Robotic Surgery and Cost

Over the last few years there has been a significant increase in the number of hospitals starting up "robotic surgery" programs. In fact, robotic assisted surgery for prostate removal has become the "standard of care" for prostatectomy. Robotic surgery in gynecology has become more controversial. I think all providers would agree that the benefits of laparoscopic approach to surgery are much greater than by traditional laparotomy or open surgery. In my view, robotic assisted surgery is merely a laparoscopic surgery that is helped by robotic or computer assistance. Robotic systems have allowed many gynecologists the opportunity to offer a less invasive approach to surgery that would otherwise have been done by a large incision. These are gynecologists who were not trained to perform advanced laparoscopic procedures. With the "buzz" around robotic surgery, hospitals have had a difficult time understanding the appropriate use of the robotic system. From which procedures to allow to appropriate training of the surgeons, hospital systems are wading through new waters to provide a better service while assuring that patient safety and economic sensibility is maintained. Many published studies have shown that robotic hysterectomy is more expensive to the healthcare system than laparoscopic or open, abdominal, hysterectomy. These studies include the purchase price or depreciation of the robotic system for each surgery performed. In most cases, the additional amount applied to surgical cost is around $2500 per surgery. The major flaw with this approach to calculating cost of robotic surgery is that any hospital that commits to a robotic prostate program has to purchase the system. The cost of the system and the annual maintenance are fixed costs that are required if only one type of procedure is done. Allowing hysterectomy to be performed robotically, does not increase the cost that hospitals have already committed to a robotics program. In fact, at one of the hospitals I practice, we did an internal cost analysis of robotic hysterectomy compared to regular laparoscopic and abdominal hysterectomy. We were surprised to find out that the robotic approach was actually the least expensive for total hospital cost of the surgery. The cost of robotic hysterectomy is close to that of laparoscopic and is significantly less than that of abdominal or open. As each day passes patients are becoming more aware that regular "open" surgery really is a thing of the past. Most abdominal surgeries can be done and should be done in a less invasive way. New surgeons are constantly being trained as they see their patients seek out providers who can offer a less invasive treatment. Patients should understand that they have a right to find the least invasive option for treating their medical conditions. This may include robotic or laparoscopic surgery or, often, treatment with medicine that doesn't require surgery. If surgery is chosen, surgeon experience and outcomes are the two most important aspects to a safe surgery with expected outcomes. There is a large myth that robotic surgery is too costly and dangerous to use for more routine surgeries. The overall cost to the healthcare system is not increased, at least in my practice. The safety of robotic surgery depends on those aspects that the safety of any surgery depends on: surgeon experience, proven techniques, experienced operative team, appropriate decision-making and educated patients.

Uterine Fibroids

Over the past few months I have seen a higher number of patients with uterine fibroids. Over the course of my practice and fellowship, I have treated one fibroid that reached a patient's liver. I recently removed 4 fibroids from a patient who still desired the possibility of having children in the future. Fibroid surgeries can be difficult, but there are many benefits that laparoscopy and robotics offer.

Uterine Fibroids or "leiomyomas" are growths of uterine muscle that often form in a circular or ball shape. They can be small or very large. On patient may have a single fibroid or many within the uterus. Honestly, most patients with fibroids don't have any symptoms. They are often diagnosed during a yearly exam when the uterus seems larger than normal or has an irregular or "bumpy" shape to it.

When fibroids do cause symptoms, some of the common ones are heavy bleeding with periods, a fulness or pressure feeling, or feeling a hard mass or ball in the low belly. Fibroids that are located deep inside the uterus next to the internal lining or cavity are the most likely to cause abnormal bleeding. Some fibroids ban be in the middle of the uterine muscle and some can be on the outside of the uterus almost like they are "attached" to the uterus. These latter two types are ones that can cause the pressure or fulness feelings when they become large or if there are multiple fibroids. The symptoms are mostly due to the bulk or size of the uterus with the fibroids. Occasionally fibroids can become painful if they outgrow their hormone or blood supply. When this happens, the inner cells start to die and pain results. This is more common during pregnancy when fibroids tend to increase rapidly in size.

Fibroid tumors are generally benign or non-cancerous. There are rare types that are cancerous but these are usually present less than 0.1% of the time. Concerning features are very large fibroids or very rapid increase in size outside of pregnancy. Also menopausal patients with an enlarging fibroid should be evaluated for the cancerous type of fibroid.

There are many options for treatment. Often the most appropriate option is observation. As fibroids are generally benign, they do not need to be treated or removed just because they are there. If there are no symptoms, it is often appropriate to check them with a periodic ultrasound and examination. When fibroids need to be treated there are a few options.

Uterine artery embolization (EUA) is a radiology procedure where the blood vessels that feed the fibroids are closed off with small particles or gel. This causes the fibroids to die and shrink down. It does not make the fibroids go away, but can decrease their size and symptoms. Care must be taken with this approach in patients who are not done with child bearing as there have been reports of the ovarian blood supply being cut off as well.

Gynecologists often treat fibroids by removing them. This is called myomectomy. Fibroids that are in the muscle portion of the uterus or toward the outside can be removed by making a cut in the uterus over the fibroid then removing the fibroid and sewing the uterus closed. This is a surgery that very often can be done without a large incision on the abdomen, just like most of the procedures I have discussed on this blog. Laparoscopy and robotic assisted laparoscopy can be a great way to manage symptomatic fibroids. This allows all the benefits of laparoscopy and often patients will be able to go home the same day. This is one of the most challenging laparoscopic procedures and care must be taken to not damage the uterus too much and to use appropriate care and skill when stitching the uterine incisions after removing the fibroids.

Many fibroids are treated by hysterectomy. In patients with symptomatic fibroids who are done having children, this probably a more logical option. Hysterectomy is less risky than myomectomy and has lower complications and blood loss. Again, most hysterectomies can be completed without a large incision on the abdomen. This can be done with laparoscopy or robotics or at times with a small 3-5 cm incision on the low belly when fibroids are very, very large.

GNRH Agonists such as Lupron can be used to shrink the fibroids prior to surgery. In my experience this makes a laparoscopic or robotic approach more difficult. GNRH agonists cause fibroids to shrink but also makes them mushy and hard to grasp during laparoscopy.

A less common approach is to isolate the uterine arteries laparoscopically and tie them off. The uterus itself continues to get blood supply from extra flow through their connection with the ovaries, but the decrease in blood supply to the fibroids causes fibroid cells to die and the fibroid to shrink down.