The number of robot-assisted surgeries continues to rise, sparking debate about cost and competition.
The nearly 7-foot-tall, white-and-black DaVinci xi robot whirred to life, moving from its post at the operating room’s wall next to the bedside of the 63-year-old patient, Mark Kuzio.
“Robot deployed,” said a mechanical robot voice.
The DaVinci robot is the third to be purchased at Maine Medical Center in Portland for an ever-expanding number of robot-assisted surgeries. Maine Med had 1,040 robot-assisted surgeries in 2017, more than double the 462 done in 2012.
The robotic devices offer a number of advantages, including smaller and less invasive surgical incisions and a faster recovery time for patients. Robotic surgery also puts less stress on doctors, who are spared some of the tough wrist, neck and shoulder movements required for prostate procedures.
However, some health care experts question the $2 million cost of the devices and whether the benefits they offer outweigh the higher charges for robotic surgeries.
On this day in late June, the DaVinci was helping with a prostatectomy, or prostate removal surgery. Kuzio, of Belfast, has intermediate-stage prostate cancer and needed the surgery or radiation therapy.
The robot’s four arms – each about 8 inches wide and wrapped in plastic for sterility – took positions over Kuzio. Surgeons had made six small incisions, each measuring about 1 to 11/2 inches, in Kuzio’s abdomen. The ports, as they are called, allow access to the prostate from various angles. Kuzio’s abdomen glowed red from the lights installed inside his pelvis.
“Install for targeting. Targeting complete,” the voice said.
The arms moved, like half of a giant mechanical spider performing a soundless dance over Kuzio. A small portion of Kuzio’s abdomen was exposed, but the rest of his body was draped for the surgery.
Several feet away, Dr. Matthew Hayn worked the controls, toggling to move surgical instruments like scissors, clamps and forceps.
A few large, well-illuminated screens displayed the surgery as it was going on, the surgical instruments moving inside Kuzio’s pelvis, controlled by Hayn. The screen showed careful cutting of tissues to get to the prostate and suturing of veins to reduce internal bleeding.
On the DaVinci robot itself, an image showed a diagram of a person lying on a table, captioned “surgery in progress.”
The surgery took about three hours, and near the end, the robot cut away the last of the connective tissues, freeing the round prostate gland, about the size of a lemon.
“It’s out,” Hayn said.
A sterile plastic bag awaited, and the robot dropped the gland into the bag, zipped it up and pulled it out of Kuzio with a string.
Maine Med purchased the DaVinci last year, and it was installed in December, the third surgical robot at the hospital.
Maine Med officials declined to say how much the device cost, citing a nondisclosure agreement with the manufacturer. However, a health industry website pegs the cost of the robots at about $2 million per unit.
Hayn said the robots are especially helpful in prostate removal, with better maneuverability for the surgeon and shorter recovery time for patients, who now have small, 1-inch incisions rather than a large 7- to 8-inch incision. Bleeding from the surgery is also much less – a “half a can of Coke,” he said.
Patients typically spend only a day at the hospital, compared to three to five days after traditional prostate surgery. Robot-assisted surgery also reduces wear-and-tear on the surgeons – for example, traditional prostate surgery strains the surgeon’s neck and shoulders.
Robots also mimic the wrist movements of surgeons, making them superior to laparoscopic surgery, which also uses small incisions, cameras and remotely controlled tools to reach into the body but doesn’t have the same ease of movement as the robots, Hayn said.
“The difficult part of a prostatectomy is the location. The prostate is embedded deep inside the pelvis,” Hayn said.
A week after the surgery, Kuzio said he was feeling good, taking walks around the block and only needing three opioids for pain control in the first few days after the procedure. The rest of the time he’s been taking over-the-counter pain medicine, and he’s been able to sleep well.
The big increase in robot-assisted operations at Maine Med from 2012 to 2017 outpaced the overall increase in surgical procedures at the hospital. All surgeries have increased by about 5 percent per year over the past several years. In addition to prostate surgeries, robots now assist surgeons with kidney cancer, difficult hernias and gynecologic cancers.
Robot-assisted surgeries have the best outcomes and are most justified for hard-to-reach areas of the body, such as for prostate removal and head and neck surgeries, according to a 2016 study published in The Milbank Quarterly, a scholarly journal. Outcomes for other surgeries – such as hysterectomies – were not as good.
Robot surgeries typically cost $3,000 to $6,000 more than traditional surgery, according to the study.
More than 90 percent of prostate removal surgeries are now done using robots, according to The Milbank Quarterly
Kuzio said that after he learned he had intermediate-stage prostate cancer, his choices were radiation or robot-assisted surgery. He said surgery was an easy choice after reading many books and articles on the topic.
