Challenging innovation

Robot-aided keyhole surgery has proven a popular option for prostate reduction or removal, accounting for 67% of procedures in the UK in 2014–15. However, researchers at the Royal Brisbane and Women’s Hospital in Australia recently made a startling assertion. “Contrary to common clinical belief, our research found no significant statistical differences between the robotic approach and open surgery,” wrote lead author Robert Gardiner.

The fact the study was conducted at all is cause for praise, according to Erik Mayer, Clinical Senior Lecturer in Urology at Imperial College London. “It’s very difficult for surgeons to conduct robust randomised trials, as they require the same type of patient and surgeons with the same level of experience in both techniques,” he says. Even so, the study had several flaws: its sample comprised only 308 men and checks were made only up to 12 weeks after surgery, a relatively short period in which to evaluate outcomes.

Since the study’s publication, implications have abounded that clinicians shouldn’t recommend expensive options without sufficient evidence. But the portrayal of open surgery as equivalent to robotic surgery misses some important points. “Robotics addresses some of the major challenges keyhole introduced for surgeons, such as a lack of depth perception and counterintuitive movements,” Mayer explains. “Robotics is also less invasive for patients; we mustn’t forget that.”

Mayer challenges the presumption that new procedures should significantly outperform the procedure they’re designed to replace: “If the innovation provides a new platform to build upon in the future, we only need to prove it is as good as what currently exists.”

Robotic prostatectomy is generally €1,600 more expensive than non-robotic keyhole. With many national health care budgets already over-stretched, the Australian study may open the
door to more robust cost-benefit analyses.