Minimally invasive surgeries have grown in use among surgeons and favor among patients and payers. Robotically assisted surgery performed using the da Vinci robot is the latest technologic upgrade, but new research is calling its effectiveness — and higher cost — into question.
But, even some healthcare executives skeptical of the da Vinci's cost-saving potential find the machine indispensable in recruiting physicians and marketing to patients.
Laparoscopic surgeries have been recognized as safe alternatives to traditional open surgeries, with shorter hospital stays, less blood loss and faster, less painful recoveries. The da Vinci robot allows surgeons to perform a type of laparoscopic surgery by controlling mechanical arms and instruments using hand controls, foot pedals and a 3-D high-definition display while seated in a booth several feet from the patient. A single da Vinci unit costs about $1.5 million and can perform a variety of minimally invasive procedures, especially for localized cancers in tough-to-access anatomic regions, including colorectal, prostate and head and neck procedures.
Ingrid Rodi, MD, a surgeon and clinical professor of obstetrics and gynecology at the Geffen School of Medicine at UCLA, said gynecologists in particular can benefit from the da Vinci if they have not yet become proficient at other types of minimally invasive surgery. "I think that gynecologic surgeons today need to have access to a robot to be able to do the highest possible percentage of cases in a minimally invasive fashion," she says.
Use of the robots in gynecologic surgery has grown rapidly in recent years. In 2007, da Vinci robots performed just 0.5 percent of U.S. hysterectomies, but jumped to 9.5 percent in 2010, according to a study published in the February 2013 edition of the Journal of the American Medical Association.
However, the JAMA study also noted that while robotically assisted hysterectomies produced slightly fewer hospital stays longer than two days than non-robotic laparoscopic hysterectomies, they performed at about the same level in regards to blood loss and operative complications — and cost about $2,189 more per procedure.
The American Congress of Obstetricians and Gynecologists released a statement in March critical of the device's appeal among physicians and hospitals, assaying its high price tag and $125,000 annual maintenance cost make it "the most expensive approach" to hysterectomies "without any demonstrable benefit" over non-robotic laparoscopic methods.
Intuitive Surgical, the Sunnyvale, Calif.-based company that makes the da Vinci, generated $2.2 billion in revenue last year, but is the subject of 26 pending lawsuits related to the company's policies or product, according to reports from BusinessWeek and Bloomberg News. In March, the FDA, which approved the robot for surgical use on humans 12 years ago, began an investigation into an increase in adverse reports from patients.
Tampa Bay, Fla.-resident and uterine cancer survivor Lee Ann Leach had a robotic hysterectomy several years ago that she said left her in extreme pain. Even though she had previously undergone two caesarean sections and one bilateral mammoplasty, she says, "I literally felt like I had been drawn and quartered after the robotic surgery." She adds, "It seems like the [physicians] are using the da Vinci robot, rather than thinking on the patients' behalf."
"It is worth the investment until a less expensive [alternative] comes along," Dr. Rodi says. "If a hospital wants to attract gynecology patients, a robot is essential" in order for all eligible patients who prefer minimally invasive procedures to receive them, she says.
Marc Smaldone, MD, a urologic oncologist at the Fox Chase Cancer Center in Philadelphia who uses the robot in more than 75 percent of his procedures, says, "It is my own opinion that the robotic platform affords procedures requiring complex reconstruction [such as] cystectomy, partial nephrectomy [and] prostatectomy to be performed in a minimally invasive fashion, but there are certainly strong market forces influencing the decision at the hospital level to purchase the robot which are hard to ignore."
Those market forces are under special scrutiny lately, as hospitals and health systems place a premium on value-based care and cost savings as they face shrinking reimbursements.
"In gynecological surgeries, here is where marketing and capitalism and healthcare can all come together to produce a catastrophe" said Kenneth L. Davis, MD, President and CEO of The Mount Sinai Medical Center in New York City, at a public interview in April. "The da Vinci robot can be highly effective for prostate and some head and neck surgeries. However, it has to be in the hands of a very skilled, well-trained surgeon who has used it in hundreds or thousands of procedures," he said.
When the da Vinci is used for gynecological procedures, Dr. Davis said, "the surgery takes longer. The cost to the healthcare system is much higher. The outcomes aren't any better. But the doctors market it because people think, 'It's a robot, it must be unbelievable, right?' Somebody has to have sanity around this." When patients and payors are calling for reducing the cost of healthcare, Dr. Davis added, it's difficult to justify spending money on robotic equipment that isn't proven to be more effective or less expensive.
Robotic surgery has its supporters on the administrative side, as well. Dave Tupponce, MD and interim CEO of Abrazo Health Care's Paradise Valley Hospital, both based in Phoenix, said its da Vinci robot draws appeal from physicians and patients alike. "If we can provide both conventional and robotic-assisted options, it makes our hospital more attractive to both populations," he says.
Paradise Valley was fortunate to acquire its da Vinci from an inter-company transfer rather than buying or leasing the robot, Dr. Tupponce says. As for effectiveness, he says he believes the skill of the surgeon coupled with appropriate patient selection is the greatest determinant in robotic surgical outcomes. He adds, "As with any type of surgery, there tend to be good correlations between outcomes and case volume."
