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Medical Forum / Diseases and Disorders / Prostate Cancer / October 2005daVinci Robot article in the Boston Globe
Today's Boston Globe has a feature article on Robotic Surgery. It contains nothing that has not been already discussed here. If you want to read it on line, it is available for a couple of days at http://www.boston.com/news/nation/articles/2005/10/01/robotic_surgery_gets_new_push/ I thought it was particularly noteworthy that some of the doctors who were interviewed had very little experience with the robot. Dr McRae had done "about a half dozen cases" and Dr Babayan had done about 30. Al > Today's Boston Globe has a feature article on Robotic Surgery. It contains > nothing that has not been already discussed here. (snip) > I thought it was particularly noteworthy that some of the doctors who were > interviewed had very little experience with the robot. Dr McRae had done > "about a half dozen cases" and Dr Babayan had done about 30. Ahem: nitpick warning. Robert A. Heinlein would not be pleased. The thing is not a robot, it's a waldo. Regards, Steve J "Perturb not Dragons, for you are crunchy and tasty with a bit of ketchup and thyme." -- Unknown Interesting. I had a lap RP but by hand rather than robot. From my (extensive!) interviewing of the surgeon who did it (and he did a truly spectacularly great job in terms of continence and erectile function) I gained the impression that he thought the robot could make a good open surgeon into a good laparoscopic surgeon very quickly - but that non-robotic lap surgery was something fewer good open surgeons ever got to be good at. More importantly, the cost of the robot and the consumables was very high. He strongly emphasised the issue mentioned in the article - that using direct lap instruments in his hands he got to feel the tissue directly which he preferred - albiet via a long stick down a thin tube! And he emphasised the benefits of having a surgeon who's done hundreds of that specific procedure - there's a steep learning curve. > Today's Boston Globe has a feature article on Robotic Surgery. It contains > nothing that has not been already discussed here. If you want to read it on [quoted text clipped - 4 lines] > interviewed had very little experience with the robot. Dr McRae had done > "about a half dozen cases" and Dr Babayan had done about 30. My surgeon also did lap surgery on me without the robot. He had done his first 40 laps with the robot but felt he could do a better and faster job without it. I was his 126th lap patient - he had done many hundreds of open surgeries as well. The robot he used was collecting dust at the hospital since he and the other docs who had used it like the regular lap procedure better or preferred open surgery. He did say the robot is useful in that it allows the doctor to "take an occasional break" since the implements are remotely controlled whereas in the regular procedure the doctor is continually standing over the patient operating the equipment directly. He also indicated that there was an additional amount of time (about one hour) under anesthesia to set up the robot before the actual surgery can begin. No matter, my results were not specatular in that I'm two years out, still dribbling, and little Willie continues his hibernation. Gotta love those low PSAs though. Dave Perry > Interesting. I had a lap RP but by hand rather than robot. From my (extensive!) interviewing of the > surgeon who did it (and he did a truly spectacularly great job in terms of continence and erectile [quoted text clipped - 14 lines] > > interviewed had very little experience with the robot. Dr McRae had done > > "about a half dozen cases" and Dr Babayan had done about 30. In defense of the Da Vince, I had a my robotic sugery in Feb 04 by Dr Joseph Wagner in Hartford. My results are excellent by the most stringent standards. He has done hundreds of them. When I was shopping, it looked to me like there are talented docs getting good outcomes with open, with hand lap, and with robotic lap. The first cut was open vs lap. If you can get the same good results with less suffering, thats a good enough reason for me to pick lap. On the hand vs robotic, I found the idea that the doc can see better, and work without tremor, fatigue, and awkward posioning to be compelling. As for cost, all technology is very costly at the start, then comes down as it gets more common. The cost to me was less with the robot because I had less down time. Steve U Steve U wrote...snip... > If you can get the same good results with less suffering, thats a > good enough reason for me to pick lap. Steve...When you use the phrase "same good results" I assume you mean recurrence-free survival. To my knowledge, equivalent freedom from biochemical recurrence at 5, or of course even better 10, years post-treatment has not been demonstrated for lap or robotic vs open RP. To me this is a key point. A recent Medscape review of the 2005 AUA meeting made the following comment on the situation, "The positive surgical margin rate continues to be higher with laparoscopic and robotic prostatectomy compared with the open approach.