Traditional vs. Robotic Laparoscopic Hysterectomies, Research Paper Example

Cost and benefits of Traditional vs. Robotic Laparoscopic Hysterectomies of Benign Gynecological Diseases and Endometrial Cancer

Abstract

Objective: Gynecological procedures performed with robotic assistance are on the rise. New advancements in robotic surgeries and telemedicine can help to explore the benefits and limitations of surgical treatment for gynecological diseases. This paper compares peri-operative outcomes of benign gynecological diseases and endometrial cancer treated with traditional laparoscopic technology versus robotic laparoscopic systems.

Study Design: A search was conducted for available literature published up until April 2017, for studies and reviews of traditional laparoscopic and robotic hysterectomies. The patient population was restricted to the United States and Europe; however, the inclusion criteria were not limited to race, socioeconomic status, or co-morbidities. A review of the literature from PubMed, Google Scholar, and JAMA was performed on randomized control trials, case-controlled studies, and retrospective studies. Factors considered in this literature review included operating time, blood loss, conversion rates, post-operative hospital stay, cost, and lymph node resection (in endometrial cancer). The validity of the articles was determined using Hillier’s et al. FORM framework.

Results: Among different studies looking at hysterectomies in benign diseases, operating time increased significantly at an average of 20-70 min, with little to no added benefit of peri-operative outcomes in blood loss, hospital stay, and conversion rates. When looking at endometrial cancer treatment, however, a recent RCT study had significantly shorter operating times with an average decrease of 43min. Average hospital stays varied amongst different studies with some stating no differences to an average of one day less in robotic cases. Conversion rates of laparoscopic procedures into open laparotomy were less common in robotic groups treating endometrial cancer but were the same in robotic groups treating benign gynecological diseases.  Lymph node yields in endometrial cancer showed mixed results when comparing robotic vs. traditional methods. One RCT indicated a little additional benefit to using robotic systems (25 lymph nodes) than the traditional (23 lymph nodes). However, a wide range of retrospective studies has been able to show greater yield from using robotic systems.

Conclusion: Hysterectomies for benign gynecological diseases are best performed using traditional laparoscopic methods than with robotic methods. This is due to insufficient data for improved peri-operative outcomes, as well as a substantial increase in the operative cost of robotic surgeries. However, in endometrial cancer, robotic procedures have shown to be useful with the increase in the number of lymph node yield along with improved patient recovery. Traditional laparoscopic methods trail at the end of studies, producing the least lymph node yield, while robotic methods have yielded at levels as high as open laparotomy. There remain more randomized control trials that need to be performed to fully appreciate the benefits and cost effectiveness of robotics used in gynecological surgeries. The learning curve, as well as purchase and maintenance cost for robotics, remains to be another obstacle in increasing the acceptance of robotics in the United States.

Methods

A systematic review was performed comparing traditional laparoscopic hysterectomies (TLH), and robotic-assisted hysterectomies (RAH) conducted within the United States and Europe. Available literature from ACOG, Google Scholar, PubMed.gov, NCBI, and JAMA was reviewed from 2013 up until the date of April 21, 2017. Some literature dates as early as 2005 for background information and history of robotic technology in gynecology. Randomized controlled trials (RCTs), rigorous nonrandomized prospective trials, case-controlled studies and retrospective studies were compared for factors, such as operating time, blood loss, conversion rates, post-operative hospital stays, lymph node resection (in endometrial cancer), and costs.  Keyword searches include benign gynecological surgery, robotic surgery, laparoscopic hysterectomies, robotic hysterectomies, endometrial cancer, da Vinci robot, robotic surgery for endometrial cancer, and lymph node yield in endometrial cancer. The patient population was restricted to the U.S. and Europe; however, the inclusion criterion was not limited to race, socioeconomic status or co-morbidities.

Introduction

Laparoscopic procedures have persistently been used in gynecologic surgery since 1988 when the very first laparoscopic hysterectomy was carried out. Today, there are far-reaching advancements in laparoscopic procedures in terms of improving the accuracy, safety and flexibility of laparoscopic surgery.[1] On account of current technical advancements that have occurred in the past three decades, complex surgical procedures are today achievable using laparoscopy.[2] A number of studies carried out over the period have showed that laparoscopic hysterectomy leads to shortened perioperative morbidity, stay in hospitals as well as a more rapid return compared to abdominal hysterectomy. In spite of these promising results, the ratio of laparoscopic hysterectomies is unfortunately relatively low — in comparison to laparotomy.¹

In a deliberate effort to make it possible for a larger number of patients to benefit from a procedure that is less insidious, robotic surgery has been extensively promoted in literature as a latent solution. At present, da Vinci surgical system-approved robotic device is used in gynecological surgery for gynecologic procedures like myomectomy, hysterectomy, prolapse surgery, endometriosis surgery, and tubal anastomosis.^1,[3] The robotic-assisted hysterectomy appears to have indicated greater levels of superiority in terms of effectiveness compared to laparoscopy.[4] However, there is a concern that robotic gynecologic surgery potentially confers advantages that are not easy to measure. Advocates of robotic surgery, on the other hand, have opined that the robotic technology enables women who would have undergone laparotomy to go through a less invasive surgical procedure. Despite this, there appears to be minimal support for such claims as robotic-assisted hysterectomy and laparoscopic are linked to low rates of complications. There is also a concern that the benefits that robotically assisted hysterectomy can present to a patient are not distinctly clear.[5]

