Comparison of Postoperative Analgesia Use Between Robotic and Laparoscopic Total Hysterectomy: A Retrospective Cohort Study

Comparison of Postoperative Analgesia Use Between Robotic and Laparoscopic Total Hysterectomy: A Retrospective Cohort Study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Comparison of Postoperative Analgesia Use Between Robotic and Laparoscopic Total Hysterectomy: A Retrospective Cohort Study Shohei Tanabe, Ryohei Yamamoto, Sachiyo Sugino, Kotaro Ichida, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-2278764/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 23 Mar, 2023 Read the published version in Journal of Robotic Surgery → Version 1 posted 4 You are reading this latest preprint version Abstract Background/Objective: Although robotic and laparoscopic total hysterectomies are widely used as minimally invasive procedures, consensus on which is superior regarding lesser postoperative pain is lacking. Thisstudy determines whether there is a difference in the proportion of postoperative use of non-steroidal anti-inflammatory drugs (NSAIDs) and acetaminophen between robotic and laparoscopic total hysterectomies. Methods: This retrospective cohort study enrolled patients who underwent robotic or laparoscopic total hysterectomy for uterine fibroids, adenomyosis, or cervical intraepithelial neoplasia grade 3 at a hospital between July 2016and November 2021. The outcome was postoperative analgesics (i.e., NSAIDs or acetaminophen) use. Unadjusted and adjusted logistic regression analyses were performed to evaluate the association between the procedure and outcome. Adjusted variables were age, body mass index, surgeon’s laparoscopic technique certification, intravenous patient-controlled analgesia, and wound local anesthesia. Results: Of 127 patients, 3 were excluded, and 124 were included. Robotic and laparoscopic hysterectomy was performed in 38 and 86 patients, respectively. Postoperative analgesics were administered to 10 (26.3%) and 52 (60.5%) patients in the robotic and laparoscopic groups, respectively. Unadjusted logistic regression analysis showed significantly more frequent analgesics use in the laparoscopy group (odds ratio [OR] 4.28; 95% confidence interval [CI] 1.85–9.93; p < 0.01). Adjusted logistic regression analysis did not detect significant differences (OR 2.62; 95% CI 0.91–7.56; p = 0.07). Conclusion: No significant difference in the proportion of postoperative analgesia was observed betweenrobotic total hysterectomy and laparoscopy. Future studies must include largersample sizes andaligned intraoperative and postoperative analgesic management. body mass index logistic models NSAIDs postoperative pain Figures Figure 1 Figure 2 Introduction Laparoscopic and robotic minimally invasive total hysterectomies are widely used in gynecological surgery. A comparison of laparoscopic and robotic total hysterectomies reported no difference in operative time, blood loss, or intraoperative complications [1]. Therefore, the outcomes related to postoperative patient-centered outcomes need to be evaluated. Several studies have been conducted to determine whether robotic or laparoscopic surgery is superior in terms of postoperative pain; however, no conclusions have been reached. In a study that compared both techniques, with postoperative pain scores as the outcome, no significant differences were detected [2]. Likewise, no differences were detected in a similar study in which postoperative opioid consumption was the outcome [3]. However, these studies focused on opioids and did not consider non-opioid use. Guidelines recommend multimodal postoperative analgesic management with non-opioid agents (non-steroidal anti-inflammatory drugs [NSAIDs] and acetaminophen) and local anesthetics in addition to opioids [4]. In other words, to understand whether robotic or laparoscopic surgery is superior for postoperative pain, an outcome assessment that considers non-opioid medications is needed. However, few studies have compared the use of NSAIDs or acetaminophen as outcomes in managing postoperative pain in patients who underwent robotic versus laparoscopic total hysterectomy [5]. This study compares postoperative analgesics use, defined as the use of NSAIDs or acetaminophen, in robotic versus laparoscopic total hysterectomy; we hypothesize that laparoscopic total hysterectomy would cause less postoperative pain than robotic total hysterectomy. Methods Study Design and Setting This was a single-center, retrospective cohort study conducted at a hospital in Kobe, Japan. The hospital has 358 beds, of which 28 are used for obstetrics and gynecology. Annually, approximately 280 surgeries are performed in the obstetrics and gynecology department. The study period was from July 2016 to November 2021. Cases were registered using consecutive sampling, and data were extracted from the medical records. This study was approved by the ethics committee of Kobe City Medical Center, West Hospital (No. 21-040). Participants Patients who underwent robotic or laparoscopic total hysterectomy for uterine fibroids, adenomyosis uteri, or cervical intraepithelial neoplasia grade 3 at our hospital were included in the study. We excluded patients who underwent robotic or laparoscopic surgery and were then converted to open surgery, had an epidural catheter placed preoperatively, or used pentazocine for postoperative analgesia. Exposure The primary exposure was laparoscopic total hysterectomy. There were 12-mm ports in the umbilicus and left lower abdomen and 5-mm ports in the mid-lower abdomen and right lower abdomen (Figure 1). There were no criteria for choosing robotic or laparoscopic technique, and each surgeon made their own subjective decisions. The control procedure was a robotic total hysterectomy. Da Vinci Si (Intuitive Surgical, Sunnyvale, CA, USA) was the equipment used. The ports were 12 mm in the umbilicus and left lower abdomen and 5 mm in two locations in the right lower abdomen and one location in the left lower abdomen (Figure 2). Common Management to Both Groups General anesthesia was administered intraoperatively to all patients. There were no criteria on whether maintenance anesthesia should be intravenous or inhaled and whether postoperative pain management should involve local anesthesia at the wound site or intravenous patient-controlled analgesia (IVPCA). These were decided by the anesthesiologist. All patients received NSAIDs or acetaminophen within 1 h of surgery completion. Outcome The primary outcome measure was analgesic use (NSAIDs or acetaminophen) from immediately after surgery to 9:00 AM the next day. A charge nurse administered medications if the patient complained of pain; whether to administer NSAIDs or acetaminophen was based on the drug not administered before the end of surgery. There were no explicit rules regarding the degree of pain for which analgesic medications were administered, and the charge nurse subjectively judged the need for analgesics in each case. Other Measurements The variables were age, body mass index (BMI), laparoscopic technique certification, IVPCA, and local anesthesia of the wound. Laparoscopic technique certification is a qualification issued by the Japanese Society of Obstetrics and Gynecology Endoscopy to physicians certified by surgical videos as having attained a certain skill level. To ensure the reliability of the variables, we checked the medical and anesthesia records multiple times. Statistical Analysis Patient characteristics were described using median and interquartile range (IQR) for continuous variables and number and percentage (%) for categorical variables. Methods of analysis included unadjusted and adjusted logistic regression analyses to examine the association between the operative technique and analgesic use. Adjusting factors included age, BMI, certified laparoscopic technologist, IVPCA with or without fentanyl, and local anesthesia of the wound. In this study, the anesthesiologist decided on a case-by-case basis for the postoperative use of IVPCA, as no postoperative analgesia protocol was established in advance. However, since