Tuesday, February 20, 2007

da Vinci Uncoded -- or, Surgical Robots Unite!

Visiting my in-laws in southern Florida, I came across a magazine story from the Westside Regional Medical Center with a story entitled "Dr. Robot is IN", extolling the virtues of their new $1.5 million da Vinci Robot Surgical System. It is also featured on their website.

The da Vinci system combines computer and robotic technologies and takes surgical treatment to the next level. Here's how it works.

As a surgeon prepares to perform a procedure using da Vinci, he or she sits at a console in the operating room that is often several feet away from the patient....

Because da Vinci magnifies images and its robotic arms follow the slightest movement of the surgeon's hands and feet (sometimes used to refocus the camera or adjust a robotic arm), da Vinci enhances dexterity, precision, and control during surgical procedures. da Vince can also scale down hand movements when the tiniest cuts are needed and eliminates hand tremors, which further enhances the technology;s precision.

A doctor at Westside says, "It offers excellent outcomes and a quick recovery, as well as many other advantages for today's on-the-go citizens -- all in the comfort of their community."

da Vinci is being set forth as the state-of-the-art approach to urological surgery, particularly prostatectomy (removal of the prostate.)

In a posting below, I set forth the current knowledge about the relative benefits of laparoscopic versus open prostate surgery. Suffice it to say that there is not a clear winner. Just so, too, in the case of regular laparoscopic surgery versus robot-assisted laparoscopic surgery.

So, in the absence of clinical evidence that the robot is better, what is going on here? Here's the answer, as set forth so clearly by Nancy Schlichting, President and CEO of the Henry Ford Health system in Detroit:

We've seen double-digit increases in the number of prostate cases performed since we introduced the da Vinci Surgical System.

And by the manufacturer:

The following are three examples of hospitals that have captured market share with the da Vinci Surgical System. These organizations have established a leadership position within their communities and have achieved a significant return on investment.

In short, what we have here is a new technology, with no proven advantage in terms of clinical results, that is rapidly moving forward in hospitals because urologists and their hospital administrators have become convinced that their market position depends on owning this robot. It apparently has worked as a marketing plan.

Since its first da Vinci System shipment, Intuitive Surgical has expanded its installed base to more than 300 academic and community hospital sites, while sustaining growth in excess of 25% annually.

Boston has not been immune from this land rush. Boston Medical Center recently bought this machine. The verdict from their surgeon: "Dr. Richard Babayan, chairman of urology at Boston Medical Center, said he's found no difference in continence rates in the 30 robotic cases he's done, compared with traditional surgery."

Notwithstanding the lack of evidence of enhanced clinical efficacy, I have been advised the following by one of our leading doctors:

Due to market forces beyond any of our control, the unfortunate reality is that without a DaVinci robot, BIDMC prostatectomy volume would likely plummet by 2010 and BIDMC would consequently quickly become a non-entity in regional prostate cancer care. This would have dire consequences for BIDMC clinical urology, radiology, radiation oncology, medical oncology, as well as for research in translational oncology. It is unlikely that [we can] fully gauge the breadth and depth of collateral damage that absence of a daVinci robot would bring to our medical center.

Why do I feel like the American Congress several years after President Bush promised them that Iraq had weapons of mass destruction?

Here you have it folks -- the problem facing every hospital, and especially every academic medical center. Do I spend over $1 million on a machine that has no proven incremental value for patients, so that our doctors can become adept at using it and stay up-to-date with the "state of the art", so that I can then spend more money marketing it, and so that I can protect profitable market share against similar moves by my competitors?

I welcome advice from those of you out there who care about the cost and quality of health care, but also from those of you in other business sectors who make choices like this all the time.

52 comments:

Anonymous said...

I guess it depends if you think the robot will eventually yield better results.

Go with whatever is going to the be the best in the future, if the clinical care given to patients is identical with the robot versus alternatives then no harm in introducing it early.

If you believe the robot is not the way of the future, skip it.

N. Turnbull said...

Paul,

I know you've written on this blog that you're not a huge fan of regulation after your DPU experience. But I don't see any way of controlling the proliferation of expensive technology without a robust state health planning process. Most other countries concluded long ago that controlling supply is a key to controlling health care costs, and to ensuring a more rational distribution of medical resources. I know previous planning efforts in the US and Massachusetts were far from perfect, but I think we need to re-engage in a serious way in figuring out how to regulate and control supply.

BC said...

You indicated that the evidence so far suggests that outcomes are no better with the robotic device than with traditional surgery. You didn't speak to whether or not there is any difference in the time it takes to perform the surgery. Assuming there is no difference, your challenge is to make it clear to patients that there is no difference in outcomes.

