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  1. Top of page
  2. OUR EXPERTS
  3. What is your overall opinion on the use of robots in your urological subspecialty?
  4. Let's talk more about outcomes. What has been your own experience with different outcomes after robotic or open surgery?
  5. What about the learning curve for robotic surgery? Is this no longer a relevant issue given that residents and fellows are exposed to it almost immediately in their training?
  6. Let's look at the marketing issue. Has marketing driven patients to request robotic surgery and physicians to use it? Do you have any concerns about how heavily the robot has been promoted?
  7. Right now, we have one major industry player in robotic surgery. Do you see any competition on the horizon? What will be its impact, if any?
  8. Let's talk more about costs. There have been a lot of cost analyses done with various results. What has been your experience with costs? Is robotic surgery really cost-effective?
  9. Other therapies, such as focal therapy, are gaining momentum, particularly in the treatment of prostate cancer? Do you see any of these trumping robotics in the future? What role will they play ‘in the mix’?
  10. It is an exciting time in urology with the application of single-site and natural orifice surgery? How do you see these techniques taking shape? What role will robotics play?
  11. In conclusion, it is time to take out your crystal ball! What are your future predictions for robotic surgery in urology, say 10 years from now? Is there something else we need to make robots more effective and less costly?
  12. DRUG AND TECHNOLOGY NEWS
  13. Clinical Trial
  14. In this issue…

Jeffrey Cadeddu, MD

Ralph C. Smith, MD, Distinguished Chair in Minimally Invasive Urologic Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA.

Michael Herman, MD

Instructor in Urology, Weill Cornell Medical College/New York-Presbyterian Hospital, New York, NY, USA

Herbert Lepor, MD

Chair, Department of Urology, Martin Spatz Professor of Urology and Pharmacology, New York University Langone, Medical Center, New York, NY, USA

Yair Lotan, MD

Helen J. and Robert S. Strauss, Professor of Urology, University of Texas Southwestern Medical Center, Dallas, TX, USA

Alexandre Mottrie, MD

Urologist, O.L.V. Clinic, Aalst, Belgium

Vipul Patel, MD

Medical Director, Global Robotic Institute

Florida Hospital, Orlando, FL, USA

Raj Pruthi, MD

Chief of Urology and Associate, Professor, Director of Urologic Oncology, University of North Carolina, Chapel Hill, NC, USA

Abhay Rane, MS, FRCS, FRCS (Urol)

Consultant Urological Surgeon, Surrey and Sussex Healthcare NHS Trust, London, UK

Joseph A. Smith Jr, MD

Chair, Department of Urologic Surgery, William L. Bray Professor of Urologic Surgery, Vanderbilt University School of Medicine Nashville, TN, USA

Despite widespread adoption by urological surgeons and keen interest from patients, robotic surgery has gained a momentum that shows no signs of stopping. Yet, controversies still swirl around the robot's application in prostatectomy and now cystectomy. Questions remain about efficacy, outcomes, learning curves, cost-effectiveness and future technologies that may trump robotics in the future. As a special addition to the BJUI supplement on robotic surgery, Uroscan recently talked with experts from around the world to get their views on the current and future state of robots in urology. They share their opinions on how the robot has changed their subspecialty, their own experience with outcomes, and the debate over learning curves. In addition, they talk about the cost-effectiveness issue, how marketing has shaped the demand from patients, new technologies on the horizon, and what the future holds for robotic surgery in general.

What is your overall opinion on the use of robots in your urological subspecialty?

  1. Top of page
  2. OUR EXPERTS
  3. What is your overall opinion on the use of robots in your urological subspecialty?
  4. Let's talk more about outcomes. What has been your own experience with different outcomes after robotic or open surgery?
  5. What about the learning curve for robotic surgery? Is this no longer a relevant issue given that residents and fellows are exposed to it almost immediately in their training?
  6. Let's look at the marketing issue. Has marketing driven patients to request robotic surgery and physicians to use it? Do you have any concerns about how heavily the robot has been promoted?
  7. Right now, we have one major industry player in robotic surgery. Do you see any competition on the horizon? What will be its impact, if any?
  8. Let's talk more about costs. There have been a lot of cost analyses done with various results. What has been your experience with costs? Is robotic surgery really cost-effective?
  9. Other therapies, such as focal therapy, are gaining momentum, particularly in the treatment of prostate cancer? Do you see any of these trumping robotics in the future? What role will they play ‘in the mix’?
  10. It is an exciting time in urology with the application of single-site and natural orifice surgery? How do you see these techniques taking shape? What role will robotics play?
  11. In conclusion, it is time to take out your crystal ball! What are your future predictions for robotic surgery in urology, say 10 years from now? Is there something else we need to make robots more effective and less costly?
  12. DRUG AND TECHNOLOGY NEWS
  13. Clinical Trial
  14. In this issue…

Vipul Patel: I'm of the generation that did all three: open, laparoscopic and robotic surgery. The advantages of robotics are unquestionable in experienced hands. Once you have experience with the robot and understand prostate anatomy, implications and outcomes, you can do a very nice operation. Over 85% of all prostatectomies in the USA are now done robotically. That's not just because of marketing or physicians wanting to do it that way. It is because outcomes have been shown.

Joseph A. Smith Jr: I've done more than 2500 open procedures on the prostate and now more than 3000 robotic procedures. Some of the robot's advantages are exaggerated. In every outcome measure, the robotic approach is at least equal to or better than the open approach. That's why I do 99% of my cases now robotically. I do think the robot is better, but not as better, as some people claim. I continue to tell patients that, in the hands of a highly experienced open surgeon, the results are probably going to be about the same as from a highly experienced surgeon in robotics. But, there aren't that many highly experienced people that fit this category. You have open surgeons who claim that you can't get better results robotically than they can with an open approach. They are probably right, but this is a small group of people with a high level of experience. That's why you’ve seen almost everyone else converting to the robot because they recognise they do get better results.

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[ ‘I think it is one of the most thoughtful, laid-out applications of a new technology in urological cancer’ ]

Raj Pruthi

Herbert Lepor: About 10 years ago, as robotics was gaining speed, I asked myself a very fundamental question. How is robotic prostatectomy going to fill any unmet need in the surgical treatment of prostate cancer? I personally have performed 4000 open retropubic procedures without a single hospital or operative mortality. In terms of intraoperative complications, I've reported 1 in 200. Patients generally go home in 1–2 days. Some of my patients have actually run quarter-mile races within the first 3 weeks after surgery; one ran a marathon in 4 weeks. Half of my patients are back to work in 2 weeks. My transfusion rate is about 3–4%, and 97% of them regain their continence.

Potency is the one thing that we really need to see an improvement in. I have no confidence that robotics will improve upon potency. According to legitimate published data, the robot has done nothing to improve outcomes for men with prostate cancer undergoing surgical intervention. Have you seen a legitimate, comparative study showing the robot to be better? That's why I did not get involved at all with the robot, because 10 years ago, I speculated it would offer nothing. Today, I would have to say the data still bear this out.

