Robotic-assisted hysterectomy: patient selection and perspectives

Noam Smorgick
International journal of women's health · 2017 · vol. Volume 9 , pp. 157–161 · doi:10.2147/ijwh.s99993 · PMID:28356774 · PMC5367602 · W2598800667
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Robotic-assisted hysterectomy is being widely adopted for benign conditions with high surgical complexity, endometrial cancer, and obese patients, despite not offering clear advantages over conventional laparoscopy and incurring higher costs.

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This paper is a narrative review of evidence and rationale for selecting patients for robotic-assisted hysterectomy versus laparoscopic hysterectomy, focusing on uncomplicated benign cases and “complex” indications such as advanced endometriosis, extensive pelvic adhesions, obesity, and large uterine size. It synthesizes randomized trial data showing no clinically meaningful differences in complication, blood loss, or length of stay for benign disease, while noting limitations including biases criticized in some trials (surgeon experience favoring nonrobotic methods) and longer operative times for robotic procedures in some studies. Observational data in higher-complexity populations report low complication and conversion rates with robotic hysterectomy, including studies where endometriosis severity correlated with higher vaginal cuff abscess risk, and studies of advanced endometriosis excision with comparable laparoscopic versus robotic outcomes overall, often conducted in tertiary centers. This paper does not explicitly discuss adenomyosis, but it directly addresses endometriosis as a key complex indication for robotic-assisted hysterectomy and summarizes multiple studies specifically involving advanced stage endometriosis.

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Abstract

Minimally invasive hysterectomy via the laparoscopic or vaginal approach is beneficial to patients when compared with laparotomy, but has not been offered in the past to all women because of the technical difficulties and the long learning curve required for laparoscopic hysterectomy. Robotic-assisted hysterectomy for benign indications may allow for a shorter learning curve but does not offer clear advantages over conventional laparoscopic hysterectomy in terms of surgical outcomes. In addition, robotic hysterectomy is invariably associated with increased costs. Nevertheless, this surgical approach has been widely adopted by gynecologic surgeons. The aim of this review is to describe specific indications and patients who may benefit from robotic-assisted hysterectomy. These include hysterectomy for benign conditions in cases with high surgical complexity (such as pelvic adhesive disease and endometriosis), hysterectomy and lymphadenectomy for treatment of endometrial carcinoma, and obese patients. In the future, additional evidence regarding the benefits of single-site robotic hysterectomy may further modify the indications for robotic-assisted hysterectomy.
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Intro

The minimally invasive surgical approach to hysterectomy (including vaginal hysterectomy, laparoscopic hysterectomy, and robotic-assisted hysterectomy) has advantages over laparotomic hysterectomy in the rates of short- and long-term complications. 1 However, the vaginal approach to hysterectomy is not feasible in many women undergoing hysterectomy owing to large uterine size, prior pelvic surgeries, need for concomitant adnexal surgery, and malignancy. Thus, the minimally invasive approach appropriate for these cases is either laparoscopic or robotic hysterectomy. For uncomplicated benign hysterectomy cases, the outcomes and complications of laparoscopic and robotic hysterectomy are comparable, while the cost of robotic hysterectomy is higher. 2 Thus, in this patient group, there is no clear advantage of robotic over laparoscopic hysterectomy. However, some patients with complex surgical pathology (such as advanced endometriosis and extensive pelvic adhesions), obesity, and those with endometrial carcinoma may benefit from robotic-assisted hysterectomy. In addition, surgical advancements such as single-site hysterectomy may change the relative advantages and disadvantages of laparoscopic versus robotic hysterectomy. In this review, we will describe the evidence and rationale for the selection of patients who are likely to benefit from robotic hysterectomy.

Robotic

As described earlier for obese patients with endometrial carcinoma undergoing a robotic procedure, obese patients with benign conditions requiring hysterectomy may also benefit from the robotic approach. A meta-analysis by Iavazzo and Gkegkes 23 described the outcomes of robotic hysterectomy for various indications (benign and malignant) in obese patients with BMI >30 kg/m 2 . Overall complications were low, and included conversion to laparotomy in 4.1%, wound complications in 2.4%, vaginal cuff complications in 0.9%, and need for blood transfusions in 0.9%.

Conclusion

Robotic-assisted hysterectomy has gained increased popularity over the last decade. The adoption of this surgical approach has enabled many patients to undergo minimally invasive hysterectomy. However, there is no clear evidence that robotic hysterectomy is superior to conventional laparoscopic hysterectomy in patients with benign conditions and moderate surgical complexity, while the cost of the robotic procedure remains higher. 28 Nevertheless, some patients may benefit from robotic procedures, including patients with endometrial carcinoma, obesity, and patients with benign conditions involving high surgical complexity such as advanced stage endometriosis and pelvic adhesive disease. The more recent availability of the single-site robotic platform may prove to be another benefit of this surgical approach.

Single Site

Single-site laparoscopic surgery has been introduced as an alternative to multiport laparoscopic surgery, with the aim of reducing port number and consequently postoperative pain, as well as improved cosmesis. This surgical approach has not yet gained widespread acceptance among minimally invasive surgeons owing to the technical difficulty in maneuvering the laparoscopic instruments through the single port, as a result of the limited triangulation. The robotic version of single-site laparoscopic surgery is available for the da Vinci platform, using specially adapted robotic ports and instruments. The single-site robotic platform is not identical to the multiport robotic platform since the instruments are not fully wristed and the degrees of movements are more limited, but it is more comfortable to use when compared to the single-site laparoscopic instruments because it does allow for some triangulation. Thus, laparoscopic suturing with the single-site robotic platform is somewhat technically challenging, and some surgeons opt to suture the vaginal cuff by transvaginal closure. 24 The current literature, which at this time includes retrospective case series, describes the outcomes of single-site robotic hysterectomy in comparison with multiport robotic hysterectomy. Several studies describe the feasibility of single-site robotic hysterectomy for benign conditions, and single-site hysterectomy and lymphadenectomy for endometrial carcinoma. 24 , 25 Bogliolo et al 24 compared single-site and multiport robotic hysterectomy for benign conditions. The main advantage of the single-site robotic hysterectomy in their study was reduced cost, with some additional benefit in the short-term postoperative pain. The cost saving was attributed to the use of two robotic instruments per procedure in the single-site surgery as opposed to three robotic instruments in the multiport procedure, and amounted to $1,500–$2,000 per case. Another advantage of the robotic single-site platform may be its shorter learning curve when compared with single-site laparoscopic hysterectomy. 26 At this time, the preliminary outcomes reported for single-site robotic hysterectomy appear promising, but most authors agree that more studies are needed to define the appropriate applications for this approach prior to widespread adoption. 27 In particular, at this time, the single-site robotic platform is unlikely to replace the multiport robotic platform when operating cases with high surgical complexity.

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endometriosis

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