Advancing technology is pushing clinicians and patients into making ever more nuanced decisions between the costs of a procedure and its value.
Several studies to be presented at the AUA annual meeting in Washington describe the cost differential between robot-assisted laparoscopic prostatectomy and standard laparoscopic prostatectomy, and between robotic kidney surgery and laparoscopic kidney surgery (partial nephrectomy and pyeloplasty). As might be expected, robotic procedures cost more in both instances: about 20% more for renal surgery and 70% or so more for prostatectomy.
"We know that oncologic and functional outcomes are generally similar," Dr. Wolf told Urology Times. "The question is whether the other advantages of robotic surgery are worth the additional expense."
Robotic RP may not be worth cost
"Studies have found substantial differences between open and minimally invasive renal surgery in terms of recovery and morbidity. No differences of such magnitude appear for prostate surgery. So, I would say the cost of minimally invasive surgery is worth it for the kidney but not clearly so for the prostate," Dr. Wolf said.
He noted that robotic technology provided an additional benefit by opening minimally invasive procedures to surgeons who otherwise might not conduct such procedures. This in turn makes the procedures available to an increased number of patients.
"But there is an added cost of making the technique available to more surgeons and therefore more patients. This raises the question as to whether the added cost is worth it to society. That is not a judgment you or I could make.
"That is a judgment for society to make," said Dr. Wolf.
Studies of laparoendoscopic single-site surgery (LESS) raise the same issues. Dr. Wolf pointed to one multinational study of more than 900 procedures.
"This is an extremely large study representing a huge amount of experience. Clearly, the surgery can be done and is reproducible in expert hands. But I have spoken with surgeons who are doing it less frequently than a year ago. The benefits are limited, compared to standard laparoscopic procedures," said Dr. Wolf, who will debate the issue with Mihir Desai, MD, of the University of Southern California, Los Angeles at a plenary session at this year's AUA annual meeting.
As these issues are being debated, robotic technology continues to advance as is evidenced by a study of a robotic system that provides a degree of haptic feedback by issuing vibrations and noise when the instruments contact tissue.
"One of the primary arguments against robotics when it was first introduced was the lack of haptic feedback. Over time, surgeons adapted their technique so they could basically 'feel with their eyes.' This new technology is going to bring haptic feedback back into the mix. I don't know how it will be accepted or if it is going to solve everything, but more sensory input to the surgeon is a good thing," said Dr. Wolf.
Illuminating renal vasculature
Another technologic advance adds yet more information to the mix. A New York team is to report on their experience with intravenous indocyanine green dye in conjunction with robotic partial nephrectomy for renal cortical tumors. The dye fluoresces when lit with near infrared, thereby illuminating renal vasculature and differentiating cortical tumors from normal parenchyma.
"We need to see some large studies of this to see if it will reduce the incidence of positive margins," Dr. Wolf explained. "Although in most cases, surgeons have very little difficulty differentiating tumor from normal parenchyma, the incidence of positive margins is never zero. There are some cases where it is hard to tell the difference [between tumor and normal tissue], and the problem is that you cannot tell which cases these are going to be until you are in there. If this technique can be applied without much trouble at minimal expense, it is worth exploring."
Another study draws on the experience of close to 100 robot-assisted partial nephrectomies to establish a clinical pathway that would allow a majority of these patients to be released with only a single night in the hospital after the procedure.
"We have spoken of procedures that are conducted at substantial expense to produce incremental improvements in outcomes," said Dr. Wolf. "There is very little cost to implementing a clinical pathway, but it can have a huge impact on costs. There is probably nothing more cost effective than a clinical pathway. At our institution, it is a rare procedure that is not associated with a clinical pathway."