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

In reply:

A recently published randomised controlled trial (RCT) of robotic and open prostatectomy1 reported that these two surgical techniques yielded similar functional outcomes at the early time point of 12 weeks. The widespread adoption of robotic prostatectomy illustrates uncritical acceptance of innovations in the belief that they are better than conventional approaches, with implications for patients and health care providers.

This long awaited publication led to critical responses questioning the relevance of RCTs in surgery. Apart from disappointing when made by opinion leaders, such statements contradict the quest for the evidence-based truths we all purport to seek. Ideally, all major innovations should be scrutinised through RCTs before acceptance by the medical profession and the public, but technological change is rapid and, therefore, discretion has to be exercised in selecting what warrants in-depth evaluation undertaken completely independent of the industry.

In the case of the robot, there has been a proliferation of surgeons doing robotic prostatectomies, with many not having undergone dedicated training. There is an accepted steep learning curve with robotic surgery2 — although experts do not agree over the numbers required3 for competency — together with the need to maintain expertise. Oberlin and colleagues4 reported that in a 6-month period in the United States, a median of only eight prostatectomies were performed, with 41% of them undertaken by highest volume robotic surgeons. There are indications that the circumstances are no different in Australia. This is relevant as best results are achieved by high volume surgeons working in high throughput units,5 indicating that there is no imperative for high volume open surgeons who obtain good results to transition to the robotic platform.

At present, trainee urologists are exposed to a dearth of open surgery and, as a number of them are destined to work peripherally where open skills are required, this will have an inevitable effect on manpower provision. Urologists are well aware of this situation and are documenting contemporary practice patterns centrally via cancer and other registries, so that objective information is available for planning present and future health care agendas. It remains critical that patients from regional areas, or those being treated in institutions that do not provide robotic prostatectomy, are reassured that they are still obtaining best practice.