Robo-Surgeons vs Robo-Sceptics

• 02 Jun 2021 10:22:14 AM
• |General Urology

Dear All,

To day is the era of Robotic Surgery and procuring Robots have become a fashion of Indian Urologists as well. Those having Robot at their centre have started believing that those do not have one should refrain from performing most of Urological Surgeries. Is this practicable in a country like ours. Many are not insured and are financially weak. Those not insured will have to pay from their own pocket for treatment. In fact, you had mentioned I a previous write up that many in India can afford such treatments and to say they cannot is a myth in present day India. Though the number of Robots availability has risen leaps and bounds in India, how many of them are functioning cost effectively. It is said in some articles that unless a minimum of 150 Robot Assisted Surgeries are performed at a centre, having a robot is not cost effective. Another aspect that is considered by many is that the overall results of a procedure done by Open technology or by Lap Technology do not differ much barring excessive costs that are involved when performed Robotically.

How much of these facts should be taken into consideration when we attempt to procure a robot at a centre should be taken. This is not ‘shouting Sour Grapes’ by those not having a robot but should all cases be referred to centres having a robot and such centres not having a robot refrain from performing such procedures.

However much the protagonists of Robot Surgeries claim, India being a vast country with varying Socioeconomic levels, many may not be able to travel long distances for getting the so called ‘Ideal’ treatment. Should they undergo the needed procedure at a close by centre or not  is a question that need consideration.

We had a debate on the need of Robotic Surgery in India in formative years at USICON, Pune Conference 2013. Much water has flown under the bridge since then with many obtaining Robots for their centre. Prokar Dasgupta in a write up in BJUI had mentioned that Robotic Surgery is not that Important than performing a proper procedure within the means available in a country.

I hope this will create some debate as to ‘whether Robotic Surgery Replace Open and lap Procedures’. I am providing an article ‘Robo-surgeons vs Robo-sceptics’: can we afford robotic technology or can we afford not to? as a beginning for this debate.

 https://journals.sagepub.com/doi/pdf/10.1177/2051415818812300

With warm regards,

Venu

Comments(6)

• 

  Ravindra Sabnis

  02 Jun 2021 04:30:42 PM

  This is very important debate & much pertinent to present condition in india. Both robo surgeons & robo sceptics have valid points. 

  Why is robot increasing in number - certainly it has benefits. Biggest benefit is that robot has reduced learning curve of complex surgeries. Partial, or radical prostate would require a person to spend 5 years with high volume to learn the technique. While that can be learned on robot in few cases. Robot has brought a surgeon with 20 years at par with surgeon with 2 years. This I feel is basic difference between robo surgeon & robo sceptics. Robo sceptics are those with high lap experience. While robo surgeons are young majority of whom have no lap experience 

  Cost will always remain an issue. However if we see that only 10% can afford - in actual number it is huge. That is power of our population. 

  Any procedure cost eventually comes down when there is competition. We saw that in eswl, laser...etc Unfortunately for Da vin ci there is no competition  till then cost will be high But moment some other robot comes, cost will be 1/4. And amanable to all. Previously CT scan was not affordable to most now everyone we do CT scan. 

  Ease of doing surgery is addictive & gives good results also. Whatever anyone wants to say, ergonomics of robot can't be achieved by any human hand - even super human. 

  So i feel this debate will continue but robot will always have upper hand. 

• 

  Dr. Roy Chally

  02 Jun 2021 08:50:46 PM

  Agree with what Sabnis wrote except about the the percentage of population who can afford this surgery. Even if the percentage is a little lower, the volume will be large. There is a need for robotic surgery for the stated advantages decreased hospital, less blood loss and less pain etc. 

  This study compares RARP and ORP

         No difference in oncological outcome

         No difference in positive surgical margin 

         No difference in continence and potency at 12 months

  Comparing salvage in RARP and ORP

          Continence is better by 16% and Potency is better by 17% in RARP. 

         Nobody will disagree that ORP still has a place in our country. Unfortunately today the oncology sub speciality is more in private sector or autonomous institutions. They have the funds to purchase the robot.  They are not going to be large volume centers for ORP. There is a need for uro-oncology specialisation in government teaching hospitals. Large volume centers can come up in government hospitals only with sub- specialisation. For better results with ORP we need uro- oncology centers in government hospitals. I see no justification for purchasing robot in government hospitals where the treatment is heavily subsidised or free. 

         If universal insurance comes will the RARP be available for poor? 

