Are robots taking over the operating theatre?
In Australia the initial uptake of robotic surgery has focused on urology for radical prostatectomies but is still slow for gynaecological surgery.
Laparoscopic surgery involves surgery with stiff instruments inserted though 5 mm openings through the skin. A radical prostatectomy procedure is difficult to complete in a narrow, male pelvis. Robotic instruments that articulate and move in 3 dimensions is much easier to do in this context and is favoured in urology.
In urology, robotic surgery has been a game changer similar to the introduction of laparoscopic surgery in gynaecology in the 1990s. Laparoscopic surgery in gynaecology allowed patients to avoid an open abdominal surgery, which has a longer recovery, longer hospital stay, and more potential complications compared to laparoscopic surgery. Most gynaecological surgery has been laparoscopic for some years already. There are very few hysterectomies, resection of endometriosis, or resection of a benign ovarian mass that requires an open, abdominal surgery.
In urology, open surgery has been the standard surgical approach until the arrival of the robot.
In gynaecology, robotic surgery has not yet taken off in Australia. In the United States robotic surgery in gyneacologic procedures began when the da Vinci surgical system was approved by FDA, and the first gynaecologic surgery was performed in the United States in 2005. Since then, the number of robotically assisted hysterectomies has steadily increased in the United States, but not in Australia.
In Australia, why is the uptake of robotic surgery slow in gynaecology?
- Costs: Above all, the costs are expensive. A robotic surgical procedure will cost the patient up to an additional $5,000 out-of-pocket expenses. This is to cover the costs of expensive robotic instruments and maintenance of the robot. These costs come to patients as an additional out-of-pocket expense and most patients would find that additional expense (in addition to other expenses) significant. Neither health funds nor hospitals would cover that expense.
- Lack of benefit over laparoscopic procedures: A large number of studies have found no major consistent advantages between robotic and laparoscopic procedures. This was determined in a sample of 264,758 women who underwent hysterectomy for benign gynaecologic disorders across the United States from 2007 to 2010. Critical review of the literature shows that robotic gynaecological surgery has almost identical surgical outcomes, and in some studies surgical complications from robotic surgery are higher. In gynaecology, the use of robotic surgery is not driven by the result of evidence-based medicine but mainly by marketing and enthusiastic surgeons.
- Longer operating and anaesthetic time: Fewer operations can be done because the operating time is significantly longer with the robot as is the anaesthetic time. “Docking time” is required to connect the robot to the patient. Even for experienced robotic surgeons longer operating time will reduce the number of patients who will have surgery.
Since there are no studies that show the benefit of robotic hysterectomy over a laparoscopic approach, I don’t believe there are any incentives to perform robotic surgery in gynaecology.
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