The ConsUmer: Questions About a Robotic Surgery

Ever since it was approved by the Food and Drug Administration in 2005, robotic surgery for hysterectomy has been heavily advertised. Surgeons promise that using the da Vinci robotic device will bring better results and an easier recovery, and many hospitals claim that patients will experience less pain and fewer complications, getting back on their feet faster.

The company that makes da Vinci robotic surgery equipment promoted it last May at free health workshops organized by the federal Office on Womens? Health. On Sunday, the Liberty Science Museum in Jersey City will host its first ?Let?s Operate Day,? offering guests ?hands-on? practice peering into video monitors and using da Vinci?s robot arms to pick up and manipulate small objects.

The cost of the new technology is rarely mentioned. But last week, a new study that evaluated outcomes in more than a quarter of a million American women raised questions about the manufacturer?s claims. The paper, published in The Journal of the American Medical Association, compared outcomes in 264,758 women who had either laparoscopic or robotically assisted hysterectomy at 441 hospitals between 2007 and 2010. Both methods are minimally invasive and involve smaller incisions than open abdominal surgery.

The researchers found no overall difference in complication rates between the two groups, and no difference in the rates of blood transfusion, even though one of the claims regarding robotic surgery is that it causes less blood loss.

But the researchers did find a big difference in cost. Robotically assisted surgery for hysterectomy costs on average about one-third more than laparoscopic surgery.

?It?s important to separate the marketing from the data,? said Dr. Jason D. Wright, the study?s lead author, an assistant professor of obstetrics and gynecology at Columbia University Medical Center. ?For the surgeon, there is a greater degree of movement and control of the instruments and the visualization is better.

?But the ultimate question is, does this change outcomes for patients? This study suggests that there really is not a lot of difference as far as quantifiable outcomes.?

The majority of patients in both groups left the hospital in less than two days, though patients who had robotic surgery were slightly more likely to go home that early: 80 percent went home in less than two days, compared with 75 percent of those who had laparoscopic surgery.

But the cost of robotic surgeries was significantly higher, with a median cost to the hospital of $8,868, compared with $6,679 for laparoscopic hysterectomy. The study did not look at the difference in patients? bills, but according to Newchoicehealth.com, the average patient price for a laparoscopic hysterectomy ranges from $7,700 in Dallas to $11,600 in Los Angeles.

With laparoscopic surgery ? sometimes called keyhole surgery ? narrow instruments and a small video camera are inserted through tiny incisions; the surgeon sees the image on a monitor and can cut and sew tissue with the instruments. With robotically assisted surgery, the surgeon sits at a console with a 3-dimensional view of the surgical site, and computer technology translates his or her hand movements into precise, scaled movements of the instruments.

Even without offering clear advantages the proportion of hysterectomies performed robotically has increased rapidly, up to nearly 10 percent of hysterectomies in 2010 from less than 1 percent in 2007, Dr. Wright said. Minimally invasive surgeries for hysterectomies are increasing across the board, he found, even at hospitals not performing robotic surgery.

Dr. Myriam J. Curet, chief medical adviser to Intuitive Surgical, which makes the da Vinci systems, did not dispute the study?s findings, but said the important message was that more women were able to receive minimally invasive surgeries because more options were available.

?That?s good for patients and for the health care system,? Dr. Curet said. Women who are not candidates for laparoscopic surgery might still be candidates for robotically-assisted surgery, she added.

Right now, however, it is not clear how to identify which women would benefit from robotic surgery and which would do well with a less expensive method.

The growing use of robotic surgery in hospitals will continue to drive up health costs, said Joel S. Weissman, of Brigham and Women?s Hospital and a co-author of an editorial published with the study.

?Once you have that robot, the tendency is to use it for all kinds of things, for which it may or may not have great value,? Dr. Weissman said. Studies like this one, he said, demonstrate the waste of health care dollars on ?something that costs a lot more and doesn?t offer any added benefit over current treatment options.?

Each year approximately 600,000 American women have hysterectomies, according to the Centers for Disease Control and Prevention. By age 60, one in three American women has had her uterus removed, often along with her ovaries and cervix.

Critics who say far too many hysterectomies are done in the United States worry that all the attention to surgical method distracts from the question of whether patients should be having the surgery at all.

Most hysterectomies are prescribed for conditions that are not life-threatening, and advocates worry that women are not fully informed of the long-term harms, which may include a loss of sexual responsiveness, depression and chronic constipation, and higher risk for osteoporosis and heart disease, said Nora W. Coffey, the founder of the nonprofit Hysterectomy Educational Resources and Services Foundation.

?That?s the conversation we should be having,? Ms. Coffey said.

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Nora W. Coffey and other experts emphasize that women considering a hysterectomy should discuss all options with their doctors.

?Ask what the alternatives are and whether watchful waiting is an option. Remember that it is irreversible, regardless of how the surgery is done.

?Learn about the nonreproductive functions of the uterus, ovaries and cervix, and the potential long-term consequences associated with their removal, as well as the function of the ovaries and cervix.

?If you proceed, discuss the advantages and disadvantages of different surgical methods with your doctor. Interview several surgeons and inquire about the cost and how much insurance will cover. Your co-pay may vary depending on the surgical method.

?Tell your surgeon if you do not want your ovaries and cervix removed.

Source: http://well.blogs.nytimes.com/2013/02/25/questions-about-a-robotic-surgery/?partner=rss&emc=rss

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