Should you choose to have a robotic hysterectomy?

In a word, no (unless you have cancer). So, let’s take cancer out of the picture and discuss hysterectomy for non-cancerous (benign) reasons.

First of all. A hysterectomy (removing the uterus) can be done via one of the 4 methods:

1. Vaginal, a small incision at the top of the vagina and the uterus is removed entirely through the vagina without any incision on the abdomen.

2. Laparoscopic surgery, where incisions are made in the belly and an operating telescope is inserted. The uterus is then removed either through a small incision in the belly wall or through the vagina.

3. A robotic surgery, which is laparoscopic surgery (see #2) performed with specialized equipment. The surgeon actually sits at a consult and operates the equipment remotely. An assistant is scrubbed in during the case to help with the equipment.

4. An abdominal hysterectomy. This requires an incision in the belly and has much longer recovery times than the other 3 options. This is what most people visualize when they think of surgery.

The American Congress of OB/GYN (ACOG) recommends vaginal hysterectomy as the least invasive method (least invasive is almost always the best option) with the best outcomes. Sometimes a vaginal hysterectomy isn’t feasible for technical reasons and then a laparoscopic approach is favored. There is no study that suggests a robotic hysterectomy offers any medical advantage over a vaginal or a laparoscopic hysterectomy when cancer isn’t the reason for the surgery.

So if there is no advantage to robotic hysterectomies, why are gynecologists pushing them? And make no mistake, they are pushing them as 3 years ago 0.5% of hysterectomies were robotic and now that number has soared exponentially to 10% (JAMA, 2013)

Why this exponential increase? I can think of four reasons:

1. They need the practice. The gynecologists want to learn the new technique (see the marketing angle below), but it takes quite a few cases to get good.

2. A marketing tool. Hey, robots are cool, they’re new, they must be better! People will want robots.

3. Hospitals are pushing GYNs to use the surgical robot, the robot that cost about $1.7 million to buy in addition to $125,000 in annual maintenance. Hospitals need to keep the robot in use to cover these expenses. That money can only come from your insurance company, your tax dollars (Medicaid and Medicare), or directly from you.

4. They don’t know the literature and believe the hype from the reps who sell the robots.

According to ACOG:

Robotic surgery is not the only or the best minimally invasive approach for hysterectomy. Nor is it the most cost-efficient. It is important to separate the marketing hype from the reality when considering the best surgical approach for hysterectomies … there is no good data proving that robotic hysterectomy is even as good as—let alone better—than existing, and far less costly, minimally invasive alternatives.

A robot adds $2000 to a hysterectomy. If every non-cancer (benign) hysterectomy in the United States were performed with a robot, ACOG estimates that $960 million to $1.9 billion will be added to the health care system each year.

If your GYN is recommending robotic surgery over a vaginal or a traditional laparoscopic hysterectomy and you don’t have cancer, you need to ask, “Why?” (and take a look to see if robotic surgery is featured prominently on the web page and the practice’s marketing).

New technology isn’t always better. While a robot can lead to improved outcomes for complex cancer cases (they allow the surgeon to do the case with a laparoscopically rather than with a big incision), using a robot for a benign hysterectomy is like driving a Ferrari with the speedometer set so the car can’t exceed 15 miles an hour. It might look cooler, but it’s going to cost you a lot more up front and in maintenance and it’s not going to get you around the city any faster or safer than a Honda.

We are all stewards of the health care system. Wasting $2000 per patient on the costs to run a robot for a benign hysterectomy is simply funding the salaries of the people who sell surgical robots and increasing the cost of health care for everyone else, because we all pay when care becomes more expensive with higher premiums and co-payments.

Jennifer Gunter is an obstetrician-gynecologist and author of The Preemie Primer. She blogs at her self-titled site, Dr. Jen Gunter.

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  • http://www.dpsinfo.com LaurieMann

    And, you don’t talk about some of the possible complications from robotic hysterectomies, while very rare, can be very traumatic due the cautery problems. If you’re trying to avoid scarring, laparoscopy seems the best way to go.

    I wound up having a classic abdominal hysterectomy last summer due to re-occuring cysts and endometriosis. I was fine after 3 weeks, and was probably back to about 95% within 6 weeks. Yes, I have an ugly scar, but other than a mild case of cellulitis, didn’t had any post-op surprises.

  • OkieShell

    I will vouch for the vaginal hysterectomy. It was the best thing I’ve ever done. Already done having children, it was pretty clear that a hysterectomy would stop the problems I was having once and for all. Because I was young (40), ablation didn’t come with that 100% guarantee. I kept my ovaries because I am not a good candidate for HRT. So surgery was on a Tuesday and by Saturday I was at the bar watching football (no pain meds and had a driver). That’s not to say that there was no recovery, because there was. But it was WAY easier than the recovery from a c-section.

    • LastoftheZucchiniFlowers

      Okie – Glad you recovered nicely and curious if you were counseled at all vis a vis potential problems with the fact that your ovaries were not removed? Any f/u advice for screening, any fhx of ovarian or other CA?

      • OkieShell

        The doctor didn’t say anything about side effects of keeping my ovaries. There was no cancer or fibroids, I just tried to bleed to death – a period that lasted for 17 weeks. :) I started feeling better almost immediately and back to work full time in 4 weeks.

  • karen3

    And, you can be sure your doctor is trained on methods 1 & 2, for 3 you might be the beginning of the learning curve

  • Guest

    The robot for hysterectomies is outrageous, in my opinion. All it does, as you astutely pointed out, is increase operative time and cost and makes no difference in outcome.

    The hospital wants to attract business by advertising their fancy, shiny new state of the art robot! The surgeons want to attract business by pushing robotic surgery on patients when laparoscopic is just as good (our general surgeons are now doing robotic cholecystectomies).

    I wonder if in 10 years we will look at the robot as an absurdity and a failed experiment. I just hope too many patients aren’t harmed in the process.

  • southerndoc1

    Why do insurers pay an extra 2K when the robot is used?

  • buzzkillerjsmith

    I don’t have a uterus, but I would like a robot to clean the house.

    • Guest

      We used to have these things. Like the robot for surgery it looked cool but just took longer to get the job done than if we did it ourselves.

      • buzzkillerjsmith

        You’re killing my buzz.

        • Guest

          Sorry.

  • LastoftheZucchiniFlowers

    In my experience, surgeons like to do surgery. It’s part of why we’ve chosen field and for a good surgeon to step away from the left side is out of character. Everyone understands that after a certain age, the ubiquitous and inevitable hand tremor requires everyone to put down the metzenbaum forever and perhaps THEN, the robot/drone surgeon might not look too bad. But for younger surgeon just hitting his/her prime? No.

  • Guest

    Bravo, and I agree. I think hysterectomies are done WAY too often, and sometimes for questionable indications. Sometimes I wonder if they are pushed onto patients so the docs can practice their techniques (be it robotic or laparoscopic).

    It’s good to be informed and aware about choices. Those people that subject themselves to the robot choose not to and that’s really their fault.

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