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Randomized trial: When a vaginal approach is feasible, the robot offers no advantages for benign hysterectomy

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The significantly higher cost of the robot-assisted approach, compared with vaginal hysterectomy, renders the latter a superior option



When investigators compared the cost of vaginal hysterectomy with robot-assisted laparoscopic hysterectomy head to head, they found hospital costs of $4,579 and $7,059, respectively, with no other significant differences between the approaches. Accordingly, they concluded that vaginal hysterectomy should be the “first-choice” approach when it is feasible.

The randomized controlled trial by Lönnerfors and colleagues also compared “traditional” minimally invasive hysterectomy (vaginal or laparoscopic approach) with robot-assisted hysterectomy in 122 women undergoing hysterectomy for benign conditions. Women with a uterine size of 16 gestational weeks or smaller were randomly allocated to:

  • traditional minimally invasive hysterectomy (n = 61) or
  • robotic assisted hysterectomy (n = 61).

In the traditional group, vaginal hysterectomy was the first-choice approach when it was feasible; otherwise, laparoscopic hysterectomy was performed. Vaginal hysterectomy was possible in 41% of cases in this group.

When costs for vaginal and laparoscopic approaches were consolidated and compared with the cost of the robot-assisted approach, the differential was $993 for the robotic approach when the robot was considered a preexisting investment. The hospital cost increased by $1,607 for the robotic approach when investment costs and maintenance expenses were included.

When laparoscopic hysterectomy was compared directly with robot-assisted hysterectomy, costs were similar ($7,016 vs $7,059, respectively) when the robot was considered a preexisting investment, and the robotic approach was associated with less blood loss and fewer postoperative complications.

Investigators noted that: “per-protocol analysis indicates that laparoscopic and robotic-assisted hysterectomy can be performed at similar hospital cost because of higher robot capacity that entails excluding the cost of investment and maintenance, i.e., the basic cost of the robot. This cost differs among institutions, depending on the number of procedures performed; however, the difference becomes less pronounced when 300 to 400 procedures or more are performed annually and the cost for instruments and disposables accounts for most of the cost of the procedure.”

This randomized controlled trial was awarded the Robert B. Hunt Award at the 2015 AAGL Global Congress in Las Vegas as the best paper published over the past year in the Journal of Minimally Invasive Gynecology.

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