What would have been gained by my adopting a robotic approach? Nothing for my patients, but they would have been exposed to a learning curve and an increase in the cost of healthcare delivery. The outcomes would have been no different.

Alexandre Mottrie: I think robotics is here to stay. It is such a marvellous technique. I'm sure it will take over most indications for open surgery. Of course, it will evolve even further. There is still a lot of room for improvement. We still don't have tactile feedback. The instruments will also get better. A lot of indications have already proven that robotics is superior. Look at the prostate. When you do a meta-analysis of all the studies available, there is a significant advantage in functional and oncological outcomes.

Raj Pruthi: I remember 6 years ago when robotics for bladder cancer was originally presented at the AUA meeting. There were some very strong critics. Their concerns were so great. Now, when you look through the evolution of papers and the case series, I think it is one of the most thoughtful, laid-out applications of a new technology in urological cancer. It is very different from the prostate where everyone is rushing to say they’ve done 500 cases.

When we began to evaluate robotics, we tried to do it in a very stepwise, very methodical way. Bladder cancer is a very different ‘animal’ from prostate cancer. It is a very aggressive disease. Half of the people with invasive bladder cancer don't live 5 years. So, the cure rate is very different from that of prostate cancer. We also do not have very good salvage therapies. If we fail, the patient often has a recurrence and this often means death. So, when we think about applying a new therapy, I think we have to be very careful. The stakes are so high in bladder cancer surgery. No new technology should ever compromise oncological integrity.

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[ ‘I would like to see robots tailor-made for different specialties’ ]

Vipul Patel

Yair Lotan: Most of the robotic procedures I do are for prostate cancer. I actually do a lot of bladder and kidney cancer, but not necessarily robotically. Obviously, there is some controversy about whether or not there is a difference in complications. In fairness, expert robotic surgeons are no better than open surgeons at their own ‘game’. You are just looking at a fairly expensive machine with costly maintenance and equipment that's not reusable, and comparing it to a knife. It isn't favourable for the robot.

Abhay Rane: We have looked at the impact of robotic surgery over the last 15 years. What has happened is that it has evolved into the ‘gold standard’ (the reference standard) for certain procedures. What will happen with robotics in the future is that it may not be in its current shape or form. So far, a lot of robotics has been restricted to urology because there weren't any other applications. Over the last 3 or 4 years, a lot of other specialties have come into the equation, especially gynaecology and otolaryngology. They have adapted the current manipulation skills to their own areas.

Michael Herman: Patients are very interested in robotics and want it. Some sort of minimally invasive surgery as a large component of genitourinary surgery is here to stay. Whether it will remain the robot or another next-generation technology, who knows? Urology has always been a technology forward field. It is not like we have achieved a status quo yet; the robot is still evolving. What we do need are more comparative studies. Everyone is moving in that direction, which will make things more rigorous from a scientific perspective and benefit the patient more.

Jeffrey Cadeddu: The introduction of competing technologies will occur in the next 5 years that should drive down cost. Cost is the main impediment to greater implementation.

Let's talk more about outcomes. What has been your own experience with different outcomes after robotic or open surgery?

  1. Top of page
  2. OUR EXPERTS
  3. What is your overall opinion on the use of robots in your urological subspecialty?
  4. Let's talk more about outcomes. What has been your own experience with different outcomes after robotic or open surgery?
  5. What about the learning curve for robotic surgery? Is this no longer a relevant issue given that residents and fellows are exposed to it almost immediately in their training?
  6. Let's look at the marketing issue. Has marketing driven patients to request robotic surgery and physicians to use it? Do you have any concerns about how heavily the robot has been promoted?
  7. Right now, we have one major industry player in robotic surgery. Do you see any competition on the horizon? What will be its impact, if any?
  8. Let's talk more about costs. There have been a lot of cost analyses done with various results. What has been your experience with costs? Is robotic surgery really cost-effective?
  9. Other therapies, such as focal therapy, are gaining momentum, particularly in the treatment of prostate cancer? Do you see any of these trumping robotics in the future? What role will they play ‘in the mix’?
  10. It is an exciting time in urology with the application of single-site and natural orifice surgery? How do you see these techniques taking shape? What role will robotics play?
  11. In conclusion, it is time to take out your crystal ball! What are your future predictions for robotic surgery in urology, say 10 years from now? Is there something else we need to make robots more effective and less costly?
  12. DRUG AND TECHNOLOGY NEWS
  13. Clinical Trial
  14. In this issue…

Pruthi: We did a prospective, randomized study of open vs robotic cystectomy in patients with no preconceived ideas about the surgery. We looked at lymph node removal and oncological outcomes as our measure of non-inferiority. The study was able to show that, oncologically, we are achieving the same goals with the robotic approach as we are with the open approach and not compromising anything. We are removing at least as many lymph nodes and not creating positive margins. Secondarily, we have less blood loss. Patients seem to recover their bowel function a little faster and use narcotics less.

Now, we just did a combined analysis with Dr Erik Castle at the Mayo Clinic in Scottsdale. We have some pretty mature, 3-year follow-up data recently presented at the AUA. In bladder cancer, 3 years is a pretty good measure of oncological outcomes. My message is that we have always had oncological outcomes driving the analysis and not the technology. I still do open cystectomies. It is not about the tool; it is about doing the right operation.

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[ ‘Some of the robot's advantages are exaggerated’ ]

Joseph A. Smith Jr

We are now doing robotic urinary diversions. The next horizon is doing everything intracorporeally. The added benefit is no additional incisions, except for the robotic ports. By doing everything within the abdomen, the bowel doesn't dry out, plus there is less manipulation of tissues. Doing the ileal conduit robotically seems to have some real benefits to the patient, such as less pain and better bowel function. With the neobladder, we are still struggling as to whether or not doing it robotically is better. It takes longer in the operating room (OR), so that increases the costs and keeps the patient under anaesthesia longer.

Cadeddu: In kidney cancer, emerging 5 and 10-year data show that ablation is as effective as surgery for small tumours. Robotics will not be able to compete with the minimal morbidity of percutaneous ablation. Competing technologies that minimize invasiveness will certainly affect the utilization of robotics for some diseases, such as prostate and kidney cancer.

Patel: There are many series out there showing that the outcomes for robotic surgery, in many ways, have surpassed those of open surgery: continence, earlier sexual function and lower positive margin rates. In addition, you have the fact that these patients have shorter hospital stays; they don't lose much blood or need transfusions.

Recently, I gave a closing statement at the end of the AUA meeting that reviewed all of the abstracts on robotic surgery. We found that there was no abstract out of all those presented that showed open surgery was superior in any way to robotic surgery. Robotic surgery was either superior or equivalent in all aspects. So, I think the data are there. The patient population has spoken in terms of what they are having done.

Lepor: My outcomes are part of an Institutional Review Board-approved, longitudinal survey of patients, where they complete validated questionnaires administered by a third-party. The only real limitation to my open approach was potency. As I've reported, about 60% of men who had the ability to engage in intercourse before surgery regained that function within 2 years.