Since surgeons already have a bias toward surgery (as opposed to radiation treatment or watchful waiting for prostate cancer), if there were an expensive device that had to be used to pay for it, at the margin, we are likely to see more surgeries, including some that either aren't necessary or at least aren't necessary yet.

If not having the device means your hospital would have lower costs, you could charge less for the procedure. That should get the attention of insurers who, presumably, would be helpful in spreading the word to patients that there is no difference in outcomes. Through proper benefit design, patients could be required to absorb more of the cost if they wanted the robotic procedure. This would be similar to requiring higher co-pays for branded drugs when a cheaper generic would be just as effective.

The risk that all of this expensive equipment poses for the system is that it drives utilization higher, especially with respect to imaging equipment. Bright CEO's and CFO's should be able to work with insurers to come up with a pricing and payment scheme that gives the patient a financial incentive to make the most cost-effective decision rather than be indifferent because "it's all covered by insurance no matter what."

Paul Levy said...

Nancy, please see BC's comment. In the absence of state regulation of supply, the insurers in the state could have a major impact on these decisions were they willing to do so. I have discussed this below with regard to the proliferation of small, under-scale transplant programs. The insurers have been willing to make some decisions along these lines with regard to managing care, but not with regard to expensive programmatic investments. Why is that the case? Legislative action requires a majority vote and a governor's signature: Insurance company action only requires three people to decide. If insurers are concerned about overuse, underuse, misuse, and waste, why isn't this on their radar screen?

Jerry Berger said...

I can certainly see the problem from a PR standpoint. We worked on a story designed to educate men that prostate problems can occur at any age. The patient was absolutely thrilled with his primary care doc and his care. But he had his surgery at Boston Medical Center because of da Vinci.

Ileana said...

Back when I was in communist Romania rumors were that Romanian surgeons and airplane pilots that escaped the regime and worked in the western world were the best surgeons and pilots over there. The explanation was that doing surgery with the lack of supporting technology and flying old airplanes made them exercise their skills better than their colleagues.

So even if the robot does not make any difference in the skill of thaose first rate surgeons, maybe it makes a second-rate surgeon perform just as good as your top surgeon... If this is the case, I don't know if buying the machine will help you. If these guys get as good as you are, there might not be much you can do other than becoming better than the robot and marketing that skill.

Pretty tough one though.

Anonymous said...

Neither the regulatory process (FDA approval) nor Medicare coverage decisions screens out technologies that have no proven clinical benefit. The acceptance of "surrogate markers" to evaluate new technologies exacerbates the problem. Medicare coverage is based on a "reasonable and necessary" standard that is totally subjective and need not conform to improvements in quality or outcomes.
Unfortunately, most insurers march in lock-step with Medicare decisions. BC is right -- so long as the "consumer" is not confronted with co-pay premiums for expensive, unproven technologies, the docs "gotta have it" to stay competitive in the arms race. The CEO now has the Hobbesian choice of losing his docs' loyalty or making dubious capital investments.

Anonymous said...

The costs of the robot do not end with the initial capital outlay. You must also consider the rather expensive proprietary disposables, dramatically longer OR times, and annual maintenance on the equipment. A VERY expensive proposition. Been there...bled lots of red ink.

Domenico Savatta, M.D. said...

I am a urologist with a subspecialty in robotic surgery. I also blog as a hobby and commend you on an excellent blog.

There are several misconceptions about robotic surgery (in expert hands at least).

I agree that there is no difference in the literature in many papers. My feeling is that the robotic prostatectomy is a superior procedure to the standard open alternative.

As a cancer cure and from a continence standpoint I think it is similar in expert hands. From a return of sexual function, the robotic provides a much quicker return of sexual function.

From a blood loss standpoint and transfusion risk, robotics is far superior. Only 1 of my 238 robotic prostatectomies have had a transfusion. And that one was related to blood thinners given after surgery for another condition.

I recommend that my patients do not donate blood. I do not usually perform and postoperative bloodwork.

Over 90% of patients are discharged the next day.

As for the robotic surgery being slower, that is not accurate. I have done robotic prostatectomies in 1 hour and 17 minutes including the robotic setup and wound closure.

There was one patient of mine who recently had a 46 minutes prostatectomy and then through the same 6 incisions, had a kidney blockage fixed. The total surgery was under 3 hours and he was discharged 20 hours after the surgery. He was working 10 hours a day after 9 days.

In my opinion, this would not have been possible with open surgery.

Many of the worlds top open surgeons have switched to robotics including my mentor, Dr. Koch (Indiana), and Drs. Ahlering (UCI) and Smith (Vanderbilt).

Yes, I agree this is driven by marketing to some extent, but I think superior outcomes will be why the open surgery is abandoned. In my 9 man urology group, we have not performed an open prostate cancer operation since we started robotics.

Paul Levy said...

