A failure of the media and surgeons – the lack of evidence based medicine to show that prostate surgery with robots is better

Modern surgery is the result of innovation in techniques, procedures and equipment. However, in the same way that drugs have to be shown to be effective e.g. allowing a cancer patient live longer, new surgical techniques need to demonstrate a clinical benefit over what they are replacing.

While randomized placebo controlled trials are not appropriate for surgery, that does not mean that evidence based medicine has no place in surgery. It is possible to conduct prospective clinical trials that compares the outcome between the “new” and the “established” surgical technique. The challenge is that surgeons may not see themselves as scientists.

At the recent European Association of Urology (EAU) meeting in Paris, Walter Artibani, Professor and Chair of Urology at the University of Verona, told the assembled media that urologists had failed as scientists in not generating robust clinical data to support the use of the da Vinci robotic system for prostate removal.

“After 10 years the urologic community missed the window to have prospective randomized clinical trial in order to have clear answers.”

What’s more he went on to say that he believed it would be unlikely we could do a prospective trial now that compared robot-assisted prostatectomy to laparascopic prostatectomy to open prostatectomy:

“Most of the patients are convinced that the new way, the novel way is the better way.”

Why are patients convinced that robotic surgery is better?

According to Professor Artibani part of that is due to how “robotic surgery” has been reported by journalists and the media:

“It is easy just to give the information that what is new is better and this must be demonstrated by robust data before giving the information. Unfortunately sensationalism is more important than to say and to write robust data.”

It is easy for the media to sensationalize the idea of robotic surgery. Physicians and hospitals are also able to effectively market and advertise the availability of innovative new medical equipment e.g. lasers, robots etc in a way that supports our bias in favor of buying new. One only has to look at car advertising and the constant focus on “this year’s new model” as somehow being better than last year’s to see how this bias becomes ingrained in our perception.

Yet the reality is that “robotic surgery” is not an automated robot performing the surgery on its own but robot assisted surgery. According to Prof. Artibani “it is an expansion of conventional laparoscopy.”

In essence, robotic surgery is a telemanipulation system where the surgeon sits at a remote console and operates a surgical cart with three or four arms that are docked with endoscopic instruments that are inserted into the patient.

While many of us may automatically associate new as meaning better, in medicine new developments need to be supported by clinical evidence to support the claims being made.

It is the responsibility of surgeons to ensure that robust evidence is obtained and that prospective clinical trials are undertaken before the standard of care is changed or new procedures are routinely offered to patients.

It is equally the responsibility of science writers and the healthcare media not to sensationalize new techniques or equipment such “robotic surgery” and to challenge surgical practice for which there is a lack of robust clinical data or evidence based medicine.

Both surgeons and healthcare media have failed in respect of robot assisted prostatectomy. Urologists failed to do prospective clinical trials and the media failed to challenge the lack of high quality clinical data in support of robot-assisted surgery for prostate removal.

According to Professor Artibani, it now appears unlikely that we will ever have level 1 evidence based medicine to show that robotic assisted prostatectomy leads to better outcomes.

Men with prostate cancer who are considering surgery do deserve better. Science writers have an important role to play in communicating information about new surgical procedures and the risks/benefits, validity of the clinical data associated with them.

A modified version of this post first appeared on Biotech Strategy Blog.