Robotic-assisted vs laparoscopic surgery compared

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Two large international studies have compared outcomes of robotic-assisted vs laparoscopic surgery for kidney removal, as well as for rectal cancer.

In one study, Dr In Gab Jeong, of the Stanford University Medical Centre, Stanford, California, and University of Ulsan College of Medicine, Seoul, and colleagues examined the use of robotic-assisted radical nephrectomy (kidney removal) in the US and compared the in-hospital outcomes and costs between this procedure and laparoscopic radical nephrectomy. The study included patients who had undergone one of these procedures for a renal mass at 416 US hospitals between January 2003 and September 2015.

The use of robotic surgery has increased in urological practice over the last decade. However, the use, outcomes, and costs of robotic nephrectomy have not been known.

Among 23,753 patients included in the study, 18,573 underwent laparoscopic radical nephrectomy and 5,180 underwent robotic-assisted radical nephrectomy. Use of robotic-assisted surgery increased from 1.5% (39 of 2,676 radical nephrectomy procedures in 2003) to 27% (862 of 3,194 radical nephrectomy procedures) in 2015. Compared with laparoscopic radical nephrectomy, robotic-assisted radical nephrectomy was not associated with an increased risk of any or major postoperative complications but was associated with prolonged operating time and higher hospital costs.

In another study, Dr David Jayne, of the University of Leeds, UK, and colleagues compared robotic-assisted vs conventional laparoscopic surgery for risk of conversion (change due to unforeseen complications that arise during surgery) to open laparotomy (surgical incision through the abdominal wall) among patients undergoing resection (surgical removal) for rectal cancer. Robotic rectal cancer surgery is gaining popularity, but limited data are available regarding safety and efficacy. A concern about robotic surgery is the cost, including the capital and ongoing maintenance charges.

The study, conducted at 29 sites in 10 countries, included patients with rectal cancer who were randomised to robotic-assisted (n = 237) or conventional (n = 234) laparoscopic rectal cancer resection. The overall rate of conversion to open laparotomy was 10.1%. The researchers found that there were no statistically significant differences in the rates of conversion to open laparotomy for robotic-assisted laparoscopic surgery compared with conventional laparoscopic surgery (8.1% vs 12.2%, respectively), and there were no statistically significant differences in complication rates or quality of life at six months.

“These findings suggest that robotic-assisted laparoscopic surgery, when performed by surgeons with varying experience with robotic surgery, does not confer an advantage in rectal cancer resection,” the authors write.

Abstract 1
Importance: Use of robotic surgery has increased in urological practice over the last decade. However, the use, outcomes, and costs of robotic nephrectomy are unknown.
Objectives: To examine the trend in use of robotic-assisted operations for radical nephrectomy in the United States and to compare the perioperative outcomes and costs with laparoscopic radical nephrectomy.
Design, Setting, and Participants: This retrospective cohort study used the Premier Healthcare database to evaluate outcomes of patients who had undergone robotic-assisted or laparoscopic radical nephrectomy for renal mass at 416 US hospitals between January 2003 and September 2015. Multivariable regression modeling was used to assess outcomes.
Exposures: Robotic-assisted vs laparoscopic radical nephrectomy.
Main Outcomes and Measures: The primary outcome of the study was the trend in use of robotic-assisted radical nephrectomy. The secondary outcomes were perioperative complications, based on the Clavien classification system, and defined as any complication (Clavien grades 1-5) or major complications (Clavien grades 3-5, for which grade 5 results in death); resource use (operating time, blood transfusion, length of hospital stay); and direct hospital cost.
Results: Among 23 753 patients included in the study (mean age, 61.4 years; men, 13 792 [58.1%]), 18 573 underwent laparoscopic radical nephrectomy and 5180 underwent robotic-assisted radical nephrectomy. Use of robotic-assisted surgery increased from 1.5% (39 of 2676 radical nephrectomy procedures in 2003) to 27.0% (862 of 3194 radical nephrectomy procedures) in 2015 (P for trend <.001). In the weighted-adjusted analysis, there were no significant differences between robotic-assisted and laparoscopic radical nephrectomy in the incidence of any (Clavien grades 1-5) postoperative complications (adjusted rates, 22.2% vs 23.4%, difference, −1.2%; 95% CI, −5.4 to 3.0%) or major (Clavien grades 3-5) complications (adjusted rates, 3.5% vs 3.8%, difference, −0.3%; 95% CI, −1.0% to 0.5%). The rate of prolonged operating time (>4 hours) for patients undergoing the robotic-assisted procedure was higher than for patients receiving the laparoscopic procedure in the adjusted analysis (46.3% vs 25.8%; risk difference, 20.5%; 95% CI, 14.2% to 26.8%). Robotic-assisted radical nephrectomy was associated with higher mean 90-day direct hospital costs ($19 530 vs $16 851; difference, $2678; 95% CI, $838 to $4519), mainly accounted for operating room ($7217 vs $5378; difference, $1839; 95% CI, $1050 to $2628) and supply costs ($4876 vs $3891; difference, $985; 95% CI, $473 to $1498).
Conclusions and Relevance: Among patients undergoing radical nephrectomy for renal mass between 2003 and 2015, the use of robotic-assisted surgery increased substantially. The use of robotic-assistance was not associated with increased risk of any or major complications but was associated with prolonged operating time and higher hospital costs compared with laparoscopic surgery.