Sorry, Dr. Savatta, but I can't make decisions based on anecdotes. Let's look at some peer-reviewed data on clinical outcomes. Can you suggest some?

(And thanks for the compliments on the blog!)

Domenico Savatta, M.D. said...

The 2 best papers I can cite are Dr. Ahlerings:
http://scholar.google.com/scholar?hl=en&lr=&q=cache:SQrthwhkFpoJ:www.uphkino.org/pdf/gold_journal_uci_dvp_outcomes.pdf+ahlering+comparison+of+open+and+robotic+prostatectomy

This comes from an excellent open surgeon who had less blood loss, quicker hospital stays, and similar cancer and urinary function comparing his last 60 open (of hundreds) and cases 45 to 105.

Also Dr. Smiths review which I link to on my blog:
http://www.njurology.com/RoboticSurgeryBlog/robotic_surgery_basics/robotic_vs_open/

Consider several points:
Open surgery is mature, with hundreds of thousands or prostatectomies already being done.
Robotics is in its infancy. Even now results are the same or better across the board and techniques are being developed. I have several new techniques that enable me to perform better (quicker, more accurate, or easier to learn) robotic surgery that I am in the process of writing up.

As the months and years go by, robotic surgery will only improve. The instruments will get better and the robots will get smaller.

Telesurgery is not that far away.

On a personal note, I have trained many urologists on robotic surgery (We have the northeast daVinci S training site), and to a man, all have agreed so far that they had not seen the anatomy as well as they had watching me operate before.

We are magnifying anatomy 10 times while being only 2 inches away, a 50-100 times improvement over open surgery.
The challenge is teaching people how to handle this magnified view of the anatomy.

Lastly, I am fairly certain that robotic surgery is cheaper than open at our institution.

We are seeing shorter OR times than open, much quicker hospital stays, and less bloodwork and complications compared to open. I am not sure if the savings are enough to pay off the service contract and purchase price yet, but this is volume dependent.

Dale Russell MD said...

"Boston Medical Center recently bought this machine. The verdict from their surgeon: "Dr. Richard Babayan, chairman of urology at Boston Medical Center, said he's found no difference in continence rates in the 30 robotic cases he's done, compared with traditional surgery.""

Interesting that you demand peer reviewed data to support robotic surgery but provide anecdotal evidence against it. There is a difficult learning curve with this procedure, which applies even to academic department chairmen. At 30 cases he is barely getting the hang of it and it is not surprising that he finds no difference. If he has the same opinion after 200 or 300 cases then I will give his opinion more weight.

Paul Levy said...

The first article from Dr Savatta compares robot-assisted prostatectomies with standard open radical postatectomies. The summary:

"We present the results of RLP and RP performed by one surgeon. With only a 100-case experience, RLP had oncologic and urinary outcomes that were at least equal to those after RP. RLP offers the benefits of minimally invasive surgery and does not compromise clinical or pathologic outcomes."

I couldn't open his second one, but the first one is off the point. Can't you see that? The point, in further response to Dr. Russell, is that when someone wants me to spend over $1 million on a device, I expect him to offer clinical evidence of incremental benefit efficacy, not evidence that it is just as good. From what you all present, that evidence does not yet exist.

You expect me to wait till the surgeon has done 200 to 300 cases for the verdict to come in? Does the manufacturer offer a money-back guarantee?

(Wait, you further expect a surgeon to admit that he was wrong after he persuaded a hospital to buy an expensive device?! When was the last time you saw that happen?)

By the way, do you buy one robot or do you have an additional one in a simulation center for training, or do you use the one in the OR for training? In the latter case, what happens to the availability of that OR while the training is taking place?

Sorry folks, but I am seeing a lot of sloppy thinking here. I worry that early adopters of the technology have become advocates to persuade themselves and others that they have made the right business and patient care choice. In an era in which evidence-based medicine is supposed to be more and more important, that is troubling. The $1+ million you want to spend here has hundreds of other potential uses in hospitals that are always strapped for cash.

Let's see if anyone out there can do better in making the case.

Domenico Savatta, M.D. said...

"In an era in which evidence-based medicine is supposed to be more and more important, that is troubling. The $1+ million you want to spend here has hundreds of other potential uses in hospitals that are always strapped for cash.

Let's see if anyone out there can do better in making the case.

I will be out of town for the next week and look forward to reviewing your messages, but I have the ultimate way to settle this.

In my opinion, the best way would be a prospective study where we compared open to robotic results. As we can not randomize patients to this, the best way would be to compare robotic outcomes to open ones.

I would prospectively compare my results to any high volume open surgeon or any groups. The open urologists can organize the study, choose the forms we will use, and analyze all pathology specimens.

In 1 year we can compare 200 + robotic patients to the open ones and see which is quicker, oncologically better by margins, potency, continence, and whatever other catgory is important to people.

