Robotic surgery needs to pass test of time, urologists say


Although most urologists agree the field is shifting toward increasingly minimally invasive approaches, they have mixed feelings about whether the move is totally justified.

Despite its widespread popularity, the robotic technique has been surrounded by questions about its relative advantages versus open and other surgical approaches. Urology Times asked urologists around the country if they think robotic procedures are delivering better outcomes than traditional procedures. Although most agree the field is shifting toward increasingly minimally invasive approaches, they have mixed feelings about whether the move is totally justified. And most think it is a bit early to say whether long-term results will hold up.

Kevin Claybrook, MD, in Little Rock, AR, has been performing robotic surgery on the kidney for 4 years, but doesn't choose the robot for all procedures.

"For partial nephrectomies, I'm not so certain. As for surgeon comfort, there's something comforting about a big open incision. There's more sense of control, in my opinion. But it still seems to work out OK."

In terms of long-term results, "they've been pretty equivalent to what other people have and equivalent to what the open procedure data would suggest. So, I don't see a big difference, and the patient has less morbidity and post-op pain," Dr. Claybrook added.

"We didn't have the 20-year experience to draw on before the use of robotics took hold. The surgery is market driven, rather than research driven. Now we're looking back at the change and trying to justify it from a clinical standpoint."

Robot is a necessity

In Manhasset, NY, Keith D. Bloom, MD, does robotic surgery and believes outcomes are, in fact, better than with an open procedure. But he acknowledges he didn't have much choice about learning the robot.

"I practice on Long Island, and this is a challenging patient population. You literally can't convince a patient to have an open prostatectomy. It can't be done. If you want to do prostate surgery, you've got to learn robotics here," he said.

That being said, Dr. Bloom does like the short-term outcomes.

"The blood loss is significantly less. The catheter is removed earlier, patients are able to go home after just one night in the hospital, and they seem to have faster return to continence, although that's not universal.

"The jury is still out on long-term results in terms of cancer control. The one caveat is that we don't have large long-term outcome data on the robot just yet. I think it's going to be equivalent, but I don't know. We don't have the data from 10- to 15-year experience with high numbers as compared to open prostatectomies. I don't see any reason it wouldn't, but I wouldn't want to make any conclusions that aren't backed up by hard data."

"The robotic sacrocolpopexy is an alternative to an open sacrocolpopexy for vault prolapse. From that regard, yes, it's terrific," she said. "The outcomes in limited studies that are available seem to be on par with the open approach, but with significantly less morbidity. It's a smaller incision, and the same arguments you've heard for every other robotic procedure in urology apply: quicker back to work, less postoperative discomfort, improved recovery parameters."

She, too, is hesitant to endorse the robotic approach unconditionally.

"You still need to have that data that shows in 10 years that a repair is going to hold up as well robotically as it will open. I think that still needs to be seen, but in terms of functional return to activity and cosmetic appeal, yes, I see an improvement," Dr. Borawski said.

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