Four years after the FDA approval of the Da  Vinci robotic surgical system for gynecological use, the NIS reported over 800,000 hysterectomies performed in 2009 and 2010 for benign conditions. The hysterectomies performed within those two years were mostly open abdominal laparotomies (OAL), with 20.6% traditional laparoscopic hysterectomies (TLH) and 5.1% robotically assisted hysterectomies (RAH). Multiple large-scale studies indicated that TLH had better perioperative outcomes than OAL. This is because smaller incisions are made with laparoscopic procedures than with OALs. Despite the greater improvement in patient care with laparoscopic procedures, OALs are more routinely performed.[6]^,[7],[8],[9] Randomized controlled trials have showed that TLH and RAH have shorter hospital stays and fewer postoperative complications than the OAL.⁵The introduction of RAH has pushed for an even further decrease in OALs. Within the last few years, the standardization of robotic techniques have rapidly entered the market at a faster rate than when traditional laparoscopic techniques were first introduced.¹

The most common benign gynecological conditions treated with hysterectomies are symptomatic uterine leyoima (40.7%), endometriosis (17.7%), and prolapse (14.5%). Hysterectomies themselves are the most common gynecological surgery performed in the United States. Over 500,000 cases are performed annually. Most of these are still performed as open abdominal laparotomies, which serve as an alternative to laparoscopic hysterectomy. In 2005, the Nationwide Inpatient Sample (NIS) from the Agency for Health Care Research and Quality (AHRQ) recorded that 14% of hysterectomies that were performed were done laparoscopically, 64% abdominally, and 22% vaginally.[10]^,[11] On account of an increasing prevalence of hysterectomies, there continues to be a greater focus toward making them more accessible and improving their recovery times.¹ Surgical staging is, therefore, an important part in determining treatment and includes a careful assessment of peritoneal structures and possible biopsy. Staging is still commonly done via OAL. However, the latest minimally invasive approaches, such as TLH and RAH, are still better for patients to reduce morbidity and length of hospital stay.^8,9 Endometrial cancer is surgically staged with TNM classifications and Federation of Gynecology and Obstetrics (FIGO) scoring. Roughly 75% of endometrial cancers are diagnosed early in FIGO stages I or II. Minimally invasive approaches have 5-year survival rates ranging from 74-91% in patients without the metastatic spread of the disease. The 5-year overall survival for FIGO stage III is 57-66% and FIGO stage IV disease at 20-26%.⁵ In cancers with the greater metastatic spread, tumor grading becomes a more important prognostic factor where the number of lymph node metastases increases as the grade increases. In surgical procedures, patients at higher metastatic risk benefit from an increased number of lymph nodes resected. Based on this background, this paper compares peri-operative outcomes of benign gynecological diseases and endometrial cancer treated with traditional laparoscopic technology versus robotic laparoscopic systems.

Study Design

The criteria used in reviewing the article included searching online for articles that attempted to compare peri-operative outcomes of benign gynecological diseases and endometrial cancer treated with traditional laparoscopic technology and robotic laparoscopic systems. Research articles targeted included those that used a mixture of observational and randomized controlled trial (RCTs), systematic review of literature, as well as those supporting, and not supporting the hypothesis. Data was extracted from studies that met these criteria. The focus was on articles documented in the English language. The databases searched included Medline, PubMed, Google Scholar, and JAMA. Keyword searches include benign gynecological surgery, robotic surgery, laparoscopic hysterectomies, robotic hysterectomies, endometrial cancer, da Vinci robot, robotic surgery for endometrial cancer, lymph node yield in endometrial cancer. A search was conducted for available literature published up until April 2017 for studies and reviews of traditional laparoscopic and robotic hysterectomies. The patient population was restricted to the United States and Europe. However, the inclusion criteria were not limited to race, socioeconomic status, or co-morbidities. A review of the literature was performed on randomized control trials, case-controlled studies, and retrospective studies. Factors considered in this literature review included operating time, blood loss, conversion rates, post-operative hospital stay, cost, and lymph node resection (in endometrial cancer). A systematic review was performed comparing traditional laparoscopic hysterectomies (TLH), and robotic-assisted hysterectomies (RAH) conducted in United States and Europe. Available literature from the above databases was reviewed with main focus from 2007 up until the date of April 21, 2017. Some literature that dated as early as 2005 were also selected for background information and historical basis of robotic technology in gynecology. Randomized controlled trials (RCTs), rigorous nonrandomized prospective trials, case-controlled studies and retrospective studies were compared for factors such as operating time, blood loss, conversion rates, post-operative hospital stays, lymph node resection (in endometrial cancer), and costs.  The validity of the articles was determined by critically appraising them using the FORM framework proposed by Hillier et al.[12] The FORM framework provides a structured framework for determining the validity of a body of evidence by examining the research question within the context of the setting it is applied, the level of evidence ascribed to a study, the level of the evidence base, the consistency of the findings, the generalizability of the results and the applicability of the results.

