Surgical removal of tumors remains a primary method for the treatment of solid organ cancers. The widespread adoption of surgical robots in surgical oncology is intended to increase operational precision and efficiency, but raises concerns about heightened costs and threats to employment. This review evaluates patient, surgeon, and surgical team perspectives, and compares the efficacy and associated costs of robot-assisted cancer surgery with conventional open as well as minimally-invasive options, finding many favorable opinions of robotic surgery but few objective advantages.
Technological innovations in the health sector are readily adopted by patients and physicians alike, often before the technologies have been thoroughly evaluated for their merits and faults. Across Europe and North America, surgical robots enable cancer surgeons (surgical oncologists) to conduct complex operations with the minimally-invasive (laparoscopic) approach, which involves fewer and far smaller incisions than traditional open surgeries. Robot use is rapidly expanding in oncology as surgery remains the definitive treatment to “cure patients with solid tumors when the tumor is confined to the anatomic site of origin,” according to Steven A. Rosenberg, the Chief of Surgery at the American National Institutes of Health .
The only surgical console on the market is the da Vinci Surgical System, produced by Intuitive Surgical. According to the company’s IPO filing to the United States Securities and Exchange Commission, the da Vinci represents the “new generation of surgery” and consists of a “surgeon’s console, a patient-side cart and a high-performance vision system”, as seen in Figure 1. The da Vinci is not truly automatic—it can operate only by translating a surgeon’s “natural hand movements” (illustrated in Figure 2) into “corresponding micro-movements of instruments positioned inside the patient through small incisions” at the patient-side cart . In the United States, the number of da Vinci installations grew by approximately 75%, from almost 800 to around 1400, between 2007 to 2009 .
Risk-benefit analyses demonstrate that, compared with conventional open or non-robotic laparoscopic surgeries, robot-assisted minimally invasive surgery (RMIS) offers greater precision and dexterity for the surgeon as well as fewer short-term complications for the patient. However, as cost- and time- efficiency are often sacrificed and the long-term benefits of RMIS are uncertain, surgical robots do not objectively raise surgeon productivity and will likely not interfere with job availability in surgical oncology.
The transition from traditional open cancer surgery to laparoscopic surgery is intended to reduce patient pain and blood loss, lessen infection rates, shorten hospitalization times, and improve surgical productivity. Efficacy of RMIS is hereby evaluated in terms of precision, speed, and frequency of patient complications.
Precision is of utmost importance in surgical oncology. Human cancer is characterized by abnormal cell growth with the potential to metastasize into “malignant” tumors that invade adjacent tissues and spread to distant locations across the host’s body, becoming lethal if not promptly treated . The primary objective of cancer surgery is to remove tumors, prior to metastasis, along with a rim of surrounding tissue known as the surgical margin. A pathologist examines this margin and reports it as positive if cancer cells are present on the outer boundary of the tissue; or negative if no cancer cells are in contact with the surface of the tissue. Positive margins occur in up to 42% of open surgery cases  and can be associated with a more than threefold risk of cancer recurrence .
Nonetheless, utilization of the da Vinci system does not inherently lower the rates of positive surgical margins. A review of 513 patients from the International Robotic Cystectomy Consortium database shows that positive surgical margin rates for robot-assisted treatment of bladder cancer were “similar” to those resulting from open surgical procedures . Such observations may be explained by surgeons’ lack of experience with surgical robots, argue Fatih Atug et al. of Tulane University. Using the statistically significant results from their study on 100 cases of robot-assisted prostatectomy (a surgical operation to remove all or part of a cancerous prostate gland), Atug et al. conclude that “experience gained with time” leads to a “decrease in the incidence of positive surgical margins” .
Surgical speed is another critical factor of productivity in surgical oncology. In this regard, RMIS is substantially less preferable than open surgery [9,10,11]. On the other hand, procedures involving the da Vinci robot are in some cases quicker than traditional laparoscopic equivalents. A comparative oncologic study of open surgery, RMIS, and traditional laparoscopy, conducted by oncologists at the University of North Carolina, shows that RMIS is slightly more efficient than laparoscopy but significantly more time-consuming than open surgery .
Finally, robotic surgery reduces short-term but not necessarily long-term post-surgery complications for cancer patients. One multi-national collaboration of urology and cancer specialists, led by Giorgio Gandaglia, MD, of the University of Montreal, performed multivariate analysis on 5,915 American prostate cancer patients, who underwent either open or robot-assisted prostatectomy. The researchers note that patients in both groups faced “similar odds of overall complications, readmission, and additional cancer therapies” . These observations are corroborated by a multi-cohort study conducted at 279 American hospitals by Jeffrey J. Leow and his colleagues from Harvard Medical School. Leow et al. state that robotic surgery for bladder tumors require “greater expenditures” than open surgeries, yet have “no [significant] impact on major complication rates” .
In practice, the da Vinci system is more expensive and yet not comprehensively superior to conventional techniques. The exchange of higher operational costs for few guaranteed benefits is favorable for neither cancer patients nor the public health system.
To increase patient demand, Intuitive Surgical has “undertaken direct-to-consumer marketing for its robots,” reports private health news source Healthline. Public response has been overwhelmingly positive. Dr. Jay Redan, a charter member of the Society of Robotic Surgery with 20 years of experience in MIS, describes that “patients will go to someone who has the [da Vinci] because it’s been marketed so much” . Accordingly, in interviews conducted by the UCLA Institute of Urologic Oncology, prostate cancer patients show complete satisfaction with their da Vinci surgical procedures, shortened hospital stays, and quickened recovery times . Although such optimistic patient perspectives are not exclusive to robotic surgery, multinational business magazine “Fortune” estimates that, within five years, “one in three U.S. surgeries—more than double that of current levels—is expected to be performed with robotic systems” . The rapid worldwide dissemination of the da Vinci, despite its few proven benefits and controversial pricing, demonstrates the potency of a successful marketing campaign rather than a successful surgical innovation.
