title: Comparison of robotic and other minimally invasive routes of hysterectomy for benign indications.
abstract: BACKGROUND
  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.
  
  
  OBJECTIVE
  We sought to compare clinical outcomes and estimated cost of robotic-assisted vs other routes of minimally invasive hysterectomy for benign indications.
  
  
  METHODS
  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.
  
  
  RESULTS
  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).
  
  
  CONCLUSIONS
  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.
authors.affiliation: Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI. Electronic address: scarolyn@med.umich.edu.
authors.forename: Carolyn W
authors.initials: CW
authors.lastname: Swenson
authors.affiliation: Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI.
authors.forename: Neil S
authors.initials: NS
authors.lastname: Kamdar
authors.affiliation: Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI.
authors.forename: John A
authors.initials: JA
authors.lastname: Harris
authors.affiliation: Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI.
authors.forename: Shitanshu
authors.initials: S
authors.lastname: Uppal
authors.affiliation: Department of Surgery, University of Michigan, Ann Arbor, MI.
authors.forename: Darrell A
authors.initials: DA
authors.lastname: Campbell
authors.affiliation: Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI.
authors.forename: Daniel M
authors.initials: DM
authors.lastname: Morgan
mesh_terms: D000328:Adult; D000368:Aged; D005260:Female; D005500:Follow-Up Studies; D017721:Hospital Costs / Q000706:statistics & numerical data; D006801:Humans; D007044:Hysterectomy / Q000191:economics / Q000379:methods*; D007431:Intraoperative Complications / Q000191:economics / Q000453:epidemiology / Q000209:etiology; D010535:Laparoscopy / Q000191:economics; D008824:Michigan; D008875:Middle Aged; D010359:Patient Readmission / Q000191:economics / Q000706:statistics & numerical data; D011183:Postoperative Complications / Q000191:economics / Q000453:epidemiology / Q000209:etiology; D012086:Reoperation / Q000191:economics / Q000706:statistics & numerical data; D012189:Retrospective Studies; D065287:Robotic Surgical Procedures / Q000191:economics; D016896:Treatment Outcome; D014591:Uterine Diseases / Q000191:economics / Q000601:surgery*
keywords: complications; cost; hysterectomy; minimally invasive; robotic