The rise of the robosurgeon: revolution or rip-off?

Humans love them — and the NHS is paying millions for them. But as new studies suggest they’re no better than real medics, we ask . . .

Robotic surgeons are on the march. Across the NHS they are taking over thousands of operations from their human counterparts for prostate cancer or kidney and bladder surgery. Science fiction has become science fact.

the machines, with their pinpointaccurate computer-controlled arms, are being introduced in the belief that they can perform minute surgical tasks such as cutting and stitching far more effectively than quiver-fingered humans, and with less risk of bleeding from excessive incisions or poor suturing.

there are now around 60 such robots, of a type called ‘da Vinci’, in NHS hospitals. these are operated by surgeons or specialists who can use them to get 3D computer visuals to see inside patients, or to control specialised instruments such as tiny cameras and ultra- small tools to perform procedures. their popularity is also driven by patients seeking the ‘latest and therefore best’ surgical technology.

but do these shiny metal surgeons live up to their futuristic reputation? After all, they cost £1.7 million each and have annual maintenance costs of £ 140,000, according to a report by the Royal college of Surgeons bulletin.

in fact, a growing body of clinical evidence suggests the robots are no better than human surgeons at a range of tasks they are used for during keyhole operations, and that the NHS may be wasting desperately-needed money in rushing to buy them for hospitals up and down the country.

THEY’RE NO BETTER THAN HUMANS

LASt october, an analysis of clinical trial results, performed by the highly respected cochrane Library organisation, concluded that even with prostate cancer operations — the most popular application for robot surgeons in the UK — the machines achieved no better outcomes for patients than keyhole surgery performed by humans.

For instance, robot surgery didn’t have lower rates of complications such as post- surgical bleeding or operations having to be redone. in fact, keyhole operations that were performed by robots did not even achieve better results than the far more invasive, non-keyhole form of operation for prostate cancer, called open radical prostatectomy.

this is where the whole prostate gland is removed through a cut made in the stomach.

Robots equal the success rates of humans, only in terms of ‘urinary continence and sexual quality of life,’ according to the epidemiologists at Monash University in Melbourne, Australia, who led the study. they concluded: ‘overall and serious postoperative complication rates appear similar.’

Another authoritative study published in the same month, this time in the Journal of the American Medical Association ( JAMA), deduced that robots are no better than humans at performing complex surgery to remove tumours from patients with rectal cancers — another common use for robots.

the research, led by David Jayne, a professor of surgery at St James’s University Hospital in Leeds, examined the outcomes from 237 robot operations and compared them with 234 humanperformed surgeries.

Again the success rates (in terms of how many operations had to be redone) appeared the same. Furthermore, the robots were no better at reducing complication rates after surgery, such as bleeding. in the same issue of the journal, a study of 23,000 patients undergoing radical nephrectomy (removal of a kidney) led by Stanford University Medical centre in california found no significant difference in outcomes between human surgeons and robots.

An editorial accompanying these two studies said ‘whether roboticassisted surgery for some procedures represents “value” for either the individual patient or the healthcare system is unlikely’.

TRIALS FUNDED BY ROBOT COMPANIES

A bAtteRy of recently published studies have also failed to prove that robots are any better than humans in keyhole operations for cancer of the liver, cervix and throat, or in stomach reduction operations for obese people.

it is not as though these studies were conducted by surgeons critical of the new technology. indeed the vast majority of research received some level of funding from robot manufacturers.

An investigation into the funding of 458 studies into robot operations, conducted in the journal Annals of Surgery by Dr ben Goldacre, a senior clinical research fellow at University of oxford last July, found that in more than half, one or more authors had at some point received payments from robot-makers that they had not disclosed in their reports. this, he says, may have possibly biased the reports towards showing the robots in their best light.

‘there is good evidence that this kind of financial support can change hearts and minds,’ Dr Goldacre told Good Health. ‘evidence shows that giving researchers money is associated with biased results. importantly, that may be just because of the researchers’ enthusiasm for the product, rather than pure financial avarice.’

We might therefore expect that research performed by manufacturer-funded investigators would have positive leanings.

but if this is the case, the studies’ rather unimpressive results suggest that robots really haven’t proved themselves to be any great shakes.

one of the original big claims of robot surgery was that a surgeon would be able to operate on a patient remotely, possibly anywhere in the world. but so far, this has only been achieved experimentally ( a major obstacle is the internet time lag).