Results of Laparoscopic Vs. Robotic Outcome in Benign Gynecological

Blood Loss

In an attempt to explore the level of complications presented by traditional versus robotic laparoscopic hysterectomies of benign gynecological diseases and endometrial cancer, Sarlos et al.¹³ investigated the difference in blood loss using a randomized control trial consisting of 100 patients. They also compared blood loss complications, use of analgesics use in traditional and robotic laparoscopic hysterectomies.  They found that the robotic group had an average of 87 (±67) mL of blood loss and concluded that this did not show a statistical difference between traditional laparoscopic groups with averages of 79 (±57) mL.[13] They also established that changes in quality of life evaluated on a linear scale between 0 and 100 were substantially higher in the robotic group, with 13 in comparison to 5 for the traditional group. However, no serious intraoperative complications were observed in both groups.¹³

Table 1. Comparison of data from two RCT studies for laparoscopic and robotic outcome in benign gynecological hysterectomies

However, when Sarlos et al.¹³ examined observable postoperative and intraoperative complications in addition to blood loss, they established a blood loss of 87 mL for robotic hysterectomy and 79 mL for the traditional group. While it is clear that observable blood loss in the traditional group was a little higher, they argued that the statistical differences are small for the two groups. At any rate, the robotic group indicated additional problems in the vascular lesion. Sarlos et al.¹³ observed a severing of the uterine artery. Although the bleeding was instantly stopped and surgery sustained consistent with the standard procedure, there was no observable excessive bleeding. In fact, the sum blood loss was only 50 mL. From their study, Sarlos’ et al. indicated that the intraoperative results of blood loss in both traditional and robotic laparoscopic hysterectomies does not indicate significant difference.¹⁰ They admitted that the caseload of their study might have been too small to show any major divergence in results in blood loss. This is particularly so, as the mean incidence was low. With these findings, Sarlos et al. then argued that for a standard benign hysterectomy procedure, the supremacy of robotic procedure is still uncertain, as indications from both intraoperative and postoperative results appear to be nearly similar to traditional laparoscopy. ¹³

In a related study, Paraiso et al. performed a randomized control trial of 53 patients. Their findings demonstrated almost similar blood loss outcome for both laparoscopic hysterectomy and robotic-assisted laparoscopic hysterectomy.[14] Their objective was to make a comparison of operative time and Intra- and postoperative complications between the robotic and traditional groups. The randomized controlled trial was done in two institutions, whereby participants comprised women who were to undergo laparoscopic hysterectomy for benign conditions. Overall, 27 women went through traditional laparoscopic while 26 women went through robot-assisted.¹¹ In comparison to laparoscopic hysterectomy, skin incision to skin closure was observed to be substantially longer for the robot group. Still, when it came to measuring the blood loss, no substantial differences was found in the two groups. Similarly, a minimal number of complications were observable; there was no apparent difference in each type of complications for the two groups. At this point, Paraiso et al. indicated that while laparoscopic and robotic-assisted hysterectomies are safe alternatives to hysterectomy, the use of robotic-assisted hysterectomy is still questionable. In addition, the technology demands substantially longer time for the safe operation to ensure minimal blood loss.

In a related study, Herman et al. observed complexities of robotic-assisted laparoscopic hysterectomy in surgical procedures in patients with obesity in his investigation into how increased body mass index affects the outcomes after robotic radical prostatectomy.[15] Their study found an increasing BMI, which had negative effects of increasing blood loss compared to the traditional group. They found that no difference in blood loss rate between the two groups reflected the small case load of their study. At any rate, like the study by Paraiso et al,¹⁴ the study by Herman et al.¹⁴ had a small sample size to discover any divergence in complications as a result of very low mean incidence.

In yet another study, Chiu et al used larger sample size of 216 patients who received hysterectomy through robotic and laparoscopic approach and found contradicting results. [16] Of the number of patients, 88 went through a robotic hysterectomy while 128 went through a laparoscopic hysterectomy. The perioperative parameters were blood loss, operation time, the length of hospital stay, complications, as well as conversion rate. Chiu et al. found that the approach is associated with less blood loss of 187.5 ± 148.7 mL compared to the traditional approach of 482.6, P=0.044.¹³

Operating Times

Reviewed literature shows that operative times for robotic cases tend to be longer compared to operative times for traditional laparoscopic cases, with an average deviation of between 20 and 70 minutes.^4,5,6,8 A randomized control study by Sarlos et al. showed that even after being corrected for the time used to dock the robot, the robotic group operating time was significantly longer at 106 (±29) min (P<.001) for their study.¹⁰ In a related study by Paraiso et al. that also compared conventional and robotic-assisted laparoscopic hysterectomy, the researchers recorded 172 (±89) min  (P=.002).¹¹ They concluded that the traditional methods’ operating time as 75 (±21) min (P<.001)¹³ and 102 (±63) min (P=.002).¹¹ However, their study had several limitations. Being a retrospective study of a small sample of patients, the operative time is potentially affected by experiences of the operating room staff. This is a factor that the researchers appear not to have taken into consideration in their study.

Still, their average operative time appears to compare favorably with the findings in related studies. Related studies have established low blood loss for robotic-assisted laparoscopic. In a retrospective study undertaken by Reynolds and Advincula, the researchers carried out robotic-assisted laparoscopic hysterectomy. In their study of 16 patients, they recorded an average operating time of 242 minutes. Blood loss was between 50 mL and 300 mL.[17]

The cost of robotic-assisted laparoscopic hysterectomy appeared to be a concern for most researches reviewed. Shashoua et al. comment that since FDA approved robotic-assisted laparoscopic hysterectomy in 2005 for use in surgical procedures, it has mostly been criticized for the associated high costs in addition to longer operating times.[18] Findings by Shashoua et al. indicated shorter operative time and reduced length of stay in hospitals and use of narcotics, despite complications and blood loss rate that were similar to the findings in the traditional group.¹⁵

