Rapid increase in number of radical prostatectomies in the USA

Another article in this week’s New England Journal of Medicine addresses the rapid increase in the number of robot-assisted surgical procedures carried out in the US between 2005 and 2008.

Barbash and Glied have studied the impact of the introduction of the da Vinci robot on the numbers of surgical procedures carried out in the US each year and the associated costs of those surgeries. The complete text of their article is again available on line.

They focus in particular in the significant increase in the annual number of radical prostatectomies that appear to have occurred because of the introduction of the da Vinci technology, and the increased costs of these surgeries.

The “New” Prostate Cancer InfoLink recognizes that there are many complex issues related to adoption of such technology. Surgical cost is just one of these. Barbash and Glied do not, however, address what may have been a significant saving from less post-surgical hospital days associated with laparoscopic as opposed to open prostate cancer surgery and a reduction in the overall need for blood transfusions.

We have no doubt that someone will, in the end, carry out a detailed analysis of the cost-benefit equation associated with robot-assisted prostatectomy. However, it is almost certainly too late to put the genie back in the bottle. For better or worse, surgeons training today have learned to carry out radical prostatectomy using the da Vinci robot. Most of them would have to be completely retrained if they needed to learn to carry out open surgeries. That is most unlikely to happen!

There is, of course, a whole different question around how many of the radical prostatectomies carried out over the past 5 years or so were actually medically justifiable in men with low-risk prostate cancer — most particularly in those men with a life expectancy of less than 10 years.

6 Responses

  1. How does the learned Sitemaster decide whether radical prostatectomies are medically justifiable? And in general: Can we take a statistics, such as “life expectancy” and make a decision in a particular case based on this number? Remember, “life expectancy” is an average. What should be the standard deviation to justify a decision not to operate?

    What would be the learned Sitemaster reaction be if he came to the doctor with a condition (not necessarily prostate cancer related) and be told that given his life expectancy, no treatment is recommended?

  2. Hmm. The post implies that all (US?) urology surgeons in training today learn prostatectomy with the da Vinci robot procedure to the exclusion of an open procedure? Is that actually the case?

    If so, it won’t be all that long until open prostatectamy is no longer a convenient option (for US prostate cancer patients). At least as relevant a question as costs and justifiability is mortality for the (medically justified) different procedures.

  3. The “learned Sitemaster” does not think that “average” life expectancies should be used to make such determinations. The question of whether an individual patient wants and is or isn’t an appropriate candidate for a certain type of treatment for a specific condition at a point in time depends on multiple factors, not just life expectancy, and two different people with exactly the same factors can rationally (or indeed irrationally) come to quite different conclusions in discussion with their doctors.

    This is as true for the “learned Sitemaster” as anyone else. And since the “learned Sitemaster” lives with a chronic condition which would affect many such decisions, he takes his reasonable life expectancy into consideration all of the time in discussions with his physicians.

    The “learned Sitemaster” also believes that Reuven’s physicians have a moral and ethical obligation to tell him if — given his clinical condition and his potential life expectancy at a point in time — they believe a specific treatment is in his best clinical interests. The decision to have that treatment is then Reuven’s — even if it is an unwise decision and he comes to regret it.

    Oh … and the “learned Sitemaster” does not ever “make decisions” about whether radical prostatectomies are medically justifiable for anyone except himself. He seeks to bring attention to issues which are relevant to that decision (and others) for individual patients and for society as a whole.

  4. I believe that the vast majority of urologists in training who expect to treat prostate cancer patients for a living are already doing the vast majority of that training using the da Vinci robot. That doesn’t mean they won’t do some open surgeries along the way as part of the training, but they are highly unlikely to have the same intimate familiarity with conduct of the open procedure as someone who completed his training in the mid-1990s. They expect to use the robot-assisted technique when they complete their training, and open surgery is something they will only use when they absolutely have to.

  5. Isn’t interesting that “tone” is something very palpable in reading posts. It is also interesting to me how things like PSA, screening, and issues regarding the type of prostatectomy which is performed can become so emotional. I think the “learned Sitemaster” does a commendable job. “Sitemaster,” however, does come off a bit chauvinistic and paternal, maybe ” the prostate arbitrator of truth” would be a better fit. Seriously, SM, keep up the good work.

  6. I am of the opinion that the Sitemaster does an excellent job of locating subjects of interest to prostate cancer patients and caregivers (and I would hope some urologists and medical oncologists as well), then providing same to we subscribers with a reasonable comment regarding the subject for our review and personal comment.

    On the subject of the rapid increase in RPs, I have found that by and large most men diagnosed with prostate cancer, despite low grade development that would permit active surveillance, are opting for early treatment because they want the cancer out by whatever means. That being the case, their numbers add up to that “rapid increase.” With the hype that came with the advent of the daVinci robotic system for laparoscopic removal of the prostate gland, this procedure appears to have replaced open surgery RP as the new “gold standard.” As to training physicians to the specialty of urology regarding the prostate and prostate cancer, to my understanding performance of open surgery is certainly part of that training. However, as noted by Sitemaster previously, likely nowhere near intense as it should be prior to moving to use of the daVinci robotic system.

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