Robotic Hysterectomy Value Remains Unclear

Larry Hand

February 20, 2013

Robotically assisted hysterectomy offers similar benefits as laparoscopic hysterectomy but costs significantly more, according to a study published in the February 20 issue of JAMA.

Jason D. Wright, MD, from the Department of Obstetrics and Gynecology, Columbia University College of Physicians and Surgeons, New York City, and colleagues analyzed the records of 264,758 women (aged from <40 to >60 years) who underwent benign hysterectomies at 441 hospitals between 2007 and 2010.

Of these women, 123,288 (46.6%) underwent abdominal hysterectomies, 54,912 (20.7%) had vaginal hysterectomies, 75,761 (28.6%) had laparoscopic hysterectomies, and 10,797 (4.1%) had robotically assisted procedures in which surgeons performed the operation from a remote console.

When the researchers compared complication rates of robotically assisted hysterectomies with those of laparoscopic hysterectomies, they found similar rates in a propensity score–matched analysis (5.5% robotic vs 5.3% laparoscopic; relative risk [RR], 1.03; 95% confidence interval [CI], 0.86 - 1.24; P = .47).

The researchers also found that robotically assisted hysterectomies cost $2189 (95% CI, $2073 - $2377) more per case than laparoscopic procedures. Median total cost came to $6679 (interquartile range [IQR], $5197 - $8673) for laparoscopic hysterectomy and $8868 (IQR, $6787 - $11,830) for robotically assisted hysterectomy.

The researchers developed statistical models using multivariate regression to analyze the effects of patient and hospital characteristics and year the procedures were performed, sorting hospitals by location, region of the country, size (<400 to >600 beds), and teaching status. They used these factors to estimate a propensity score (0 - 1), or probability that a patient would undergo a robotically assisted procedure.

"[A]t 3 years...after the first robotic procedure in each hospital where robotics were used, robotic-assisted hysterectomy accounted for 22.4% of all hysterectomies," the researchers write, whereas numbers of vaginal, laparoscopic, and abdominal procedures declined. At hospitals that did not offer robotic procedures, laparoscopic procedures grew from 24.2% to 34.7% and abdominal and vaginal procedures declined, they write.

Among other findings, robotic procedures were more likely to be performed in the latter years of the study and at larger metropolitan hospitals; black women were less likely (RR, 0.86; 95% CI, 0.80 - 0.93) to undergo a robotic procedure than white women, and Medicare recipients (RR, 0.88; 95% CI, 0.80 - 0.96), Medicaid (RR, 0.84; 95% CI, 0.73 - 0.97), and uninsured (RR, 0.53; 95% CI, 0.42 - 0.66) patients were less likely to have robotic procedures than commercially insured patients.

The researchers did find some value in robotically assisted procedures. Those who underwent robotic-assisted procedures were less likely to stay longer than 2 days in the hospital (19.6% vs 24.9%; RR, 1.03; 95% CI, 0.86 - 1.24), less likely to require transfusions (1.4% vs 1.8%; RR, 0.80; 95% CI, 0.67 - 0.92), and less likely to be discharged to a nursing facility (0.2% vs 0.3%; RR, 0.79; 95% CI, 0.35 - 1.76).

"Our findings highlight the importance of developing rational strategies to implement new surgical technologies," the researchers write.

"From a public health standpoint, defining subsets of patients with benign gynecologic disorders who derive benefit from robotic hysterectomy, reducing the cost of robotic instrumentation, and developing initiatives to promote laparoscopic hysterectomy are warranted," they conclude.

In an accompanying editorial, Joel S. Weissman, PhD, and Michael Zinner, MD, from Brigham and Women's Hospital, Boston, Massachusetts, write, "In the absence of additional research or decreases in price, the path taken by the medical and payer community should be one of caution. At a minimum, manufacturers might begin by voluntarily restricting their promotional activities."

This study was supported in part by the National Cancer Institute. The authors and Dr. Zinner have disclosed no relevant financial relationships. Dr Weissman has reported having received a research grant from the National Pharmaceutical Council.

JAMA. 2013;309:689-697, 721-722. Full text