• 

  Dr. Anil Takvani

  03 Jun 2021 06:55:43 PM

  Practicing at peripheral center for  more than 20 years,  I can say cost is definitely a major factor for at least 60% of my patients.

  For others as their income improved, more health insurance and more companies reimbursement their capacity to spent for costly treatment improved. Almost 30% are dependent on free or almost free treatments as they are BPL. 

  
  

  Agree; ease for surgeons, less bleeding, reduced hospital stay and less pain are advantages but as Dr. Roy Chelly sir mentioned no difference in overall long term outcomes on survival, incontinence and erectile dysfunction.

  Reasons: Indications of radical prostatectomy completely changed to have large volumes to reach to certain numbers to be viable or satisfying number race.

  Though natural history of ca. prostate not changed or not rewritten.

  Can this because of corporate influence? Can this be because huge investments involved. 

  I am seeing cases of RARP in very old age patients with metastasis explained benefits of local control though larger local residual tumor left with local recurrences and eventually death after huge expenditures of RARP....

  I am not trying preaching, I am too small to do it, but we need to have self or institutional audits....

  Thanks 

• 

  Dr G G Laxman Prabhu

  06 Jun 2021 07:24:06 AM

  I am neither a critique nor a sceptic!

  Having said this, when it comes to radical prostatectomy, the ergonomics provided by the robot in the retropubic space is matchless. Only a surgeon afflicted by Ehlers- Danlos syndrome might have greater flexibility!. Robotics has also made nephron sparing surgery precise and enucleation of benign enlarged prostate elegantly performable. 

  
  

  According to 2011 census, India had 51 million males.This is expected to grow to 75 million plus by 2026. The prevalence of Cancer prostate in men above 60 years is around 13 percent. This would mean India will have at least 10 million men who could be having cancer prostate at any point. If robotics is established in the public sector and made available to common man free, then there should be no dearth of work. This arithmetic might be appealing but can we afford the cost ? It is not like the footwear industry seeing a business opportunity in a country where people are walking bare footed!  

  In surgery it is said, to do good, one to do what one is good at. Newer techniques replace older ones on certain most needed virtues of the newer over the old. There was time when TUR was not available in all the centers in the country. The academicians cried foul saying there is so much of discrepancy in training. At that time many urologists continued to perform open prostatectomy for BEP with elan and finesse!. It was needed then. Likewise, accomplished laparoscopists and open surgeons should continue to do surgeries till such time that robotics becomes affordable to the most deprived man in the society. Then there will be social justice in the truest sense.

  On the other hand, a committed subspecialist in uro-oncology should continue in a dedicated manner with robotics and excel. It is atrocious to call committed professionals reckless by saying - " a fool with a tool is still a fool". Sloganeering is nice in public speaking, not in practice. Establishments managed by doctors and not businessmen can make lot of difference here. We have such institutions in India.

  In the mean time, those engaged in curriculum drafting should think of means to bridge the discrepancies in training.

  Finally,  to quote Victor Hugo, no force on earth can stop an idea or means whose time has come.

  I would ask the sceptics to await that moment.

  
  

  Dr G G Laxman Prabhu

• 

  Dr G G Laxman Prabhu

  06 Jun 2021 09:41:47 AM

  
  

  Erratum

  Please read - In surgery, it is said that to do good, one to do what one is good at as: In surgery, it is said, to do good, one has to do what one is good at!

• 

  Dr. Roy Chally

  02 Jul 2021 01:16:45 PM

  Agree with what Sabnis wrote except about the the percentage of population who can afford this surgery. Even if the percentage is a little lower, the volume will be large. There is a need for robotic surgery for the stated advantages decreased hospital, less blood loss and less pain etc. 

  This study compares RARP and ORP

         No difference in oncological outcome

         No difference in positive surgical margin 

         No difference in continence and potency at 12 months

  Comparing salvage in RARP and ORP

          Continence is better by 16% and Potency is better by 17% in RARP. 

         Nobody will disagree that ORP still has a place in our country. Unfortunately today the oncology sub speciality is more in private sector or autonomous institutions. They have the funds to purchase the robot.  They are not going to be large volume centers for ORP. There is a need for uro-oncology specialisation in government teaching hospitals. Large volume centers can come up in government hospitals only with sub- specialisation. For better results with ORP we need uro- oncology centers in government hospitals. I see no justification for purchasing robot in government hospitals where the treatment is heavily subsidised or free. 

         If universal insurance comes will the RARP be available for poor?