Point/Counterpoint--Do we really need the robot?

PRO: Robotic surgery’s time has come 

Amy K. Schutt, MD and Ertug Kovanci, MD

Dr. Schutt is a Reproductive Endocrinology and Infertility Fellow at Baylor College of Medicine, Houston, Texas.

Dr. Kovanci is an Assistant Professor for Obstetrics and Gynecology at Baylor College of Medicine and Chief of Gynecologic Surgery at Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas.

Neither author has a conflict of interest to report regarding the content of this article.

Hysterectomy is the second-most-common surgical procedure in the United States and estimates indicate that 1 in 9 women will undergo it in their lifetime. Before robotic platform was approved by the US Food and Drug Administration for gynecologic surgery, rates of laparoscopic hysterectomy in the United States remained underwhelmingly stagnant. Although the first laparoscopic hysterectomy was performed in this country more than 20 years ago, in 1990 and 2003 only 0.3% and 11.8% of hysterectomies, respectively, were performed laparoscopically.¹

Conversely, the rate of robot-assisted hysterectomies increased rapidly from 0.5% in 2007 to 9.5% of all hysterectomies in 2010, a span of just 3 years. In hospitals with a robot, the rate of robotic hysterectomy increased to 22.4% of all hysterectomies in the 3 years after the first robotic procedure was performed.² These statistics illustrate that, despite multiple documented benefits of minimally invasive surgery (decreased hospital stay, decreased pain, faster recovery times, and fewer infections), laparoscopic hysterectomies remained underutilized for years until the advent of the robot.

In 2005, 64% of hysterectomies in the United States were performed abdominally, a number that remained unchanged for decades. From 2007 to 2010, as robotic hysterectomies increased, abdominal hysterectomies decreased overall from 53.6% to 40.1%.³ In essence, gynecologic surgeons viewed the robot as a catalyst to overcome the barriers associated with adopting laparoscopic hysterectomy techniques.

Related: Does the robot hurt or help?

For many surgeons, a lack of previous training combined with the promise of longer operative times, painful ergonomics, and a steep learning curve were powerful deterrents preventing the switch in surgical approach. Most gynecologic surgeons understand that laparoscopic hysterectomies are associate with better profiles for recovery and postoperative complication than abdominal hysterectomies, but the approach was not feasible until the robotic surgical platform became commercially available.

The vaginal approach remains the gold standard for minimally invasive hysterectomy, but complex pathology such as pelvic adhesive disease from endometriosis, chronic pelvic inflammatory disease, and uterine fibroids present significant challenges for the gynecologic surgeon. In these cases, opting for a robotic hysterectomy may prevent an abdominal hysterectomy. The robot serves as a powerful mechanism for gynecologic surgeons to dramatically (and more comfortably) shorten the learning curve for laparoscopic hysterectomy.

The robotic surgical platform should be embraced as a tool that allows the average gynecologic surgeon to excel in laparoscopic surgery-performing fewer abdominal hysterectomies while offering more patients the benefits of minimally-invasive surgery when a vaginal approach is deemed inappropriate. In hospitals with a robot, the platform has resulted in a reduction in the rate of abdominal hysterectomies by more than 20% in just 3 years, a figure previously unchanged for decades. The robot has existed in gynecologic surgery for only 8 years and it has already radically altered the future of minimally invasive surgery. When compared to traditional laparoscopy, the trajectory for the adoption of the robotic surgical platform in gynecology aims higher: to help patients achieve better outcomes with fewer complications and to help surgeons perform hysterectomies efficiently, skillfully, and safely.

When Dr. Kurt Semm, the founder of laparoscopic surgery, submitted a manuscript documenting a laparoscopic appendectomy to the American Journal of Obstetrics and Gynecology, it was declared unfit for publication due to “unethical” surgical technique. Critics in the 1960s mockingly suggested that Dr. Semm undergo a brain scan as “only a person with brain damage would perform laparoscopic surgery.”⁴ Now Dr. Semm’s laparoscopic techniques are used by gynecologic surgeons around the world.

Ever since the world accepted Dr. Semm’s endorsement of laparoscopic surgery in the 1990s, gynecologic surgeons have been at the forefront of technological innovations. Resistance to the most advanced tool we have today is a reminder of the resistance to video laparoscopy that occurred earlier; critics decried the increased expense, longer operating times, and necessity of the new technology, arguing instead for mini-laparotomy and vaginal surgery.⁵ We find it hard to believe that we will be performing surgery with “straight sticks” in 20 years. The next generation of laparoscopy is here and the time has come to embrace this change.

References

1. Wu JM, Wechter ME, Geller EJ, Nguyen TV, Visco AG. Hysterectomy rates in the United States, 2003. Obstet Gynecol. 2007;110(5):1091–1095.

2. Wright JD, Ananth CV, Lewin SN, Burke WM, Lu YS, Neugut AI, et al. Robotically assisted vs laparoscopic hysterectomy among women with benign gynecologic disease. JAMA. 2013;309(7):689–698.

3. Rosero EB, Kho KA, Joshi GP, Giesecke M, Schaffer JI. Comparison of robotic and laparoscopic hysterectomy for benign gynecologic disease. Obstet Gynecol. 2013;122(4):778–786.