In terms of the nerves, I delineated the pathway of these nerves with Dr Patrick Walsh in the early 1980s. These nerves are microscopic; they are neither visible to the eye nor with the magnification used in robotics. When I release the nerves, I release them sharply with a knife. When you release the nerve bundle during a robotic prostatectomy, you do this with electrocautery. I feel this has a greater likelihood of damaging the nerves. There is not a shred of evidence, not one legitimate comparative study, where you have actually evaluated potency in surgeons of equal skill and experience that shows potency to be superior with robotics.

Smith: There is no dispute of less bleeding with the robotic approach. There is also a lower rate of bladder neck contractures and a shorter length of stay overall. We have found no difference in postoperative pain.

Where the ‘rubber really meets the road’ is continence, potency and tumour control. I've been disappointed that we haven't made more gains on the continence and potency fronts. I get about the same results with both procedures. The robotic approach is certainly not inferior. We have a slight trend toward superiority with the robot but it is not statistically significant. With regard to tumour control, for low-risk disease, it is comparable. For high-risk disease, I think it is better robotically. That's a statement most people would be surprised by. But, if we want to perform a wide resection of the prostate, I think we can do it better robotically than we can with an open procedure. Initially, we stayed away from high-grade tumours that required a wider resection. Now, we think the robotic approach is actually advantageous. Some people also say you can't do a sterile lymph node dissection by using the robot, but that's simply not true. If you are willing to devote the time and attention, you can do a comparable dissection.

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[ ‘I have no confidence that robotics will improve upon potency’ ]

Herbert Lepor

What about the learning curve for robotic surgery? Is this no longer a relevant issue given that residents and fellows are exposed to it almost immediately in their training?

  1. Top of page
  2. OUR EXPERTS
  3. What is your overall opinion on the use of robots in your urological subspecialty?
  4. Let's talk more about outcomes. What has been your own experience with different outcomes after robotic or open surgery?
  5. What about the learning curve for robotic surgery? Is this no longer a relevant issue given that residents and fellows are exposed to it almost immediately in their training?
  6. Let's look at the marketing issue. Has marketing driven patients to request robotic surgery and physicians to use it? Do you have any concerns about how heavily the robot has been promoted?
  7. Right now, we have one major industry player in robotic surgery. Do you see any competition on the horizon? What will be its impact, if any?
  8. Let's talk more about costs. There have been a lot of cost analyses done with various results. What has been your experience with costs? Is robotic surgery really cost-effective?
  9. Other therapies, such as focal therapy, are gaining momentum, particularly in the treatment of prostate cancer? Do you see any of these trumping robotics in the future? What role will they play ‘in the mix’?
  10. It is an exciting time in urology with the application of single-site and natural orifice surgery? How do you see these techniques taking shape? What role will robotics play?
  11. In conclusion, it is time to take out your crystal ball! What are your future predictions for robotic surgery in urology, say 10 years from now? Is there something else we need to make robots more effective and less costly?
  12. DRUG AND TECHNOLOGY NEWS
  13. Clinical Trial
  14. In this issue…

Patel: Now, surgeons are learning robotically. Most residency programmes are teaching robotic surgery. I would expect this trend to continue. The robotic approach is much easier to teach and to learn. When you are doing it, everybody can watch what you are doing. They can record it, review it and watch it over and over again. Even if you were assisting someone in open surgery, sometimes you cannot see the key structures. Robotically, everyone can see every part of the operation.

Mottrie: I do not agree at all that the learning curve is quite high in robotics. You may not underestimate the learning curve, however, which some people do. Of course, there is a progressive learning curve, but what is the definition of learning curve? You can write 10 papers about that! You must distinguish between an already established urologist and a resident. For students, it is no more difficult to learn robotic surgery today. Now, they can follow it on the screen. In my time, when you were doing open surgery, you had your hands in the wound and couldn't see anything.

Herman: When I started out as a resident, I was introduced to robotics quite early. The main crux of the robotic experience comes later on in the last 2 years of residency. Those 2 years are so intense in terms of the robot that you just get an amazing experience.

I see residents coming out of some training programmes very fluent and comfortable with minimally invasive and robotic surgery. Obviously, you need to do open surgery as well. One of the concerns is that if a programme is heavily minimally invasive, can it still teach residents open surgery? It is something that is definitely doable. Some people say you need to learn the anatomy during open surgery first and then translate it to minimally invasive surgery. But, I feel it also goes just as well the other way. If you see a lot of minimally invasive surgery and do a lot of it during your residency, you are able to take that knowledge to the open procedure.

Pruthi: Our recommendation has always been for surgeons to master robotic prostatectomy first before learning robotic cystectomy. That's where your numbers are going to come from in terms of high volume. The surgeon should get accustomed to doing that laparoscopically and then robotically, dissecting within the pelvis that way. Then, they can transition to robotic cystectomy. We recommend doing the first 10 procedures on males, where you already know the pelvic anatomy. Once the surgeon gets that down, they can transition to female pelvic anatomy. It takes about 20 cases before you see significant blood loss reduction. The cut-off point for operating time is about 40 cases.

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[ ‘I do not agree at all that the learning curve is quite high in robotics’ ]

Alexandre Mottrie

Smith: Most of the learning-curve debate is no longer relevant. It is more for those who make the switch in the midst of clinical practice. With everyone getting robotic experience during their residency and fellowship, it is just not an issue anymore. There are still some hospitals that acquire a robot and have career urologists who have to learn how to do it. They may not have younger colleagues to help them with it. There is definitely a learning curve for them.

Let's look at the marketing issue. Has marketing driven patients to request robotic surgery and physicians to use it? Do you have any concerns about how heavily the robot has been promoted?

  1. Top of page
  2. OUR EXPERTS
  3. What is your overall opinion on the use of robots in your urological subspecialty?
  4. Let's talk more about outcomes. What has been your own experience with different outcomes after robotic or open surgery?
  5. What about the learning curve for robotic surgery? Is this no longer a relevant issue given that residents and fellows are exposed to it almost immediately in their training?
  6. Let's look at the marketing issue. Has marketing driven patients to request robotic surgery and physicians to use it? Do you have any concerns about how heavily the robot has been promoted?
  7. Right now, we have one major industry player in robotic surgery. Do you see any competition on the horizon? What will be its impact, if any?
  8. Let's talk more about costs. There have been a lot of cost analyses done with various results. What has been your experience with costs? Is robotic surgery really cost-effective?
  9. Other therapies, such as focal therapy, are gaining momentum, particularly in the treatment of prostate cancer? Do you see any of these trumping robotics in the future? What role will they play ‘in the mix’?
  10. It is an exciting time in urology with the application of single-site and natural orifice surgery? How do you see these techniques taking shape? What role will robotics play?
  11. In conclusion, it is time to take out your crystal ball! What are your future predictions for robotic surgery in urology, say 10 years from now? Is there something else we need to make robots more effective and less costly?
  12. DRUG AND TECHNOLOGY NEWS
  13. Clinical Trial
  14. In this issue…

Cadeddu: There is hype around the ‘sexiness’ of robotic surgery. Both marketing and the Internet have driven robotic growth. Patients do not understand that there is no difference in outcomes, although the robotic approach is easier for the surgeon.

