Robotic Surgery May Improve Quality of Care For Kidney Cancer Patients

12 Dec Robotic Surgery May Improve Quality of Care For Kidney Cancer Patients

Posted at 02:57h in Author Interviews, NYU, Surgical Research by Marie Benz MD FAAD

MedicalResearch.com Interview with:
Ganesh Sivarajan, MD
Department of Urology
New York University Langone Medical Center

Medical Research: What is the background for this study? What are the main findings?

Dr. Sivarajan: The surgical robot was designed to facilitate laparoscopic surgery. The surgeon sits at a console several feet away from the patient and is linked to a multi-armed robot which translates the surgeon’s movements from the console to surgical instruments inside the patient’s insufflated abdomen. The robot is equipped with a high resolution three dimensional camera which improves visualization over traditional open surgery and allows the manipulation of instruments in directions and angles which are difficult in traditional open surgery.

In light of these apparent advancements, the robot was rapidly adopted for use during radical prostatectomy. The outcomes data for men undergoing robotic versus open prostatectomy, however, have not demonstrated any clear advantage of robotic surgery, with some studies demonstrating benefit and other demonstrating harm. This fact coupled with the relatively high cost of the robot and its disposable equipment have led many to criticize robotic surgery and its rapid adoption.

Partial nephrectomy is a procedure performed for renal cancer in which just the malignant tumor is excised while the remaining healthy kidney is saved. It is increasingly considered to be preferable to the previous gold standard operation – radical nephrectomy or removal of the entire kidney largely secondary to the benefits accrued from preserving renal function. Despite actual changes in the treatment guideline recommending increased use of partial nephrectomy it remains vastly underutilized nationwide likely because of the technical challenges associated with its performance.

It has been suggested that the surgical robot facilitates the performance of partial nephrectomy, but this has not been definitively demonstrated in a model which controls for important variables as the effects of changing guidelines, secular trends supporting increased utilization over time and a variety of other hospital-level characteristics.

We sought to determine whether acquisition of the surgical robot was independently associated with increased utilization of partial nephrectomy – a guideline-supported procedure. If true, it would suggest that the acquisition of the surgical robot may have improved the quality of care of renal cell carcinoma patients.

Medical Research: What should clinicians and patients take away from your report?

Dr. Sivarajan: In our multivariate analysis, our hypothesis that the acquisition of the surgical robot was associated with increased utilization of partial nephrectomy was confirmed. Specifically, we found that hospital acquisition of the surgical robot between 2001-2004 was independently associated with 29% increased utilization of partial nephrectomy in the year 2005 and 35% increased utilization of partial nephrectomy in 2008. Later acquisition of the robot, between 2005-2008, was still associated with a 16% increased utilization of partial nephrectomy in the year 2008.

Thus although the robot was initially often acquired for application toward radical prostatectomy, a procedure for which it has not been demonstrated to improve patient outcomes, its acquisition was associated with increased utilization of partial nephrectomy, an otherwise underutilized yet guideline-encouraged procedure. Thus robot acquisition seems to have unexpectedly improved the quality of care for renal cell carcinoma patients.

Medical Research: What recommendations do you have for future research as a result of this study?

Dr. Sivarajan: The unexpected benefits of surgical robot acquisition on the management of renal tumors are an example of “reinvention” or the manner in which a new innovation is altered in the process of its adoption and implementation after its initial development. Although hospitals and physicians have been criticized for adopting this unproven technology early in its development, our data suggests that greatest increase in proportion of partial nephrectomy was observed among those earliest adopters.

This example suggests that the benefits from early adoption of new technology might not be apparent to policy makers, researchers, or physicians a priori and that there might be some benefit to ensuring access to new technology for select institutions. Future research should focus on the clinical outcomes and cost-effectiveness of robotic partial nephrectomy in this setting.

Citation: