I don’t have any intrinsic objection to robotic prostatectomy – in fact I’m trained in it, just as I’m trained in open and laparoscopic (‘hands on’ keyhole) prostate surgery. The cause of my reticence towards robotic surgery relates more to unnecessary cost and unrealistic expectations than to anything else.
The steep growth of robotic prostatectomy in the US is a classic example of putting the cart before the horse and because it has largely been motivated by the wrong (commercial) reasons. This has resulted on the other side of the Atlantic in a stampede towards robotic surgery by hospitals that are nervous about losing potential customers to their neighbouring hospitals which have a technological edge and before the evidence of its superiority over existing techniques has been demonstrated by its early adopters. Analysis of the existing data demonstrates generally that high-volume surgeons get better results than low-volume surgeons and that keyhole (robotic and laparoscopic) surgery is associated with a number of advantages over open surgery – no surprises there!
In Europe, where costs in healthcare are more of an issue than in the States, the rush to buy robots has been rather more restrained. Hospital administrators, quite reasonably, want to know why they should part with the equivalent of £1.5 million to buy one, £100,000 a year to run one and £1,000 extra per case for semi-disposable instruments. The usual keystone of any business case to buy a robot is the extra business that it will bring in but the greater the number of robots in any given area the more this logic fails to deliver.
In many parts of the world robotic surgery is never going to be affordable, but conventional laparoscopic surgery generally can be and can offer all of the advantages of keyhole surgery: excellent vision for the surgeon and much less bleeding and a faster recovery for the patient. I operate several times a year in Jamaica, where the incidence of prostate cancer is much higher that in the West and where the genetics of the cancer causes it to behave more aggressively. Because few patients have access to PSA blood tests prostate cancer in Jamaica also tends to present late. The results of the laparoscopic prostatectomies that I’ve done there together with local surgeon Roy McGregor emphasise the sense of spending time, money and effort in training surgeons in the infinitely more flexible laparoscopic surgery, which can be done using equipment found in most operating theatres around the world, rather than sinking it into the capital expenditure of a very expensive surgical tool.
Patients aren’t necessarily happy with robotic surgery either. In a recent study of 400 American men who had either robotic (RALP = robot-assisted laparoscopic prostatectomy) or open prostatectomy ‘patients who underwent RALP were more likely to be regretful and dissatisfied possibly because of high expectations of a new procedure’. This finding, which was published by Schroeck and colleague in European Urology highlights the gap that sometimes exists between hype and reality, especially when surgeons fail to advise patients using their own personal results, rather than those published by high-volume centres.