Robotic surgery draws following despite little study

Outcome’s quality over traditional method is unclear

By Gina Kolata
New York Times / February 14, 2010

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NEW YORK - At 42, Dr. Jeffrey A. Cadeddu feels like a dinosaur in urologic surgery. He was trained to take out cancerous prostates the traditional laparoscopic way: making small incisions in the abdomen and inserting tools with his own hands to slice out the organ.

But now, patient after patient is walking away. They do not want that kind of surgery. They want surgery by a robot, controlled by a physician not necessarily even in the operating room, face buried in a console, working the robot’s arms with remote controls.

“Patients interview you,’’ said Cadeddu, a urologist at the University of Texas Southwestern Medical Center at Dallas. “They say: ‘Do you use the robot? OK, well, thank you.’ ’’ And they leave.

On one level, robot-assisted surgery makes sense. A robot’s slender arms can reach places human hands cannot, and robot-assisted surgery is spreading to other areas of medicine.

But robot-assisted prostate surgery costs more - about $1,500 to $2,000 more per patient. And it is not clear whether its outcomes are better, worse, or the same.

One large national study, which compared outcomes among Medicare patients, indicated that surgery with a robot might lead to fewer in-hospital complications, but that it might also lead to more impotence and incontinence. But the study included conventional laparoscopic surgery patients among the ones who had robot-assisted surgery, making it difficult to assess its conclusions.

It is also not known whether robot-assisted prostate surgery gives better, worse, or equivalent long-term cancer control than the traditional methods, either with a 4-inch incision or with smaller incisions and a laparoscope. And researchers know of no large studies planned or underway.

Marketing has moved into the breach, with hospitals and surgeons advertising their services with assertions that make critics raise their eyebrows. For example, surgeons in private practice at the New Jersey Center for Prostate Cancer and Urology advertise on their website that robot-assisted surgery provides “cancer cure equally as well as traditional prostate surgery’’ and “significantly improved urinary control.’’

And robot-assisted prostate surgery has grown at a nearly unprecedented rate.

Last year, 73,000 American men - 86 percent of the 85,000 who had prostate cancer surgery - had robot-assisted operations, according to the robot’s maker, Intuitive Surgical, the only official source of such data. Eight years ago there were fewer than 5,000, Intuitive says.

Dr. Sean R. Tunis, director of the Center for Medical Technology Policy, a nonprofit organization that evaluates medical technology, said few other procedures had made such rapid inroads in medicine.

Medical researchers say the robot situation is emblematic of a more general issue. New technology has sometimes led to big advances, which can justify extra costs. But often, technology spreads long before investigators know whether it is worthwhile.

With drugs, the Food and Drug Administration requires extensive tests to determine safety and efficacy. But surgeons are free to innovate, and few would say that surgery can or should be held to the same standards as drugs. Still, a situation like robot-assisted surgery illustrates how patients may end up making what can be life-changing decisions based on little more than assertive marketing or the personal prejudices of their surgeon.

“A guy who is at the top of his game has little motivation to pick up new tools,’’ says Dr. Jason D. Engel, director of urologic robotic surgery at George Washington University Medical Center in Washington. “I completely understand that.’’

But some in the old guard think the old way is better in this case.

Dr. Gerald L. Andriole Jr., chief of urologic surgery at Washington University, does laparoscopic prostate surgery, and although he tried the robot, he went back to the old ways.

“I just think that in this particular instance, with this particular robot,’’ he said, “there hasn’t been a quantum leap in anything.’’

Evaluating technology is complicated. As often happens in surgery, doctors can become enthusiasts without rigorous studies being done.

And, Engel said, with prostate cancer, more is at stake than just an academic dispute. One in 6 American men develop prostate cancer. Treatment options include radiation and watchful waiting, but the most popular is surgery.

“With the stream of prostate cancer patients that come through,’’ Engel said, “this is a big, big business.’’

Dr. Michael J. Barry, a professor of medicine at Massachusetts General Hospital in Boston, said that once a hospital invests in a robot - $1.39 million for the machine and $140,000 a year for the service contract, according to Intuitive - it has an incentive to use it. Doctors and patients become passionate advocates, assuming that newer means better.

Soon, patients who may have waited - or not had the operation - are drawn in, which is a real driver of increased health care costs, Barry said.

“Doctors and medical centers advertise it, and patients demand it,’’ he said.

The robot’s ability to reach into small spaces comes with tradeoffs. Ordinarily, doctors can feel how forcefully they are grabbing tissue, how well they are cutting, how their stitches are holding. With the robot, that is lost. And the robot is slow; it typically takes 3 1/2 hours for a prostate operation, according to Intuitive, twice as long as traditional surgery.