Surgeons told to pull the plug on robotically assisted hysterectomy

US researchers are calling for curbs on the rapidly increasing use of robotically assisted hysterectomy after an extensive study of the technique showed that it fails to improve outcomes over laparoscopy.

The authors say their findings raise major questions about the economic viability of the procedure, which costs an additional US$ 2000 (€ 1527) compared with the laparoscopic method.

The study, published in JAMA, included 264,758 women undergoing hysterectomy for benign gynecologic disorders in the USA from 2007 to 2010.

The rate of vaginal and abdominal surgery declined during the study period, from 21.7% to 19.8%, and 53.6% to 40.1%, respectively. Conversely, the authors note a remarkable overall increase in robotic surgery from just 0.5% in 2007 to 9.5% in 2010 and, in hospitals where robotic surgery was available, the rate reached 22.4% at the end of the study. Laparoscopic surgery also grew from 24.3% to 30.5% of procedures over the same period.

Hospitalization for longer than 2 days was significantly less common among patients in the robotically assisted group, at 19.6% compared with 24.9% in the laparoscopic group. However, there was no significant difference between women who underwent robotically assisted and laparoscopic procedures in terms of the rate of complications (5.5 and 5.3%, respectively), rates of transfusion (1.4 and 1.8%, respectively), reoperation (0.1 and 0.1%, respectively), nonroutine discharge (0.2 and 0.3%, respectively), or in-hospital mortality (0 in both groups).

Meanwhile, robotically assisted hysterectomy was associated with a median total cost of US$ 8868 (€ 6774) compared with US$ 6679 (€ 5102) for laparoscopic hysterectomy.

The authors Jason Wright (Columbia University, New York) and colleagues say that unlike prostatectomy, for which robotically assisted surgery was initially the only minimally invasive technique available, there are several alternatives for minimally invasive hysterectomy.

"From a public health standpoint," they add, "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."

In an accompanying editorial, Joel Weissman and Michael Zinner of Brigham and Women's Hospital, Boston, Massachusetts, describe the findings as "stark", and suggest that the growing popularity of robotic surgery is misguided by manufacturer promotion.

"The medical and surgical community can move more quickly to improved patient outcomes and higher value by not spending scarce resources on less-effective options," they conclude.

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