Robotic and Laparoscopic Surgery in Gynecology

For patients who are considering hysterectomy, uterine myomectomy, treatment of ovarian cysts, or other gynecologic surgeries, the following is some information and recommendations that you may find useful. The Amercian College of Obstetricians and Gynecologists and the Society of Gynecologic Surgeons has issued a Committee Opinion Number 628-March 2015 entitled “Robotic Surgery in Gynecology”. This bulletin has also been endorsed by the American Urogynecologic Society. This opinion emphasizes that for the most part there is no proven benefit of Robotic surgery over traditional laparoscopic surgery

Here are some excerpts from the committee opinion:

Summary of Current Evidence

“The rapid adoption of robotic technology for gynecologic surgery is not supported by high-quality patient outcomes, safety, or cost data.” ” Four randomized controlled trials compared robot-assisted surgery for benign gynecologic disease with laparoscopy, and none showed any benefit form using the robotic approach.” “Adoption of new surgical techniques should be driven by what is best for the patient, as determined by evidence-based medicine rather than external pressures.”

Benign Hysterectomy

“Overall, the current literature shows conflicting evidence and is of poor quality. Based on Randomized controlled trials and two large cohort studies, robot-assisted hysterectomy appears to have similar morbidity profiles to laparoscopic procedures but results in significantly higher costs. Further comparative studies that assess long-term outcomes and patient safety and identify subgroups of patients who would benefit from a robotic approach are warranted. Reporting of adverse events is currently voluntary and unstandardized, and the true rate of complications is not known”

Myomectomy

“Despite the purported benefits of robot assistance, data are limited to observational studies of varying quality and power. Although shown to have significantly shorter postoperative recovery times than abdominal myomectomy, robot-assisted laparoscopic myomectomies have longer operative times and significantly higher costs than abdominal and laparoscopic approaches.” “Furthermore, the current literature is insufficient to comment on post procedure conception rates or pregnancy outcomes. Comparative effectiveness studies are needed to better evaluate outcomes, safety, and cost of robot-assisted myomectomy”

Other Gynecologic Procedures

“Patients scheduled for gynecologic procedures of short duration and low complexity are unlikely to benefit from robotic-assisted surgery. The College and SGS suggest that there is no advantage, and that there are possible disadvantages, to performing the following procedures with robotic assistance compared with other minimally invasive approaches: Tubal ligation, Simple ovarian cystectomy, Surgical management of ectopic pregnancy, Prophylactic bilateral salpingo-oophorectomy”

On March 14, 2013 a “Statement on Robotic Surgery” was published by the President of the American College of Obstetrics and Gynecology. Here are some excerpts:

“Many women today are hearing about the claimed advantages of robotic surgery for hysterectomy, thanks to widespread marketing and advertising. Robotic surgery is not the only or the best minimally invasive approach for hysterectomy. Nor is it the most cost-efficient. It is important to separate the marketing hype from the reality when considering the best surgical approach for hysterectomies.”

“Vaginal hysterectomy, performed through a small opening at the top of the vagina without any abdominal incisions, is the least invasive and least expensive option. Based on its well-documented advantages and low complication rates, this is the procedure of choice whenever technically feasible. When this approach is not possible, laparoscopic hysterectomy is the second least invasive and costly option for patients.”

“Robotic hysterectomy generally provides women with a shorter hospitalization, less discomfort, and faster return to full recovery compared with traditional total abdominal hysterectomy(TAH) which requires a large incision. However, both vaginal and laparoscopic approaches also require fewer days of hospitalization and a far shorter recovery than TAH. These two established methods also have proven track records for outstanding patient outcomes and cost efficiencies.”

Bottom Line:

When a hysterectomy is indicated my personal preference as a Board Certified ObGyn physician is to perform vaginal hysterectomy or laparoscopic hysterectomy when possible. These are time proven methods with low complications and less costly than Robotics. There are certain specific complicated cases that I feel may benefit from a Robotic approach. In these situations I refer my patient to a surgeon whom I know is an expert in the field of Robotics and has a practice concentrated in this area, since there is a steep learning curve in Robotics. My approach has always been to recommend the procedure that I feel is best for the patient, and to have this performed by the physician that I feel is most competent to perform the procedure. We are always glad to perform second opinions regarding best surgical approaches for each individual patient.

Keith Reisler – author

Board Certified in Obstetrics and Gynecology