Outcomes of Robotic Hysterectomy for Treatment of Benign Conditions: Influence of Patient Complexity

Lisa J Herrinton, Tina Raine-Bennett, Liyan Liu, Stacey E Alexeeff, Wilfredo Ramos, Betty Suh-Burgmann, Lisa J Herrinton, Tina Raine-Bennett, Liyan Liu, Stacey E Alexeeff, Wilfredo Ramos, Betty Suh-Burgmann

Abstract

Introduction: Robotic hysterectomy may offer advantages for complex cases over the conventional laparoscopic approach.

Objective: To assess the association of surgical approach (robotic vs conventional) with blood loss, risks of readmission, reoperation, complications, and average operative time.

Methods: In a retrospective cohort study, we used the electronic medical records of Kaiser Permanente Northern California, 2011 to 2015, to estimate outcomes of robotic and conventional laparoscopic hysterectomy among women with complex or noncomplex benign disease. Mixed-effects regression models accounted for patient characteristics and surgeon volume.

Results: The study included 560 robotic and 6785 conventional laparoscopic cases. Overall, 1836 patients (25%) met criteria for being complex. The average operative time was 152 minutes for robotic hysterectomy and 157 minutes for conventional laparoscopic hysterectomy (p < 0.0001). Complex surgical cases averaged 190 minutes and noncomplex cases averaged 144 minutes. The difference in operative time for high-volume surgeons treating complex patients with robotic hysterectomy vs conventional hysterectomy was 21 minutes faster (p < 0.05). After adjustment, the risk of blood loss at least 51 mL was lower for robotic surgery than for conventional surgery for complex and noncomplex patients. Other than risk of urinary tract complications, we observed no differences in the risks of complications or risk of reoperation between robotic and conventional laparoscopy for complex and noncomplex patients.

Conclusion: For women with complex disease, the robotic approach, when used by a higher-volume surgeon, may be associated with shorter operative time and slightly less blood loss, but not with lower risk of complications.

Conflict of interest statement

Disclosure Statement

The author(s) have no conflicts of interest to disclose.

Figures

Figure 1
Figure 1
Inclusion of study population. LAH = laparoscopic abdominal hysterectomy; TLAH = total laparoscopic abdominal hysterectomy.
Figure 2
Figure 2
Operative time by surgeon volume. For conventional surgeons, the slope reflects the average performance of 345 individual surgeons across 6432 conventional surgeries, and the intercept reflects their first conventional surgeries. For robotic surgeons, the slope reflects the average performance of 31 individual surgeons across 544 robotic surgeries, and the intercept reflects their first robotic surgery, with the average number of conventional procedures before first robotic surgery being 232. We defined low volume as less than or equal to 49, medium as 50 to 199, and high as 200 or more cases for conventional surgeons. For robotic surgeons, we defined low as 24 or fewer, medium as 25 to 74, and high as 75 or more cases. Light gray = conventional surgery; dark gray = robotic surgery.
Figure 3
Figure 3
Distribution of blood loss (mL) in relation to robotic (RLAH) and conventional total laparoscopic abdominal hysterectomy (TLAH).