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But, even some healthcare executives skeptical of the da Vinci's cost-saving potential find the machine indispensable in recruiting physicians and marketing to patients.
Rise of the robots
Laparoscopic surgeries have been recognized as safe alternatives to traditional open surgeries, with shorter hospital stays, less blood loss and faster, less painful recoveries. The da Vinci robot allows surgeons to perform a type of laparoscopic surgery by controlling mechanical arms and instruments using hand controls, foot pedals and a 3-D high-definition display while seated in a booth several feet from the patient. A single da Vinci unit costs about $1.5 million and can perform a variety of minimally invasive procedures, especially for localized cancers in tough-to-access anatomic regions, including colorectal, prostate and head and neck procedures. Ingrid Rodi, MD, a surgeon and clinical professor of obstetrics and gynecology at the Geffen School of Medicine at UCLA, said gynecologists in particular can benefit from the da Vinci if they have not yet become proficient at other types of minimally invasive surgery. "I think that gynecologic surgeons today need to have access to a robot to be able to do the highest possible percentage of cases in a minimally invasive fashion," she says.
Use of the robots in gynecologic surgery has grown rapidly in recent years. In 2007, da Vinci robots performed just 0.5 percent of U.S. hysterectomies, but jumped to 9.5 percent in 2010, according to a study published in the February 2013 edition of the Journal of the American Medical Association.
However, the JAMA study also noted that while robotically assisted hysterectomies produced slightly fewer hospital stays longer than two days than non-robotic laparoscopic hysterectomies, they performed at about the same level in regards to blood loss and operative complications — and cost about $2,189 more per procedure.
The American Congress of Obstetricians and Gynecologists released a statement in March critical of the device's appeal among physicians and hospitals, assaying its high price tag and $125,000 annual maintenance cost make it "the most expensive approach" to hysterectomies "without any demonstrable benefit" over non-robotic laparoscopic methods.
Intuitive Surgical, the Sunnyvale, Calif.-based company that makes the da Vinci, generated $2.2 billion in revenue last year, but is the subject of 26 pending lawsuits related to the company's policies or product, according to reports from BusinessWeek and Bloomberg News. In March, the FDA, which approved the robot for surgical use on humans 12 years ago, began an investigation into an increase in adverse reports from patients.
Tampa Bay, Fla.-resident and uterine cancer survivor Lee Ann Leach had a robotic hysterectomy several years ago that she said left her in extreme pain. Even though she had previously undergone two caesarean sections and one bilateral mammoplasty, she says, "I literally felt like I had been drawn and quartered after the robotic surgery." She adds, "It seems like the [physicians] are using the da Vinci robot, rather than thinking on the patients' behalf."
Providers' take
"It is worth the investment until a less expensive [alternative] comes along," Dr. Rodi says. "If a hospital wants to attract gynecology patients, a robot is essential" in order for all eligible patients who prefer minimally invasive procedures to receive them, she says.Marc Smaldone, MD, a urologic oncologist at the Fox Chase Cancer Center in Philadelphia who uses the robot in more than 75 percent of his procedures, says, "It is my own opinion that the robotic platform affords procedures requiring complex reconstruction [such as] cystectomy, partial nephrectomy [and] prostatectomy to be performed in a minimally invasive fashion, but there are certainly strong market forces influencing the decision at the hospital level to purchase the robot which are hard to ignore."
Those market forces are under special scrutiny lately, as hospitals and health systems place a premium on value-based care and cost savings as they face shrinking reimbursements.
"In gynecological surgeries, here is where marketing and capitalism and healthcare can all come together to produce a catastrophe" said Kenneth L. Davis, MD, President and CEO of The Mount Sinai Medical Center in New York City, at a public interview in April. "The da Vinci robot can be highly effective for prostate and some head and neck surgeries. However, it has to be in the hands of a very skilled, well-trained surgeon who has used it in hundreds or thousands of procedures," he said.
When the da Vinci is used for gynecological procedures, Dr. Davis said, "the surgery takes longer. The cost to the healthcare system is much higher. The outcomes aren't any better. But the doctors market it because people think, 'It's a robot, it must be unbelievable, right?' Somebody has to have sanity around this." When patients and payors are calling for reducing the cost of healthcare, Dr. Davis added, it's difficult to justify spending money on robotic equipment that isn't proven to be more effective or less expensive.
Robotic surgery has its supporters on the administrative side, as well. Dave Tupponce, MD and interim CEO of Abrazo Health Care's Paradise Valley Hospital, both based in Phoenix, said its da Vinci robot draws appeal from physicians and patients alike. "If we can provide both conventional and robotic-assisted options, it makes our hospital more attractive to both populations," he says.
Paradise Valley was fortunate to acquire its da Vinci from an inter-company transfer rather than buying or leasing the robot, Dr. Tupponce says. As for effectiveness, he says he believes the skill of the surgeon coupled with appropriate patient selection is the greatest determinant in robotic surgical outcomes. He adds, "As with any type of surgery, there tend to be good correlations between outcomes and case volume."
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