IVPCA may affect the frequency of postoperative analgesic use [6], we added an analysis stratified by the presence or absence of IVPCA. Therefore, we divided the patients into subgroups according to the presence or absence of IVPCA and performed the analysis using the same adjustment variables as in the main analysis. In addition, to confirm the robustness of the main analysis, we performed sensitivity analyses with different definitions of the outcome. In the first sensitivity analysis, we defined outcome as the use of acetaminophen, NSAIDs, or IVPCA flushes. We evaluated the association between the procedure and outcome using multivariable logistic regression analysis. A second sensitivity analysis was conducted to evaluate the association between the procedure and outcome using multivariable logistic regression analysis, with outcomes defined as the use of acetaminophen, NSAIDs, or IVPCA flushes, stratified by the presence or absence of IVPCA. Since this was a small, single-center study, and all cases within the relevant period were included, the sample size based on effect estimation was not calculated. Statistical significance was set at p < 0.05. All statistical analyses were performed using EZR (Saitama Medical Center, Jichi Medical University, Saitama, Japan), a graphical user interface for R (The R Foundation for Statistical Computing, Vienna, Austria). More precisely, it is a modified version of the R commander designed to add statistical functions frequently used in biostatistics [7]. Results Study Participants During the study period, 127 patients underwent robotic or laparoscopic total hysterectomies, oh which 3 were excluded and 124 were included in the study (Figure 1). Robotic hysterectomy was performed in 38 patients, and laparoscopic hysterectomy was performed in 86 patients. The median age was 46.0 years (IQR, 44.0–52.0 years), median BMI was 22.0 (IQR, 20.2–25.4), 52 (42.0%) of the procedures were performed by laparoscopic technicians, 25 (65.8%) were performed by laparoscopic hysterectomy specialists, IVPCA was used in 42 (33.9%) robotic hysterectomies and 21 (55.3%) laparoscopic hysterectomies, and local anesthesia was used in 22 (17.7%) robotic hysterectomies and 14 (36.8%) laparoscopic hysterectomies (Table 1). Outcomes The primary outcome of acetaminophen or NSAID use was 10 (26.3%) in the robotic hysterectomy group and 52 (60.5%) in the laparoscopic hysterectomy group. In the IVPCA group, analgesic use was observed in 2 (5.26%) patients in the robotic hysterectomy group and 6 (7.00%) in the laparoscopic hysterectomy group (Table 2). Association Between Surgical Procedure and Outcome In the primary analysis, unadjusted logistic regression analysis showed that laparoscopic surgery was associated with significantly greater use of postoperative analgesia than robotic total hysterectomy (odds ratio [OR] 4.28; 95% confidence interval [CI] 1.85–9.93; p < 0.01). However, adjusted logistic regression analysis did not detect a significant difference (OR 2.62; 95% CI 0.91–7.56; p = 0.07). In all subgroup and sensitivity analyses, no significant differences were detected in the multivariable logistic regression analysis (Table 2). Discussion Summary of Key Findings Our findings showed no significant difference in the use of postoperative analgesics between robotic and laparoscopic total hysterectomy. The effect of IVPCA was additionally examined in subgroup and sensitivity analyses, with no difference in results. Relationship with Previous Literature Univariate analysis showed that analgesic use was higher for laparoscopic total hysterectomy than for robotic total hysterectomy. Meanwhile, multivariable analysis showed no significant difference was detected. However, there was a trend toward greater analgesic use with total laparoscopic hysterectomy, with an OR of 2.62 and a 95% CI of 0.91–7.56. One reason is that robotic surgery may result in less postoperative pain due to using more stable trocars. Previous reports have suggested that robotic surgery, where the trocar is stable at the abdominal wall, may cause less postoperative pain than laparoscopic surgery as trauma to the abdominal wall is reflected in postoperative pain [8,9]. Also, since this study had a small sample size, it may be possible to detect differences in the percentage of postoperative analgesic use between robotic and laparoscopic total hysterectomy by studying a larger sample size. These points may explain the trend toward greater postoperative analgesic use in the laparoscopic surgery group in the multivariable analysis. Implication This study showed no significant difference in postoperative pain between robot-assisted and laparoscopic total hysterectomy when non-opioid pain management involving NSAIDs and acetaminophen was used. Since robotic surgery is more expensive than laparoscopic surgery [9], it is reasonable to select laparoscopic surgery as an option for minimally invasive total hysterectomy. In addition, a new postoperative pain assessment item, postoperative analgesics, was used in this study, and patients did not require analgesics even when the numerical rating scale (NRS) score was 4–6, suggesting that the interpretation of the NRS may differ between providers and patients [10]. This study is new in the evaluation of postoperative pain as it uses an assessment of whether the patient wants analgesics. Limitations This study has several limitations. First, the sample size is small. Although six variables were adjusted for in the multivariable analysis, the event power variable was < 10. The results might have differed if the sample size had been sufficient. Another limitation was the presence of confounding factors. We adjusted for age, BMI, surgeon skill (certified laparoscopic technologist or not), IVPCA with or without fentanyl, and local wound anesthesia. However, we could not adjust the surgeon’s preference for robotic or laparoscopic total hysterectomy. Further, the outcome (percentage of postoperative analgesia used) did not include opioids. There are currently no reported outcomes for which opioid and non-opioid use can be evaluated as a single measure. Therefore, opioids were analyzed as adjustment variables in this study. We believe treating only non-opioids as an outcome is reasonable in Japan, where opioids are not frequently used postoperatively. In addition, we used wound local anesthesia instead of the transversus abdominis plane (TAP) block. It has been reported that the TAP block is superior to wound local anesthesia at the port site for postoperative pain in patients undergoing robotic and laparoscopic total hysterectomy [11]. Therefore, using a TAP block instead of wound local anesthesia might have affected the results. Conclusion When multimodal postoperative pain management with NSAIDs and acetaminophen was used, no significant reduction in postoperative pain was detected with robotic total hysterectomy compared with laparoscopic total hysterectomy. Future studies with larger sample sizes and more comprehensive set of intraoperative and postoperative analgesic management protocols remain warranted. Statements And Declarations Acknowledgments: We would like to thank Dr. Yamamoto for his guidance in this study. We would also like to thank Drs. Sugino, Ichida, Niiyai, and Morishima for their help in writing and revising the paper. Data availability statement: The datasets generated and analyzed during the current study are available from the corresponding author upon reasonable request. Competing interests: The authors have no relevant financial or non-financial interests to disclose. Author contributions: Shohei Tanabe wrote the main manuscript. Ryohei Yamamoto provided advice on study design and statistical analysis. All authors reviewed and edited the manuscript. Funding: This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. Ethics approval Consent to participate References Gitas G, Alkatout I, Proppe L et al (2021) Surgical outcomes of conventional laparoscopic and robotic-assisted hysterectomy . Int J Med Robot 17:e2225. Park JH, Lee C, Shin Y, An JH, Ban JS, Lee JH (2015) Comparison of oxycodone and fentanyl for postoperative patient-controlled analgesia after laparoscopic gynecological surgery . Korean J Anesthesiol 68:153–158. Turner TB, Habib AS, Broadwater G et al (2015) Postoperative pain scores and narcotic use in robotic-assisted Versus laparoscopic hysterectomy for endometrial cancer staging . J Minim Invasive Gynecol 22:1004–1010. Gabriel RA, Swisher MW, Sztain JF, Furnish TJ, Ilfeld BM, Said ET (2019) State of the art opioid-sparing strategies for postoperative pain in adult surgical patients . Expert Opin Pharmacother 20:949–961. Mangalath AS, Kumar L, Sawant AB, Kesavan R, Ravindran G, Sunil R (2021) Comparison of analgesic requirements in robot-assisted versus conventional laparoscopic abdominal surgeries . J Anaesthesiol Clin Pharmacol 37:79–84. Kim YH, Mun SH, Kim HS, Woo CH, Kim YC (2009) Remifentanil for postoperative patient-controlled analgesia after laparoscopic-assisted vaginal hysterectomy: dose-finding study . Korean J Anesthesiol 56:54–59. Kanda Y (2013) Investigation of the freely available easy-to-use software ‘EZR’ for medical statistics . Bone Marrow Transplant 48:452–458. Leitao MM, Jr., Malhotra V, Briscoe G et al (2013) Postoperative pain medication requirements in patients undergoing computer-assisted (“Robotic”) and standard laparoscopic procedures for newly diagnosed endometrial cancer . Ann Surg Oncol 20:3561–3567. Alshowaikh K, Karpinska-Leydier K, Amirthalingam J et al (2021) Surgical and patient outcomes of robotic Versus conventional laparoscopic hysterectomy: A systematic review . Cureus 13:e16828. van Dijk JF, van Wijck AJ, Kappen TH, Peelen LM, Kalkman CJ, Schuurmans MJ (2012) Postoperative pain assessment based on numeric ratings is not the same for patients and professionals: a cross-sectional study . Int J Nurs Stud 49:65–71. Hutchins J, Argenta P, Berg A, Habeck J, Kaizer A, Geller MA (2019) Ultrasound-guided subcostal transversus abdominis plane block with liposomal bupivacaine compared to bupivacaine infiltration for patients undergoing robotic-assisted and laparoscopic hysterectomy: a prospective randomized study . J Pain Res 12:2087–2094. Tables Table 1. Preoperative and intraoperative patient characteristics Overall (n = 124) Robot (n = 38) Laparoscopy (n = 86) Variables Age (year), median (IQR) 46.0 (44.0, 52.0) 51.0 (43.5, 61.2) 46.0 (44.0, 49.0) BMI (kg/m 2 ), median (IQR) 22.0 (20.2, 25.4) 24.5 (20.3, 27.6) 21.6 (20.2, 23.6) Anesthesia Inhalation anesthesia, n (%) 113 (91.1) 35 (92.1) 78 (90.7) TIVA, n (%) 11 (8.80) 3 (7.90) 8 (9.30) Fentanyl, mcg, median (IQR) 250 (200, 300) 250 (200, 300) 250 (200, 300) Operation License, n (%) 52 (42.0) 25 (65.8) 27 (31.4) Uterus, g, median (IQR) 194 (121, 282) 125 (81.5, 214) 219 (143, 295) Surgery time, min, median (IQR) 221 (173, 274) 257 (233, 314) 204 (155, 258) Postoperative analgesia IVPCA, n (%) 42 (33.9) 21 (55.3) 21 (24.4) TAP, n (%) 22 (17.7) 14 (36.8) 8 (9.30) BMI, body mass index; TIVA, intravenous patient-controlled analgesia; IVPCA, patient-controlled analgesia; TAP, transversus abdominis plane block; IQR, interquartile range Table 2. Association between outcome and exposure Robotic (n = 38) Laparoscopic (n = 86) Unadjusted Adjusted Use of Analgesia n (%) OR [95% CI] p-value OR [95% CI] p-value Primary analysis 10 (26.3%) 52 (60.5%) 4.28 (1.85–9.93) < 0.01 2.62 (0.91–7.56) 0.07 Subgroup analyses IVPCA-no use 8 (21.1%) 46 (53.5%) 2.72 (0.91–8.12) 0.07 2.20 (0.60–8.12) 0.24 IVPCA use 2 (5.26%) 6 (7.00%) 3.80 (0.67–21.6) 0.13 12.3 (0.93–161) 0.06 Sensitivity analyses 1 13 (34.2%) 58 (67.4%) 3.98 (1.78–8.94) < 0.01 2.31 (0.87–6.14) 0.09 Sensitivity analyses 2 IVPCA-no use 8 (21.1%) 46 (53.5%) 2.72 (0.91–8.12) 0.07 2.20 (0.60–8.12) 0.24 IVPCA use 5 (13.2%) 12 (14.0%) 4.27 (1.13–16.1) 0.03 7.94 (0.76–82.6) 0.08 IVPCA, intravenous patient-controlled analgesia Primary analyses: outcome was the use of acetaminophen, NSAIDs. Sensitivity analyses 1: outcome was the use of acetaminophen, NSAIDs, or IVPCA flushes. Sensitivity analysis 2: subgroup analysis (IVPCA use or not) of sensitivity analysis 1. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 23 Mar, 2023 Read the published version in Journal of Robotic Surgery → Version 1 posted Editorial decision: Accepted 18 Mar, 2023 Editor assigned by journal 25 Nov, 2022 Submission checks completed at journal 16 Nov, 2022 First submitted to journal 16 Nov, 2022 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-2278764","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":152611657,"identity":"d5d360ca-c928-429e-8cb5-7eb0f00a61d5","order_by":0,"name":"Shohei Tanabe","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA9UlEQVRIiWNgGAWjYBACCRDxocKGh5+ZsfEBkM3DR4wWxhln0mQk25ubDUBa2IjRwszbdtjGoOd4G9hKglokZ2Qnfpxx5jCPgURiW+XXHDsZNgbmh49u4NEiLZG7WeJDRTqPOVDLbdltyUCHsRkb5+DRIieRu0FyxhlrHssZQC2S25iBWnjYpAlo2fybt42Zx+BGYlux5LZ6wlqADtsmzdvmzGNw5mAb48dthwlrkex5u80SGMg8ku2NzdKM247zsDET8IvE8dzNN4BRac/PzP7w489t1fb87M0PH+PTggKYecAkscpBgPEHKapHwSgYBaNgxAAATw1Itd/hrycAAAAASUVORK5CYII=","orcid":"","institution":"Kobe City Medical Center West Hospital","correspondingAuthor":true,"submittingAuthor":false,"prefix":"","firstName":"Shohei","middleName":"","lastName":"Tanabe","suffix":""},{"id":152611658,"identity":"19a496e9-7ab3-414b-a5d4-6ab8535e1532","order_by":1,"name":"Ryohei Yamamoto","email":"","orcid":"","institution":"Kyoto University","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Ryohei","middleName":"","lastName":"Yamamoto","suffix":""},{"id":152611659,"identity":"3416c8d7-5c64-4582-b2e7-b444fd9fc8ea","order_by":2,"name":"Sachiyo Sugino","email":"","orcid":"","institution":"Kobe City Medical Center West Hospital","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Sachiyo","middleName":"","lastName":"Sugino","suffix":""},{"id":152611660,"identity":"83591d2c-83ea-4706-b251-e053b18f0173","order_by":3,"name":"Kotaro Ichida","email":"","orcid":"","institution":"Kobe City Medical Center West Hospital","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Kotaro","middleName":"","lastName":"Ichida","suffix":""},{"id":152611662,"identity":"cb04e44b-9c7b-48f8-9a93-ca5b7d95b4cc","order_by":4,"name":"Kiyoshi Niiya","email":"","orcid":"","institution":"Kobe City Medical Center West Hospital","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Kiyoshi","middleName":"","lastName":"Niiya","suffix":""},{"id":152611664,"identity":"41b1a4ba-f8ec-41b5-8a67-45d401ac2610","order_by":5,"name":"Syuji Morishima","email":"","orcid":"","institution":"Kobe City Medical Center West Hospital","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Syuji","middleName":"","lastName":"Morishima","suffix":""}],"badges":[],"createdAt":"2022-11-16 05:44:21","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-2278764/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-2278764/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1007/s11701-023-01581-3","type":"published","date":"2023-03-23T20:06:05+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":29249072,"identity":"f4be231b-aac5-4b39-b0c1-abc8138828ba","added_by":"auto","created_at":"2022-11-18 16:21:45","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":43104,"visible":true,"origin":"","legend":"\u003cp\u003eFlow diagram\u003c/p\u003e","description":"","filename":"Figure1.png","url":"https://assets-eu.researchsquare.com/files/rs-2278764/v1/af23d2f50362bb2c8462f480.png"},{"id":29249073,"identity":"62015118-a1ce-41be-9364-915cc3a8df11","added_by":"auto","created_at":"2022-11-18 16:21:46","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":202561,"visible":true,"origin":"","legend":"\u003cp\u003ePort_placement_and diameter_for_laparo and robot\u003c/p\u003e","description":"","filename":"Figure2.png","url":"https://assets-eu.researchsquare.com/files/rs-2278764/v1/a092abe473740506cf5e371b.png"},{"id":44723138,"identity":"19e1e147-ba19-45c7-b9e1-ceced9aaf917","added_by":"auto","created_at":"2023-10-16 20:13:58","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":579802,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-2278764/v1/298e89b4-5eeb-4d5c-af2b-621e6a40c58e.