Thanks again for going on the record with your sincere thoughts on a difficult subject. At our hospital the CEO took 2 years of flack from the time he bought his first unit until I started working there.

As for your other question, we have 3 robots, 2 in the operating room and 1 in our training center.


As a last question, do you guys have a cyberknife or any expensive new radiation therapy that is far more expensive than a robot and also lacks the clinical evidence it is better than the older radiation units.

We have seen a lot of marketing from institutions that have cyberknifes for prostate cancer in the NY/NJ area.

Paul Levy said...

Thanks. We do have a Cyberknife, which we purchased because it can do clinical treatments that are not possible with traditional approaches, i.e., irradiating tumors that otherwise could not be irradiated or doing so where surgery would be impossible. Plus, the highly targeted radiation does less damage to surrounding tissues. See: http://www.bidmc.harvard.edu/display.asp?leaf_id=11422

Before you say, "Aha!", please be assured that we had reviewed the clinical results before purchasing, and we found them persuasive. Here, as noted, we expanded clinical capabilities and offered the public life-saving options that were not previously available. And, yes we also did a business analysis.

Also, we did not pay for the machine because a donor offered to! That really helps the return on investment. If you are offering to donate a da Vinci, let me know! :))

So, I am not a complete Luddite! Each case is a case in itself. We try to approach them in a highly disciplined way.

The Independent Urologist said...

At some point the market will become saturated and you'll be left holding the bag. My impression, though I may be wrong, is that we are nearing a saturation point for the Da Vinci, and at a $1 million plus price tag, you may have to wait quite a while for ROI. Maybe try a contrarian approach.

Anonymous said...

What would you do if a wealthy donor offered to finance it?

Paul Levy said...

Hey, I am a businessperson. A donation like that would mean a VERY high rate of return . . .

Since the clinical results apparently are no worse (!) and it would provide an opportunity for doctors to learn a new technology and it might enhance our market presence, it could change the calculation considerably.

Do I sound hypocritical? I hope not. As mentioned, I have an underlying problem of scarce capital resources. In the absence of other factors, I have to look at documented quality, safety, and other clinical metrics first. If capital ceases to be a constraint, it can be interesting to try out new technologies.

But it never works that way. Seldom does a donor come along with only one interest. You would have to compare this project with other ones in which he or she might have an interest.

Anonymous said...

If you want infinite ROI, get the donor to invest in cool new imaging technology that will allow for earlier detection and staging that would screen for aggressive versus indolent tumors that won't require surgery. Surgeons, like most experts, are hammers looking for nails, and, like the Pentagon, will support $1M hammers if they believe that's what the market will bear!

Anonymous said...

Henry Ford also performed a study referenced here:

http://www.henryfordhealth.org/body.cfm?xyzpdqabc=0&id=46335&action=detail&ref=544

Anonymous said...

Dr Levy, Great blog and interesting topic. Please allow me a patient's point of view. You responded, "RLP offers the benefits of minimally invasive surgery and does not compromise clinical or pathologic outcomes."

I couldn't open his second one, but the first one is off the point. Can't you see that? The point, in further response to Dr. Russell, is that when someone wants me to spend over $1 million on a device, I expect him to offer clinical evidence of incremental benefit efficacy, not evidence that it is just as good. From what you all present, that evidence does not yet exist."

From a patient's standpoint, if the efficacy is equal to open surgery yet offers minimal invasiveness this is BETTER from our standpoint. Less hospital stay would cause me to choose the daVinci if the outcome were the same. Perhaps this is what is really driving demand. The patient sees no difference in outcome, but will recover far quicker. This also reduces the need for hospital services, and presumably will lower costs. Win-Win?

Respectfully,
Potential Patient

Paul Levy said...

Dear Potential Patient,

You can have minimally invasive surgery performed by a doctor without a robot.

Dear Anonymous (1),

Excellent point. Surgery is but one option, and not always the right one. See the pubication cited just below for more details on that issue.

Dear Anonymous (2)

I guess we have differing references. Quoting from a recent Harvard Medical School publication, Perspectives on Prostate Disease, Winter 2007, Volume 1, number 1, p. 24:

"Proponents of this approach claim that robotic-assisted laparoscopic prostatectomy offers greater magnification and surgical precision than the alternatives, but thus far the evidence indicates that success rates and chances of complications are about the same as for traditional laparoscopic postatectomy and radical prostatectomy (so called "open" surgery.)

Anonymous said...

I'm just a dumb retired pathologist, but when constantly faced with a new and expensive lab instrument for which all kinds of claims were being made, I used the following quote, author unknown to me, which goes something like:

"Do not be the first by which the new is tried, nor yet the last to lay the old aside."