“Everything I read was completely positive. I feel very confident,” said Kuzio, a potter who is married and has an adult daughter, a day before the surgery.
Hayn said just because the hospital has more robots doesn’t change the fact that robot use has to be justified. For instance, in prostate cancer, which is often slow-growing, the guidelines suggest “active surveillance” of the cancer is better in many cases than surgery, depending on the age of the patients.
The research showing improved outcomes must be available before Maine Med will add more types of surgical procedures that use the robots. Hayn sits on a 20-person robot committee that considers proposals to add procedures to the list that can use the robots.
“It doesn’t mean it’s always the right thing to do. Just because you can do something doesn’t mean you should,” Hayn said.
Dr. Brad Waddell, interim chief of surgery at Eastern Maine Medical Center in Bangor, agreed, noting that EMMC has a steering committee to decide whether to use robots for certain surgeries.
“It’s a balancing act,” Waddell said. “We make sure the (robotic) surgeries are only used when appropriate.” But he noted that as medicine advances, more procedures are being found to benefit from robotic surgery.
Eastern Maine, which like Maine Med has three robots, uses them for some colorectal and thoracic surgeries, some hernias and hysterectomies. Eastern Maine performed 783 robot-assisted surgeries in 2017, and is expected to do more than 1,000 this year and in 2019.
Laparoscopic surgery became much more common in the 1990s, while robot-assisted surgery started in the 2000s, with increasing frequency in the last five to 10 years.
CRITICISM, COSTS AND COMPETITION
Some health experts criticize the expansion of robot-assisted surgery, especially for certain types of surgeries.
According to a 2017 Stanford University study of 24,000 kidney removals, robotic surgery did not provide better outcomes than laparoscopic surgery, but hospitals were more likely to use robotic surgeries anyway. By 2015, 27 percent of all kidney removals were being done with robots, compared to 23 percent with laparoscopic surgery, even though robotic surgeries cost $2,700 more and the research did not indicate outcomes were better using robots.
The study said that “there may be an expectation on the part of the hospital or the surgeons themselves to justify the large initial investment in purchasing the robot by using it for many types of procedures.”
“There is a certain incentive to use very expensive equipment,” Dr. Benjamin Chung, an associate professor of urology at Stanford, said in a statement. “But it is also important to be cognizant as to how our health care dollars are being spent. Although robotic surgery has some advantages, are those advantages relevant enough in this type of case to justify an increase in cost?”
Chung, in an interview with the Maine Sunday Telegram, said there’s a “keeping-up-with-the-Joneses” mentality at some hospitals, and for certain procedures, such as prostate removal, patients are demanding robot-assisted surgery.
“If you’re not offering these surgeries in some cases, patients are going to walk,” Chung said. He said there’s also pressure on hospital doctors and administrators to use the robots. If they’re underutilized, upgrades and replacements become difficult to justify.
“You can imagine these conversations between doctors and administrators. ‘You want a new robot? Well, why aren’t we using the one we already have?’ ” Chung said.
Healthline, a health industry website, cast doubt on whether the robotic surgeries were providing enough of an advance over laparoscopic surgeries to justify the cost in an August 2016 article.
“This is a technology that is costing the health care system hundreds of millions of dollars and has been marketed as a miracle – and it’s not,” Dr. John Santa, former medical director at Consumer Reports Health, told Healthline. “It’s a fancier way of doing what we’ve always been able to do.”
Despite the criticism, robot-assisted surgeries are increasingly common.
There are more than 500,000 robot-assisted surgeries in the United States per year and that number is expected to grow, according to Decisions Resources Group, a global firm that provides “proprietary data” for the health care industry.
One in three surgeries by the early 2020s will be performed using robots, according to a 2016 Fortune magazine article.
But the Healthline article also noted that for certain surgeries that couldn’t be done or were difficult to do with a laparoscope – such as prostate removals – the robots were better.
Both Hayn and Waddell, when asked by the Sunday Telegram, didn’t believe that robots would one day completely take over some surgeries, with a surgeon pressing a button and watching the robot perform the operation. Waddell said it’s not like the robotic vacuum cleaners, where you can push a button and watch the robot clean your carpet.
“There are so many layers of complexity to surgery, I just can’t see it,” Waddell said. “But if you had asked me 20 years ago whether the iPhone would exist, I would have said no to that as well.”
Susan Nelson, a certified surgical technician, helps to perform robot-assisted surgery at Maine Medical Center in Portland. The hospital has three robots and went from 462 robot-assisted surgeries in 2012 to 1,040 in 2017. (Derek Davis/Portland Press Herald)