With hysterectomy, a pure vaginal approach has long been viewed by many experts as the preferable approach whenever possible – the most cost-effective minimally invasive method – and some experts are concerned that the growing popularity of robotics may chip away at its use.
"Vaginal hysterectomy is an art, so the question is, are we killing the art with the new technology we’re using for laparoscopy and now robotics? Maybe ... there are some studies suggesting [this], but we have no definitive data," Dr. Pasic said.
Dr. Javier Magrina
Dr. Javier Magrina, a professor of obstetrics and gynecology and director of gynecologic oncology at the Mayo Clinic in Scottsdale, Ariz., who has written and lectured extensively on robotic surgery from the standpoint of both benign and malignant disease, said that so far, vaginal hysterectomy rates appear to be "stable in spite of robotics," comprising about 20%-25% of all hysterectomies. "The increase of robotic hysterectomy so far has decreased the number of laparotomies, which is very good," he said in an interview.
Dr. Jed Delmore and his colleagues at the University of Kansas in Wichita found just this when they compared the types of hysterectomy performed at their teaching hospital and two outpatient surgery centers during two periods of time: before robotic surgery became locally available (2006-2007) and 2 years after it arrived (2009-2010).
Using electronic medical record and billing data to identify hysterectomies, they found that the number of abdominal hysterectomies decreased significantly, while the number of vaginal hysterectomies remained relatively constant. The unpublished findings were presented at the American Congress of Obstetricians and Gynecologists District VII meeting in Kansas City in September.
"At least in our community of 400,000 women, there was a positive shift," Dr. Delmore said in an interview.
Still, he said, the potential longer-term impact of robotics on vaginal hysterectomy is a concern. "If there’s a big shift from abdominal surgery to robotic surgery, that will be cost-effective. ... But if it turns out that over time fewer women end up having vaginal hysterectomies, and have robotic hysterectomies instead, there will be greater expense to individuals and society," said Dr. Delmore, professor of obstetrics and gynecology and director of gynecologic oncology at the university.
An even larger concern, he noted, is "whether robotic surgery, as it becomes more and more available, will increase the total volume of hysterectomies – in women who would have previously been treated with hormone therapy or [other modalities]."
Dr. Jed Delmore
Such a trend may be occurring with prostatectomy, note the authors of the New England Journal of Medicine cost analysis, with robotic technology possibly contributing to the substitution of surgical for non-surgical treatments for prostate cancer.
This does not appear to be happening with hysterectomy in the Kansas City area thus far, Dr. Delmore said.
The undercurrents may already exist, however. Gynecology is one of Intuitive Surgical’s five main "target markets," according to a company investor presentation, and hysterectomy is one of four "target" gynecologic procedures, along with sacral colpopexy, myomectomy, and endometrial resection.
With an estimated 600,000 hysterectomies being performed each year in the United States, Intuitive sees potential for growth. As of this fall, the 2011 surgical volume with the da Vinci had increased 30% over 2010 volume across all types of procedures, said Intuitive Surgical’s Mr. Simmonds.
Having a surgical robot has become a status symbol of sorts for hospitals in many urban areas – as of September, Intuitive had installed 1,478 da Vinci surgical systems in the United States – and ob.gyns. may feel compelled to keep up with market demands.
"General ob.gyns. don’t want to be the only physicians in the community not offering it," said Dr. Delmore, who teaches robotic surgery as a proctor for Intuitive Surgical.
Many ob.gyns., moreover, find robotic-assisted laparoscopy much easier than conventional laparoscopy to learn and adopt. Suturing is easier, and Dr. Magrina and other proponents of robotics maintain that the advantages of instrument articulation and steady three-dimensional vision have proven even higher than expected – for hysterectomies as well as more complex gynecologic procedures.
While the learning curve for robotics is said to be relatively short, Dr. Pasic and his coauthors caution that robotic assistance should not be used by physicians who are unwilling to invest time and effort into laparoscopic training. Exuberance for the da Vinci could have an "unintended negative effect on resident and fellow training as it relates to overall laparoscopic competencies," they said.
Institutions, in the meantime, are individually attempting to determine how best to train residents in robotic-assisted surgery. The University of Kansas is implementing a training model for ob.gyn. residents that includes an online tutorial, training with inanimate objects, animal lab training, and bedside assistance in real robotic-assisted hysterectomies.