Lepor: Here we have a technology that was marketed. The company went to the public with false claims, which a Johns Hopkins study recently showed. Then, the company went to the doctors telling them ‘the guy down the street has a robot. He's going to get all of the business’! Then the hospital buys him a robot. I've been to many hospitals where, as you walk in the door, they have a display showing that they are now state-of-the-art because they have a robot.

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[ ‘Expert robotic surgeons are no better than open surgeons’ ]

Yair Lotan

Patients have a total unrealistic expectation about the robot because that's how you sell and market it. The robot is marketed as causing less pain. The only study assessing pain proved that claim false. Patients think

they are having this minimally invasive procedure that is going to have wondrous effects on their quality of life. The group at Duke University published a paper looking at patient satisfaction with outcomes after robotic or open surgery. They found that patients had a four-times greater likelihood of being dissatisfied if they had the robot. There is no other study that has countered this observation.

I published a study based on patient assessment of satisfaction. It was refereed by an independent third party that reviewed all of the surveys. There was a 93% satisfaction rate with the open procedure across all the timelines. Why did I get such a high satisfaction rate? It is because I tell patients the truth based on all of my outcomes. If you ask patients what drives satisfaction, they talk about cure, continence and potency.

Pruthi: Marketing is not as much of a driver with bladder cancer. This makes things a little more pure in the analyses. However, we have found that most patients with bladder cancer go to the Internet for information. The Internet is a wonderful resource but it is also the ‘Wild West’. They use and trust it as much as their own physician. We found there are some completely erroneous statements about bladder cancer on the Internet, some even coming from academic medical centres. One surgeon from a centre in New York City simply stated that robotic cystectomy removes 14% more cancer than the open procedure. That's just a ludicrous statement! These are things you would never say to each other in a peer-reviewed environment. We have to be very careful about marketing. In bladder cancer, we have a different level of obligation to the patient. The primary goal is to keep your patient with bladder cancer alive.

Right now, we have one major industry player in robotic surgery. Do you see any competition on the horizon? What will be its impact, if any?

  1. Top of page
  2. OUR EXPERTS
  3. What is your overall opinion on the use of robots in your urological subspecialty?
  4. Let's talk more about outcomes. What has been your own experience with different outcomes after robotic or open surgery?
  5. What about the learning curve for robotic surgery? Is this no longer a relevant issue given that residents and fellows are exposed to it almost immediately in their training?
  6. Let's look at the marketing issue. Has marketing driven patients to request robotic surgery and physicians to use it? Do you have any concerns about how heavily the robot has been promoted?
  7. Right now, we have one major industry player in robotic surgery. Do you see any competition on the horizon? What will be its impact, if any?
  8. Let's talk more about costs. There have been a lot of cost analyses done with various results. What has been your experience with costs? Is robotic surgery really cost-effective?
  9. Other therapies, such as focal therapy, are gaining momentum, particularly in the treatment of prostate cancer? Do you see any of these trumping robotics in the future? What role will they play ‘in the mix’?
  10. It is an exciting time in urology with the application of single-site and natural orifice surgery? How do you see these techniques taking shape? What role will robotics play?
  11. In conclusion, it is time to take out your crystal ball! What are your future predictions for robotic surgery in urology, say 10 years from now? Is there something else we need to make robots more effective and less costly?
  12. DRUG AND TECHNOLOGY NEWS
  13. Clinical Trial
  14. In this issue…

Mottrie: It is never good when there is one company having the monopoly. There are some other companies working on new systems. I hope these robots will come soon and that the costs will be lowered.

Rane: In its current shape and form, robotic surgery is not cost-effective. Once you have competition, you’ll see prices drop to more realistic levels. In the next couple of years, patents are going to expire. It will be a good thing that the monopoly will be phased out. The robotic technology we are using today is what was developed 10 years ago. There hasn't been much in the way of innovation. There are a lot of companies waiting in the wings with ideas. They are going to bring to fruition new robots. I look forward to what the other vendors will have to offer. It's going to be very interesting in the next few years.

Lotan: I'm not sure if future competition will drive costs lower. Almost every other technology, cars, computers and televisions, gets more effective and cheaper. In medicine, you don't see that at all. Things don't become cheaper just because of competition or time passing. For example, current shockwave lithotripters are currently less effective and more costly than the older HM3 was 25–30 years ago. Even trocars for laparoscopy, which are used all the time, are not cheaper and are no better than they were 10–15 years ago. Where are the cost savings and the economies of scale? They do not exist in medicine.

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[ ‘In its current shape and form, robotic surgery is not cost-effective’ ]

Abhay Rane

I don't think that if you have competition, the costs will go down. The next company would have to recoup its costs. When Viagra® was available and then new agents came out, nothing came down. Some people even say Viagra costs a few dollars more than when it first came out. Coke® and Pepsi® have their wars but Viagra® and Levitra® don't. Even when generic drugs come out, the cost of the main drug usually does not drop. Generics are not that much cheaper.

Medicine is a bizarre economic beast. Why do you think USA healthcare costs exceed almost everything else? No economies of scale! A lot of it is driven by the way medicine is structured. The patient does not care how much a trocar or a robot costs because they pay their insurance premium and deductible. If their hospitalization costs $5,000 or $100,000 they don't care! Physicians are also completely unaffected by the costs of technology. We can order 100 tests for a single diagnosis that could be diagnosed with just one test. It doesn't impact us.

Let's talk more about costs. There have been a lot of cost analyses done with various results. What has been your experience with costs? Is robotic surgery really cost-effective?

  1. Top of page
  2. OUR EXPERTS
  3. What is your overall opinion on the use of robots in your urological subspecialty?
  4. Let's talk more about outcomes. What has been your own experience with different outcomes after robotic or open surgery?
  5. What about the learning curve for robotic surgery? Is this no longer a relevant issue given that residents and fellows are exposed to it almost immediately in their training?
  6. Let's look at the marketing issue. Has marketing driven patients to request robotic surgery and physicians to use it? Do you have any concerns about how heavily the robot has been promoted?
  7. Right now, we have one major industry player in robotic surgery. Do you see any competition on the horizon? What will be its impact, if any?
  8. Let's talk more about costs. There have been a lot of cost analyses done with various results. What has been your experience with costs? Is robotic surgery really cost-effective?
  9. Other therapies, such as focal therapy, are gaining momentum, particularly in the treatment of prostate cancer? Do you see any of these trumping robotics in the future? What role will they play ‘in the mix’?
  10. It is an exciting time in urology with the application of single-site and natural orifice surgery? How do you see these techniques taking shape? What role will robotics play?
  11. In conclusion, it is time to take out your crystal ball! What are your future predictions for robotic surgery in urology, say 10 years from now? Is there something else we need to make robots more effective and less costly?
  12. DRUG AND TECHNOLOGY NEWS
  13. Clinical Trial
  14. In this issue…

Smith: Robotic surgery may cost a little bit more because of the equipment needs, but the other costs are the same. It is not enormously more expensive. Once a surgeon becomes experienced, the time is shortened. We use the same pathway for patient management regardless of the approach. Almost all of our patients, 99%, go home the next day after robotic prostatectomy and do not require blood transfusions. All of these costs should be about the same.