As published by the Canadian Agency for Drugs and Technologies in Health, the cumulative cost of installing one da Vinci system is around 3.2 million CAD and annual maintenance costs average at over 514,000 CAD . Prostate cancer researchers at the Vancouver Prostate Centre and the University of British Columbia calculate that the cost difference between open and robotic prostatectomy is 5629 CAD per case. Due to the “incremental hours of operating room time, additional disposable supplies, depreciation and service contract costs associated with the robot,” RMIS doubles the cost of open prostate surgery .
Fortunately for patients, the expenses of da Vinci surgery are covered by any insurance schemes encompassing regular MIS. To date, American hospitals have been “eager to attract patients” by absorbing the “higher costs associated with robotic surgery,” states Kaiser Health News, an independent, non-partisan news service. But future health plans will “incentivize the appropriate surgery” in an effort to “reward quality outcomes,” states Susan Pisano, spokeswoman for America’s Health Insurance Plans, a trade group representing 1300 U.S. health insurance companies .
SURGICAL ONCOLOGIST PERSPECTIVE
There is no consensus among surgical oncologists concerning the da Vinci. In response to criticism of the costs of robotic surgery published in the New England Journal of Medicine, the oldest peer-reviewed medical journal, three surgeons of the Weill Cornell Medical College affirm that their institution has “shown that robot-assisted surgery can result in considerable savings in costs because it is associated with decreased postoperative complications.” In their letter to the editor, the Cornell surgeons also maintain that “the growing interest in robot-assisted surgery has been supported by sound scientific evaluation” . In fact, an editorial published in peer-reviewed medical journal “The Lancet” reports that “many doctors and patients feel that robotic surgery is so much better” than open surgery or traditional laparoscopy that it “would be unethical to randomize patients” in comparative trials . This is problematic considering the current lack of clinical research on da Vinci.
Refuting unfounded claims of robot advantage, James T. Breeden, MD, president of the American Congress of Obstetricians and Gynecologists, contends that “robotic surgery is not the only or the best minimally invasive approach.” Breeden advises patients that robotic uterine operations are “best used for unusual and complex clinical conditions.” He also emphasizes that “the outcome of any surgery is directly associated with the surgeon’s skill” . Job training, a foundation of working productivity, is as crucial for surgeons using RMIS as it is for surgeons who specialize in open surgery or regular laparoscopy.
SURGICAL TEAM PERSPECTIVE
Team coordination and management are central to surgical productivity. Rebecca Randell, Ph.D., and a team of American and British physicians interviewed 44 operating room personnel from nine British hospitals. They note that, in RMIS procedures, the surgeon’s reduced “situational awareness” potentially disrupts coordination with assistants. Moreover, surgeons are unaware of “robotic arms impinging upon each other.” In one case, the robot arms would have “collided with a patient’s head” had an operating room nurse not intervened . Effective team communication remains essential in RMIS and assistants are necessary to monitor the surgery as well as to insert and remove the robot’s arms from the patient’s body. Thus, the da Vinci does not pose a substantial threat to operation-room job availability.
Investment in the da Vinci surgical system burdens hospitals with high installation and maintenance costs, especially as operating times are increased and major complications are not reduced. Compared with conventional surgery, RMIS also increases costs by requiring additional surgeon training and similar amounts of team management. Surgical precision and dexterity, however, can be greatly increased by robot assistance. Overall, surgical robots do not increase surgical oncology productivity but possess sufficient potential, and have received enough positive reception, to warrant further research and development.
The number of patients in need of oncological procedures is projected to rise by 24 to 51 percent by 2020  yet “no more than 50 surgical oncologists [are] produced yearly in the United States” . As a result, relatively simple cancer surgeries are commonly performed by general surgical teams. One potential solution is to program robots such as the da Vinci to conduct simple tumor removals autonomously, thereby reducing the workload of RAMIS-specialized surgical oncologists. Technology researchers at the University of Oxford observe that general oncologists are already “using IBM’s Watson computer to provide chronic care and cancer treatment diagnostics.” These same researchers concluded, however, that the surgical occupation faces a mere 0.0042 probability of computerization .
Incorporating the da Vinci into surgical oncologists’ customary training is advisable for improving operational speed and precision. Dan Veljovich et. al, a team of American oncologists, reason that a typical cancer surgeon performs “at least 20 or so cases” of RMIS before “demonstrating significant decreases in surgical time” . Training with the da Vinci may increase the duration of the surgical oncology fellowship, which already spans two years in addition to general surgical residency and medical school.
The medical sector must, therefore, adjust to the multiple aspects by which RMIS will increase expenditures, and healthcare plans should not automatically cover robot-assisted oncologic procedures unless benefits are certain. A possible means of directly reducing RMIS costs is through the development of alternative surgical consoles to compete with the da Vinci and dissolve the monopoly that Intuitive Surgical holds on RMIS, thereby reducing Intuitive’s profits and making surgical robots more accessible.
Productivity and investment value in cancer RMIS was pragmatically assessed using three criteria: surgical precision, operational efficiency, and patient complications. Assessments of social impact (such as job satisfaction), historic trends, and randomized patient trials, along with more detailed financial analyses, are necessary to validate the conclusions and solutions reached in this review. For the time being, the efficacy of RMIS in oncology depends largely on the surgical team operating the robot. Hence, surgical robots, so long as they remain non-autonomous, will not replace human surgical teams and do not offer a substantial net productivity advantage for conventional procedures in surgical oncology.
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