In other words, wait for as much good data as you can find before you rush in, but don't be the last one in your market either. I am old enough to be reminded of the debates about CT scanners when they were first developed, and about laparoscopic surgery itself when it first came into vogue. Both are now commonplace; who knows if da Vinci or one of its competitors will follow?

By the way, after 21 years of struggling to figure out what my hospital administrators were ever thinking (or if they did think), your blog is absolutely refreshing. Your hospital is lucky to have you.

retiredpath, M.D.

Paul Levy said...

Thanks!

A true message from my assistant today, "A rep from daVinci just came by. She said she’s been hearing all over the city that BIDMC is looking to purchase a robot, and she wanted to talk with you about it!"

Anonymous said...

As a previous hospital executive, I have witnessed the introduction of new or disruptive technologies and the impact that this has created. I was informed of a recent AUA post that 60+% of all urologic surgeons in the US said they would prefer to have their prostate removed with the robot. That tells me all I need to know at this early date. Additionally, there are thirteen robots in my current market and those without a robot have lost nearly all of their prostate cancer cases and all of the minor cases that the urologist was performing at the hospital. My final thoughts are as follows; call the top 10 urologists in the US and ask them what they think, call the top 20 robotic hospitals and ask what they think. A computer in the operating room between the patient and the surgeon is inevitable, period! Read any book about staying ahead in any field and you will hear a recurring theme, "if you are waiting for the data, you are too late." By the time the data is where you want it to be to become comfortable, you have missed the growth phase of any new or disruptive technology. Were you a late adoptor of laproscopic gall bladder removal,64 slice CT, drug eluding stents? Good luck with your decision.

john said...

Paul, ben a while. The unspoken issue is $$ - although I haven't seen a study, urologists say that the $/hour returns from the DaVinci are orders of magnitude better than other prostatectomy methods. But if patients (to quote one expert) remain "impotent and leaky," maybe it's time to ask about the procedure itself, rather than revenue maximizing methods.

William Halverson said...

I'll let others comment on our business experiences with our DaVinci; my comment is directed at the use of DaVinci from the perspective of 'quality control'.

I reinforce Ileana's comment about the way a robot can increase the proficiency of the average, not best, surgeons in your area.

First, there is a chain of hospitals in the CO/AZ/NM area that is using robotic simulation as a way to test surgeons before they get their credentials. Because the machine keeps a record of the surgeon's movements, they can be measured against a recording of the 'experts' in the procedure. We can see where that will lead.

Second, there are emerging technologies to allow reliable use of long distance communications networks in combination with robotic systems. The implications of this are less clear, and implementing the business agreements to allow the technology to fulfill its promise will be complicated; nevertheless as the dearth of specialists grows, the use of 'tele-robotic' surgury will become common practice.

Anonymous said...

"Tele-roboting", yikes! What next?
Labor and delivery automated kiosks? I thought we were entering the era of personalized medicine and now we're being told to embrace roboticized care.
Maybe it's not a bad thing that there will be a dearth of certain types of practitioners who embrace the new new thing because their self-images, or perception of market-savvy, require them to be early adopters rather than laggards. I'll say it again: the better investment strategy for patients and the system at large is in technologies that promote early detection and enhance the ability to properly stage a cancer. We still don't have enough data on how many unnecessary prostate surgeries are done every day, and our diagnostic and staging tools are amazingly primitive.

Michael said...

How do you define value?
daVinci can help with surgeon recrutiment and retention. It's Video capabilities also can be a great tool to educate the physician referral pattern on the clinical advantages (anecdotal eveidence). With more procedures perahps there would be more evidence.

Anonymous said...

The Da Vinci carries about $1.4M start up tag (last time I did a pro forma and negotiated-6 months ago) and frankly unless you have a very busy Urology practice or more like the only one in Boston, your IRR will take 2 to 3 years or longer and frankly the outcomes do not support such a purchase in most hospitals or soon physician owned surgical clinics. it is what us consultants call a "toy for tots"...a new gimmic for doctors to play with but as an administrator don't think it will impact outcome or core measures and ultimately help you with Medicare Pay for Performance etc...you know it will not...it is an expensive capital outlay that looks most excellent in a brochure for branding but at the end of the day grow your INR and Geri business...and do some FQHC outreach expansion to start managing your ever increasing charity and indigent cases coming into the EDs and the frequent flyers becasue we all need care but the appropriate level of care....and a Da Vinci is not promote better anything but darn it is fun to play with at the demos...

