A randomized trial comparing vaginal and laparoscopic hysterectomy vs robot-assisted hysterectomy.

To investigate the hospital cost and short-term clinical outcome of traditional minimally invasive hysterectomy vs robot-assisted hysterectomy in women primarily not considered candidates for vaginal surgery. Randomized controlled trial (Canadian Task Force classification I). University Hospital in Sweden. One hundred twenty-two women with uterine size ≤ 16 gestational weeks scheduled to undergo minimally invasive hysterectomy because of benign disease. Robot-assisted hysterectomy or traditional vaginal or laparoscopic minimally invasive hysterectomy. All women underwent surgery as randomized. There were no demographic differences between the 2 groups. Vaginal hysterectomy was possible in 41% in the traditional minimally invasive group, at a mean hospital cost of $4579 compared with $7059 for traditional laparoscopic hysterectomy. This was reflected in a mean hospital cost of $993 more per robotic-assisted hysterectomy than for traditional minimally invasive hysterectomy when the robot was a preexisting investment. This hospital cost increased by $1607 when including investments and cost of maintenance. A per-protocol subanalysis comparing laparoscopy and robotics demonstrated similar hospital cost when the robot was a preexisting investment ($7059 vs $7016). Robotic-assisted hysterectomy was associated with less blood loss and fewer postoperative complications. A similar hospital cost can be attained for laparoscopy and robotics when the robot is a preexisting investment. From the perspective of hospital costs, robotic-assisted hysterectomy is not advantageous for treating benign conditions when a vaginal approach is feasible in a high proportion of patients.

Lönnerfors C ，Reynisson P ，Persson J 《-》

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

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

Swenson CW ，Kamdar NS ，Harris JA ，Uppal S ，Campbell DA Jr ，Morgan DM ... -  《-》

A systematic review and cost analysis of robot-assisted hysterectomy in malignant and benign conditions.

In order to assess the effectiveness and costs of robot-assisted hysterectomy compared with conventional techniques we reviewed the literature separately for benign and malignant conditions, and conducted a cost analysis for different techniques of hysterectomy from a hospital economic database. Unlimited systematic literature search of Medline, Cochrane and CRD databases produced only two randomized trials, both for benign conditions. For the outcome assessment, data from two HTA reports, one systematic review, and 16 original articles were extracted and analyzed. Furthermore, one cost modelling and 13 original cost studies were analyzed. In malignant conditions, less blood loss, fewer complications and a shorter hospital stay were considered as the main advantages of robot-assisted surgery, like any mini-invasive technique when compared to open surgery. There were no significant differences between the techniques regarding oncological outcomes. When compared to laparoscopic hysterectomy, the main benefit of robot-assistance was a shorter learning curve associated with fewer conversions but the length of robotic operation was often longer. In benign conditions, no clinically significant differences were reported and vaginal hysterectomy was considered the optimal choice when feasible. According to Finnish data, the costs of robot-assisted hysterectomies were 1.5-3 times higher than the costs of conventional techniques. In benign conditions the difference in cost was highest. Because of expensive disposable supplies, unit costs were high regardless of the annual number of robotic operations. Hence, in the current distribution of cost pattern, economical effectiveness cannot be markedly improved by increasing the volume of robotic surgery.

Tapper AM ，Hannola M ，Zeitlin R ，Isojärvi J ，Sintonen H ，Ikonen TS ... -  《-》

Health resource utilization and costs during the first 90 days following robot-assisted hysterectomy.

Dandolu V ，Pathak P 《-》

Comparison of laparoscopic-assisted vaginal hysterectomy with traditional hysterectomy for cost-effectiveness to employers.

Lenihan JP Jr ，Kovanda C ，Cammarano C 《AMERICAN JOURNAL OF OBSTETRICS AND GYNECOLOGY》