Robotic radical nephrectomy: There is a rationale

The following is in response to an editorial by J. Stuart Wolf, Jr., MD (“Robotic radical nephrectomy: Really?,” July 2014, page 6). The editorial concerned the article, “Use of robotic RN rising, despite unclear advantages” (July 2014, page 9).

Dear Stuart,

I enjoyed your Perspective in Urology Times. As a surgeon who has done both robotic and laparoscopic nephrectomies, I see your point. However, there is rationale for doing robotic nephrectomies. One of the reasons I do these cases robotically is that I feel more comfortable doing them than I ever did laparoscopically. The robotic visualization and improved instrumentation play a role.

In addition, we do perform partial nephrectomies when possible. I feel that doing nephrectomies robotically helps keep my skill level high and helps me be prepared for doing partial nephrectomies. In addition, in our practice we use a nurse as the bedside assistant for most robotic cases.

In terms of the cost issues, I think it depends on how you do the accounting. Aside from the cost of the robot, the cost may be very similar when you add up the cost of all of the laparoscopic instrumentation.

No question, somebody who feels comfortable doing these cases open, laparoscopically, or robotically should continue to do these cases with the tools available at their hospital. Somebody with your laparoscopic skills may not need robotic assistance to do partial or complete nephrectomies. However, if a surgeon feels comfortable doing robot-assisted cases and they have the equipment with good surgical outcome, should they not do these cases? Just my thoughts.

Marc Beaghler, MD

Ventura, CA

Next: Dr. Wolf responds

Dr. Wolf responds:

Dr. Beaghler makes several interesting points. In the weeks since my commentary was published, colleagues from around the country have made similar comments to me, but only Dr. Beaghler has been willing to have his thoughts published. Thank you, Marc.

First, “Aside from the cost of the robot, the cost maybe very similar when you add up the cost of all the laparoscopic instrumentation.” Most studies have suggested that robotic surgery adds cost compared to open surgical and laparoscopic surgery. My concerns with the application of robotic surgery center primarily on this increased cost; I do not have any opposition to robotic surgery otherwise.

We should remember that in the early days of laparoscopic surgery, the cost was greater than with open surgery and only as experience was gained did they equalize. I accept that the same might happen with robotic surgery, although at this time this is hard to imagine if the costs of the robot and the limited-use instruments are properly included. If the costs do truly equalize, though, then my criticism is withdrawn.

Second, “Doing nephrectomies robotically helps keep my skill level high and helps me be prepared for doing partial nephrectomies.” While a high robot-assisted surgical volume likely will help maintain robotic skills and this is of value to be sure, is it fair and just to increase the cost of a minimally invasive radical nephrectomy by doing it robotically (as opposed to laparoscopically) to maintain skills? Is it correct to “practice” during clinical patient care?

This strikes at the heart of the ongoing debate about how to train surgeons. Surgeons in training programs make this choice between education and cost every day. Taking a resident through a surgical case makes the case longer (and therefore more costly) than if the experienced attending is the primary surgeon. Looking at it that way, I increase the cost of almost every case I do in order to help the resident “practice.” As a profession, we must continue to struggle to find the best way to train and maintain skills.

Third, “One of the reasons I do these cases robotically is that I feel more comfortable doing these than I ever did laparoscopically.” I agree that this is the primary motivation for robotic nephrectomy. If the only option for a surgeon to offer minimally invasive nephrectomy with a high degree of competence was robotic surgery, then I would support that 100% under the presumption that the benefit to the patient was worth the increased cost.

The point I make in my commentary, however, is that there is another option if the surgeon does not feel comfortable with standard laparoscopy, that being hand-assisted laparoscopy. In the current era of single-site surgery and robotic assistance, the simplicity and effectiveness of this technique is often forgotten. None of the comparative studies of robotic nephrectomy and standard laparoscopic nephrectomy have shown any benefit of the former, but the literature does show that hand-assisted laparoscopic nephrectomy is at least equivalent to standard laparoscopic nephrectomy and in some measures is superior (J Endourol 2011; 25:1095-104). If you don’t feel comfortable with standard laparoscopic, then reach for the hand port instead of the robot!

J. Stuart Wolf, Jr., MD

Ann Arbor, MI

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