References

    1. Wright JD, Ananth CV, Lewin SN, et al. Robotically assisted vs laparoscopic hysterectomy among women with benign gynecologic disease. JAMA. 2013 Feb 20;309(7):689–98. doi: 10.1001/jama.2013.186.
    1. Desai VB, Xu X. An update on inpatient hysterectomy routes in the United States. Am J Obstet Gynecol. 2015 Nov;213(5):742–3. doi: 10.1016/j.ajog.2015.07.038.
    1. Zaritsky E, Tucker L-Y, Neugebauer R, et al. Minimally invasive hysterectomy and power morcellation trends in a west coast integrated health system. Obstet Gynecol. 2017 Jun;129(6):996–1005. doi: 10.1097/AOG.0000000000002034.
    1. Harris JA, Swenson CW, Uppal S, et al. Practice patterns and postoperative complications before and after US Food and Drug Administration safety communication on power morcellation. Am J Obstet Gynecol. 2016 Jan;214(1):98.e1–13. doi: 10.1016/j.ajog.2015.08.047.
    1. Swenson CW, Kamdar NS, Harris JA, Uppal S, Campbell DA, Jr, Morgan DM. Comparison of robotic and other minimally invasive routes of hysterectomy for benign indications. Am J Obstet Gynecol. 2016 Nov;(5):650.e1–8. doi: 10.1016/j.ajog.2016.06.027.
    1. Liu H, Lawrie TA, Lu D, Song H, Wang L, Shi G. Robot-assisted surgery in gynaecology. Cochrane Database Syst Rev. 2014 Dec 10;(12):CD011422. doi: 10.1002/14651858.CD011422.
    1. Rosero EB, Kho KA, Joshi GP, Giesecke M, Schaffer JI. Comparison of robotic and laparoscopic hysterectomy for benign gynecologic disease. Obstet Gynecol. 2013 Oct;122(4):778–86. doi: 10.1097/AOG.0b013e3182a4ee4d.
    1. Gala RB, Margulies R, Steinberg A, et al. Society of Gynecologic Surgeons Systematic Review Group. Systematic review of robotic surgery in gynecology: Robotic techniques compared with laparoscopy and laparotomy. J Minim Invasive Gynecol. 2014 May-Jun;21(3):353–61. doi: 10.1016/j.jmig.2013.11.010.
    1. Lönnerfors C, Reynisson P, Persson J. A randomized trial comparing vaginal and laparoscopic hysterectomy vs robot-assisted hysterectomy. J Minim Invasive Gynecol. 2015 Jan;22(1):78–86. doi: 10.1016/j.jmig.2014.07.010.
    1. Woelk JL, Casiano ER, Weaver AL, Gostout BS, Trabuco EC, Gebhart JB. The learning curve of robotic hysterectomy. Obstet Gynecol. 2013 Jan;121(1):87–95. doi: 10.1097/AOG.0b013e31827a029e.
    1. Sendag F, Zeydek B, Akdemir A, Ozgurel B, Oztekin K. Analysis of the learning curve for robotic hysterectomy for benign gynaecological disease. Int J Med Robot. 2014 Sep;10(3):275–79. doi: 10.1002/rcs.1567.
    1. Aarts JW, Nieboer TE, Johnson N, et al. Surgical approach to hysterectomy for benign gynaecological disease. Cochrane Database Syst Rev. 2015 Aug 12;(8):CD003677. doi: 10.1002/14651858.CD003677.pub5.
    1. Twijnstra AR, Blikkendaal MD, van Zwet EW, van Kesteren PJ, de Kroon CD, Jansen FW. Predictors of successful surgical outcome in laparoscopic hysterectomy. Obstet Gynecol. 2012 Apr;119(4):700–8. doi: 10.1097/AOG.0b013e31824b1966.
    1. Driessen SR, Sandberg EM, la Chapelle CF, Twijnstra AR, Rhemrev JP, Jansen FW.Case-mix variables and predictors for outcomes of laparoscopic hysterectomy: A systematic review J Minim Invasive Gynecol 2016. March-April233317–30. 10.1016/j.jmig.2015.11.008
    1. Ruiz MP, Chen L, Hou JY, et al. Outcomes of hysterectomy performed by very low-volume surgeons. Obstet Gynecol. 2018 Jun;131(6):981–90. doi: 10.1097/AOG.0000000000002597.
    1. Brown DN. Doing what is best for the patient: When surgical volume matters. Obstet Gynecol. 2018;131:977–9. doi: 10.1097/AOG.0000000000002597.
    1. Vree FE, Cohen SL, Chavan N, Einarsson JI.The impact of surgeon volume on perioperative outcomes in hysterectomy JSLS 2014. April-May182174–81. 10.4293/108680813X13753907291594
    1. Committee on Gynecologic Practice, Society of Gynecologic Surgeons, and American College of Obstetricians and Gynecologists. Committee Opinion No. 628. Washington, DC: American College of Obstetricians and Gynecologists; Mar, 2015. Robotic surgery in gynecology [Internet] reaffirmed 2017 [cited 2017 Jun 21]. Available from: .
    1. Charlson M, Szatrowski TP, Peterson J, Gold J. Validation of a combined comorbidity index. J Clin Epidemiol. 1994 Nov;47(11):1245–51. doi: 10.1016/0895-4356(94)90129-5.
    1. Wood SN. Generalized additive models: An introduction with R. Boca Raton, FL: Chapman & Hall/CRC Press; 2006.
    1. Boyd LR, Novetsky AP, Curtin JP. Effect of surgical volume on route of hysterectomy and short-term morbidity. Obstet Gynecol. 2010 Oct;116(4):909–15. doi: 10.1097/AOG.0b013e3181f395d9.
    1. Myers ER, Steege JF. Risk adjustment for complications of hysterectomy: Limitations of routinely collected administrative data. Am J Obstet Gynecol. 1999 Sep;181(3):567–75. doi: 10.1016/S0002-9378(99)70494-1.
    1. Visco AG, Barber MD, Myers ER. Early physician experience with laparoscopically assisted vaginal hysterectomy and rates of surgical complications and conversion to laparotomy. Am J Obstet Gynecol. 2002 Oct;187(4):1008–12. doi: 10.1067/mob.2002.126642.
    1. Wright JD, Hershman DL, Burke WM, et al. Influence of surgical volume on outcome for laparoscopic hysterectomy for endometrial cancer. Ann Surg Oncol. 2012 Mar;19(3):948–58. doi: 10.1245/s10434-011-2090-8.
    1. Paraiso MF, Ridgeway B, Park AJ, et al. A randomized trial comparing conventional and robotically assisted total laparoscopic hysterectomy. Am J Obstet Gynecol. 2013 May;208(5):368.e1–7. doi: 10.1016/j.ajog.2013.02.008.
    1. Patzkowsky KE, As-Sanie S, Smorgick N, Song AH, Advincula AP.Perioperative outcomes of robotic versus laparoscopic hysterectomy for benign disease JSLS 2013. January-March171100–6. 10.4293/108680812X13517013317914
    1. Sarlos D, Kots L, Stevanovic N, von Felten S, Schär G. Robotic compared with conventional laparoscopic hysterectomy: A randomized controlled trial. Obstet Gynecol. 2012 Sep;120(3):604–11. doi: 10.1097/AOG.0b013e318265b61a.
    1. van Weelden WJ, Gordon BB, Roovers EA, et al. Perioperative surgical outcome of conventional and robot-assisted total laparoscopic hysterectomy. Gynecol Surg. 2017;14(1):5. doi: 10.1186/s10397-017-1008-2.
    1. Payne TN, Dauterive FR.A comparison of total laparoscopic hysterectomy to robotically assisted hysterectomy: Surgical outcomes in a community practice J Minim Invasive Gynecol 2008. May-June153286–91. 10.1016/j.jmig.2008.01.008
    1. Wright KN, Jonsdottir GM, Jorgensen S, Shah N, Einarsson JI.Costs and outcomes of abdominal, vaginal, laparoscopic and robotic hysterectomies JSLS 2012. October-December164519–24. 10.4293/108680812X13462882736736

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