Doctors defend use of surgery robots amid study questioning their cost

2013-02-24T00:00:00Z 2014-07-30T17:17:20Z Doctors defend use of surgery robots amid study questioning their costStephanie Innes Arizona Daily Star Arizona Daily Star
February 24, 2013 12:00 am  • 

A study published last week in the Journal of the American Medical Association has some local surgeons defending their use of expensive robots for medical procedures.

In a time of spiraling medical costs, some local doctors and proponents of the robot worry that the Columbia University study's findings will lead to less support for advanced medical technologies that can improve patient recovery times and outcomes.

The study from researchers at Columbia University says the robots may not be worth the money, at least when it comes to hysterectomies versus the same procedure done laparascopically and without a robot.

"The robot is a surgical tool. I don't do every surgery with a pair of scissors. That is another tool," said Dr. Farid Gharagozloo, chief of cardiothoracic robotic surgery at the University of Arizona Medical Center. "So you shouldn't do every surgery with a robot. The robot is just part of a good surgery program.

"With all the changes in health care coming, there will be no question you can't use things that are too expensive. (But) there are definitely places where robotics could be useful," added Gharagozloo, who is a board member of the Society of Robotic Surgery and an internationally recognized expert in robotics.

At least seven Tucson-area hospitals have spider-like da Vinci robots for surgery, and some have more than one. Thirty-seven of the robots have been sold in Arizona, says the company, California-based Intuitive Surgical Inc., and 66 surgeons within 100 miles of Tucson have been trained to use them.

The systems can cost as much as $2.3 million, and an additional servicing cost is about $140,000 per year.

Doctors operate the robots from a console. Many say it makes surgical movements more precise, filtering out any tremor a hand might have, for example.

But robotic surgery has had critics ever since it was introduced in the U.S. in 2000, noted Dr. Carlos Galvani, director of minimally invasive, bariatric and robotic surgery at the UA Medical Center.

"Sometimes the robot can get in the way. If it makes me better, then I use it," he said. Galvani does between 120 and 150 robotic surgeries per year.

Company officials say their da Vinci system is the only one approved by the U.S. Food and Drug Administration for gynecological surgery.

The UA Medical Center has two da Vincis, as does Tucson Medical Center. At TMC, the da Vinci was used for 441 gynecological procedures in 2012, and 430 of them were hysterectomies.

Linda Wojtowicz, TMC's chief operating operator, said surgeons consider which method will bring the best possible outcome for the patient.

"Physicians will tell you that patients who need some sort of surgery will come in asking if it can be done on the da Vinci. Patients are becoming more informed about the benefits and are requesting it," Wojtowicz added.

Since the robots were approved for gynecological surgery in 2005, the percentage of hysterectomies performed with them has risen from 0.5 percent to nearly 10 percent, the study's authors found. At the same time, hysterectomies with the robot show no benefit over the less expensive laparoscopic hysterectomy, they concluded.

"Without a doubt I think it's important for the patients and consumer to know that robotics is good in certain areas and not so good in others," Gharagozloo said. "The JAMA article is about gynecological, and that is still a work in progress. It is not clear whether it has any benefit at all. There is no disputing that."

But Gharagozloo has done more than 1,600 robotic surgeries. "And now it is very clear that in thoracic surgery, the robot is a game changer," he said. "That's why thoracic surgeons all over the country are trying to learn this."

Dr. Robert Poston, chief of cardiothoracic surgery at the UA Medical Center, also reacted to the study. There is indeed a "long and costly" training period for surgeons to use the robots, said Poston, who has been doing robotic mitral valve and coronary bypass surgeries for about six years.

Still, the high up-front costs of surgical robots - the investment in both the device and the doctor training - eventually pays for itself, he said.

"All the high cost goes away after you gain experience," he said. "So if you looked at, say, my last 50 cases, you'd say, 'wow, this is really cheaper than the traditional approach.' But if you looked at my first 50 cases, it would be a completely different picture."

After his 100th case in Tucson, the company renegotiated the equipment cost and offered a discount, Poston said, adding: "The robot is a fabulous tool."

The robots can be used for various types of surgery, including prostatectomies, kidney surgeries and thoracic procedures.

Officials at Northwest Medical Center, which has two da Vinci robots, say a major advantage to the devices is that they magnify and provide a three-dimensional view of the surgical site, giving surgeons better visibility of the area.

Other advantages include smaller incisions, a lower risk of infection and blood loss, and minimizing of scars, say local health-care providers who use the technology.

A 2012 study of prostatectomies in men with clinically localized prostate cancer also cast some question on the robotic method. The study, led by researchers at Massachusetts General Hospital and published in the Journal of Clinical Oncology, found that risks of problems with continence and sexual function are high after both robotic and traditional open procedures. Medicare-age men should not expect fewer adverse effects following robotic prostatectomy, the study said.

However, there are many other peer-reviewed studies that show clear advantages to robotics, said Dr. Myriam Curet, chief medical advisor at Intuitive Surgical Inc.

MARKETING TOOL

The robots are often used in hospital marketing campaigns.

In Tucson, medical providers routinely bring demo da Vinci robots to local shopping malls for public viewing.

But hyping the devices, which start at $1 million apiece, might be unduly influencing the public, suggests an editorial accompanying a paper published last week in the Journal of the American Medical Association.

"When the innovation being advertised is of questionable advantage, direct-to-consumer promotion may only fuel unnecessary utilization," it says.

Contact reporter Stephanie Innes at sinnes@azstarnet.com or 573-4134.

Copyright 2014 Arizona Daily Star. All rights reserved. This material may not be published, broadcast, rewritten or redistributed.

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