Seduction by Robot

Seduction by robot??? Sounds strange does it not?application for the technology. However, recently
But that is exactly what appears to be happening atwhen speaking to a urology colleague about the
a hospital near you. Perhaps you have not yet heardincidence of complications in robot-assisted surgery
of the da Vinci Surgical System. However, I canhe informed me that his colleagues were beginning to
assure you, your hospital administrators have, asquestion this benefit and some of their contemporary
have the surgeons who practice in your area. What isliterature was refuting it, as well.
it? When did it arrive on the scene? And, perhaps,It was during this conversation that I was discussing
most importantly, why should you care?another of the potential issues with this
Originally launched in January of 1999 by Intuitiverobot-assisted surgery, that is of complications and
Surgical, The da Vinci Surgical System is described bywhat is more concerning, unrecognized complications.
its creators as, "...a sophisticated robotic platformAny surgeon will tell you that if you operate enough,
designed to enable complex surgery using a minimallyeventually, you will have complications. There is no
invasive approach. The da Vinci System consists ofway around it. It is part of surgical medicine. The
an ergonomic surgeon's console, a patient-side cartbest, most gifted surgeons in the world have surgical
with four interactive robotic arms, acomplications. One strives, as a surgeon, to minimize
high-performance 3D HD vision system andcomplications through thorough training, proper
proprietary Endowrist instruments. Powered bypreparation, careful surgical technique and vigilance.
state-of-the-art robotic technology, the da VinciEven with all of these things sometimes complications
System is designed to scale, filter, and seamlesslywill occur. When they do occur, you, as a surgeon,
translate the surgeon's hand movements into morewant to recognize that a complication has occurred
precise movements of the Endowrist instruments.and address it appropriately and timely thus minimizing
The net result is an intuitive interface withthe impact it has on the patient.
breakthrough surgical capabilities."We have already mentioned that the learning curve
Wow! Sounds great, does it not? Sign me up! As afor physician training with the da Vinci system is very
surgeon, I cannot wait to place my hands on one ofsteep and time-consuming. It is one of the few, if
these things. What patient would not want theirnot only, products on the market of which I can
surgery to have this technology incorporated intothink that charges the surgeon a fee to learn how to
their procedure? "Seamlessly translate the surgeon'suse its product. The system itself is very hands-on
hand movements into more preciseand labor intensive not only for the surgeon but for
movements...state-of-the-art...breakthrough surgicalthe operating room personnel, as well. It only makes
capabilities." Seems like a no-brainer, right? Hospitalssense, that depending on where any given surgeon is
around the nation and the world seem to think so.on that curve, the potential for complications may
And they have snatched these robots up in a "Weincrease. The discussion I was having with this
don't want to be left out" frenzy. Many surgeonsurologic colleague stemmed from a patient recently
have also been eager to jump on board. However,referred to me following a robot-assisted gynecologic
wait a tick. Let us take a closer look.procedure during which the patient sustained injuries
There exist several potential issues with this deviceto her bladder and ureter. The ureteral injury was
as well as issues with how it has been marketed.unrecognized at the time of surgery. This colleague
Some of these include the cost of the device,discussed with me the increasing number of
monthly maintenance costs, significantly increasedrobot-assisted surgical injuries that he is seeing in his
operative times, steep learning curve, increasedpractice, as well.
complications and, at least in one area, presentationThere are numerous surgical fields that are
of the robot as the least invasive approach when aattempting to incorporate robot-assisted procedures
lesser invasive procedure is available. These potentialinto their practice. I have read some reports from
problems deserve a closer look.cardiovascular physicians and oncologists who report
Consistently, the cost of the da Vinci Surgical Systemenjoying using the da Vinci Surgical System and feel it
is reported to be $1-1.2 million. A hospital administratorhas benefits in their field. You can read many of
recently informed me that the monthly maintenancethese posted on the company's website (perhaps,
for the system is in the neighborhood of $10,000.00.not the most objective source). As I have no
That is a significant amount of money. Add to thatexpertise in those fields I am not qualified to opine.
the enormous cost of training in terms of both timeWhere I can voice concern is in my own area of
and money, and we are talking about an even largerexpertise in how this technology is being employed in
sum. This is something of which any hospital systemgynecology. I recently had a conversation with a
that acquires one of these robots will be acutelygynecologic oncologist who was planning to use the
aware. This presents one of the issues I have foundrobot in a benign gynecologic case, not because the
most concerning surrounding this device, morerobot offered any particular benefit to the patient,
specifically, its marketing.but simply because he wished to use the robot.
