Robotic surgery: revisiting “no innovation without evaluation”BMJ 2013; 346 doi: https://doi.org/10.1136/bmj.f1573 (Published 11 March 2013) Cite this as: BMJ 2013;346:f1573
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Paul and colleagues should be commended for highlighting the need for national registries on robotic surgery to more effectively collect data on rare events, long term outcomes and quality assurance. We would, however, caution against drawing hasty conclusions on the comparative effectiveness of robotic versus traditional minimally invasive surgery (MIS) based on such information alone.
Robotic assistance should be appreciated as an adjunct to traditional MIS, rather than providing a de novo surgical approach. A relevant analogy is the introduction of the operating microscope to intracranial neurosurgery over fifty years ago. The full impact of this was much better elucidated over time in the work of subsequent generations of neurosurgeons, in particular those who started their neurosurgical training with the microscope as a tool in routine use. A comparative study in the early years may have yielded inadequate evidence for the growth of microneurosurgery. The difference in outcomes between robot-assisted and traditional MIS is likely to be so incremental when performed by expert surgeons that it might be unrecognisable in smaller clinical trials. To this end, the quantitative indices that are currently scrutinized in evaluating open and MIS surgical approaches may not necessarily be best suited to comparing robot-assisted and traditional MIS.
Clearly, there are a multitude of factors driving the popularity of robotic surgery, many of which might not be easily measurable using the quantitative data obtained through high quality trials and national registries. Arguably the greatest role of contemporary first-generation robotic surgical systems is as a “great leveller”, reducing the learning curve of keyhole approaches[3 4], and enabling surgeons to perform MIS when they would otherwise resort to open surgery. The introduction of robot-assisted minimally invasive prostatectomy, for example, heralded an increase in the adoption of MIS versus open approaches from 1.4% in 2002 to 29.5% in 2008, with fewer associated complications reported and a reduced length of hospital stay.
Future robotic systems will be driven towards overcoming the current economic, clinical and technical barriers to clinical translation and wider adoption[2 6]. It is unlikely we will see even larger and more expensive systems used for the entire procedure, but rather smaller, intelligent devices designed for certain generic steps of the surgery. The pace of technological development means that comparative effectiveness research on robotic surgery faces a diverse and evolving target. While the importance of clinical trials and national registries cannot be overstated, evidence-based approaches to assessing robotic surgery must be similarly dynamic and consider the context of surgery where robotic assistance makes clinical and economic sense. This will help fully evaluate the safety and efficacy of new devices as they are introduced.
1. Paul S, McCulloch P, Sedrakyan A. Robotic surgery: revisiting "no innovation without evaluation". Bmj 2013;346:f1573.
2. Sodergren MH, Darzi A. Robotic cancer surgery. Br J Surg 2013;100(1):3-4.
3. Benway BM, Wang AJ, Cabello JM, Bhayani SB. Robotic partial nephrectomy with sliding-clip renorrhaphy: technique and outcomes. Eur Urol 2009;55(3):592-9.
4. Herrell SD, Smith JA, Jr. Robotic-assisted laparoscopic prostatectomy: what is the learning curve? Urology 2005;66(5 Suppl):105-7.
5. Hofer MD, Meeks JJ, Cashy J, Kundu S, Zhao LC. Impact of increasing prevalence of minimally invasive prostatectomy on open prostatectomy observed in the national inpatient sample and national surgical quality improvement program. J Endourol 2013;27(1):102-7.
6. Marcus H, Nandi D, Darzi A, Yang GZ. Surgical Robotics Through a Keyhole: From Today's Translational Barriers to Tomorrow's "Disappearing" Robots. IEEE Trans Biomed Eng 2013;60(3):674-81.
Competing interests: All authors are involved in the development and use of robotic surgical systems.