DO THEY DRAIN NHS CARE?

tHe need for close monitoring by doctors, along with the extra time

that the robots themselves require to perform operations, helps to explain why robot operations cost considerably more than the same operations performed by a human surgeon.

Studies show this to be around £ 1,000 extra ( or more than 10 per cent) per operation.

There is an argument, therefore, that robots are draining the cash-strapped NHS of vital funds that could be put to better use cutting waiting times.

‘The big thing about robot surgery is it’s dramatically expensive,’ Professor Jayne has said. ‘The NHS is forking out millions of pounds and before our study we had no idea if there was any benefit.’

Between 2010 and 2017 there was a sudden increase in NHS trusts buying the machines, which were first introduced in 2000 in the U.S.

Only 12 NHS centres had one in 2010, but that figure had more than trebled to 42 by last year.

So why are NHS hospitals rushing to buy them? In the cash-skewed world of the NHS market, robots offer a sales edge, because patients have quickly become convinced of the robots’ superiority.

A study last October, for example, found that men with prostate cancer are so keen to choose hospitals equipped with robot surgeons that NHS units that don’t have them are being forced to shut down through lack of custom.

The report published in the journal Lancet Oncology warned that 16, or one in four, NHS prostate cancer units in England has been forced to close in the past seven years because they did not have expensive surgical robots.

‘Patients were attracted to centres offering robotic surgery, and other centres adopted this technology to preserve their market share,’ said Ajay Aggarwal, an oncology researcher at the London School of Hygiene and Tropical Medicine, who led the Lancet study.

‘NHS trusts appear to have bought the robots not because they are better, but because they pull in more customers.’

Robots may confer a commercial advantage in the NHS market, but on the plain basis of clinical cost-effectiveness alone, the benefits are not so evident.

Indeed, Canadian health authorities announced in October that they are refusing to fund the purchase of any more robot surgeons.

The expert committee that advises Ontario city on buying new health technologies said there is no justification for purchasing new surgical robots while the clinical evidence shows their results are no better than humans in performing surgery such as prostate cancer operations.

SURGEON’S SKILL STILL THE KEY

IN BRITAIN, however, the robot horse may have already bolted. It is estimated that robots currently perform half of all NHS prostate removal operations.

But now the Royal College of Surgeons is calling for national oversight on the introduction of these machines.

‘ The purchase of surgical robots has to date often been driven by local NHS trusts without sufficient regard to local, regional and national need for them,’ says Richard Kerr, a consultant neurosurgeon and council member of the Royal College of Surgeons.

‘The NHS therefore must play a role in centrally planning the use of surgical robots, identifying where patient need greatest,’ he adds.

‘The medical expertise of the NHS and the skills offered by the technology sector must be channelled to ensure robotics is better targeted to the NHS’ needs.’

The Royal College of Surgeons is certainly not anti-robot. Mr Kerr calls the technology ‘exciting’ and says a ‘ recently launched commission on the future of surgery will be looking at how increasingly advanced robotics will impact surgery over the next five, ten and 20 years.’

Christopher Eden, a professor of urology at the University of Surrey, has performed prostate operations using both keyhole surgery and robots.

He says the hype about robotics misses a vital point: it is the skill and experience of the surgeon that counts, regardless of whether they are performing it with their hands or by controlling the arms of a robot.

‘There are a few reports that do show robotics can have slightly better outcomes, but really you are looking at the fact that the surgeons involved are high in experience and expertise,’ he told Good Health.

‘I advise anyone considering a prostate operation to look at the surgeon’s short-term and long-term outcomes, not what kit they are using.’

This can be found on the NHS Choices website.

There are specific areas where a robot may hold an advantage, he adds. For example, in a relatively new technique called Retzius-sparing prostatectomy.

Conventional surgery removes the prostate from the front of the patient, behind their pubic bone, but this often damages an area called the Cave of Retzius that is vital for male continence, Professor Eden explains.

Retzius- sparing surgery approaches the prostate from behind, and has a three-times greater rate of success in ensuring that men are not left incontinent by the operation — a complication that can affect up to 10 per cent of patients.

However, the area in which the surgeon must operate is so small that only a robot can safely reach into it.

‘This is a new operation, and is where I believe that the future of robotics in prostate surgery properly lies, rather than in inexperienced surgeons using the hype of robots to attract patients.’