Robotic surgery - time to reassess?

5 Mar 2010

Robotic surgery for prostate cancer has taken off to the dismay of those stuffy academics who think randomised trials are the only gateway to acceptance of novel treatments. But overjoyed and disbelieving urologists are laughing all the way to their banks. Can you really earn 100,000 dollars a week, just doing a bit of Play Station on a few dozen willing (or gullible?) well heeled men? Apparently so. Without a randomised trial in sight? So why do we do trials if it’s that easy? Well JAMA must have got it wrong, as there must be randomised trials going on somewhere. Urologists please update us (and JAMA).

JAMA have just published a non randomised comparison (presumably they couldn’t find a randomised one) which described the complications associated with conventional open access prostate surgery with the modish robotic approach. The obvious advantages of the latter are in the immediate post operative period, with less blood loss, infections and time in hospital. What is however staggering is the claim that late complications are seriously tilted in the opposite direction! Many more instances of urinary incontinence and erectile dysfunction. What seems to be more remarkable than the lack of serious scrutiny of a new treatment, though one wonders if the obsessional attention to new drugs might be directed also to appliances, is the commentary from JAMA to the effect that men in higher socioeconomic groups seem to have fallen for the sales pitch of the techie people! 

No questions asked, apart perhaps “How long am I off work?”. Can men be so much more naive than women whom one couldn't imagine accepting such a pitch without evidence. Think for a moment how slowly partial surgery for breast cancer has replaced the mutilation of mastectomy. Umberto Veronesi (who co-founded ecancer with me) published the first ever randomised trial comparing the two, a quarter of a century ago, and still some patients, and sadly some doctors too, have their doubts. How long will the follow up of his trial on intraoperative radiotherapy versus six weeks of post op external beam irradiation need to be before women start demanding ELIOT machines in every operating room (that’s assuming that the two treatments are equivalent, which we don/t yet know for sure)?

We know that men are more ignorant about health matters than women, we suspect that they may believe in their invincibility, and we know now that they will jump at a gimmicky new tool without demanding evidence that it is better than standard treatment, (think iPhone!). It would be interesting to poll male and female doctors on the issue. And where are the voices of the radiation oncologists in the debate, now that their sophisticated image based targeted radiation treatment for prostate cancer is proving superior to standard regimes, proving in randomised trials, that is? One law for the surgical urologists, another for other ranks?