Four studies compared robotic myomectomy with either laparoscopic or open techniques. Two included open cohorts,5,6
two included laparoscopy,6,7
and one was a meta-analysis that compared all three techniques.8
Two studies summed up their experience in robotic myomectomy, one of which underlining the size of the myoma as the main focus of the study,9 and the other consisting of a more general overview of the surgery and its results.10
One retrospective study reported on the fertility outcome in a cohort of women treated by robotic myomectomy.11
Operative times were similar in the robotic and the laparoscopic myomectomy groups.6–8 Open myomectomy was much less time-consuming compared to robotic myomectomy (126–138.6 min versus 181–192.3 min, P<0.001).5,6
Regarding blood loss during surgery, Bedient et al.7 found a statistically significant advantage in favor of the robotic myomectomy group (100 mL versus 250 mL, P=0.02), an advantage that was not observed by Barakat et al.6 (100 mL versus 150 mL, P=0.08). In comparison to the open myomectomy group, estimated blood loss was significantly lower in the robotic myomectomy group (100–200 mL versus 100–437.5 mL).6
Length of post-surgical hospitalization was similar in the two groups according to Bedient et al.7 When compared to open myomectomy, Ascher-Walsh et al.5 and Barakat et al.6 found that length of post-surgical hospitalization was shorter with robotic myomectomy (0.51 day versus 3.28 days, P<0.001; and 1 day versus 3 days, P<0.001, respectively).
The afore-mentioned meta-analysis8 included eight studies that compared robotic and laparoscopic myomectomy and nine studies that compared robotic and open myomectomy. In total, 2,027 patients were included. Robotic myomectomy proved to be significantly inferior regarding operative time (85 min in the open myomectomy group), but proved its superiority in terms of estimated blood loss (93 mL in the robotic myomectomy group), the need for transfusion (981 patients in the open myomectomy group), total complications (1,101 patients in the open myomectomy group), and length of post-surgical hospitalization (1.84 days/ patient in the robotic myomectomy group). Long-term outcomes including pain management, fertility, and pregnancy rates postoperatively in addition to recurrence rates still need to be studied.
Gunnalaet al.9 examined the feasibility of robotic myomectomy in patients with myomas larger than 9 cm, comparing them in a retrospective case–control manner with patients with myomas smaller than 9 cm. A statistically significant increase in operative time (130 min versus 92 min) and estimated blood loss (100 mLversus 25 mL) was found in the ≥9 cm group. A myoma larger than 15 cm was seen in 4.8% of the patients, and specimen weight was over 900 g in 5.3% of the patients, with little effect on clinical adverse outcomes. Patients in both groups were discharged on the day of surgery. The main conclusion was that myoma size should not be a factor taken into consideration when attempting robotic myomectomy. Also, patients undergoing robotic myomectomy may be discharged on the day of surgery.
Asmar et al.10 reported their experience with 36 robotic myomectomies performed at the Foch hospital in Paris. The median post-surgical hospitalization time was 3.29 days. Post-surgical anemia (hemoglobin measured 9.5–10.5 g/dL) due to excessive blood loss was detected in 19.5% of the patients, none of whom required blood transfusion. Post-surgical pregnancy rates were as high as 80% among women desiring pregnancy. No surgical site infection, resistant pain, or re-hospitalization for any reason was documented among the patients.
Sangha et al.11 conducted a seven-year retrospective study of 310 women who had undergone myomectomy, 40% of whom desired pregnancy. Of the women desiring pregnancy 40% conceived; 61% of those who conceived delivered a viable infant in their first pregnancy, 6% in their second pregnancy (2 after a miscarriage and 1 after an ectopic pregnancy). Ten percent of the women desiring pregnancy delivered a second viable infant. Surgical technique, patient age or race, number of uterine incisions, and endometrial cavity invasion had no effect on the occurrence or outcome of pregnancy. Thus, myomectomy performed to preserve fertility resulted in approximately 25% live births, independent of surgical technique.
In conclusion of this section, robotic myomectomy is superior to laparoscopic and open myomectomy in terms of morbidity rates, esthetic results, adhesions, recovery, surgical accessibility (when compared to laparoscopic and not open surgery), and quality of sutures (when compared to laparoscopic and not open surgery, though there are insufficient data regarding uterine rupture during sequential pregnancies). Robotic myomectomy has the same effect on fertility compared to laparoscopic and open myomectomy. Robotic myomectomy is extremely expensive compared to the other surgical approaches, a fact restraining its access. Ultimately, randomized clinical trials (RCTs) are urgently needed to support the influx of data regarding the advantages of robotic surgery.
