Robotic nephrectomy on the rise, but why?

New Orleans-The advantages that robotic technologies bring to prostate procedures, partial nephrectomies, and other surgeries that can involve complex reconstruction are not readily apparent in simple extirpative surgeries such as radical nephrectomy. This raises two questions: Are robots being used in radical nephrectomies and if so, why?

The answer to the first question is “yes, increasingly,” according to a study from the Columbia University Medical Center, New York. The reasons underlying this response are not readily apparent and require some thought and elaboration.

“Are there significant advantages to using robots in a purely extirpative procedure such as a radical nephrectomy? The basic answer is no. Generally, for the past 10 years, since the da Vinci robot (Intuitive Surgical, Inc., Sunnyvale, CA) was FDA approved in the United States, very few to none of these procedures have been performed. But that is changing. More and more robotic radical nephrectomies are being done and there are reasons for that,” senior study author Ketan Badani, MD, associate professor of urology and director of robotic and minimally invasive surgery at Columbia University Medical Center, told Urology Times.

For the study, which was presented at the 2013 World Congress of Endourology and SWL in New Orleans, Dr. Badani and co-author Aaron Weinberg, MD, reviewed 59,922 radical nephrectomies reported to the Nationwide Inpatient Sample database from the last quarter of 2008 through 2010. The overwhelming majority of these (77.98%) were conducted as open procedures. Of the remaining procedures, 15.94% were laparoscopic and 6.08% were robotic.

Although minimally invasive procedures constituted a minority of nephrectomies, their numbers were sufficient to identify trends and establish some yet-to-be explained utilization relationships.

During the 27 months encompassed by the study, open radical nephrectomies decreased 2.9% and laparoscopic nephrectomies decreased 3.04%, whereas robotic radical nephrectomies increased 5.67%.

The data indicate that robotic utilization varied according to hospital size and geographic location, and that privately owned medical centers were more likely to perform robotic radical nephrectomies than state-owned hospitals. Institutions that frequently used robots in radical prostatectomies and partial nephrectomies were more likely to use them in radical nephrectomies.

Increased familiarity may drive trend

There may be several answers to the question as to why robotic nephrectomies are increasing. One is that physicians and their surgical teams are becoming increasingly familiar with advanced technologies. This familiarity is encouraging them to not only expand applications, but also transform traditional laparoscopic procedures to robotic, said Dr. Badani.

“The study raises questions,” he said. “Do surgeons who do a lot of robotic surgery in general do more radical nephrectomies? Are these procedures conducted more frequently in the bigger hospitals or teaching hospitals? My gut feeling is that there is a trend to doing more and more robotic radical nephrectomies and that it is going to continue as more physicians become familiar with the technology.

“Urology, as a field, is becoming more confident and experienced with robotic surgery. Those who do a lot of laparoscopy are converting to robotics. I think that is what this study is showing. If an index procedure existed for this trend, it would be a radical nephrectomy. I cannot say whether the conversion to robotics is good or bad, but it is happening,” Dr. Badani told Urology Times.

He made a point of saying that the robot presently does not appear to offer any distinct clinical advantages, adding that this is a question that needs to be fully explored. He anticipates the future will bring outcomes data on complication rates, hospital stay, and other findings that might better delineate the clinical differences in the surgical approaches.

At present, the expense of robots is a clear economic disadvantage for this procedure, but this too may be changing as the devices see increased use. A significant portion of the expense associated with robotics comes from the disposable costs associated with the technology, but as experience increases, the efficiency of the procedure improves and operating room time decreases. This could actually translate into robotic nephrectomy being cost equivalent to laparoscopic surgery in many centers.

In the near past, Dr. Badani noted, residents interviewing for residency slots in urology would ask if they would get experience with laparoscopic and robotic technologies. Recently, these candidates have been asking if they would get experience with open procedures. The conclusion to be drawn is that these young men and women were getting substantial experience with advanced technologies but were afraid they would be lacking experience with traditional procedures.UT

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