Robotic compared with conventional laparoscopic hysterectomy: a randomized controlled trial

Pain management after laparoscopic hysterectomy: systematic review of literature and PROSPECT recommendations

BACKGROUND AND OBJECTIVES

Laparoscopic hysterectomy is increasingly performed because it is associated with less postoperative pain and earlier recovery as compared with open abdominal hysterectomy. The aim of this systematic review was to evaluate the available literature regarding the management of pain after laparoscopic hysterectomy.

STRATEGY AND SELECTION CRITERIA

Randomized controlled trials evaluating postoperative pain after laparoscopic hysterectomy published between January 1996 and May 2018 were retrieved, according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, from the EMBASE and MEDLINE databases and the Cochrane Register of Controlled Trials. Efficacy and adverse effects of analgesic techniques were assessed.

RESULTS

Of the 281 studies initially identified, 56 were included. Of these, 31 assessed analgesic or anesthetic interventions and 25 assessed surgical interventions. Acetaminophen, non-steroidal anti-inflammatory drugs, and dexamethasone reduced opioid consumption. Limited evidence hindered recommendations on alpha-2-agonists. Inconsistent evidence was found in the studies investigating pregabalin and transversus abdominis plane block, and no evidence was found for intraperitoneal local anesthetics, port site infiltration, or single-port laparoscopy. Measures to lower peritoneal insufflation pressure or humidify or heat insufflated gas seem to reduce the incidence of shoulder pain, but not abdominal pain.

CONCLUSIONS

The baseline analgesic regimen for laparoscopic hysterectomy should include acetaminophen, a non-steroidal anti-inflammatory drug, dexamethasone, and opioids as rescue analgesics.

Review of strategies and factors to maximize cost-effectiveness of robotic hysterectomies and myomectomies in benign gynecological disease

Common benign gynecologic procedures include hysterectomies and myomectomies, with hysterectomy being the most common gynecologic procedure in the United States [1]. While historically performed via laparotomy, the field of gynecologic surgery was revolutionized with the advent of laparoscopic techniques, with the most recent advancement being the introduction of robotic-assisted surgery in 2005. Robotic surgery has all the benefits of laparoscopic surgery such as decreased blood loss, quicker return to activities, and shorter length of hospital stay. Additional robotic-specific advantages include but are not limited to improved ergonomics, 3D visualization, and intuitive surgical movements. Despite these advantages, one of the most commonly cited drawbacks of robotic surgery is the associated cost. While the initial cost to purchase the robotic console and its associated maintenance costs are relatively high, robotic surgery can be cost-effective when utilized correctly.This article reviews application strategies and factors that can offset traditional costs and maximize the benefits of robotic surgery.

Infectious complications of laparoscopic and robotic hysterectomy: a systematic literature review and meta-analysis

OBJECTIVE

We performed a systematic review of the literature and meta-analysis of the infectious complications of hysterectomy, comparing robotic-assisted hysterectomy to conventional laparoscopic-assisted hysterectomy.

METHODS

We searched PubMed, CINAHL, CDSR, and EMBASE through July 2018 for studies evaluating robotic-assisted hysterectomy, laparoscopic-assisted hysterectomy, and infectious complications. We employed random-effect models to obtain pooled OR estimates. Heterogeneity was evaluated with I2 estimation and the Cochran Q statistic. Pooled ORs were calculated separately based on the reason for hysterectomy (eg, benign uterine diseases, endometrial cancer, and cervical cancer).

RESULTS

Fifty studies were included in the final review for the meta-analysis with 176 016 patients undergoing hysterectomy. There was no statistically significant difference in the number of infectious complication events between robotic-assisted hysterectomy and laparoscopic-assisted hysterectomy (pooled OR 0.97; 95 % CI 0.74 to 1.28). When we performed a stratified analysis, similar results were found with no statistically significant difference in infectious complications comparing robotic-assisted hysterectomy to laparoscopic-assisted hysterectomy among patients with benign uterine disease (pooled OR 1.10; 95 % CI 0.70 to 1.73), endometrial cancer (pooled OR 0.97; 95 % CI 0.55 to 1.73), or cervical cancer (pooled OR 1.09; 95 % CI 0.60 to 1.97).

CONCLUSION

In our meta-analysis the rate of infectious complications associated with robotic-assisted hysterectomy was no different than that associated with conventional laparoscopic-assisted hysterectomy.

Is Robotic-Assisted Surgery Safe in the Elderly Population? An Analysis of Gynecologic Procedures in Patients ≥ 65 Years Old

BACKGROUND

The elderly population is expanding worldwide but is underrepresented in clinical trials. We sought to assess the safety of robotic gynecologic surgery in an elderly cohort and to identify factors associated with unfavorable outcomes.

METHODS

All patients ≥ 65 years who underwent a robotically assisted procedure at a single institution between May 2007 to December 2016 were divided into three age groups: 65-74 (Group 1); 75-84 (Group 2); ≥ 85 (Group 3). Perioperative outcomes were recorded in patients who did not require conversion to laparotomy. We compared clinical variables among groups and performed multivariate logistic regression to detect variables associated with major complications (≥ Grade 3) or 90-day mortality.

RESULTS

We retrospectively identified 982 cases: 685 in Group 1; 249 in Group 2; 48 in Group 3. Median age = 71 years. Median BMI = 28.9. Malignancy was documented in 72.8% of cases; the majority were endometrial cancer (61.8%). Thirty-four patients (3.5%) were readmitted within 30 days. Seventy-seven (7.8%) had a postoperative complication, and 23 (2.3%) had a major complication. Ninety-day mortality was 0.5%. There was significant difference between groups with respect to body mass index (P = 0.026), ECOG PS (P ≤ 0.001), > 5 comorbidities (P = 0.005), hospital stay (P < 0.001), major complications (P = 0.001), and 90-day mortality (P < 0.001). On multivariable logistic regression, age ≥ 85 years was associated with major complications. Body mass index, age ≥ 85 years, and major complications were significantly associated with 90-day mortality.

CONCLUSIONS

Robotic-assisted surgery appears to be safe in an elderly cohort. The incidence of overall and major complications is consistent with those reported in the literature. Patients ≥ 85 years old appear to be at higher risk of unfavorable outcomes.

Impact of Laparoscopic Hysterectomy on Quality of Life

There is an ongoing debate regarding the benefits and drawbacks of the various routes of hysterectomy. A number of studies have examined overall quality of life outcomes as well as specific patient-reported outcomes including physical, psychosocial, and sexual functioning after hysterectomy. Existing studies have used varied methodologies with widely heterogeneous results, but patient satisfaction appears to be very high after laparoscopic hysterectomy, with many studies favoring the laparoscopic approach over other routes of hysterectomy. There are many opportunities for further investigation into the impact of laparoscopic hysterectomy on quality of life-an outcome measure that may be 1 of the most important in surgeries for benign indications.

Robotic, Laparoscopic, or Open Hysterectomy: Surgical Outcomes by Approach in Endometrial Cancer

STUDY OBJECTIVES

To compare patient outcomes by surgical approach in the management of endometrial cancer (EC) in Washington State from 2008 to 2013.

DESIGN

Population-based retrospective cohort study (Canadian Task Force classification II-2).

SETTING

Washington State.

PATIENTS

EC patients treated with robotic-assisted surgery (RAS), laparoscopy (LS), or laparotomy (XLAP).

INTERVENTIONS

Comprehensive Hospital Abstract Reporting System to identify patients and assess the association of surgical approach with length of stay, readmissions, and perioperative complications.

