Imagine a surgery, and you’re probably picturing a scene right out of Grey’s Anatomy: a surgeon leaning over a patient’s open chest, wrist deep in flesh, asking for a scalpel. But since the 1990s, there has been a push away from this type of open surgery towards minimally invasive surgery, where doctors make small incisions and thread long plastic tubes through the incisions into the area that they’re operating on. They then work through the tubes, with the help of long instruments and a small camera.
After it was introduced, the benefits of minimally invasive surgery quickly became clear. It results in faster recovery times and shorter hospital stays – and has become the standard for many operations as a result.
More recently, robotic surgery entered the picture, with at least two dozen robots currently in use across Canada. The high-tech surgery uses up to four long, robotic arms, each topped with a different instrument – and removes the surgeon from the bedside altogether. Rather, from a console a few feet away, looking at a high-definition 3D viewing screen, the surgeons manipulate foot pedals and joysticks, their movements mirrored by the robot’s instruments within the patient.
“It’s like you’re playing a video game,” says Bob Kiaii, chair of cardiac surgery at Western University, who uses a robot often in his operations. “You move your hands, and that exact movement gets translated into the movement inside the patient’s cavity.”
Robotic surgery has an instinctive, futuristic appeal. Hospitals in the US use it in their advertising to attract patients, and Canadian hospitals may use it as a recruitment tool to get the best surgeons.
But 15 years after robotic surgery was first introduced in Canada, research hasn’t revealed overwhelming benefits to patients. The robots are expensive, and as a result, many have questioned whether they’re worth the cost.
Partially as a response to this debate, Health Quality Ontario is currently looking into the issue, starting with a focus on prostate surgery, the most popular robot-assisted procedure. The analysis, which builds on a 2014 report on the same topic, will look at the benefits and harms, and value for money. “We feel that enough time has passed that we should look at this subject again,” says Irfan Dhalla, vice president of evidence development and standards at Health Quality Ontario. (He’s also a member of the Healthy Debate editorial board.) “This time around, we will also probably make a clearer recommendation about whether this should be publicly funded.”
The landscape of robotic surgery in Canada
Robotic surgery entered the Canadian marketplace when the da Vinci Surgical System was first approved by Health Canada in 2001. The da Vinci robots still have a monopoly on the market, says Tammy Clifford, vice-president of Medical Device and Rapid Response Programs at CADTH. “When we’re using the phrase robotic surgery, we’re thinking da Vinci. They’re basically synonymous right now.”
But the robots come at a cost of upwards of $2 million – the Lois Hole Hospital for Women in Edmonton recently paid $3.3 million for a da Vinci robot. In addition, they cost about $180,000 a year for maintenance, and $3,500 extra per procedure, a number that includes the cost of extra operating room time.
They’re popular with surgeons. “[With the robot] it’s much, much easier. The vision is much better, the instruments are better, and physically it’s much easier on the surgeon as well,” says Rodney Breau, a cancer surgeon at the Ottawa Hospital.
In difficult procedures, the traditional way is “like operating with chopsticks,” agrees Kiaii. “With the robot, you have the same degrees of freedom as you do in an open operation, but with even more accuracy and higher dexterity.”
And they’re a favourite of patients as well. “I get more requests from patients themselves than from the specialists,” says Kiaii. People often find out about the robot-assisted procedure while searching on the internet or through word of mouth from others who have had it.
The evidence behind robots’ effectiveness
“In general, robotic-assisted laparoscopic surgery is safe and feasible,” says Christopher Schabowsky, a program manager at the ECRI Institute, an American non-profit that evaluates new health care technologies. “Overall, if your surgeon and surgical team are adequately trained, it is as safe as open surgery and laparoscopic surgery.”
But robotic surgery’s benefits are “procedure specific,” says Schabowsky. For many surgeries, especially those that are traditionally done in a minimally invasive way, it appears to be equal. For some – mostly those that are difficult or impossible to do minimally invasively without the robot – robotic surgery results in less blood loss, shorter hospital stays and faster recovery times.
