Tech Savvy
Susan Doyle-Lindrud, DNP, AOCNP®, DCC—Associate Editor
Use of Robotics in Oncology Surgery Susan Doyle-Lindrud, DNP, AOCNP®, DCC
Robotic surgery is an exciting technology that allows the surgeon to sit at a computer console near the operating table, using mechanical arms with surgical instruments attached to them. This type of surgery is minimally invasive, and the procedure is performed through tiny incisions. This technology is widely used in the United States and is expected to evolve over time with an increase in the number and types of procedures. At a Glance • Robotic surgery will increasingly play a role in oncology surgery. • Benefits include decreases in blood loss and postoperative pain. • Barriers include the cost and maintenance of the systems. Susan Doyle-Lindrud, DNP, AOCNP®, DCC, is an assistant dean of Academic Affairs and a director of the Doctor of Nursing Practice Program and Oncology Program in the School of Nursing at Columbia University in New York, NY. The author takes full responsibility for the content of the article. The author did not receive honoraria for this work. No financial relationships relevant to the content of this article have been disclosed by the author or editorial staff. Description of products does not indicate or imply endorsement by the Clinical Journal of Oncology Nursing or the Oncology Nursing Society. Doyle-Lindrud can be reached at [email protected], with copy to editor at [email protected]. Key words: robotic surgery; robotics; oncology surgery Digital Object Identifier: 10.1188/15.CJON.265-266
R
obotic surgery is a surgical procedure that adds a computer technology–enhanced device to the interaction between a surgeon and a patient during a surgical operation. This technology assumes a degree of control previously only reserved for the surgeon (Herron & Marohn, 2008). The surgeon sits at a console, typically in the operating room, directing and controlling the movements of one or more robotic arms. This technology has taken off in the United States during the past few years. Da Vinci® Surgical System, the leading robotic technology manufactured by Intuitive Surgical, Inc. (2014), has become the first robotic surgical platform commercially available in the United States to be cleared by the U.S. Food and Drug Administration. Use of robotic surgery has seen rapid growth. From 2007–2010, the number of robotic surgeries worldwide has almost tripled, and da Vinci robots
have been installed in 1,400 hospitals in the United States, an increase of 75% (Barbash & Glied, 2010).
Potential Benefits Minimally invasive surgery began in 1987 with laparoscopic cholecystectomy (Polychronidis, Laftsidis, Bounovas, & Simopoulos, 2008). The advantages of laparoscopic surgery over conventional surgery are smaller incisions, less blood loss, less postoperative pain, and shorter hospital stays. The weaknesses of this approach include the loss of natural hand– eye coordination and dexterity, making delicate dissections and anastomoses more difficult (Lanfranco, Castellanos, Desai, & Meyers, 2004). Robotic surgery was developed with the hope of overcoming these laparoscopic obstacles. One of the advantages of robot-assisted laparoscopy over conventional laparosco-
Clinical Journal of Oncology Nursing • Volume 19, Number 3 • Tech Savvy
py is the provision of three-dimensional images of the operative field instead of two-dimensional images. The robot also stabilizes the instruments, minimizing surgeon tremor and improving ergonomics for the operating surgeon. The surgeon can be in a seated position rather than standing, decreasing surgeon fatigue (Herron & Marohn, 2008; Oppenheimer, Weghorst, MacFarlane, & Sinanan, 1999). Conventional and robotic laparoscopy may have advantages over the open surgical laparotomies, including potentially shorter hospital stays, decreased blood loss, faster postoperative recovery, and improved aesthetics of incision areas because of the smaller incisions (Reza, Maeso, Blasco, & Andradas, 2010). Robotic surgeries are now performed in oncologic (Hayn et al., 2010), nononcologic (Mufarrij, Shah, Berger, & Stifelman, 2007), pediatric (Peters, 2004), and urologic procedures (Ghani et al., 2013).