Patel: Just looking at the cost of the machine alone is not enough. You have to look at the overall impact of the hospital stay and also the impact on society. We have patients that are getting healthier, having better outcomes and getting back to work faster.

I think cost-effectiveness is really related to the efficiency of the surgery and how you look at it. The surgical times for robotic surgery are probably quicker than for most open surgeries. These patients don't require transfusions or narcotics and often go home the day after surgery. In terms of the social aspects, they return to work very quickly, usually 10–14 days at the most. This translates into massive savings in terms of disability and work force.

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[ ‘Patients are very interested in robotics and want it’ ]

Michael Herman

Pruthi: Cost-analysis is one of the trickiest things to do. We have done a couple of these studies for robotic cystectomy. The more I research and look into this, the more difficult I realise it is. The more you look at it, the more complex it becomes. It is how you draw the circle. You can do cost analysis any way you want. What do you define as cost?

We took 20 robotic and 20 open cystectomy cases and then looked at estimated costs, average OR costs and length of stay. We found that there does come a point when robotics is less expensive than open. Robotic surgery took longer in the OR but had a shorter length of stay. OR costs were higher but hospital costs were lower. If you reduce your hospital costs enough, it balances out. The difference was ≈£1600 more expensive for the robot. This study only captured in-hospital costs. It didn't address the issue of recovering faster outside of the hospital. There is obviously a different disability cost to that, if you go back to work at 4 weeks vs 6 weeks or are in less pain afterwards.

Later, we did a separate analysis, reported at the AUA last year, where we looked at actual not estimated costs. We found that there were no significant differences in the costs. Dr Erik Castle also did a cost analysis. He found robotics to be less expensive when he included other factors, such as complications.

Lotan: In general, robotic prostatectomy is not cost effective. The issue is that it is difficult to show that something is more cost effective when it not more effective and has higher costs. The largest disadvantage with robotics is that there is only a small margin you can get in terms of costs from less transfusions and a bit shorter length of stay, when other parameters, such as OR time, continence, potency and margin status are fairly equivalent at best. There are some ways to mitigate these issues. For example, high-volume robotic surgeons are more cost effective than low-volume surgeons.

Overall, the robot is not a cost-effective tool right now. This is based on the fact that one company has a monopoly and wants to make money. They certainly could make it much more cost effective if they allowed you to use a robotic needle driver more than 10 times. Nothing happens to that piece of equipment that makes it dull! You could use it probably a thousand times and it would work just fine. It is the company's decision that they want to charge you for a new piece of equipment after you use it 10 times. You may want scissors after five times because they become a little bit dull, but you may not need a new grasper or needle driver after 100 times. But the computer counts it after every use. This type of equipment costs $1500–1700 per case ‘right off the bat’. That eliminates a lot of profit margin, which is much narrower now for prostatectomy than it used to be.

Even if you make a small profit, you could have made a larger profit on it. There are some people who say ‘we don't lose money on it, but you don't make as much as if you did it open’. They would argue that if you did it open, nobody would come to you, and you wouldn't be doing it at all. But, that's not necessarily a justification for saying the robot is cost effective! That's just saying the market may have been pushing it that way. It comes at a cost.

Other therapies, such as focal therapy, are gaining momentum, particularly in the treatment of prostate cancer? Do you see any of these trumping robotics in the future? What role will they play ‘in the mix’?

  1. Top of page
  2. OUR EXPERTS
  3. What is your overall opinion on the use of robots in your urological subspecialty?
  4. Let's talk more about outcomes. What has been your own experience with different outcomes after robotic or open surgery?
  5. What about the learning curve for robotic surgery? Is this no longer a relevant issue given that residents and fellows are exposed to it almost immediately in their training?
  6. Let's look at the marketing issue. Has marketing driven patients to request robotic surgery and physicians to use it? Do you have any concerns about how heavily the robot has been promoted?
  7. Right now, we have one major industry player in robotic surgery. Do you see any competition on the horizon? What will be its impact, if any?
  8. Let's talk more about costs. There have been a lot of cost analyses done with various results. What has been your experience with costs? Is robotic surgery really cost-effective?
  9. Other therapies, such as focal therapy, are gaining momentum, particularly in the treatment of prostate cancer? Do you see any of these trumping robotics in the future? What role will they play ‘in the mix’?
  10. It is an exciting time in urology with the application of single-site and natural orifice surgery? How do you see these techniques taking shape? What role will robotics play?
  11. In conclusion, it is time to take out your crystal ball! What are your future predictions for robotic surgery in urology, say 10 years from now? Is there something else we need to make robots more effective and less costly?
  12. DRUG AND TECHNOLOGY NEWS
  13. Clinical Trial
  14. In this issue…

Lepor: Potency is a real limitation of open and robotic surgery, even when it is performed by an experienced surgeon. How can we improve this? When I look at my data, case 2000, 3000, 4000, I'm not getting any better and the robot isn't making it any better either! Focal or targeted therapy will be the opportunity. It is going to be an entirely different paradigm. We will be able to better control the disease in many men while preserving sexual function. The whole robotic story has just been a distraction from the real issues that we have a responsibility to resolve, such as the way we diagnose prostate cancer and how we have to over treat in order not to under treat.

  • image

[ ‘There is hype around the ‘sexiness’ of robotic surgery’ ]

Jeffrey Cadeddu

Patel: Focal therapy will become more desirable and more valid once we have longer-term outcomes and once we have better ways to image where the cancers are. The problem with focal therapy these days is that we don't always know where all the tumours are. After focal therapy, you still have to biopsy patients in order to follow them. It will be better once we have more accurate imaging. There is something coming out called HistoScanning®, which is actually very popular in Europe. Using some nice algorithms, HistoScanning can start to localize where the cancers are. So, when this imaging technology becomes more viable and widely available, you will essentially do more active surveillance and focal therapy, which will be very nice.

Lotan: I don't think focal therapy will trump robotics that significantly. Prostate cancer is still a multifocal disease. Minimally invasive therapies are a little bit more likely to steal business away from radiation therapy than they are from surgery. The reason I say that, is I feel that surgeons operate on who they want to operate on and will continue to do so. Focal therapies are never going to dominate the prostate cancer market because most people who have prostate cancer are still going to have more than one positive biopsy. Focal therapy may steal away from the surveillance crowd, which is growing, and may take over some of the older patients, but it won't take away from the vast majority of 50- and 60-year-olds who have multiple, positive biopsies where you don't feel comfortable treating part of the gland.

