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Robotic surgery is unnecessary in the developing world

Costly robot-assisted surgery is not viable in the developing world considering that there is no convincing data on the superiority of these expensive robot technologies, says a UK-based expert.

During the joint EAU- Société Internationale d’Urologie (SIU) session, part of the Urology Beyond Europe programme, experts clashed on the perceived importance of robot-assisted surgeries particularly in prostate disease.

“Strive to become a better surgeon, particularly if you are in the developing world. Stop obsessing about technology… There are no differences in outcomes,” said Prof. Prokar Dasgupta (GB). “Only 5% of operations are robotic. The cost of robot-assisted procedures rose by 13% in three years, resulting in around $2.5 billion in additional healthcare costs. The robot is an unnecessary luxury in the developing world.”

Dasgupta rebutted the arguments of Dr. Sudhir Rawal (IN) noting that a centre needs to perform over 100 cases of robot-assisted surgery in order for it to be cost-effective. He also examined the issue of a shorter hospital stay, stating that hospital stay depends on the country where the patient lives.

“It has nothing to do with the surgery,” said Dasgupta, adding“a fool with a tool is still a fool.”

Conversely, Rawal anchored his arguments within the context of the Indian experience where he said there is a clear need for a more efficient alternative to open and laparoscopic approaches. He noted that there are opportunities to save money with robotic surgeries, and mentioned that robotic procedures in India are much less expensive when compared, for instance, with the United States. He also insisted that there are clear benefits in terms of blood loss, warm ischemia time, and a shorter learning curve for surgeons compared to laparoscopy.

The session also covered some other key controversies in uro-oncology. Prof. Axel Bex (NL) argued that lymphadenectomy in renal cancer is unnecessary, against the pro-statements of Dr. Frederic Pouliot (CA), whilst Profs. Shin Egawa (JP) and Fred Witjes (NL) debated the merits of metastasectomy in urothelial cancer and Profs. Peter Wiklund ( SE) and Paolo Gontero (IT) discussed the necessity of intracorporeal diversion.

Bex said the likelihood of lymph node involvement is small and the low overall rate of local recurrence does not seem to be altered by lymphadenectomy. “Between 58 to 95% of patients with lymph node involvement have distant metastases anyway,” he said, adding that metastectomy of isolated lymph node metastases is unlikely to be curative in the majority of patients.

Witjes opposed Egawa on urothelial cancer, arguing that metastasectomy is of limited use. “There is almost no role for surgery in metastatic UC, but in selected cases removal of initial or recurrent metastatic disease can increase cancer specific survival (CSS).”

The session also took up other issues in general urology such as minimally invasive techniques for Benign Prostatic Hyperplasia, the role of HOLEP, primary urethral repair after pelvic fracture, and the uses and drawbacks of social media in clinical medicine.

Prof. Declan Murphy (AU) argued against Prof. Jim Catto (GB) with the latter warning of the potential disadvantages of frequent social media use, such as loss of confidentiality, the limited understanding of complex issues that cannot be properly examined on social media platforms, and the loss of a doctor’s professional boundaries.

Article by Joel Vega