Making the Most of Robotic-Assisted Surgery

The Right Surgery for the Right Patient

Medscape: How does this play out in urologic surgery?

Dr. Parsons: Initially, when the robot was introduced for prostatectomy, there were claims that it improved not only perioperative outcomes, such as length of stay, bleeding risk, and transfusion prevalence, but also long-term outcomes with respect to side effects of surgery, such as urinary incontinence and erectile dysfunction. Although later studies showed that the long-term effects on incontinence and erectile dysfunction were not better when compared with outcomes from surgeons of comparable experience who were performing open prostatectomies, the perioperative benefits were generally confirmed.^[2,3,4] The problem is that it's not so clear how some of these perioperative benefits, which are statistically significant, translate into clinical benefit for patients undergoing this procedure because most patients who undergo prostatectomy are pretty healthy, and their risk for transfusion is pretty low to begin with.

The data for partial nephrectomy are also robust in showing that robotic-assisted laparoscopic surgery decreases length of stay, risk of bleeding, and transfusion risk.^[5] In addition, because open nephrectomies require very large incisions and a lot of muscle tissue is cut, anecdotally, most surgeons will agree that patients undergoing robotic-assisted laparoscopic partial nephrectomies will recover faster after surgery.

In regard to cystectomy, some advantages have been shown with respect to length of stay, bleeding risk, and transfusion risk,^[6,7] and, as with partial nephrectomy, these advantages are probably clinically significant. Patients with bladder cancer tend to be older and sicker, so any advantage that can reduce morbidity in these patients can potentially benefit the patient's recovery. Although these advantages are probably comparable to those seen with pure laparoscopic surgery, most laparoscopic partial nephrectomies and cystectomies are now done robotically.

Unfortunately there are no randomized trials comparing the different types of surgery, so there is no level-1 evidence for robotic-assisted laparoscopic procedures in urologic surgery. Most of the evidence we have is level 3, single-institution case series, with some level-2 cohort studies using nationwide administrative databases comparing one type of surgery with another. So the overall evidence comparing one type of procedure with another is not as robust as it is with other kinds of innovations that have been studied in medicine.

Medscape: There seem to be 2 threads running through these examples: first, that benefit from robotic-assisted surgery depends on the procedure, and second, that it depends on the patient population that you're treating with that procedure.

Dr. Parsons: Yes, that is true. As with any surgical tool, or any medical therapy, for that matter, selecting the right intervention for the right patient is very, very important.

I found the statement by the American Congress of Obstetricians and Gynecologists (ACOG) interesting, in which they stated that they could not discern any distinct advantages to a robotic-assisted procedure over a traditional laparoscopic approach.^[8] I'm obviously not an expert in hysterectomy, but to me, they're suggesting the same principle -- that this type of tool should not be applied too broadly, and that careful patient selection should come to bear.