Robotic assisted laparoscopic procedures are gaining in popularity throughout the US for complicated procedures such as hysterectomy. With any new procedure, dedicated investigators conduct evaluations to determine whether it is an improvement over the traditional approach. Researchers affiliated with Columbia University (New York, New York) conducted a study to evaluate the about the incorporation of the procedure into practice, its complication profile, or its costs compared with other routes of hysterectomy. They published their findings on February 20 in the Journal of the American Medical Association (JAMA).
The researchers note that a hysterectomy for benign gynecologic disease (i.e., fibroid tumors and bleeding problems) is one of the most commonly performed procedures for women. Overall, 1 in 9 women in the United States will undergo the procedure during her lifetime. While hysterectomy has traditionally been performed abdominally via laparotomy, vaginally, or by laparoscopy, robotically assisted hysterectomy has been introduced as an alternative minimally invasive approach to hysterectomy. Potential benefits of robotic surgery include increased range of motion with the instrumentation, 3-dimensional stereoscopic visualization, and improved ergonomics for the operating surgeon; instead of hunching over an operating table, the surgeon sits comfortably at a console and the robot in making fine, precise motions that are viewed under magnification.
The objectives of the study were too analyze the uptake of robotically assisted hysterectomy, to determine the association between use of robotic surgery and rates of abdominal and laparoscopic hysterectomy, and to compare the in-house complications of robotically assisted hysterectomy vs. abdominal and laparoscopic procedures.
The study group comprised 264,758 women who underwent hysterectomy for benign gynecologic disorders at 441 hospitals across the United States from 2007 to 2010. The main outcome measures were the uptake of and factors associated with utilization of robotically assisted hysterectomy. Complications, transfusion, reoperation, length of stay, death, and cost for women who underwent robotic hysterectomy compared with both abdominal and laparoscopic procedures were analyzed.
The researchers found that the use of robotically assisted hysterectomy increased from 0.5% in 2007 to 9.5% of all hysterectomies in 2010. During the same time period, laparoscopic hysterectomy rates increased from 24.3% to 30.5%. Three years after the first robotic procedure at hospitals where robotically assisted hysterectomy was performed, robotically assisted hysterectomy accounted for 22.4% of all hysterectomies. The rates of abdominal hysterectomy decreased both in hospitals where robotic-assisted hysterectomy was performed as well as in those where it was not performed. The researchers found that the overall complication rates were similar for robotic-assisted and laparoscopic hysterectomy (5.5% vs. 5.3%). Although patients who underwent a robotic-assisted hysterectomy were less likely to have a length of stay longer than two days (19.6% vs. 24.9%), transfusion requirements (1.4% vs. 1.8%) ,and the rate of discharge to a nursing facility (0.2% vs. 0.3%) were similar. Total costs associated with robotically assisted hysterectomy were $2,189 more per case than for laparoscopic hysterectomy.
The authors concluded that between 2007 and 2010, the use of robotically assisted hysterectomy for benign gynecologic disorders increased substantially. Robotically assisted and laparoscopic hysterectomy had similar morbidity profiles; however, the use of robotic technology resulted in substantially more costs.
Take home message:
Last year, I interviewed Oliver Dorigo, MD, PhD, an assistant professor of gynecology at the UCLA David Geffen School of Medicine, Department of Obstetrics and Gynecology. Dr. Dorigo is passionate about the procedure and has performed many complicated cancer surgeries, including radical hysterectomies for cancer, with robotic assistance. The magnification and ability to make precise movements has allowed him to carefully inspect and remove cancerous tissue. The question becomes should robotic assisted surgery be the method of choice for all hysterectomies? At present, the answer is no. In my opinion, the procedure of choice for selected patients is a vaginal hysterectomy. The candidate for this approach is a woman who has delivered children vaginally, does not have a significantly enlarged uterus, and does not have adhesions (scar tissue from infection, endometriosis or prior surgery. If nothing untoward occurs, the procedure can be accomplished in as 15 minutes. It does not require any abdominal incisions (laparoscopic surgery requires several small incisions) and recovery is usually rapid with a short hospital stay.