With few exceptions, the rates of complications, readmissions, and reoperations were similar among patients who underwent robotic hysterectomy for benign indications, compared with those who underwent the procedure by other minimally invasive routes, results from a large analysis demonstrated.
Yet the price tag for nonrobotic, minimally invasive approaches to hysterectomy was 24% lower overall per case.
Dr. Carolyn W. Swenson
“In general, people tend to favor newer technologies over older ones because the assumption is that because it’s new, it’s better,” Dr. Carolyn W. Swenson, lead study author, said in an interview before the annual scientific meeting of the Society of Gynecologic Surgeons. “Physicians are not immune to this kind of thinking. But in medicine, we have an obligation to use evidence-based practices to try and optimize outcomes for our patients. If study after study is concluding that, for benign hysterectomy, the additional cost of the robot doesn’t produce better outcomes, then we should be seriously evaluating why and how we choose to use this tool.”
In the past 10 years, use of the robot for benign hysterectomy has increased by more than 25-fold in the Unites States, while other routes of minimally invasive hysterectomy (vaginal and conventional laparoscopic) have decreased, according to Dr. Swenson, a specialist in female pelvic medicine and reconstructive surgery at the University of Michigan, Ann Arbor.
“We know that robot-assisted technology adds, on average, $2,000 to $3,000 per hysterectomy, but that major complications are no different when compared to conventional laparoscopy,” she said. “Vaginal hysterectomy is actually the most minimally invasive and most cost-effective route and it’s also associated with lower complications compared to abdominal and conventional laparoscopic routes. But vaginal hysterectomy is often left out of comparative studies with robotic hysterectomy. So what we’ve been missing up to this point is a study comparing outcomes between robot-assisted laparoscopy and all other routes of minimally invasive hysterectomy, including vaginal and vaginal-assisted laparoscopic routes in addition to conventional laparoscopy.”
In an effort to compare the clinical outcomes and the estimated cost of robot-assisted hysterectomy to all other routes of minimally invasive hysterectomy for benign indications, the researchers analyzed records from a statewide database in Michigan for all such procedures performed from July 1, 2012, to July 1, 2014. They used propensity-matched scoring to control for demographic, clinical, and hospital factors and went on to perform a one-to-one match between women who had a hysterectomy with robotic assistance, and those had a hysterectomy by other minimally invasive routes (laparoscopic and vaginal, with or without laparoscopy). Next, they compared the two cohorts for perioperative outcomes, intraoperative bowel and bladder injury, 30-day postoperative complications, readmission, and reoperation.
Dr. Swenson reported results from 11,004 hysterectomy cases. Of these, 6,222 were performed with robotic assistance, while the remaining 4,782 were performed via other minimally-invasive surgical routes. Over the study period, the proportion of hysterectomies performed with robotic assistance ranged from 43% to 45%, while rates of laparoscopy were 10%-13%, and rates of vaginal hysterectomy (with or without laparoscopy) were 19%-24%.
“I was surprised at how many robotic hysterectomies are being done in the state of Michigan for benign indications,” she said. “The rate is over three times the national average.”
After the propensity score analysis was done, 1,338 hysterectomies from each group were successfully matched and the researchers found that compared with the other minimally invasive routes, hysterectomy cases done with robotic assistance had lower estimated blood loss (94.2 vs. 175.3 mL, respectively; P less than .0001); longer surgical time (2.3 vs. 2 hours; P less .0001), and larger specimen weights (178.9 vs. 160.6 grams; P less than .0001). Intraoperative and bladder complications were similar between the two groups.
Compared with the other minimally invasive hysterectomy routes, the rate of any postoperative complication was lower among cases performed with robotic assistance (3.5% vs. 5.6%; P = .01) and was driven by lower rates of superficial surgical site infections (SSIs) (.07% vs. .7%; P = .01) and blood transfusion (.8% vs. 1.9%; P = .02). However, rates of major complications including deep/organ space SSI, thromboembolic events, MI/stroke, pneumonia, sepsis or death, and readmission and reoperation rates did not differ between the two groups.
After applying hospital cost estimates drawn from published data to results from the hysterectomies included in the propensity match, Dr. Swenson and her associates estimated that the nonrobotic minimally invasive hysterectomy routes led to a 24% lower overall cost per case ($10,160, compared with $13,429 per case performed with robotic assistance), even when considering the cost of additional cases of superficial SSI and blood transfusion. This calculation excluded maintenance costs of the robot.