Costs high, benefits limited for robotic hysterectomy, study finds

A large multiyear cohort study by investigators at Columbia University in New York City shows limited short-term benefit and significantly higher cost for robotic-assisted hysterectomy than for laparoscopic hysterectomy. The findings, say the researchers, point to the need for “rational strategies to implement new surgical technologies.”

More than 400 hospitals across the United States were represented in the population-based analysis, which included 264,758 women who underwent hysterectomy for benign gynecologic disorders between 2007 and 2010. The study, published in The Journal of the American Medical Association, looked at the association between use of robotic surgery and rates of abdominal and laparoscopic hysterectomy and compared in-house complications of robotically assisted hysterectomy with abdominal and laparoscopic procedures.

Between 2007 and 2010, the percentage of hysterectomies that were robotically assisted increased from 0.5% to 9.5%, compared with an increase in laparoscopic hysterectomy from 24.3% to 30.5%. During the study period, the rate of vaginal hysterectomy fell from 21.7% to 19.8%. Of the women represented in the study, 46.6% underwent abdominal procedures, 20.7% had vaginal hysterectomies, 28.5% underwent laparoscopic procedures, and 4.1% had robotically assisted surgery.

Robotically assisted procedures were more likely to be performed at larger hospitals and metropolitan centers. Use of the technology was less likely (P<.001) for women with pelvic organ prolapse and more likely (P=.002) for those whose surgical indication was abnormal bleeding.

Nonrobotic surgery was less common in patients with Medicare and Medicaid and the uninsured than in those with commercial insurance. Race, too, was a factor, with white women more likely than black women to have a robotic procedure.

Robotically assisted hysterectomy was more expensive, in terms of hospital costs, than either open surgery or a laparoscopic procedure ($8854 vs $6712 and $6671, respectively). Rates of unadjusted complications for laparoscopic and robotically assisted procedures were similar (5.3% vs 5.5%; P=.47). A similar pattern was reported for intraoperative complications (2.5% vs 2.4%), surgical site complications (1.7% vs 2.0%), and medical complications (1.6% vs 1.2%).

The authors say the study findings support the theory that robotic surgery enables more women to have minimally invasive procedures and “also raise concern regarding the economic viability of the procedure.” Their recommendations are “defining subsets of patients with benign gynecologic disorders who derive benefit from robotic hysterectomy, reducing the cost of robotic instrumentation, and developing initiatives to promote laparoscopic hysterectomy.”

Wright JD, Ananth CV, Lewin SN, et al. Robotically assisted vs laparoscopic hysterectomy among women with benign gynecologic disease. JAMA. 2013;309(7):689-698.