SCOTTSDALE, ARIZ. – The advent of robotic technology has shifted both the approach used for hysterectomies and the involvement of residents in this surgery, suggest results of a retrospective cohort study reported at the annual meeting of the Society of Gynecologic Surgeons.
Researchers studied women undergoing hysterectomy at four hospitals that had both residents and fellows, comparing 732 surgeries from the pre-robot era (the year before the first robotic hysterectomy at the hospital) with 709 from the postrobot era (2011).
Dr. Peter C. Jeppson
Results showed a significant decrease in the proportion of all hysterectomies that were total vaginal hysterectomies from 43% to 31%. Meanwhile, robotic hysterectomies accounted for 23% of the total by 2011.
In other findings, there was no significant change in the proportion of all hysterectomies having at least some resident involvement, according to operative reports: That value stood at 81% before robotic hysterectomy began and 82% afterward. However, in the postrobot era, residents were involved in nearly 89% of all nonrobotic hysterectomies, but only about 59% of robotic ones.
"These data provide early data on potential implications for robotic implementation," commented first author Dr. Peter C. Jeppson, a urogynecology fellow at Brown University, Providence, R.I. "At this point, the impact of the increasing diversity of hysterectomy approaches on resident education warrants further study."
"Resident involvement was based on dictated operative reports, so we do not know how much of each case was actually performed by the resident," he acknowledged at the meeting jointly sponsored by the American College of Surgeons. "However, one could argue that observing or assisting in more surgical cases provides important educational experience."
Invited discussant Dr. Shawn A. Menefee, an obstetrician-gynecologist at Kaiser Permanente, San Diego, noted, "While the rates of vaginal hysterectomy decreased in the postrobotic period, they still remained above what has been reported in the past. ... Given that resident training often reflects what technique is performed over a surgeon’s career, what impact do you believe this decrease in TVH [total vaginal hysterectomy] rates will have in the United States?"
"At this point, it’s a little bit speculative to state how this will impact the future global rates within the United States," Dr. Jeppson replied. "But I think that it is certainly possible that as the numbers decrease in training, that those numbers also decrease for postgraduates because it seems unlikely to me that residents in training, after graduating, would choose to do a procedure that they weren’t trained to do well."
Dr. Menefee noted that about one-fifth of cases were done by attendings who were urogynecologists. "Is vaginal hysterectomy becoming a procedure performed by subspecialists, and if you remove the urogynecologists at the sites, what would be the percentage of transvaginal hysterectomies performed?" he asked.
Urogynecologists performed about 40% of all hysterectomies in both eras, according to Dr. Jeppson. When these hysterectomies were removed from analyses, the share of the total that were done vaginally still fell, from 31% to 22%.
"While robotic hysterectomy offers limited-to-no benefits for benign hysterectomy, compared with other minimally invasive approaches, it does appear to impact residents’ already limited exposure. Can we adequately teach residents to safely perform multiple approaches, or do we have to choose which ones to teach?" Dr. Menefee wondered.
"My personal opinion is that we should be training residents to perform what’s best for the patients. So different patients may need a different type of surgery," Dr. Jeppson replied. "But with the restrictions placed on duty work hours and with the increasing diversity of the approaches that can be used, that may be difficult. But time will tell."
Session attendee Dr. Hal C. Lawrence III, executive vice president and CEO of the American Congress of Obstetricians and Gynecologists, asked, "What do you think we need to do as a specialty to get people back to doing vaginal surgery, which is just as effective, a whole lot less expensive, and has fewer complications?"
"I think that that will be something that we will have to address on the national level," Dr. Jeppson commented. "But having a commitment to vaginal surgery would be the place to start – there are other modalities that are important and useful, but to not abandon the proven approaches that have been established over a long period of time."
For the study, the researchers analyzed hysterectomies captured by the Fellows’ Pelvic Research Network, excluding those performed in the oncology setting and those done for emergent indications.
The women undergoing hysterectomy in the pre- and postrobot eras did not differ significantly with respect to age, body mass index, prior abdominal or pelvic surgery, insurance type, or mean uterine weight, reported Dr. Jeppson. Also, dysfunctional uterine bleeding was the most common indication for hysterectomy in both groups.