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Comparison of Postoperative Analgesia Use Between Robotic and Laparoscopic Total Hysterectomy: A Retrospective Cohort Study","fulltext":[{"header":"Introduction","content":"\u003cp\u003eLaparoscopic and robotic minimally invasive total hysterectomies are widely used in gynecological surgery. A comparison of laparoscopic and robotic total\u0026nbsp;hysterectomies\u0026nbsp;reported no difference in operative time, blood loss, or intraoperative complications [1]. Therefore, the outcomes related to postoperative patient-centered outcomes need to be evaluated.\u003c/p\u003e\n\u003cp\u003eSeveral studies have been conducted to determine whether robotic or laparoscopic surgery is superior in terms of postoperative pain; however,\u0026nbsp;no conclusions have been reached. In a study that compared both techniques, with postoperative pain scores as the outcome, no significant differences were detected [2].\u0026nbsp;Likewise, no\u0026nbsp;differences were detected in a similar study in which postoperative opioid consumption was the outcome [3].\u0026nbsp;However, these\u0026nbsp;studies focused on opioids and did not consider non-opioid use. Guidelines recommend multimodal postoperative analgesic management with non-opioid agents (non-steroidal anti-inflammatory drugs [NSAIDs]\u0026nbsp;and acetaminophen) and local anesthetics in addition to opioids [4]. In other words, to\u0026nbsp;understand\u0026nbsp;whether robotic or laparoscopic surgery is superior\u0026nbsp;for\u0026nbsp;postoperative pain, an outcome assessment that\u0026nbsp;considers\u0026nbsp;non-opioid medications is needed. However,\u0026nbsp;few\u0026nbsp;studies\u0026nbsp;have compared\u0026nbsp;the use of NSAIDs or acetaminophen as\u0026nbsp;outcomes\u0026nbsp;in\u0026nbsp;managing\u0026nbsp;postoperative pain\u0026nbsp;in\u0026nbsp;patients who underwent robotic versus laparoscopic total hysterectomy [5].\u003c/p\u003e\n\u003cp\u003eThis study compares postoperative analgesics use, defined as the use of NSAIDs or acetaminophen, in robotic versus laparoscopic total hysterectomy; we hypothesize that laparoscopic total hysterectomy would cause less postoperative pain than robotic total hysterectomy.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003e\u003cstrong\u003e\u003cem\u003eStudy\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003cstrong\u003e\u003cem\u003eDesign\u003c/em\u003e\u003c/strong\u003e\u003cstrong\u003e\u003cem\u003e\u0026nbsp;and\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003cstrong\u003e\u003cem\u003eSetting\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis\u0026nbsp;was a single-center, retrospective cohort study conducted at a hospital in Kobe, Japan. The hospital has 358 beds, of which 28 are\u0026nbsp;used\u0026nbsp;for obstetrics and gynecology. Annually, approximately 280 surgeries are performed in the obstetrics and gynecology\u0026nbsp;department. The\u0026nbsp;study\u0026nbsp;period\u0026nbsp;was\u0026nbsp;from July 2016 to November 2021. Cases were registered\u0026nbsp;using\u0026nbsp;consecutive sampling, and data\u0026nbsp;were extracted from\u0026nbsp;the\u0026nbsp;medical records.\u0026nbsp;This\u0026nbsp;study was approved by the\u0026nbsp;ethics committee\u0026nbsp;of Kobe City Medical Center, West Hospital (No. 21-040).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eParticipants\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePatients who underwent robotic or laparoscopic total hysterectomy for uterine fibroids, adenomyosis uteri, or cervical intraepithelial neoplasia grade 3 at our hospital were included in the study. We excluded patients who underwent robotic or laparoscopic surgery and\u0026nbsp;were\u0026nbsp;then converted to open surgery, had an epidural catheter placed preoperatively, or used pentazocine for postoperative analgesia.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eExposure\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe primary exposure was laparoscopic total hysterectomy.\u0026nbsp;There\u0026nbsp;were 12-mm ports in the umbilicus and left lower abdomen and 5-mm ports in the mid-lower abdomen and right lower abdomen (Figure 1). There were no criteria for choosing robotic or laparoscopic technique, and each surgeon made\u0026nbsp;their\u0026nbsp;own subjective\u0026nbsp;decisions. The control procedure was a robotic total hysterectomy.\u0026nbsp;Da Vinci Si (Intuitive Surgical, Sunnyvale, CA, USA) was the\u0026nbsp;equipment used. The ports\u0026nbsp;were 12 mm in the umbilicus and left lower abdomen and 5 mm in two locations in the right lower abdomen and one location in the left lower abdomen (Figure 2).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eCommon Management to Both Groups\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eGeneral anesthesia was administered intraoperatively to all patients.\u0026nbsp;There were no criteria on whether maintenance anesthesia should be intravenous or inhaled and whether postoperative pain management should involve local anesthesia at the wound site or intravenous patient-controlled analgesia (IVPCA). These were decided by the anesthesiologist. All patients received NSAIDs or acetaminophen within 1 h of surgery completion.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eOutcome\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe primary outcome measure was analgesic use (NSAIDs\u0026nbsp;or acetaminophen) from immediately after surgery\u0026nbsp;to\u0026nbsp;9:00 AM the next day.\u0026nbsp;A\u0026nbsp;charge nurse\u0026nbsp;administered medications\u0026nbsp;if the patient complained of pain; whether to administer NSAIDs or acetaminophen was based on the drug not administered\u0026nbsp;before\u0026nbsp;the end of surgery. There were no explicit rules regarding the degree of pain for which analgesic medications were administered, and the\u0026nbsp;charge\u0026nbsp;nurse subjectively judged the need for analgesics in each case.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eOther\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003cstrong\u003e\u003cem\u003eMeasurements\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe variables\u0026nbsp;were\u0026nbsp;age,\u0026nbsp;body mass index (BMI),\u0026nbsp;laparoscopic technique certification, IVPCA, and local anesthesia of the wound. Laparoscopic technique certification is a qualification issued by the Japanese Society of Obstetrics and Gynecology Endoscopy to physicians certified by surgical videos as having\u0026nbsp;attained\u0026nbsp;a certain skill level. To ensure the reliability of the variables, we checked the medical and anesthesia records multiple times.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eStatistical\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003cstrong\u003e\u003cem\u003eAnalysis\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePatient characteristics were described using median and interquartile range (IQR) for continuous variables and number and percentage (%) for categorical variables. Methods of analysis included unadjusted and adjusted logistic regression\u0026nbsp;analyses\u0026nbsp;to examine the association between\u0026nbsp;the\u0026nbsp;operative technique and analgesic use. Adjusting factors included age, BMI, certified laparoscopic technologist, IVPCA with or without fentanyl, and local anesthesia\u0026nbsp;of\u0026nbsp;the wound.\u003c/p\u003e\n\u003cp\u003eIn this study, the anesthesiologist decided on a case-by-case basis\u0026nbsp;for the postoperative\u0026nbsp;use\u0026nbsp;of\u0026nbsp;IVPCA, as no postoperative analgesia protocol was established in advance. However, since IVPCA may affect the frequency of postoperative analgesic use [6], we added an analysis stratified by the presence or absence of IVPCA. Therefore, we divided the patients into subgroups according to the presence or absence of IVPCA and performed the analysis using the same adjustment variables as in the main analysis. In addition, to confirm the robustness of the main analysis, we performed sensitivity analyses with different definitions of\u0026nbsp;the\u0026nbsp;outcome.