Economics of robotic surgery: does it make sense and for whom?

Suprapubic Transvesical Adenoma Resection of the Prostate (STAR-P): A Novel Technique for Surgical Treatment of Benign Prostatic Hyperplasia

BACKGROUND AND OBJECTIVE

Several minimally invasive treatments have been developed to treat benign prostatic obstruction (BPO) via a transurethral approach, with a non-negligible risk of complications such as urethral stricture and external sphincter damage. Our aim was to present the Gozzi surgical technique for suprapubic transvesical adenoma resection of the prostate (STAR-P) for BPO and to assess its safety, feasibility, and outcomes.

METHODS

We conducted a retrospective analysis of 44 consecutive patients who underwent STAR-P for BPO. All the procedures were performed in a single private hospital by one surgeon from 2020 to 2022. An innovative resectoscope designed by the surgeon was subsequently produced by Tontarra Medizintechnik (Wurmlingen, Germany) with a 42.06 Fr external sheath that allows the use of loops of three different sizes. The instrument is inserted into the bladder via suprapubic access, which ensures greater freedom of movement without compromising the external sphincter. Clinical data were retrospectively collected. Preoperative and intraoperative variables, postoperative complications, and functional outcomes of the STAR-P procedure were assessed. A descriptive statistical analysis was performed.

KEY FINDINGS AND LIMITATIONS

No intraoperative complications were observed. Two patients (4.5%) experienced urinary urgency symptoms after catheter removal that resolved within 90 d. Median times were 105 min for surgery overall and 65 min for resection. All patients showed an improvement in voiding quality.

CONCLUSIONS AND CLINICAL IMPLICATIONS

STAR-P is a safe, feasible, and cost-effective procedure that spares the bulbomembranous and penile urethra and the external urethral sphincter, and should be discussed with patients as a possible option for treatment of BPO.

PATIENT SUMMARY

We describe a new, safe, and feasible technique for surgical treatment of urinary obstruction caused by a large prostate. Keyhole surgery is performed through the lower abdomen, which means that the urethra below the prostate is not damaged. Only a small scar of 2-3 cm in the lower abdomen is evident at the end of the healing process.

Robot-Assisted Surgery in Gynecology

The advancement of robotics-based procedures in the medical industry is the subject of this review article. The purpose of the surgical robot is to increase surgical abilities and address human shortcomings. The robot's success has been predicated on its ability to accurately and consistently repeat tasks. The following are a few objectives and quantifiable benefits of robotic technology improving surgical maneuverability and physical capabilities. In 2005, the FDA granted gynecological surgery approval for the Da Vinci surgical system. It has been quickly embraced and has already taken on a significant role at many of the locations where it is offered. It consists of a cart with robotic branches next to the patient and a high-resolution three-dimensional (3D) vision system. This study covers laparoscopy via robots in benign gynecological surgeries, myomectomy surgery, hysterectomies, endometriosis, tubal anastomosis, and sacrocolpopexy. The appropriate published studies were evaluated after a PubMed search was conducted. Additionally, procedures that may be used in the future are highlighted. In benign gynecological illness, most currently available research does not show a substantial benefit over traditional laparoscopic surgery. Robotics, however, does provide help in more complicated operations. Compared to laparoscopy, robotic assistance has a lower conversion rate to open procedures. Endo wrist movement of an automated machine during myomectomy surgery can perform proper and better suturing than traditional laparoscopy. The automated program is a noticeable improvement over laparoscopic surgery and, if price issues are resolved, can gain popularity among gynecological surgeons around the globe.

Patient Interest in Robotic Total Joint Arthroplasty Is Exponential: A 10-Year Google Trends Analysis

Background

The use of robotics in arthroplasty continues to increase. Patient demand, patient expectations, and patient-directed marketing by industry and care providers each likely contributes to its increasing popularity. Trends in patient interest have not been well described. We used the online Google Trends tool to analyze trends in national public interest toward robotic and nonrobotic arthroplasty between 2011 and 2021.

Material and methods

Google Trends online was queried for search terms related to nonrobotic hip and knee arthroplasty in addition to robotic hip, robotic knee, and general robotic arthroplasty between January 1, 2011, and December 31, 2021.

