Comparison of Robotic and Other Minimally-Invasive Routes of Hysterectomy for Benign Indications

The popularization of robotic-assisted laparoscopic hysterectomy (RH) over the past decade has provided an alternative approach to performing minimally invasive hysterectomy. However, no evidence has demonstrated improved clinical outcomes with the robotic procedure over other minimally invasive surgical (MIS) routes for benign indications The primary aim of this retrospective study was to compare perioperative outcomes and complications of hysterectomies performed for benign indications with robotic assistance versus all other MIS routes (laparoscopic and vaginal, with or without laparoscopy). A secondary aim was to compare estimated costs of the robotic procedure with that of other MIS routes. A statewide database was used to obtain utilization and outcomes of minimally invasive hysterectomy performed for benign indications between January 1, 2013, and July 1, 2014. Outcomes among women who had a hysterectomy with robotic assistance and other MIS routes were evaluated using a one-to-one propensity score-matched analysis. Perioperative outcomes, intraoperative complications (including bowel and bladder injury), 30-day postoperative complications, readmissions, and reoperations were compared in the propensity score-matched cohorts. Postoperative complications evaluated within 30 days of the hysterectomy included superficial surgical site infection and blood transfusion. Cost estimates for hysterectomy routes, surgical site infection, and postoperative blood transfusion were obtained from published data. A total of 8313 hysterectomy cases were identified: 4527 using robotic assistance and 3786 using other minimally invasive routes; 1338 women from each group were successfullymatched using propensity score matching. Compared with other MIS routes, robotic-assisted hysterectomies had lower estimated blood loss (94.2 +/- 124.3 vs 175.3 +/- 198.9 mL, P < 0.001), longer surgical time (2.3 +/- 1.0 vs 2.0 +/- 1.0 hours, P < 0.001), larger specimen weights (178.9 +/- 186.3 vs 160.5 +/- 190 g, P = 0.007), and shorter length of hospital stay (14.1% [189/1338] vs 21.9% [293/1338] of >= 2 days, P < 0.001). The rate of any postoperative complication was lower with the robotic-assisted route (3.5% [47] vs 5.6% [75], P = 0.01), which was largely due to lower rates of superficial surgical site infection (0.07% [1] vs 0.7% [9], P = 0.01) and blood transfusion (0.8% [11] vs 1.9% [25], P = 0.02). There were no significant differences between groups in major postoperative complications, intraoperative bowel and bladder injury, readmissions, and reoperations. Using hospital cost estimates and considering the incremental costs associated with surgical site infection and blood transfusions, the average net savings for MIS routes compared with the robotic procedure was $3269 per case, representing a 24% lower cost compared with robotic-assisted hysterectomy ($10,160 vs $13,429). These data show that in comparison to other MIS routes robotic-assisted laparoscopy did not decrease major morbidity following hysterectomy for benign indications. Although superficial surgical site infection and blood transfusion rates were statistically lower in the robotic-assisted group, these complications occur rarely. It will be difficult to justify use of robotic-assisted hysterectomy without proof of substantial reductions in clinically and financially burdensome complications.