\u0026nbsp;In the first sensitivity analysis, we defined outcome as the use of acetaminophen,\u0026nbsp;NSAIDs, or IVPCA flushes. We evaluated the association between the procedure and outcome using multivariable logistic regression analysis. A second sensitivity analysis was conducted to evaluate the association between\u0026nbsp;the\u0026nbsp;procedure and outcome using multivariable logistic regression analysis, with\u0026nbsp;outcomes\u0026nbsp;defined as the use of acetaminophen,\u0026nbsp;NSAIDs, or IVPCA flushes, stratified by the presence or absence of IVPCA.\u003c/p\u003e\n\u003cp\u003eSince this was a small, single-center study, and all cases within the relevant period were included, the sample size based on effect estimation was not calculated. Statistical significance was set at p \u0026lt; 0.05. All statistical analyses were performed using EZR (Saitama Medical Center, Jichi Medical University, Saitama, Japan), a graphical user interface for R (The R Foundation for Statistical Computing, Vienna, Austria). More precisely, it is a modified version of the R commander designed to add statistical functions frequently used in biostatistics [7].\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003e\u003cstrong\u003e\u003cem\u003eStudy\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003cstrong\u003e\u003cem\u003eParticipants\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDuring the study period, 127 patients underwent robotic or laparoscopic total\u0026nbsp;hysterectomies, oh which\u0026nbsp;3 were excluded and 124 were included in the study (Figure 1). Robotic hysterectomy was performed in 38 patients,\u0026nbsp;and laparoscopic hysterectomy\u0026nbsp;was performed\u0026nbsp;in 86 patients.\u0026nbsp;The median\u0026nbsp;age was 46.0 years (IQR, 44.0–52.0 years), median BMI was 22.0 (IQR, 20.2–25.4), 52 (42.0%) of the procedures were performed by laparoscopic technicians, 25 (65.8%) were performed by laparoscopic hysterectomy specialists, IVPCA was used in 42 (33.9%) robotic hysterectomies and 21 (55.3%) laparoscopic hysterectomies, and local anesthesia was used in 22 (17.7%) robotic hysterectomies and 14 (36.8%) laparoscopic hysterectomies (Table 1).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eOutcomes\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe primary outcome of acetaminophen or\u0026nbsp;NSAID\u0026nbsp;use was 10 (26.3%) in the robotic hysterectomy group and 52 (60.5%) in the laparoscopic hysterectomy group. In the IVPCA\u0026nbsp;group, analgesic use was\u0026nbsp;observed in 2\u0026nbsp;(5.26%)\u0026nbsp;patients\u0026nbsp;in the robotic hysterectomy group and 6 (7.00%) in the laparoscopic hysterectomy group (Table 2).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eAssociation\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003cstrong\u003e\u003cem\u003eBetween Surgical Procedure\u003c/em\u003e\u003c/strong\u003e\u003cstrong\u003e\u003cem\u003e\u0026nbsp;and\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003cstrong\u003e\u003cem\u003eOutcome\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIn the primary analysis, unadjusted logistic regression analysis showed that laparoscopic surgery was associated with significantly greater use of postoperative analgesia than robotic total hysterectomy (odds ratio [OR] 4.28; 95% confidence interval [CI] 1.85–9.93; p \u0026lt; 0.01). However, adjusted logistic regression analysis did not detect a significant difference (OR 2.62; 95% CI 0.91–7.56; p = 0.07). In all subgroup and sensitivity analyses, no significant differences were detected in the multivariable logistic regression analysis (Table 2).\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003e\u003cstrong\u003e\u003cem\u003eSummary of\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003cstrong\u003e\u003cem\u003eKey Findings\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eOur findings showed no significant difference in the use of postoperative analgesics between robotic and laparoscopic total hysterectomy. The\u0026nbsp;effect of IVPCA was additionally examined in\u0026nbsp;subgroup and sensitivity analyses, with no difference in results.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eRelationship\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003cstrong\u003e\u003cem\u003ewith Previous Literature\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eUnivariate analysis showed that analgesic use was higher for laparoscopic total hysterectomy than for robotic total hysterectomy. Meanwhile, multivariable analysis showed no significant difference was detected. However, there was a trend toward greater analgesic use with total laparoscopic hysterectomy, with an\u0026nbsp;OR\u0026nbsp;of 2.62 and a 95%\u0026nbsp;CI\u0026nbsp;of 0.91–7.56.\u003c/p\u003e\n\u003cp\u003eOne reason is that robotic surgery may result in less postoperative pain due to using more stable trocars. Previous reports have suggested that robotic surgery, where the trocar is stable at the abdominal wall, may cause less postoperative pain than laparoscopic surgery as trauma to the abdominal wall is reflected in postoperative pain [8,9]. Also,\u0026nbsp;since this\u0026nbsp;study\u0026nbsp;had\u0026nbsp;a small sample size,\u0026nbsp;it\u0026nbsp;may be\u0026nbsp;possible\u0026nbsp;to detect differences in the percentage of postoperative analgesic use between robotic and laparoscopic total hysterectomy\u0026nbsp;by studying a larger sample size.\u0026nbsp;These points may explain the trend toward greater postoperative analgesic use in the laparoscopic surgery group in the multivariable analysis.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eImplication\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis\u0026nbsp;study\u0026nbsp;showed\u0026nbsp;no significant difference in postoperative pain between\u0026nbsp;robot-assisted and laparoscopic total hysterectomy when non-opioid pain management involving NSAIDs and acetaminophen was used. Since robotic surgery is more expensive than laparoscopic surgery [9], it is reasonable to select laparoscopic surgery as an option for minimally invasive total hysterectomy. In addition, a new postoperative pain assessment item, postoperative analgesics, was used in this study, and patients did not require analgesics even when the\u0026nbsp;numerical rating scale (NRS) score was 4–6, suggesting that the interpretation of the NRS may differ between providers and patients [10].\u0026nbsp;This\u0026nbsp;study is new in the evaluation of postoperative pain\u0026nbsp;as\u0026nbsp;it uses an assessment of whether the patient wants analgesics.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eLimitations\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study has several limitations. First, the sample size is small. Although six variables were adjusted for in the multivariable analysis, the event power variable was \u0026lt; 10. The results might have differed if the sample size had been sufficient. Another limitation was the presence of confounding factors. We adjusted for age, BMI, surgeon skill (certified laparoscopic technologist or not), IVPCA with or without fentanyl, and local wound anesthesia. However, we could not adjust the surgeon’s preference for robotic or laparoscopic total hysterectomy. Further, the outcome (percentage of postoperative analgesia used) did not include opioids.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThere are currently no reported outcomes for which opioid and non-opioid use can be evaluated as a single measure. Therefore, opioids were analyzed as adjustment\u0026nbsp;variables\u0026nbsp;in this study. We believe treating only non-opioids as an outcome is reasonable in Japan, where opioids are not frequently used postoperatively.\u0026nbsp;In addition, we used wound local anesthesia instead of\u0026nbsp;the\u0026nbsp;transversus abdominis plane\u0026nbsp;(TAP) block. It has been reported that\u0026nbsp;the\u0026nbsp;TAP block\u0026nbsp;is\u0026nbsp;superior to wound local anesthesia at the port site for postoperative pain in patients undergoing robotic and laparoscopic total hysterectomy [11]. Therefore,\u0026nbsp;using a\u0026nbsp;TAP block instead of wound local anesthesia might\u0026nbsp;have affected\u0026nbsp;the results.