Consistent with this finding, a study by Payne and Dauterive in 2008 observed difference in operating times between robotic and traditional groups of only 27 minutes. Their study of robotic-assisted laparoscopic hysterectomy also showed conversion rate of 0 percent in comparison to the 11 percent for the traditional group.[19] At this rate, it is clear that as the operative times for robotic-assisted laparoscopic hysterectomy approach those of traditional laparoscopy, it appears to be practicable for routine clinical procedures. Indeed, Shashoua et al. had showed that it has an added advantage of high precision in addition to a capacity for 3-dimensional vision, and a more rapid learning curve. These make them practicable for larger sets of patient population.¹⁵

Hospital Stay

The reviewed research literature results indicate that robotic-assisted laparoscopic hysterectomy could be linked to a shorter hospital stay. In a study of robotic surgery procedures in gynecology, Sinha’s et al. findings indicated that averagely, hospital stays for robotic surgeries tend to be one day shorter than for traditional laparoscopic surgeries, with same day discharges becoming more popular for robotic cases.⁴ However, randomized control studies by Sarlos et al. contradicted these results. Their findings failed to observe a statistically significant decrease in hospital stay for robotic-assisted laparoscopic hysterectomy 3.3 (±0.9) days (P<.153), despite being comparatively lower than the traditional laparoscopic group who’s perioperative hospital stay 3.6 (±3.9) days (P<.153).¹⁰ Still, Sarlos et al. failed to explain what accounted for this finding. On the other hand, while Paraiso et al. failed to specify the difference, they stated that the length of stay was 1.4 (± 0.9) days, with no difference between robotic and traditional groups.¹¹

It appears that since the researchers found no significant difference in hospital stay between the two groups, it could reflect the small case load of their study. They studied small samples to discover any divergence in complications as a result of very low mean incidence. Using a larger sample size of 216 patients who received hysterectomy through robotic and laparoscopic approach, Chiu et al. found contradicting results.¹³ Of the number of patients, 88 went through a robotic hysterectomy while 128 went through a laparoscopic hysterectomy. The perioperative parameters were blood loss, operation time, the length of hospital stay, complications, as well as conversion rate. Chiu et al. found that the robotic approach is associated with reduced operative time of 113.9 ± 38.4 min compared to the traditional approach were 164.3 ± 81.4 min.

In a related study by Shashoua, the researchers’ findings seem to disagree with that of Sarlos et al.¹⁰ and Paraiso et al.¹¹ They established that robotic-assisted laparoscopic hysterectomy tended to have a shorter hospital stay of averagely one day compared to the traditional group.¹⁵ This finding is consistent with that Betcher’s et al., which suggested that robotic-assisted laparoscopic hysterectomy could be superior to traditional hysterectomy as it has a shorter hospital stay and less pain.[20]

Conversion Rates

In the RCT studies that Sarloset al.¹⁰ and Paraiso et al.¹¹ carried out for a total of 153 patients, only one conversion to laparotomy happened from the traditional laparoscopic group. The study by Sarloset al.¹⁰ indicated a very low conversion rate yet there was no conversion in the conventional laparoscopic group. It appears that the idea that the researchers found no difference in conversion rates between the two groups reflects the small case load of their study. It is possible that the small sample size made it difficult to discover any divergence in complications as a result of very low mean incidence. These findings contradict an earlier study by Payne and Dauterive, which established higher conversation rate of laparoscopic hysterectomy compared with that of robotic hysterectomy.¹⁷

Using a larger sample size of 216 patients who received hysterectomy through robotic and laparoscopic approach, Chiu et al. found contradicting results. Of the number of patients, 88 went through a robotic hysterectomy while 128 went through a laparoscopic hysterectomy.¹³ The perioperative parameters were blood loss, operation time, length of hospital stay, complications, and conversion rate. Chiu et al. found that the approach is associated with less conversation rate of 0% compared to the traditional approach of 3.1%, particularly for complicated procedures. Similarly, Friedman et al. found robotic-assisted hysterectomy to be linked to lower conversion rates of 1.5% compared to traditional approach of 11.6%.[21]

Results of Laparoscopic Vs. Robotic Outcomes of Endometrial Cancer Surgeries

Blood Loss

Thus far, there appears to be only one randomized controlled trial that compared the laparoscopic outcome to robotic outcomes of endometrial cancer surgeries. The study by Mäenpää et al. surveyed a total of 99 patients.¹⁵A majority of studies that compared robotic-assisted laparoscopic surgery to traditional laparoscopic in gynecologic oncology have tended to be retrospective. Focus has mostly been on endometrial cancer.[22] Mäenpää et al. performed their study to indicate as a minimum a 25 percent divergence in the operation time through a two-sided significance level of .05. They tested the difference between the traditional group and robotic groups using Mann-Whitney test, Fisher exact test, Pearson ?2 test. Mäenpää et al. established that among patients randomized within robotic and traditional laparoscopic groups blood loss remained nearly identical to an average of 50 mL (P<.504). ¹⁹

