QUALITY: Robotic Surgery Gone Awry

Shocking news from the Boston Globe's Liz Kowalczyk: minimally invasive prostate removal, often performed with surgical robots like the da Vinci, more than doubled the rates of incontinence or impotence experienced by patients compared to those who opted for traditional open surgery.

Not good.

The study, which has solid but imperfect methodology, was published recently in the Journal of the American Medical Association. Other findings: success at controlling the cancer was about the same; minimally invasive got patients home in two days instead of three, and those patients also had fewer short-term complications like respiratory problems. In a nutshell, short-term effects were better with minimally invasive; long-term effects were better with traditional surgery.

According to the Globe, the study's lead author doesn't think the surgical robot itself is the problem:

Instead, he believes that many surgeons do not have enough experience using it. Studies suggest that it takes several hundred cases to become proficient at operating with a robot, he said, when the average surgeon does just 12 cases a year. The US Food and Drug Administration, Hu said, mandates that surgeons take a weekend course before starting to use the robot for prostate surgery, and then be monitored briefly by a surgeon who has done at least 20 cases. 

"If we were honest with ourselves in the surgery field, we'd say you can't do this operation well after a two-day course and a proctor helping you on a few cases,'' he said.

In other words, practice makes perfect. David Cutler tells us that in his book. But do you want to be the patient that gets "practiced" on?  I hope physicians, who largely regulate themselves, will consider more stringent training requirements. Whenever these machines are idle is a chance for it to be used as a training device, one would think. 

Another important question to consider is the study population. The JAMA piece looked at male Medicare beneficiaries age 65 and older. The reason isn't that men over 65 are the only ones that get prostate cancer -- they aren't -- but because the data are free and easily available via Medicare claims. It reminded me of this David Leonhardt article from July where a clinician researcher familiar with the effectiveness data from prostate surgery said she would recommend "watchful waiting" -- not any surgery at all -- to a family member diagnosed with this condition. 

While prostate cancer patients under 65 may well have reason to opt for aggressive treatment, American men over 65 will probably die of something else before their prostate cancer becomes life-threatening. We aren't talking about rationing or making this treatment unavailable for American males, but patients should be given all the information about possible treatment options -- and outcomes. Some will opt for surgery and some will not -- but at least they will be informed. 

As readers of this blog know, this is a subject we've written on quite a bit -- here, here, and here. First brought to our attention by blogging hospital CEO Paul Levy, I subsequently published a piece in the Post online arguing for the need for more comparative effectiveness research.

I love technology. I am fanatical about my Palm Pre. But I put quality of care on the highest pedestal. Hype and lack of training should not get in the way of the best care for all patients.