It is an exciting time in urology with the application of single-site and natural orifice surgery? How do you see these techniques taking shape? What role will robotics play?

  1. Top of page
  2. OUR EXPERTS
  3. What is your overall opinion on the use of robots in your urological subspecialty?
  4. Let's talk more about outcomes. What has been your own experience with different outcomes after robotic or open surgery?
  5. What about the learning curve for robotic surgery? Is this no longer a relevant issue given that residents and fellows are exposed to it almost immediately in their training?
  6. Let's look at the marketing issue. Has marketing driven patients to request robotic surgery and physicians to use it? Do you have any concerns about how heavily the robot has been promoted?
  7. Right now, we have one major industry player in robotic surgery. Do you see any competition on the horizon? What will be its impact, if any?
  8. Let's talk more about costs. There have been a lot of cost analyses done with various results. What has been your experience with costs? Is robotic surgery really cost-effective?
  9. Other therapies, such as focal therapy, are gaining momentum, particularly in the treatment of prostate cancer? Do you see any of these trumping robotics in the future? What role will they play ‘in the mix’?
  10. It is an exciting time in urology with the application of single-site and natural orifice surgery? How do you see these techniques taking shape? What role will robotics play?
  11. In conclusion, it is time to take out your crystal ball! What are your future predictions for robotic surgery in urology, say 10 years from now? Is there something else we need to make robots more effective and less costly?
  12. DRUG AND TECHNOLOGY NEWS
  13. Clinical Trial
  14. In this issue…

Cadeddu: Robotic technology to facilitate these techniques is imperative in order to increase their utilization. Currently, robotic technology is not designed for these approaches.

Rane: Whatever surgical procedure is contemplated, we try to do it in a single hole. What the current robotic platform utilizes is very precise. But, the way in which the manipulator arms work, they have to come in at a certain angle and be kept inches from each other. What we tried to do is see if we can use the same arm but in a slightly different fashion. Over the last 2 years, a number of centres have used robotics for single-port surgery. A lot of them have very good results.

I feel very strongly that if single-port surgery is to develop, robotics has to be a part of it. However, I doubt very much that it will be in the current form using robotic arms on the existing system. There will be a herd of early, experimental technologies being developed. In the next few years, we are going to see the Spider® Surgical System and new instruments designed for this use. At the end of the day, whether single-port surgery develops with robotics or not depends a lot on what the different companies can offer us.

In conclusion, it is time to take out your crystal ball! What are your future predictions for robotic surgery in urology, say 10 years from now? Is there something else we need to make robots more effective and less costly?

  1. Top of page
  2. OUR EXPERTS
  3. What is your overall opinion on the use of robots in your urological subspecialty?
  4. Let's talk more about outcomes. What has been your own experience with different outcomes after robotic or open surgery?
  5. What about the learning curve for robotic surgery? Is this no longer a relevant issue given that residents and fellows are exposed to it almost immediately in their training?
  6. Let's look at the marketing issue. Has marketing driven patients to request robotic surgery and physicians to use it? Do you have any concerns about how heavily the robot has been promoted?
  7. Right now, we have one major industry player in robotic surgery. Do you see any competition on the horizon? What will be its impact, if any?
  8. Let's talk more about costs. There have been a lot of cost analyses done with various results. What has been your experience with costs? Is robotic surgery really cost-effective?
  9. Other therapies, such as focal therapy, are gaining momentum, particularly in the treatment of prostate cancer? Do you see any of these trumping robotics in the future? What role will they play ‘in the mix’?
  10. It is an exciting time in urology with the application of single-site and natural orifice surgery? How do you see these techniques taking shape? What role will robotics play?
  11. In conclusion, it is time to take out your crystal ball! What are your future predictions for robotic surgery in urology, say 10 years from now? Is there something else we need to make robots more effective and less costly?
  12. DRUG AND TECHNOLOGY NEWS
  13. Clinical Trial
  14. In this issue…

Pruthi: Using the current platform, we are able to apply robotics to more and more different operations. Urinary diversion is the next step. As the new technological advances happen with prostate cancer, bladder cancer will become the secondary beneficiary. I look forward to innovations in single-port surgery. I love the idea of having an imaging-interface. Can we use imaging as we operate in some way? Robotics is like the pilot of an airplane. When the pilot looks out, he has all this instrumentation in front of him.

Maybe we can begin to add that sort of information to what we already envision, seeing not just the surface of the bladder but also within it.

Herman: Robotic surgical simulators are still in their infancy. At Cornell, we recently acquired the RoSS® robotic surgical simulator, which is consistent with the platform currently in use. The hope is to reduce the learning curve. We will be moving along the lines of what airlines are doing. More and more, the medical field is walking this pathway of check lists, etc. Simulation is a huge component of pilot training. There are a lot of efforts going into this because the airline industry has been very successful at creating a safe environment. In the medical field, we are not there yet.

Patel: I would like to see robots tailor-made for different specialties. One robot does not fit all. Other specialties and different procedures would have different kinds of robots. Smaller and miniature robots are also needed. Imaging guidance would be very nice. If you can see where these tumours are, you can choose an alternative approach.

Lotan: I think 10 years down the road we are still going to be dominated by one vendor. I have a hard time seeing any other vendor coming in to compete. One reason is the pervasiveness of the robot currently available. Let's say that a new competitor's robot costs $200,000. You already have a $2 million robot that you are still paying off. If you want the newer, cheaper one, your hospital is going to say you are crazy. We already bought this thing! Plus, everyone will have to retrain on the new robot.

Think about a new robot company that comes out. They are not going to be able to sell just a few robots because they have to recoup their development costs. Maybe there will be a company that comes out in China or India and sells 100 cheaper robots there, where they sell $8,000 cars. No one sells $8,000 cars in the USA. But, they do in China and India. The company can't enter the American market with this robot but maybe can go elsewhere and sell 500–1000 robots in one country. I just don't think they would impact the USA market.

I'm worried the robot will become a perk in the USA. The day Medicare gets cuts and caps are placed on treating localized prostate cancer, you can start imagining a whole lot of Pandora's boxes opening. Everyone will be fighting. There will be ‘blood on the floor’.