MEASUREMENTS AND RESULTS

We identified 3712 cases of EC managed with either RAS, LS, or XLAP. Mean length of stay was not clinically different for RAS (1.5 days) and LS (1.6 days) but was 2.31 days longer for XLAP compared with LS (p < .001). Odds of any readmission did not differ for either RAS or XLAP compared with LS; however, early readmissions were half as likely for RAS compared with LS (p = .014). Complications were more than 2.5 times as likely for XLAP versus LS (p < .001), whereas complications did not differ for RAS versus LS (p = .931).

CONCLUSIONS

RAS is as an alternative to LS in the treatment of EC and is preferable to XLAP. The use of RAS resulted in fewer early readmissions compared with LS and resulted in an increased proportion of cases via minimally invasive surgery.

Robot-assisted laparoscopic surgery versus conventional laparoscopic surgery in randomized controlled trials: A systematic review and meta-analysis

Importance

This review provides a comprehensive comparison of treatment outcomes between robot-assisted laparoscopic surgery (RLS) and conventional laparoscopic surgery (CLS) based on randomly-controlled trials (RCTs).

Objectives

We employed RCTs to provide a systematic review that will enable the relevant community to weigh the effectiveness and efficacy of surgical robotics in controversial fields on surgical procedures both overall and on each individual surgical procedure.

Evidence review

A search was conducted for RCTs in PubMed, EMBASE, and Cochrane databases from 1981 to 2016. Among a total of 1,517 articles, 27 clinical reports with a mean sample size of 65 patients per report (32.7 patients who underwent RLS and 32.5 who underwent CLS), met the inclusion criteria.

Findings

CLS shows significant advantages in total operative time, net operative time, total complication rate, and operative cost (p < 0.05 in all cases), whereas the estimated blood loss was less in RLS (p < 0.05). As subgroup analyses, conversion rate on colectomy and length of hospital stay on hysterectomy statistically favors RLS (p < 0.05).

Conclusions

Despite higher operative cost, RLS does not result in statistically better treatment outcomes, with the exception of lower estimated blood loss. Operative time and total complication rate are significantly more favorable with CLS.

Comparison of Perioperative Complications by Route of Hysterectomy Performed for Benign Conditions

OBJECTIVE

The aim of this study was to compare perioperative complications by route of hysterectomy before and after the introduction of robotic surgery.

METHODS

This is an ancillary analysis of a multicenter, retrospective cohort study with historical controls through the Fellows' Pelvic Research Network. Hysterectomies performed for benign conditions were collected prior to introduction of the robot (prerobot) and the year after introduction of the robot (postrobot) at each institution. To obtain a representative annual case distribution for each institution, a maximum of 20 cases per month were selected using stratified random sampling. Patient demographics and intraoperative and postoperative complication data were collected.

RESULTS

One thousand four hundred forty cases were included in this study, 732 in the prerobot and 708 in the postrobot period. Intraoperative complications in the prerobot group were highest in the abdominal group (7.4%) followed by vaginal (3.9%) and laparoscopic (3.7%) groups. Postoperative complications were higher in the vaginal (8.3%) and abdominal (7.4%) groups compared with laparoscopic (1.8%) groups (P = 0.03), because of a higher proportion of infections. In the postrobot period, intraoperative complications were lower in the vaginal (2.8%), robotic (3%), and laparoscopic (4.6%) groups compared with abdominal (10.8%) (P = 0.04). Postoperative complications were lowest in the vaginal (5.1%), laparoscopic (3.6%), and robotic (3%) approaches compared with the abdominal (13.9%) approach (P = 0.003).

CONCLUSIONS

Vaginal hysterectomy has comparable rates of perioperative complications when compared with robotic and laparoscopic approaches and should be considered as a primary surgical approach in the growing armamentarium of minimally invasive approaches for hysterectomy for benign conditions.

Movement to outpatient hysterectomy for benign indications in the United States, 2008-2014

INTRODUCTION

The past decade has witnessed adoption of conservative gynecologic treatments, including minimally invasive surgery (MIS), alongside steady declines in inpatient hysterectomies. It remains unclear what factors have contributed to trends in outpatient benign hysterectomy (BH), as well as whether these trends exacerbate disparities.

MATERIALS AND METHODS

Retrospective cohort of 527,964 women ≥18 years old who underwent BH from 2008 to 2014. BH surgical approaches included: open/abdominal hysterectomy (AH), vaginal hysterectomy (VH), laparoscopic hysterectomy (LH), and robotic-assisted hysterectomy (RH). Quarterly frequencies were calculated by care setting and surgical approach. We used multilevel logistic regression (MLR) using the most recent year of data (2014) to examine the influence of patient-, physician-, and hospital-level preoperative factors and surgical approaches on outpatient migration.

RESULTS

From 2008-2014, surgical approaches for LH and RH increased, which coincided with decreases in VH and AH. Overall, a 44.2% shift was observed from inpatient to outpatient settings (P<0.0001). Among all outpatient visits MIS increased, particularly for RH (3.6% to 41.07%). We observed increases in the proportion of non-Hispanic Black and Medicaid patients who obtained MIS in 2014 vs. 2008 (P<0.001). Surgical approach (51.8%) and physician outpatient MIS experience (19.9%) had the greatest influence on predicting outpatient BH. Compared with LH, RH was associated with statistically significantly higher likelihood of outpatient BH overall (OR 1.23; 95% CI, 1.16-1.31), as well as in sub-analyses of more complex cases and hospitals that performed ≥1 RH (P<0.05).

CONCLUSION

From 2008-2014, rates of LH and RH significantly increased. A significant shift from inpatient to outpatient setting was observed. These findings suggest that RH may facilitate the shift to outpatient BH, particularly for patients with complexities. The adoption of MIS in outpatient settings may improve access to disadvantaged patient groups.

Arm reduced robotic-assisted laparoscopic hysterectomy with transvaginal cuff closure

INTRODUCTION

The use of robotics for benign etiology in gynecology has not proven to be more beneficial when compared to traditional laparoscopy. The major concern regarding robotic hysterectomy stems from its high cost.

AIM

To evaluate the clinical utility and effectiveness of one-arm reduced robotic-assisted laparoscopic hysterectomy as a cost-effective surgical option for total robotic hysterectomy.

MATERIAL AND METHODS

A sample population of 54 women who underwent robotic-assisted laparoscopic surgery for benign gynecologic indications was evaluated, and two groups were identified: (1) the two-armed robotic-assisted laparoscopic surgery group (n = 38 patients), and (2) the three-armed robotic-assisted laparoscopic surgery group (n = 16 patients).

RESULTS

An increased cost was observed when three-armed robotic surgery was employed for benign gynecologic surgery (p < 0.001). The cost reduction observed in the study group was primarily derived from one robotic arm reduction and vaginal closure of the cuff. This cost reduction was achieved without an increase in complication rates or undesirable postoperative outcomes. An estimated profit between $399.5 and $421.5 was made for each patient depending on the suture material chosen for cuff closure. Two-armed surgery resulted in an 18.6% reduction in procedure-specific costs for robotic hysterectomy.

CONCLUSIONS

Two-armed robotic-assisted laparoscopic hysterectomy appears to be a cost-effective solution for robotic gynecologic surgery. This surgical solution can be performed as effectively as classical three-armed robotic hysterectomies for benign indications without the risk of increased surgical-related morbidities. This approach has the potential to be a widely preferred surgical approach in medical communities where cost reduction is one of the primary determinants of surgery type.