Results

Google Trends Data demonstrated a significant linear increase in online searches related to nonrobotic total knee and hip arthroplasty. Online search volume for robotic hip arthroplasty was significant and linear, while that of robotic knee arthroplasty was significant and exponential. When combined, robotic joint arthroplasty demonstrated an exponential trend over the 10-year period. This increase was noted to be statistically significant when compared with nonrobotic arthroplasty search volume.

Conclusion

Our study demonstrates that public interest in robotic total joint arthroplasty has increased significantly from 2011 through 2020. When compared with online search volume for conventional arthroplasty, this increasing growth is statistically significant. Public interest in robotic arthroplasty is anticipated to continue to increase, and care providers should be aware of this trend that impacts patient perceptions and expectations. Despite significant growth in interest for robotic arthroplasty, there is incomplete evidence supporting its use over nonrobotic arthroplasty. Additional high-quality studies are needed to inform provider decision-making and appropriately guide public interest in robot-assisted arthroplasty.

Image-Guided Robotics for Standardized and Automated Biopsy and Ablation

Image-guided robotics for biopsy and ablation aims to minimize procedure times, reduce needle manipulations, radiation, and complications, and enable treatment of larger and more complex tumors, while facilitating standardization for more uniform and improved outcomes. Robotic navigation of needles enables standardized and uniform procedures which enhance reproducibility via real-time precision feedback, while avoiding radiation exposure to the operator. Robots can be integrated with computed tomography (CT), cone beam CT, magnetic resonance imaging, and ultrasound and through various techniques, including stereotaxy, table-mounted, floor-mounted, and patient-mounted robots. The history, challenges, solutions, and questions facing the field of interventional radiology (IR) and interventional oncology are reviewed, to enable responsible clinical adoption and value definition via ergonomics, workflows, business models, and outcome data. IR-integrated robotics is ready for broader adoption. The robots are coming!

Technological implementation in General Surgery services in Spain. National survey and results

Technology is one of the pillars of surgery in the 21st century and is a key factor in achieving better surgical results. The current surgical process involves not only surgical techniques, but also a very high degree of specialisation and the knowledge and use of techniques and devices from other fields. In Spain, there are no studies published at a national level in this regard. From the Minimally Invasive Surgery and Technological Innovation section of the Spanish Association of Surgeons we have designed a study whose main objective is to evaluate the degree of technological implantation in the specialty of General Surgery in Spain, as well as to analyze the devices available in the different centres of the country. We propose to make a detailed description of the applications of these devices and techniques by areas of interest, pointing out the pathologies and procedures in which this technology is used.

Technological implementation in General Surgery services in Spain. National survey and results

Technology is one of the pillars of surgery in the 21st century and is a key factor in achieving better surgical results. The current surgical process involves not only surgical techniques, but also a very high degree of specialisation and the knowledge and use of techniques and devices from other fields. In Spain, there are no studies published at a national level in this regard. From the Minimally Invasive Surgery and Technological Innovation section of the Spanish Association of Surgeons we have designed a study whose main objective is to evaluate the degree of technological implantation in the specialty of General Surgery in Spain, as well as to analyze the devices available in the different centres of the country. We propose to make a detailed description of the applications of these devices and techniques by areas of interest, pointing out the pathologies and procedures in which this technology is used.

Outcomes of Gender Affirming Peritoneal Flap Vaginoplasty Using the Da Vinci Single Port Versus Xi Robotic Systems

BACKGROUND

Robotic-assisted peritoneal flap gender-affirming vaginoplasty (RPGAV) with the da Vinci Xi system has been reported to be a safe alternative to traditional penile inversion vaginoplasty. Utilizing the Single Port (SP) robot system, our surgical approach has evolved.

OBJECTIVE

To describe a step-by-step technique for RPGAV using the SP robot and to compare outcomes between Xi and SP systems.

DESIGN, SETTING, AND PARTICIPANTS

A total of 145 transgender women underwent RPGAV between September 2017 and December 2019. We retrospectively reviewed data for patients with a minimum 6 mo of follow-up.

SURGICAL PROCEDURE

Peritoneal flaps are harvested from the posterior bladder and pararectal fossa. The vaginal space is dissected transabdominally. Inverted penile flap with or without scrotal graft is sutured to the peritoneal flaps, which form the neovaginal apex.

