April 02, 2012
Robotic Assist Lowers Bladder Surgery Complications

Better life through robotics.

The researchers used information from 2009, the most recent date for which data were available on radical cystectomy for bladder cancer at the time the study was conducted. The team looked at 1,444 traditional open surgeries and 224 robotic-assisted laparoscopic procedures. They found that robotic-assisted surgeries accounted for 13 percent of all radical cystectomies in 2009.

Using statistical analysis, Hu and his colleagues compared hospital-level information, including in-patient deaths, complications, length of hospital stays and costs for the two procedures.

One of the most striking findings the team reported was that one in 100 patients receiving open radical cystectomy (2.5 percent) died during hospitalization, but there were no in-hospital deaths for patients who underwent robotic-assisted cystectomy.

The lack of deaths from robotic-assisted surgeries could just be luck due to the smaller sample size. We need a larger sample set to be certain that robotic assistance really lowers death rates from surgical errors. But the differences in complications suggest that the death rate difference is probably real.

The researchers also found that patients who underwent robotic-assisted laparoscopic surgery experienced fewer in-patient complications than those who had the traditional open procedure (49.1 percent vs. 63.8 percent).

After the robotic procedure, patients also had less need of parenteral nutrition than their open-surgery counterparts (6.4 percent vs. 13.3); parenteral nutrition is provided intravenously if there is delayed recovery of bowel function.

Robotic assist currently lengthens the length of surgery sessions and costs a few thousand dollars more. But it seems inevitable that as the robotic capabilities increase surgery times will fall and costs will fall as well.

I see much more highly automated surgical robots as essential for the development of rejuvenation therapies. Once tissue engineering and stem cell manipulations advance to the point where the growth of replacement organs becomes easy and common place we are going to need much safer and lower cost ways to do organ upgrades. Robotic surgeons will be needed to safely and quickly replace several old organs with younger organs in a single surgical session. Human error rates are just too high to make this sort of surgery safe enough without robots doing most of the work.

Share |      Randall Parker, 2012 April 02 09:18 PM  Robots Medicine

PacRim Jim said at April 2, 2012 11:13 PM:

It's difficult to believe that a robot is more precise than the hands of a trained surgeon, within the chaotic environment of the human body.

philw1776 said at April 3, 2012 3:38 PM:

It's robotic ASSIST. The sturgeon (sic) manipulates the robotic arms via Waldoes that step down his movements so that very small and precise manipulations are possible. I had a radical prostatectomy via robotic assist. The operation used to gut you like cleaning a fish, but no more. Although they do disconnect the bladder to get at that little sucka, the prostate and then stitch the urethra back onto the bladder. I left the hospital the next day and threw away all the meds they gave me. Never tops as much as an aspirin.

PacRim Jim said at April 3, 2012 6:38 PM:

@philw1776 Thanks for the explanation. I always wondered about that.

Guilherme said at April 3, 2012 6:52 PM:

Nice article, but terrible insights:

"The team looked at 1,444 traditional open surgeries and 224 robotic-assisted laparoscopic procedures. They found that robotic-assisted surgeries accounted for 13 percent" -> Fantastic!!! 224/(1,444+224) = 13%

"One of the most striking findings the team reported was that one in 100 patients receiving open radical cystectomy (2.5 percent) died during hospitalization" -> One in 100 wouldn't be 1%???

"The researchers also found that patients who underwent robotic-assisted laparoscopic surgery experienced fewer in-patient complications" -> Are there out-patient complications then?

Randall Parker said at April 3, 2012 7:18 PM:

PacRim Jim,

Like philw1776 says: These devices aren't really replacing much human movement. They aren't making substantial decisions yet. At this stage the surgeon is just avoiding the shaky hand and telling something else to do each move. But I expect the sort of progress we see with cars where each successive step gradually enhances and replaces human decisions.

It makes sense to build in fancier image processing capability and start running feedback loops so that, for example, the robot will stop cutting when it detects certain things and where it will lift tissue with a variable amount of force based on feedback of how well the tissue is lifting up.


