OB/GYN society warns against robotic hysterectomy
Robotic assisted laparoscopic procedures are gaining in popularity throughout the US for complicated procedures such as hysterectomy. With any new procedure, dedicated investigators conduct evaluations to determine whether it is an improvement over the traditional approach. On March 14, the American Congress of Obstetrics and Gynecology (ACOG) published a statement that noted for many women, a better and less expensive procedure was available for a hysterectomy.
Hysterectomy is one of the most common major surgeries in the US and costs our healthcare system more than $5 billion a year. The statement issued by ACOG President James T. Breeden, MD noted that many women today are hearing about the claimed advantages of robotic surgery for hysterectomy, thanks to widespread marketing and advertising. It noted that robotic surgery is not the only or the best minimally invasive approach for hysterectomy nor is it the most cost-efficient. Thus, it is important to separate the marketing hype from the reality when considering the best surgical approach for hysterectomies.
The outcome of any surgery is directly associated with the surgeon’s skill. Highly skilled surgeons attain expertise through years of training and experience. Studies show there is a learning curve with new surgical technologies, during which there is an increased complication rate. Expertise with robotic hysterectomy is limited and varies widely among both hospitals and surgeons. While there may be some advantages to the use of robotics in complex hysterectomies, especially for cancer operations that require extensive surgery and removal of lymph nodes, studies have shown that adding this expensive technology for routine surgical care does not improve patient outcomes. Consequently, there is no good data proving that robotic hysterectomy is even as good as—let alone better—than existing, and far less costly, minimally invasive alternatives.
As an alternative, the report cites a vaginal hysterectomy, which is performed through a small opening at the top of the vagina without any abdominal incisions. It is the least invasive and least expensive option. Based on its well-documented advantages and low complication rates, this is the procedure of choice whenever technically feasible. When this approach is not possible, laparoscopic hysterectomy is the second least invasive and costly option for patients.
The report affirms that robotic hysterectomy generally provides women with a shorter hospitalization, less discomfort, and a faster return to full recovery compared with the traditional total abdominal hysterectomy (TAH), which requires a large incision. It notes, however, both vaginal and laparoscopic approaches also require fewer days of hospitalization and a far shorter recovery than TAH. These two established methods also have proven track records for outstanding patient outcomes and cost efficiencies.
At a time when there is a demand for more fiscal responsibility and transparency in healthcare, the use of expensive medical technology should be questioned when less-costly alternatives provide equal or better patient outcomes, notes the report. At a price of more than $1.7 million per robot, $125,000 in annual maintenance costs, and up to $2,000 per surgery for the cost of single-use instruments, robotic surgery is the most expensive approach. A recent Journal of the American Medical Association (JAMA) study found that the percentage of hysterectomies performed robotically has soared from less than 0.5% to nearly 10% over the past three years. A study of more than 264,000 hysterectomy patients in 441 hospitals also found that robotics added an average of $2,000 per procedure without any demonstrable benefit.
The report notes that if most women undergoing hysterectomy for benign conditions each year chose a vaginal or laparoscopic procedure—rather than TAH or robotic hysterectomy—performed by skilled and experienced surgeons, pain and recovery times would be reduced while providing dramatic savings to our health care system. Conversely, an estimated $960 million to $1.9 billion will be added to the health care system if robotic surgery is used for all hysterectomies each year.
Take home message:
As a practicing obstetrician/gynecologist with several decades of practice experience, I fully concur with the ACOG performed. I have performed hundreds of vaginal hysterectomies and am well aware of its advantages for appropriate patients. I have also kept abreast of the latest technology, including robotic hysterectomy. Last year, I interviewed Oliver Dorigo, MD, PhD, an assistant professor of gynecology at the UCLA David Geffen School of Medicine, Department of Obstetrics and Gynecology. Dr. Dorigo is passionate about the procedure and has performed many complicated cancer surgeries, including radical hysterectomies for cancer, with robotic assistance. The magnification and ability to make precise movements has allowed him to carefully inspect and remove cancerous tissue. For many women, the best choice is a vaginal hysterectomy. The candidate for this approach is a woman who has delivered children vaginally, does not have a significantly enlarged uterus, and does not have adhesions (scar tissue from infection, endometriosis or prior surgery. If nothing untoward occurs, the procedure can be accomplished in as little as 15 minutes. It does not require any abdominal incisions (laparoscopic surgery requires several small incisions) and recovery is usually rapid with a short hospital stay.
This page is updated on May 11, 2013.