Surgery to remove the uterus with a $1.45 million robot from Intuitive Surgical Inc. costs thousands of dollars more without reducing complications compared with standard less-invasive surgery, a study found.
Researchers examined data from 264,758 women who had a hysterectomy for benign conditions such as fibroids at 441 U.S. hospitals from 2007 to 2010. The robot operations cost hospitals $2,189 more per procedure than performing the same surgery without the robot, according to the study released yesterday in the Journal of the American Medical Association.
The research illustrates how the adoption of expensive medical technology can outpace data proving its benefits, said Jason Wright, a gynecologic oncologist at Columbia University College of Physicians and Surgeons and the study’s lead author. Robot operations rose to 9.5 percent of hysterectomies in 2010 from 0.5 percent in 2007, the data showed. Yet there are few large studies charting the benefits over conventional less invasive operations, he said.
“The major concern is that the robotic procedure really didn’t show a lower complication rate yet it was substantially more expensive,” Wright said. Why the robot took off so fast “is the million dollar question.”
With standard minimally invasive surgery, called laparoscopy, surgeons manipulate instruments through several tiny incisions in the abdomen while looking inside the patient through a camera called a laparoscope.
Robotic surgery is similar, except that the surgeon sits at a console a few feet away and maneuvers robotic arms while looking into a high-definition display. Unlike the standard equipment, the robotic instruments have wrists, potentially enabling finer control and movement.
Hysterectomy is one of the most common operations, with about 600,000 performed in the U.S. annually, mostly for benign conditions, Wright said.
The study found complication rates were 5.5 percent for robotic hysterectomy and 5.3 percent for laparoscopic surgery, a difference that wasn’t statistically significant.
The costs of robot operations were higher even when the fixed price of buying the robot was excluded, Wright said. How hospitals make back the extra cost is unclear as most insurers don’t pay a higher rate for robot operations, he said.
The study found one clear benefit: as use of the robot increased, there was a decrease in the percentage of women who received a traditional “open” hysterectomy, in which the uterus is removed through a large incision in the abdomen.
Hospitals without a robot may have increased their use of minimally invasive operations to compete with hospitals that had a robot, Wright said.
“The message I get from this paper is with the advent of robotics you are seeing more patients being done minimally invasively and that is good,” said Myriam Curet, chief medical adviser for Sunnyvale, California-based Intuitive Surgical, said in a telephone interview. “Robotics is clearly allowing more patients to have a minimally invasive surgery.”
She said the Columbia cost analysis was limited because it didn’t look at potential longer-term benefits of robot surgery, such as whether it helps women recover and get back to work sooner. The study also didn’t examine whether minimally invasive surgeons need to convert less often to open surgeries when they use the robot, as Intuitive’s analysis indicates, she said.
The robot was cleared by the U.S. Food and Drug Administration in 2000 and became popular among urologists performing prostate cancer surgery, where minimally invasive methods had been uncommon. The robot was approved for gynecologic procedures in 2005.
For hysterectomies, multiple types of minimally invasive surgery have been available for years, Wright said. In addition to laparoscopic hysterectomy, doctors often can remove the uterus through the vagina, the least invasive method, he said.
“Patients need to be aware there are a lot of different options for hysterectomy,” Wright said. More studies need to be performed to understand whether there are certain subgroups of women who clearly benefit from using the robot over other minimally invasive options.
Mario Leitao, a gynecologic oncologist at Memorial Sloan- Kettering Cancer Center in New York who uses the robot, said the study results won’t change how often he uses the device.
“It is like asking a jet fighter pilot to go back to a World War II airplane because it is cheaper,” said Leitao, who has consulted for Intuitive. “The robot is here to stay.”
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