E. said...

Hi Paul,
I am neither a urologist, a robot marketer, nor am I am a wealthy potential donor. I understand it the outcomes of "daVinci surgery" (clinical and pathological) are comparable to the gold standard. If the surgery is less invasive, the blood loss is less, and the recovery is quicker then the questions are about cost effectiveness. This is not based on "surgical outcomes" (as this is the same) but quality of life issues in terms of possible increases patient satisfaction, patient volume (due to increased speed, and the bit you are appropriately uncomfortable about "market acceptablity" of robotic surgery), decreased time to return to work and related issues. I suggest that you get someone to do an assessment of the level of benefit necessary (including and excluding assumptions about the impact on patient volumes) to justify the outlay. You may have already done this. Anyway you have used the blog well in that you have raised issues about what should influence our decisions. Will be watching to if:
A) The daVinci rep lets you have one to test for a year
B) A daVanci machine is delivered along with and a blank cheque for a year's worth of supplies
C) You continue just fine without it
D)?

Anonymous said...

I must admit that my primary care is provided through BIDMC. That my prostate cancer was diagnosed at BIDMC. But, after my exhaustive research, when it came time to have my surgery, I went to BWH which has the DaVinci robot. The post-op recovery was remarkably uneventful and almost painless. I am a strong advocate of the procedure and highly recommend it to others.

Richard

Anonymous said...

In reply to Richard, what he doesn't realize is that he and many like him could have had the same outcome with an open or no-robotic lap surgeryas with the costlier robot. No matter, however, as many men in his shoes are also 'wowed' with the robotic technology and gravitate to it despite no multi-institutional, long term data, and that pattern of American consumer behavior won't change unless studies prove the robot vastly inferior (unlikely). In reply to Domenico, the prospective study comparing hundreds of robotic, laparosocpic, and open prostatectomies he's requesting is under way as part of a national HRQOL study funded by an NIH grant. Participating hospitals included BIDMC, MGH, Brigham, Cleveland Clinic, Washington University, UCLA, MD Anderson, University of Michigan, and UCLA. Accrual was completed in March 2006. Preliminary findings were reported in part at last year's AUA meeting, and an expanded evaluation will be reported at this year's AUA meeting in May 2007. It will take another year for the analyses to complete the peer-review process and be published. In the meantime, as a surgeon who has performed prostatectomy using each of the three principal techniques - robotic, laparoscopic, and retropubic - and as an investigator familiar with data presented in these preliminary analyses, I can relate three concerns that any surgeons who have expertise with all three would likely confirm: 1) Lap or robot techinques have less blood loss than open, due not to the robot but instead to reduced venous pressure from pneumoperitoneum that is required for laparoscopic surgery; 2) Lap or robotic techniques bring the dissection closer to the prostate, and whether or not this leads to worse cancer control (leave cancer behind) will not be clear for several years; 3) The robot is not a magic bullet that eliminates incontinence or impotence; 4) The robot does make the laparoscopic operation substantially easier for the surgeon, reducing operative time and inter-surgeon variance and thereby facilitating patient access to more consistent surgical care. Large cost, modest gain - and probably sufficiently meritorius to warrant an investment now for your hospital to keep pace with the cutting edge and impact the evolution of prostate cancer care. It's not that different than the reality of MRI 20 years ago...

Pat McCarthy said...

My husband had a robot assisted (da Vinci Surgical) prostatectomy on December 20, 2006.

An hour and a half into the surgery a high intensity light bulb on the control tower exploded splattering glass onto the operating room wall. The surgeon converted to open surgery. During the open surgery my husband required three blood transfusions. His pulse went up to 190. He spent the next two days in intensive care and two more days on the cardiac floor. Recovery time went from three weeks to six weeks.

At first it looked like the hospital, Central Dupage Hospital, Winfield, Il was pointing the finger at Intuitive Surgical. A representative from Intuitive flew out the evening of the occurrence to inspect the equipment. There was speculation that a fan that cooled the light bulb had failed which caused it to overheat and eventually explode.

I called the hospital yesterday and the VP of Operations that was so caring in December was less than responsive in March.

Both the hospital and Intuitive Surgical are not saying much about the event now. I feel like a victim. Everyone else has glowing reports of this procedure.

We did our research and thought we had chosen the best procedure. We certainly didn't anticipate this outcome.

Anonymous said...

Paul;

Here is a link from the Washington Business Journal re what is happening in Baltimore with the da Vinci system. For a mere 0.5 mill more, you can now get 4 arms! Seriously, perhaps it will help pay for itself with TCV surgery and/or training capabilities....
http://washington.bizjournals.com/washington/othercities/baltimore/stories/2007/03/05/focus1.html?b=1173070800^1424991

Herman Kattlove said...

Unfortunately there will be no randomized controlled trials to evaluate robotic surgery. Urologists don't seem to believe in this approach to clinical medicine. We still don't know if PSA screening saves lives. But complications such as blood loss are low (see my post regarding article in European Urology from Henry Ford Hospitals -kattlovecancerblog.blogspot.com) and most surgeons can learn the procedure. Sure a great surgeon is probably as good, but how many of them are there?

Dale said...

