RP vs. LRP vs. RLRP - Part 3. Robotic Surgery (RLRP)

[updated November 21, 2008]

This is part 3 of a 4 part series comparing Open Surgery (RP),
Laparascopic Surgery (LRP) and Robotic Laparascopic Surgery (RLRP).

RP vs. LRP vs. RLRP - Part 1. Open Surgery (RP)
RP vs. LRP vs. RLRP - Part 2. Laparascopic Surgery (LRP)
RP vs. LRP vs. RLRP - Part 3. Robotic Surgery (RLRP)
RP vs. LRP vs. RLRP - Part 4. What Surgeons and Others Say


Robotic Surgery

Robotic surgery is a fast-growing form of laparascopic surgery in which the surgeon makes use of the da Vinci robot. Articles describing it include Thaly, 2007, MGH, 2007 and the 2005 Hospital Physician article by robotic surgeons El-Hakin & Tewari. Many of the same considerations apply that were already discussed under laparascopic (i.e. in Part 2); however, in the case of the robot there some additional advantages:

1. 3d. There are two optical channels to handle the 3d visualization problem.


2. Instrument Handling. The instrument handling is more comparable to open than in freehand laparascopic.


3. Training. While still taking longer to learn than open surgery, robotic takes less time to learn than freehand laparascopic.


4. Surgical time. The time to perform a surgery with the robot is roughly comparable to open surgery.


5. Stability. The robot provides additional stability by filtering out surgeon's hand tremors according to [link].
   
6. Studies. Studies cited in Oncoloytics 2005Q2 by El-Hakim and Tewari (last article) and the University of Maryland Medical Center show favorable negative margin and other results for robotic surgery. This 2008 study [PMID: 17919694], also mentioned in Part 1, found less pain and quicker recovery for robotic surgery relative to open surgery although the differences were not large. See [link]. Thaly, 2007 notes that robotic surgery "shows promise"; however, as it is only 5 years old time is needed to get longer term followup data. A study at Duke University compared robotic surgery and open surgery prostatectomies done there and found that the robotic surgeries required secondary treatment in only 7.8% of all cases where open surgeries required secondary treatment in 16.9% of surgeries. [PMID: 18585849] [Full Text] thus fewer robotic patients needed less subsequent treatment than the open surgery patients even though the open surgery patients had more experienced surgeons. More on the Duke study under Disadvantages.

Disadvantages of robotic surgery would be similar to those of laparascopic plus:

1. Cost. Lotan et al (2004) [PMID: 15371862] estimate that robotic surgery costs $1,726 more per operation than open surgery and $487 more than freehand laparascopic. There may be fewer procedures performed in the initial years after purchase as surgeons are trained and that may initially reduce the utilization and increase costs beyond that; on the other hand, the FDA may approve additional surgical procedures that may be performed with the machine which could, in the future, increase utilization and decrease costs (see Hartford Hospital). Also costs may come down when additional manufacturers are approved according to this link. Other sources of cost information are: MGH and El-Hakim and Tewari, 2005


2. Malfunction. Any complex piece of equipment may malfunction. At the 2006 AUA meeting, Kozlowski et al reported that in the first 200 patients "at their institution, there were 8 equipment failures necessitating abandonment of the robotic approach. Malfunctions were related to joint setup (2), arm malfunction (2), software incompatibility (1), 'power off' error (1), monocular monitor loss (1), and camera malfunction (1). The group wisely concludes that multiple contingency plans should be set in place, including additional da Vinci units, development of straight laparoscopic skills, and counseling of patients to determine their preference should the system fail." [Best of 2006 AUA Meeting] [PMID: 17466155]
3. Unsubstantiated Claims. Dr. Wayne Hellstrom, summarizing the presentation by C. Rojas-Cruz and JP. Mulhall "Sexual Health misinformation on robotic prostatectomy websites" writes in [link]: "Nearly half of radical prostatectomies performed in the United States were robotic-assisted radical prostatectomy (RARP). Marketing of this technique has focused on decreased pain, improved cancer control, and recovery (despite there being no published comparative analysis data on outcomes related to erectile function). One group of investigators reviewed hospital Web pages for claims relating to RARP. Of the 116 sites reviewed, 75 had information on the DaVinci system, surgical technique, and outcomes.[2] Of these sites, 78% (half university and half community hospitals) stated that RARP yielded better erectile function outcomes than open prostatectomy. Only 7 sites (15%) provided any data on postoperative erectile function, and only 2 offered their own data on this subject. The authors concluded that the claims for better erectile function outcomes are misleading and give patients choosing RARP unrealistic expectations and postoperative disappointment. Such disappointment is further discussed in the Duke study mentioned under advantages above [PMID: 18585849] [Full Text] [New York Times blog] where the authors found that the likelihood of satisfaction among patients with open surgery was higher than patients with robotic surgery. They hypothesized that the reason was not due to actual outcomes but due to having been oversold on robotic surgery resulting in expectations were too high relative to the likely outcome whereas those who had open surgery had more realistic expectations.
4. Recovery Time Advantage Small. Recovery time and pain reduction advantages over were found exist but be small in [PMID: 17919694]. Deceptive marketing giving the impression of the contrary is discussed in this March 2008 Urology Times article.

As of December 31, 2006 there were 429 da Vinci robots in North America, 92 in Europe, and 38 in the rest of the world. The number of da Vinci prostatectomies increased 75% in 2006 vs. 2005 and are expected to increase another 50% from 2006 to 2007. Intuitive Surgical, the maker of the da Vinci robot has licensed patents to force-reflecting haptic devices and associated software from Sensable Technology to use in their robotic surgical systems, so it is expected that the haptics problem cited in Part 1 of this series will ultimately be addressed, at least in robotic surgeries. (Financial and operating results are based on Intuitive Surgical 2006 SEC filing of 10-K form).

Comments by robotic surgeons Dr. Domenico Savatta are here and Dr. El-Hakim and Tewari are here (2005) and here (2003). (In case of link failure, the reader can find similar articles to El-Hakim and Tewari (2005) here (2005), here (2004) and here (2004).)

Other Parts of this Series

RP vs. LRP vs. RLRP - Part 1. Open Surgery (RP)
RP vs. LRP vs. RLRP - Part 2. Laparascopic Surgery (LRP)
RP vs. LRP vs. RLRP - Part 3. Robotic Surgery (RLRP)
RP vs. LRP vs. RLRP - Part 4. What Surgeons and Others Say

Other Surgery Posts

Choosing a Surgeon - Part 1. Considerations
Choosing a Surgeon - Part 2. Finding a Surgeon

Lymph Node Dissection

Inguinal Hernia and Prostatectomy

Seminal Vesicle Ablation