With the increasing utilization of robotic technology for minimally invasive surgical techniques, the outcomes of this approach must be compared to other approaches to assess feasibility. The focus of this study was on minimally invasive surgical approaches for benign hysterectomy at a large institution. Such analyses will help better define the role of this new approach to hysterectomy. The advantages of the minimally invasive approach to hysterectomy as compared to laparotomy are well known; however, many approaches to minimally invasive hysterectomy exist including the most recent addition of the robotic approach, which needs to be reviewed in comparison studies. Experience with vaginal hysterectomy is limited in most obstetrics and gynecology training institutions in the United States, thus it was not available to most patients who do not have small and descendant uteri. Laparoscopic assistance helped in overcoming some of the barriers to performing hysterectomies without laparotomy, but this approach came with another barrier, which is a slow learning curve. The improved vision and enhanced instrumentation of the da Vinci system helped simplify the laparoscopic approach, making it more available to a wider range of patients by assisting surgeons to overcome their limitations.12–14
Our analysis of 297 patients demonstrates comparable surgical outcomes between patients undergoing robotic hysterectomy versus other types of minimally invasive hysterectomy with some interesting findings. Similarly, a Swiss case-control study that compared robotic-assisted laparoscopic hysterectomy with total laparoscopic hysterectomy and found no significant differences between the 2 groups regarding complications, conversions to laparotomy, intraoperative bleeding, and hospital stay.15
Another study by Shashoua et al.16
with the same comparison reported that robotic TLH was associated with a shorter hospital stay and decrease in narcotic but did show a difference in EBL and drop in hemoglobin. The operative time in RH was longer but was associated with the need for laparoscopic morcellation, BMI, and uterine weight.
When comparing patients who had robotic hysterectomy to those undergoing other minimally invasive hysterectomy procedures in our institution, both groups of patients were similar in demographics and had similar body mass index measures and outcomes. However, women who underwent robotic hysterectomy had statistically significantly larger uteri, with a larger proportion of patients with uteri > 500 g. Several other studies have discussed the advantages of the robotic approach in complex hysterectomy and in hysterectomy for patients with larger uterine weight.10,17,18
These studies have also shown that the robotic approach allows for completion of TLH with robotic assistance in patients with large BMI, thus suggesting a possible advantage to the robotic approach in these more complex procedures.19
In our cohort, all attempted robotic hysterectomy procedures were successfully completed in obese patients and in patients with very large uteri. The 2 conversions occurred for suspicion of malignancy and equipment failure. Comparatively, the 3 conversions in the nonrobotic MIH group occurred because of intraoperative uncontrollable bleeding in a patient with a large uterus, failure to gain intraperitoneal access, and secondary to obesity (BMI = 53), and inability to remove a uterus vaginally secondary to size of the uterus. In one of the pivotal studies by Payne et al.7
comparing robotic hysterectomy to total laparoscopic hysterectomy after introduction of this new technique in their institution, also showed that the introduction of the robotic approach reduced the conversion rate.
There has been concern about prolonged operative times related to robotic hysterectomy procedures, especially early in the learning curve.12,13,20
Despite the fact that the robotic hysterectomy procedures in this study included those within the learning curve of the surgeons who were trained in the procedure, overall operative time was only 25 min longer than all other nonrobotic MIH procedures combined and was actually 25 min shorter compared to time for total laparoscopic hysterectomy procedures alone. This contradicts a few other comparisons that reported longer operative time for robotic-assisted versus laparoscopic TLH.16,20,22
Thus, the procedures that led to reduced operative time were those that included the vaginal approach in the technique.
have commented on the low estimated blood loss associated with robotic hysterectomy procedures, and this can be attributed to the better vision and easier dissection allowing the avoidance of bleeding.7,8,21,23,24
In our study, estimated blood loss was also less in robotic hysterectomy compared to other types of hysterectomy, and this was statistically significant. This held true for all subgroups as well and was supported by a statistically significant difference in change in hemoglobin. A 100 mL decreased estimated blood loss may not be clinically significant but can reflect a general tendency to less potential for excessive bleeding with the robotic approach. Hospital stays overall were also shorter for robotic hysterectomy compared to vaginal and LAVH procedures, although this was only statistically significant when compared to LAVH procedures that tended to have 2-d long hospital stays in our institution. Hospital stay can reflect recovery and return to normal activities and thus does indirectly reflect the morbidity of a surgical procedure. However, it is also affected by surgeon and institutional experience as well as postoperative nursing care. Because all the procedures included in this study were performed at the same institution, we can consider this as a method of comparing our patients' recovery.
With any minimally invasive procedure, especially when newer techniques are being introduced there is always concern about increasing complications compared to the traditional approaches to surgery. In our comparison, interestingly, a higher percentage of minor complications, the largest estimated blood loss, and most transfusions were in the LAVH group. LAVH originated to complete hysterectomies vaginally as opposed to performing a hysterectomy through an abdominal incision in patients where the vaginal approach alone was not sufficient. Major complication rates were however stable across all groups. MIH patients had a statistically significant increased number of minor complications, but not major complications, compared to RH patients. Most common minor complications were related to vaginal cuff issues, which had been reported more in robotic hysterectomy procedures in other studies, especially in early reports of robotic hysterectomy.25
Interestingly, even this type of complication was much more common in the nonrobotic group compared to the robotic group.
One strength of this study is its generalizability based on a wide demographic in both groups of patients and a large sample size. Since the analysis included general experience at both a suburban and inner city population by all the gynecologists at both hospitals, the data may reflect outcomes that may be more typical in the community setting, rather than those reported by expert surgeons. Robotic hysterectomy was compared to multiple other minimally invasive hysterectomy methods, and to our knowledge, this has not been compared previously in one institution. Our combined inpatient and outpatient Electronic Medical Record system provided us with a comprehensive review of the patients' experience allowing us to capture even the mildest adverse effects. The largest limitation of our study is the retrospective study design, as this does not allow control for either surgeon experience or selection bias. Thus, selection of hysterectomy method was left to surgeon preference rather than randomization or criterion for assignment, which thus may not control for confounders. Also, the cases were managed by a surgeon whose experience ranged from resident to seasoned senior staff, and thus there was variable surgeon experience. Controlling for surgeon decision-making and surgical experience requires a prospective study with a limited pool of surgeons who explain their recommendation and perform all the types of hysterectomy studied. However, reports of institutional experience are valuable in that they reflect the real world application of these methods of surgery.
Robotic hysterectomy was found to have comparable outcomes to other methods of minimally invasive hysterectomy without increased risk of conversion or complications. Although procedure duration is slightly increased (25 min) for RH compared to MIH procedures with a vaginal approach, estimated blood loss and minor complication rates may be decreased, and the benefit of short length of hospital stay is maintained or improved. These data also suggest that the robotic approach may allow surgeons to overcome conversions associated with obesity or extremely large uteri, but additional data are required to assess this further. However, it is evident that robotic hysterectomy is an acceptable and safe option that may serve as an alternative method in some patients desiring a minimally invasive approach to hysterectomy.