Robotically assisted hysterectomy has risen substantially

Major Finding: The rate of robotically assisted hysterectomy increased from 0.5% to 9.5% of all hysterectomies between 2007 and 2010.

Data Source: A population-based analysis of data on 264,758 hysterectomies at 441 U.S. hospitals in 2007-2010.

Disclosures: This study was funded in part by the National Cancer Institute. No financial conflicts of interest were reported.

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Stark contrast in costs

Joel S. Weissman, Ph.D., and Dr. Michael Zinner comment: The "stark" contrast in costs between robotically assisted hysterectomy and all other approaches – $2,000 more per case, or nearly one-third of the total cost – comes without any significant advantage in clinical outcomes, said Joel S. Weissman, Ph.D., and Dr. Michael Zinner.

"Would it be a better use of resources to train more surgeons in laparoscopic techniques than to spend the money on more robot machines?" they asked.

"As reimbursement policies stand today, payments for laparoscopic surgery are the same whether or not the procedures are robotically assisted. Therefore, neither patients, physicians, nor hospitals have the motivation to pursue the less expensive option," Dr. Weissman and Dr. Zinner wrote.

Dr. Weissman is at the center for surgery and public health and the patient-centered comparative effectiveness research center at Brigham and Women’s Hospital, Boston. Dr. Zinner is also at Brigham and Women’s Hospital. They reported no potential financial conflicts of interest, except that Dr. Weissman has received a research grant from the National Pharmaceutical Council. These remarks were taken from their editorial accompanying Dr. Wright’s report (JAMA 2013;309:721-2).

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The use of a robotic surgical platform to perform hysterectomy for benign disease has increased substantially since its introduction and now accounts for nearly 10% of all hysterectomies nationwide, according to a report in the Feb. 20 issue of JAMA.

At hospitals across the United States where robotically assisted hysterectomy is performed, the procedure has shown notably rapid uptake: Within 3 years it accounted for more than 20% of hysterectomies, said Dr. Jason D. Wright of Columbia University, New York, and his associates.

Dr. Jason Wright

However, robotically assisted hysterectomy is no more effective than laparoscopic hysterectomy, and it has a similar perioperative morbidity profile. But it is markedly more expensive than any other modality of hysterectomy. "Our study indicates ... the robotic procedure offers little short-term benefit and is accompanied by significantly greater costs," the investigators wrote.

Dr. Wright and his colleagues performed a population-based analysis of the diffusion of robotically assisted hysterectomy using information from the Perspective national database, which measures resource utilization and quality. They focused on 264,758 hysterectomies for benign indications done at 441 hospitals in 2007-2010.

This included 123,288 abdominal hysterectomies, 54,912 vaginal hysterectomies, 75,761 laparoscopic hysterectomies, and 10,797 robotically assisted hysterectomies.

The rate of vaginal hysterectomy declined during the study period from 21.7% of all procedures in the first quarter of 2007 to 19.8% in the first quarter of 2010. Similarly, the rate of abdominal hysterectomy declined from 53.6% to 40.1%.

In contrast, the rate of laparoscopic hysterectomy increased during that time period, from 24.3% of all procedures in the first quarter of 2007 to 30.5% in the first quarter of 2010.

The rate of robotically assisted hysterectomy increased the most, from 0.5% to 9.5%, the investigators reported (JAMA 2013;309:689-98).

They compared complication rates between laparoscopic and robotically assisted hysterectomies, and found that the unadjusted rates of overall complications were very similar, at 5.3% and 5.5%, respectively. Also similar were the rates of intraoperative complications (2.4% vs. 2.5%), surgical site complications (2.0% vs. 1.7%), medical complications (1.2% vs. 1.6%), transfusion (1.8% vs. 1.4%), reoperation (0.1% in both groups), nonroutine hospital discharge (0.3% vs. 0.2%), and hospital mortality (0% in both groups).

However, the median cost for laparoscopic hysterectomy was $6,679, compared with $8,868 for robotically assisted hysterectomy. "Even when we excluded the fixed cost of the robotic platform and examined only variable costs, we noted that robotic hysterectomy remained the most costly modality for hysterectomy," Dr. Wright and his associates wrote.

Other researchers have posited that if robotically assisted hysterectomy replaced conventional surgery, health care costs would increase by more than $2.5 billion, Dr. Wright and his colleagues added.

Findings of the current investigation "highlight the importance of developing rational strategies to implement new surgical technologies," they said.

The reasons for the rapid uptake of robotic gynecologic surgery are not yet known, but several factors likely contributed. Robotic surgery may be easier to learn than laparoscopy "because it is more analogous to traditional open surgery." Also, robotic assistance may permit surgeons to perform "more technically demanding cases that would otherwise have required laparotomy," the investigators said.

And importantly, "robotic surgery has been the subject of extensive marketing, not only to surgeons and hospitals, but also to medical consumers," Dr. Wright and his colleagues noted.

They added that their analysis was limited because the data set didn’t include several important factors that likely influenced the selection of a given surgical approach, such as the patient’s body mass index and surgical history, as well as the estimated weight of the uterus.

This study was funded in part by the National Cancer Institute. No financial conflicts of interest were reported.

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