MEASUREMENTS

Demographics, perioperative data, and clinical outcomes were evaluated.

RESULTS AND LIMITATIONS

A total of 100 (Xi = 47; SP = 53) patients had a minimum 6 mo of follow-up. The mean age was 36.2 (range 16.1-71.4) yr. Average procedure times were 4.2 and 3.7 h in Xi and SP cohorts, respectively (p <0.001). At the mean follow-up of 11.9 (range 6.0-25.4) mo, vaginal depth and width were 13.6 (range 9.7-14.5) and 3.7 (range 2.9-3.8) cm in the Xi group, and 14.1 (range 9.7-14.5) and 3.7 (range 3.5-3.8) cm in the SP group (p =0.07 and 0.04, respectively). Complications included transfusion (6%), rectovaginal fistula (1%), bowel obstruction (2%), pelvic abscess (1%), and vaginal stenosis (7%).

CONCLUSIONS

RPGAV using the SP robot reduces operative time by facilitating a dual-surgeon abdominal-perineal approach. There is no difference in complication rates between the two approaches.

PATIENT SUMMARY

We studied the outcomes of robotic peritoneal flap vaginoplasty with two robot systems. With both systems, patients had good vaginal depth and width at an average follow-up of 1 yr. Surgery time was shorter with the Single Port (SP) robot.

Robot set-up time in urologic surgery: an opportunity for quality improvement

INTRODUCTION

Robotic-assisted techniques are widespread in urology. However, prolonged preparation time for robotic cases hinders operating room (OR) efficiency and frustrates robotic surgeons. Pre-operative times are an opportunity for quality improvement (QI) and enhancing OR throughput. We have previously shown that pre-operative times in robotic cases are highly variable and that increasing patient complexity was associated with longer times. Our objective was to characterize set-up times in robotic urology cases and to determine whether prolongation was due to robot set-up, in particular.

MATERIALS AND METHODS

Patients undergoing robotic-assisted urology procedures at our academic institution had routine peri-operative collection of demographic data and OR time stamps. Following IRB approval, we retrospectively reviewed set-up times from an OR database. Multivariable analysis was used to assess the influence of independent patient variables-gender (M/F), smoking history, age, BMI, American Society of Anesthesiologists (ASA) Physical Status Classification, and Charlson Comorbidity Index (CCI)-on robot set-up times. Institutional factors including procedure, surgeon, and case year were also assessed.

RESULTS

A total of 808 patients undergoing 816 robotic-assisted procedures from 2013 to 2018 met inclusion criteria. Robot set-up times varied only by gender (F > M) but not by general patient complexity. Age, BMI, smoking status, ASA, and CCI did not play a role in prolonging robot set-up times. There was marked variability of robot set-up times, even within procedure type. Robot set-up times generally improved over time for a given surgeon.

CONCLUSIONS

Robot set-up time is not affected by patient complexity, in contrast to pre-operative time. It is affected by procedure type and does improve with experience. There is wide variability of robot set-up times and this is an important target for surgical QI.

Oncologic Resection in Laparoscopic Versus Robotic Transhiatal Esophagectomy

Background and Objectives:

As the use of robotic surgery continues to increase, little is known about robotic oncologic outcomes compared with traditional methods in esophagectomy. The aim of this study was to examine the perioperative oncologic outcomes of patients undergoing laparoscopic versus robot-assisted transhiatal esophagectomy (THE).

Methods:

Thirty-six consecutive patients who underwent laparoscopic and robot-assisted THE for malignant disease over a 3-year period were identified in a retrospective database. Eighteen patients underwent robotic-assisted THE with cervical anastomosis, and 18 patients underwent laparoscopic THE. All procedures were performed by a single foregut and thoracic surgeon.

Results:

Patient demographics were similar between the 2 groups with no significant differences. Lymph node yields for both laparoscopic and robot-assisted THE were similar at 13.9 and 14.3, respectively (P = .90). Ninety-four percent of each group underwent R0 margins, but only 1 patient from each modality had microscopic positive margins. All of the robot-assisted patients underwent neoadjuvant chemoradiation, whereas 83.3% underwent neoadjuvant therapy in the laparoscopy group (P = .23). Clinical and pathologic stagings were similar in each group. There was 1 death after laparoscopic surgery in a cirrhotic patient and no mortalities among the robot-assisted THE patients (P = .99). One patient from each group experienced an anastomotic leak, but neither patient required further intervention.

