Jamal Mourad, DO: I have seen a steady, progressive growth in the number of robotic procedures performed at our institution. Initially, the urology department used our robotic equipment to perform prostatectomies. Shortly after that, quick acceptance by several departments, including gynecology, oncology, general surgery, colorectal surgery, and pediatric surgery, led to widespread use and acceptance.
OBG Management: Does increasing use of the robot make it more likely that it will be used in hysterectomy for benign indications?
Rosanne M. Kho, MD: Our primary approach to the simple hysterectomy for benign conditions (including nulliparous women, those with a uterus larger than 12 weeks’ size, and women who have undergone previous pelvic surgery) is still vaginal. Patients with pelvic pain, known endometriosis, and suspicious adnexal masses are approached laparoscopically or robotically.
Compared with conventional laparoscopy, we have found the robot particularly useful in obese patients and in cases requiring extensive dissection and suturing, such as in benign complex gynecology (involving endometriosis, ovarian remnant syndrome), urogynecology (for prolapse and fistulas), and all aspects of gynecologic oncology.
In our hands, the robot has been a facilitating tool, allowing us to perform complex procedures that would otherwise have been difficult to perform with conventional laparoscopy.
Which benign conditions are being addressed robotically?
OBG Management: What benign procedures in gynecologic surgery is the robot used for at your institution, Dr. Advincula?
Arnold P. Advincula, MD: It’s used for the entire gamut of benign procedures in gynecologic surgery, ranging from complex hysterectomy to reproductive surgical cases such as myomectomy and endometriosis resection to pelvic reconstructive surgery. Our success with such a broad range of applications is very much attributable to the infrastructure that we have in place that allows us to use the robot safely and efficiently.
OBG Management: What makes the robot so attractive?
Jamal Mourad, DO: Robotic technology allows for much-improved visualization, better dexterity and maneuverability, and near total control of the surgical field. I have found that the combination of these advantages permits predictable and reproducible procedures, less tissue trauma, less blood loss, a shorter hospital stay, and fewer conversions to laparotomy, even in very difficult and challenging situations, such as cases involving dense adhesions, a large uterus, or deep infiltrating endometriosis.
Cheryl B. Iglesia, MD: At my institution, the robot is used for sacrocolpopexy, some myomectomy and endometriosis cases (although haptic feedback for these tough endometriosis cases often makes laparoscopy more useful), and, rarely, fistulas (vesicouterine, ureterovaginal).
Jamal Mourad, DO: There are several experienced minimally invasive surgeons at my institution. In addition to hysterectomy, we perform sacrocolpopexy, myomectomy, and resection of severe endometriosis using the robot.
Marie Fidela R. Paraiso, MD: We use the robot for hysterectomy, myomectomy, sacrocolpopexy, Burch colposuspension, paravaginal repair, tubal reanastomosis, endometriosis resection, ureterolysis, and cerclage.
Jason D. Wright, MD: At my institution, robotic surgery for benign indications has been used predominately for hysterectomy and myomectomy, as well as sacrocolpopexy. Given the lack of data to guide implementation of robotic surgery in gynecology, it is difficult to determine which patients derive the most benefit from robotic-assisted procedures.
Should the robot be used for benign hysterectomy?
OBG Management: Do you believe use of the robot is justified in hysterectomy for benign indications?
Cheryl B. Iglesia, MD: No, I believe that most hysterectomies should be done vaginally. If, for some reason, the vaginal approach is not feasible, then laparoscopic hysterectomy is the next best choice and more cost-effective than robotic hysterectomy. Comparative studies and Dr. Wright’s JAMA article seem to concur.1 Open abdominal hysterectomy should be the last option.
Rosanne M. Kho, MD: I do believe that the robot is justified for use in hysterectomy for benign indications. It has provided many patients with the benefits of minimally invasive surgery, as studies have shown.1,9 In an ideal world, simple hysterectomies would be performed vaginally first and, as Dr. Iglesia noted, laparoscopically second. We do know, however, that not only are the learning curves for the vaginal and laparoscopic approaches steep, it is a challenge to teach these approaches effectively. The robotic platform has overcome these challenges with the 3D view, articulation of instruments, and a simulation and teaching console.
Marie Fidela R. Paraiso, MD: I agree with Dr. Iglesia. I do not think that use of the robot is justified for benign indications unless it is shown to be cost-effective and results in the same cure and complication rates, or if a surgeon does not have the skills or training in traditional laparoscopy and desires to offer his/her patients minimally invasive abdominal surgery. So far, two prospective trials have demonstrated that robotic-assisted hysterectomy for benign disease requires longer operative time and is, therefore, more costly in centers where there are surgeons who specialize in advanced laparoscopy.5,6 We still have not defined the subset of patients who would benefit from robotic-assisted laparoscopy if all things are equal.