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Vaginal hysterectomy or robotic hysterectomy; which is better?

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In recent years, robotic surgical procedures have increased significantly; however, a new study assessed the cost, safety, surgery time, and hospital stay of robotic-assisted hysterectomies, abdominal hysterectomies, and vaginal hysterectomies. Researchers at the Mayo Clinic published their findings in the February edition of the journal Obstetrics & Gynecology.

The study authors note that because healthcare spending continues to increase, significant effort is currently placed on curbing costs without compromising patient care. They explain that one such effort—with the sole purpose of cost containment is the Independent Payment Advisory Board, created under the Affordable Care Act in 2010. Thus, it is expected that in gynecology, the cost of various routes of hysterectomy will likely come under scrutiny.

The investigators note that the American College of Obstetricians and Gynecologists (ACOG0 recommend that a vaginal hysterectomy is the preferable route in many instances; in addition, studies have shown that this approach is less costly than either abdominal or traditional laparoscopic procedures. They explain that advantages of the robotic approach have led healthcare practitioners to incorporate it into their practice, although several studies have shown that the robotic technique may be more expensive than either traditional laparoscopy or a laparotomy (abdominal hysterectomy). Despite the foregoing, the authors note that data on this topic are currently lacking; only two studies in the medical literature have compared inpatient costs between the two methods. Therefore, they conducted a study to assess the cost of robotic hysterectomies and compare it with abdominal and vaginal routes. Their secondary objective was to estimate the changes in cost in the presence of operative complications.

The authors reviewed all cases of robotically assisted hysterectomy, with or without bilateral salpingo-oophorectomy (removal of the fallopian tubes and ovaries) treated at the Mayo Clinic from January 1, 2007 through December 31, 2009. These robotic cases were matched on a one-to-one basis to cases of vaginal and abdominal hysterectomies, selected randomly from January 1, 2004, through December 31, 2006; this period of time preceded the acquisition of the robotic surgical system). All billed costs were determined through the sixth postoperative week from the Olmsted County Healthcare Expenditure and Utilization Database and compared. Costs of surgical complications were also estimated.

The total number of abdominal hysterectomies evaluated for comparison was 234; the total number of vaginal hysterectomies was 212. The predicted average cost of a robotically assisted hysterectomy was $2,253 higher than that of vaginal hysterectomy ($13,619 compared with $11,366); however, the costs of complications were not significantly different. The predicted average costs of robotically-assisted compared with abdominal hysterectomy were similar ($14,679 compared with $15,588). The costs of complications were not significantly different.

A comparison of the robotic and abdominal hysterectomy groups found that intraoperative complications were significantly more frequent with an abdominal hysterectomy; however, the occurrence of postoperative complications and uterine weight did not differ between the groups. Length of hospitalization was shorter (1.6 vs. 3.4 days) and operative time was longer (3.0 vs. 1.8 hours) for the robotic group compared with the abdominal hysterectomy group. The patients who underwent a robotic procedure had a higher rate of postoperative complications, a longer surgery time, and an overall larger uterine weight. However, the length of hospitalization was significantly shorter for the robotic hysterectomy group.

The researchers concluded that the vaginal approach is safer, faster, and more cost-effective than the robotic approach. The noted that robotic hysterectomy may have advantages under certain situations; however, they cautioned that robotic-assisted surgery should note be adopted for widespread use. Rather, their data reinforce the ACOG recommendation that the preferred route of hysterectomy be vaginal.

Take home message:
This study that reinforces the concept that a vaginal hysterectomy is preferable over a robotically-assisted procedure in many cases. A number of factors are involved in determining the best surgical approach. The best candidate for a vaginal hysterectomy is a woman with a normal-sized uterus who has had one or more children. For a woman with an enlarged uterus and pelvic adhesions (scar tissue), a robotic-assisted procedure or an abdominal hysterectomy is preferable. For a women considering either the robotic or vaginal approach, it is prudent to ascertain how many of that type of procedure your surgeon has performed. Skill level can vary significantly. A general rule of thumb is to select a surgeon who has performed at least 50 procedures and has a low complication rate.

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