CURE

WINTER / 2013

Is Robot-Assisted Surgery the Best Treatment for Your Cancer?

Consider all factors when deciding on a surgeon and a surgical technique for your cancer surgery.

As a cardiologist, David Martin is accustomed to reading scientific studies. So when he received a prostate cancer diagnosis in October 2012, he pored over the medical literature to learn as much as possible about his treatment options. Martin, from Medford, Ore., was 50, and with a wife and three sons, he wanted to maximize his chances of having the tumor permanently eliminated, while minimizing his chances of complications. These complications, such as erectile dysfunction and urinary incontinence, occur at rates Martin found to be “disturbingly” high.

As a result of his research, Martin ruled out radiation therapy because the complications can tend to show up later on. Instead, he opted to face the issue upfront. “I wanted to get it treated and move on with my life,” he says. That meant he would have to undergo a radical prostatectomy, either by regular open surgery or by minimally invasive surgery, using a laparoscope (a thin tube with a light and lens at the end) or a robotic surgical system.

David Martin carefully considered all his options before choosing robot-assisted surgery for his prostate cancer. Photos by Christin Szczesniak.

Many prostate cancer surgeries are now performed using robotic systems, and they’re increasingly being used in other cancers, too, including gynecologic, head and neck, and thoracic. When performing an open operation, the surgeon makes an incision large enough to see into the body. In a laparoscopic procedure, the surgeon directly manipulates special instruments through small incisions. With robot-assisted surgery, the incisions are still tiny, but the surgeon sits at a console to perform the procedure by directing the robotic arms. This process enables finer movements yet prevents the surgeon from feeling the tissue in the same way as in open surgery.

When performed correctly by well-trained surgeons in appropriate patients, robot-assisted procedures have the potential to prevent short-term complications, such as blood loss, and to reduce the length of hospital stays, compared with open surgery.

Weighing the Benefits

Even with all the potential benefits, there exists little research proving that robot-assisted surgery can improve long-term outcomes compared with open or laparoscopic surgery. There is also a lack of trials comparing this surgery with laparoscopic procedures. Moreover, robotic systems are expensive. According to a recent observational study, robotic surgery systems add about $2,200 to the cost of a hysterectomy for a benign condition. (These extra costs are generally absorbed by the hospital, with insurers and patients paying the same amount for the procedure regardless of whether the surgeon uses a robot.)

We think there are some areas where there’s currently a benefit, some areas where there’s probably a future benefit, and many areas where there’s no clinical benefit.

—Martin Makary

Still, the few studies concerning this surgical technique are promising. A 2012 review of robot-assisted oncologic surgery reported that observational and population-based studies demonstrated fewer surgical complications for some robot-assisted procedures that have been in use for more than five years, including prostatectomy and bladder removal. For robot-assisted radical prostatectomy, the review found that oncologic outcomes were “at least equivalent” to open approaches, with improved rates of decreased surgical complications compared with both laparoscopic and open surgeries. But comparisons of long-term oncologic and functional outcomes—such as incontinence—are “sparse,” according to the study’s authors.

“We think there are some areas where there’s currently a benefit, some areas where there’s probably a future benefit, and many areas where there’s no clinical benefit,” says Martin Makary, a surgeon at the Johns Hopkins Hospital in Baltimore, who has researched robot-assisted surgery. The challenge is determining which technique will benefit a particular patient.

Surgeons using robotic systems say they can perform minimally invasive operations that would be very difficult or impossible using a traditional laparoscopic procedure. “When you do laparoscopic surgery, you have a hole in the patient and use long instruments, using part of the body as a fulcrum,” says John Meehan, a surgeon at Seattle Children’s Hospital in Seattle. “With the robot, you get 3-D vision and instruments” that bend or hinge like a real arm, he explains. Some surgeons also point out that it’s more comfortable to sit at an ergonomically designed console versus standing at a patient’s side maneuvering awkwardly with laparoscopic instruments. These ergonomic benefits are believed to reduce surgeon fatigue and potential technical errors, particularly during long operations.