Barriers Robotic surgical systems have high fixed costs, with prices ranging from $1 million to $2.5 million for each unit, as well as significant annual maintenance costs of about $100,000–$150,000 per unit (Intuitive Surgical, Inc., 2014). On average, the additional expense associated with robotic-assisted approaches is $1,600 per procedure, as compared to open surgery. If robotic technology replaces traditional surgery, it could mean about a $2.5 billion increase in healthcare costs. In addition, surgeons must perform 150–250 procedures to become adept in using the system (Barbash & Glied, 2010). One example of a surgery that has a rapidly rising number of procedures performed by a robot is robot-assisted 265
prostatectomy. On average, prostatectomy surgery is performed by surgeons less than 10 times per year, making it difficult to obtain the necessary hours to make a doctor skilled in the procedure (Savage & Vickers, 2009). Limited benefit from the procedure has been observed based on studies comparing radical prostatectomy surgery and robot-assisted prostatectomy (Kaye, Mullins, Carter, & Bivalacqua, 2014). The findings from studies exploring quality of life after prostate surgery have been mixed. In one study with patients who had undergone a robot-assisted radical prostatectomy, participants were more dissatisfied with their outcomes than patients undergoing an open radical prostatectomy (Malcolm et al., 2010; Schroeck et al., 2008).
Conclusion Robotic surgeries are a technology that will continue to evolve over time. The number of robotic surgical procedures and types of procedures will likely continue to rise. These new technologies are marketed to physicians and consumers, with surgeons wanting to keep up with market demand and hospitals wanting to attract and retain surgeons (Barbash & Glied, 2010). A consensus document on robotic surgery developed in 2007 by the leadership of the Society of American Gastrointestinal and Endoscopic Surgeons and the Minimally Invasive Robotic Association provided recommended guidelines for the training and credentialing of physicians to maintain better uniformity of standards. The guidelines call for formal specialty training in robotic surgery, with a curriculum that includes therapeutic robotic devices, documentation of practical experience, an appropriate volume of cases with satisfactory outcomes with an expert proctor, and formal assessment of competency (Herron & Marohn, 2008). Outcome studies comparing the outcomes from various robotic surgeries to laparoscopic or open procedures need to be done. These studies will better inform surgeons, healthcare organizations, hospitals, insurance companies, and the public on the benefits and risks of the ro-
266
botic technology for specific procedures. Ultimately, patients and the healthcare system will benefit from looking at the data to determine which types of surgical procedures result in the best and most cost-effective outcomes.
References Barbash, G.I., & Glied, S.A. (2010). New technology and health care costs—The case of robot-assisted surgery. New England Journal of Medicine, 363, 701–704. doi:10.1056/NEJMp1006602 Ghani, K.R., Rogers, C.G., Sood, A., Kumar, R., Ehlert, M., Jeong, W., . . . Menon, M. (2013). Robot-assisted anatrophic nephrolithotomy with renal hypothermia for managing staghor n calcu li. Journal of Endourology, 27, 1393–1398. doi:10.1089/end.2013.0266 Hayn, M.H., Hussain, A., Mansour, A.M., Andrews, P.E., Carpentier, P., Castle, E., . . . Guru, K.A. (2010). The learning curve of robot-assisted radical cystectomy: Results from the International Robotic Cystectomy Consortium. European Urology, 58, 197–202. doi:10.1016/j.eururo .2010.04.024 Herron, D.M., & Marohn, M. (2008). A consensus document on robotic surgery. Surgical Endoscopy, 22, 313–325. doi:10.1007/s00464-007-9727-5 Intuitive Surgical, Inc. (2014). Products. Retrieved from http://www.intuitive surgical.com/products Kaye, D.R., Mullins, J.K., Carter, H.B., & Bivalacqua, T.J. (2014). Robotic surgery in urological oncology: Patient care or market share? Nature Reviews. Urology, 12, 55–60. doi:10.1038/nrurol.2014.339 Lanfranco, A.R., Castellanos, A.E., Desai, J.P., & Meyers, W.C. (2004). Robotic surgery: A current perspective. Annals of Surgery, 239, 14–21. doi:10.1097/01.sla .0000103020.19595.7d
