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Anonymous Blogger Reviews The Lack Of Evidence For Robotic Surgery

The surgeon who blogs as Skeptical Scalpel writes that he (she?) is unable to contain him(her)self any longer and then lunges into a review of evidence (or lack thereof) for robotic surgery.

You may disagree with Skeptical Scalpel’s decision to be anonymous, but he/she explains:

Operating-Room.jpg“I’ve been a surgeon for almost 40 years and a surgical department chairman for over 23 of those years. During much of that time, conforming to the norms, rules and regulations of government agencies, accrediting bodies, hospitals, societies, and social convention was necessary for survival. I was always somewhat outspoken but in a controlled way most of the time. I now have a purely clinical surgery practice with no meetings, site visits or administrative hassles. I am free to speak my mind about medicine or anything else.”

On robotics, Skeptical Scalpel writes:

The problem with robotic surgery is that it has never been shown to improve patient outcomes for any procedure. Let’s look at the literature. The review articles cited below are almost exclusively based on non-randomized studies.

Laparoscopic Cholecystectomy. A review by the noted Cochrane Group involving five studies and 453 patients showed no differences in any outcome measure when comparing robotic surgery to conventional laparoscopic surgery.

Esophageal Reflux Disease. A review of 11 papers comparing standard laparoscopic anti-reflux surgery to Robot-Assisted Laparoscopic Fundoplication [acronym “RALF”] in 533 patients showed no differences in peri-operative complication rates or length of hospital stay. The robotic procedure took significantly longer. Another recent paper demonstrates the lack of quality research on this topic.

Colorectal Surgery. A review of 17 studies, one of which was randomized and controlled, showed no difference in the rates of complications and cancer outcomes. Robotic procedures took longer an cost more than conventional laparoscopic colon surgery. Despite the results, the authors felt that “Robotic colorectal surgery is a promising field and may provide a powerful additional tool…”

Gynecologic Surgery. A review of 22 non-randomized studies found that robotic surgery resulted in less blood loss [statistically significant but not clinically significant differences] and shorter hospital stays but no differences in overall complication rates when compared to conventional laparoscopic or open surgery. The authors commented that the methods used in the papers reviewed were poor and better studies are needed before concluding that robotic surgery offered any true advantages.

Abdominal Surgery. A paper from 2010 looked at 31 studies of nine different abdominal operations [robotic vs. conventional laparoscopic], 6 of which were randomized, controlled trials [RCTs]. The total number of patients included in all the studies was 2166. The number of patients who were participants in RCTs was 230. No RCT involved more than 50 patients. Not surprising was that the results were mixed with robotic surgery offering no clear advantage. These authors also called for larger and better designed studies.

Prostate Cancer. To date, there are no good RCTs comparing robotic to open or standard laparoscopic prostatectomy. This quote from a recent review of the literature on prostate cancer surgery says it all:

“Robotic prostatectomy is definitely here to stay and although a randomized, controlled trial comparing the open to robotic techniques would be ideal, it is clear that this is unlikely to occur.”

The issue may already be settled. According to the New York Times, patients are voting with their feet, preferring to have robotic surgery when it is available. This appears to be true in Wisconsin as well. A recent paper reveals that when hospitals purchase a robot, their volume of prostate cancer surgery doubles.

Questions. Can anything be done about this? Should Medicare and private insurance companies pay for expensive, unproven treatments?

See the comment left on the blog by an anonymous commenter about a lawsuit involving a death 10 days after robotic prostatectomy….and Skeptical Scalpel’s response that this may be just the tip of the iceberg.

I always remind readers that the plural of anecdote is not data. But with any technology for which we only hear about benefits and rarely hear about harms, one wonders how many such anecdotes we never hear about.

*This blog post was originally published at Gary Schwitzer's HealthNewsReview Blog*

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