“In gynecologic cancer surgery, the robot has made a big impact because we’ve converted a lot of our open cases into [minimally invasive] cases,” says Chad Michener, a gynecologic oncologist at the Cleveland Clinic in Cleveland.

Robotic Risks

Even surgeons who aren’t extensively trained in conventional laparoscopic techniques can learn to use robotic systems because of their easier-to-use instruments and shorter learning curve. Myriam Curet, a surgeon and chief medical adviser at Intuitive Surgical, manufacturer of the widely used da Vinci system, says the technology is not intended to substitute for proven laparoscopic procedures, but to extend the benefits of minimally invasive surgery.

Still, no surgery is without risks. While studies show that robot-assisted procedures are generally safe, Makary says, complications can occur. For example, procedures could take longer to perform, meaning patients would spend more time under anesthesia. Also, the robotic controls make it more difficult for a surgeon to feel other tissues and organs in the body. This makes it easier to nick an artery or other crucial area. The Food and Drug Administration issued a warning to Intuitive Surgical for failing to report such adverse events, and the company was sued over injuries allegedly caused by its robotic system. Curet says that, overall, complication rates from robot-assisted procedures are comparable with those seen in open surgery, based on current data.

Physicians say it’s essential to determine which cases might better benefit from the robot-assisted approach. “Who are those patients? What are the characteristics of the surgery or the cancer?” asks Jason Wright, an assistant professor of obstetrics and gynecology at NewYork-Presbyterian Hospital/Columbia University Medical Center in New York. It’s hard to recruit patients for randomized trials that might answer those questions because so many patients want robot-assisted surgery, regardless of whether it’s appropriate for their situation. “Some people do come in requesting it,” says Kirsten Greene, associate professor of urology at the University of California, San Francisco.

Training Time

As medical facilities compete for every healthcare dollar by marketing their technology, patients not only expect but also demand access to the latest devices, regardless of evidencebased outcomes. Wright was an author of a 2012 study examining the marketing of robot-assisted gynecologic surgery on 432 hospital websites. While most sites reported improved short-term outcomes with a robotic system, very few cited limitations of the devices, such as complications, operative time or cost. And a study co-authored by Makary and published in the Journal of Healthcare Quality in 2011 reported that of the 41 percent of 400 hospital websites mentioning robotic surgery, 89 percent made statements of clinical superiority, and 32 percent specifically cited improved cancer outcomes. None mentioned any specific robotic-surgery risks.

Like acquiring any expertise, surgeons have a prolonged learning curve as they get up to speed using a robotic system. Intuitive Surgical provides training, including practice procedures through simulators and models, but training needs vary according to the surgeon’s baseline skills and other factors, Curet says. Requirements for how many supervised cases surgeons perform before operating independently and how many cases they must regularly perform to maintain their skills are determined by hospitals, so there’s no universal standard. In the department of obstetrics and gynecology at the Cleveland Clinic, for example, surgeons must perform 20 to 25 supervised surgeries before they can perform the procedures on their own, and must perform 20 robot-assisted procedures per year to maintain their privileges, Michener says.

It’s important when people who are confronted with this to look at the surgeon’s experience and outcomes and feel like they’re cared for.

—David Martin

Jim Hu, director of urologic robotic and minimally invasive surgery at the University of California, Los Angeles, who performs both open and robot-assisted procedures, says patients should focus their search on the surgeon, not the technique. “A robot in the hands of someone who isn’t very good isn’t going to help cure cancer more than someone who is good performing an open surgery,” he says.

“It’s just another tool that a surgeon uses,” Greene says. And it’s not appropriate for everyone. Certain problems, such as severe lung or heart disease, or extensive scarring from previous surgeries, actually make laparoscopic and robotic procedures more dangerous, she adds.

Martin opted to have Hu use a robotic system to operate on him in January. He says his physical recovery was swift and his function rapidly returned. He urges other patients to do their homework before deciding on a treatment. “It’s important when people are confronted with this to look at the surgeon’s experience and outcomes and feel like they’re cared for,” he says.

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