Malcolm, J.B., Fabrizio, M.D., Barone, B.B., Given, R.W., Lance, R.S., Lynch, D.F., . . . Schellhammer, P.F. (2010). Quality of life after open or robotic prostatectomy, cryoablation or brachytherapy for localized prostate cancer. Journal of Urology, 183, 1822–1828. doi:10.1016/j .juro.2009.12.102 Mufarrij, P.W., Shah, O.D., Berger, A.D., & Stifelman, M.D. (2007). Robotic reconstruction of the upper urinary tract. Journal of Urology, 178, 2002–2005. doi:10.1016/j.juro.2007.07.018 Oppenheimer, P., Weghorst, S., MacFarlane, M., & Sinanan, M. (1999). Immersive surgical robotic interfaces. Studies in Health Technology and Informatics, 62, 242–248. Peters, C.A. (2004). Robotically assisted surgery in pediatric urology. Urologic Clinics of North America, 31, 743–752. doi:10.1016/j.ucl.2004.06.007 Polychronidis, A., Laftsidis, P., Bounovas, A., & Simopoulos, C. (2008). Twenty years of laparoscopic cholecystectomy: Philippe Mouret—March 17, 1987. Journal of the Society of Laparoendoscopic Surgeons, 12, 109–111. Reza, M., Maeso, S., Blasco, J.A., & Andradas, E. (2010). Meta-analysis of observational studies on the safety and effectiveness of robotic gynaecological surgery. British Journal of Surgery, 97, 1772–1783. doi:10.1002/bjs.7269 Savage, C.J., & Vickers, A.J. (2009). Low annual caseloads of United States surgeons conducting radical prostatectomy. Journal of Urology, 182, 2677–2679. doi:10.1016/j.juro.2009.08.034 Schroeck, F.R., Krupski, T.L., Sun, L., Albala, D.M., Price, M.M., Polascik, T.J., . . . Moul, J.W. (2008). Satisfaction and regret after open retropubic or robotassisted laparoscopic radical prostatectomy. European Urology, 54, 785–793. doi:10.1016/j.eururo.2008.06.063
Do You Have an Interesting Topic to Share? Tech Savvy discusses the ways in which technology affects nurses, patients, the healthcare team, and the oncology setting. Length should be no more than 1,000–1,500 words, exclusive of tables, figures, insets, and references. If interested, contact Associate Editor Susan Doyle-Lindrud, DNP, AOCNP®, DCC, at [email protected].
June 2015 • Volume 19, Number 3 • Clinical Journal of Oncology Nursing
Copyright of Clinical Journal of Oncology Nursing is the property of Oncology Nursing Society and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
Susan Doyle-Lindrud, DNP, AOCNP®, DCC—Associate Editor
Use of Robotics in Oncology Surgery Susan Doyle-Lindrud, DNP, AOCNP®, DCC
Robotic surgery is an exciting technology that allows the surgeon to sit at a computer console near the operating table, using mechanical arms with surgical instruments attached to them. This type of surgery is minimally invasive, and the procedure is performed through tiny incisions. This technology is widely used in the United States and is expected to evolve over time with an increase in the number and types of procedures. At a Glance • Robotic surgery will increasingly play a role in oncology surgery. • Benefits include decreases in blood loss and postoperative pain. • Barriers include the cost and maintenance of the systems. Susan Doyle-Lindrud, DNP, AOCNP®, DCC, is an assistant dean of Academic Affairs and a director of the Doctor of Nursing Practice Program and Oncology Program in the School of Nursing at Columbia University in New York, NY. The author takes full responsibility for the content of the article. The author did not receive honoraria for this work. No financial relationships relevant to the content of this article have been disclosed by the author or editorial staff. Description of products does not indicate or imply endorsement by the Clinical Journal of Oncology Nursing or the Oncology Nursing Society. Doyle-Lindrud can be reached at [email protected], with copy to editor at [email protected]. Key words: robotic surgery; robotics; oncology surgery Digital Object Identifier: 10.1188/15.CJON.265-266
R
obotic surgery is a surgical procedure that adds a computer technology–enhanced device to the interaction between a surgeon and a patient during a surgical operation. This technology assumes a degree of control previously only reserved for the surgeon (Herron & Marohn, 2008). The surgeon sits at a console, typically in the operating room, directing and controlling the movements of one or more robotic arms. This technology has taken off in the United States during the past few years. Da Vinci® Surgical System, the leading robotic technology manufactured by Intuitive Surgical, Inc. (2014), has become the first robotic surgical platform commercially available in the United States to be cleared by the U.S. Food and Drug Administration. Use of robotic surgery has seen rapid growth. From 2007–2010, the number of robotic surgeries worldwide has almost tripled, and da Vinci robots
have been installed in 1,400 hospitals in the United States, an increase of 75% (Barbash & Glied, 2010).