Alternatives to hysterectomy: The burden of fibroids and the quality of life

Uterine fibroids are the most common benign tumor in reproductive-aged women. While the majority of women are asymptomatic, those with symptoms may suffer from abnormal uterine bleeding, infertility, pelvic pain or pressure, and urinary dysfunction. Fibroids represent a significant healthcare burden for women and society as a whole. Women with fibroids have compromised overall quality of life and impairment in many specific domains including work productivity, sexuality, self-image, relationships, and social emotional and physical well-being. Many women are reluctant to ask for help and delay seeking treatment. To date, myomectomy remains the gold standard for treating fibroid-related symptoms in reproductive-aged women. However, many less invasive uterine preserving approaches have been developed. Quality of life is improved in many women following treatment for fibroids. This article aims to provide an overview of the substantial impact of fibroids on health-related quality of life.

Managing Postoperative Pain After Minimally Invasive Gynecologic Surgery in the Era of the Opioid Epidemic

In this review, we examine the evidence behind nonopioid medication alternatives, peripheral nerve blocks, surgical techniques, and postoperative recovery protocols that can help minimize and effectively treat postoperative pain after minimally invasive gynecologic surgery (MIGS). Because of the depth and heterogeneity of the data, a narrative review was performed of reported interventions. A comprehensive review was performed of PubMed, Embase, and the Cochrane Database with a focus on randomized controlled trials. In the absence of literature specific to benign gynecology, similar specialty or procedural data were reviewed. A variety of nonopioid medications, surgical techniques, and postoperative recovery protocols have shown significant improvements in postoperative pain after gynecologic surgery. Nonopioid medication options that are beneficial include acetaminophen, nonsteroidal anti-inflammatories, and antiepileptics. Incision infiltration with local anesthesia also significantly reduces pain. Surgically, minimally invasive approaches, reducing the laparoscopic trocar size to <10 mm, and evacuating the pneumoperitoneum at the end of the case all have significant benefits. Lastly, enhanced recovery pathways show promise in reducing pain after MIGS. By using a multimodal approach, minimally invasive gynecologic surgeons can help to minimize and manage postoperative pain with less reliance on opioid pain medications.

Systematic review of the limited evidence for different surgical techniques at benign hysterectomy: A clinical guideline initiated by the Danish Health Authority

Hysterectomy for benign gynecological conditions is a common operation that has developed extensively through the last 20 years. Methods and surgical techniques vary throughout the regions in Denmark as well as internationally. Consequently, the Danish Health Authority initiated a national clinical guideline on the subject based on a systematic review of the literature. A guideline panel of seven gynecologists formulated the clinical questions for the guideline. A search specialist performed the comprehensive literature search. The guideline panel reviewed the literature and rated the quality of evidence according to the Grading of Recommendations Assessment, Development and Evaluation (GRADE). Finally, the panel weighted the evidence and formulated the clinical recommendations. Based on the limited available literature and the corresponding quality of evidence according to GRADE, the guideline panel gave the following recommendations: ↓ Subtotal hysterectomy should only be preferred over total hysterectomy after careful consideration because there are documented disadvantages such as persistent cyclic vaginal bleeding (⊕ΟΟΟ). ↑ Consider vaginal hysterectomy rather than conventional laparoscopic hysterectomy for non-prolapsed uteri when feasible (⊕ΟΟΟ). ↓ Robot-assisted laparoscopic hysterectomy should only be preferred over conventional laparoscopic hysterectomy after careful consideration because the beneficial effect is uncertain and because of the longer operating time (⊕⊕ΟΟ). ↑ Consider concomitant bilateral salpingectomy at the time of hysterectomy if the procedure is not considered to increase the risk of complications significantly (⊕ΟΟΟ). ↑ Consider vaginal vault suspension to the cardinal and the uterosacral ligaments when performing hysterectomy for non-prolapsed uteri (⊕ΟΟΟ). Though supporting evidence is missing, the guideline panel emphasizes that it is good practice not to morcellate uteri with presumed fibroids inside the peritoneal cavity (√). The recommendations serve as professional advice in specific clinical situations. The implementation of the guideline in Denmark will be monitored through the national Danish Hysterectomy and Hysteroscopy Database.

Health care cost consequences of using robot technology for hysterectomy: a register-based study of consecutive patients during 2006-2013

The objective of this study is to examine the costs attributable to robotic-assisted laparoscopic hysterectomy from a broad healthcare sector perspective in a register-based longitudinal study. The population in this study were 7670 consecutive women undergoing hysterectomy between January 2006 and August 2013 in public hospitals in Denmark. The interventions in the study were total and radical hysterectomy performed robotic-assisted laparoscopic hysterectomy (RALH), total laparoscopic hysterectomy (TLH), or open abdominal hysterectomy (OAH). Service use in the healthcare sector was evaluated 1 year before to 1 year after the surgery. Tariffs of the activity-based remuneration system and the diagnosis-related grouping case-mix system were used for valuation of primary and secondary care, respectively. Costs attributable to RALH were estimated using a difference-in-difference analytical approach and adjusted using multivariate linear regression. The main outcome measure was costs attributable to OAH, TLH, and RALH. For benign conditions RALH generated cost savings of € 2460 (95% CI 845; 4075) per patient compared to OAH and non-significant cost savings of € 1045 (95% CI -200; 2291) when compared with TLH. In cancer patients RALH generated cost savings of 3445 (95% CI 415; 6474) per patient when compared to OAH and increased costs of € 3345 (95% CI 2348; 4342) when compared to TLH. In cancer patients undergoing radical hysterectomy, RALH generated non-significant extra costs compared to OAH. Cost consequences were primarily due to differences in the use of inpatient service. There is a cost argument for using robot technology in patients with benign disease. In patients with malignant disease, the cost argument is dependent on comparator.

Robotic single-site supracervical hysterectomy with manual morcellation: Preliminary experience

AIM

To evaluate the feasibility, safety and peri- and postoperative outcomes of robotic single-site supracervical hysterectomy (RSSSH) for benign gynecologic disease.

METHODS

We report 3 patients who received RSSSH for adenomyosis of the uterus from November 2015 to April 2016. We evaluated the feasibility, safety and outcomes among these patients.

RESULTS

The mean surgical time was 244 min and the estimated blood loss was 216 mL, with no blood transfusion necessitated. The docking time was shortened gradually from 30 to 10 min. We spent 148 min on console operation. Manual morcellation time was also short, ranging from 5 to 10 min. The mean hospital stay was 5 d. Lower VAS pain score was also noted. There is no complication during or after surgery.

CONCLUSION

RSSSH is feasible and safe, incurs less postoperative pain and gives good cosmetic appearance. The technique of in-bag, manual morcellation can avoid tumor dissemination.

Perioperative surgical outcome of conventional and robot-assisted total laparoscopic hysterectomy

BACKGROUND

To evaluate surgical outcome in a consecutive series of patients with conventional and robot assisted total laparoscopic hysterectomy.

METHODS

A retrospective cohort study was performed among patients with benign and malignant indications for a laparoscopic hysterectomy. Main surgical outcomes were operation room time and skin to skin operating time, complications, conversions, rehospitalisation and reoperation, estimated blood loss and length of hospital stay.

RESULTS

A total of 294 patients were evaluated: 123 in the conventional total laparoscopic hysterectomy (TLH) group and 171 in the robot TLH group. After correction for differences in basic demographics with a multivariate linear regression analysis, the skin to skin operating time was a significant 18 minutes shorter in robot assisted TLH compared to conventional TLH (robot assisted TLH 92m, conventional TLH 110m, p0.001). The presence or absence of previous abdominal surgery had a significant influence on the skin to skin operating time as did the body mass index and the weight of the uterus. Complications were not significantly different. The robot TLH group had significantly less blood loss and lower rehospitalisation and reoperation rates.

