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Doctors, patients find robots may be a cut above for hysterectomies

Dr. Gregory Wilkerson performs a robot-assisted hysterectomy on Cynthia Cobbins, 41, at Florida Hospital Tampa.


Dr. Gregory Wilkerson performs a robot-assisted hysterectomy on Cynthia Cobbins, 41, at Florida Hospital Tampa.

TAMPA — Cynthia Cobbins knew little about hysterectomies, until her doctor told her she needed one.

She had heard stories from friends and family: the long scar the surgery leaves, the long recovery, the weeks or months spent away from work.

But her obstetrician-gynecologist told her about a procedure in which robotic arms are inserted through tiny incisions in the abdomen to remove the uterus. Compared with traditional surgery, robotic laparoscopy would mean she would lose less blood, spend less time in the hospital and recovering, and get back to her job quicker.

"I thought, 'That's great,' " said Cobbins, 41, who had the procedure due to fibroids, benign tumors on her uterus. She had a successful surgery Wednesday and left the hospital two days later.

Yet, despite growing evidence and recommendations that minimally invasive approaches are best for most women, Cobbins is in the minority. About two-thirds of the nearly 600,000 hysterectomies performed in the United States each year are still done through open abdominal procedures.

Why? Doctors say it's a matter of training, time and the preferences of doctors and patients. Many veteran ob-gyns aren't trained in newer techniques, said Dr. Larry Glazerman, director of the minimally invasive gynecologic surgery program at the University of South Florida.

And women often want their longtime ob-gyns — the ones who delivered their babies — to also do their hysterectomies, Glazerman said.

Considering the high cost of hospital stays, the continued popularity of open hysterectomies is an example of why health costs in the United States are so high, some doctors say. (So, many say, is the American fondness for this procedure; see sidebar.)

Minimally invasive procedures are more expensive in the operating room, particularly those involving pricey robots. Still, they generally save money because they involve shorter hospitalizations.

But slowly, the tide is turning.

Florida Hospital Tampa now does nearly 80 percent of hysterectomies through minimally invasive methods. Others, including Tampa General Hospital and Bayfront Medical Center in St. Petersburg, are following suit.

"We decided to take a stand to say this is what's best for women," said Margie Boyer, a nurse and administrative director for Florida Hospital Tampa's Women's Center, which two years ago spent $1.4 million on a surgical robot.

Dr. Gregory Wilkerson, one of two ob-gyns to operate on Cobbins, put it more bluntly.

"The days of doing abdominal hysterectomies, except in rare instances, are over," he said.

• • •

Doctors can remove the uterus several ways, through a 5- to 7-inch abdominal incision, vaginally (which may be laparascopically assisted), or through fully laparascopic methods, which can involve a robot or not.

In 2009, the American College of Obstetricians and Gynecologists recommended that in most cases, minimally invasive procedures are preferable to the abdominal method.

The group cited a Cochrane review (a respected health care information source) of 4,495 patients that concluded vaginal hysterectomies had the best outcomes, and that laparoscopic hysterectomies had numerous advantages to abdominal ones, including faster return to normal activity, shorter hospital stays, less blood loss and fewer wound infections. Complication rates for all minimally invasive procedures were lower than for abdominal hysterectomies.

Vaginal hysterectomies involve the removal of the uterus through a cut in the vagina, but several factors — including the size and shape of the vagina — may make the method unfeasible.

Laparoscopic procedures involve small incisions in the abdomen through which instruments and a camera are inserted to remove the uterus.

Two years ago, Florida Hospital Tampa (then known as University Community Hospital) purchased da Vinci Surgery equipment to do robotic hysterectomies, and sent ob-gyns who practice there for training. Since then, the hospital has gone from 46 percent of hysterectomies performed laparoscopically to 77 percent so far this year.

A hospital may make more money doing abdominal hysterectomies, due to longer patient stays and less time needed in the operating room, Boyer said. But the decision should come down to what's best for the patient, she said.

How do the costs differ? One report, which compared hysterectomy costs to treat endometrial cancer, found that when factoring in hospital costs, equipment expenses and the patient's lost wages, a nonrobotic laparoscopic procedure costs $10,128, a robot-assisted laparoscopy $11,476 and an open hysterectomy $12,847.

Bayfront Medical Center purchased the surgical robot over the summer, and has quickly put it to use, said Dr. Megan Indermaur, co-medical director of the hospital's robotics program.

"We pushed them," Indermaur said, pointing out that Bayfront was losing business to a neighboring hospital that already had the technology.

Prior to getting the robot, about half of the 450 hysterectomies performed at the hospital in the past year were done laparoscopically.

But Indermaur expects those numbers to change. "I pretty much try to do all my cases robotically now," she said.

• • •

Critics say the robot-assisted method may be getting its traction due to marketing and patient demand for the next big thing.

But is it better than a laparoscopic hysterectomy without a robot?

A study in the Journal of Minimally Invasive Gynecology found that the difference between the two was "minimal," and suggested the robot-assisted method might be less efficient, given the cost.

Besides the $1.5 million price for the robot itself, the machine's robotic arms, which cost more than $1,000 apiece, must be replaced after every 10 uses. Training to use the robot also costs about $10,000 per doctor.

Furthermore, doctors need to perform about 50 robot-assisted surgeries to become proficient, and need to continue doing them regularly to stay proficient, said USF's Glazerman.

Not every ob-gyn does a lot of this surgery: One study showed that a quarter of hysterectomies in New York were done by ob-gyns who perform them only about once a month.

And laparoscopy is not perfect. The American College of Obstetricians and Gynecologists report found such procedures — with or without a robot — mean longer surgeries and a higher risk of urinary tract injury, though that still is fairly rare.

And if a woman has a particularly large uterus or mass that is being removed, an open surgery may be the only alternative.

Dr. Robert Yelverton, chief medical officer for Women's Care Florida, a Tampa-based network of more than 100 ob-gyns, said women need to do their homework and make sure they choose the procedure and surgeon that are right for them.

"Just because new technology comes doesn't mean surgeons will get trained in it," he said. "And just because a doctor will market that he does robotics doesn't mean he is better skilled."

Facts about hysterectomies

• Hysterectomies are the second most frequent major surgical procedure among premenopausal women in the United States, trailing only cesarean section deliveries.

• Hysterectomies treat a variety of problems, including cancer of the uterus, ovary or cervix; noncancerous tumors, called fibroids, which grow in the wall of the uterus; and when the tissue that lines the uterus extends outside the uterus onto the ovaries or fallopian tubes.

• Nearly one in three women in the United states is expected to have one before age 60, compared with one in five women in the United Kingdom.

• The Centers of Disease Control and Prevention attributes the high numbers to advances in medical technology that allow for early and accurate diagnosis of uterine problems, and an increased awareness by women concerning their health and risk of gynecologic problems. Still, some experts believe a large number of hysterectomies performed in the United States are unnecessary.

Sources: U.S. Department of Health and Human Services and the Centers for Disease Control and Prevention

Doctors, patients find robots may be a cut above for hysterectomies 10/30/11 [Last modified: Monday, October 31, 2011 2:21pm]
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