Potential Benefits Minimally invasive surgery began in 1987 with laparoscopic cholecystectomy (Polychronidis, Laftsidis, Bounovas, & Simopoulos, 2008). The advantages of laparoscopic surgery over conventional surgery are smaller incisions, less blood loss, less postoperative pain, and shorter hospital stays. The weaknesses of this approach include the loss of natural hand– eye coordination and dexterity, making delicate dissections and anastomoses more difficult (Lanfranco, Castellanos, Desai, & Meyers, 2004). Robotic surgery was developed with the hope of overcoming these laparoscopic obstacles. One of the advantages of robot-assisted laparoscopy over conventional laparosco-
Clinical Journal of Oncology Nursing • Volume 19, Number 3 • Tech Savvy
py is the provision of three-dimensional images of the operative field instead of two-dimensional images. The robot also stabilizes the instruments, minimizing surgeon tremor and improving ergonomics for the operating surgeon. The surgeon can be in a seated position rather than standing, decreasing surgeon fatigue (Herron & Marohn, 2008; Oppenheimer, Weghorst, MacFarlane, & Sinanan, 1999). Conventional and robotic laparoscopy may have advantages over the open surgical laparotomies, including potentially shorter hospital stays, decreased blood loss, faster postoperative recovery, and improved aesthetics of incision areas because of the smaller incisions (Reza, Maeso, Blasco, & Andradas, 2010). Robotic surgeries are now performed in oncologic (Hayn et al., 2010), nononcologic (Mufarrij, Shah, Berger, & Stifelman, 2007), pediatric (Peters, 2004), and urologic procedures (Ghani et al., 2013).
Barriers Robotic surgical systems have high fixed costs, with prices ranging from $1 million to $2.5 million for each unit, as well as significant annual maintenance costs of about $100,000–$150,000 per unit (Intuitive Surgical, Inc., 2014). On average, the additional expense associated with robotic-assisted approaches is $1,600 per procedure, as compared to open surgery. If robotic technology replaces traditional surgery, it could mean about a $2.5 billion increase in healthcare costs. In addition, surgeons must perform 150–250 procedures to become adept in using the system (Barbash & Glied, 2010). One example of a surgery that has a rapidly rising number of procedures performed by a robot is robot-assisted 265
prostatectomy. On average, prostatectomy surgery is performed by surgeons less than 10 times per year, making it difficult to obtain the necessary hours to make a doctor skilled in the procedure (Savage & Vickers, 2009). Limited benefit from the procedure has been observed based on studies comparing radical prostatectomy surgery and robot-assisted prostatectomy (Kaye, Mullins, Carter, & Bivalacqua, 2014). The findings from studies exploring quality of life after prostate surgery have been mixed. In one study with patients who had undergone a robot-assisted radical prostatectomy, participants were more dissatisfied with their outcomes than patients undergoing an open radical prostatectomy (Malcolm et al., 2010; Schroeck et al., 2008).
Conclusion Robotic surgeries are a technology that will continue to evolve over time. The number of robotic surgical procedures and types of procedures will likely continue to rise. These new technologies are marketed to physicians and consumers, with surgeons wanting to keep up with market demand and hospitals wanting to attract and retain surgeons (Barbash & Glied, 2010). A consensus document on robotic surgery developed in 2007 by the leadership of the Society of American Gastrointestinal and Endoscopic Surgeons and the Minimally Invasive Robotic Association provided recommended guidelines for the training and credentialing of physicians to maintain better uniformity of standards. The guidelines call for formal specialty training in robotic surgery, with a curriculum that includes therapeutic robotic devices, documentation of practical experience, an appropriate volume of cases with satisfactory outcomes with an expert proctor, and formal assessment of competency (Herron & Marohn, 2008). Outcome studies comparing the outcomes from various robotic surgeries to laparoscopic or open procedures need to be done. These studies will better inform surgeons, healthcare organizations, hospitals, insurance companies, and the public on the benefits and risks of the ro-
266
botic technology for specific procedures. Ultimately, patients and the healthcare system will benefit from looking at the data to determine which types of surgical procedures result in the best and most cost-effective outcomes.
