Sur­gi­cal ro­bots’ rapid rise not with­out doubters

‘Revo­lu­tion’ vs. ‘di­nosaur’ in prostate treat­ment de­bated in terms of cost

The Hamilton Spectator - - LOCAL - JOANNA FRKETICH jfr­ketich@thes­pec.com 905-526-3349 | @Jfr­ketich

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.”

HAND­OUT, ST. JOSEPH’S HEALTH­CARE

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.

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