CONCLUSIONS

This study compares conventional TLH with robot assisted TLH and shows shorter operating times, less blood loss and lower rehospitalisation and reoperation rates in the robot TLH group.

Robotic-assisted hysterectomy: patient selection and perspectives

Minimally invasive hysterectomy via the laparoscopic or vaginal approach is beneficial to patients when compared with laparotomy, but has not been offered in the past to all women because of the technical difficulties and the long learning curve required for laparoscopic hysterectomy. Robotic-assisted hysterectomy for benign indications may allow for a shorter learning curve but does not offer clear advantages over conventional laparoscopic hysterectomy in terms of surgical outcomes. In addition, robotic hysterectomy is invariably associated with increased costs. Nevertheless, this surgical approach has been widely adopted by gynecologic surgeons. The aim of this review is to describe specific indications and patients who may benefit from robotic-assisted hysterectomy. These include hysterectomy for benign conditions in cases with high surgical complexity (such as pelvic adhesive disease and endometriosis), hysterectomy and lymphadenectomy for treatment of endometrial carcinoma, and obese patients. In the future, additional evidence regarding the benefits of single-site robotic hysterectomy may further modify the indications for robotic-assisted hysterectomy.

Comparison of cost and operative outcomes of robotic hysterectomy compared to laparoscopic hysterectomy across different uterine weights

Operative cost and outcomes between robotic and laparoscopic hysterectomy across different uterine weights. Retrospective cohort study including patients undergoing robotic and laparoscopic hysterectomy for benign disease at an Academic university hospital. One hundred and ninety six hysterectomies were identified (101 robotic versus 95 laparoscopic). Demographic and surgical characteristics were statistically equivalent. Robotic group had a higher body mass index (±SD) (32.9 ± 6.5 versus 30.4 ± 7.1, p 0.012) and more frequent history of adnexal surgery (12.9 versus 4.2%, p 0.031). Laparoscopic group had a higher number of concurrent salpingectomy (81 versus 66.3%, p 0.02). Estimated blood loss did not differ between procedures. Compared to robotic hysterectomies, laparoscopic procedures added 47 min (CI: 31-63 min; p < 0.001) of operative time, costed $1648 more (CI: 500-2797; p = 0. 005) and had triple the odds of having an overnight admission (OR = 2.94 CI: 1.34-6.44; p = 0.007). After stratification of cases by uterine weight, the mean operative time difference between the two groups in uteri between 750 and 1000 g and in uteri >1000 g was 81.3 min (CI: 51.3-111.3, p < 0.0001) and 70 min (CI: 26-114, p < 0.005), respectively, in favor of the robotic group. Mean direct cost difference in uteri between 750 and 1000 g and uteri >1000 g was 1859$ (CI: 629-3090, p < 0.006) and 4509$ (CI: 377-8641, p < 0.004), respectively, also in favor of the robotic group. In expert hands, robotic hysterectomy for uteri weighing more than 750 g may be associated with shorter operative time and improved cost profile.

New Developments in Robotics and Single-site Gynecologic Surgery

Within the last 10 years there have been significant advances in minimal-access surgery. Although no emerging technology has demonstrated improved outcomes or fewer complications than standard laparoscopy, the introduction of the robotic surgical platform has significantly lowered abdominal hysterectomy rates. While operative time and cost were higher in robotic-assisted procedures when the technology was first introduced, newer studies demonstrate equivalent or improved robotic surgical efficiency with increased experience. Single-port hysterectomy has not improved postoperative pain or subjective cosmetic results. Emerging platforms with flexible, articulating instruments may increase the uptake of single-port procedures including natural orifice transluminal endoscopic cases.

Limited Evidence for Robot-assisted Surgery: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

PURPOSE

To evaluate available evidence on robot-assisted surgery compared with open and laparoscopic surgery.

METHOD

The databases Medline, Embase, and Cochrane Library were systematically searched for randomized controlled trials comparing robot-assisted surgery with open and laparoscopic surgery regardless of surgical procedure. Meta-analyses were performed on each outcome with appropriate data material available. Cochrane Collaboration's tool for assessing risk of bias was used to evaluate risk of bias on a study level. The GRADE approach was used to evaluate the quality of evidence of the meta-analyses.

RESULTS

This review included 20 studies comprising 981 patients. The meta-analyses found no significant differences between robot-assisted and laparoscopic surgery regarding blood loss, complication rates, and hospital stay. A significantly longer operative time was found for robot-assisted surgery. Open versus robot-assisted surgery was investigated in 3 studies. A lower blood loss and a longer operative time were found after robot-assisted surgery. No other difference was detected.

CONCLUSIONS

At this point there is not enough evidence to support the significantly higher costs with the implementation of robot-assisted surgery.

Randomized controlled trial comparing operative times between standard and robot-assisted laparoscopic hysterectomy

OBJECTIVE

To compare the operative time between robot-assisted laparoscopic hysterectomies and standard laparoscopic hysterectomies.

METHODS

A prospective, randomized controlled trial enrolled women aged 18-80 years attending Penn State Hershey Medical Center between April 23 and October 20, 2014 to undergo hysterectomy. Participants were randomized using a random number generator to undergo either robot-assisted or standard laparoscopic hysterectomy. The primary outcome was the total operative time (surgeon incision to surgeon stop, including robot docking time, if applicable). Intention-to-treat analyses were performed and the operative time was compared between the two treatments for non-inferiority, defined as a difference in operative time of no longer than 15 minutes.

RESULTS

There were 72 patients randomized to each treatment arm. The mean operative time was 73.9 minutes (median 67.0 minutes; interquartile range 59.0-83.0 minutes) in the robot-assisted hysterectomy group and 74.9 minutes (median 65.5 minutes; interquartile range 57.0-90.5 minutes) in the standard laparoscopic hysterectomy group. The upper bound of the 95% confidence interval of the difference in operative time was 6.6 minutes, below the 15-minute measure of non-inferiority.

CONCLUSION

When performed by a surgeon experienced in both techniques, the operative time for robot-assisted laparoscopic hysterectomy was non-inferior to that achieved with standard laparoscopic hysterectomy. CLINICALTRIALS.GOV: NCT02118974.

Comparison of robotic and other minimally invasive routes of hysterectomy for benign indications

BACKGROUND

Despite a lack of evidence showing improved clinical outcomes with robotic-assisted hysterectomy over other minimally invasive routes for benign indications, this route has increased in popularity over the last decade.

OBJECTIVE

We sought to compare clinical outcomes and estimated cost of robotic-assisted vs other routes of minimally invasive hysterectomy for benign indications.

STUDY DESIGN

A statewide database was used to analyze utilization and outcomes of minimally invasive hysterectomy performed for benign indications from Jan. 1, 2013, through July 1, 2014. A 1-to-1 propensity score-match analysis was performed between women who had a hysterectomy with robotic assistance vs other minimally invasive routes (laparoscopic and vaginal, with or without laparoscopy). Perioperative outcomes, intraoperative bowel and bladder injury, 30-day postoperative complications, readmissions, and reoperations were compared. Cost estimates of hysterectomy routes, surgical site infection, and postoperative blood transfusion were derived from published data.