\u003c/p\u003e\n"},{"header":"Conclusion","content":"\u003cp\u003eWhen multimodal postoperative pain management with NSAIDs and acetaminophen was used, no significant reduction in postoperative pain\u0026nbsp;was\u0026nbsp;detected with robotic total hysterectomy compared\u0026nbsp;with\u0026nbsp;laparoscopic total hysterectomy. Future studies with larger sample\u0026nbsp;sizes\u0026nbsp;and more\u0026nbsp;comprehensive\u0026nbsp;set of intraoperative and postoperative analgesic management protocols remain warranted.\u003c/p\u003e"},{"header":"Statements And Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgments:\u0026nbsp;\u003c/strong\u003eWe would like to thank Dr. Yamamoto for his guidance in this study. We would also like to thank Drs. Sugino, Ichida, Niiyai, and Morishima for their help in writing and revising the paper.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData availability statement:\u0026nbsp;\u003c/strong\u003eThe datasets generated and analyzed during the current study are available from the corresponding author upon reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting\u003c/strong\u003e\u003cstrong\u003einterests:\u0026nbsp;\u003c/strong\u003eThe authors have no relevant financial or non-financial interests to disclose.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor contributions: Shohei Tanabe wrote the main manuscript.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eRyohei Yamamoto provided advice on study design and statistical analysis.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAll authors reviewed and edited the manuscript.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u0026nbsp;\u003c/strong\u003eThis research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent to participate\u003c/strong\u003e\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eGitas G, Alkatout I, Proppe L et al (2021) Surgical outcomes of conventional laparoscopic and robotic-assisted hysterectomy\u003cem\u003e.\u003c/em\u003e Int J Med Robot\u003cem\u003e\u0026nbsp;\u003c/em\u003e17:e2225.\u003c/li\u003e\n \u003cli\u003ePark JH, Lee C, Shin Y, An JH, Ban JS, Lee JH (2015) Comparison of oxycodone and fentanyl for postoperative patient-controlled analgesia after laparoscopic gynecological surgery\u003cem\u003e.\u003c/em\u003e Korean J Anesthesiol\u003cem\u003e\u0026nbsp;\u003c/em\u003e68:153\u0026ndash;158.\u003c/li\u003e\n \u003cli\u003eTurner TB, Habib AS, Broadwater G et al (2015) Postoperative pain scores and narcotic use in robotic-assisted \u003cem\u003eVersus\u003c/em\u003e laparoscopic hysterectomy for endometrial cancer staging\u003cem\u003e.\u003c/em\u003e J Minim Invasive Gynecol\u003cem\u003e\u0026nbsp;\u003c/em\u003e22:1004\u0026ndash;1010.\u003c/li\u003e\n \u003cli\u003eGabriel RA, Swisher MW, Sztain JF, Furnish TJ, Ilfeld BM, Said ET (2019) State of the art opioid-sparing strategies for postoperative pain in adult surgical patients\u003cem\u003e.\u003c/em\u003e Expert Opin Pharmacother 20:949\u0026ndash;961.\u003c/li\u003e\n \u003cli\u003eMangalath AS, Kumar L, Sawant AB, Kesavan R, Ravindran G, Sunil R (2021) Comparison of analgesic requirements in robot-assisted \u003cem\u003eversus\u003c/em\u003e conventional laparoscopic abdominal surgeries\u003cem\u003e.\u003c/em\u003e J Anaesthesiol Clin Pharmacol 37:79\u0026ndash;84.\u003c/li\u003e\n \u003cli\u003eKim YH, Mun SH, Kim HS, Woo CH, Kim YC (2009) Remifentanil for postoperative patient-controlled analgesia after laparoscopic-assisted vaginal hysterectomy: dose-finding study\u003cem\u003e.\u003c/em\u003e Korean J Anesthesiol\u003cem\u003e\u0026nbsp;\u003c/em\u003e56:54\u0026ndash;59.\u003c/li\u003e\n \u003cli\u003eKanda Y (2013) Investigation of the freely available easy-to-use software \u0026lsquo;EZR\u0026rsquo; for medical statistics\u003cem\u003e.\u003c/em\u003e Bone Marrow Transplant 48:452\u0026ndash;458.\u003c/li\u003e\n \u003cli\u003eLeitao MM, Jr., Malhotra V, Briscoe G et al (2013) Postoperative pain medication requirements in patients undergoing computer-assisted (\u0026ldquo;Robotic\u0026rdquo;) and standard laparoscopic procedures for newly diagnosed endometrial cancer\u003cem\u003e.\u003c/em\u003e Ann Surg Oncol 20:3561\u0026ndash;3567.\u003c/li\u003e\n \u003cli\u003eAlshowaikh K, Karpinska-Leydier K, Amirthalingam J et al (2021) Surgical and patient outcomes of robotic \u003cem\u003eVersus\u003c/em\u003e conventional laparoscopic hysterectomy: A systematic review\u003cem\u003e.\u003c/em\u003e Cureus 13:e16828.\u003c/li\u003e\n \u003cli\u003evan Dijk JF, van Wijck AJ, Kappen TH, Peelen LM, Kalkman CJ, Schuurmans MJ (2012) Postoperative pain assessment based on numeric ratings is not the same for patients and professionals: a cross-sectional study\u003cem\u003e.\u003c/em\u003e Int J Nurs Stud 49:65\u0026ndash;71.\u003c/li\u003e\n \u003cli\u003eHutchins J, Argenta P, Berg A, Habeck J, Kaizer A, Geller MA (2019) Ultrasound-guided subcostal transversus abdominis plane block with liposomal bupivacaine compared to bupivacaine infiltration for patients undergoing robotic-assisted and laparoscopic hysterectomy: a prospective randomized study\u003cem\u003e.\u003c/em\u003e J Pain Res\u003cem\u003e\u0026nbsp;\u003c/em\u003e12:2087\u0026ndash;2094.\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003e\u003cstrong\u003eTable 1.\u0026nbsp;\u003c/strong\u003ePreoperative and intraoperative patient characteristics\u003c/p\u003e\n\u003ctable border=\"0\" cellpadding=\"0\" cellspacing=\"0\" width=\"662\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"35.703479576399396%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"21.482602118003026%\"\u003e\n \u003cp\u003eOverall (n = 124)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"19.969742813918305%\"\u003e\n \u003cp\u003eRobot (n = 38)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"22.844175491679273%\"\u003e\n \u003cp\u003eLaparoscopy\u0026nbsp;(n = 86)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"35.703479576399396%\"\u003e\n \u003cp\u003eVariables\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"21.482602118003026%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"19.969742813918305%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"22.844175491679273%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"35.703479576399396%\"\u003e\n \u003cp\u003eAge\u0026nbsp;(year), median (IQR)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"21.482602118003026%\"\u003e\n \u003cp\u003e46.0 (44.0, 52.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"19.969742813918305%\"\u003e\n \u003cp\u003e51.0 (43.5, 61.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"22.844175491679273%\"\u003e\n \u003cp\u003e46.0 (44.0, 49.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"35.703479576399396%\"\u003e\n \u003cp\u003eBMI (kg/m\u003csup\u003e2\u003c/sup\u003e), median (IQR)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"21.482602118003026%\"\u003e\n \u003cp\u003e22.0 (20.2, 25.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"19.969742813918305%\"\u003e\n \u003cp\u003e24.5 (20.3, 27.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"22.844175491679273%\"\u003e\n \u003cp\u003e21.6 (20.2, 23.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"35.703479576399396%\"\u003e\n \u003cp\u003eAnesthesia\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"21.482602118003026%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"19.969742813918305%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"22.844175491679273%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"35.703479576399396%\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;Inhalation anesthesia, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"21.482602118003026%\"\u003e\n \u003cp\u003e113 (91.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"19.969742813918305%\"\u003e\n \u003cp\u003e35 (92.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"22.844175491679273%\"\u003e\n \u003cp\u003e78 (90.