A crisis situation during minimally invasive urologic surgery is equally rare during either a robotic or a laparoscopic procedure. However, use of the robot may negatively impact the outcome of the event and particularly among healthier patients, according to the findings of a recent study.
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“The main message from our research may be that the overall rate of catastrophic complications during minimally invasive urologic surgery is very low. Most pending crises can be controlled, and my personal sense is that they can be better controlled during a robotic procedure than laparoscopically,” said first author Courtney K. Rowe, MD, a urology resident at Brigham and Women’s Hospital, Boston, who presented the findings at the 2015 AUA annual meeting in New Orleans on behalf of a multi-institutional group.
“However, our study should start the conversation about ways to improve the design of robotic technology to allow quicker access if something bad happens as well as advances in emergency simulation so that surgeons can be prepared for these rare events if they occur,” added Dr. Rowe, who worked on the study with Steven L. Chang, MD, MS, and co-authors.
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Aiming to investigate whether the set-up of a robotic procedure with the surgeon displaced from the bedside and the complexity of the equipment might affect the risk and outcomes of a crisis, the authors performed a comparative population-based analysis using a nationally representative discharge hospital database. They evaluated a survey-rated sample of nearly 600,000 patients who underwent a robotic or laparoscopic procedure between 2003 and 2013.
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The case mix differed between the two surgical groups, with the laparoscopic cohort primarily comprised of patients undergoing nephrectomy and the robotic procedures primarily comprised of radical prostatectomies. However, there were no statistically significant differences between the overall laparoscopic and robotic cohorts with respect to demographic characteristics, Charlson comorbidity index (CCI), or insurance status.
The study focused on massive hemorrhage to represent a surgical crisis, and crisis cases were identified as any using three or more suction canisters in the operating room and in which the patient received a blood transfusion on postoperative day 0. Based on that definition, a surgical crisis occurred in 0.25% of laparoscopic cases and 0.18% of robotic cases.
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The primary endpoint for comparing outcomes in the two groups was 90-day major complications. In the univariate analysis, the rate was higher in the robotic crisis group than in the laparoscopic crisis group (21.5% vs. 12.7%), but the difference was not statistically significant. Results of other outcomes analyses showed median OR time was significantly longer in the robotic group compared with the laparoscopic approach (363 vs. 252 minutes), but there were no significant differences between groups in median length of stay or 90-day readmission rate.
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Higher likelihood of complication with robot
A multivariate analysis controlling for age, CCI insurance status, hospital characteristics (type, location, size, region), and procedure type found the likelihood of a patient experiencing a major complication within 90 days after a surgical crisis was 2.6-fold higher among patients in the robotic group compared with the laparoscopic group. The increased risk was statistically significant.
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A subgroup analysis of the probability of a major complication stratified patients by CCI. The results showed the adjusted probability of a major complication after a crisis among patients with a CCI of 0 or 1 was about 50% in the robotic group and about 30% in the laparoscopic group, while it was about 30% regardless of the surgical group in patients with a CCI ≥2.
“We recognize there may be cherry picking of the healthiest patients for a robotic approach, and this limitation is reflected in our cohort by the fact that none of the crisis patients in the robotic group had a CCI greater than 4,” said Dr. Rowe.
“Despite this selection bias, we found the increased risk for a major complication in the robotic group was most pronounced in the healthiest patients.”
Postulating an explanation for the latter finding, Dr. Rowe suggested that surgeons may be more confident that everything will go well when operating on healthier patients and so they may be less prepared to respond to a crisis in terms of personnel on hand and room setup. In addition, surgeons may be more reluctant to convert to an open procedure in these healthier patients, and as a result of the delay, the patient may lose more blood.
Dr. Rowe noted that she and her co-investigators are now working with others in their respective institutions to develop a robotic surgical crisis flow sheet that will include specific suggestions for management.
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