In yet another study, Ran et al. performed a meta-analysis of ten studies and established lower rates of blood loss in the robotic approach compared to the traditional approach. They also observed no statistical divergence in the rate of transfusions that both procedures performed.  Another retrospective review performed by Coronado et al. found that on average, blood loss was 99.4 ml in robotic, 190.0 ml in laparoscopy and 231.5 ml in laparotomy (p=0.000).[23] In a Prospective analysis of 67 patients by Magrina et al., the researchers also compared perioperative outcomes in patients who went through surgeries for procedures endometrial cancer by way of robotics and traditional laparotomy approaches. Magrina et al. fond mean blood loss of robotic approach to be 141.4ml compared to 300.0ml.[24] In a related study based on retrospective chart review of cases by Cardenas-Goicoechea et al., the researchers compared peri-operative and post-operative complications and outcomes of robotic-assisted surgery with traditional laparoscopic surgery for women with endometrial cancer.[25] Cardenas-Goicoechea et al. identified 275 cases, whereby102 patients went through the robotic approach staging while 173 patients went through a conventional approach. They found the robotic approach to have a considerably lower blood loss of 109 ml compared to traditional approach which had a blood loss of 187 ml (p<0.0001).²¹

Operative Time

In their randomized control trial, Mäenpää et al. found that total time spent in the operating room was shorter in the robotic group. The robotic group showed a statistically significant shorter operating time at 141 (±23) min (P<.001) than the traditional laparoscopic group who’s operating time averaged at 178 min (±32) (P<.001).¹⁵ In a retrospective analysis of 67 patients by Magrina et al., the researchers found the mean operation times for patients who went through a robotic approach to be 181.9 min. This was judged to be lower than that of the traditional approach of 189.5 min. In a related study based on retrospective chart review of 275 cases by Cardenas-Goicoechea et al., the researchers found the robotic approach to a have a longer mean operative time of 237 min compared to the traditional approach of 178 min.²¹

Hospital Stay

Mäenpää’s et al. RCT established shorter stays of on average 7.2 hours for robotic- assisted hysterectomy compared to the traditional laparoscopic procedures for endometrial cancer treatments.¹⁵ Similar results were observed by Magrina et al. when established mean operating times for patients who undergo robotic-assisted hysterectomy to be lower by 1.9 days compared to traditional approach, which recorded to 3.5 days. Cardenas-Goicoechea et al. also established similar results. His results showed that there is no statistically significant difference for hospital stay after operation in the two approaches. The robotic approach had 1.88 days while the traditional approach had 2.31 days.²¹

Conversion Rates

Mäenpää et al. RCT had a total of 5 conversions to laparotomy (P=.27) all of which were within the traditional laparoscopic group for reasons that included adhesions, disseminated cancer, bleeding from trocar site on abdominal wall, uterus too large to remove vaginally.¹⁵

Ran et al had similar results in their meta-analysis of 4420 patients that showed significantly fewer conversions in robotic groups than traditional laparoscopy groups.[26] Conversions to laparotomy from both robotic and traditional laparoscopic approaches were viewed as tending to have higher complications. A retrospective analysis by Nezhat and Nezhat compared perioperative results of robotic-assisted approach and traditional laparoscopic surgery.[27] A total of 105 patients were reviewed, who went through endometrial cancer surgical procedures through traditional or robotic-assisted laparoscopy. Nezhat and Nezhat found Robotic-assisted laparoscopy to have a conversion rate of 1 compared to the traditional approach, which had 0.²³

Lymph node yield

A review of research articles on endometrial cancer lymph node removal indicated an increased yield in robotic surgeries. Increasing the number of lymph nodes removed in endometrial cancer surgeries gave patients a decreased risk for metastatic spread.[28] Mäenpää et al. RCT found that lymph nodes harvested did not differ between groups, traditional laparoscopy yielded on average of 23 lymph nodes (11-50) and 25 lymph nodes (14-52) with (P=.160).¹⁵

Laparoscopic Vs. Robotic Outcomes Benign Gynecological Hysterectomies

Blood Loss

A review of two RCT studies performed by Sarlos et al.¹⁰ and Paraiso et al¹¹ shows that there seems to be no statistically significant data to suggest that robotic-assisted laparoscopic hysterectomy has an added benefits over the traditional laparoscopic hysterectomy in reducing blood loss during surgery.  Related retrospective studies showed differing data. They found a greater blood loss for traditional laparoscopic surgeries than robotic.[29] They also showed that blood loss in the traditional group was a little higher and that the statistical differences are small for the two groups. At any rate, the robotic group indicated additional problems in the vascular lesion.  From, Sarlos’ et al.¹⁰ study, intraoperative results of blood loss in both traditional and robotic laparoscopic hysterectomies does not indicate a significant statistical difference.

Operating Times

Operating time in a majority of studies was found to be longer for robotic-assisted laparoscopic hysterectomy than traditional laparoscopic approaches. ^4,6,7,813,14 From the RCT studies done by Sarlos et al. and Paraiso et al., there appears to be three key variables that affect the operating time for an endoscopic hysterectomy. These include the experiences of the surgeons, the attributes of the patients like adhesions, and uterine weight. For instance, in Sarlos’s et al. study, the mean uterine weight was 255 grams for the patients who went through a robotic-assisted laparoscopic hysterectomy and 247 grams for patients who went to the traditional laparoscopic group. At this rate, it is clear that as the operative times for robotic-assisted laparoscopic hysterectomy approach those of traditional laparoscopy, it appears to be practicable for routine clinical procedures. Indeed, a related study by Shashoua et al. showed that it has an added advantage of high precision in addition to a capacity for 3-dimensional vision as well as a more rapid learning curve, which make them practicable for larger sets of patient population.¹⁵ Therefore, robotic-assisted laparoscopic hysterectomy could be done with great precision and safety rate in patients with complex cases despite their relatively high operative times. Robotic-assisted hysterectomy is therefore generally safe as operative times appear to be acceptable in complex surgical procedures. However, compared to traditional laparoscopy, it appears to be linked to longer operative times. Additionally, it does appear to demonstrate a shorter hospital stay and to necessitate minimized usage of narcotics in patients who undergo robotic-assisted procedures.

