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Return to Could Robotic Hysterectomy Become a Standard of Care? Overview

More on Could Robotic Hysterectomy Become a Standard of Care?

Could Robotic Hysterectomy Become a Standard of Care?

New York (May 15, 2009)

Medical team in the operating room

The benefits of robotic surgery have been well documented: smaller incisions, less blood loss, shorter hospital stay, and faster recovery. These advantages have been widely observed among urologic surgeons using the technique to resect malignant prostate tumors. In more recent years, gynecologic oncologists at NewYork-Presbyterian Hospital have been employing surgical robots to perform hysterectomies in patients with endometrial and cervical cancers for whom removal of the uterus is the indicated treatment.

"The dexterity of the robot tools and the three-dimensional magnified view of the surgical field bring all of the comforts of laparotomy to the minimally invasive setting," explained Kevin Holcomb, MD.

Skilled Surgeons Still Needed

Like other technological advances in surgery, the robot is but a tool that still requires the skill of a trained surgeon. During the procedure, the surgeon sits comfortably at a console, viewing the surgical field through the robot's "vision system." He uses hand and foot controls to operate the various arms and cameras of the robot, which are placed into position by surgical assistants.

The hand controls scale down the surgeon's movements into precise micro-movements with a 360-degree range of motion, and also enable the surgeon to zoom the camera in or out of the surgical field. The foot pedals allow the hand controls to switch between manipulating the camera and the robotic arms, and they are also used to cauterize the site of bleeding.

During robotic hysterectomy, the incisions are made in the abdomen and the uterus is removed transvaginally; the operative time is about four hours for the hysterectomy plus lymph node dissection.

Study Evidence: Robotic Hysterectomy Effective

The useful characteristics of robotic hysterectomy have been documented by scientific papers in the medical literature. For example, University of North Carolina researchers reported a case-control study last year which showed that patients with early-stage cervical cancer who had the robotic approach experienced a shorter operative time, less blood loss, a shorter inpatient stay (1 vs. 3.2 days), and less than half the incidence of postoperative complications (7.8 percent vs. 16.3 percent) compared with those who had laparotomy. Using robotics surgeons are also able to harvest more lymph nodes. (1)

A 2009 multicenter study showed that the overall median operative time for robotic hysterectomy was 215 minutes, the overall median estimated blood loss was 50 cc, and the median lymph node count was 25. Intraoperative complications occurred in 4.8 percent of patients and postoperative complications were reported in 12 percent. (2)

Matching Robotic Hysterectomy With Patients

Not all hysterectomy patients are candidates for the robotic approach, however. Thomas Herzog, MD, explained that the technique is especially well suited for obese patients (which accounts for most patients with endometrial cancer) and for the dissection of high periaortic lymph nodes. "However, the robotic system does enable surgeons who are more familiar with conventional laparotomy than laparoscopy to perform minimally invasive procedures, making this approach available to more patients," he added.

Dr. Holcomb offers the robotic approach to any of his patients who are candidates for laparoscopy, but he does not use it for anything less than a hysterectomy. "We have to draw the line where robotics is unnecessary," he noted. "There are cost considerations."

Dr. Herzog emphasized as well that the high cost of using the robotic platform needs to be taken into consideration when selecting an approach for gynecologic surgery. "The robotic approach is not necessarily better than conventional laparoscopy in all cases," he said. "We need to do more cost-modeling studies to determine the most appropriate use, especially in this era of healthcare reform."

He added that future competition may help drive down costs. Today there is only one manufacturer of robotic platforms: Intuitive Surgical, Inc., which makes the da Vinci® Surgical System.

Robotics is not a fad. It's here to stay," concluded Dr. Holcomb. "I think it's going to grow in use and acceptance."

Faculty Contributing to this Article:

Kevin Holcomb, MD is an Associate Attending Obstetrician and Gynecologist at NewYork-Presbyterian Hospital, and an Associate Professor of Clinical Obstetrics and Gynecology at Weill Cornell Medical College.

Thomas Herzog, MD is an Attending Obstetrician and Gynecologist at NewYork-Presbyterian Hospital, and a Professor of Clinical Obstetrics and Gynecology at Columbia University College of Physicians and Surgeons.

References

1. Boggess JF et al. A case-control study of robot-assisted type III radical hysterectomy with pelvic lymph node dissection compared with open radical hysterectomy. Am J Obstet Gynecol. 2008;199:357.e1-7.

2. Lowe MP et al. A multi-institutional experience with robotic-assisted radical hysterectomy for early stage cervical cancer. Gynecol Oncol. 2009 Feb. 25. (Epub ahead of print)

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