Robotically Assisted vs Laparoscopic Hysterectomy Among Women With Benign Gynecologic Disease

Abstract

There has been increasing enthusiasm for robotic gynecologic surgery in recent years. Most data supporting robotically assisted hysterectomy for benign gynecologic disease were from small studies conducted in single institutions or centers with surgery performed by highly experienced surgeons. The results of these studies may not be applicable to the practice of gynecology in a community setting. A meta-analysis of randomized trials comparing robotic and laparoscopic surgery for benign gynecologic disease concluded that both procedures were associated with similar outcomes and complications; however, the robotic procedure was considerably more expensive. At present, benefits of robotically assisted hysterectomy for women with benign gynecologic disease are unclear. The aims of this population-based study were to determine rates of uptake of robotically assisted hysterectomy over a 3-year period and to compare the association between use of robotic surgery and rates of abdominal and laparoscopic hysterectomy during this period. In-hospital complications and costs were also compared. The cohort was composed of 264,758 women who underwent hysterectomy for benign gynecologic disorders at 441 hospitals in the United States from 2007 to 2010. The primary outcome measures were uptake of robotic-assisted hysterectomy and factors associated with its utilization. Factors evaluated in the participants included complications, transfusion, reoperation, length of stay, death, and cost. A propensity score–matched analysis was performed to analyze outcomes and minimize selection bias and to estimate the propensity to undergo a robotic-assisted hysterectomy. Uptake of robotically assisted hysterectomy increased rapidly over the 3-year study period from 0.5% to 9.5% of all hysterectomies. Laparoscopic hysterectomy rates during this same time period increased from 24.3% to 30.5%. At hospitals where the robotic procedure was used starting in 2007, it accounted for 22.4% of all hysterectomies by 2010. Increased uptake of robotic-assisted hysterectomy was paralleled by a decrease in the rate of abdominal hysterectomy both in hospitals where robotic-assisted hysterectomy was performed and in those where it was not performed. Propensity score–matched analysis showed similar complication rates for robotic-assisted and laparoscopic hysterectomy (5.5% vs 5.3%); relative risk [RR] was 1.03, with a 95% confidence interval (CI) of 0.86 to 1.24. Hospitalization for longer than 2 days was significantly less common in patients who underwent robotic-assisted hysterectomy compared with the laparoscopic hysterectomy cohort (19.6 vs 24.9%, P < 0.001), whereas there was no difference in the rate of transfusion (1.4% vs 1.8%; RR, 0.80; 95% CI, 0.55–1.16) or the rate of discharge to a nursing facility (0.2% vs 0.3%; RR, 0.79; 95% CI, 0.35–1.76; P > 0.05 for both comparisons). The total costs of robotically assisted hysterectomy per case was more than for laparoscopic hysterectomy; the difference was $2189 (95% CI, $2030–$2349). These data show that the uptake of robotically assisted hysterectomy for benign gynecologic disorders increased substantially between 2007 and 2010. The morbidity profiles for robotically assisted and laparoscopic hysterectomy were similar, but the cost of the robotic procedure was substantially higher.