The laparoscopic approach has many advantages over open abdominal hysterectomy and is widely used. However, there are several limitations to laparoscopic hysterectomy (LH). These include a steep learning curve, longer operating times, counterintuitive hand movement, 2-dimensional visualization, and limited range of motion. Robotic-assisted laparoscopic surgery overcomes some of these limitations of conventional laparoscopy, providing better ergonomics, 3-dimensional stereo vision, and a wider range of motion. There has been increasing use of robotic-assisted hysterectomy for benign gynecologic disease. About half of gynecologic procedures now use the Intuitive daVinci System. The available data comparing the effectiveness of conventional and robotic laparoscopic procedures are limited to observational studies and 2 small randomized trials involving 148 patients. Data from these studies showed similar outcomes for both procedures but higher costs for robotic-assisted hysterectomy. Because most published data came from surgical centers highly experienced with robotic techniques, these results may not be applicable to gynecological practices that are less experienced with robotic LH.
This study examined recent nationwide data to compare clinical outcomes, safety, and cost of robotic and LH in patients with benign gynecologic conditions. Data were obtained for women undergoing robotic or LH for benign disease from the United States 2009 and 2010 Nationwide Inpatient Sample, an all-payer representative nationwide population-based database. A logistic regression model was used to derive propensity scores for matched cohorts of patients who underwent robotic and conventional LH. Differences between the matched groups in in-hospital complications, hospital length of stay, and cost of hospital care were assessed.
Between 2009 and 2010, 804,551 hysterectomies were performed in the United States for benign conditions; 20.6% were laparoscopic and 5.1% robotically assisted. The use of robotic-assisted hysterectomy for minimally invasive hysterectomies increased from 9.5 in 2009 to 13.6% in 2010 (P = 0.002). Propensity-matched analysis showed that the overall complication rates were similar for the 2 procedures (8.80% for robotic hysterectomy and 8.85% for LH; the relative risk was 0.99 with a 95% confidence interval (CI) of 0.89–1.09, P = 0910. Robotic-assisted hysterectomy was associated with a significantly lower incidence of blood transfusions compared with LH (2.1% vs 3.1%, P < 0.001). However, patients undergoing the robotic procedure were 2 times more likely to experience postoperative pneumonia than patients undergoing LH (relative risk, 2.2; 95% CI, 1.24–3.78, P = 0.005). There was no significant difference between the groups in the hospital length of stay. The median cost of hospital care for robotic hysterectomy was $9788 (interquartile range, $7105–$12,780) and was $7299 for LH (interquartile range, $5650–$9583) (P < 0.001). Accordingly, hospital cost of care estimates were on average $2489 (95% CI, $2313–$2664) higher for patients undergoing robotic-assisted hysterectomy.
The use of robotic hysterectomy increased from 2009 to 2010. The greater costs with robotic-assisted hysterectomy were not associated with improved outcomes.
From the Departments of Anesthesiology and Pain Management and Obstetrics, and Gynecology, University of Texas Southwestern Medical Center, Dallas, TX