The case for robotic-assisted hysterectomy
During my address as president of the Board of Trustees of the AAGL in 2008, I noted that essentially 95% of all cholecystectomies, 95% of all bariatric surgery, and 70% of all appendectomies in the United States were performed laparoscopically. Unfortunately, less than 20% of hysterectomies were performed via a minimally invasive route.
Subsequently, at the time of my 2012 presidential address for the International Society for Gynecologic Endoscopy (ISGE), I noted that the percentage of minimally invasive hysterectomies performed in the United States now reached 50%, while the percentage of laparoscopic and vaginal hysterectomies was still mired at 18% and 14%, respectively. The increase in a minimally invasive approach to hysterectomy appeared to be due to the newest method of hysterectomy; that is, robotic-assisted hysterectomy.
On March 14, 2013, Dr. James T. Breeden, president of the American College of Obstetricians and Gynecologists, released a statement regarding robotic surgery. In that, he noted, "While there may be some advantages to the use of robotics in complex hysterectomies ... studies have shown that adding this expensive technology for routine surgical care does not improve patient outcomes. Consequently, there is no good data proving that robotic hysterectomy is even as good as – let alone better than – existing, and far less costly, minimally invasive alternatives."
Dr. Breeden then went on to refer to a recent article in the Journal of the American Medical Association (JAMA 2013;309:689-98) to make the point that, in a study of 264,758 patients undergoing hysterectomy in 441 hospitals in the Premier hospital group, robotics added an average of $2,000/procedure without any demonstrable benefit.
Interestingly, however, the authors of the JAMA article acknowledge that while uptake of laparoscopic hysterectomy has been slow since its inception in the early 1990s, accounting for only 14% of hysterectomies in 2005, within 3 years of the introduction of the adoption of robotics for hysterectomy, nearly 10% of all cases were completed by this enabling technology. Furthermore, the authors comment that, "The introduction of robotic gynecologic surgery was associated with a decrease in the rate of abdominal hysterectomy and an increase in the use of minimally invasive surgery as a whole, including both laparoscopic and robotic hysterectomy." The authors acknowledge that robotic surgery may be easier to learn and that robotic assistance may allow for the completion of more technically demanding cases. In addition, they note that the increase in numbers of laparoscopic hysterectomy may have occurred because of competitive pressures or an increased awareness and appreciation of minimally invasive surgical options.
In comparison, the authors found that in hospitals at which robotic surgery was not performed as of the first quarter of 2010, nearly 50% of all hysterectomies were performed via an open abdominal route, while less than 40% of hysterectomies were performed with a laparotomy incision when robotic hysterectomy was performed at the hospital. With the future adoption of the robotics in gynecologic surgery, I am sure there will be a continued reduction in open abdominal hysterectomy. Benefit ... a resounding yes!
Another fascinating finding of the JAMA study was the fact that overall complication rates were similar for robotic-assisted and laparoscopic hysterectomy (5.5% vs. 5.3%; relative risk, 1.03; 95% confidence interval, 0.86-1.24). Moreover, patients who underwent a robotic-assisted hysterectomy were less likely to have a length of stay longer than 2 days (19.6% vs. 24.9%; RR, 0.78; 95% CI, 0.67-0.92).
Despite no differences in complications in the JAMA study, given the fact that robotics is an emerging technology, one can easily extrapolate that the percentage of cases performed in the study by relatively inexperienced robotic surgeons, as compared with laparoscopic surgeons, was higher. Therefore, with increased surgeon experience, as with any new technology, the rate of complications would be expected to be further decreased. To this end, one must remember that early in its inception, the New York Assembly voiced concerns with laparoscopic cholecystectomy secondary to complications. Now, virtually 95% of all cholecystectomies in the United States are performed via a laparoscopic route. Currently, what is the latest focus in cholecystectomy ... robotic assisted single site cholecystectomy that is being rapidly adopted throughout the country.
While one must acknowledge that, at present, robotic-assisted surgery would appear to be more expensive to perform than laparoscopic surgery is, it is difficult to ascertain what that cost differential is truly. Furthermore, one would anticipate with increased experience and efficiency that cost would, indeed, decrease. While in 1996, Dr. James H. Dorsey published an article on the higher costs associated with laparoscopic surgery (N. Engl. J. Med. 1996;335:476-82), more recent studies by Warren L., et al. (J. Minim. Invasive Gynecol. 2009;16:581-8), and Jonsdottir G.M., et al. (Obstet. Gynecol. 2011;117:1142-9) actually show that the laparoscopic route can be more cost effective.
