Robot-assisted versus open radical cystectomy: no clear signs of immediate benefit

Many readers of this blog have probably heard or read the reports like this one on the CBS Evening News or this one on the Reuters web site that there were no significant short-term (perioperative) differences in outcome between robot-assisted radical cystectomy (complete removal of the bladder) and the older open surgical procedure.

As regular readers of this blog will be aware, we have long cautioned our readers that the skill of the surgeon probably has more to do with the quality of surgical outcomes than the technical details of how the operation is done (with or without robot assistance being just one example of this). The current data provides one more example of this.

The study in question was carried out based on surgical procedures by seven experienced and specialized surgeons at Memorial Sloan-Kettering Cancer Center (MSKCC) in New York — and anyone who is doing radical cystectomies on bladder cancer patients at MSKCC is probably — even early in his or her career — among the best bladder cancer surgeons of his or her generation. This implies that what this study tells us is really only that among high-quality surgeons operating at a specialized, high-quality, tertiary cancer center, there is no difference in short-term outcomes of open vs. robot-assisted radical cystectomies. The authors themselves write that:

Because the trial was performed by experienced surgeons at a single, high-volume referral center, the results may not be generalizable to all clinical settings.

It should be noted that surgeons at MSKCC reported similar results when they compared open and laparoscopic outcomes after radical prostatectomies some years ago now.

The full text of the study report (by Bochner et al.) is available in a Letter to the Editor on the web site of the New England Journal of Medicine, and was published yesterday.

As implied by the authors, one needs to be cautious about over-emphasizing and over-applying the results of this study. Less skilled surgeons may (or may not) be able to get better results using robot assistance. Younger surgeons who trained using robots may have very little (if any) experience of carrying out open radical cystectomies or prostatectomies … and these operations really do require some very different skills to be applied when carried out with or without robot assistance. From the patient’s perspective, the important issue is that a surgeon should be operating in the way that he or she feels most competent.

On the other hand, from a societal perspective, there is a significant cost factor involved. Robot-assisted surgery is more expensive for payers and more profitable for hospitals (although this probably makes no difference to the revenue of the actual surgeon). There is therefore a serious question about whether the additional costs are worth us paying for as a society … because those costs add up rapidly over time.

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