Robotic Surgery Hype

[Gfunk6]

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Here is a very interesting (albeit long) article on Bloomberg News on the hype behind robotic surgery.

 

[deleted4401]

It's a lot of "he says, she says". I don't doubt the content, but the reporting doesn't leave the reader with much certainty. We work with MacKoul, the gyn onc in Silver Spring who is excellent. But, the way it reads, sounds like sour grapes, like he's just upset he lost referrals.

Didn't like the tone. Wanted to be an expose, ends up sounding salacious and provocative.

 

[medgator]

It's a lot of "he says, she says". I don't doubt the content, but the reporting doesn't leave the reader with much certainty. We work with MacKoul, the gyn onc in Silver Spring who is excellent. But, the way it reads, sounds like sour grapes, like he's just upset he lost referrals.

Didn't like the tone. Wanted to be an expose, ends up sounding salacious and provocative.

Yup. Would've been nice to have some facts and figures to compare morbidity from laparoscopic and robotic procedures

 

[anonperson]

Here is a very interesting (albeit long) article on Bloomberg News on the hype behind robotic surgery.

Interesting article.

MacKoul is bitter that his referral base is down.

Speaking from the GYN side of things, I will be the first to say that the robot is over utilized for a couple of reasons.

-It let's surgeons who are less proficient at laparoscopic hysterecomies perform minimally invasive surgery. The visualization and the ability to manipulate the instruments is night and day compared to traditional laparoscopic instruments.

-Surgeon comfort-Being able to sit for a case compared to arching your neck/back is huge and although this isn't advertised as much.

-Although this article paints the picture of surgeons pushing the robot on patients etc. The truth lies in the middle. It's fairly common for patients to come in wanting a robotic procedure or showing a great deal of interest in it. I don't have any firm numbers, but anecdotally, it's at least 50% in this area of the United States.

For a straightforward hysterectomy in a patient with menorrhagia or even endometrial cancer with no real prior abdominal surgery and a relatively small uterus, a regular laparoscopic hysterectomy is quicker and more cost efficient. No question about it.

But the real value is in cases that can't be performed with regular laparoscopy that otherwise would have been open cases. Taking down a bladder in a patient with 4 prior C sections is possible with the robot. The dissection is much more primitive with regular laparoscopy. Similarly, adhesiolysis in patient's with endometriosis or prior abdominal surgery is much more realistic robotically when in the past these cases would have been open.

As far as the complications the article discusses. Bowel and vascular injuries are known complications of laparoscopy and laparoscopic entry, even when not using the robot. The risk of vaginal cuff dehiscence is elevated in robotic cases which is something this article doesn't even mention which I think is something important for patient's to understand and know.

 

[Palex80]

I am thankful for the robot.
No surgeon has managed to produce so many R1-prostatectomy as the robot. That's a lot of PSA-failures in vast need of prostate bed irradiation. 😀

 

[medgator]

I am thankful for the robot.
No surgeon has managed to produce so many R1-prostatectomy as the robot. That's a lot of PSA-failures in vast need of prostate bed irradiation. 😀

Lol.

Anecdotally it seems like that happens a lot

 

[BobbyHeenan]

I recall reading this in JCO a year or so ago - "Adverse Effects of Robotic-Assisted Laparoscopic Versus Open Retropubic Radical Prostatectomy Among a Nationwide Random Sample of Medicare-Age Men."

Conclusion: Risks of problems with continence and sexual function are high after both procedures. Medicare-age men should not expect fewer adverse effects following robotic prostatectomy.

 

[seper]

I am thankful for the robot.
No surgeon has managed to produce so many R1-prostatectomy as the robot. That's a lot of PSA-failures in vast need of prostate bed irradiation. 😀

Robotic-assisted laparoscopic surgery is here to stay. It's like discussing "hype" behind IMRT now.

Regarding positive prostatectomy margins and adjuvant XRT, I see this a lot too. This truly amounts to intended combined modality approach, which is unfortunate, since morbidity of doing sloppy prostatectomy followed by XRT is unfavorable, without a doubt.

 

[Brim]

I am thankful for the robot.
No surgeon has managed to produce so many R1-prostatectomy as the robot. That's a lot of PSA-failures in vast need of prostate bed irradiation. 😀

Absolutely agree!
Someone should do a SEER-based population outcomes analysis to identify robotic prostatectomy as a risk factor for needing salvage RT.

 

[ramsesthenice]

Robotic-assisted laparoscopic surgery is here to stay. It's like discussing "hype" behind IMRT now.

Regarding positive prostatectomy margins and adjuvant XRT, I see this a lot too. This truly amounts to intended combined modality approach, which is unfortunate, since morbidity of doing sloppy prostatectomy followed by XRT is unfavorable, without a doubt.

Everyone sees a lot of this but what burns me is a lot of it is very avoidable. But since patients go through urology first they don't get a fair shake. Im sick of having conversations with men with high volume high risk PC getting surgery and then being suprised they need adjuvant radiation. Their MSKCC normograms only predicted a 10-20% chance of organ confied disease but the surgeons just did the operation anyways. Not only do they not tell them chances are they will need radiation (thereby increasing complications) a few of our guys always sell it with the BS that if they do surgery first then we have the option or radiation for salvage but if we start with radiation we can't do surgery. Because, you know all that data showing that surgery + XRT + ADT has a higher cure rate and better tolorance...oh wait, you don't either

 

[medgator]

Everyone sees a lot of this but what burns me is a lot of it is very avoidable. But since patients go through urology first they don't get a fair shake. Im sick of having conversations with men with high volume high risk PC getting surgery and then being suprised they need adjuvant radiation. Their MSKCC normograms only predicted a 10-20% chance of organ confied disease but the surgeons just did the operation anyways. Not only do they not tell them chances are they will need radiation (thereby increasing complications) a few of our guys always sell it with the BS that if they do surgery first then we have the option or radiation for salvage but if we start with radiation we can't do surgery. Because, you know all that data showing that surgery + XRT + ADT has a higher cure rate and better tolorance...oh wait, you don't either

Out of all the types of cancer treated in the community, this is by far the most tethered to its respective specialist. At least with a lung mass or breast bx, the primary can get us involved early. No such luck with the elevated psa dx.

It's pretty much why urorads is the most prevalent form of single specialty abuse of radiation therapy in this country