Robotic-assisted TLH can be performed safely, with acceptable operative times even in challenging patients. Average uterine weight and BMI were considerably greater in our series than in those recently published.3,4,5,6
Despite this, average operative time compares favorably with operative times in previous reports. Within our series, need for laparoscopic morcellation, uterine size, and BMI were independently associated with longer operative times. After controlling for these factors, robotic assistance was no longer associated with longer operative times. Postoperative outcomes were improved with robotic assistance.
We demonstrated a decrease in length of stay and parenteral narcotic use, while EBL and complication rate were equally low in both groups. While decreased pain associated with robotic surgery has been reported previously, it is unclear how this benefit is achieved. In this review, it is possible that physician experience with surgical technique improved over time. It is also possible that reduced tissue destruction with robotic dissection improves postoperative outcomes.
The difficulty of robotic surgery in obese patients has previously been reported. Herman et al8
showed that increasing BMI negatively impacted operative time, blood loss, and positive surgical margin rate in men undergoing radical prostatectomy. Multiple factors may account for the difference in operative time we experienced with increasing BMI. Bowel retraction, limitation of Trendelenburg positioning, and limited vaginal access may all contribute to increased operative time.
Several challenges are also present with larger uteri. Port positioning and the ability to limit instrument exchanges are compromised in the presence of a large uterus. Additionally, vaginal removal of the specimen is difficult when the specimen is >150 grams. In patients undergoing traditional total laparoscopic hysterectomy, our preference was to vaginally morcellate the specimen. Robotic surgery limits visualization for morcellation and may require undocking the robot to safely remove the specimen vaginally. This may have led to a greater utilization of laparoscopic morcellation in this series.
Our study has some limitations. It is a retrospective review of a small number of patients. Procedure time may be impacted by the experience of the operating room staff, a factor not taken into account in our review. In addition, as with other series published on robotic surgery,3,4,5,6
the primary surgeon had extensive experience with advanced laparoscopy prior to implementing robotics. As robotic surgery gains popularity, further studies are needed to examine operative times, learning curve, costs and clinical outcomes for less experienced surgeons.
We do not believe laparoscopic or robotic hysterectomy should replace conventional vaginal hysterectomy. During the study period, vaginal hysterectomy was utilized when indicated. As with any new technology, however, there is opportunity for overutilization of robotic surgery as the approach is learned, with a reduction in the number of vaginal hysterectomies performed. While more costly, outcomes for laparoscopic and robotic hysterectomy are similar to costs for vaginal hysterectomy. A Cochrane review of surgical approaches to hysterectomy9
found no evidence for a benefit of one technique over the other. A recent randomized prospective trial comparing laparoscopic and vaginal hysterectomy showed a shorter hospital stay, less blood loss, and less postoperative pain in the laparoscopic arm.10
Adoption of new technology is potentially costly to the healthcare system, but cost alone should not limit the use of new technologies. Determining return on investment for a hospital's robotic system is complicated. Multiple issues affect cost and revenue including operative time, length of stay, disposable instrument use, complication rate, payer mix, and payer contracting. Many hospitals now consider a robotic surgical system a sunk cost, or an unrecoverable cost of business, and do not include the capital outlay in the cost analysis of the hospital's robotic program. Certainly, if the capital outlay for a robotic system is included in determining cost of procedure, the cost of robotic hysterectomy increases significantly.
Based on our experience with robotic surgery, we believe patients should be counseled individually on mode of hysterectomy. The indication for surgery, uterine weight, patient weight, previous surgeries, uterine descent, known pelvic adhesive disease or significant endometriosis should be taken into account when considering the surgical plan. We currently use robotic surgery for hysterectomy in patients who are not good candidates for vaginal hysterectomy, and in whom the likelihood exists for significant pelvic adhesive disease or significant endometriosis. We also perform robotic hysterectomy for patients undergoing concomitant sacral colpopexy. We recommend total laparoscopic hysterectomy in patients who are not good candidates for vaginal hysterectomy and have pelvic pain as the indication for surgery. In patients with larger uteri that may require morcellation, we prefer traditional total laparoscopic hysterectomy over robotic hysterectomy. Further study is needed to validate this decision algorithm.
Multiple issues regarding the utilization of robotics in gynecology remain. Short- and long-term patient outcomes need to be further evaluated with randomized prospective trials. Surgical costs, taking into account postoperative variables, need critical review. Robotic surgical systems can facilitate a minimally invasive approach in very challenging surgical candidates who traditionally would have undergone abdominal hysterectomy. Randomized controlled trials evaluating this hypothesis are needed. Of concern are also issues related to resident training and the potential decline in vaginal hysterectomies with routine introduction of robotics. Further studies are needed to address these questions.