Several times over the last year I have received andNever mind the aforementioned increased cost to
read advertisements with invitations for people inthe patient and our medical system but also the
neighboring communities to attend a meeting orincreased operative and anesthesia times and
dinner to learn about a new minimally invasivepotential risks. This is concerning.
procedure available for hysterectomy. This, in and ofWhen discussing increased operative times, we are
it itself, poses no problem. However, the slantnot talking about 20-30 minutes. Unfortunately,
presented appeared to be that this new technologydoubling, tripling and even quadrupling of operative
(read robot) was less invasive than "traditional"times is common. Approximately 3 years ago when
hysterectomy. This is where the problems arise.returning from a medical conference I was discussing
There can be no argument that the LEAST invasivethe pros and cons with one of the more experienced
hysterectomy is a vaginal hysterectomy. The vaginal"robotic" surgeons in my area. He stated that, at the
hysterectomy has also consistently proven to be thetime, a case that might require 45 minutes for him to
safest in terms of dangerous complications likecomplete with traditional laparoscopy might require 2.5
ureteral injury. However, the purpose of theseto 3 hours with the robot. He reported that he did
meetings is to "inform" people of this less (read,not mind the increased operative time because he
least) invasive option of robotic hysterectomy. Areally enjoyed robotic surgery. And this, he reported,
more skeptical assessment might be that thesewas a significant improvement over the initial increase
meetings intend on "selling" prospectivein operative times. He explained that one could
hysterectomy patients on the idea that this robotexpect even longer times when first learning the
offers the least invasive approach to hysterectomy.system. Is this reasonable? Is this acceptable in the
Let us not forget, these da Vinci systems arefield of gynecology, or in any field for that matter?
extremely expensive and it appears from theseDoes the end justify the means? When is this the
marketing efforts, that these hospital systems arebest approach? Most cost-effective? Safest? Is it
looking to drum-up business to help cover their costs.ever any of those things or does it offer all those
If, in so doing, they are deliberately misleadingthings and more? The answers to these questions
patients that the robot offers the LEAST invasiveare certainly not clear and require further evaluation,
option for hysterectomy then it is, at a minimum,at a minimum.
wrong and, at worse, potentially assault and battery.There are often numerous choices in the approach a
But let us back-up for a moment. Let us examinesurgeon uses to perform a procedure. Some
potential issues with this da Vinci Surgical Systemsurgeons are trained in multiple approaches to the
craze in more general terms. When news begansame procedure, others perhaps only one. Numerous
making its rounds in surgical circles about this devicefactors go in to deciding on which procedure is most
and as most of us watched procedures beingappropriate. Factors include surgeon's skill, patient
performed "robot-assisted", there was one commentfactors such as their health, size, or organ size, as in
heard time and time again. That comment was thathysterectomies. Never should a more invasive
the system seemed to be a "technology looking forprocedure be chosen simply because a physician finds
an application." In other words, yes, this is anit to be more "fun" or "interesting." Additionally, a
interesting, fancy machine, but it really had not beenprocedure should never be chosen because it is a
able to demonstrate a benefit in any particular areapart of an efficient marketing machine. I was caught
of surgery that could come close to justifying itsa little off-guard the first time I saw a physician
enormous costs. Keep in mind that these costsadvertising themselves as a "robotic surgeon." Does
consist of much more than the cost of the machinethat sound like a good thing? I know what they are
itself and its monthly maintenance costs (which wetrying to say/ advertise. But does anyone truly want
have seen are substantial), but the enormous costs ina "robotic" surgeon? Not me. I want a skilled surgeon
terms of increased surgical times, increasedwho has the ability, adaptability and fluidity to adjust
anesthesia costs and increased costs of surgicaltheir approach as the case requires, not plod aimlessly
training.forward in robotic fashion without regard to the
These are some of the costs speaking in financialcircumstances of the specific case. This is clearly not
terms. Potential personal costs to the patient includewhat they mean, but it sounds a little odd.
increased operative times, increased time underThe most appropriate procedure should always be
anesthesia and the potential for increased operativethe least-invasive procedure that can be safely
risks and injury. More on this in a moment.performed in a particular surgeon's hands at a given
When I first began learning about robotic assistedsurgical facility.
surgery, the one area where they felt they couldI am not saying that there does not or never will
definitively state that there existed a significantexist a place in medicine for robot-assisted surgery. I
proven benefit to the patient when robotic-assistedpersonally know many well-respected surgeons who
surgery was employed was in the area of a radicalare using the product and believe it offers a benefit
prostatectomy. There existed decreased risk ofin their hands. I am simply saying that in a world with
erectile dysfunction and other morbidity and thean increasingly scarce healthcare dollar we should tap
surgeons apparently really raved about the benefitsthe brakes a bit and determine if this or any other
of robot-assistance with this procedure. Radicaltechnology is appropriate for any given medical field.
prostatectomy is way out of my area of expertiseAnd whether it truly offers a cost-effective benefit
but it certainly sounded reasonable to me at the timeto our patients without increasing their risks.
and I was pleased to hear they had a truly beneficial