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Although almost 9 years have passed since the FDA approved the da Vinci Surgical System for use in gynecologic surgery, questions and controversy about the role of robotic-assisted procedures persist. This debate is well illustrated in a suite of four articles in the January 2014 issue of Obstetrics and Gynecology.
In a randomized trial involving 78 patients and 5 surgeons at two hospitals, researchers compared robotic-assisted and traditional laparoscopic approaches to sacrocolpopexy. Initial surgical costs (e.g., hospital and physician services, purchase and maintenance of robot), any rehospitalization costs, patients' postoperative pain, prolapse stage, quality of life, and adverse events were assessed. The robotic group had higher initial costs (US$19,616 vs. $11,573) that remained higher through 6 postoperative weeks ($20,898 vs. $12,170); however, when robotic purchase and maintenance costs were excluded, the difference was not statistically significant initially ($12,586 and $11,573) or at 6 weeks ($13,867 and $12,170). Although total surgery times (including concomitant procedures such as hysterectomy) were similar between groups, laparoscopic times averaged 24 minutes longer in the robotic group. Patients in the robotic group reported more postoperative pain at 1 week, but intergroup pain differences diminished by 2 weeks.
In addressing the challenges of implementing new technologies, commentary authors describe five milestones leading to a successful robotics program: (1) teams built of competent members who view themselves as stakeholders, yet are open to change; (2) culture of patient safety in which errors and outcomes are openly reviewed and recommendations are implemented; (3) recognition that learning curves require time; (4) central goal to improve patients' quality of life; and (5) business perspective that addresses both long- and short-term strategies.
Anger JT et al. Robotic compared with laparoscopic sacrocolpopexy: A randomized controlled trial. Obstet Gynecol 2014 Jan; 123:5. (http://dx.doi.org/10.1097/AOG.0000000000000006)
Desai PH et al. Milestones to optimal adoption of robotic technology in gynecology. Obstet Gynecol 2014 Jan; 123:13. (http://dx.doi.org/10.1097/AOG.0000000000000055)
Advincula AP.Robotics in gynecology: Is the glass half empty or half full? Obstet Gynecol 2014 Jan; 123:3. (http://dx.doi.org/10.1097/AOG.0000000000000073)
Steege JF and Einarsson JI.Robotics in benign gynecologic surgery: Where should we go? Obstet Gynecol 2014 Jan; 123:1. (http://dx.doi.org/10.1097/AOG.0000000000000072)
Comment
These trial results are consistent with previous findings that robotic-assisted laparoscopic surgery for benign gynecologic conditions costs more than traditional laparoscopy but does not improve outcomes (NEJM JW Womens Health Dec 8 2011). An editorialist voices a concern about this study: Because the only requirement for participating surgeons was 10 cases per surgeon per technique, lack of experience with robotic techniques could have influenced outcomes. He also points out that capital equipment and maintenance costs in the traditional laparoscopy arm were not included for comparison. Authors of a second editorial emphasize that “the potential advantages of robotic assistance in laparoscopy … have not been borne out by subsequent research and clinical reports” and that “advocacy of the robot in benign gynecologic cases becomes unsupportable” in the face of rising costs without clear benefit.
Nonetheless, evidence is emerging that robotic-assisted laparoscopy in gynecologic oncology does have advantages over traditional laparoscopy — and the five milestones provide us with suggestions on how to succeed when implementing such programs. Although robotic technology has been claimed to make life in the operating room easier, these milestones illustrate the extra effort required to implement such advances safely and effectively. To achieve proficiency, high-quality outcomes, and financial viability, a robotics program requires a talented, motivated staff and high-volume surgeons. But clinicians in gynecologic surgery are faced with limited healthcare dollars, less-invasive alternatives for managing benign conditions, questions about priorities in the surgical training of residents, and lack of clear risk–benefit profiles for benign cases. Thus, the question of how many robotic centers can — or should — exist within the current system remains unanswered.