at every randomized study, and they don’t find a distinct advantage.

So why are we doing it? The OR time is the same. The complications do not appear substantively lower by using the robot. It really begs the question, how did this costly, invasive, marketing tactic become so widespread? And why are so many surgeons so confident the robot is best?

The authors give one teaser. They write, “In the published literature on robotic surgery, two thirds of articles have authors who received speaking fees, consulting fees, or honoraria.” Well, that’s one of the challenges in this space. We all know the da Vinci robot makes a lot of people a lot of money. It makes the manufacturer of the robot a lot of money. The courses that need to be done before you can use the robot, also bring in money. And the robot may be a marketing tactic for hospitals to bring in business through its door. Even if the robot offers no real advantages over conventional or laparoscopic surgery, which is what this review seems to show. No substantive advantages that are clear, that occur across all of the studies in this space, or even all of the studies for a single indication.

This paper is a sobering and important reflection on medical technology. It’s easy to be seduced by the newest and sexiest medical technology. It’s hard to know that it actually makes people better off and is worth it. In this case, the robot, it has a certain operative time that’s longer than laparoscopic surgery, and it doesn’t appear that it offers any advantages.

Now, the authors of this study say that, you know, the future might be different than the past. The robot might prove its worth. One way the robot might prove its worth is, you drop a robot off in some remote corner of the world and the surgeon can be across the planet and control that robot. Well, that’s an interesting idea, but we have yet to see it in practice. So we shall see if that can materialize.

The other thing the authors talk about is that right now it’s called a robot, but it’s really like a drill. You use it like any other tool — it’s not a robot, it doesn’t do anything of its own accord. Well, what if you could automate some things? What if you could use artificial intelligence? I found this remarkable that they said that because for years I’ve been joking that the only thing that robot needed was a cyborg controlling it. And then it would be perfect. And in fact, that’s what they’re alluding to — an AI cyborg. Well, we shall see.

But the truth is medical technologies are one of the reasons why healthcare spending is so high in this country. And we’ve got to make sure that these technologies are used wisely and actually improve patient outcomes. And experience can be very misleading. I know many surgeons who swear by the robot, but swearing by the robot is not the same thing as performing well done randomized controlled trials, showing the robot is better than what you used to be doing. There are a lot of people who don’t like the robot, this study will vindicate a lot of their feelings. It’s costly, it takes longer in the OR, and it’s not substantively associated with a reduction in complications. So my view is this is a very important paper, and the robot has a lot to prove before we keep using it.

I’m Vinay Prasad for MedPage Today.

Vinay Prasad, MD, MPH, is a hematologist-oncologist and associate professor of medicine at the University of California San Francisco, and author of Malignant: How Bad Policy and Bad Evidence Harm People With Cancer.

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