No benefits to robotic colorectal surgery, study says

Norman Swan: Another technology that has had huge publicity, putting pressure on surgeons to offer it, is robotic surgery where instruments attached to robotic arms are inserted into the abdomen via keyhole incisions, and the surgeon sits at a console operating the devices remotely. It is used mostly for prostate, kidney and rectal operations, with either the explicit or implicit promise of fewer complications and better outcomes. The question is whether robotic surgery fulfils the hype, not to mention the expense. A large trial of the robots used in rectal cancer compared to standard laparoscopic surgery where the surgeon is hands-on has just been published, and one of the authors was Alessio Pigazzi, a colorectal surgeon at the University of California Irvine.

Alessio Pigazzi: We focused on the rectum because the rectum is the most difficult part of the bowel to approach surgically.

Norman Swan: You're tucked down into the bony pelvis and it can be quite a narrow…particularly in men, quite a narrow area in which to operate.

Alessio Pigazzi: Absolutely. In addition there are a lot of important structures surrounding the rectum, such as the bladder and then the prostate and the vagina. There are a lot of nerves that are in charge of our genital and urinary function that are very delicate.

Over the last decade there has been a lot of excitement, a lot of hype surrounding the use of robotic surgery, but really very little data in terms of being able to show that it is better than doing what you said, conventional keyhole laparoscopic surgery which is simpler and clearly a lot cheaper than using an expensive robotic system. And so we wanted to see if in the most difficult bowel surgery, which is rectal cancer surgery, the robot could provide an advantage over conventional laparoscopic surgery.

Norman Swan: And the theoretical reason was better visibility, perhaps easier to manipulate via the robotic gadgets than just a laparoscope going in, held by one or two surgeons.

Alessio Pigazzi: Exactly. What the robot does really, it provides a stable camera, it provides three-dimensional vision, which we don't have in laparoscopy, it provides more instruments and instruments that also articulate, so they kind of move like the human hand. So there is no doubt that in theory there are some technical advantages, but nobody had ever proved in a randomised trial, which is obviously the highest level of scientific evidence in medicine, whether the robot could provide an advantage over conventional laparoscopy.

Norman Swan: And before we get to the results, it also comes at a cost because the consumables in robotic surgery can be thousands of dollars, not to mention the $3 million for a machine, and it takes longer to do.

Alessio Pigazzi: Absolutely, the robot is a very expensive system and obviously that is a concern in a lot of healthcare systems.

Norman Swan: So, what did you find?

Alessio Pigazzi: Well, what we found is, first of all, not a hell of a lot unfortunately. We found that the robot compared to laparoscopy is safe and effective, meaning patients should not fear a robotic approach if done by surgeons who have good experience with it.

Norman Swan: So that means it takes out the tumour and you get what they call good margins. The side effects, the complications of cancer surgery can be quite considerable; erectile dysfunction in men, female sexual dysfunction, bladder problems. When you looked at complications, and this has often been the big promise of robotics, that because you can see all these structures you can do a finer dissection and save nerves and save structures, when it came to complications, what did it show?

Alessio Pigazzi: Well, when it came to complications it showed that they were identical essentially. And mortality was very low, the chance of dying was less than 1%.

Norman Swan: So they are equipoised in terms of benefits, and the argument would be then it is not necessarily worth the extra money for the robot if you can do it more cheaply and just as effectively with laparoscopic surgery. The other question is about operative time because if you're going to take an operating theatre up for another hour or two when another patient could be getting in and getting another surgery, that's a significant cost to the system. And what about operating time, comparing the two?

Alessio Pigazzi: Yes, the robot took a little bit longer to do these procedures robotically, about an hour longer on average, which is obviously an issue. One aspect that I think is important to know is that the robot did show superior outcomes in terms of conversion, meaning the chances of converting the procedure to an open, having to make a cut in the abdomen to complete the operation in men and in obese patients, and in tumours that were very low, so stuck deep down into the bony pelvis. In these three subgroups we did notice a trend toward a superiority of the robot.

Norman Swan: But it wasn't statistically significant?

Alessio Pigazzi: We couldn't prove it…yes, but practitioners like myself do see the advantage of that, regardless of statistical significance.

Norman Swan: Spoken like a true surgeon, Alessio!

Alessio Pigazzi: But it's what I am!

Norman Swan: But to be serious here, what you're saying is there may be a subgroup of men or men with obesity where the robot might actually be worth doing, because in the end they are all going to do just as well but you extend it to an open operation.

Alessio Pigazzi: Yes.

Norman Swan: And so I should just be sure here because when you are talking about these sort of trials…who funded this trial?

Alessio Pigazzi: The study was funded by the Medical Research Council in England, it was not funded by any industry, it was completely unbiased, and we are very, very proud of that. The most important thing that I think patients across the world need to understand is far more than the tool, it is the surgeon that matters, to go to a practitioner who has broad, extensive and proven experience with a procedure, whether that procedure is laparoscopic, robotic or even open. There are some cancers that are probably best done open. It's really the fundamental issue, finding someone who has great experience, and trusting them as opposed to believing a lot of slogans and marketing statements that are really not supported by data.

Norman Swan: Thank you very much for joining us.

Alessio Pigazzi: Thank you so much, I appreciate talking to you Norman.

Norman Swan: And to support that there is evidence from Australia that if you do get referred to such a surgeon, there's up to a three-fold benefit in survival in rectal cancer. And generically there is also evidence that female surgeons are better.

Alessio Pigazzi is Professor of Surgery at the University of California Irvine.