Robotic-assisted surgery for kidney removal and rectal cancer was associated with higher costs and longer operating times and resulted in no improvement in short-term outcomes compared with laparoscopic procedures, according to two studies published in JAMA.
While laparoscopy has been shown to be safe and associated with few complications and shorter hospital stays for many procedures, robotic-assisted surgery has emerged as an alternate minimally invasive surgical option.
In the first study, investigators examined the trends in use of robotic-assisted radical nephrectomy and compared the outcomes and costs with those of laparoscopic radical nephrectomy. The study by In Gab Jeong, MD, PhD, of Stanford University Medical Center and Ulsan College of Medicine in Seoul, South Korea, and colleagues, included patients who underwent either robotic-assisted or laparoscopic radical nephrectomy at 416 U.S. hospitals between January 2003 and September 2015.
Of the 23,754 patients in the study, 18,575 underwent laparoscopic radical nephrectomy and 5,180 underwent robotic-assisted radical nephrectomy. The use of robotic-assisted surgery increased from 1.5% in 2003 to 27% in 2015.
The researchers found no significant differences between the two procedures in major postoperative complications, but the rate of prolonged operating time (>4 hours) for patients undergoing the robotic-assisted procedure was higher than for patients undergoing the laparoscopic procedure (46.3% versus 25.8%; risk difference 20.5%; 95% CI, 14.2% to 26.8%).
Significantly, the team said, robotic-assisted radical nephrectomy was associated with higher mean 90-day direct hospital costs ($19,530 versus $16,851; difference, $2,678; 95% CI, $838 to $4,519).
In the second study, a team led by David Jayne, MD, of Leeds Institute of Biological and Clinical Sciences of the University of Leeds in the U.K., evaluated the effect of robotic-assisted surgery compared with conventional laparoscopic surgery on the risk of having to convert to open laparotomy for patients undergoing resection for rectal cancer.
The study cohort included 471 patients with rectal adenocarcinoma suitable for curative resection from 29 sites across 10 countries. The patients were randomized to either robotic-assisted (n=237) or conventional laparoscopic rectal cancer resection (n=234).
Jayne et al found that the overall rate of conversion to open laparotomy was 10.1%, and the conversion rates for robotic-assisted and laparoscopic surgery were 8.1% and 12.2, respectively.
“There was no statistically significant difference between robotic-assisted and conventional laparoscopic surgery with respect to odds of conversion (adjusted OR = 0.61 [95% CI, 0.31 to 1.21]),” the team reported.
As for complication rates up to 6 months postoperatively, there again was no statistically significant difference between the two groups (14.8% in the conventional laparoscopic group and 15.3% in the robotic-assisted laparoscopic group), and the same held true for quality of life.
“These findings suggest that robotic-assisted laparoscopic surgery, when performed by surgeons with varying experience with robotic surgery, does not confer an advantage in rectal cancer resection.”
The researchers also analyzed the healthcare costs associated with the surgeries on the 190 U.S. and U.K patients included in the study.
The healthcare costs in the robotic-assisted laparoscopic group (mean of £11 853 or $13 668 [95% CI, $13 025-$14 350]) were higher than in the conventional laparoscopic group (mean of £10 874 or $12 556 [95% CI, $11 889- $13 223]). The difference was statistically significant (mean difference = £980 or $1132 [95% CI, $191-$2072].
The researchers found that the main drivers behind the increased costs associated with robotic-assisted surgery were longer operating times as well as the costs of the equipment.
In an editorial accompanying the two studies, Jason D. Wright, MD, chief of the Division of Gynecologic Oncology at Columbia University Medical Center in New York City, wrote that robotic-assisted surgery has been intensely marketed, “not only to physicians and hospitals, but also directly to patients.”
He noted that a previous study by his group suggested that robotic-assisted procedures increased costs by an average of 13% across a range of different operations, and that the findings reported for radical nephrectomy and rectal resection in the two new studies are consistent with those estimates. “Whether robotic-assisted surgery for some procedures represents ‘value’ for either the individual patient or the health care system is unlikely,” he added.
Wright also pointed out that there were limitations to the two studies: For example, the study by Jeong et al was observational and subject to selection bias and the influence of unmeasured confounders; and the study by Jayne et al was a relatively small clinical trial that had a lower than anticipated rate of the primary outcome of conversion to laparotomy.
“Accordingly, these findings should be replicated in other studies and with other procedures to determine the potential comparative benefits of robotic-assisted surgery,” Wright concluded.
F. Perry Wilson, MD, MSCE Assistant Professor, Section of Nephrology, Yale School of Medicine and Dorothy Caputo, MA, BSN, RN, Nurse Planner