4. Mettler L. Historical profile of Kurt Karl Stephan Semm, born March 23, 1927 in Munich, Germany, resident of Tucson, Arizona, USA since 1996. JSLS. 2003;7(3):185–188.

5. Pitkin RM, Parker WH. Operative laparoscopy: a second look after 18 years. Obstet Gynecol. 2010;115(5):890–891.

CON: Conventional surgery is more cost-effective and patient-centered

Linda Shiber, MD, and Resad Pasic, MD, PhD

Dr. Shiber is a Fellow and Instructor in the Center of Minimally Invasive Gynecologic Surgery, at the University of Louisville Department of Obstetrics, Gynecology and Women's Health, Louisville, Kentucky.

Dr. Pasic is Professor of Obstetrics and Gynecology, Director of the Center of Minimally Invasive Surgery and Co-Director of the Fellowship in Advanced Gyn Laparoscopy at the University of Louisville Department of Obstetrics, Gynecology and Women's Health, Louisville, Kentucky.

Dr. Shiber reports receiving salary/honorarium from Ethicon. Dr. Pasic reports receiving consulting fees from Ethicon and fees from Storz and Cooper Surgical.

Minimally invasive approaches to benign gynecologic surgery have been shown to result in superior clinical outcomes. In recent years, robotic systems have been adopted in benign gynecology, at great cost to the health care system and with no validated clinical benefits.

There is no clear indication for preferential use of robot-assisted laparoscopy over conventional laparoscopy in benign gynecology.^1,2 Some may argue that the robotic approach is helpful in surgeries requiring extensive dissection and/or suturing, such as myomectomy or sacrocolpopexy. Existing evidence has shown no significant difference in complication rates or surgical outcomes; to the contrary, evidence has indicated robot-assisted procedures are longer and far more costly.^3-5 Arguments regarding benefits of robotic surgery in obese gynecologic patients lack the insight that obese patients benefit from any minimally invasive approach. And it remains unclear whether robotics provides any technical advantages over laparoscopy in these patients.

We do acknowledge the fact that adoption of robot-assisted laparoscopic hysterectomy may decrease rates of abdominal hysterectomy among surgeons not skilled in conventional laparoscopy. However, we argue it is paramount to be skilled in the basics prior to adopting a new technology. If a robotic procedure cannot be completed as such, the default should be conventional laparoscopy, not laparotomy, necessitating a solid laparoscopic skill set before attempting robotics. Once a surgeon acquires this skill set, the “need” for robotic assistance is obviated.

The significant cost of robotic technology cannot be ignored in today’s medico-economic environment. It is estimated that for hysterectomy alone, robotic procedures cost, on average, $2,600 more per surgery than laparoscopic procedures.⁴ This number does not include the net cost of each robot system, which is approximately $1 million to $2.5 million (excluding maintenance costs, single-use appliances, etc.).^5,6 The American Association of Gynecologic Laparoscopists (AAGL) estimates that if all hysterectomies in the United States were performed robotically, an additional $960 million to $1.9 billion would be added to health care system costs.² It is exceedingly difficult to justify this astronomical and additive cost for a surgical approach that has not been shown to be clearly indicated or to afford short/long term clinical benefits in benign gynecologic surgery.

Furthermore, as our national health care environment evolves and Accountable Care Organizations continue to audit cost-effectiveness and quality of health care, we feel that the growing use of robotic technology in benign gynecology will not be sustainable.

In conclusion, we echo the recent AAGL position statement, as well as the findings of the 2012 Cochrane Review, when we state that robot- assisted laparoscopic surgery should not be the preferred approach for patients with benign gynecologic disease. With evidence indicating no surgical or clinical advantage to robotic surgery and cost analyses consistently showing the incredible burden of robotics on health care spending, clinicians should critically and thoroughly evaluate the clinical necessity of choosing a robotic approach over vaginal or conventional laparoscopy for patients with benign gynecologic conditions. Focusing on improving laparoscopic training for practicing gynecologists, as well as ob/gyn residents, would be a far more cost-effective and patient-centered way of allocating health care dollars.

References

1. Liu H, Lu D, Wang L, Shi G, Song H, Clarke J. Robotic surgery for benign gynaecological disease. Cochrane Database Syst Rev. 2012;(2):CD008978.

2. AAGL Position Statement: robotic-assisted laparoscopic surgery in benign gynecology. J Minim Invasive Gynecol. 2013;20(1):2–9.

3. Paraiso MFR, Ridgeway B, Park, AJ, et al. A randomized trial comparing conventional and robotically assisted total laparoscopic hysterectomy. Am J Obstet Gynecol. 2013;208:368.e1–7.

4. Pasic RP, Rizzo JA, Fang H, Ross S, Moore M, Gunnarsson C. Comparing robot-assisted with conventional laparoscopic hysterectomy: Impact on cost and clinical outcomes. J Minim Invasive Gynecol. 2010;17(6):730–738.

5. 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.

6. Barbash GI, Glied SA. New technology and health care costs-The case of robot-assisted surgery. N Engl J Med. 2010;363(8):701–704.