RESULTS

In all, 8313 hysterectomy cases were identified: 4527 performed using robotic assistance and 3786 performed using other minimally invasive routes. A total of 1338 women from each group were successfully matched using propensity score matching. Robotic-assisted hysterectomies had lower estimated blood loss (94.2 ± 124.3 vs 175.3 ± 198.9 mL, P < .001), longer surgical time (2.3 ± 1.0 vs 2.0 ± 1.0 hours, P < .001), larger specimen weights (178.9 ± 186.3 vs 160.5 ± 190 g, P = .007), and shorter length of stay (14.1% [189] vs 21.9% [293] ≥2 days, P < .001). Overall, the rate of any postoperative complication was lower with the robotic-assisted route (3.5% [47] vs 5.6% [75], P = .01) and driven by lower rates of superficial surgical site infection (0.07% [1] vs 0.7% [9], P = .01) and blood transfusion (0.8% [11] vs 1.9% [25], P = .02). Major postoperative complications, intraoperative bowel and bladder injury, readmissions, and reoperations were similar between groups. Using hospital cost estimates of hysterectomy routes and considering the incremental costs associated with surgical site infections and blood transfusions, nonrobotic minimally invasive routes had an average net savings of $3269 per case, or 24% lower cost, compared to robotic-assisted hysterectomy ($10,160 vs $13,429).

CONCLUSION

Robotic-assisted laparoscopy does not decrease major morbidity following hysterectomy for benign indications when compared to other minimally invasive routes. While superficial surgical site infection and blood transfusion rates were statistically lower in the robotic-assisted group, in the absence of substantial reductions in clinically and financially burdensome complications, it will be challenging to find a scenario in which robotic-assisted hysterectomy is clinically superior and cost-effective.

Robotic-assisted vs traditional laparoscopic surgery for endometrial cancer: a randomized controlled trial

BACKGROUND

Previous studies comparing robotic-assisted laparoscopic surgery to traditional laparoscopic or open surgery in gynecologic oncology have been retrospective. To our knowledge, no prospective randomized trials have thus far been performed on endometrial cancer.

OBJECTIVE

We sought to prospectively compare traditional and robotic-assisted laparoscopic surgery for endometrial cancer.

STUDY DESIGN

This was a randomized controlled trial. From December 2010 through October 2013, 101 endometrial cancer patients were randomized to hysterectomy, bilateral salpingo-oophorectomy, and pelvic lymphadenectomy either by robotic-assisted laparoscopic surgery or by traditional laparoscopy. The primary outcome measure was overall operation time. The secondary outcome measures included total time spent in the operating room, and surgical outcome (number of lymph nodes harvested, complications, and recovery). The study was powered to show at least a 25% difference in the operation time using 2-sided significance level of .05. The differences between the traditional laparoscopy and the robotic surgery groups were tested by Pearson χ² test, Fisher exact test, or Mann-Whitney test.

RESULTS

In all, 99 patients were eligible for analysis. The median operation time in the traditional laparoscopy group (n = 49) was 170 (range 126-259) minutes and in the robotic surgery group (n = 50) was 139 (range 86-197) minutes, respectively (P < .001). The total time spent in the operating room was shorter in the robotic surgery group (228 vs 197 minutes, P < .001). In the traditional laparoscopy group, there were 5 conversions to laparotomy vs none in the robotic surgery group (P = .027). There were no differences as to the number of lymph nodes removed, bleeding, or the length of postoperative hospital stay. Four (8%) vs no (0%) patients (P = .056) had intraoperative complications and 5 (10%) vs 11 (22%) (P = .111) had major postoperative complications in the traditional and robotic surgery groups, respectively.

CONCLUSION

In patients with endometrial cancer, robotic-assisted laparoscopic surgery was faster to perform than traditional laparoscopy. Also total time spent in the operation room was shorter in the robotic surgery group and all conversions to laparotomy occurred in the traditional laparoscopy group. Otherwise, the surgical outcome was similar between the groups. Robotic surgery offers an effective and safe alternative in the surgical treatment of endometrial cancer.

Risk factors for robotic gynecologic procedures requiring conversion to other surgical procedures

OBJECTIVE

To determine the incidence of, and risk factors for, conversion from robotic gynecologic procedures to other procedure types.

METHODS

A retrospective cohort study included data from women who underwent any robotic gynecologic procedures between January 1, 2011 and December 31, 2012 at a tertiary care referral center in the USA. Demographic data, perioperative data, and surgeon experience (monthly case volume) data were retrieved; potential risk factors were compared between robotic procedures that were converted to other procedures and those completed as robotic procedures.

RESULTS

There were 942 robotic procedures during the study period. Conversion from robotic to any other type of procedure was recorded for 47 (5.0%, 95% confidence interval 3.8-6.6) procedures and robotic-to-open-surgery conversion occurred in 16 (1.7%, 95% confidence interval 1.0-2.7) procedures. Conversion from robotic surgery to another approach was associated with higher body mass index (P<0.001), previous laparotomy (P=0.042), and surgeons having a lower monthly robotic surgical case volume (P=0.011). Asthma (P=0.008), intra-operative bowel injury (P<0.001), intra-operative vascular injury (P=0.003), and single-port robotic surgery (P=0.034) were associated with increased odds of requiring conversion from robotic procedures.

CONCLUSION

The overall incidence of conversion from robotic surgery to laparotomy was low. Higher body mass index, previous laparotomy, history of asthma, using a single-port approach, and surgeon case volume were associated with the risk of conversion.

Minimally Invasive Gynecologic Surgery for Benign Conditions: Progress and Challenges

OBJECTIVE

The objective of this review is to evaluate the progress made in laparoscopic and hysteroscopic gynecologic surgery and address challenges still faced by surgeons using minimally invasive techniques to improve the care of women with noncancerous gynecologic problems.

METHODS

Relevant literature was reviewed and evidence-based arguments put forward in the article for the progress that has been made and the deficiencies that still exist.

RESULTS

In the last 2 decades, enormous progress has been made in providing minimally invasive surgical options for women with gynecologic diseases. The progress has been especially striking in the performance of hysterectomy, the most common major surgery performed on nonpregnant women. The recent controversy over power morcellation has revealed a poor understanding of the literature concerning leiomyosarcoma leading to confusion and consequently denial of minimally invasive surgical options for many women. Hysteroscopic surgery has been evolving rapidly with the development of hysteroscopic morcellator, global endometrial ablation systems, and hysteroscopic tubal sterilization.

CONCLUSIONS

Although huge advances have been made in minimally invasive gynecologic surgery, high-quality evidence from well-designed clinical trials is lacking for many of the new technologies. Accurate estimates regarding the risk of occult leiomyosarcoma are also lacking. Additional research is urgently needed to address these deficiencies.

Cost analysis of minimally invasive hysterectomy vs open approach performed by a single surgeon in an Italian center

Despite the rapid uptake of robotic surgery, the effectiveness of robotically assisted hysterectomy (RAH) remains uncertain, due to the costs widely variable. Observed the different related costs of robotic procedures, in different countries, we performed a detailed economic analysis of the cost of RAH compared with total laparoscopic (TLH) and open hysterectomy (OH). The three surgical routes were matched according to age, BMI, and comorbidities. Hysterectomy costs were collected prospectively from September 2014 to September 2015. Direct costs were determined by examining the overall medical pathway for each type of intervention. Surgical procedure cost for RAH was €3598 compared with €912 for TLH and €1094 for OH. The cost of the robot-specific supplies was €2705 per intervention. When considering overall medical surgical care, the patient treatment average cost of a RAH was €4695 with a hospital stay (HS) of 2 days (range 2-4) compared with €2053 for TLH and €2846 for OH. The main driver of additional costs is disposable instruments of the robot, which is not compensated by the hospital room costs and by an experienced team staff. Implementation of strategies to reduce the cost of robotic instrumentation is due. No significant cost difference among the three procedures was observed; however, despite the optimal operative time, the experienced, surgeon and the lower HS, RAH resulted 2, 3 times and 1, 6 times more expensive in our institution than TLH and OH, respectively.