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"35.703479576399396%\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;TIVA, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"21.482602118003026%\"\u003e\n \u003cp\u003e11 (8.80)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"19.969742813918305%\"\u003e\n \u003cp\u003e3 (7.90)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"22.844175491679273%\"\u003e\n \u003cp\u003e8 (9.30)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"35.703479576399396%\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;Fentanyl, mcg, median (IQR)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"21.482602118003026%\"\u003e\n \u003cp\u003e250 (200, 300)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"19.969742813918305%\"\u003e\n \u003cp\u003e250 (200, 300)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"22.844175491679273%\"\u003e\n \u003cp\u003e250 (200, 300)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"35.703479576399396%\"\u003e\n \u003cp\u003eOperation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"21.482602118003026%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"19.969742813918305%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"22.844175491679273%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"35.703479576399396%\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;License, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"21.482602118003026%\"\u003e\n \u003cp\u003e52 (42.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"19.969742813918305%\"\u003e\n \u003cp\u003e25 (65.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"22.844175491679273%\"\u003e\n \u003cp\u003e27 (31.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"35.703479576399396%\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;Uterus, g, median (IQR)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"21.482602118003026%\"\u003e\n \u003cp\u003e194 (121, 282)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"19.969742813918305%\"\u003e\n \u003cp\u003e125 (81.5, 214)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"22.844175491679273%\"\u003e\n \u003cp\u003e219 (143, 295)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"35.703479576399396%\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;Surgery time, min, median (IQR)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"21.482602118003026%\"\u003e\n \u003cp\u003e221 (173, 274)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"19.969742813918305%\"\u003e\n \u003cp\u003e257 (233, 314)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"22.844175491679273%\"\u003e\n \u003cp\u003e204 (155, 258)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"35.703479576399396%\"\u003e\n \u003cp\u003ePostoperative\u0026nbsp;analgesia\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"21.482602118003026%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"19.969742813918305%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"22.844175491679273%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"35.703479576399396%\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;IVPCA, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"21.482602118003026%\"\u003e\n \u003cp\u003e42 (33.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"19.969742813918305%\"\u003e\n \u003cp\u003e21 (55.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"22.844175491679273%\"\u003e\n \u003cp\u003e21 (24.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"35.703479576399396%\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;TAP, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"21.482602118003026%\"\u003e\n \u003cp\u003e22 (17.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"19.969742813918305%\"\u003e\n \u003cp\u003e14 (36.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"22.844175491679273%\"\u003e\n \u003cp\u003e8 (9.30)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eBMI, body mass index; TIVA, intravenous patient-controlled analgesia; IVPCA, patient-controlled analgesia; TAP, transversus abdominis plane block; IQR, interquartile range\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003cstrong\u003eTable 2.\u003c/strong\u003e Association between outcome and exposure\u003c/p\u003e\n\u003ctable border=\"0\" cellpadding=\"0\" cellspacing=\"0\" width=\"881\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"21.45289443813848%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"14.074914869466514%\"\u003e\n \u003cp\u003eRobotic (n = 38)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.188422247446084%\"\u003e\n \u003cp\u003eLaparoscopic\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e(n = 86)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" width=\"24.51759364358683%\"\u003e\n \u003cp\u003eUnadjusted\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" width=\"25.766174801362087%\"\u003e\n \u003cp\u003eAdjusted\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"21.477272727272727%\"\u003e\n \u003cp\u003e \u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" width=\"28.181818181818183%\"\u003e\n \u003cp\u003eUse of Analgesia\u0026nbsp;n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.363636363636363%\"\u003e\n \u003cp\u003eOR [95% CI]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.181818181818182%\"\u003e\n \u003cp\u003ep-value\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.363636363636363%\"\u003e\n \u003cp\u003eOR [95% CI]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.431818181818182%\"\u003e\n \u003cp\u003ep-value\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"21.45289443813848%\"\u003e\n \u003cp\u003ePrimary analysis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.074914869466514%\"\u003e\n \u003cp\u003e10 (26.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.188422247446084%\"\u003e\n \u003cp\u003e52 (60.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.34506242905789%\"\u003e\n \u003cp\u003e4.28 (1.85\u0026ndash;9.93)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.172531214528945%\"\u003e\n \u003cp\u003e\u0026lt; 0.01\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.34506242905789%\"\u003e\n \u003cp\u003e2.62 (0.91\u0026ndash;7.56)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.421112372304199%\"\u003e\n \u003cp\u003e0.07\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"21.45289443813848%\"\u003e\n \u003cp\u003eSubgroup\u0026nbsp;analyses\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.074914869466514%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"14.188422247446084%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"16.34506242905789%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"8.172531214528945%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"16.34506242905789%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"9.421112372304199%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"21.45289443813848%\"\u003e\n \u003cp\u003eIVPCA-no use\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.074914869466514%\"\u003e\n \u003cp\u003e8 (21.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.188422247446084%\"\u003e\n \u003cp\u003e46 (53.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.34506242905789%\"\u003e\n \u003cp\u003e2.72 (0.91\u0026ndash;8.12)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.172531214528945%\"\u003e\n \u003cp\u003e0.07\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.34506242905789%\"\u003e\n \u003cp\u003e2.20 (0.60\u0026ndash;8.12)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.421112372304199%\"\u003e\n \u003cp\u003e0.24\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"21.45289443813848%\"\u003e\n \u003cp\u003e\u0026nbsp; IVPCA use\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.074914869466514%\"\u003e\n \u003cp\u003e2 (5.26%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.188422247446084%\"\u003e\n \u003cp\u003e6 (7.00%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.34506242905789%\"\u003e\n \u003cp\u003e3.80 (0.67\u0026ndash;21.