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Hospitals with Surgical Robots More Likely to Perform "Nephron-Sparing" Partial Nephrectomy

Hospitals with robotic surgical systems are more likely to perform "nephron-sparing" partial nephrectomy--a recommended alternative to removal of the entire kidney--in patients with kidney cancer, reports a study in the December issue of Medical Care. The journal is published by Lippincott Williams & Wilkins, a part of Wolters Kluwer Health.

"Hospital acquisition of the surgical robot is associated with greater proportion of partial nephrectomy, an underutilized, guideline-encouraged procedure," write Dr Ganesh Sivarajan of New York University Langone Medical Center and colleagues. Their study suggests an unexpected benefit of surgical robots--a costly technology that has been criticized for rapid adoption without evidence of patient benefit.

Surgical Robots Affect Partial Nephrectomy Rate

The standard treatment for kidney cancer has been radical nephrectomy: removal of the entire kidney. But in recent years, partial nephrectomy--surgery to remove the cancer, while preserving as much functioning kidney as possible--has been recommended.

This "nephron-sparing" approach is just as effective in controlling the kidney cancer, but with lower long-term rates of cardiovascular disease, kidney failure, and death. Partial nephrectomy is a technically challenging and "under-utilized" procedure; most patients still undergo total nephrectomy.

Dr Sivarajan and colleagues examined whether acquisition of the surgical robot, which affords surgeons improved magnification and manual dexterity, led to increased use of partial nephrectomy. Using linked nationwide databases, they identified more than 21,500 patients in seven states who underwent surgery for kidney cancer in 2001, 2005, or 2008.

They found that hospitals with surgical robots performed more partial nephrectomies. For hospitals that acquired a robot between 2001 and 2004, the number of partial nephrectomies increased by 30 percent in 2005, and 35 percent in 2008. For hospitals acquiring a robot between 2005 and 2008, the increase was smaller (15.5 percent) but still significant.

'Early Adopters' of New Technologies May Find Unexpected Benefits

Surgical robots were approved for use in prostate cancer surgery in 2001, and their use has expanded rapidly since then. There has been criticism about the high use and costs of robot-assisted surgery, in the absence of data showing that it improves prostate cancer outcomes.

Meanwhile, robots are being used for many different types of surgical procedures, despite a lack of evidence showing benefit to patient care. Regional-level studies have suggested that the availability of surgical robots has led to increased use partial nephrectomy.

The new study shows a similar pattern nationwide, with hospitals performing more partial nephrectomies in the years after acquiring a surgical robot. The association is significant even considering the background trend: a gradual increase in nephron-sparing surgery.

Dr Sivarajan and colleagues believe their study has implications for the adoption of new medical technology. They write, "The unexpected benefits of surgical robot acquisition on the management of renal tumors are an example of 're-invention' or the manner in which a new innovation is altered in the process of its adoption and implementation after its initial development."

The greatest increases in partial nephrectomy occurred among the "earliest adopters"--suggesting that even if the benefits aren't immediately apparent, "[T]here might be some benefit to ensuring access to new technology for select institutions." Dr Sivarajan and colleagues add, "While much research and data are clearly necessary prior to widespread adoption, policy mechanisms... should remain in place to encourage some degree of limited technology adoption, even if the technology may not immediately appear cost-effective."


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