Help or Hype: The True Costs of Robotic Surgery

Jul 14, 2014, 10:29 AM, Posted by Sheree Crute

Joe Meyer is the model of a well-educated, engaged patient. A self-described “typical Midwestern guy” who settled in Chapel Hill, N.C., to raise a family and build a career, Meyer did everything in his power to make the best decisions when his 2013 physical produced unexpected and frightening results.

“I live a pretty healthy lifestyle. I exercise. I eat well,” says the 62-year-old chief operating officer of a large manufacturing company. “I was very surprised when my PSA test came back at 5.1 [3 to 4 is normal]. Further testing showed that I had prostate cancer.”

One of more than 200,000 men who are diagnosed each year, Meyer put his faith in his physician and the health care system when gathering information about treatment.

“After the biopsy, they told me my Gleason score was 7. [The higher the score on a scale of 1 to 10, the more likely a cancer will spread.] I realized I was high risk, so I started reading as much as I could about the choices I was offered—hormone therapy, radiation, or prostate removal.” He chose robotic prostatectomy over open or laparoscopic prostatectomy. Surgery, as opposed to hormone therapy or radiation, was widely considered a good decision for someone with Meyer’s prognosis.

Not the type of guy to watch and wait, Meyer says, “I’ve been in management a lot of years. I’ve learned, if you got a problem, you address it right away. He adds that he “would have been happy to choose the non-robotic prostate surgery,” if it had been what was available in his area.

Making sure that our system of medical innovation is working well enough to give men like Meyer a full range of treatment options, no matter where they live, and the information needed to make a well-informed, cost-effective choices is the primary goal of Charles D. Scales Jr., MD, and Jonathan Bergman, MD, both urologists and Robert Wood Johnson Foundation/U.S. Department of Veterans Affairs Clinical Scholars (2011-2013).

In their case study “Robotic Surgery,” they contend that the rapid uptake and aggressive marketing of robotic prostate surgery is an example of a “‘medical arms race’ between competing hospitals that is driving up health care costs ... while there is scant evidence of improved surgical outcomes and even some evidence that robotic surgery may create problems.” Their work is part of the RAND report Redirecting Innovation in U.S. Health Care: Options to Decrease Spending and Increase Value.

Hidden Risks for Patients

By many measures, robotic surgery appears to be a successful new technology. Bergman offers the option in his practice at the David Geffen School of Medicine at UCLA, and he explains that many patients do have “shorter post-surgical hospital stays.” Meyer, for example, went home from the hospital the day after surgery.

Health care systems have also been purchasing robotic equipment at a furious rate.

“In 10 years, we went from open prostate surgery to robotic surgery being used for 80 percent of cases,” Scales says. “This is dramatic—it’s one of the biggest changes in modern medical practice. It’s also being driven by patient demand. After 2005, hospitals without a robot—primarily the da Vinci®Surgical System—saw an estimated 41.2 percent decrease in cases.”

But Scales and Bergman question whether patients armed with promotional materials, rather than research, are getting the information they need to make the best decisions.

Advertising campaigns touting robotic prostatectomy as the “gold standard” (according to Duke Medicine, where Meyer was treated and Scales is a professor of surgery) and offering reduced hospital stays are common. The Cleveland Clinic promises the procedure allows for “more precision, offering patients improved outcomes.” Columbia University Medical Center contends that patients will experience improved urinary continence and sexual function after surgery.

Information offered online also focuses primarily on robotic procedures. A small study of Internet search results conducted at MD Anderson Cancer Center in Houston, Texas, showed that Internet information on prostate surgery is biased toward robotic prostatectomy.

Scales is not surprised that this type of advertising persuades patients to choose robotic procedures. “Men are justifiably concerned about the effects of any treatment for prostate cancer because it’s linked to their quality of life. Anything that promises to protect that would understandably draw their attention.”

 At least one of those claims holds up. But on others, the benefits are less conclusive. “The robotic procedure does offer faster recovery times [it’s less invasive and there is less bleeding]. But, there’s no data proving improved urinary continence or sexual function. There is also no evidence of better, post-surgery cancer control,” Scales says.  

“The major potential harm is that you do prostate surgery on someone when it is not necessary,” says Bergman. They report that, since 2005, the number of prostatectomies among American men has increased 60 percent.

“I do what the patient asks,” says Bergman, “but we just don’t have the data.” A small number of observational trials are the basis for most assertions that robotic prostatectomy is superior.

“It is misleading to tell prostate cancer patients that robotic surgery will lead to improved outcomes, beyond less bleeding and a shorter hospital stay,” Bergman says. There is also concern that robot-related complications are not shared with patients.

All surgical procedures have a learning curve, Scales and Bergman agree, but a spate of recent lawsuits from injured patients, robotic surgical instrument recalls, and several reports about a da Vinci robot surgical tool burning patients, suggest that more research is needed.

There also may be more to the story. A 2013 study conducted at Johns Hopkins University found that adverse events related to robotic procedures “were underreported to the Food and Drug Administration.”

Rising Hospital Costs

Beyond their concern for patients, Bergman and Scales explain that, while hospitals and physicians earn no more for robotic procedures than open surgical procedures, other hospital fees may be raised to compensate for robot-related costs.

“The savings from shorter hospital stays are erased by the much higher costs of acquiring the robot and replacing the expensive, disposable instruments needed for robotic procedures,” Bergman says. “They can also charge more for services associated with the robot.”

“We are not against new medical technology; we want to see innovative procedures adopted based on research that shows we are doing our best for patients,” Scales adds. They suggest that “moving away from a fee-for-service payment system that rewards hospitals and physicians for procedures to reimbursement based on quality and patient outcomes” would spur patient-centered, cost-effective medical innovation.