Monday, 11 June 2012

Invasion of the robots


In my institution, the surgeons are keen to get some government money to turn us into a robotic surgery centre. I fear they are doing it for the reputation and the referrals, but this would be cynical rather than skeptical (see upcoming blog on the difference). So I will simply say that they are not doing it to benefit the patients. They may think they are, but I am not aware of any evidence that patient-based outcomes are better with robotic surgery. I am however, aware of empirical evidence that robots cost a lot, because I have seen the bill.

It turns out that robotic surgery is yet another example of something that sounds good, with some research showing improvements in some aspects, but with the whole thing falling down when it comes to improving patient health.

Systematic reviews or the clinical research on robotic surgery are plentiful (although not nearly as plentiful as websites promoting robotic surgery) so I have looked at the most recent reviews for the most common applications.

1.     For bariatric surgery (for obesity), a review from this year failed to show any clinical benefit from robotic surgery.
2.     This recent review on urological surgery showed some improvement with certain outcomes (length of stay and blood loss) but not with patient health. And the best thing I can get out of this review of robotic prostatectomy from high volume centres is that it is “safe”.
3.     From 2011, this review on robotics for gynaecology showed no clinical benefit, and the Cochrane review on the same topic didn’t help the cause either.
4.     This paper, this paper and this paper, all from 2012 only showed that robotic surgery was feasible for colorectal surgery, with no clinical benefit.
5.     For cholecystectomy (removing the gall bladder), you only need to read the title of the Cochrane review to realise that having a robot do your operation  “appears safe but does not offer any advantage”. 

It is amazing how awestruck we are when we see high tech wizardry, and how we assume that it must be better than whatever it is that we are doing now. Ask for the evidence before paying thousands of dollars extra for robotic surgery (like many patients around here).

The blog that got me started on this was from Skeptical Scalpel, who picked up on a video clip of a robot folding a paper plane. The blog and the video are good, and they are an example of how we are impressed by the wrong things. Another post on robotics from Skeptical Scalpel (here) is an example of how authors can bias their findings by writing an abstract (summary) that is in contrast to the actual findings of the research paper. Robotic surgery is a pet subject of his, and his posts on subject are all listed here.

4 comments:

  1. Its very informative and interesting article.all the points are very useful. Simple but very effective writing. Thanks for sharing such a nice post.
    Health Care in Chennai

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    1. Thanks Shankarabarathi, "Simple but effective" is what I am aiming at. Feel free to spread the word. I will be lecturing in India in a few months - looking forward to it.

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  2. Thanks for a great article Dr Skeptic.

    I definitely agree that the data is lacking to support the use of robotic surgery, but this is perhaps due to the relative novelty of the technology. And having said that, there should not be such an emphasis to direct (a large amount of) public resources towards robotic surgery without concrete supporting evidence. There, however, does seem to be opinion (the evidence was scant) supporting the use of robotic surgery in head and neck surgery, especially in cases of cancer.

    http://www.ncbi.nlm.nih.gov/pubmed/20202612
    http://www.ncbi.nlm.nih.gov/pubmed/21155450
    http://www.ncbi.nlm.nih.gov/pubmed/21658808

    But as mentioned, nothing concrete has been shown so far in support. Out of interest, would there be another link to the first urological surgery article? I could not find it on the Skeptical Scalpel blog. And what is your opinion towards robotic surgery in the private setting?

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    1. Thanks AA,
      There is plenty of "opinion" supporting robotic surgery, and plenty of articles in journals "discussing" the benefits. I think you are getting to the core of my message: that the perception of benefit from many medical interventions is not aligned with the reality, as provided by sound scientific inquiry; the more scientifically we look at things, the less rosy our view of the medical landscape becomes.
      The first urology link is wrong, and I will try to track down the review and change the hyperlink shortly.

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