Laparoscopic Sacrocolpopexy vs Robotic Sacrocolpopexy

Transcription

1 Laparoscopic Sacrocolpopexy vs Robotic Sacrocolpopexy Magnus Murphy FRCSC Clinical Assistant Professor Department of Obstetrics and Gynecology University of Calgary Division of Urogynecology

2 Where To The Robot? He s coming for YOUR job But not just yet..

3 Claims: Surgeons More surgeons can perform complex procedures Easier to learn Superior visualization Enhanced dexterity Greater precision and ergonomic comfort

4 Claims: Patients Less pain Less blood loss fewer transfusions Shorter hospital stay Quicker recovery Faster return to normal activity More access to minimally invasive procedures

5 History FDA cleared: 2000 Approved for Gynecological surgery: 2005 Process was similar to mesh kit introduction: premarket notification approved on similarity with already approved products. There were only 2 people in FDA office approving surgical devices Lawsuits have started (Mesh déjà vu) Complications (stray currents etc) Doctors not trained in minimally invasive surgery are using it

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9 Intuitive Surgical

10 Great Business- Absolutely; Great Medicine not yet Total value on June 10: $216,789,918.00

11 Popularity Contest Easier to learn Shorter learning curve Enable more complex procedures Prestige Technophiles love it Hospitals competing: Sexy and attractive campaigns Physician ergonomics

12 Power Of Marketing

13 Literature review Up to end of 2013 LCS and RCS with at least 12 mo fu 256 articles screened 69 selected and reviewed LCS: 1221 patients Mean OR time 124 min (55-185). Conversion 0-11% Cure: Objective 91%; Subjective 92% RCS: Mean OR 202 ( ). Conversion 0-4% Cure: Objective 94% Subjective 95% Main Finding: No benefit of RCS over LCS Lee, Richard K., Alexandre Mottrie, Christopher K. Payne, and David Waltregny. A Review of the Current Status of Laparoscopic and Robot-Assisted Sacrocolpopexy for Pelvic Organ Prolapse. European Urology 65, no. 6 (June 2014):

14 Robo Problems in General Gynecology Cuff dehiscence? Electrocautery technique Power morcellation issues Credentialling issues Expensive machine must work; shortcuts No evidence of improved outcomes for general gynecology (hyst etc), except decrease of abdo surgery (but also decrease in vag surg)

15 Laparoscopic SCP First reported by Dr. Nezhat et al in 1994 Not gained widespread adoptation Difficulty with laparoscopic suturing RCP gained fast acceptance

16 LSCP vs RSCP Paraiso et al Robot much more expensive: $ per case more on average No difference in anatomical outcome or quality of life outcomes RSCP OR time significantly longer Post op pain worse in RSCP group Paraiso, Marie Fidela R. Robotic-Assisted Laparoscopic Surgery for Hysterectomy and Pelvic Organ Prolapse Repair. Fertility and Sterility 102, no. 4 (October 2014): Paraiso, Marie Fidela R., J. Eric Jelovsek, Anna Frick, Chi Chung Grace Chen, and Matthew D. Barber. Laparoscopic Compared with Robotic Sacrocolpopexy for Vaginal Prolapse: A Randomized Controlled Trial. Obstetrics and Gynecology 118, no. 5 (November 2011):

17 Continued: Possible benefit: Increased uptake of MIS surgery and decrease of open surgery HOWEVER: mainly because of decreased vaginal surgery

18 Confirmation Same results confirmed by other studies Nosti et al (2014) large retrospective cohort (ASC vs MISC) No difference in anatomical failure between LSC and RSC Both MIS options had far fewer complications than ASC No difference in failure between ASC and MISC Nosti, Patrick A., Uduak Umoh Andy, Sarah Kane, Dena E. White, Heidi S. Harvie, Lior Lowenstein, and Robert E. Gutman. Outcomes of Abdominal and Minimally Invasive Sacrocolpopexy: A Retrospective Cohort Study. Female Pelvic Medicine & Reconstructive Surgery 20, no. 1 (February 2014): 33 37

19 Lagging behind Gynecological Oncology held in high regard why? Worldwide seen as recognized subspecialty Intensive surgical training No shortcuts Robot is a tool in the hand of an expert, not a crutch to save the mediocre Urogynecology Subspecialty status variable. Embarrassed ourselves with mesh disaster Free-for-all expansion of pelvic floor surgeons was huge mistake Risk of robot becoming a crutch, to hide deficiencies

20 The Only Proven Benefit

21 Thank You CUMMING SCHOOL OF MEDICINE