Robotic Assisted Hysterectomies: Worth It?

In February, the Journal of the American Medical Association (JAMA) published a study that examined the use of robotic assisted hysterectomies. Authors set out with the objective of determining whether the robots were more effective than less invasive alternatives. The findings, which have garnered attention from mainstream media outlets such as National Public Radio (NPR), suggest that in fact the robotic surgeries may be less desirable overall than traditional methods.

This study is far from new news. Just one year ago in February of last year, the Cochrane Database of Systematic Reviews published a very similar article titled “Robotic Surgery for Benign Gynaecological Disease.” The new JAMA study is titled “Robotically Assisted vs. Laparoscopic Hysterectomy Among Women With Benign Gynecologic Disease.”

A hysterectomy is the surgical removal of the uterus, and may be total or partial. Partial hysterectomies leave the cervix intact. Performed on one in nine women, it is the most common gynecological surgery, and is one of the most common general procedures undergone by women. A hysterectomy may be necessary in cases of uterine cancer, endometriosis (where the uterine lining grows outside the uterine cavity), gender transitional surgeries, or even for elective reasons (which is controversial).

The 2012 study cited “mounting evidence that demonstrates the feasibility and safety of robotic surgery in benign gynecological disease.” While robotic surgery is touted to provide more precise vision, improve ergonomics and shorten hospital stays, it is more costly. Disposable instruments and physician and nurse retraining contribute to the high cost of robotic assisted surgeries. The study concluded, from two separate trials, that “robotic and laparoscopic surgery seemed comparable regarding intraoperative outcome, complications, length of hospital stay and quality of life.”

Following a study of more than 260,000 women who underwent hysterectomy for benign gynecologic disorders at 441 hospitals across the United States from 2007 to 2010, the JAMA study concluded that robotic assisted hysterectomies were indeed more expensive. They cost an average of $8,868, compared to $6,679 for laparoscopic hysterectomies. The researchers also found that while patients who received robotic assisted hysterectomies were less likely than others to require hospitalization for more than two days, there were no significant differences between the two patient groups with regards to surgical complications.

Robotic assisted hysterectomies are still only used on a minority of candidates, but the number grew quickly from 0.5 percent to 9.5 percent between 2007 and 2010. In hospitals with robots, researchers said, robotic surgeries accounted for 22.4 percent of all hysterectomies three years after the robots were acquired.

“As a tool, robotic surgery helps surgeons overcome the limitations of traditional [minimally invasive surgical] techniques to provide patients with a less invasive option and prevent the downstream costs and complications of an open procedure,” Angela Wonson, a spokeswoman for Intuitive Surgical, told NPR. Intuitive Surgical is the Sunnyvale, Calif. manufacturer of the Da Vinci system, a robotic system designed for use on several surgeries including hysterectomies.

Women who have already had multiple abdominal procedures or those with larger uteruses—“anything that might make the surgery technically difficult”—may be good candidates for robotic hysterectomies, said Jason D. Wright, M.D., lead author on the JAMA study and assistant professor of women’s health at Columbia University College of Physicians and Surgeons in New York, N.Y. While Wright uses the robot, he told NPR the choice is not always obvious. “One of the things we struggle most with is to figure out which patient will benefit most with robotic surgery.”