I suspect the press release writer tried to translate some of the numbers into more intuitive-sounding representations. Hence the loss of precision.

Radi8 said at April 4, 2012 11:53 AM:

Or these patients could have kept their own bladder with equivalent cancer outcomes by having radiation therapy...

philw1776 said at April 4, 2012 11:56 AM:

I forgot to mention that the DaVinci robot has 5 or 6 "arms" so the surgeon can position camera arm(s) use another couple to hold various eviscerated body parts in place and the last couple as his Waldos to perform the stepped down gear surgery. Not said here but somewhat of a warning is that it's very difficult to learn the robot. Poor ergonomics. Inexperienced surgeons have done damage with this tool and maimed people. I selected the Dr who had done several hundred and was the trainer for Lahey, but had it done at a small NH hospital where he lived but didn't do the training as in Burlington MA.

There needs to be more competition to advance the state of the art more rapidly as one company with one design dominates the market. Randal's ideas need implementation but R&D is expensive. Tough to justify engineering expense when marketing dominates the market.

Dennis said at April 5, 2012 8:29 AM:

It's NOT robotic at all!

The so called robot is simply a set of manipulators that are operated by the surgeon. Think, Robert Heinlein's 'waldos' instead.

A robot has some level of autonomy or at least, pre programming. These things have none, they're under direct control. Also, because of the design, the surgeon is operating 'backwards' compared to what he's used to with other laparascopic instruments. Which introduces an unnecessary problem.

The improved outcomes aren't from 'robotics' but from the laparascopic procedure, which uses smaller incisions, doesn't cut across muscles, causes less lasting pain, etc, etc.

Dennis, RN

BBM said at April 6, 2012 8:25 AM:

As Dennis notes. I'm a surgeon that does laparoscopic surgery. You'll notice that the comparision is from traditional "open" surgery to robotic assisted. No study has demonstrated a benefit in robotic-assisted when compared to laparoscopic surgery.

The "robot" is really just a fine instrument and has no autonomy at all.

It is VERY expensive... about 2 million dollars, and each case costs much more than the laparoscopic surgery counterpart due to disposable instruments. Robot assisteed operations also take significantly longer due to set up times, and OR time is exorbitantly expensive etc.

Now then, I am in the process of getting robot certified (out of pocket costs are ~$10,000 for me plus opportunity costs and overhead of being out of my practice).

With no demonstrated benefit over laparoscopic surgery, and much higher costs, why am I getting robot trained?

1) The current healthcare market evolution (driven in part by the proposals of healthcare reform) is about hospitals buying up referring MDs and creating closed systems... i.e. gaining critical mass market share. The "robot" is an excellent marketing tool in this regard, and we ave to keep up with the competition in this regard.
2) The robot, while requiring a completely new set of skills compared to open surgery, is actually much easier to use than laparoscopic surgery. There is much less physical fatigue and stress on joints and muscles. Surgery really is physically laborious. The surgeon can assume a relaxed ergonomic position, and I have no doubt that this ill extend my professional lifespan. My rotator cuffs are worn out from hours of manipulating the camera, laproscopic instruments, etc. Back and neck issues are very common.
3) Certain cases are very difficult/impossible to perform laparoscopically, e.g. prostatectomy, low rectal cancers in a narrow male pelvis, etc.
4) Although currently there has not been demonstrated any benefit compared to laparoscopic surgery, future improvements in miniaturization (e.g. combining robotic assistance with single site/incision access) may lead to improvements in hospital stay and return to work etc. Probably will not lead to improvements in, say, cancer-specific outcomes.

Interestingly, the studies that I have seen in prostate cancer suggest that the robotic assist may actually be inferior (currently) to open surgery when looking at post op nerve function (eg impotence) and possibly also in terms of cancer specific outcomes like margins etc.

If I were to have prostate ca, radiation therapy is probably the best choice as someone noted above... but if I needed surgery? I'd probably go with the standard open approach for now.

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