Conclusions:

Laparoscopic and robot-assisted THEs yield similar perioperative oncologic results including lymph node yield and margin status. In the transition from laparoscopic surgery, robotic surgery should be considered oncologically noninferior compared with laparoscopy.

Financial Impact of the Robotic Approach in Liver Surgery: A Comparative Study of Clinical Outcomes and Costs Between the Robotic and Open Technique in a Single Institution

BACKGROUND

One of the perceived major drawbacks of minimally invasive techniques has always been its cost. This is especially true for the robotic approach and is one of the main reasons that has prevented its wider acceptance among hospitals and surgeons. The aim of our study was to evaluate the clinical outcomes and economic impact of robotic and open liver surgery in a single institution.

METHODS

Sixty-eight robotic and 55 open hepatectomies were performed at our institution between January 1, 2009 and December 31, 2013. Demographics, perioperative data, and postoperative outcomes were collected and compared between the two groups. An independent company performed the financial analysis. The economic parameters comprised direct variable costs, direct fixed costs, and indirect costs.

RESULTS

Mean estimated blood loss was significantly less in the robotic group (438 versus 727.8 mL; P = .038). Overall morbidity was significantly lower in the robotic group (22% versus 40%; P = .047). Clavien III/IV complications were also lower, with 4.4% in the robotic versus 16.3% in the open group (P = .043). The length of stay in the intensive care unit (ICU) was shorter for patients who underwent a robotic procedure (2.1 versus 3.3 days; P = .004). The average total cost, including readmissions, was $37,518 for robotic surgery and $41,948 for open technique.

CONCLUSIONS

Robotic liver resections had less overall morbidity, ICU, and hospital stay. This translates into decreased average costs for robotic surgery. These procedures are financially comparable to open resections and do not represent a financial burden to the hospital.

Hospital-Based Analysis of Trends and Outcomes for Patients Undergoing Pyelolithotomy

OBJECTIVE

To determine trends in pyelolithotomy, evaluate risk factors for complications, and evaluate the difference in outcomes and charges between open and minimally invasive (MI) techniques.

PATIENTS AND METHODS

We used the Nationwide Inpatient Sample to identify patients with a diagnosis of having nephrolithiasis undergoing pyelolithotomy from 2008 to 2012. Total charges were inflation-adjusted to U.S. dollars in 2012. Patient demographics, hospital characteristics, and outcomes were reported and compared between open and MI groups after survey weighting.

RESULTS

We included a survey-weighted population of 17,294 patients, of whom 841 (4.9%) had MI pyelolithotomy. The proportion of MI cases increased by 2.57% annually (r² = 0.921, p = 0.01), although total pyelolithotomy cases remained stable. Simultaneous pyeloplasty occurred in 6.6% of all patients. Patients receiving open surgery experienced longer length of stay (3.9 days vs 2.7 days; p < 0.001), but accrued equivalent inflation-adjusted charges ($49,588 ± 2088 vs $51,716 ± 4893; p = 0.665). On multivariable analysis, higher Elixhauser comorbidity index and presence of any genitourinary anomaly were associated with experiencing a complication, while undergoing surgery at a top quartile hospital and elective admission status were protective against complications. MI technique and simultaneous ureteropelvic junction repair did not alter complication risk.

CONCLUSION

While the annual number of pyelolithotomy cases was stable, there was an increasing trend toward MI technique. Both patient and hospital factors can significantly alter the risk for complications following pyelolithotomy.

Application of robotics in gastrointestinal endoscopy: A review

Multiple robotic flexible endoscope platforms have been developed based on cross specialty collaboration between engineers and medical doctors. However, significant number of these platforms have been developed for the natural orifice transluminal endoscopic surgery paradigm. Increasing amount of evidence suggest the focus of development should be placed on advanced endolumenal procedures such as endoscopic submucosal dissection instead. A thorough literature analysis was performed to assess the current status of robotic flexible endoscopic platforms designed for advanced endolumenal procedures. Current efforts are mainly focused on robotic locomotion and robotic instrument control. In the future, advances in actuation and servoing technology, optical analysis, augmented reality and wireless power transmission technology will no doubt further advance the field of robotic endoscopy. Globally, health systems have become increasingly budget conscious; widespread acceptance of robotic endoscopy will depend on careful design to ensure its delivery of a cost effective service.

