Thursday, August 15, 2013
Update on Transitioning From Open to Robotic Assisted Radical Prostatectomy
Since I first blogged on robotic surgery in July last year, it has become the predominant manner by which I perform prostate cancer surgery. I continue to offer open surgery and particularly for those who cannot afford the cost of robotic surgery - it is important to not make them feel inadequate and that there is a reasonable alternative approach available. Robotic surgery for prostate cancer is rapidly moving towards being the predominant manner by which prostate cancer surgery is being performed in Australia.
Sydney had the lowest concentration of robotic platforms per capita in any of the mainland capital cities and for many years there was only one hospital with the technology. Subsequent to a second hospital acquiring the technology and the significant marketing that followed, the dominos fell rapidly. In the space of less than two years, there are now 7 hospitals in Sydney which now gives it the highest concentration of robotic platforms in Australia. The competition for men to undergo robotic assisted radical prostatectomy has never been more palpable. Many surgeons feel they are being forced into the technology on the basis of marketing pressures rather than being able to transition into the technology on their own terms. There has been a sense of urgency for surgeons to enter into the robotics space and enthusiastically offer their services and there is this sense of urgency for surgeons to announce that they have reached a certain threshold of cases or are now the most experienced with the technology for a particular geographical part of Sydney. The tenor of competitive marketing material has lowered to include accusations of how one hospital is much more expensive than another without any factual basis to make such statements.
One surgeon's overzealous attempts to market his services went to the extremes of misleading readers of his training credentials and true level of experience. His marketing was excessive to the extreme that he has been formally counselled by his university and reprimanded by our professional body, the Urological Society of Australia and New Zealand. He has also been referred to the Royal Australasian College of Surgeons for investigation of breach of its Code of Practice and to the Australian Health Practitioners Regulatory Authority for investigation of breach of advertising regulations. Others have provided more carefully crafted glossy brochures to referring general practitioners and it is becoming increasingly common to have the addition of the term "Robotic Surgeon" to their professional stationary. I hope that I will continue to not have to resort to these measures in order to maintain my existing sub-specialised practice in prostate surgery.
I digress for just a moment to recount how a mentor of mine once told me when I started practice that the best advertising you could do was to look after your patients well. In other words, your patients would be your best advertisement. Maybe this is an old fashioned approach but for as long as this still works for me, then I will consider myself fortunate. That said, back on topic.
I feel very grateful for the fact that I have been in the position to pick and choose which patients that I felt that I could safely offer robotic surgery instead of open surgery in my hands. This enabled me to get comfortable with doing easier cases before taking on more complex cases. I am now comfortable with offering robotic assisted radical prostatectomy for all men for whom surgery is an appropriate option. I have been extremely fortunate to have undergone transitioning to this technology in an era where training tools (such as the virtual reality simulator), an established technique and surgical proctoring were so readily available to me. I am particularly grateful for my friends and colleagues Damien Bolton (Melbourne) and Peter Swindle (Brisbane) making an effort to come to Sydney to help train me without accepting any remuneration for my over and above minimum expected proctored cases.
Robotic surgery is clearly here to stay and to be fair, the advantages of less pain and quicker recovery have turned out to be more profound than what I had anticipated. It was very easy to be critical of such claims when I had no personal experience with the technology and given that I had thought that my patients undergoing open surgery were doing just fine with no need improve upon this. It has also been gratifying to see that my cancer clearance rates and recovery of continence are unchanged although I have an impression that the latter is actually better. It is too early to know for sure of my outcomes for recovery of erectile function but my impression at this early stage is that it may in fact be better. In spite of great anxiety and trepidation in making this transition, it is pleasing to report that my personal experience with adopting robotic surgery has turned out to be a particularly positive and exciting period of my surgical career. My only disappointment has been the aggressive marketing and collegial fragmentation seen in association with the rapid uptake of the technology. As one very astute GP wrote to me regarding a second opinion referral that he had sent to me: "I am concerned that the joy of a new technology and one's desire to expand their series is impacting on clinical decision making" - I sincerely hope that the race to adopt robotic surgery does not become a prostate harvesting exercise after the huge leaps forward that have been made in embracing conservative approaches such as active surveillance for those with clinically insignificant disease.