Total Laparoscopic (S-LPS) versus TELELAP ALF-X Robotic-Assisted Hysterectomy: A Case-Control Study

STUDY OBJECTIVE

To compare the feasibility and safety of the TELELAP ALF-X system and standard laparoscopy for total hysterectomy to treat patients with benign and early malignant gynecologic disease.

DESIGN

Single-institution retrospective case-control study (Canadian Task Force classification II-2).

SETTING

Catholic University of the Sacred Heart, Rome, Italy.

PATIENTS

Between October 2013 and May 2015, 203 women underwent TELELAP-ALF X (group 1) or standard laparoscopic (group 2) total hysterectomy and were enrolled.

INTERVENTIONS

Total standard laparoscopy vs TELELAP ALF-X robot-assisted hysterectomy for benign and early malignant gynecologic disease.

MEASUREMENTS AND MAIN RESULTS

In group 1, the median age was 55 years (range, 40-79 years), median body mass index (BMI) was 25 kg/m(2) (range, 17-38 kg/m(2)), and 51 patients (58%) had undergone previous abdominal surgery. In the control group, the median age was 55 years (range, 34-90 years), median BMI was 25 kg/m(2) (range, 17-41 kg/m(2)), and 31 patients (27%) had previous abdominal surgery. The median operative time was 147 minutes (range, 58-320 minutes) in group 1 and 80 minutes (range, 22-300 minutes) in group 2 (p = .055). The median estimated blood loss was 57 mL (range, 0-600 mL) in group 1 and 99 mL (range, 0-400 mL) in group 2, with no significant differences between the 2 groups (p = .963). Procedures were successfully performed without conversion in 94.3% of cases in the group 1 and in all cases in group 2. Early postoperative pain was significantly lower in group 2.

CONCLUSION

TELELAP ALF-X hysterectomy in patients with benign and early malignant gynecologic disease is feasible and safe, and can be considered a valid option for these patients.

Robotic surgery: current perceptions and the clinical evidence

BACKGROUND

It appears that a discrepancy exists between the perception of robotic-assisted surgery (RAS) and the current clinical evidence regarding robotic-assisted surgery among patients, healthcare providers, and hospital administrators. The purpose of this study was to assess whether or not such a discrepancy exists.

METHODS

We administered survey questionnaires via face-to-face interviews with surgical patients (n = 101), healthcare providers (n = 58), and senior members of hospital administration (n = 6) at a community hospital that performs robotic surgery. The respondents were asked about their perception regarding the infection rate, operative time, operative blood loss, incision size, cost, length of hospital stay (LOS), risk of complications, precision and accuracy, tactile sensation, and technique of robotic-assisted surgery as compared with conventional laparoscopic surgery. We then performed a comprehensive literature review to assess whether or not these perceptions could be corroborated with clinical evidence.

RESULTS

The majority of survey respondents perceived RAS as modality to decrease infection rate, increase operative time, decrease operative blood loss, smaller incision size, a shorter LOS, and a lower risk of complications, while increasing the cost. Respondents also believed that robotic surgery provides greater precision, accuracy, and tactile sensation, while improving intra-operative access to organs. A comprehensive literature review found little-to-no clinical evidence that supported the respondent's favorable perceptions of robotic surgery except for the increased costs, and precision and accuracy of the robotic-assisted technique.

CONCLUSIONS

There is a discrepancy between the perceptions of robotic surgery and the clinical evidence among patients, healthcare providers, and hospital administrators surveyed.

Robotic Surgery in Gynecology

Minimally invasive surgery (MIS) can be considered as the greatest surgical innovation over the past 30 years. It revolutionized surgical practice with well-proven advantages over traditional open surgery: reduced surgical trauma and incision-related complications, such as surgical-site infections, postoperative pain and hernia, reduced hospital stay, and improved cosmetic outcome. Nonetheless, proficiency in MIS can be technically challenging as conventional laparoscopy is associated with several limitations as the two-dimensional (2D) monitor reduction in-depth perception, camera instability, limited range of motion, and steep learning curves. The surgeon has a low force feedback, which allows simple gestures, respect for tissues, and more effective treatment of complications. Since the 1980s, several computer sciences and robotics projects have been set up to overcome the difficulties encountered with conventional laparoscopy, to augment the surgeon’s skills, achieve accuracy and high precision during complex surgery, and facilitate widespread of MIS. Surgical instruments are guided by haptic interfaces that replicate and filter hand movements. Robotically assisted technology offers advantages that include improved three-dimensional stereoscopic vision, wristed instruments that improve dexterity, and tremor canceling software that improves surgical precision.

Robotic Single-Site and Conventional Laparoscopic Surgery in Gynecology: Clinical Outcomes and Cost Analysis of a Matched Case-Control Study

STUDY OBJECTIVE

To assess the clinical outcomes and costs associated with robotic single-site (RSS) surgery compared with those of conventional laparoscopy (CL) in gynecology.

DESIGN

Retrospective case-control study (Canadian Task Force classification II-2).

SETTING

University-affiliated community hospital.

PATIENTS

Female patients undergoing RSS or CL gynecologic procedures.

INTERVENTIONS

Comparison of consecutive RSS gynecologic procedures (cases) undertaken between October 2013 and March 2014 with matched CL procedures (controls) completed during the same time period by the same surgeon.

MEASUREMENTS AND MAIN RESULTS

Patient demographic data, operative data, and hospital financial data were abstracted from the electronic charts and financial systems. An incremental cost analysis based on the use of disposable equipment was performed. Total hospital charges were determined for matched RSS cases vs CL cases. RSS surgery was completed in 25 out of 33 attempts; 3 cases were aborted before docking, and 5 were converted to a multisite surgery. There were no intraoperative complications or conversions to laparotomy. The completed cases included 11 adnexal cases and 14 hysterectomies, 3 of which included pelvic lymph node dissection. Compared with the CL group, total operative times were higher in the RSS group; however, there were no significant between-group differences in estimated blood loss, length of hospital stay, or complication rates. Disposable equipment cost per case, direct costs, and total hospital charges were evaluated. RSS was associated with an increased disposable cost per case of $248 to $378, depending on the method used for vaginal cuff closure. The average total hospital charges for matched outpatient adnexal surgery were $15,450 for the CL controls and $18,585 for the RSS cases (p < .001), and the average total hospital charges for matched outpatient benign hysterectomy were $14,623 for the CL controls and $21,412 for the RSS cases (p < .001).

CONCLUSION

Although RSS surgery and CL have comparable clinical outcomes in selected patients, RSS surgery remains associated with increased incremental disposable cost per case and total hospital charges. Careful case selection and judicious use of equipment are necessary to maximize cost-effectiveness in RSS gynecologic surgery.

Robotic surgery: disruptive innovation or unfulfilled promise? A systematic review and meta-analysis of the first 30 years

Background

Robotic surgery has been in existence for 30 years. This study aimed to evaluate the overall perioperative outcomes of robotic surgery compared with open surgery (OS) and conventional minimally invasive surgery (MIS) across various surgical procedures.

Methods

MEDLINE, EMBASE, PsycINFO, and ClinicalTrials.gov were searched from 1990 up to October 2013 with no language restriction. Relevant review articles were hand-searched for remaining studies. Randomised controlled trials (RCTs) and prospective comparative studies (PROs) on perioperative outcomes, regardless of patient age and sex, were included. Primary outcomes were blood loss, blood transfusion rate, operative time, length of hospital stay, and 30-day overall complication rate.

