Robotic Versus Laparoscopic Hysterectomy for Benign Disease: A Systematic Review and Meta-Analysis of Randomized Trials

Abstract

We conducted a systematic review and meta-analysis to assess the safety and effectiveness of robotic versus laparoscopic hysterectomy in women with benign uterine disease, as determined by randomized studies. We searched MEDLINE, EMBASE, the Cochrane Library, ClinicalTrials.gov, and Controlled-Trials.com from inception to October 9th, 2014, using the intersection of the themes “robotic” and “hysterectomy.” We included only randomized and quasi-randomized controlled trials of robotic versus laparoscopic hysterectomy in women for benign disease. Four trials met inclusion criteria and were included in the analyses. Data was extracted and studies were assessed for methodological quality in duplicate. For meta-analysis, we used random effects to calculate pooled risk ratios (RR) and weighted mean differences. For our primary outcome, we used a modified version of the Expanded Accordion Severity Grading System to classify perioperative complications. We identified 41 total complications among 326 patients. When comparing robotic to laparoscopic hysterectomy, we found no statistically significant differences in the rate of class 1 and 2 complications (RR=0.66, 95% Confidence Interval (CI) 0.23–1.89) or in the rate of class 3 and 4 complications (RR=0.99, 95%CI 0.22–4.40). Analyses of secondary outcomes were limited due to heterogeneity, but showed no significant benefit of robotic compared to laparoscopic technique in terms of length of hospital stay (weighted mean difference= −0.39 days, 95%CI −0.92–0.14), total operating time (weighted mean difference=9.0 minutes, 95%CI −31.27–47.26), conversions to laparotomy, or blood loss. Outcomes of cost, pain, and quality of life were inconsistently reported and not amenable to pooling. Current evidence demonstrates neither statistically significant, nor clinically meaningful differences in surgical outcomes between robotic and laparoscopic hysterectomy for benign disease. The role of robotic surgery in benign gynecology remains unclear.

Pedagogic Approach in the Surgical Learning: The First Period of “Assistant Surgeon” May Improve the Learning Curve for Laparoscopic Robotic-Assisted Hysterectomy

“…The demographics of our population were similar to the literature as it was reported by Albright et al (21). This meta-analysis only reported one count lower of patient with previous abdominal surgery (40–90% for Albright et al) that it could explain the difference in terms of complication that those described in our cohort (21).…”

Comparison of robotic and other minimally invasive routes of hysterectomy for benign indications

“…5 Albright et al recently performed a systematic review and meta-analysis of randomized trials comparing the same groups and also found similar rates of mild, moderate, and severe complications. 7 Although our analysis does show a statistically significant reduction in blood transfusion and superficial SSI rates with the robotic-assisted route compared to other MIS routes, these complications were rare and the difference may not be clinically significant. Furthermore, when a sub-analysis was performed between the specific MIS routes, increased rates of blood transfusion in the laparoscopic group appeared to be driving the overall difference compared to robotic hysterectomies.…”

“…While the decrease in abdominal hysterectomy rates seen over this same time period is indeed a positive trend, 1,2 the superiority of the robotic-assisted route over other minimally-invasive surgical (MIS) routes for benign hysterectomy has yet to be proven. 3–7 Although cited benefits of the robotic-assisted route over conventional laparoscopy include lower estimated blood loss and shorter length of stay, complication rates appear to be similar and costs significantly higher with robotic technology. 4,8–12 Vaginal hysterectomy remains the preferred route when possible and is recommended as such by the American Congress of Obstetricians and Gynecologists.…”

6: Comparison of robotic and other minimally-invasive routes of hysterectomy for benign indications

“…5 Albright et al recently performed a systematic review and metaanalysis of randomized trials comparing the same groups and also found similar rates of mild, moderate, and severe complications. 7 Although our analysis does show a statistically significant reduction in blood transfusion and superficial SSI rates with the robotic-assisted route compared to other MIS routes, these complications were rare and the difference may not be clinically significant. Furthermore, when a sub-analysis was performed between the specific MIS routes, increased rates of blood transfusion in the laparoscopic group appeared to be driving the overall difference compared to robotic hysterectomies.…”

“…While the decrease in abdominal hysterectomy rates seen over this same time period is indeed a positive trend, 1,2 the superiority of the robotic-assisted route over other minimally-invasive surgical (MIS) routes for benign hysterectomy has yet to be proven. [3][4][5][6][7] Although cited benefits of the robotic-assisted route over conventional laparoscopy include lower estimated blood loss and shorter length of stay, complication rates appear to be similar and costs significantly higher with robotic technology. 4,[8][9][10][11][12] Vaginal hysterectomy remains the preferred route when possible and is recommended as such by the American Congress of Obstetricians and Gynecologists.…”