The body mass index also appeared to play a significant role in determining the operating times, particularly in increasing the number of complexities. Indeed, the robotic-assisted laparoscopic hysterectomy is also associated with some complexities. Indeed, Herman et al. observed the complexity of robotic-assisted laparoscopic hysterectomy in surgical procedures in patients with obesity. It could be reasoned from Herman’s et al. findings that increased BMI has a negative effect of increasing operative time in men who undertake radical prostatectomy.  It is, therefore, possible that increased BMI may account for this. Regarding the RCT performed by Mäenpää et al.¹⁵ in endometrial cancer, their team was able to perform the surgeries faster suggesting that a possible learning curve that could be overcome to reduce operating times in even benign gynecological hysterectomies.

Hospital Stay

The results from RCT studies by Sarloset al and Paraiso et al indicate that robotic-assisted laparoscopic hysterectomy could be linked to a shorter hospital stay. It could be reasoned from their finding that hospital stays for the traditional group and robotic group are either shorter¹ or similar.^10,11 It could also be argued at this point that robotic-assisted laparoscopic hysterectomy procedures may not lead to an increase in hospital stay unless complications develop during the surgical procedure.

This conclusion is not particularly surprising as both the robotic and traditional procedures in Sarloset al.¹⁰ and Paraiso’s et al.[30] studies are endoscopic minimally invasive procedures. Therefore, the results indicate comparable postoperative outcomes. A larger comparative analysis by Pasic et al. indicated no significant dissimilarity in postoperative hospital stay between the two cohorts under study. Still, such findings have to be cautiously interpreted while attempting to make out their clinical relevancies. In respect to a large dissimilarity in postoperative hospital stay in the studies, it is still significant to examine the dissimilar hospitalization practices where the studies were undertaken. At this rate, it is worth concluding that an apparent consistent finding from the literature surveyed is the shorter length of hospital stay after robotic-assisted laparoscopic hysterectomy. This could, in part, be as a result of reduced postoperative pain because of the fulcrum effect in addition to a higher level of precision it is associated with. In supporting this idea, two comparative studies surveyed indicated considerably reduced the use of narcotic after robotic surgery.²⁶ Despite this, the small sample size of the studies reviewed, along with a lack of collaborating pain scores from the use of narcotic, restrict interpretation of these results.

Shashoua’s findings suggested that robotic-assisted laparoscopic hysterectomy has a shorter hospital stay of averagely one day compared to the traditional group.¹³ This shows that the robotic approach has a significantly shorter length of perioperative hospital stay compared to robotic cohort and traditional cohort in Sarlos’s et al.¹⁰ RCT study. This type of variability in hospital stay among different locations is somewhat a concern when looking at data of traditional vs. robotic procedures. Discharge protocols can vary from hospital to hospital and can lead to inappropriate measures for hospital stays. To counter this, it could  be suggested a t this point that a long-term RCT performed at one location will in future provide a better sense of benefits in hospital stay between traditional and robotic gynecological surgeries.

Conversion Rates

Both RCT studies only had one incidence of conversion to robotic laparotomy from the traditional laparoscopic group.^10,11 It appears that the idea that the researchers found no difference in conversion rates between the two groups reflects the small case load of their study, which had a small sample size to discover any divergence in complications as a result of very low mean incidence.  Therefore, because of the low risk of conversion rates, it is reasoned at this point that a larger scaled study needs to be performed to get a better idea to determine which approach is better.

In concluding remarks, patients requiring hysterectomies for benign diseases should preferably be treated using traditional laparoscopic methods.¹⁰ Indeed, in a meta-analysis performed by Albright et al. of four randomized trials with 326 total participants, the researchers showed no statistically significant or clinically meaningful difference between the robotic and laparoscopic approaches to hysterectomy for benign disease.[31] Robotic and traditional laparoscopy is still closely related to one another in perioperative outcomes for hysterectomies of benign gynecological diseases. However, the outcome for endometrial cancer was significantly improved in treatment and staging using robotic systems than traditional laparoscopic.  This does imply that the robotic approach is specifically suitable for elderly persons, who are increasingly fragile and are higher risks of minor complications.[32]

Endometrial Cancer Surgeries

Blood Loss

There have been some studies that suggest that Blood loss is lower in robotic than in traditional laparoscopic surgeries for endometrial cancer.[33] The RCT, however, showed that there was no significant statistical difference in blood loss. Similarly, there seems to be no statistically significant data suggesting the robotics has an added benefit of reducing blood loss during surgery. It is, therefore, plausible to argue that a blood transfusion is less likely to be administered in robotic-assisted procedures compared to traditional laparoscopic procedures. While it is clear that observable blood loss in the traditional group was a little higher, it is also conceivable that the statistical differences are small for the two groups. At any rate, the robotic group indicated additional problems in the vascular lesion.