Results

We identified 99 relevant articles (108 studies, 14,448 patients). For robotic versus OS, 50 studies (11 RCTs, 39 PROs) demonstrated reduction in blood loss [ratio of means (RoM) 0.505, 95 % confidence interval (CI) 0.408–0.602], transfusion rate [risk ratio (RR) 0.272, 95 % CI 0.165–0.449], length of hospital stay (RoM 0.695, 0.615–0.774), and 30-day overall complication rate (RR 0.637, 0.483–0.838) in favour of robotic surgery. For robotic versus MIS, 58 studies (21 RCTs, 37 PROs) demonstrated reduced blood loss (RoM 0.853, 0.736–0.969) and transfusion rate (RR 0.621, 0.390–0.988) in favour of robotic surgery but similar length of hospital stay (RoM 0.982, 0.936–1.027) and 30-day overall complication rate (RR 0.988, 0.822–1.188). In both comparisons, robotic surgery prolonged operative time (OS: RoM 1.073, 1.022–1.124; MIS: RoM 1.135, 1.096–1.173). The benefits of robotic surgery lacked robustness on RCT-sensitivity analyses. However, many studies, including the relatively few available RCTs, suffered from high risk of bias and inadequate statistical power.

Conclusions

Our results showed that robotic surgery contributed positively to some perioperative outcomes but longer operative times remained a shortcoming. Better quality evidence is needed to guide surgical decision making regarding the precise clinical targets of this innovation in the next generation of its use.

Comparative Effectiveness of Minimally Invasive Hysterectomy for Endometrial Cancer

PURPOSE

Despite the potential benefits of minimally invasive hysterectomy for uterine cancer, population-level data describing the procedure's safety in unselected patients are lacking. We examined the use of minimally invasive surgery and the association between the route of the procedure and long-term survival.

METHODS

We used the SEER-Medicare database to identify women with stage I-III uterine cancer who underwent hysterectomy from 2006 to 2011. Patients who underwent abdominal hysterectomy were compared with those who had minimally invasive hysterectomy (laparoscopic and robot-assisted). Perioperative morbidity, use of adjuvant therapy, and long-term survival were examined after propensity score balancing.

RESULTS

We identified 6,304 patients, including 4,139 (65.7%) who underwent abdominal hysterectomy and 2,165 (34.3%) who underwent minimally invasive hysterectomy; performance of minimally invasive hysterectomy increased from 9.3% in 2006 to 61.7% in 2011. Robot-assisted procedures accounted for 62.3% of the minimally invasive operations. Compared with women who underwent abdominal hysterectomy, minimally invasive hysterectomy was associated with a lower overall complication rate (22.7% v 39.7%; P < .001), and lower perioperative mortality (0.6% v 1.1%), but these women were more likely to receive adjuvant pelvic radiotherapy (34.3% v 31.3%) and brachytherapy (33.6% v 31.0%; P < .05). The complication rate was higher after robot-assisted hysterectomy compared with laparoscopic hysterectomy (23.7% v 19.5%; P = .03). There was no association between the use of minimally invasive hysterectomy and either overall (HR, 0.89; 95% CI, 0.75 to 1.04) or cancer-specific (HR, 0.83; 95% CI, 0.59 to 1.16) mortality.

CONCLUSION

Minimally invasive hysterectomy does not appear to compromise long-term survival for women with endometrial cancer.

Cost comparison of robotic-assisted laparoscopic hysterectomy versus standard laparoscopic hysterectomy

The aim of the study was to assess if the cost of robotic-assisted total laparoscopic hysterectomy is similar to the cost of standard laparoscopic hysterectomy when performed by surgeons past their initial learning curve. A retrospective chart review of all hysterectomies was performed for benign indications without concomitant major procedures at Orange Coast Memorial Medical Center (OCMMC) and Saddleback Memorial Medical Center between January 1, 2013 and September 30, 2013. Robotic-assisted total laparoscopic hysterectomies (RTLH) and standard laparoscopic hysterectomies (LAVH and TLH) were compared. Data analyzed included only those hysterectomies performed by surgeons past their initial learning curve (minimum of 30 previous robotic cases). The primary outcome was the direct total cost of patient's hospitalization related to hysterectomy. The secondary outcomes were estimated blood loss, surgery time, and days in hospital post-surgery. A multiple linear regression model was applied to evaluate the difference between RTLH and LAVH/TLH in hospital cost, blood loss, and surgery time, while adjusting for hospital, patient's age, body mass index (BMI), whether or not the patient had previous abdominal/pelvic surgery, and uterine weight. The χ (2) test was applied to examine the association between hospital stay and surgery type. There were 93 hysterectomies (5 LAVH, 88 RTLH) performed at OCMMC and 90 hysterectomies (6 LAVH, 17 TLH, 67 RTLH) performed at Saddleback Memorial Medical Center. The hospitalization total cost result showed that, after adjusting for hospital, age, BMI, previous abdominal/pelvic surgery, and uterine weight, RTLH was not significantly more expensive than LAVH/TLH (mean diff. = $283.1, 95 % CI = [-569.6, 1135.9]; p = 0.51) at the 2 study hospitals. However, the cost at OCMMC was significantly higher than Saddleback Memorial Medical Center (mean diff. = $2008.7, 95 % CI = [1380.6, 2636.7]; p < 0.0001); and the cost increased significantly with uterine weight (β = 3.8, 95 % CI = [2.3, 5.3]; p < 0.0001). Further analysis showed significantly less blood loss (mean diff. = -78.5 ml, 95 % CI = [-116.8, -40.3]; p < 0.0001) and shorter surgery time (mean diff. = -21.9 min., 95 % CI = [-39.6, -4.2]; p = 0.016) for RTLH versus LAVH/TLH. There was no significant association between hospital stay and surgery type (p = 0.43). After adjusting for patient-level covariates, there was no statistically significant cost difference of performing robotically assisted laparoscopic hysterectomy versus standard laparoscopic hysterectomy when performed by surgeons past their initial learning curve at two community hospitals.

Robotic hysterectomy using the Vessel Sealer for myomatous uteri: technique and clinical outcome

OBJECTIVE

Robotic procedures using the Vessel Sealer are not well reported in the literature, especially given the advantages of sealing devices already studied in standard laparoscopic procedures. This study reports our experience with the EndoWrist(®) One™ Vessel Sealer in robotic hysterectomy for myomatous uteri.

STUDY DESIGN

In this retrospective cohort study of the first 50 consecutive patients with myomatous uteri undergoing a robotic hysterectomy, we report our experience with the EndoWrist(®) One™ Vessel Sealer (Intuitive Surgical Inc., Sunnyvale, CA) during this procedure. The learning curve was evaluated, and the operative times as well as the complications were recorded.

RESULTS

After the first 10 cases, the median console and total (skin-to-skin) operative time dropped significantly from 110 to 60min and from 158 to 105min, respectively (p=0.018 and p=0.008 respectively). The body mass index (≤ or >30kg/m(2)), uterine weight (≤ or >250g), and uterine size had no statistical significant effect on the total operative time. Median blood loss during surgery was 63mL in all cases (range: 0-400mL). The morbidity was low, and approximately 50% of cases could be discharged from the hospital after one to two days.

CONCLUSION

Robotic hysterectomy using the Vessel Sealer has, after a short learning curve of 10 cases, similar operative times than other published reports on robotic hysterectomy or laparoscopic hysterectomy using a sealing device for myomatous or large uteri.

