Robotic Thyroid Surgery Falls Out of Favor in US‏

Veronica Hackethal, MD

August 17, 2015

A new study details trends in robotic thyroid surgery (RTS) in the United States, noting lower rates than in Asia and a recent drop in RTS. Results also suggest that low-volume centers perform the majority of robotic-surgery cases and experience higher complication rates than high-volume centers.

The results were published in the August issue of Thyroid.

"In general, what our findings support is that robotic surgery for the thyroid [in the United States] is not going to be like it is in Asia," commented lead author Brendan Stack Jr, MD, a professor at the University of Arkansas for Medical Sciences in Little Rock.

"In the future, I imagine there's going to be a couple hundred RTS cases performed annually [in the United States]. It's going to be performed generally at higher-volume centers, which people are going to seek out when they have a desire not to have a neck incision," he added.

RTS Never Accounted for More Than 1% of Thyroid Surgeries in United States

First pioneered in 2007 by surgeons in South Korea, RTS uses the da Vinci Surgical System (Intuitive Surgical). In 2009, Intuitive began promoting the da Vinci system for use in thyroid surgery in the United States.

But in October 2011, the company announced in that it would withdraw promotion, training, and support, in reaction to reports of complications related to the da Vinci system as well as concern about whether Intuitive had received appropriate FDA approval for use of the device in thyroid surgery.

These events motivated Dr Stack and colleagues to look at how trends in RTS may have changed in the United States before and after Intuitive withdrew commercial support.

They used the University Health System (UHS) Consortium, a large hospital-based discharge database that covers 112 academic medical centers and over 250 affiliated hospitals, to identify patients who received RTS between 2009 and 2013. They also evaluated data from Tulane University Medical Center, New Orleans, Louisiana, which was not part of UHS.

The researchers identified complications and hospital-acquired conditions using the International Classification of Disease, 9thRevision (ICD-9) codes. They defined low-volume centers as those that performed one RTS during the study period, moderate volume as those that performed between two and four RTS, and high volume as those that performed five or more RTS.

Results showed that 484 RTS were performed at 61 institutions between 2009 and 2013, and this low number of operations never accounted for more than 1% of total thyroid surgeries in the United States.

Between 2009 and 2011, annual robotic thyroid surgeries increased from 39 to 140. After the withdrawal of support by Intuitive, RTS volume dropped over 50%, so that only 69 cases were performed in 2012, although there was an increase again after that, reaching 93 cases in 2013.

Cultural Differences, Cost May Play a Role in Rates of RTS

The situation may be different in Asia, Dr Stack pointed out. Asians in general have lower body mass indexes (BMIs) than Americans. For example, over 10% of US patients in this study were obese, and having a higher BMI can make RTS more difficult to perform, he explained.

In addition, monetary incentives in Asia, especially in Korea, may have encouraged the use of RTS. These incentives have recently been rolled back, according to Dr Stack, and it is unclear how this change will affect the use of RTS in Asia.

RTS is expensive and had a mean cost of $13,287 ($5,125 – 42,444) in the current study.

Moreover, there may be a "cultural imperative" in Asian countries to avoid having a scar on the neck, whereas this desire may not apply to the United States, he pointed out.

"I stopped doing RTS partly because there wasn't much of a demand in middle America to do these procedures," he explained. "In the future, I see cosmopolitan people wanting this. I'm not sure the majority of Americans in flyover country are going to really have a big desire to have this done."

The paradox is that the scar left from RTS is actually larger (about 7 – 8 cm) than the one left by open thyroidectomy (about 3 – 4 cm).

But the difference is in location — the scar from RTS lies near the armpit or in the facelift region, so it's less visible than a scar left by an anterior neck incision.

Patients Who Want RTS Should Go to a High-Volume Surgeon

The trade-off, though, may be new complications introduced by RTS, which are not usually seen with open thyroidectomy, including hemorrhage events, brachial plexopathy, and tracheal injuries.

In fact, the current study showed that RTS complication rates increased from 2011 to 2013, with hematoma formation (3.7%) being the most common. Less than 1% of patients experienced brachial plexus or axillary skin flap injuries. One death occurred.

High-volume centers had significantly lower complication rates (16.7%), compared with moderate-volume (41.7%) and low-volume centers (51.9%) (P = .02).

To avoid complications, the key is to go to an experienced surgeon at a high-volume center, according to Dr Stack.

"One of the take-home messages is that, if you're going to have RTS, don't just go to anyone, go to somebody who has RTS experience and has a basis of good high-volume thyroid surgical numbers," he emphasized.

The authors report no relevant financial relationships.

Thyroid. 2015;25:919-926. Article

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