From their study, Sarlos’ et al.¹⁰ concluded that the intraoperative results of blood loss in both traditional and robotic laparoscopic hysterectomies does not indicate a significant difference. The population size of their study may have been too small to show any major divergence in results in blood loss. This is particularly so as findings show that the mean incidence was low. Still, with this study, it is reasonable to argue that for a standard benign hysterectomy procedure, preeminence of the robotic procedure is still tentative as indications from both intraoperative and postoperative results appear to be nearly similar to traditional laparoscopy. Due to the insignificant statistical rate of blood loss, it is observed that while laparoscopic and robotic-assisted hysterectomies are safe alternatives to hysterectomy, it appears that use of robotic-assisted hysterectomy should still be explored in future RCT studies to decisively validate rate of blood loss. In fact, it demands substantially longer time for the safe operation to ensure minimal blood loss.

Operating Times

Operating time in a majority of studies appears to be comparatively shorter for robotic-assisted laparoscopic hysterectomy compared to traditional laparoscopic approaches. Within the randomized control trial that total time spent in the operating room was shorter in the robotic group.¹⁵ Several other studies had shown the complete opposite with longer times of 42 min increases on average spent in the operating room.^4,18 When looking at all three forms of surgical approaches to endometrial cancer, laparotomy is the shortest in operating time with traditional laparoscopic procedures second and robotics with the longest. The cause for increased operative time in robotics versus laparoscopy is mainly due to increased time required in setting up the robotic system rather than the procedure itself.[34] However, some studies did not take this extra time into consideration. Still, during the robotic set up, the patients were observed to have remained intubated resulting to increased anesthesia time for the patient.

Hospital Stay

The RCT study did not take into consideration the length of hospital stay in their study. However, some studies suggest that the length of hospital stay was shorter on average of 7.2 hours.^4,28 This is similar to studies from the benign gynecological hysterectomy studies where hospital length has been either the same between robotic and laparoscopic procedures or have been shorter.^1,13,14 There was also some reduction in post-operative stays for robotic cases^4,28making the procedure seem less burdensome for women. In a related study, Chen et al. also conducted a meta-analysis and established that robotic surgical platform lowers blood loss levels and hospital stay.[35]

A majority of the studies shows that there appears to be reduced length of hospital stay during the period of study for the patient cohorts that went through a robotic approach. Still, the difference does not appear to have reached statistical significance. It could be argued that endometrial cancer patients treated through the robotic-assisted approach tended to happen in the intestinal tract. On the other hand, patients in the traditional group were treated for injuries that affecting their ureters and bladder. It is likely that improved visualization resulting from a three-dimensional imaging capability of the robotic system enabled better identification of the body components. This may have led to lower rates of complications and length of hospital stay. It may also led to greater ease of operation and lower blood loss.

Apparently, robotic-assisted surgery could be considered as an acceptable alternative to traditional laparoscopy for more invasive endometrial cancer. At this stage, the robotic approach appears to be superior to the traditional one as it leads to shorter stay in hospitals, lower rates of blood loss and lower conversion rates for invasive endometrial cancer patients.

Conversion Rates

In a meta-analysis conducted by Chen et al., it was established that robotic surgical platform lowers the number of complications and conversion rates.³⁴ Better visualization with 3D stereoscopes in robotic consoles is likely to have reduced the number of complications – such as accidental damage to surrounding structures, in robotic surgeries than that of traditional laparoscopic approaches. However, the issue with the lack of haptic feedback during surgery can offset the benefit of 3D stereoscopic aid. Surgeons may sometimes not feel nay resistance during surgery. This is possibly because the robotic system lacks a crucial touch sense that surgeons still have when working with traditional laparoscopic tools.¹⁰  

Lymph Node Yield

The RCT study performed by Mäenpääet al.¹⁵ showed that the lymph node yield was the same between robotic and traditional groups. However, there are multiple other studies that found that robotics performed lymph node resection is on a par with open laparotomies.[36] One theory for this discrepancy could be that the surgeons in Mäenpää et al.‘s RCT¹⁵ had performed the surgery faster and therefore produced a lower lymph node yield. This RCT was the only study performed where robotic surgery was performed faster than laparoscopic.

The number of lymph node resection is highest for robotic and open laparotomy. Studies reviewed were observed to have reproduced results of greater yield in the number of lymph node dissections to numbers close to that of laparotomy and significantly higher than laparoscopy. ^4,30  For endometrial cancer, the robotic approach was observed to have greatly reduced surgeon fatigue due to smaller and lighter movements performed on the robot vs. manual manipulation of laparoscopic tools.²⁴ For endometrial cancer, the number of lymph nodes that a surgeon can resect can reduce the risk of metastatic spread.  However, fatigue can limit a surgeon’s performance during a procedure. If the surgeon can work longer, he can increase the number of lymph nodes resected in endometrial cancer patients at higher risk for metastatic spread.

Costs

A majority of the studies indicated that robotic-assisted hysterectomy tended to be costlier than the traditional laparoscopic procedures. The increase costs could be associated with additional costs that come with of maintenance fees and repairs.^6,[37] While it can be established that a robotic surgery attracts a higher cost than with laparoscopy, it is also possible that robotic surgery could become a more practicable alternative method once costs are reduced. Some non-randomized studies, such as that of Herling et al. that studied the effectiveness of the robotic-assisted approach tried to justify its greater outcomes for the associated high costs.[38] However, as no randomized controlled trials are included in this study to review the costs, it is believed that the findings accessible could be biased. Therefore, more studies in future could provide a greater opportunity to fully evaluate the long-term outcomes of the robotic approach new technology in endometrial cancer. Such long-term trials could incorporate costs, in addition to other related factors like quality of life outcomes and rates of success that are needed for determining the cost-benefit analysis of robotic-assisted hysterectomy and traditional laparoscopic approaches.[39]

Limitations of Robotic Surgeries

Some studies find that there are fewer complications in traditional laparoscopy than in robotic.²⁰ The multiple discrepancies need to be evaluated for variables in patient populations, body habitus, co-morbidities, the extent of tumor spread and the learning curve that is associated with new surgeons treating endometrial cancer with robotic assistance.