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.172531214528945%\"\u003e\n \u003cp\u003e0.13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.34506242905789%\"\u003e\n \u003cp\u003e12.3 (0.93\u0026ndash;161)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.421112372304199%\"\u003e\n \u003cp\u003e0.06\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"21.45289443813848%\"\u003e\n \u003cp\u003eSensitivity analyses 1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.074914869466514%\"\u003e\n \u003cp\u003e13 (34.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.188422247446084%\"\u003e\n \u003cp\u003e58 (67.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.34506242905789%\"\u003e\n \u003cp\u003e3.98 (1.78\u0026ndash;8.94)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.172531214528945%\"\u003e\n \u003cp\u003e\u0026lt; 0.01\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.34506242905789%\"\u003e\n \u003cp\u003e2.31 (0.87\u0026ndash;6.14)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.421112372304199%\"\u003e\n \u003cp\u003e0.09\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"21.45289443813848%\"\u003e\n \u003cp\u003eSensitivity analyses 2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.074914869466514%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.188422247446084%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.34506242905789%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.172531214528945%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.34506242905789%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.421112372304199%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"21.45289443813848%\"\u003e\n \u003cp\u003e\u0026nbsp; IVPCA-no use\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.074914869466514%\"\u003e\n \u003cp\u003e8 (21.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.188422247446084%\"\u003e\n \u003cp\u003e46 (53.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.34506242905789%\"\u003e\n \u003cp\u003e2.72 (0.91\u0026ndash;8.12)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.172531214528945%\"\u003e\n \u003cp\u003e0.07\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.34506242905789%\"\u003e\n \u003cp\u003e2.20 (0.60\u0026ndash;8.12)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.421112372304199%\"\u003e\n \u003cp\u003e0.24\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"21.45289443813848%\"\u003e\n \u003cp\u003e\u0026nbsp; IVPCA use\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.074914869466514%\"\u003e\n \u003cp\u003e5 (13.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.188422247446084%\"\u003e\n \u003cp\u003e12 (14.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.34506242905789%\"\u003e\n \u003cp\u003e4.27 (1.13\u0026ndash;16.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.172531214528945%\"\u003e\n \u003cp\u003e0.03\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.34506242905789%\"\u003e\n \u003cp\u003e7.94 (0.76\u0026ndash;82.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.421112372304199%\"\u003e\n \u003cp\u003e0.08\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eIVPCA, intravenous patient-controlled analgesia\u003c/p\u003e\n\u003cp\u003ePrimary analyses: outcome was the use of acetaminophen, NSAIDs.\u003c/p\u003e\n\u003cp\u003eSensitivity analyses 1: outcome was the use of acetaminophen, NSAIDs, or IVPCA flushes.\u003c/p\u003e\n\u003cp\u003eSensitivity analysis 2: subgroup analysis (IVPCA use or not) of sensitivity analysis 1.\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"journal-of-robotic-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"jors","sideBox":"Learn more about [Journal of Robotic Surgery](http://link.springer.com/journal/11701)","snPcode":"11701","submissionUrl":"https://submission.nature.com/new-submission/11701/3","title":"Journal of Robotic Surgery","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"body mass index, logistic models, NSAIDs, postoperative pain","lastPublishedDoi":"10.21203/rs.3.rs-2278764/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-2278764/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground/Objective:\u003c/strong\u003eAlthough robotic and laparoscopic total hysterectomies are widely used as minimally invasive procedures, consensus on which is superior regarding lesser postoperative pain is lacking. Thisstudy determines whether there is a difference in the proportion of postoperative use of non-steroidal anti-inflammatory drugs (NSAIDs) and acetaminophen between robotic and laparoscopic total hysterectomies.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods:\u003c/strong\u003e This retrospective cohort study enrolled patients who underwent robotic or laparoscopic total hysterectomy for uterine fibroids, adenomyosis, or cervical intraepithelial neoplasia grade 3 at a hospital between July 2016and November 2021. The outcome was postoperative analgesics (i.e., NSAIDs or acetaminophen) use. Unadjusted and adjusted logistic regression analyses were performed to evaluate the association between the procedure and outcome. Adjusted variables were age, body mass index, surgeon’s laparoscopic technique certification, intravenous patient-controlled analgesia, and wound local anesthesia.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults: \u003c/strong\u003eOf 127 patients, 3 were excluded, and 124 were included. Robotic and laparoscopic hysterectomy was performed in 38 and 86 patients, respectively. Postoperative analgesics were administered to 10 (26.3%) and 52 (60.5%) patients in the robotic and laparoscopic groups, respectively. Unadjusted logistic regression analysis showed significantly more frequent analgesics use in the laparoscopy group (odds ratio [OR] 4.28; 95% confidence interval [CI] 1.85–9.93; p \u0026lt; 0.01). Adjusted logistic regression analysis did not detect significant differences (OR 2.62; 95% CI 0.91–7.56; p = 0.07).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion:\u003c/strong\u003e No significant difference in the proportion of postoperative analgesia was observed betweenrobotic total hysterectomy and laparoscopy. Future studies must include largersample sizes andaligned intraoperative and postoperative analgesic management.\u003c/p\u003e","manuscriptTitle":"Comparison of Postoperative Analgesia Use Between Robotic and Laparoscopic Total Hysterectomy: A Retrospective Cohort Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2022-11-18 16:21:41","doi":"10.21203/rs.3.rs-2278764/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Accepted","date":"2023-03-18T18:44:11+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2022-11-25T22:10:18+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2022-11-16T12:54:33+00:00","index":"","fulltext":""},{"type":"submitted","content":"Journal of Robotic Surgery","date":"2022-11-16T05:40:35+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"journal-of-robotic-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"jors","sideBox":"Learn more about [Journal of Robotic Surgery](http://link.springer.com/journal/11701)","snPcode":"11701","submissionUrl":"https://submission.nature.com/new-submission/11701/3","title":"Journal of Robotic Surgery","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"366a0dd2-ea7e-4133-8535-c9aebc7fc36d","owner":[],"postedDate":"November 18th, 2022","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2023-10-16T20:10:09+00:00","versionOfRecord":{"articleIdentity":"rs-2278764","link":"https://doi.org/10.1007/s11701-023-01581-3","journal":{"identity":"journal-of-robotic-surgery","isVorOnly":false,"title":"Journal of Robotic Surgery"},"publishedOn":"2023-03-23 20:06:05","publishedOnDateReadable":"March 23rd, 2023"},"versionCreatedAt":"2022-11-18 16:21:41","video":"","vorDoi":"10.1007/s11701-023-01581-3","vorDoiUrl":"https://doi.org/10.1007/s11701-023-01581-3","workflowStages":[]},"version":"v1","identity":"rs-2278764","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-2278764","identity":"rs-2278764","version":["v1"]},"buildId":"-HB7Z8yhvgn0wM9Nzuekk","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}