Hysterectomy for Benign Indications
Six studies compared robotic hysterectomy for benign indications with either laparoscopic, abdominal, or vaginal techniques; two studies included either open or vaginal techniques,12,13
and all of them included laparoscopy.12–17
Five of the comparative studies were retrospective,12–14,16,17
and one was a randomized clinical trial.15
Four studies compared robotic and laparoscopic hysterectomies regarding operative times and clinical outcome. Landeen et al.12 found that there was no difference in surgical time (117.2 min versus 118.3 min). Sarlos et al.14 found that robotic surgery lasted longer than laparoscopic surgery (108.9 min versus 82.9 min, P=0.05). Swenson et al.17 also found that robotic surgery had longer operative times (2.3 h versus 2.0 h, P<0.001), though the study also took into account uterine weights, that were apparently larger in the robotic group (178.9–186.3 g versus 160.5–190 g, P=0.007). In the study by Moawad et al.16 there was a bias in the form of a higher body mass index (BMI) (32.9±6.5 versus 30.4±7.1, P=0.012) and more frequent history of adnexal surgery (12.9% versus 4.2%, P=0.031) in the robotic surgery group, while the laparoscopic group had a more frequent history of salpingectomy (81% versus 66.3%, P=0.02). Interestingly, although maybe due to the bias, laparoscopic hysterectomies had longer operative time, adding 47 min (31–63 min, P=0.001).
Swenson et al.17 found that the rate of post-surgical complications was lower in the robotic surgery group (3.5% versus 5.6%, P=0.01), including lower rates of surgical site infection (0.07% versus 0.7%, P=0.01) and need for blood transfusion (0.8% versus 1.9%, P=0.02). Major post-surgical complications such as intraoperative bowel and bladder injury, readmissions, and the need for reoperations were similar between groups. Thus, robotic hysterectomy did not decrease major morbidity following hysterectomy for benign indications when compared to laparoscopic hysterectomy. Though total complications were lower, in the absence of substantial reductions in clinically and financially burdensome complications, it seems that hysterectomy for benign indications via robotic technique is not clinically superior or cost-effective.
Estimated blood loss and length of post-surgical hospitalization were reduced with robotic hysterectomy in three out of four studies (P<0.0001). Only Moawad et al.16 found that estimated blood loss was the same with both techniques.
Two retrospective studies conducted by Landeen et al.12 and Matthews et al.13 compared robotic and open hysterectomy. Landeen et al.12 found that robotic hysterectomy required longer operative time (117.2 min versus 83.7 min, P<0.001). Both studies found in the robotic hysterectomy a 2- to 4-fold reduction in estimated blood loss (82.3 mL versus 430 mL, P<0.001; and 109.3 mL versus 269.8 mL, P=0.001), and a 50% reduction in length of post-surgical hospitalization (1.5 days versus 3.5 days, P=0.001; and 1.3 days versus 2.7 days, P<0.001).
The only RCT comparing robotic versus laparoscopic hysterectomy for benign indications so far was conducted by Deimling et al.15 Seventy-two patients were randomized to each surgical arm. Mean operative time was the same in both surgical groups: 73.9 min (median 67.0 min; interquartile range 59.0–83.0 min) in the robotic hysterectomy group, and 74.9 min (median 65.5 min; interquartile range 57.0–90.5 min) in the laparoscopic hysterectomy group. The study concluded that when performed by a surgeon experienced in the chosen technique, robotic hysterectomy was non-inferior, in terms of operative time, to laparoscopic hysterectomy.
Six studies compared robotic sacrocolpopexy (SCX) to either laparoscopic,18–20
approaches; two studies were RCTs,18,22
and two were cost-effectiveness tests.20,23
Two case series concerned robotic SCX, one of which summarized cases regarding robotic SCX for the treatment of vaginal vault prolapse,24 the other reporting on cases regarding a new approach in robotic SCX, the single-port approach.25
One study evaluated the impact of obesity on robotic SCX.26
Paraiso et al.18 conducted a RCT in which 35 women had undergone robotic SCX and 33 women had undergone laparoscopic SCX. In the laparoscopic SCX group, total operating room time was shorter (199 min versus 265 min, P<0.001): shorter SCX time (162 min versus 227 min, P<0.001) and shorter SCX suturing time (68 min versus 98 min, P<0.001). Post-surgical hospitalization was similar in the two groups (43 h versus 34 h, P=0.17).
Two studies19,21 retrospectively compared laparoscopic and robotic SCX. Estimated blood loss was lower in the robotic SCX group in both studies (P<0.0001). Awad et al.19 found that mean operative times did not differ significantly (176 min [110–380] versus 186 min [105–345], P=0.34); however, Geller et al.21 found that robotic SCX had longer operative times (328 min versus 105 min, P<0.001). In both studies, mean post-surgical hospitalization was shorter for the robotic group (P<0.0001). There were no significant adverse events in either group.