Surgical approach to hysterectomy for benign gynaecological disease

BACKGROUND

The four approaches to hysterectomy for benign disease are abdominal hysterectomy (AH), vaginal hysterectomy (VH), laparoscopic hysterectomy (LH) and robotic-assisted hysterectomy (RH).

OBJECTIVES

To assess the effectiveness and safety of different surgical approaches to hysterectomy for women with benign gynaecological conditions.

SEARCH METHODS

We searched the following databases (from inception to 14 August 2014) using the Ovid platform: Cochrane Central Register of Controlled Trials (CENTRAL); MEDLINE; EMBASE; Cumulative Index to Nursing and Allied Health Literature (CINAHL) and PsycINFO. We also searched relevant citation lists. We used both indexed and free-text terms.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) in which clinical outcomes were compared between one surgical approach to hysterectomy and another.

DATA COLLECTION AND ANALYSIS

At least two review authors independently selected trials, assessed risk of bias and performed data extraction. Our primary outcomes were return to normal activities, satisfaction, quality of life, intraoperative visceral injury and major long-term complications (i.e. fistula, pelvi-abdominal pain, urinary dysfunction, bowel dysfunction, pelvic floor condition and sexual dysfunction).

MAIN RESULTS

We included 47 studies with 5102 women. The evidence for most comparisons was of low or moderate quality. The main limitations were poor reporting and imprecision. Vaginal hysterectomy (VH) versus abdominal hysterectomy (AH) (nine RCTs, 762 women)Return to normal activities was shorter in the VH group (mean difference (MD) -9.5 days, 95% confidence interval (CI) -12.6 to -6.4, three RCTs, 176 women, I(2) = 75%, moderate quality evidence). There was no evidence of a difference between the groups for the other primary outcomes. Laparoscopic hysterectomy (LH) versus AH (25 RCTs, 2983 women)Return to normal activities was shorter in the LH group (MD -13.6 days, 95% CI -15.4 to -11.8; six RCTs, 520 women, I(2) = 71%, low quality evidence), but there were more urinary tract injuries in the LH group (odds ratio (OR) 2.4, 95% CI 1.2 to 4.8, 13 RCTs, 2140 women, I(2) = 0%, low quality evidence). There was no evidence of a difference between the groups for the other primary outcomes. LH versus VH (16 RCTs, 1440 women)There was no evidence of a difference between the groups for any primary outcomes. Robotic-assisted hysterectomy (RH) versus LH (two RCTs, 152 women)There was no evidence of a difference between the groups for any primary outcomes. Neither of the studies reported satisfaction rates or quality of life.Overall, the number of adverse events was low in the included studies.

AUTHORS' CONCLUSIONS

Among women undergoing hysterectomy for benign disease, VH appears to be superior to LH and AH, as it is associated with faster return to normal activities. When technically feasible, VH should be performed in preference to AH because of more rapid recovery and fewer febrile episodes postoperatively. Where VH is not possible, LH has some advantages over AH (including more rapid recovery and fewer febrile episodes and wound or abdominal wall infections), but these are offset by a longer operating time. No advantages of LH over VH could be found; LH had a longer operation time, and total laparoscopic hysterectomy (TLH) had more urinary tract injuries. Of the three subcategories of LH, there are more RCT data for laparoscopic-assisted vaginal hysterectomy and LH than for TLH. Single-port laparoscopic hysterectomy and RH should either be abandoned or further evaluated since there is a lack of evidence of any benefit over conventional LH. Overall, the evidence in this review has to be interpreted with caution as adverse event rates were low, resulting in low power for these comparisons. The surgical approach to hysterectomy should be discussed and decided in the light of the relative benefits and hazards. These benefits and hazards seem to be dependent on surgical expertise and this may influence the decision. In conclusion, when VH is not feasible, LH may avoid the need for AH, but LH is associated with more urinary tract injuries. There is no evidence that RH is of benefit in this population. Preferably, the surgical approach to hysterectomy should be decided by the woman in discussion with her surgeon.

Robotic Versus Laparoscopic Hysterectomy for Benign Disease: A Systematic Review and Meta-Analysis of Randomized Trials

We conducted a systematic review and meta-analysis to assess the safety and effectiveness of robotic vs laparoscopic hysterectomy in women with benign uterine disease, as determined by randomized studies. We searched MEDLINE, EMBASE, the Cochrane Library, ClinicalTrials.gov, and Controlled-Trials.com from study inception to October 9, 2014, using the intersection of the themes "robotic" and "hysterectomy." We included only randomized and quasi-randomized controlled trials of robotic vs laparoscopic hysterectomy in women for benign disease. Four trials met our inclusion criteria and were included in the analyses. We extracted data, and assessed the studies for methodological quality in duplicate. For meta-analysis, we used random effects to calculate pooled risk ratios (RRs) and weighted mean differences. For our primary outcome, we used a modified version of the Expanded Accordion Severity Grading System to classify perioperative complications. We identified 41 complications among 326 patients. Comparing robotic and laparoscopic hysterectomy, revealed no statistically significant differences in the rate of class 1 and 2 complications (RR, 0.66; 95% confidence interval [CI], 0.23-1.89) or in the rate of class 3 and 4 complications (RR, 0.99; 95% CI, 0.22-4.40). Analyses of secondary outcomes were limited owing to heterogeneity, but showed no significant benefit of the robotic technique over the laparoscopic technique in terms of length of hospital stay (weighted mean difference, -0.39 day; 95% CI, -0.92 to 0.14 day), total operating time (weighted mean difference, 9.0 minutes; 95% CI, -31.27 to 47.26 minutes), conversions to laparotomy, or blood loss. Outcomes of cost, pain, and quality of life were reported inconsistently and were not amenable to pooling. Current evidence demonstrates neither statistically significant nor clinically meaningful differences in surgical outcomes between robotic and laparoscopic hysterectomy for benign disease. The role of robotic surgery in benign gynecology remains unclear.

Transversus abdominis plane (TAP) block after robot-assisted laparoscopic hysterectomy: a randomised clinical trial

BACKGROUND

Transversus abdominis plane (TAP) block is widely used as a part of pain management after various abdominal surgeries. We evaluated the effect of TAP block as an add-on to the routine analgesic regimen in patients undergoing robot-assisted laparoscopic hysterectomy.

METHODS

In a prospective blinded study, 70 patients scheduled for elective robot-assisted laparoscopic hysterectomy were randomised to receive either TAP block (ropivacaine 0.5%, 20 ml on each side) or sham block (isotonic saline 0.9%, 20 ml on each side). All patients had patient-controlled analgesia (PCA) with morphine on top of paracetamol and ibuprofen or diclofenac. For the first 24 post-operative hours, we monitored PCA morphine consumption and pain scores with visual analogue scale (VAS) at rest and while coughing. Post-operative nausea and number of vomits (PONV) were recorded.

RESULTS

Sixty-five patients completed the study, 34 receiving TAP block with ropivacaine and 31 receiving sham block with isotonic saline. We found no differences in median (interquartile range) morphine consumption the first 24 h between the TAP block group [17.5 mg (6.9-36.0 mg)] and the placebo group [17.5 mg (2.9-38.0 mg)] (95% confidence interval 10.0-22.6 mg, P = 0.648). No differences were found for VAS scores between the two groups, calculated as area under the curve/1-24 h, neither at rest (P = 0.112) nor while coughing (P = 0.345), or for PONV between groups.

CONCLUSIONS

In our study, the TAP block combined with paracetamol and Nonsteroidal anti-inflammatory drugs (NSAID) treatment, had no effect on morphine consumption, VAS pain scores, or frequency of nausea and vomiting after robot-assisted laparoscopic hysterectomy compared with paracetamol and NSAID alone.