Significant increase in prostatectomy and decrease in radiation for clinical T3 prostate cancer from 1998 to 2012

PURPOSE

We aimed to describe changes in treatment patterns for clinical T3 prostate cancer (PCa) from 1998 to 2012, specifically investigating what factors influence receipt of prostatectomy or radiation.

MATERIALS AND METHODS

Using the Surveillance, Epidemiology, and End Results database, we studied 11,604 men with clinical T3N0M0 PCa from 1998 to 2012, with treatment categorized as radiation, radical prostatectomy (RP), or no curative therapy. We calculated rate of treatment type by year of diagnosis to investigate trends in treatment patterns, further stratifying by clinical T3a, defined as unilateral and bilateral extracapsular extension (n = 3,842), vs. T3b (defined as extension to seminal vesicles (n = 3,665). Finally, a multivariable logistic regression analysis measured association of demographic and clinical variables with type of treatment received for years 2010 to 2011.

RESULTS

Rates of prostatectomy increased significantly from 1998 to 2012 (12.5% vs. 44.4%), radiation decreased significantly (55.8% vs. 38.4%), and receipt of no treatment also decreased (31.7% vs. 17.2%, all P<0.001). These trends were similar for clinical T3a and T3b. Rates of prostatectomy surpassed radiation by 2008 in clinical T3a, reaching 49.8% vs. 37.1%, respectively, in 2012 (P = 0.002), and were statistically similar to radiation in 2012 for clinical T3b, reaching 41.6% vs. 42.1% (P = 0.92). Multivariable logistic regression analysis demonstrated that patients were less likely to receive prostatectomy than radiation if biopsy Gleason scores of 8 to 10 (adjusted odds ratio [AOR] = 0.41, 0.32-0.53), higher initial prostate-specific antigen (AOR = 0.97, 0.97-0.98), and older age (AOR = 0.92, 0.90-0.03, all P<0.01). The likelihood of RP was similar among cT3b vs. cT3a (AOR = 0.95, 0.71-1.26, P = 0.74).

CONCLUSIONS

Since 1998, there has been a significant increase in the use of RP for clinical T3 PCa and a significant decrease in the use of radiation such that in 2012, the use of prostatectomy exceeded the use of radiation.

Robotic pancreaticoduodenectomy: comparison of complications and cost to the open approach

BACKGROUND

Robotic pancreaticoduodenectomy (RP) has shown some advantages over open pancreaticoduodenectomy (OP) but no data has been published providing a cost comparison.

METHODS

Retrospective analysis of all pancreaticoduodenectomies at a single quaternary cancer referral center was performed. Patient demographics, comorbidities, operative characteristics, complications, and charge data were recorded, and then compared using standard statistical methods.

RESULTS

71 pancreaticoduodenectomies were performed: 22 RP and 49 OP. Patients undergoing OP had similar demographics, comorbidities, pathology, and oncologic characteristics as patients undergoing RP. While operative charges were higher for RP, once inpatient stay associated costs and follow-up costs were included, there was no difference in total costs between RP and OP.

CONCLUSIONS

Patients undergoing RP have equivalent rates of R0 resection as OP, and benefit from decreased number of complications, surgical site infections, and length of stay in the intensive care unit. Once cost of complications and follow-up are incorporated, no significant difference between procedures exists. Copyright © 2015 John Wiley & Sons, Ltd.

Innovation in surgical technology and techniques: Challenges and ethical issues

The pace of medical innovation continues to increase. The deployment of new technologies in surgery creates many ethical challenges including how to determine safety of the technology, what is the timing and process for deployment of a new technology, how are patients informed before undergoing a new technology or technique, how are the outcomes of a new technology evaluated and how are the responsibilities of individual patients and society at large balanced. Ethical considerations relevant to the implementation of ECMO and robotic surgery are explored to further discussion of how we can optimize the delicate balance between innovation and regulation.