Behind the Knife, the Surgery Podcast, relevant and engaging content designed to help you dominate the day.

Hey everyone, it's great to be back with you on Behind the Knife with the Minimum Ace of Surgery team from the University of Washington.

I'm Mike Wykamp and as usual, I'm joined by Doctors Nicole White, Nick Citrulo and Andrew Wright for our third general review podcast.

For today's episode, we're going to do a deeper dive into a topic that we just scratched the surface of in our first general review podcast, the Cost of Robotic Surgery.

To frame this conversation, we're going to discuss a 2021 British Journal of Surgery article entitled, Clinical Outcomes and Cost of Robotic Ventual Hurnier Repair, A Systematic Review, by Dr. Linda Yee and her colleagues.

Dr. White, would you mind walking our listeners through how this review was done?

Of course. Dr. Yee and her colleagues performed a thorough review of the contemporary literature pertaining to Robotic Ventual Hurnier Repair and Cost, focusing on studies that included a direct comparison to either open Ventual Hurnier Repair, laparoscopic Ventual Hurnier Repair or both.

The review yielded almost 3,600 articles, which were evaluated using the Prisma guidelines for systemic reviews and after screening content by title and abstract and excluding things like case series, studies with overlapping patient populations, studies that did not contain a comparison to laparoscopic or open surgery.

The authors were left with 25 articles to be included in their review.

Of these 22 were observational studies and three were randomized control trials, all of which contain cost comparisons between Robotic and either open or laparoscopic Ventual Hurnier Repair, some of which also contain clinical outcomes comparisons.

Amongst the 22 observational studies, the review team also delineated between those that used propensity score matching and those that did not.

As a part of their evaluation, the authors also performed rigorous assessments of each included articles risk of bias using the Cochrane Risk of Bias tool for RCTs and the Robins One system for observational trials.

The detailed results of these bias assessments are a little outside the focus of our discussion today except to say that they were performed, which demonstrated a wide range of susceptibility to sources of bias and extent of bias.

However, of note as part of this process, one of the three randomized control trials was deemed to be an unacceptable high risk of bias and was therefore excluded from their final analysis.

If I can make a note about bias, there's a lot of emerging literature on conflict of interest.

I think it's important that having an interaction with industry isn't necessarily a bad thing and as surgeons we need to work with industry to advance our field.

And I almost think it's important that the RCT that was excluded from this paper due to bias wasn't excluded due to industry conflict of interest but instead due to methodological limitations of this study.

So it was a methodologic problem rather than a conflict of interest problem.

That said, there is evidence that papers of undisclosed conflict of interest tend to show results that favor the company or the industry that's involved.

And also that the surgical literature is rife with undisclosed interest, undisclosed conflict of interest.

So I think we just have to be careful when we're looking at papers to see who is publishing them and what sort of industry relations they might have.

Thanks, Dr. Ray. Dr. Sturlow, can you bring us through what the authors found as far as their clinical outcomes before we dive into the cost analysis?

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