Surgical robots’ rapid rise not without doubters
‘Revolution’ vs. ‘dinosaur’ in prostate treatment debated in terms of cost
A robot controlled by a doctor is rapidly becoming the surgery of choice in Hamilton and worldwide to remove a cancer patient’s prostate gland.
The rise of the robot, known as da Vinci, has been staggering since it was approved in the United States in 2000 and in Canada in 2001.
“It basically took over and became the most popular prostate operation in the United States,” said Dr. Andrew Loblaw, a radiation oncologist specializing in prostate cancer at Sunnybrook Health Sciences Centre.
“But there wasn’t a single stitch of evidence that it actually did a better job,” said Loblaw, co-chair of a group at Cancer Care Ontario that evaluates evidence. “Why has this new technology crept in all around the world with no good data supporting its use?”
The lack of proof has created a divide over whether the technology improves cancer treatment or just adds to the cost.
Adding fuel to the fire is a recommendation to the province in July by the Ontario Health Technology Advisory Committee (OHTAC) against publicly funding it.
“Technological change is a double-edged sword,” said Livio Di Matteo, professor of health economics at Lakehead University and an expert with the Evidence Network. “On average, it improves outcomes, but it comes at a cost. … More money for robotic procedures might mean less money for something else. We have to do this balancing act.”
While it’s estimated the robot would cost Ontario a modest $800,000 to $3.4 million more a year, it’s still considered not “good value for money” by OHTAC.
“In health care, rather than trying to fix how we price services, we’ve tried to limit technology that increases volume,” said Herb Emery, professor of economics at the University of New Brunswick and an expert with the Evidence Network. “It’s keeping us back.”
Muddying the waters further is that laparoscopic prostate surgery is so technically difficult to perform that the robot is the main minimally invasive procedure.
“A prostate sits in the lion’s den,” says Hamilton urologist Dr. Bobby Shayegan, who performs among the most robotic radical prostatectomies in Ontario. “The male pelvis is narrow and there is a lot of fat usually. It sits on critical areas between the urethra and the sphincter, which is responsible for urinary control. The rectum is directly behind it, the bladder is above it and there are major nerves and vascular structures around it.”
There are significant challenges operating in this difficult space using a two-dimensional screen and instruments like chopsticks with tips that open and close.
Shayegan calls the robot “the next frontier,” allowing doctors to “do things they otherwise couldn’t do previously.”
“The instruments are held by the robot, which you control remotely,” he said. “The big difference is you are looking at a magnified three dimensional (visualization). Further to that, the instruments have a built-in human-like wrist … that pushes you to the next level.”
The tried and true method is open surgery with a large incision. But that’s falling to the wayside with 85 per cent of radical prostatectomies in the U.S. now done with the robot.
“It’s a complete revolution in the field,” said Dr. David Samadi, chief of robotic surgery at Lenox Hill Hospital in New York. “Open surgery is a dinosaur. It doesn’t make sense.”
He says the biggest factor when robotic and open surgeries are compared head-to-head is the surgeon. Open surgery with an experienced doctor is better than robotic with an inexperienced surgeon, he said. But he believes nothing beats the robot when the surgeon is skilled and does a high number of cases.
“The robot doesn’t do the surgery, the person does,” he said.
Demand for the procedure suggests patients want the robot. Canadians regularly go to New York and pay out of pocket, says Samadi.
Canada has been more conservative in adopting the technology, while hospitals in Alberta, Quebec, British Columbia and Ontario offering it.
Ontario-wide, about one in three radical prostatectomies are done with the da Vinci robot system. But in Hamilton, the vast majority is done with the robot.
The extra cost of about $6,000 a surgery is paid by donors, including a major gift from Mountain Cablevision founders the Boris family.
“We’re really pushing for this technology because we do think it’s the best for our patients,” said Dr. Anthony Adili, chief of surgery at St. Joseph’s. “You have decreased length of stay, decreased blood loss, decreased pain, smaller incision and quicker return to activity … We see it every day with our patients. We know the outcomes.”
But so far there is no high-quality evidence to prove Adili’s claims. St. Joseph’s is already working on studies that will gather both patient and cost data to refute the OHTAC recommendation.
However, doing the highest standard of research — a randomized controlled trial — is now practically impossible. Doctors ethically can’t randomize patients to open surgery if they believe it’s an inferior treatment and too few patients are willing to risk foregoing the robot to prove its benefits.
“I think the big problem is that it was introduced in the U.S. first and the U.S. is driven by market share,” said Adili. “It took almost a decade for it to come into Canada and by that time the horse was out of the barn.”
Adding to the problem is that surgical instrumentation isn’t subject to the same research as drugs before getting regulatory approval.
To make sure this controversy does not happen again, St. Joseph’s is leading a randomized control trial on robotic surgery for thoracic or head and neck surgeries.
“We’re seizing this opportunity not to make the same mistake,” said Adili. “It’s quickly catching on and it’s going to get to the point where we’re in the same place.”
Dr. Bobby Shayegan, left, does the vast majority of prostate cancer surgeries with the da Vinci Si Surgical Robotic System at St. Joseph’s Hospital. He is shown here with urologist Dr. Eric Cole.