Robotic-assisted laparoscopic approach challenged for rectal, renal cancer patients
medwireNews: Research casts doubt on the benefit of robotic-assisted laparoscopic surgery for patients requiring rectal resection or radical nephrectomy, finding no significant benefits over a conventional laparoscopic approach.
Although robotic-assisted laparoscopic procedures offered comparable short-term outcomes to laparoscopy for patients in both studies reported in JAMA, the surgeries took longer to perform and had higher costs.
The author of an accompanying editorial notes that, despite heavy marketing of robotic-assisted surgery, the findings follow earlier studies indicating that the benefits usually found with robotic-assisted surgery versus open surgery do not follow when comparing laparoscopic procedures.
“Without clear demonstration of improved outcomes associated with robotic-assisted procedures, the complicated issue of the cost will become increasingly important,” says Jason Wright (Columbia University College of Physicians and Surgeons in New York, USA).
The first study reports the outcomes for patients with operable rectal adenocarcinoma who were randomly assigned to undergo robotic-assisted (n=236) or conventional (n=230) laparoscopic surgery with curative intent. Participating surgeons had conducted a median of 50 (range, 30–101) prior robotic-assisted procedures and 91 (range, 45–180) conventional laparoscopic operations.
Conversion to open laparotomy occurred in a comparable 8.1% of the patients who underwent robotic-assisted surgery and 12.2% of the patients who received conventional surgery.
The surgical groups also had similar outcomes with regard to the rates of positive circumferential resection margins, intra- and postoperative complications, 30-day mortality, and bladder or sexual dysfunction.
But robotic-assisted patients had a longer operating time than their conventional laparoscopic surgery counterparts, at 298.5 versus 261.0 minutes (difference, 37.5 minutes), and the average cost of surgery was significantly more expensive, at £11,853 or $13,668 per patient versus £10,874 or $12,556 (difference, £980 or $1132).
Lead author David Jayne, from St James’s University Hospital in Leeds, UK, and team therefore conclude that “robotic-assisted laparoscopic surgery, when performed by surgeons with varying robotic experience, does not confer a clinically important benefit over conventional laparoscopic surgery in the short term.”
The second study compared the outcomes of 5180 patients included in the US Premier Healthcare database who had undergone robotic-assisted radical nephrectomy for a renal mass between 2003 and 2015 with that of the 18,573 patients who had undergone a conventional laparoscopic surgery over the same period.
After adjustment for the inverse probability of treatment weighting, the robotic-assisted and laparoscopic patients did not significantly differ in the rate of any (22.2 vs 23.4%) or major (3.5 vs 3.8%) complications, or with regard to requirement for blood transfusion (21.2 vs 17.8%).
However, 46.3% of the robotic-assisted radical nephrectomy patients had an operating time of over 4 hours compared with just 25.8% of the conventional laparoscopic patients, say In Gab Jeong (University of Ulsan College of Medicine, Seoul, South Korea) and co-investigators.
Robotic-assisted radical nephrectomy was also more expensive than conventional laparoscopic surgery, with average 90-day direct hospital costs of $19,530 versus $16,851, a difference of $2678 which the authors attribute mainly to operating room and supply costs.
Editorialist Jason Wright concludes: “From a policy perspective, robotic-assisted surgery exemplifies the difficulty of balancing surgical innovation with evidence-based medicine.
“Both the generation of high-quality evidence evaluating new procedures and then the utilization of this evidence to guide practice should remain priorities for surgical disciplines.”
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