IMPORTANT PAPERS YOU MAY HAVE MISSED…

JOURNAL WATCH

  • inline imageElevated fracture risk for men with prostate cancer. Melton LJ 3rd, Lieber MM, Atkinson EJ, et al. Fracture risk in men with prostate cancer: A population-based study. J Bone Miner Res 2011; 26: 1808–1
  • Giant condyloma acuminatum of the scrotum in a man with AIDS. Nthumba PM, Ngure P, Nyoro P. Giant condyloma acuminatum of the scrotum in a man with AIDS: a case report. J Med Case Reports 2011; 5: 272
  • inline imageSevere lactic acidosis in a patient with metastatic prostate cancer. Munoz J, Khushman M, Hanbali A, Stoltenberg M. Severe lactic acidosis in a patient with metastatic prostate cancer. J Cancer Res Ther 2011; 7: 201–2
  • inline imagePatupilone reduces symptoms in patients with metastatic castration-resistant prostate cancer previously treated with docetaxel Chi KN, Beardsley E, Eigl BJ et al. A phase 2 study of patupilone in patients with metastatic castration-resistant prostate cancer previously treated with docetaxel: Canadian Urologic Oncology Group study P07a. Ann Oncology 2011[Epub ahead of print]. DOI: 10.1093/annonc/mdr336
  • inline imageSimvastatin has no effect on penile erection Mastalir ET, Carvalhal GF, Portal VL. The effect of simvastatin in penile erection: a randomized, double-blind, placebo-controlled clinical trial (Simvastatin treatment for erectile dysfunction-STED TRIAL). Int J Impot Res 2011[Epub ahead of print]. DOI: 10.1038/ijir.2011.33.

DRUG AND TECHNOLOGY NEWS

  1. Top of page
  2. OUR EXPERTS
  3. What is your overall opinion on the use of robots in your urological subspecialty?
  4. Let's talk more about outcomes. What has been your own experience with different outcomes after robotic or open surgery?
  5. What about the learning curve for robotic surgery? Is this no longer a relevant issue given that residents and fellows are exposed to it almost immediately in their training?
  6. Let's look at the marketing issue. Has marketing driven patients to request robotic surgery and physicians to use it? Do you have any concerns about how heavily the robot has been promoted?
  7. Right now, we have one major industry player in robotic surgery. Do you see any competition on the horizon? What will be its impact, if any?
  8. Let's talk more about costs. There have been a lot of cost analyses done with various results. What has been your experience with costs? Is robotic surgery really cost-effective?
  9. Other therapies, such as focal therapy, are gaining momentum, particularly in the treatment of prostate cancer? Do you see any of these trumping robotics in the future? What role will they play ‘in the mix’?
  10. It is an exciting time in urology with the application of single-site and natural orifice surgery? How do you see these techniques taking shape? What role will robotics play?
  11. In conclusion, it is time to take out your crystal ball! What are your future predictions for robotic surgery in urology, say 10 years from now? Is there something else we need to make robots more effective and less costly?
  12. DRUG AND TECHNOLOGY NEWS
  13. Clinical Trial
  14. In this issue…

••••PEOPLE AND PLACES••••

CANCER WARNINGS ADDED TO REDUCTASE INHIBITOR LABELS IN THE USA

Based on results from prostate cancer prevention studies, the Food and Drug Administration (FDA) has made labelling changes for all 5a-reductase inhibitors (5-ARI), including dutasteride and finasteride. Labels will now warn providers about an increased risk of high-grade prostate cancer in patients being treated with these drugs. Back in December, 2010, the FDA Oncologic Drugs Advisory Committee recommended against approval of a prevention indication for 5-ARIs based on results from the Prostate Cancer Prevention Trial (PCPT) and the Reduction by Dutasteride of Prostate Cancer Events (REDUCE).

More information about the labelling changes can be found at http://www.fda.gov/.

MOBILE APPLICATION HELPS CANCER PATIENTS PRESERVE FERTILITY

A multimedia suite of resources are now available to help young adults and the parents of children diagnosed with cancer with preserving fertility before and during cancer treatment. Called ‘SaveMyFertility’, the educational programme is offered by The Hormone Foundation, part of The Endocrine Society. It was developed in conjunction with the Oncofertility Consortium at Northwestern University in Chicago, IL, USA.

The print aspect is a pocket guide series for providers to give to patients and parents. It outlines treatment options and talking points for better communication with their doctors. There is also a website http://www.SaveMyFertility.org featuring downloadable versions of the pocket guides and four patient fact sheets.

inline image Finally, a mobile application, available from the Apple App Store, is designed for physicians to download the pocket guides and e-mail fact sheets directly to patients. All resources are available in English and Spanish versions.

inline image Michael Herman, MD, recently joined the faculty at Weill Cornell Medical College/New York-Presbyterian Hospital in New York City, NY, as an instructor in urology with a special interest in robotic simulation training.

Christopher Kane, MD, is the inaugural holder of the $2.5 million C. Lowell and JoEllen Parsons Endowed Chair in Urology at the University of California San Diego Health System. A specialist in prostate cancer and RCC, Dr Kane also serves as Professor of Surgery and Chief of the Division of Urology. The Endowed Chair honours Dr Parsons, a world expert in interstitial cystitis, whose work led to the discovery of Elmiron®.

inline image Richard K. Lee, MD, MBA has been appointed as Assistant Professor of Urology also at Weill Cornell Medical College/New York-Presbyterian Hospital. In addition to his residency, Dr Lee completed his fellowship there.

inline image Shahrokh F. Shariat, MD, has been promoted to Associate Professor of both Urology and Medical Oncology also at Weill Cornell Medical College/New York Presbyterian Hospital.

Clinical Trial

  1. Top of page
  2. OUR EXPERTS
  3. What is your overall opinion on the use of robots in your urological subspecialty?
  4. Let's talk more about outcomes. What has been your own experience with different outcomes after robotic or open surgery?
  5. What about the learning curve for robotic surgery? Is this no longer a relevant issue given that residents and fellows are exposed to it almost immediately in their training?
  6. Let's look at the marketing issue. Has marketing driven patients to request robotic surgery and physicians to use it? Do you have any concerns about how heavily the robot has been promoted?
  7. Right now, we have one major industry player in robotic surgery. Do you see any competition on the horizon? What will be its impact, if any?
  8. Let's talk more about costs. There have been a lot of cost analyses done with various results. What has been your experience with costs? Is robotic surgery really cost-effective?
  9. Other therapies, such as focal therapy, are gaining momentum, particularly in the treatment of prostate cancer? Do you see any of these trumping robotics in the future? What role will they play ‘in the mix’?
  10. It is an exciting time in urology with the application of single-site and natural orifice surgery? How do you see these techniques taking shape? What role will robotics play?
  11. In conclusion, it is time to take out your crystal ball! What are your future predictions for robotic surgery in urology, say 10 years from now? Is there something else we need to make robots more effective and less costly?
  12. DRUG AND TECHNOLOGY NEWS
  13. Clinical Trial
  14. In this issue…

CORTICOSTEROIDS FOR CHILDREN WITH FEBRILE URINARY TRACT INFECTIONS (STARRS)

PROTOCOL ID NCT01391793

SUMMARY This randomized, double-blind, placebo-controlled trial will determine the efficacy of dexamethasone on renal scarring 6 months after a first febrile UTI. The trial is based on the premise that inflammatory response is the last and most important step in the formation of renal scars. Previous animal studies have shown that corticosteroids are effective in preventing post-pyelonephritic scarring. Participants will receive 0.15 mg/kg of dexamethasone twice-daily for 3 days or a placebo. In addition, all participants will receive antibiotics.