I thought that this article may be of interest: http://www.medicineatyale.org/v3i1_jan_feb_2007/robot.html

Anonymous said...

how many radical prostatectomies must be done to prevent one death from prostate cancer? this thread concerns a fancy way of doing an operation that has marginal utility. this is true of a great deal of what is being done in medicine and surgery today.

scot s w said...

Paul, in these comments you write,

"Sorry, Dr. Savatta, but I can't make decisions based on anecdotes."

True -- yet, in the initial posting you write,

"The verdict from their surgeon: 'Dr. Richard Babayan, chairman of urology at Boston Medical Center, said he's found no difference in continence rates in the 30 robotic cases he's done, compared with traditional surgery.'"

Is that not the epitome of anecdotal? And are one's surgeon's continence rates the whole picture?

Presuming you have done more reading than you reference in your post, what has that told you about outcomes?

And are you looking at this strictly through the lens of one type of procedure? In evaluating whether to make this purchase, isn't this a more strategic question of whether your hospital wants to be involved in robotic surgery in general in the 21st Century -- rather than a smaller question of marginally better/worse protestectomy outcomes?

Russell said...

My father recently passed away as the result of his prostate cance. That being said, I vividly recall the days following his initial diagnosis and subsequent open surgery which was performed by a very competent surgeon. He suffered a great deal during recovery.

As anyone who has had surgery will surely attest, surgery under anesthesia is not memorable. Recovery following surgery is most memorable.

As I am now of the age where I must closely monitor the health of my prostrate, I feel some comfort in knowing a procedure exists which offers improved post-surgery recovery and less blood loss.

Anonymous said...

This is a wonderful blog for anybody contemplating prostate surgery and Paul, I congratulate you. However, I think you underappreciate the bigger picture - that this is the way of the future, not just for prostate surgery but for many other types of procedures.

In 10 years time, this will likely be the preferred method for gynecologic surgery, many forms of cardiac surgery, and maybe even neurosurgery.

Hospitals that get a reputation as leaders in robotic surgery will be able to leverage this in the other fields and, at the other end of the spectrum, those that get a reputation as trailers will be disadvantaged.

BTW, Paul what is the latest status of the debate at your hospital?

Anonymous said...

So far the debate has been on the robotic assisted laparoscopic surgery against the open surgery.

Not quite a fair comparison.

There is evidence (see ref below ) that the pure laproscopic surgery provides the similar surgical benefits at the cost of the open surgery.

The pure laparoscopic surgery does not provide as much operation comfort as the robotic assisted version, but it is cheaper with nearly all the benefits. (Intuitive now provides a special chair for the operating surgeon now.)
When money isn't the issue, I am sure everyone would choose da Vinci S with the ($100k+) HD endoscopic system. But in other countries, they may not be able to afford these. That is why so far there is one da Vinci in Russia, two in China (one of the two in Hong Kong), one or two in India.

Prostatectmy require fairly high precision, so the operation comfort is important though not essential. But for hysterectmy and many other surgeries, precision isn't that critical as there is no nerve sparing etc ...

Da Vinci has a lot of (over complicated) mechanical parts that are unreliable. The rate of abort-conversion-to-open is an indication of the failure cases. Normally surgeons abort and convert after no more than two locks. So the $100k annual service is unavoidable.

Any comments from surgeons on promoting the use of the cheaper pure laparoscopic surgery?

Reference;
Alternative technologies to the robot to improve outcomes of laparoscopic radical prostatectomy. Poster. Julio M. Pow-Sang, Alejandro Rodriguez. World Congress of EndoUrology September 2006 Cleveland, OH. H. Lee Moffitt Cancer Center Tampa, Florida, USA.

Anonymous said...

Would like to know how this delicate situation has continued to unfold. I am aware of the robotic situation in the Boston area and since the last posting a number of things have happened.

Lahey Hospital in the northern suburbs has installed a second machine and hired a second robot doctor. Winchester Hospital has installed a machine. Partners has finally installed a machine at MGH which goes on line late Feb 2008. In addition the BWH gyn-oncologists have all jumped on that machine as the 'second' wave adopters and BWH is installing a second machine to handle that demand.

In essence the number of robots in the Boston area has jumped from 3 at the beginning of 2007 to 7 by the end of Feb 2008. How long can the 25yr referral pattern at BIDMC remain relatively intact in the face of such penetration of a 'disruptive' technique.

Many thanks
Matthew

Anonymous said...

I think one of the CLEAR factors to the sham... is that Urologist tend to get into ANY business that makes money and has good outcomes: ESWL or Lithotriptors... they will fight to STOP a hospital from purchasing one... so they can rent theirs. They buy lasers, and other equipment to rent to the hospitals. THEN since they can't make money in an LLC with their own Robot... they stron arm a hospital to take the "bath" on the device and lose significant amounts on each prostate.

