The OBG Management expert panel
Arnold P. Advincula, MD, is Professor of Obstetrics and Gynecology at the University of Central Florida College of Medicine in Orlando, Florida. He is Medical Director of the Center for Specialized Gynecology at Florida Hospital Celebration Health and oversees its Fellowship Program in Minimally Invasive Surgery.
Cheryl B. Iglesia, MD, is Director of the Section of Female Pelvic Medicine and Reconstructive Surgery at MedStar Washington Hospital Center. She is also Associate Professor, Departments of Obstetrics and Gynecology and Urology, at Georgetown University School of Medicine in Washington, DC. She serves on the OBG Management Board of Editors.
Rosanne M. Kho, MD, is Associate Professor of Obstetrics and Gynecology at the Mayo Clinic in Scottsdale, Arizona.
Jamal Mourad, DO, practices Obstetrics and Gynecology at Southwest Women’s Care in Phoenix, Arizona.
Marie Fidela R. Paraiso, MD, is Professor of Surgery, Cleveland Clinic Lerner College of Medicine at Case Western Reserve University, and Head of the Center for Urogynecology and Reconstructive Pelvic Surgery of the Obstetrics, Gynecology, and Women’s Health Institute at the Cleveland Clinic in Ohio. Dr. Paraiso also holds a joint appointment in the Cleveland Clinic Glickman Urological and Kidney Institute.
Jason D. Wright, MD, is Levine Family Assistant Professor of Women’s Health and Florence Irving Assistant Professor of Obstetrics and Gynecology, Division of Gynecologic Oncology, at Columbia University College of Physicians and Surgeons in New York, New York.
Dr. Iglesia, Dr. Kho, Dr. Mourad, Dr. Paraiso, and Dr. Wright report no financial relationships relevant to this article. Dr. Advincula reports that he is a consultant to Blue Endo, Cooper Surgical, Covidien, Intuitive Surgical, and Surgiquest.
The publication of a large cohort study of hysterectomy for benign indications revived a debate over robotic assistance in gynecologic surgery.1 The study—by Jason D. Wright, MD, and colleagues—included 264,758 women who underwent hysterectomy for benign indications in 441 US hospitals from 2007 to 2010, and it produced some dramatic findings:
- The use of robotic assistance increased from 0.5% of all hysterectomies in 2007 to 9.5% in 2010
- Three years after the first robotic procedure in each hospital where robotics were used, robotic-assisted hysterectomy accounted for 22.4% of all hysterectomies
- Laparoscopic hysterectomy increased as well, from 24.3% of all hysterectomies in the first quarter of 2007 to 30.5% in the first quarter of 2010
- The rate of vaginal hysterectomy declined from 21.7% to 19.8% of all hysterectomies during the same time period
- Abdominal hysterectomy decreased from 53.6% to 43.1% of all hysterectomies
- Although robotic-assisted and laparoscopic hysterectomy had similar complication rates, transfusion requirements, and rates of discharge to a nursing facility, the robotic-assisted approach cost $2,189 more.1
An editorial accompanying this study opined that physicians and hospitals have a “duty” to make sure patients are aware not only of the benefits and risks of each surgical option but also of its financial cost.2 The editorialists suggested that cost should be taken into account by the surgeon, as well. When a more expensive treatment proves to be more effective than the conventional approach, there typically is little argument about paying the higher cost. When the new treatment or technology is equally effective, however, as is the case with robotic hysterectomy and the laparoscopic approach, the choice of treatment “should be more straightforward.”2 That is, the lower-cost treatment should be preferred, the editorialists concluded.
The study by Wright and colleagues and the accompanying editorial prompted some important questions:
- Should robotic assistance be offered for patients undergoing hysterectomy for benign indications when it produces outcomes equivalent to laparoscopic hysterectomy but costs one-third more?
- Is the robotic approach justified in other benign gynecologic surgical procedures?
To explore these questions, we invited a roster of experts in minimally invasive gynecologic surgery to share their perspective and experience, including the lead author of the article mentioned above, Jason D. Wright, MD. In this roundtable discussion, these experts discuss the robotic experience at their respective institutions, characterize the data to date, and offer valuable suggestions about whether and when to incorporate the robot into your surgical practice.
To read 9 recent articles from OBG Management on the pros and cons of robotic surgery, click here.
What is driving the demand?
OBG Management: How much of the demand for the robot do you think is patient-driven? Hospital-driven? Physician- or data-driven?
Cheryl B. Iglesia, MD: With any new technology, there is a honeymoon phase when providers, patients, and hospitals really tout innovation. With its superior optics and 3D vision, the robot certainly enjoyed an extended honeymoon, driven by innovation and a “cool factor.” However, as experience, comparative studies, and longer-term outcomes data become known, demand for new technology is tempered and refined. The choice of technology also has to include an acknowledgement of its cost-effectiveness—or lack of it.