Surgeon Bias for Robotics

More complex hysterectomies are performed robotically for conditions such as severe pelvic adhesions, history of multiple past surgeries, stage III-IV endometriosis, and larger uterus size. Surgeons prefer robotics in complicated surgical procedures due to improved control of tissue, especially in the setting of the heavier uterus. However, complications, EBL, and operative time remain the same for RH and LH.⁴

What needs to be improved for Robotics

Aside from costs, increased operative time is one of the most pressing issues for surgeons preferring traditional laparoscopic. The bulkiness of the system also makes the setup time for the patient longer than typical laparoscopic procedures and has come with some resistance from surgeons that prefer older methods that they have mastered. This same type of resistance was also met when traditional laparoscopic procedures were first introduced in surgery.⁴ Laparoscopic procedures required extra training, longer operating times, and were more costly than laparotomy. However, the benefits from laparoscopic procedures after some time showed a great improvement in patient morbidity and quality of life.²⁰

Financial Considerations

Costs of Purchasing a Robotic System

The current cost of purchasing a da Vinci Surgical System ranges from $600,000 – $2.5Million. With yearly maintenance fees that can add up to $100,000-$170,000.^6,[40] Robotic surgeries for benign gynecological diseases did not show any increase in safety, effectiveness, or improvement in patient quality of life than traditional laparoscopic surgeries. There was however only a substantial increase in operative costs with robotic surgeries.^4,20

Costs-effective Future

Technology has the proponent of competitive markets that will push for reduced cost surgical systems. With more surgeons being trained in robotics the learning curve for a new application in technology that has longer operative times should also trend downwards.^6,32 This, however, will have to be continuously researched and may need to have collaborative efforts with tech companies to improve reduce machine setup time. With more innovative features, increasing sales of units and competitors entering the market for robotic surgical systems in gynecology, we would expect the technology of robotic surgical systems to trend towards cheaper and less bulky units.^4,32 A study that looked that the readmission rates of robotic vs. traditional laparoscopic showed that reduced readmission of robotics surgery was cost saving when compared to traditional laparoscopic surgery.[41]

Training Time Required for Mastering Laparoscopic vs. Robotic Procedures

The American Congress of Obstetricians and Gynecologist (ACOG) have current recommendations for robotic-assisted surgical training.  The surgeon must learn the skill of abdominal and laparoscopic approaches of gynecological surgeries before training for robotic approaches.[42] The technology is relatively new to the field of gynecological surgeries and remains to be a considerable learning curve for robotic-assisted hysterectomies for both benign diseases and endometrial cancer.[43]

Standardization of Training

The FDA only requires a short two-day certification training to be allowed to use the da Vinci robotic surgical system. However, this type of training does not mean that surgeons are prepared to start operating on patients. Training in robotic surgeries still lack formal standardization of privileging or credentialing for surgeons.⁴

Role of First-Assist Surgical PAs

There are guidelines recommended for privileging first assist surgical PAs in robotic surgeries and how hospitals can train qualified applicants. Non-physician robotics assistant privileges can be given to the licensed PAs after certain criteria are met. The criteria include 4 hours of hands-on robotic beside orientation, observe two successful robotic surgeries, must be proctored while assisting on two successful robotic surgeries, as well as final directions on roles and responsibilities the primary surgeon deems necessary. PAs who have completed all requirements successfully are only allowed to assist surgeons who have received prior approval for using PAs in robotic surgeries.[44]

CME Courses

Robotics Coordinator at NYU has CME courses that train PAs in first assist laparoscopic robotic surgeries in urology, general, colorectal, and gynecology. Objectives include patient safety, positioning, communication, troubleshooting technical components, and describe everyone’s roles during key procedural steps.[45]

Conclusion

Hysterectomies for benign gynecological diseases can still be performed more satisfactorily using traditional laparoscopic methods compared to robotic methods.  Randomized studies established that traditional laparoscopic methods can be more effective than robotic methods, except for complex surgeries. However, retrospective studies showed differing data as they indicated greater blood loss for traditional laparoscopic surgeries than robotic procedures. The robotic-assisted laparoscopic hysterectomy could be done with great precision and safety rate in patients with complex cases despite higher operative times. Robotic-assisted hysterectomy is therefore generally safe, as operative times appear to be effective in cases considered to be challenging. However, when compared to traditional laparoscopy, it appears to be linked to longer operative times. Additionally, it does appear to demonstrate a shorter hospital stay and minimized use of narcotics in patients who undergo robotic-assisted procedures. However, the body mass index also appeared to play a significant role in determining the operating times, particularly as it potentially increases the number of complexities for patients with obesity.  At any rate, there is insufficient data for improved peri-operative outcomes, as well as a substantial increase in the operative cost of robotic surgeries. However, in endometrial cancer, robotic procedures have shown to be useful with the increase in the number of lymph node yield along with improved patient recovery. Traditional laparoscopic methods trail at the end of studies producing the least lymph node yield, while robotic methods have yielded at levels as high as open laparotomy. This indicates a need for more RCT studies to validate this finding and to fully appreciate the benefits and cost effectiveness of robotics used in gynecological surgeries.

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