by Stephen Pinn

Minimally-invasive procedures are now considered to be the gold standard for a wide variety of cancers requiring surgery – from prostatectomy, through cystectomy for tumours of bladder, to liver and lung resection.

Not surprisingly, perhaps, the range of surgical options now available is becoming increasingly sophisticated – and robot-assisted techniques are now being championed throughout Europe, the US and other international surgical communities that have the wherewithal to fund such advanced technologies.

The European Institute of Oncology (EIO) is at the forefront of many robot-assisted cancer surgery initiatives, as are a handful of specialist tertiary referral centres in the UK.

There appear to be clear benefits for the patients – and for those surgeons who, as Dr Robert Cerulio comments, are prepared to undergo the “steep learning curve” required to master the subtle robotic techniques (Cerulio et al, 2011).

Looking back on a series of 150 patients undergoing robotic-assisted surgery for general thoracic surgical indications - lobectomy, thymectomy and a handful of benign oesophageal procedures – he reports: “Robotic surgery is safe and oncologically sound. It requires training of the entire operating room team.

“The learning curve is steep, involving port placement, availability of the proper instrumentation, use of the correct robotic arms, and proper patient positioning. The robot provides an ideal surgical approach for thymectomy and other mediastinal tumours.

Its advantage over thoracoscopy for pulmonary resection is unproven - however, we believe complete thoracic lymph node dissection and teaching is easier.”

Dr Cerulio (Division of Cardiothoracic Surgery, University of Alabama, Birmingham, US) also reports that the median operative time for robotic thymectomy was 119 minutes, and median length of stay was one day. The median time for robotic lobectomy was 185 minutes, and median length of stay was two days. There were no operative deaths, while morbidity occurred in 23 patients (15%).

In Europe, Dr Giulia Veronesi (Division of Thoracic Surgery, EIO, Milan, Italy) is a leading proponent of robot-assisted surgery for lung and mediastinal tumours.

While conceding that video-assisted thoracoscopic (VAT) procedures currently represent the standard in this field, she is convinced that the benefits of the robotic approach in terms of optimal lymph node resection, the very high degree of ambidextral precision afforded the surgeon, increased visualisation in the surgical field, minimal blood loss, less pain, less risk of infection, faster recovery times and shorter hospital stays for the patient can no longer be ignored. “It takes the uncertainty out of lung resection,” she emphasised.

Dr Veronesi and colleagues have recently reported data from a multi-institutional retrospective review of patients undergoing robotic lobectomy for NSCLC (Park et al, 2011). Data from 325 patients was analysed, resulting in the following outcomes:
 

-       conversion rate to thoracotomy  8% (27/325)

-       overall morbidity rate 25.2% (82/325)

-       major complication rate 3.7% (12/325)

-       median length of stay 5 days

With a median follow-up of 27 months, overall 5-year survival was 80%, while 3-year survival for patients with stage IIIA disease was 43%.

She and her colleagues concluded: “Robotic lobectomy for early-stage NSCLC can be performed with low morbidity and mortality. Long-term stage-specific survival is acceptable and consistent with prior results for VATS and thoracotomy.”

In the UK, prostate cancer has thus far been the most popular target for robot-assisted strategies – none more so than the Royal Marsden Hospital in London, where Mr Christopher Ogden and his team are perfecting their techniques.

Reporting to the British Association of Urological Surgeons (BAUS) and the American Urological Association (AUA) in 2010, Mr Ogden reported on a series of 309 patients undergoing robot-assisted laparoscopic prostatectomy (RALP), with a biochemical/clinical recurrence rate of 7.1% (Lavan et al 20102 – 1 and 2).

He concluded: “Robotic radical prostatectomy delivers safe, short-stay treatment with minimal morbidity. Early oncologic outcomes are excellent with minimal biochemical failures…

 “In this relatively high risk patient cohort, RALP provides good oncological control. As expected, T3 disease appears to have a higher incidence of biochemical recurrence – but surgical cure appears possible in more than 50% of pT3 patients.”

Robot-assisted surgery is now making inroads into many areas of cancer surgery, including: adrenalectomy, liver wedge resection, pancreatectomy, myotomy for hiatal hernia, thyroidectomy, splenectomy, colon resection, rectopexy for rectal prolapse and other related procedures, low anterior resection for pelvic floor dysfunction and even gastric surgical procedures for obesity-related disorders. This is by no means an exhaustive list of candidates for robot-assisted surgery.

However, as with any new surgical intervention that requires an expensive capital outlay, as well as considerable expenditure on maintenance, the question of cost vs benefit invariably divides opinion.

In a recent paper, US surgeons estimated that compared to conventional laparoscopy, the additional cost-per-case of using robotic-assisted surgery to remove the uterus in women diagnosed with endometrial cancer was approximately US$1,300 (Wright et al, 2012).

The mean hospital cost for laparoscopic surgery was US$8,996 compared to US$10,618 for a robotic procedure.

These data were based on a cohort of 2,464 women, nearly 58% of whom underwent a robotic-assisted procedure. In 8.1% of these patients, complications such as bladder injury, wound infection or kidney failure, compared to 9.8% of those undergoing laparoscopy.

The authors concluded that the extra expense – even without taking into account purchase costs of up to US$2.25million for each robotic machine – did not outweigh the slight reduction in adverse events.