Anonymous said...

This blog site is rather humorous.

As another experienced robotic prostatectomist (over 150 cases) I can tell you tell you several things.

1) Every single chief of urological oncology in our surrounding area has said, in the past, that they see no need to do a surgery robotically when they do such a good job open. Well, all of those surgeons are now doing robotic prostatectomy, and are touting the results.

2) Along the same line as 1)...any surgeon, academic or not, that scrutinizes robotic surgery has ABSOLUTELY no idea what they are talking about until they try it.

3) In my experience, yes it is anectodal for now, but will be published...... 95 percent of patients go home post op day one. The transfusion rate is less than 1 percent. The positive margin rate is better than with open surgery....10 percent...most of those positive apical margins, focally, which we know are not true positive margins....not one has had a detectable PSA. One half of patients take no pain meds. Return to full activity is 2-3 weeks!...definitely faster than in open surgery. Continence is much quicker, and return of erections is far superior.

One cannot compare the two (open vs robotic) without having experienced MORE than the thirty cases discussed in the one study mentioned in this blog. It does take time to learn the technique...but once one gains the experience....the visualization is far superior...there is NO COMPARISON in nerve sparing.....the anastamosis robotically is FAR SUPERIOR and completely WATERTIGHT..completely visualized during the procedure...

Yes, there are no randomized studies showing superiority yet...however, Dr. Academic Urologist...I challenge you to get an answer from any academic urologist who has experience in this procedure to agree with your scepticism. Experience means more than 100 cases.... Outcomes are most definitely different than with open surgery. One sitting in their Ivory Tower just thinking about these things and looking at one study comparing 30 patients is completely blind. Open your eyes and see what is going on in the real world.

host said...

Paul, I am interested in your take on da Vinci adoption for hysterectomies and whether it will mirror what happened in prostatectomies.

My rough understanding of da Vinci prostatectomies is as follows: Though clinical proof is arguably elusive, most doctors believe they are able to spare more nerves and patients have shorter recovery times. Since nerve sparing can mean better continence/sexual performance, there is strong patient demand for the da Vinci. This has led to widespread adoption by hospitals (to avoid losing patients, to attract top urologists/oncologists, and to market hospital as cutting edge.)

I am wondering whether the hysterectomy story will be different. Similarities abound, but it seems that nerve sparing is less of a concern. Also, trans-vaginal or lap-assisted trans-vaginal present less invasive alternatives to the robot.

As a hospital CEO, are you seeing demand for da Vinci from gynecologists that mirrors prostatectomy demand from a couple years back? Are insurance companies starting to reimburse for the higher cost of da Vinci? Or does this remain a questionable investment for the hospital to make, in the absence of hard data that supports better patient outcomes.

Thanks for any insight you can provide.. I appreciate your time.

Paul Levy said...

To answer your three questions: Yes, no, yes.

Anonymous said...

WOW...i really can not believe that Beth Israel Deaconess Medical Center doesn't have a da Vinci....you can argue all you want about 'is it better', 'are there studies' and so on...but what you can not argue is the consumer demand for better outcomes (perceived or real). Think of it like this, if you had to have surgery would you pick A)24 hr hospital stay and back on the golf course in 3 weeks OR B)48-72 Hr hospital stay and at least 6 weeks of no golf....AND as a bonus if you pick option A we will toss in a much greater chance that you can get a stiffy again....the biggest problem is you are thinking like a CEO and not like a customer...

tantrik said...

From a dumb doctor,

I am fascinated with the discussion as to the merits and demerits of an equipment where the benefitted do not even have to weigh in. A health care system where the consumer is out of the loop and not at risk for at leasta small portion of the cost of a service leaving you the profound people to make the decision onhis behalf leads to demented health care system. So here on record I propose that all health insurance be 50/50 insurance meaning the insurance portion has to be equal to deductible portion, that the deductible be kept bythe patient who does not use it and can invest similar to his IRA, that the government provide those that are not covered by employer again with the caveat they can keep it if they dont use it, similar to HSA accounts, that the employers who only use 50/50 be given deductibility for taxes. When you put the patient in the loop, he will make the decision and I believe this great country was built on those principle and is at risk of rapid demise because even our most educated and profesionals such as our illustrious CEO forgot what the problem is and is worrying about who is right and wrong. IMHO

Ann C said...

Paul
It is now October 2009... what are your feelings about this technology now ....

Paul Levy said...

See here: http://runningahospital.blogspot.com/2008/11/uncle.html

tom.affeld said...

While filming a TV Commercial for Health First's New da Vinci Robotic Surgery system there were a few out takes that did not make the final cut. We have put these outtakes together in one video for your viewing enjoyment.

View the Video Here:
http://youtu.be/KmOIbNPQNj0