References Barbash, G.I., & Glied, S.A. (2010). New technology and health care costs—The case of robot-assisted surgery. New England Journal of Medicine, 363, 701–704. doi:10.1056/NEJMp1006602 Ghani, K.R., Rogers, C.G., Sood, A., Kumar, R., Ehlert, M., Jeong, W., . . . Menon, M. (2013). Robot-assisted anatrophic nephrolithotomy with renal hypothermia for managing staghor n calcu li. Journal of Endourology, 27, 1393–1398. doi:10.1089/end.2013.0266 Hayn, M.H., Hussain, A., Mansour, A.M., Andrews, P.E., Carpentier, P., Castle, E., . . . Guru, K.A. (2010). The learning curve of robot-assisted radical cystectomy: Results from the International Robotic Cystectomy Consortium. European Urology, 58, 197–202. doi:10.1016/j.eururo .2010.04.024 Herron, D.M., & Marohn, M. (2008). A consensus document on robotic surgery. Surgical Endoscopy, 22, 313–325. doi:10.1007/s00464-007-9727-5 Intuitive Surgical, Inc. (2014). Products. Retrieved from http://www.intuitive surgical.com/products Kaye, D.R., Mullins, J.K., Carter, H.B., & Bivalacqua, T.J. (2014). Robotic surgery in urological oncology: Patient care or market share? Nature Reviews. Urology, 12, 55–60. doi:10.1038/nrurol.2014.339 Lanfranco, A.R., Castellanos, A.E., Desai, J.P., & Meyers, W.C. (2004). Robotic surgery: A current perspective. Annals of Surgery, 239, 14–21. doi:10.1097/01.sla .0000103020.19595.7d
Malcolm, J.B., Fabrizio, M.D., Barone, B.B., Given, R.W., Lance, R.S., Lynch, D.F., . . . Schellhammer, P.F. (2010). Quality of life after open or robotic prostatectomy, cryoablation or brachytherapy for localized prostate cancer. Journal of Urology, 183, 1822–1828. doi:10.1016/j .juro.2009.12.102 Mufarrij, P.W., Shah, O.D., Berger, A.D., & Stifelman, M.D. (2007). Robotic reconstruction of the upper urinary tract. Journal of Urology, 178, 2002–2005. doi:10.1016/j.juro.2007.07.018 Oppenheimer, P., Weghorst, S., MacFarlane, M., & Sinanan, M. (1999). Immersive surgical robotic interfaces. Studies in Health Technology and Informatics, 62, 242–248. Peters, C.A. (2004). Robotically assisted surgery in pediatric urology. Urologic Clinics of North America, 31, 743–752. doi:10.1016/j.ucl.2004.06.007 Polychronidis, A., Laftsidis, P., Bounovas, A., & Simopoulos, C. (2008). Twenty years of laparoscopic cholecystectomy: Philippe Mouret—March 17, 1987. Journal of the Society of Laparoendoscopic Surgeons, 12, 109–111. Reza, M., Maeso, S., Blasco, J.A., & Andradas, E. (2010). Meta-analysis of observational studies on the safety and effectiveness of robotic gynaecological surgery. British Journal of Surgery, 97, 1772–1783. doi:10.1002/bjs.7269 Savage, C.J., & Vickers, A.J. (2009). Low annual caseloads of United States surgeons conducting radical prostatectomy. Journal of Urology, 182, 2677–2679. doi:10.1016/j.juro.2009.08.034 Schroeck, F.R., Krupski, T.L., Sun, L., Albala, D.M., Price, M.M., Polascik, T.J., . . . Moul, J.W. (2008). Satisfaction and regret after open retropubic or robotassisted laparoscopic radical prostatectomy. European Urology, 54, 785–793. doi:10.1016/j.eururo.2008.06.063
Do You Have an Interesting Topic to Share? Tech Savvy discusses the ways in which technology affects nurses, patients, the healthcare team, and the oncology setting. Length should be no more than 1,000–1,500 words, exclusive of tables, figures, insets, and references. If interested, contact Associate Editor Susan Doyle-Lindrud, DNP, AOCNP®, DCC, at [email protected].
June 2015 • Volume 19, Number 3 • Clinical Journal of Oncology Nursing
Copyright of Clinical Journal of Oncology Nursing is the property of Oncology Nursing Society and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