In contrast, when outcomes and costs for 143 women who underwent robotic hysterectomies at a Canadian tertiary cancer centre were compared to 160 women undergoing laparoscopy during the five years before robotic-assisted procedure was introduced, a different picture emerged (Lau et al,2012).

Robotic surgery was associated with longer operating times (233 vs 206 minutes), but far fewer adverse events (13% vs 42%, p<0.001), lower estimated median blood loss (50mL vs 200mL, p<0.001) and shorter median hospital stay (1 vs days, again p<0.001).

Overall hospital costs were significantly lower for robotic procedures compared to laparoscopy (Can$7,644 vs Can$10,368, p<0.001), even when acquisition and maintenance cost were taken into account.

Included.

Within two years following surgery, the short-term recurrence rate was lower for robotic-assisted surgery than for laparoscopy (11 vs 19 recurrences, p<0.001).

In another recent paper from the US comparing robotic-assisted procedures and conventional laparoscopy to open surgery in patients requiring the most common interventions for urological cancer (radical prostatectomy, nephrectomy and pyeloplasty), the authors were more equivocal in their findings (Yu et al, 2012 - 1).

Robotic-assisted surgery was performed for 52.7% of radical prostatectomies, 27.3% of pyeloplasties, 11.5% of partial nephrectomies and 2.3% of nephrectomies.

The robotic approach resulted in significantly shorter hospital stays for radical prostatectomy and partial nephrectomy (a mean difference of 1 day favouring   p <0.001), while for most procedures, robotic and other minimally-invasive strategies  resulted in fewer deaths (0 vs 2 per 1,000), complications, transfusions (>2% vs 5%) and more routine discharges than open surgery.

However, robotic-assisted surgery was more costly than conventional laparoscopic surgery and open surgery for most urological procedures.

Turning finally to radical cystectomy for bladder cancer, US researchers reviewed data from 1,444 women undergoing open surgery and 224 of those experiencing robotic-assisted laparoscopic procedures Yu et al, 2012 – 2).

It was found that patients who underwent robotic-assisted surgery experienced fewer in-patient complications than those who had the traditional open procedure (49.1% vs 63.8%). A significant finding was that no deaths were reported with robot-assisted intervention, whereas open surgery resulted in one death per 100 patients.

It was further reported that delayed bowel function often occurs following major surgical procedures, and that patients with this complication require parenteral feeding. Those patients who underwent the robotic procedure had less need of parenteral nutrition than those that underwent the open procedure (6.4% vs 13.3%). The length of hospital stay was similar for both groups (approximately eight days).

Total costs for robotic surgery significantly higher - an increase in excess of US$3,000, which was attributed to longer surgery time as well as the greater use of disposable instruments with the robot. It was emphasised that this analysis did not include expenses for the purchase of the robot or its maintenance.

The authors commented: "While we expected to see greater expenses associated with the robotic procedure for bladder cancer, we were surprised to see the significant reduction in deaths and complications, particularly this early in its adoption,"

Final word to two Japanese surgical technology specialists from Kyushu University, Fukuoka, where the inspiration for robot-assisted surgery first emerged.  Although these observations were published eight years’ ago (Hashizume, Tsugawa, 2004), they remain as relevant today as they did then.

They called for the introduction of image-guided surgical assistant systems, smaller sized forceps for robots, capsule endoscopic surgery and a surgical robotic system. In education and training, training centers for robotic surgery, such should be established around the world.

They envisaged that, in the future, as robotic technology continues to develop almost all endoscopic and open cancer surgery could and would be performed with the aid of new robot-assisted technology. “It will replace traditional surgery not only in the treatment of benign diseases but also in malignant illnesses.”

References

Cerulio RJ, Bryant AS, Minnich DJ. Starting a robotic program in general thoracic surgery: why, how and lessons learned. Ann Thoracic Surg 2011;91:1721-1737

Park BJ et al. Robotic lobectomy for non-small cell lung cancer (NSCLC): long-term oncologic results. J Thorac Cardiovasc Surg 2012:143(2):383-9.

Lavan L et al. The oncological outcomes of robotic-assisted radical prostatectomy in a high volume UK institution. Poster 534, presentation British Association of Urological Surgeons, 2010

Lavan L et al. Robotic-assisted laparoscopic prostatectomy in a predominantly non-screened population – findings in a single UK institution. Abstract 10070705, presentation to American Association of Urologists 2010

Wright JD et al. Comparative effectiveness of robotic versus laparoscopic hysterectomy for endometrial cancer. J Clin Oncol 2012;30:783

Lau S et al. Outcomes and cost comparisons after introducing a robotics program for endometrial cancer surgery. Obstet Gynecol 2012;119(4):717-24

Yu H-y et al. Use, costs and comparative effectiveness of robotic assisted, laparoscopic and open urological surgery. J Urol 2012; 187(4):1392-1399

Yu H-y et al. Comparative analysis of outcomes and costs following open

radical cystectomy versus robot-assisted laparoscopic radical

cystectomy: results From the US nationwide inpatient sample. European Urology 2012;61:1239-1244

Hashizume M, Tsugawa K. Robotic surgery and cancer: the present state, problems and future vision. Jpn J Clin Oncol 2004;34(5):227-237

Related article: Robotic-assisted prostate cancer surgery drives up costs

Stephen Pinn is a freelance medical writer