Patients are more and more demanding that urologists use robotic surgery for prostatectomies, but insurers are hesitant to provide coverage, claiming that there is insufficient evidence that the technology improves outcomes.
UnitedHealthcare, for example, in its medical policy manual, says, “When compared to conventional procedures, the use of robotic surgical systems provides no additional health benefits to patients.”
Further, it says that there is “insufficient evidence to conclude that robotic-assisted surgical procedures provide comparable outcomes to conventional open or minimally invasive surgical procedures.”
The patient demand might be great, but the definitive evidence that one method is better than the other is lacking.
“There hasn’t been a prospective comparative trial comparing the robotic approach to the open approach,” says J. Brantley Thrasher, MD, chairman of the department of urology at the University of Kansas and a spokesman for the American Urological Association.
Prostatectomies are performed using an open approach (characterized by either a perineal or retropubic incision), or a laparoscopic approach.
The robot is used during laparoscopic surgery. Using a robot can aid a surgeon’s manual dexterity. It also provides greater magnification of the area undergoing surgery.
Urologists feel pressure to use the robots.
“If a patient comes in and asks if the surgeon uses a robot, but the surgeon says ‘I don’t think it’s a good idea in your case,’ the patient gets up and goes down the street to the next guy,” says Thrasher. “A lot of the demand is patient-driven and corporate-driven.”
Last year, 73,000 (86 percent) of the 85,000 American men who had prostate cancer surgery had robot-assisted operations, according to the manufacturer, Intuitive Surgical. Just eight years ago, there were fewer than 5,000 robot-assisted surgeries.
Thrasher says there is some benefit when using the robot (for example, slightly quicker recovery and less blood loss), but it’s not a “quantum leap in improvement.”
He has performed prostatectomies using all three approaches (perineal, retropubic, and robot-assisted). When it comes to incontinence and impotence, two major concerns with prostate surgery, “there isn’t a major improvement between the three.” In his experience, “the patient undergoing robot-assisted laparoscopic surgery experiences less blood loss and in most cases can go home from the hospital the next day. A patient undergoing an open surgery tends to stay an additional 12 hours in the hospital before discharge,” says Thrasher.