ELIGIBILITY Those eligible for enrolment are males or females ages 0.25–6 years. Inclusion criteria are the evidence of pyuria and a fever of at least 38.33 °C (101 °F) within 24h of diagnosis. The study is expected to enrol 390 subjects.

LOCATIONS AND CONTACTS There will be four sites at children's hospitals located in Columbus, OH; Madison, WI; Pittsburgh, PA; and Washington, DC, USA. Contact Nader Shaikh, MD at (412) 692-8111, e-mail: nader.shaikh@chp.edu/

  • Want to share some drug, technology or research news?
  • Know of a new clinical trial recruiting patients?
  • Changing positions?
  • Won an award?
  • Landed a grant?
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We want to know about it!

email Kevin D. Blanchet. kblanchet@roadrunner.com

In this issue…

  1. Top of page
  2. OUR EXPERTS
  3. What is your overall opinion on the use of robots in your urological subspecialty?
  4. Let's talk more about outcomes. What has been your own experience with different outcomes after robotic or open surgery?
  5. What about the learning curve for robotic surgery? Is this no longer a relevant issue given that residents and fellows are exposed to it almost immediately in their training?
  6. Let's look at the marketing issue. Has marketing driven patients to request robotic surgery and physicians to use it? Do you have any concerns about how heavily the robot has been promoted?
  7. Right now, we have one major industry player in robotic surgery. Do you see any competition on the horizon? What will be its impact, if any?
  8. Let's talk more about costs. There have been a lot of cost analyses done with various results. What has been your experience with costs? Is robotic surgery really cost-effective?
  9. Other therapies, such as focal therapy, are gaining momentum, particularly in the treatment of prostate cancer? Do you see any of these trumping robotics in the future? What role will they play ‘in the mix’?
  10. It is an exciting time in urology with the application of single-site and natural orifice surgery? How do you see these techniques taking shape? What role will robotics play?
  11. In conclusion, it is time to take out your crystal ball! What are your future predictions for robotic surgery in urology, say 10 years from now? Is there something else we need to make robots more effective and less costly?
  12. DRUG AND TECHNOLOGY NEWS
  13. Clinical Trial
  14. In this issue…

Urological Oncology

RISK OF METACHRONOUS RENAL CELL CARCINOMA IS LOW AFTER SURGERY FOR ONCOCYTOMA P816

Although it is benign, renal oncocytoma is difficult to differentiate from metachronous RCC. Also, a substantial proportion of patients with multifocal renal tumours will also have RCC in addition to oncocytoma. For these reasons, surgery is indicated. After surgery, some support renal-imaging surveillance, although there is no consensus on this. Childs et al have added a great deal to the understanding of the risk for developing RCC after surgical removal of an oncocytoma. The findings from their large cohort of 424 patients suggest that the risk of developing metachronous RCC after surgery is low. With this risk similar to that of the general population, less aggressive radiological surveillance can be conducted with ultrasonography instead of CT.

The 424 patients in this series were treated for primary renal oncocytoma between 1970 and 2007. The median follow-up for subsequent renal tumours was 7.1 years. After surgery, 17 patients (4%) went on to develop a metachronous renal tumour; the median period was 3 years. Of these, eight were oncocytomas and four were RCCs. The remaining five tumours were not resected or biopsied. In all, 11 of the 17 tumours developed after a solitary primary tumour, while five occurred after multifocal unilateral primaries. The last tumour developed after multifocal bilateral primaries. The estimated 10-year tumour-free survival rate was 94.8%. The estimated metachronous renal tumour-free survival rate was 98.7% at 10 years. When a metachronous renal neoplasm did develop in a patient with a previous oncocytoma, it was more likely to be benign compared with patients presenting with renal tumours for the first time. However, multifocal primary oncocytoma is associated with metachronous renal tumours.

Reconstructive and Paediatric Urology

PELVIC OSTEOTOMY HELPS ADULT FEMALES WITH EXSTROPHY P908

There is no question that the management of classical bladder exstrophy in adolescent and adult females is complex. These patients undergo multiple failed closures in early childhood, recurrent pelvic organ prolapses, and significant diastasis of their pubic bones, among other conditions. Osteotomy and pubic approximation may set the stage for better restoration of pelvic floor anatomy. In turn, the patient has less risk of developing a bladder and uterine/vaginal prolapse. Gandhi et al report on their experience with pelvic osteotomy in six patients, including three who had undergone prior uterine suspension. Their findings suggest that the technique is a valuable addition to pelvic floor reconstruction in young women of childbearing age.

The six women all had uterine/vaginal prolapse. In addition, they were concerned and self-conscious of abdominal wall scarring from their failed closures in early childhood. One patient had five previous attempts at suspension; all had failed. External genitalia were also unattractive. Using an anterior approach, bilateral innominate (transverse) and vertical iliac osteotomies were performed with placement of an external fixator. During 2–3 weeks, cranking of the fixator and pelvic bones was done until a diastasis of < 4 cm was achieved. Next, sacrocolpopexy was performed with revision of the abdominal wall. Revision genitoplasty was also done on four patients. There was also placement of an intrasymphyseal titanium plate.

Two patients had transient femoral nerve palsy. Another patient had foot drop secondary to sciatic nerve stretch; however, this resolved with time. Three patients required the removal of the symphyseal plate due to pain, discharge, and erosion into the anterior wall of the vagina. After a mean follow-up of 60.7 months, all six patients reported being satisfied with the functional and cosmetic outcomes of their abdominal wall reconstruction and genitoplasty. At present, five of the six patients are sexually active but there are no pregnancies. In addition, there have been no prolapse recurrences.

Upper Urinary Tract

MINIPERC OFFERS ADVANTAGES OVER PERCUTANEOUS NEPHROLITHOTOMY FOR NONBULKY STONES P896

The ‘mini-perc’ technique refers to performing a percutaneous nephrolithotomy (PNL) through a sheath too small to accommodate a standard rigid nephroscope. Instruments used during mini-perc procedures have shaft calibers of 12–20 F. In their study, Mishra et al compare the miniperc technique to PNL in the treatment of renal stones of 1–2 cm. While stone-free rates and complications were similar with both approaches, the miniperc procedure offers several significant advantages to the patient.

Their study included 27 procedures done by miniperc and 28 performed with standard PNL. All of the procedures were performed by one surgeon. The miniperc used the holmium laser as the energy source; PNL utilized a pneumatic lithotripter.

Operative time was longer for the miniperc procedure, taking an average of 45.2 min. The PNL was done in 31 min. However, several advantages were found for the miniperc technique. Patients had significantly reduced haemoglobin drops with miniperc (0.8 gram%) compared with PNL patients (1.3 gram%). Those undergoing the miniperc also had less need for analgesics. Hospital stays were also shorter, 3.2 days for the miniperc vs 4.8 days for PNL. None of the miniperc patients required a blood transfusion, whereas one in the PNL group did. As a result of significantly less bleeding, miniperc ended more frequently in a tubeless procedure. Complete stone clearance rates were 96% for the miniperc and 100% for the PNL.