Two cost-effectiveness studies20,23 were performed to compare robotic and open SCX. Judd et al.20 compared robotic, laparoscopic, and open SCX approaches and found that the robotic approach was the most expensive one. Elliott et al.23 found that open SCX was less expensive than robotic SCX, possibly due to differences such as inclusion of hysterectomy, longer operating time, and higher cost of disposable instruments.
Westermann et al.22 conducted a RCT that compared perioperative pain and recovery on post-operative day 1, and at 2 and 6 weeks post-surgery, between women who had undergone vaginal hysterectomy with uterosacral ligament suspension (USLS) and robotic SCX. Each group included 39 women. In the robotic SCX group patients had lower nursing verbal pain scores (P=0.04), less narcotic consumption (P=0.02), and lower estimated blood loss (P=0.01). Operating time was longer in the robotic group (P<0.001). At 2 and 6 weeks post-surgery, there were no significant differences between the two groups. The investigators concluded that both approaches had similar quality-of-life scores after surgery. The robotic approach is associated with less pain and less narcotic use post-surgery.
Pellegrino et al.24 retrospectively evaluated the feasibility and clinical outcomes of robotic SCX for the treatment of vaginal vault prolapse in 31 consecutive cases. Mean follow-up time was 27 months (range 2–48). Average total operative time was 185 min (range 170–235). Estimated blood loss was 50 mL (range 30–150). Except for one case of cystotomy, no other intraoperative complications occurred. Successful outcome was reported in 94% of the patients.
Kissane et al.25 retrospectively compared operative times of robotic SCX across a range of BMI values. They compared 179 women, 61 (34%) of whom were normal weight (BMI 25 kg/m2), 72 (40%) of whom were overweight (BMI 25–30 kg/m2), and 46 (26%) of whom were obese (BMI 30+ kg/m2). Overweight patients were significantly older, more parous, more frequently postmenopausal, and more frequently had undergone concomitant salpingo-oophorectomy. Median operative time was 202, 206, and 216 min, respectively (P=0.53).
Robotic Single-port SCX
Matanes et al.26
reviewed a state-of-the-art robotic surgical technique, single-port SCX, during which the surgeon operated almost exclusively through a single entry point, leaving only a single small scar. The investigators’ aims were to evaluate the new technique’s learning curve and, in addition, to share tips for improved single-port robotic SCX based on the first 25 patients to have undergone single-port robotic SCX. Median age was 59 years (range 35–74). Median “pelvic organ prolapse quantification” stage was 3 (range 2–4). Median total operative time was 190 min (range 114–308). Median console time was 130 min (range 85–261). A comparison between the first 15 cases and the next 10 cases demonstrated significant reductions in median operative times and console times: 226 min (range 142–308) versus 156 min (range 114–180), and 170 min (range, 85–261) versus 115 min (range 90–270), respectively (P
<0.008). No intraoperative adverse events occurred in any of the cases. Postoperative adverse events were extremely rare and included one case of small-bowel adhesions that required a second laparoscopic surgery for adhesiolysis and led to the addition of mesh peritonization in all the successive cases; median peritonization time was 8 min (range 5–15 min). The investigators concluded that single-port robotic SCX was a feasible technique with lower complication rates, minimal blood loss and postsurgical pain, faster recovery, shorter post-surgical hospitalization, and virtually scar-free results.
Chen et al.27
conducted a meta-analysis meant to evaluate the safety and efficacy of robotic versus laparoscopic surgery for the treatment of advanced-stage endometriosis. Due to lack of suitable clinical trials only two studies were included. No significant differences were observed between the two groups in terms of estimated blood loss, complication rate, and post-surgical hospitalization. Mean operative time in the robotic surgery group was longer (73.85 min, P
<0.00001). Thus, the benefits of robotic surgery over laparoscopic surgery in the treatment of advanced-stage endometriosis remain uncertain.
Conversion from Robotic Approach to Other Approaches
Unger et al.28
attempted retrospectively to determine the incidence of, and risk factors for, conversion from robotic procedures to other surgical techniques. Patients’ demographic and perioperative data were retrieved, in addition to surgeon experience based upon monthly case volume. During the period reviewed 942 robotic procedures were performed. Conversion from robotic to any other surgical technique was recorded for 47 procedures (5.0%), of which 16 (1.7%) were conversions to open surgery. Conversion from robotic surgery to another surgical technique was associated with higher BMI (P
=0.001), previous laparotomy (P
=0.042), and poor surgeon experience (P
=0.011). Asthma (P
=0.008), intraoperative bowel injury (P
<0.001), intraoperative vascular injury (P
=0.003), and single-port robotic surgery (P
=0.034) were associated with increased odds for conversion.