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A robotic hysterectomy is more expensive, but is it better?

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

 And

  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.   

 

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Discussion

6 thoughts on “A robotic hysterectomy is more expensive, but is it better?

  1. I’m curious to know how these recommendations have changed over the past 20 years since I had my abdominal (“bikini cut”) hysterectomy. At the time, I was told that the vaginal method had a higher risk of complications, and laparoscopic wasn’t even mentioned. (I did have adenomyosis and a small fibroid – not sure how that factored in.)

    Posted by Theo Bromine | March 19, 2013, 10:28 am
  2. The question should also be asked why are so many hysterectomies (whether robotic, abdominal, laparoscopic or vaginal) being pushed on women for benign gynecological conditions when other less drastic options may serve their needs just as well if not better than a hysterectomy.

    Take for example, uterine fibroids …. The first recommendation given to me to solve my fibroid problem was hysterectomy. I was also told it could be done robotically … as if that somehow was supposed to make it more palatable to me … it didn’t. Sadly I don’t think my doctor would have discussed other possible
    options with me had I not done my own research and known to ask about them.

    My story is not unique. Having participated in some online fibroid groups I know this happens to many other women where they are only offered hysterectomy.

    Hysterectomy is definitely one choice for handling a fibroid problem but is not the ONLY choice. I have a problem with doctors who fail to let their patients know there are other options — abdominal, laparoscopic, or robotic and/or hysteroscopic myomectomy; uterine fibroid embolization, possibly focused ultrasound (still somewhat experimental). For heavy bleeding, endometrial ablation is also an option. In my case I suffered from bulk symptoms and heavy bleeding causing anemia. I opted for laparoscopic and hysteroscopic myomectomies of my fibroids followed by endometrial ablation. This was the treatment option I felt most comfortable with after weighing all the pros and cons of the various treatment options in the context of my own personal health history and sensibilities about my own body. I will add that future fertility was not an issue for me.

    A worthy read on the overuse of hysterectomies can be found
    here: http://www.more.com/health/wel… Also worth reading on the subject of ovary
    conservation – http://www.ovaryresearch.com/

    Posted by jdlittle | May 25, 2013, 2:18 pm

Trackbacks/Pingbacks

  1. Pingback: The Slaughterhouse Mentality | The Treating Physician - March 18, 2013

  2. Pingback: Insurance companies should stop paying for robotic hysterectomies | Dr. Jen Gunter - October 12, 2013

  3. Pingback: [Reblog from KevinMD.com] Insurers should stop paying for robotic hysterectomies « Health and Medical News and Resources - November 7, 2013

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