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Urology Ethics Social determinants of health Health services administration
Volume 207 - Issue 2

Robotic prostatectomy took off, despite a lack of evidence and risks of inequity

Authors:  Katrina Hutchison, Drew Carter and Jane Johnson

Med J Aust 2017; 207 (2): 89-90. || doi: 10.5694/mja16.00916
Published online: 17 July 2017
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Editor’s note:
The Lancet recently published an important Australian randomised controlled trial of robotic and open prostatectomy. We publish the following non-commissioned correspondence by Hutchison and colleagues together with an invited response from the corresponding author of the trial, Robert Gardiner, because of the relevance of the debate to Australian health care.

To the Editor:

Robotic prostatectomy took off quickly, despite the cost. In Australia, most prostatectomies are now done with a robot that costs almost $10 000 in capital and maintenance per procedure, or between $442 and $3548 more than an open prostatectomy.1 The robotic option was meant to reduce side effects relating to impotence and incontinence; however, preliminary findings from the world’s first randomised controlled trial suggest that this is not the case.2

Uptake of innovative surgery tends to outpace evidence because it is hard to design and run randomised studies. In addition, placebo surgery is rare and controversial, and recruitment is challenging, as surgeons and patients often prefer one option. Trial results may also be difficult to interpret: if the same surgeon performs both operations, they may be better at one; or if different surgeons operate, one may be superior.3 Australia is not immune to these challenges, despite local initiatives to improve quality of care4 and evaluate the benefits of the robotic procedure.5

The industry understands this. Intuitive Surgical aggressively marketed its robot while the jury was still out on its comparative benefits. Celebrity stories have also driven demand; for instance, radio personality Alan Jones has been an outspoken advocate.6

But even when evidence commends a surgical innovation, introducing it to the public health care system may create or exacerbate inequity.

Suppose that the robot, or some successor, eventually proves superior to alternatives. Expensive equipment and difficult procedures require high patient throughput to justify the costs and maintain surgeons’ skills, so they tend to be concentrated in the biggest, busiest hospitals. Therefore, patients in regional areas are often expected to travel for treatment, with little or no financial support; and the barrier is even higher for people who do not have the social and economic resources to get themselves to a big city hospital.7

We should resist the hype of a new technology and wait for good evidence before expending scarce health care dollars. This will sometimes mean lagging behind other countries and saying no to patients. However, it will also mean safeguarding patients and the public purse from innovations that turn out to be no better, or maybe worse, than existing options. Moreover, when a new technology is introduced, we should also fund the supports that people need to access it.

Authors

  • Katrina Hutchison1
  • Drew Carter2
  • Jane Johnson1
  • 1. Macquarie University, Sydney, NSW
  • 2. University of Adelaide, Adelaide, SA

Correspondence: katrina.hutchison@mq.edu.au

Competing interests

Jane Johnson was one of the chief investigators on a linkage grant from the Australian Research Council (LP110200217), with linkage partner organisations Bellberry Ltd, Western Sydney Local Health District, Houston-Thomson, the Royal Australasian College of Surgeons and the University of Otago. Katrina Hutchison was a post-doctoral researcher on the grant-funded project, but was not one of the grant recipients.

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