No Short-Term Gain With Robotic-Assisted Versus Laparoscopic Rectal, Renal Surgery

Research questions the role of robotic-assisted laparoscopic procedures for rectal resection and radical nephrectomy

medwireNews: Two studies published in JAMA suggest that a robotic-assisted approach does not confer a short-term advantage compared with conventional laparoscopy among patients undergoing rectal resection or radical nephrectomy, but is associated with prolonged operating time and higher costs.

In the first study, led by David Jayne, from St James’s University Hospital in Leeds, UK, 466 patients with operable rectal adenocarcinoma were randomly assigned to undergo either robotic-assisted or conventional laparoscopic surgery with curative intent. Participating surgeons had conducted a median of 50 (range, 30–101) prior robotic-assisted procedures and 91 (range, 45–180) conventional laparoscopic operations.

The primary endpoint was the rate of conversion to open laparotomy, which occurred in a comparable 8.1% of 236 patients in the robotic-assisted group and 12.2% of 230 participants in the control group.

The treatment arms also did not differ significantly with respect to any of the secondary endpoints, including the rate of circumferential resection margin positivity, intra- and postoperative complications, 30-day mortality, and bladder or sexual dysfunction.

However, the average operative time was longer for patients undergoing robotic-assisted than conventional laparoscopic surgery, at 298.5 versus 261.0 minutes (difference, 37.5 minutes), and the mean costs per case were significantly higher, at £11,853 or $13,668 versus £10,874 or $12,556 (difference, £980 or $1132).

These findings suggest that “robotic-assisted laparoscopic surgery, when performed by surgeons with varying robotic experience, does not confer a clinically important benefit over conventional laparoscopic surgery in the short term”, the team concludes.

For the second study, In Gab Jeong, from the University of Ulsan College of Medicine in Seoul, South Korea, and colleagues used the US Premier Healthcare database to identify 5180 patients who underwent robotic-assisted radical nephrectomy for a renal mass between 2003 and 2015, whereas their 18,573 counterparts had a conventional laparoscopic procedure.

The robotic-assisted and laparoscopic groups were comparable in terms of the rates of any (22.2 vs 23.4%) or major (3.5 vs 3.8%) complications and blood transfusion (21.2 vs 17.8%) after adjusting for the inverse probability of treatment weighting.

But the likelihood of a prolonged (>4 hours) operative time was higher for the robotic-assisted than the laparoscopic surgery arm, with rates of 46.3% and 25.8%, respectively.

And again, the robotic-assisted approach was associated with higher costs than the conventional approach, with average 90-day direct hospital costs of $19,530 versus $16,851 (difference, $2678), which the authors say were mainly driven by operating room and supply charges.

Editorialist Jason Wright, from Columbia University College of Physicians and Surgeons in New York, USA, says that “[w]ithout clear demonstration of improved outcomes associated with robotic-assisted procedures, the complicated issue of the cost will become increasingly important.”

He adds: “From a policy perspective, robotic-assisted surgery exemplifies the difficulty of balancing surgical innovation with evidence-based medicine.

“Both the generation of high-quality evidence evaluating new procedures and then the utilization of this evidence to guide practice should remain priorities for surgical disciplines.”

References

Jayne D, Pigazzi A, Marshall H, et al. Effect of robotic-assisted vs conventional laparoscopic surgery on risk of conversion to open laparotomy among patients undergoing resection for rectal cancer. The ROLARR randomized clinical trial. JAMA 2017; 318: 1569–1580. doi:10.1001/jama.2017.7219

Jeong IG, Khandwala YS, Kim JH, et al. Association of robotic-assisted vs laparoscopic radical nephrectomy with perioperative outcomes and health care costs, 2003 to 2015. JAMA 2017; 318: 1561–1568. doi:10.1001/jama.2017.14586

Wright JD. Robotic-assisted surgery. Balancing evidence and implementation. JAMA 2017; 318: 1545–1547. doi:10.1001/jama.2017.13696

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