When is the robot truly the best option for gynecologic surgery?

When laparoscopic hysterectomy was pioneered in the late 1980s, uptake among the gynecologic surgical community was slow—despite the fact that the benefits of laparoscopy soon were evident. Compared with abdominal hysterectomy, the laparoscopic approach offered less blood loss, shorter length of hospitalization, less pain, an earlier return to activity, and improved cosmesis.

Contrast this slow start with the rapid introduction of robotic assistance in gynecologic surgery. Soon after the robot was approved for gynecology in 2005, adoption of the new technology surged. In recent years, in fact, use of the robot has grown faster than use of laparoscopy for benign hysterectomy.

At the Pelvic Anatomy and Gynecologic Surgery (PAGS) Symposium in December 2014, Tommaso Falcone, MD, and Javier Magrina, MD, discussed the rapid adoption of the robot, its role in gynecologic surgery, and how it compares with traditional laparoscopy in a key domain—cost. When OBG Management asked these experts to defend their preferred route of hysterectomy, a lively discussion ensued.

Advantages of laparoscopy
OBG Management: What is your preferred approach for hysterectomy, and why do you consider it superior to other options?

Dr. Falcone: I’m a reproductive endocrinologist by training. In my practice at the Cleveland Clinic, I treat only benign disease—no cancer. For hysterectomy, I favor conventional laparoscopy for several reasons. First, it’s time-proven, with a long history of efficacy over the past 20 years. Second, apart from vaginal hysterectomy, it’s the most cost-effective approach to removal of the uterus in patients with benign disease.

Dr. Magrina: I have practiced as a gynecologic oncologist at the Mayo Clinic, Arizona, for the past 27 years, but I also do surgical procedures for benign disease. During my initial training, there were only two ways to perform a hysterectomy—either you made an incision in the abdomen, or you went through the vagina, which is a NOTES (natural orifice transluminal endoscopic surgery) procedure. Of the two, the vaginal approach is the most effective. It also is cheapest and offers the fastest recovery, but it never surpassed the abdominal approach in practice. The reason: The vaginal approach requires you to work through a small opening using specialized instruments, so it’s more difficult for the surgeon and has reduced ­visualization.

Laparoscopic hysterectomy—or, more specifically, laparoscopically assisted vaginal hysterectomy—arrived in 1989. This approach never gained popularity, but even pure laparoscopy, which came along shortly afterward, took a long time for surgeons to adopt. A main problem was that the technology made it counterintuitive for the surgeon. With the abdominal approach, the surgeon can work with his or her hands in the abdomen, with direct visualization and tactile feedback. In laparoscopy, however, the surgeon uses instruments inside of the abdomen with visualization via a camera. As a result, laparoscopy has a much steeperlearning curve, so it never replaced abdominal hysterectomy in the way that we ­expected.

When robotic surgery came along, in contrast, it quickly became an enabling technology for surgeons who could not perform conventional laparoscopy, and it has overtaken laparoscopy for that reason.

Today there are four options for hysterectomy: the abdominal approach, the vaginal approach, the laparoscopic approach, and robotic assistance. I prefer robotics for complicated surgeries—primarily gynecologic cancer and advanced endometriosis. I also prefer robotics when the patient is obese.

In our practice at Mayo Clinic, Arizona, the abdominal open option essentially doesn’t exist for benign disease. If the patient has a simple problem, such as menorrhagia, which can be corrected by removing the uterus, I would choose a vaginal approach. However, if she has pain in addition to menorrhagia—particularly if it is not cyclic pain—I would prefer a laparoscopic ­approach.

How cost comes into play
Dr. Falcone: I think that what has influenced this discussion in recent years is the cost of medicine. Both Dr. Magrina and I trained in an era when we taught ourselves laparoscopy—as no one else was using it—and then began to try to teach others. And Dr. Magrina is correct when he describes the very slow process of absorption of the new technology. Laparoscopic hysterectomy was performed at a low frequency for a long time, and then robotic technology came along—an enabling technology, to be sure—and minimally invasive surgery took off.

Now, however, cost pressures are increasing. Let’s say the robot is the “Lamborghini” of surgical technology, as it is the most expensive of all the approaches. Until a couple of years ago, we could say, “OK, you need a Lamborghini to cross the finish line, fine. We are so wealthy, you can buy that Lamborghini. I prefer the ‘Honda’ (laparoscopy) but as long as we both cross the finish line, there’s no problem.” Now we can no longer afford the Lamborghini.

The aim is not to eliminate the robot entirely. It definitely has a role in minimally invasive surgery. But doctors who need a sophisticated enabling device to perform minimally invasive surgery now may be discouraged from using the robot, owing to its higher cost. In the future, robotics cases are more likely to be performed by surgeons who can do complex procedures at a high volume. That’s already the model at the Mayo Clinic and Cleveland Clinic. More and more, we’re going to say, “You don’t do enough hysterectomies. Although you are performing the ones you do satisfactorily with the robot, you simply aren’t doing enough. So we’re going to move them into the hands of someone who can do them more cost-effectively.”

It’s the cost variable that has changed the game.

Dr. Magrina: I fully agree that we are in an era in which cost-effectiveness is imperative. At our institution, we have four gynecologic surgeons performing robotic, laparoscopic, and vaginal procedures. I happen to be in the low expensive end of the four, particularly in robotics, largely because I limit the number of robotic instruments—two or three, one assistant, and no manipulator. I utilize a reusable probe, and I look for ways to minimize costs. For example, instead of using an additional needle holder to suture the vaginal cuff, I use one of the robotic graspers already used in the hysterectomy part.

When surgeons begin performing robotic hysterectomy, they try multiple instruments, making the approach very expensive. As surgeons gain experience and begin to watch their costs, however, the expense comes down somewhat.