Authors
In Gab Jeong; Yash S Khandwala; Jae Heon Kim; Deok Hyun Han; Shufeng Li; Ye Wang; Steven L Chang; Benjamin I Chung

Abstract 2
Importance: Robotic rectal cancer surgery is gaining popularity, but limited data are available regarding safety and efficacy.
Objective: To compare robotic-assisted vs conventional laparoscopic surgery for risk of conversion to open laparotomy among patients undergoing resection for rectal cancer.
Design, Setting, and Participants: Randomized clinical trial comparing robotic-assisted vs conventional laparoscopic surgery among 471 patients with rectal adenocarcinoma suitable for curative resection conducted at 29 sites across 10 countries, including 40 surgeons. Recruitment of patients was from January 7, 2011, to September 30, 2014, follow-up was conducted at 30 days and 6 months, and final follow-up was on June 16, 2015.
Interventions: Patients were randomized to robotic-assisted (n = 237) or conventional (n = 234) laparoscopic rectal cancer resection, performed by either high (upper rectum) or low (total rectum) anterior resection or abdominoperineal resection (rectum and perineum).
Main Outcomes and Measures: The primary outcome was conversion to open laparotomy. Secondary end points included intraoperative and postoperative complications, circumferential resection margin positivity (CRM+) and other pathological outcomes, quality of life (36-Item Short Form Survey and 20-item Multidimensional Fatigue Inventory), bladder and sexual dysfunction (International Prostate Symptom Score, International Index of Erectile Function, and Female Sexual Function Index), and oncological outcomes.
Results: Among 471 randomized patients (mean [SD] age, 64.9 [11.0] years; 320 [67.9%] men), 466 (98.9%) completed the study. The overall rate of conversion to open laparotomy was 10.1%: 19 of 236 patients (8.1%) in the robotic-assisted laparoscopic group and 28 of 230 patients (12.2%) in the conventional laparoscopic group (unadjusted risk difference = 4.1% [95% CI, −1.4% to 9.6%]; adjusted odds ratio = 0.61 [95% CI, 0.31 to 1.21]; P = .16). The overall CRM+ rate was 5.7%; CRM+ occurred in 14 (6.3%) of 224 patients in the conventional laparoscopic group and 12 (5.1%) of 235 patients in the robotic-assisted laparoscopic group (unadjusted risk difference = 1.1% [95% CI, −3.1% to 5.4%]; adjusted odds ratio = 0.78 [95% CI, 0.35 to 1.76]; P = .56). Of the other 8 reported prespecified secondary end points, including intraoperative complications, postoperative complications, plane of surgery, 30-day mortality, bladder dysfunction, and sexual dysfunction, none showed a statistically significant difference between groups.
Conclusions and Relevance: Among patients with rectal adenocarcinoma suitable for curative resection, robotic-assisted laparoscopic surgery, as compared with conventional laparoscopic surgery, did not significantly reduce the risk of conversion to open laparotomy. These findings suggest that robotic-assisted laparoscopic surgery, when performed by surgeons with varying experience with robotic surgery, does not confer an advantage in rectal cancer resection.

Authors
David Jayne, Alessio Pigazzi, Helen Marshall, Julie Croft, Neil Corrigan, Joanne Copeland, Phil Quirke, Nick West, Tero Rautio, Niels Thomassen, Henry Tilney, Mark Gudgeon, Paolo Pietro Bianchi, Richard Edlin, Claire Hulme, Julia Brown

JAMA material
JAMA abstract 1
JAMA abstract 2
JAMA editorial


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