• Robotic hysterectomies not worth the cost

    Joel Weissman and Michael Zinner summarize recent work on robotic surgery.

    Wright et al compared the use of robotically assisted hysterectomy for benign gynecologic disease with other approaches. Whereas past research relied on smaller samples in single institutions with limited generalizability, this study used a large national database involving 264,758 women who underwent hysterectomy at 441 hospitals and included detailed clinical variables, comorbidities, and outcomes of perioperative mortality and morbidity. The findings were stark. From 2007 to 2010, overall use of robotically assisted hysterectomy increased from 0.5% to 9.5%, and at hospitals that performed robotic procedures, robotically assisted hysterectomy accounted for 22.4% of all hysterectomies within 3 years. In addition, compared with laparoscopic surgery, robotic surgery was much more expensive—$2000 more per case or nearly a third higher than the median total cost for laparoscopic hysterectomy—without a significant advantage in clinical outcomes.

    On these results alone, the call is a simple one. At current prices and on the basis of health outcomes, robotic hysterectomies are not worth the cost.

    Limitation: Write et al.’s study is not an RCT. Prior TIE coverage of robotic surgery by Kevin and me.


    • Almost all new technologies in medicine cost more and their benefits/risks are not clearly defined for years so one cannot make the call just yet, but I could understand an insurer being willing to pay for only the lower cost treatment. On the surface the procedure doesn’t seem to provide a clear benefit over laparoscopic surgery but they list some potential benefits which may not help improve the results in this case.

      “Potential benefits of robotic surgery include increased range of motion with the instrumentation, 3-dimensional stereoscopic visualization, and improved ergonomics for the operating surgeon”

      I don’t know, but all things being equal one possible benefit not mentioned is that it trains the surgeon in the technique which might improve gynecological surgery for those with gynecologic malignancies and problems that are not contained within one organ. I think a big question is will the cost of this procedure fall.

    • I think this is one of the issues that drives high prices in the US. If a new technology comes out that is neither better nor cheaper, investing in it in America, allows providers to charge more. Advertising to patients makes them think the technology is superior. Medicare pays. Insurance companies pay.

      We all pay so that someone can reap profits, not so anyone can get better or more cost-effective care.

      • Re profits (I recognize that you were discussing all profits and not just physician’s profit):

        Is the physician reaping the profits? Yes and no. Physicians are well paid no doubt and probably some physicians are over paid while others underpaid. But, in the scheme of things physicians aren’t the big cause of expenses.

        The physician group which includes more than M.D.’s are responsible for ~20% of the costs. Their overhead is ~50%. That leaves 10% that the physician receives and from that he has to pay taxes, any debts incurred in training, retirement planning and the rest is left to the physician to spend on personal needs. Maybe or maybe not physicians as a whole are paid too much, but how much ever that is it is rather small compared to the whole especially since physicians are the basic entity that diagnoses and treats the patient. A 100% reduction in physician take-home might equal the inflation rate of healthcare in many years.

        But I agree with you we pay way too much. What is happening with our system? Why are so many feeding off of the healthcare dollar? There are too many involved parties in healthcare and the patient has been kept out of the equation. Where are some of the costs coming from that need not exist? Government is one though many will angrily oppose that idea. There are plenty of others that should be looked at, but in many cases government has been involved in their inefficiency as well

        I’ll give one example in the form of a question. If the costs of colonoscopy in an outpatient surgical center can be performed for a lot less than in a hospital, why does government prevent outpatient centers from opening up?

    • Years ago Pres Eisenhower warned of the military-industrial complex. Todays health care- pharmaceutical-hospital complex is the equivalent. Because of their immense lobbying their influence is too great and is becoming to entrenched in how we approach health care in this country. It is over priced for the results we get.

    • I appreciate and am sensitive to all of the above comments, and would like to share my opinion. The data is being collected that will undoubtedly answer in a positive light the question regarding benign robotic gyn surgery, but will not be available for some time.

      Important fact: looking simply at hysterectomies in the US since 2005 when the FDA approved the used of daVinci Robotic platform for Gyn use, the rate of OPEN/abdominal hysterectomy (meaning, a 3-4day hospital stay and 6-8wk recovery/work loss etc) was approximately 75%. Traditional laparoscopic hysterectomy and vaginal hysterectomy were around for over16 years, but did not account for more than approximately 15% of surgery for hysterectomy , and the trend was not changing. *Since the robotic platform was introduced, the rate of OPEN laparotomy for hysterectomy has now dropped to approx 32%. That is simply astounding and these numbers are available from national data base. This is also in the “infancy” of this new technology, and has done it safely!

      There is something unique and beneficial to this platform to have produced that result. “Benign gynecology” simply means NON -cancerous, but does not mean that the surgery is not “complex”/challenging in pathology. It is the advanced unprecedented 3D vision, articulation of instruments, correction of tremor and increased surgeon control that allows patients to have a minimally invasive approach to a complex surgery. I have performed or instructed over 700 cases, and have see this improve my patient outcomes for over 7 years. Other surgeries are performed via the robotic platform, of course, and they also allow for the same day or one night stay and release from the hospital and a rapid 1-2wk recover. Many of my patients go back to work within a week!

      The study above was comparing expert laparoscopic surgeons to surgeons many of whom were still in their learning curve in their experience! The rate of OPEN hysterectomy in the group I joined before I trained them on robotics was 58%, and last year was 2%. I am an expert traditional laparoscopic surgeon, and have converted to 100% robotic platform because I am a better surgeon for my patients – and THAT is what you or I would want from a surgeon performing a surgery on a loved one..