Although a larger sample size and longer follow-up would be ideal, this study demonstrates a low rate of recurrent prolapse 1 year after the procedure.
WHAT THIS EVIDENCE MEANS FOR PRACTICE
Robotic sacrocolpopexy appears to provide long-term durability for the treatment of advanced vaginal vault prolapse.
How to choose an approach when planning sacrocolpopexy
Depending on where you practice, you may have as many as three options: abdominal, laparoscopic, or robotic-assisted. Here are basic questions you should address when choosing one:
- How familiar are you with the technique? if the answer is “not much,” you can anticipate that the cost and time required to perform it will be significantly higher.
- Are the appropriate instruments and surgical team available?
- Does the patient have comorbidities? Consider, for example, the fact that she may not be able to tolerate a steep Trendelenberg position—required for the robotic-assisted approach—if she has severe cardiac or pulmonary disease. However, if she has a risk of poor wound healing, a large abdominal incision may not be advisable and postoperative immobility can be risky. if she is obese, laparoscopic or robotic port placement is challenging, but visualization and retraction will be easier. The need for anticoagulation is another consideration, as it will affect estimated blood loss and the choice of an incision, among other things.
- Let’s not forget the patient. Given the pros and cons, what approach does she prefer?
How much do laparoscopic, abdominal, and robotic-assisted sacrocolpopexy cost?
Judd JP, Siddiqui NY, Barnett JC, et al. Cost-minimization analysis of robotic-assisted, laparoscopic, and abdominal sacrocolpopexy. J Minim Invasive Gynecol. 2010;17: 493–499.
This cost-minimization analysis concluded that robotic-assisted sacrocolpopexy incurs the highest hospital charges but is reimbursed by Medicare at a rate similar to reimbursement for the abdominal and laparoscopic routes (TABLE 2).
TABLE 2
Cost of sacrocolpopexy is significant—especially using the robotic approach
| Approach | Cost of a procedure | Operative time, min (range) |
|---|---|---|
| Robotic-assisted | $8,508 | 328 (130–383) |
| Laparoscopic | $7,353 | 269 (97–334) |
| Abdominal | $5,792 | 170 (110–286) |
| Source: Judd JP, Siddiqui NY, Barnett JC, Visco AG, Havrilesky LJ, Wu JM. Cost-minimization analysis of robotic-assisted, laparoscopic, and abdominal sacrocolpopexy. J Minim invasive Gynecol. 2010;17(4):493–499. | ||
The analysis accounted for realistic practices, such as the inclusion of concurrent hysterectomy and other procedures.
Details of the trial
Surgeons from Duke University developed a decision-analysis model in which a hypothetical group of women with advanced vaginal prolapse could choose between one of the three routes of sacrocolpopexy: abdominal, laparoscopic, or robotic-assisted. Researchers postulated two different scenarios:
- the hospital had ownership of a robotic system
- the hospital invested in the initial purchase and maintenance of such a system.
Researchers reviewed the literature to formulate their estimates of operative time, rate of conversion to laparotomy, rate of transfusion, and length of hospital stay. In addition, the costs of initial anesthesia setup, professional fees, per-minute intraoperative fees, and postanesthesia care were applied to each approach. Operating room costs per minute and the cost of disposable items such as drapes, gowns, gloves, and single-use instruments were added. For the robotic approach, the costs of reusable instruments were distributed across 10 operations. Reusable instruments for laparoscopic and abdominal surgery were assumed to incur no additional investment. Last, postoperative care—including laboratory tests, pharmacy usage, and the need for a hospital room—were individualized for each route of surgery and applied to the cost.
Costs were estimated in 2008 US dollars, based on procedure costs incurred at Duke University Medical Center.
Physician reimbursement data were obtained from Medicare reimbursement rates for anesthesia and from surgeon Current Procedural Terminology (CPT) codes specific to each procedure.
Quality-of-life assessments were not measured. Nor was the cost to society of the postoperative loss of productivity and wages for each surgical route. Had these losses been recognized, the authors observed, the cost of robotic surgery may have been lower.
The cost of robotic surgery was equivalent to the cost of laparoscopy in only two instances:
- when the operative time of robotic surgery was reduced to 149 minutes
- when the cost of robotic disposable items was less than $2,132 (reduced from a baseline cost of $3,293).
WHAT THIS EVIDENCE MEANS FOR PRACTICE
Robotic sacrocolpopexy is costly. this is an important consideration when implementing new technology. cost-saving scenarios are useful to maximize patient benefit and minimize financial burden.
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