An example is radical prostatectomy, which is difficult to do in a minimally invasive way without the robot. Before the Ottawa hospital got its da Vinci robot, it did most of its procedures openly. “Only about 5% of radical prostatectomies were performed laparoscopically before we got the robot, and now it’s 95%,” says Breau.
Radical prostatectomies are one of the most popular procedures to do robotically – in the U.S., about 80% to 85% of radical prostatectomies are robot-assisted. That’s why the first randomized controlled study on the procedure, recently published in the Lancet, caused some debate. The study will follow patients for two years after the procedure, and this publication reported only outcomes up to 12 weeks after the surgery. But it found no differences in quality of life, including urinary function or sexual function, between people who had open versus minimally invasive robotic surgery. It did find people who had robotic surgery lost three times less blood, though no patients in either group needed transfusions. They also had shorter hospital stays, from 3.27 days to 1.55.
A 2014 review from HQO looked at results for Ontario patients. It found that people who had robot-assisted radical prostatectomies were significantly less likely to require blood transfusions (less than 1% versus 11%) and had shorter hospital stays.
Two systematic reviews published in 2012 looked at the results from more long-term studies, and did find significantly less sexual dysfunction and incontinence after a year in patients who had received robot-assisted surgery.
Shorter hospital stays and less blood loss is enough of a benefit for Breau, who argues that “somehow the costs are over scrutinized with equipment, compared to medications…If this was a drug, it would be [funded] without question. Because it’s an instrument, there are a lot more questions.”
In fact, a 2012 review from the UK’s National Institute for Health Research compared laparoscopic surgery for prostate removal with robotic-assisted surgery. It found that there were significant improvements with the robotic surgery, especially around removing all the cancer. (They found 18% of robotic prostatectomies had failed to remove all the cancer, whereas 24% of laparoscopic procedures had.) It also looked at costs, and found that the cost-benefit of robot-assisted surgery was in the range of a technology that the NHS would normally fund (under £30,000 per quality-adjusted life-year). The review highlighted that in order to be cost-effective, the robots needed to be used frequently – around 150 to 200 procedures per year or more.
There’s a trend towards using robots more in general surgery in the US. But that use isn’t justified by the research yet, says Schabowsky. “ECRI is really eyeing the evidence when it comes to hernia repair, colorectal surgery and gallbladder removal,” he says. “Right now, gallbladder surgery is the most controversial, because unless you run into abnormal anatomy, it is a very simple surgery, and it can be performed traditionally very quickly and easily. So there is a question of why would you introduce the robot – you’d really be only adding on operative time and expense.”
The Canadian Agency for Drugs and Technologies in Health looked at the cost of robot surgeries in a 2012 review of observational studies (no randomized clinical trials were available). It found that prostatectomy was the most expensive robot-assisted surgery. Cardiac surgery was the cheapest overall – in fact, the increased surgical costs of using the robot were offset by shorter hospital stays and less time spent by patients in intensive care. It also estimated that in 75% of cases, robotic surgery was more expensive than open surgery and minimally invasive surgery, even after accounting for lower hospitalization costs.
In addition to purchasing and maintenance costs, hospitals spend about $3,500 per case on robot-assisted procedures. “For prostate cancer, we’re losing approximately $3,000 to $4,000, per case,” says Alan Forster, vice president of quality, performance and population health at The Ottawa Hospital. “We’re in a situation as a provider where we have let’s call it equivocal evidence, and we’re stuck deciding if we should provide this or not.”
The challenge, says Clifford, is balancing supporting innovation with demanding evidence. One way to do that would be for academic hospitals using these robots to track their outcomes and contribute to research around this – something that they’ve generally failed to do.
Forster agrees. “I would argue that we should be working with the Ministry of Health on this and carving out small amounts of money to do randomized trials. If we did them across the province, and we had standard outcomes [among institutions], in two or three years, we’d have the answer.”
As robots continue to get better, and the evidence continues to accumulate, the answers to these questions will hopefully become more clear. “Just like any health care technology, robotic surgery is going to continue to improve as devices get smaller and more nimble,” says Schabowsky. “The story’s going to continue to evolve.”