Robot diffusion linked to increased adverse event risk

The widespread diffusion of minimally invasive robotic surgery for prostate cancer has been associated with an increase in the risk of adverse events, according to a recent study that one leading urologic surgeon described as "provocative."

For the study, which was published online in JAMA Surgery (July 2, 2014), the authors used patient safety indicators developed by the Agency for Healthcare Research and Quality (AHRQ) to develop a nationwide data sample to analyze surgical provider performance and potential in-hospital adverse events from 2003-2009. Data for the prevalence of robotic prostatectomy were pulled from AHRQ and compared to published data from Intuitive Surgical Inc., the manufacturer of the da Vinci robotic system.

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Rapid diffusion onset of minimally invasive radical prostatectomy (MIRP) took place in 2006, when the procedure accounted for 10.4% of all radical prostatectomies in the U.S., the authors reported. The previous year, patients were twice as likely to experience an adverse event if they were undergoing MIRP compared to open radical prostatectomy.

In a press release from the University of California, San Diego, first author J. Kellogg Parsons, MD, MHS, discussed possible solutions to address the problem.

“One potential intervention would be the development of standardized training and credentialing programs, much like the aviation industry requires of flight crews inexperienced with new types of aircraft. An independent, continuously updated tracking system for the adoption of new surgical technology is also essential. Prior estimates of robotic prostatectomy uptake, provided exclusively by the robot manufacturer, substantially overestimated the speed with which it was adopted by the surgical community,” said Dr. Parsons, of the University of California, San Diego Health System.

In an invited commentary piece also published online in JAMA Surgery, co-authors Mohamad E. Allaf, MD, and Alan W. Partin, MD, of Johns Hopkins University, Baltimore, discussed their “different conclusions” from the study.

“The only finding with statistical significance is a 2-fold increase in the adjusted odds ratio of patient safety indicators for minimally invasive radical prostatectomy compared with open radical prostatectomy in 2005… If anything, this study demonstrates that even in its early adoption, minimally invasive radical prostatectomy seems to be comparable with open radical prostatectomy in terms of patient safety indicators reported.”

Urology Times Editorial Council member J. Stuart Wolf, Jr., MD, who was not involved with the study, called the findings "provocative" and said the authors' findings were not universal for all procedures.

"The same group that performed this work revealed no such finding for minimally invasive partial nephrectomy, although in that analysis the 'tipping point' may not yet have been reached," said Dr. Wolf, of the University of Michigan, Ann Arbor (Surg Endosc 2013; 27:1674-80).

"Inasmuch as patient safety is of paramount concern, measures such as more thorough training, mentorship by experienced surgeons, and strict credentialing should be considered," added Dr. Wolf.

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