Study: Acquisition of robot leads to increased prostatectomy rates

When hospitals acquire surgical robotic technology, men in that region are more likely to undergo radical prostatectomy, according to a recent multicenter study.

"The use of the surgical robot to treat prostate cancer is an instructive example of an expensive medical technology becoming rapidly adopted without clear proof of its benefit," said lead study author Danil V. Makarov, MD, MHS, of New York University’s Langone Medical Center. "Policymakers must carefully consider what the added value is of costly new medical devices, because, once approved, they will most certainly be used."

The retrospective cohort study surveyed the regional and hospital rates of radical prostatectomy surgeries between 2001 and 2005 and determined whether they were affected by the acquisition of surgical robotic technology. During this early adoption phase, 36 of 71 regions studied had at least one hospital with a robot, and 67 of the 554 hospitals studied had a robot. According to the study, regions and hospitals with robots had higher increases in radical prostatectomy than those without. Additionally, hospitals with surgical robots increased surgery cases an average of 29.1 per year, while those without robots experienced a decline in radical prostatectomy by 4.8 cases.

"Patients should be aware that if they seek care at a hospital with a new piece of surgical technology, they may be more likely to have surgery and should inquire about its risks as well as its benefits," Dr. Makarov said. "Hospital administrators should also consider that new technology may increase surgical volume, but this increase may not be sufficient to compensate for its cost."

Results from the study were published in Medical Care (2011; 49:333-9).

A comment regarding this study, as well as a response from one of the study's authors, David F. Penson, MD, MPH, follow. The comment:

This is a very poor attempt to suggest overuse of a technology. If 67 hospitals had an increase of 29.1 cases per year, this totals 1949 new cases. The 487 hospitals without a robot lost 4.8 cases per year, totalling 2337 fewer prostatectomies, or a net decrease by 388 in the total number of operations. This study strongly suggest patients are going to hospitals with more technology and leaving those without it.

Dr. Penson's response:

As the senior urologic author on Dr. Makarov’s study, I read with confusion GOLund’s [the user name provided for the comment above] criticism that the study is a "poor attempt to suggest overuse of a technology". We actually did not suggest "overuse" anywhere in the manuscript nor does the study even attempt to address the issue of over or underutilization. As we note in the abstract and elsewhere in the study "the total RPs decreased from 14801 to 14420 during the study". What we conclude is that the "acquisition of a robot increases surgical volume", which is what GOLund notes in his comment.

The important take-home message from the report is that the massive adoption of robotic technology occurred in the absence of good evidence to support its uptake and that it was likely driven more by marketing and consumer forces than by science. We know from Nguyen, et al’s excellent publication in JCO that proportion of prostatectomies performed in Medicare using a minimally invasive approach (presumably most of these were robotic) increased from 1.5% in 2002 to 28.7% in 2005. We also know from Nguyen’s study and many others that robotic surgery costs more than open surgery. To date, the evidence that the robotic approach is superior to the open approach in terms of long-term quality of life outcomes, cancer control or survival is questionable at best and actually may favor the open approach, at least for impotence and incontinence (see Hu, et al, Jama 2009).

So whats the point here? Well, our study shows that if a hospital gets a robot, it is very likely to use it and if it doesn’t, then patients go elsewhere. This occurs in the absence of conclusive scientific evidence documenting the superiority of the robot over open surgery. Furthermore, the robot is more costly. Would you call the rapid replacement of a less expensive older therapy with a technique that is more expensive but has not been shown to be superior in terms of effectiveness "overuse"? Well, those were your words, GOLund, not mine…but I say "if the shoe fits…"