Use of robotic RN rising, despite unclear advantages

July 2, 2014

The use of robot-assisted radical nephrectomy increased by 6% over a recent 3-year period, and high-volume robotic centers for partial nephrectomy were found more likely to perform robotic radical nephrectomy despite its increased cost and similar complications to laparoscopic radical nephrectomy, according to a recent study.

Orlando, FL-The use of robot-assisted radical nephrectomy increased by 6% over a recent 3-year period, and high-volume robotic centers for partial nephrectomy were found more likely to perform robotic radical nephrectomy despite its increased cost and similar complications to laparoscopic radical nephrectomy, according to a recent study.

Commentary - Robotic radical nephrectomy: Really?

At the AUA annual meeting in Orlando, FL, researchers reported that a growing number of centers now routinely perform robot-assisted partial nephrectomy and robot-assisted radical prostatectomy, despite debate over whether, in the case of the latter surgery, this is the right utilization of this technology and whether overutilization may be occurring. Researchers analyzed the utilization and complications of robotic, laparoscopic, and open radical nephrectomy (RN) and factors that predict its use.

For the study, the authors mined the Nationwide Inpatient Sample to identify patients undergoing RN from the last quarter of 2008 through 2010. They identified 124,462 patients who had undergone RN (robotic, 5.7%; laparoscopic, 14.7%; open, 80.6%). They stratified population and hospital demographics by frequency of RN surgical approach. Complication rates were compared among patients undergoing open, laparoscopic, and robotic RN.

“To our knowledge, this is the first analysis that has attempted to identify patient- and hospital-specific factors predictive of use of a specific surgical approach for performing RN. Overall, in terms of trends of utilization, we are seeing that use of the robotic surgical platform for RN has been increasing over the sampled time period. In total, there has been a 6% increase,” said study investigator Michael Rothberg, a medical student and urologic oncology research fellow at Columbia University Medical Center, New York.

The da Vinci surgical robot (Intuitive Surgical, Inc., Sunnyvale, CA) may provide advantages in terms of complex intracorporeal reconstruction and suturing during minimally invasive surgery. However, the authors question whether this potential advantage applies to RN, and they looked at what factors may be driving the increased utilization of robotic RN.

 

Next: Hospital factors appear to predict use of robot

 

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Rothberg and his co-authors found that the proportion of robot-assisted procedures increased from 2% to 8% over the 2-year study period. What stood out was that hospital factors appeared to predict the use of robotic surgery. Larger medical centers were less likely to perform robot-assisted nephrectomy. However, the hospitals in the middle and higher tertile for robotic partial nephrectomy were more likely to perform robot-assisted RN.

“We found hospitals with a higher volume of robotic partial nephrectomy were more likely to perform robotic RN despite it being more expensive, being a more complex surgery, having no statistical difference in complication rate when compared to laparoscopy, and, lastly, having demonstrated no advantage in terms of oncologic control over laparoscopy,” said Rothberg, who worked on the study with first author Aaron C. Weinberg, MD, senior author Ketan K. Badani, MD, and colleagues.

Patient factors not linked with robot use

The study showed that patient factors were not associated with utilization of robot-assisted RN. A greater percentage of patients undergoing robotic RN (45.7%), as directly compared to laparoscopic (42.1%) and open RN patients (40.1%), had private insurance, were male (55.3% vs. 52.1% vs. 57.0%), and Caucasian (79.4% vs. 73.2% vs. 71.9%). Patients were also more likely to undergo the robotic procedure if they had more than two preoperative comorbidities (27.7% vs. 25.8% vs. 25.0%), and were in the very high-income quartile (23.1% vs. 21.6% vs. 22.4%).

The findings also suggest that the robot-assisted technique afforded no more protection against complications than the laparoscopic technique (robotic, 26.7%; laparoscopic, 27.4%; open, 35.3%). The authors concluded that surgeon comfort level, hospital efficiency with robotic surgery, and hospital teaching status may account for the findings. They said they believe additional studies are warranted to compare cost-effectiveness of the different techniques.UT

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