[54,69,70] It is unclear how this will translate into disease-free and overall survival, since the laparoscopic and robotic experience is still immature. Nonetheless, it is cause for concern." Even Guillonneau, the man who adapted lap procedures to RRP, has recently said, "Nevertheless, longer followup and more mature data are needed definitively to establish laparoscopic radical prostatectomy as an alternative to the retropubic approach." While we all hope that LRP or RLRP will be equivalent or superior to RRP in terms of disease-free survival, I don't think that very important point has yet been demonstrated...Best wishes and good health, Ron Funny you should raise this - I've just reviewed some real data on that very issue. I'm a medical epidemiologist, so when I got back to work, my surgeon asked me to check over an analysis they'd just completed on a 1000 consecutive RPs in their urology unit (the series was closed before I was operated!) - about 280 laps and the rest open. No significant difference in positive margin risk for open vs lap after adjustment for patient characteristics in a logistic regression model. With a finding of no difference, the first question is whether there was enough statistical power, but 1000 cases gives a reasonable probability to detect an important difference if there was one. It will be published soon - but you heard it first on ascp :-) > While we all hope that LRP or RLRP will be equivalent or superior to > RRP in terms of disease-free survival, I don't think that very > important point has yet been demonstrated...Best wishes and good > health, Ron Ross...Any idea why your conclusions differ from those in references 54, 69 and 70 cited above? That would be an important point to address in the publication, IMO. Further, was there a difference in the positive margin locations between the open and lap groups? Finally, 280 laps out of 1000 cases doesn't sound like a highly-powered study to me; that's just my opinion, I'm not a statistician and I'm not trying to be cantankerous...Best wishes and good health, Ron > Ross...Any idea why your conclusions differ from those in references > 54, 69 and 70 cited above? That would be an important point to address Haven't read them so no idea. I'll have to read them thanks! > in the publication, IMO. Further, was there a difference in the > positive margin locations between the open and lap groups? Finally, Positive distal and proximal margins were relatively uncommon so not informative to test separately. Peripheral margins were the largest group of positives as is expected with this disease. > 280 laps out of 1000 cases doesn't sound like a highly-powered study to > me; that's just my opinion, I'm not a statistician and I'm not trying Power to detect a difference is always higher with more cases or larger subgroups, but it's hard to collect high quality data on large series - 1000 is a reasonable sample in this game AFAIK. Ideally, all surgeons and urology groups would contribute their outcomes data to a central repository so we could make better informed Rx decisions. Sadly, in my experience, getting a group of surgeons to agree on just about anything is like herding cats.... > to be cantankerous...Best wishes and good health, Ron We academics tend to be cantankerous by profession, so feel free while you live well, and long :-) Ron, You wrote "When you use the phrase "same good results" I assume you mean recurrence-free survival. " I don't. The robot has not been around long enough, but who has 15 years to make their decision? I used clean margin as a surogate for indicating increased chance of cure. My doc's record was 29% positive for open, and 22% positive for RLRP. This was consistent with numbers published by Tewari and Menon in the British Journal of Urology 92:205, 2003, and Ahlering in Urology 63:819, 2004. I think many studies using combined data include people who have not done many cases and/or are not that good at it. Also, there is some cherry picking going on at some places. Other docs take more challenging cases. I heard DrMenon speak a few months back. He complained about the dificulty he has had getting things published about robotic results. Of course I'm now totally sold and biased because I was ready to go back to work day #6, have no urinary symptoms, and I got my erection back. The literature is a sea of doubt. My own results are personally very compelling. Be well. Steve U |
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