Elsevier

Gynecologic Oncology

Volume 111, Issue 3, December 2008, Pages 407-411
Gynecologic Oncology

Comparison of outcomes and cost for endometrial cancer staging via traditional laparotomy, standard laparoscopy and robotic techniques

https://doi.org/10.1016/j.ygyno.2008.08.022Get rights and content

Abstract

Objectives

The study purpose was to compare hysterectomy and lymphadenectomy completed via robotic assistance, laparotomy, and laparoscopy for endometrial cancer staging with respect to operative and peri-operative outcomes, complications, adequacy of staging, and cost.

Methods

One hundred and ten patients underwent hysterectomy with bilateral salpingo-oophorectomy, pelvic and para-aortic lymphadenectomy for endometrial cancer staging. All cases were performed by a single surgeon, at a single institution (40 robotic, 40 laparotomy, and 30 laparoscopic) and were retrospectively reviewed to compare demographics and peri-operative variables including, operative time, estimated blood loss, lymph node count, hospital stay, complications, and return to normal activity. Additionally, a cost comparison between all three modalities was performed.

Results

Patients undergoing robotic assisted hysterectomy and staging experienced longer operative time than the laparotomy cohort with no difference in comparison to the laparoscopic cohort (184 min, 108.6 min, 171 min, p < 0.0001, p = 0.14). Estimated blood loss was significantly reduced for the robotic cohort in comparison to the laparotomy cohort and comparable to laparoscopic cohort (166 cc, 316 cc, 253 cc, p = 0.01, p = 0.25). The complication rate was lowest in the robotic cohort (7.5%) relative to the laparotomy (27.5%) and laparoscopic cohorts (20%) (p = 0.015, p = 0.03). Average return to normal activity for the robotic patients was significantly shorter than those undergoing laparotomy (24.1 days versus 52 days, p < 0.0001) and those undergoing laparoscopy (31.6 days, p = 0.005). Lymph node retrieval did not differ between the 3 groups (robotic 17 nodes, laparotomy 14 nodes, laparoscopic 17 nodes). The total average cost for hysterectomy with staging completed via laparotomy was $12,943.60, for standard laparoscopy $7569.80, and for robotic assistance $8212.00. The difference in cost between laparotomy and robotic cohorts was significant p = 0.0001 while there was no statistically significant difference in cost between laparoscopy and robotic cohorts p = 0.06.

Conclusions

Robotic hysterectomy provides comparable node retrieval to laparotomy and laparoscopic procedures in the case of the experienced laparoscopic surgeon. While robotic hysterectomy takes longer to perform than hysterectomy completed via laparotomy, it is equivalent to laparoscopic hysterectomy and provides the patient with a more expeditious return to normal activity with reduced post-operative morbidity. Additionally, the average cost for hysterectomy and staging was highest for laparotomy, followed by robotic, and least for standard laparoscopy.

Introduction

Surgical staging for endometrial cancer is considered the standard of care. Surgical approach can vary from traditional laparotomy, standard laparoscopy, and the newest surgical approach — robotic total laparoscopic hysterectomy with staging. Robotic gynecologic surgery has been FDA approved since March 2005, and several investigators have switched to the robotic approach. The advantage of robotic surgery is that it restores the 3 dimensional approach to surgery that is lost with laparoscopy while maintaining the minimally invasive approach. Additionally, robotic instruments articulate with 6 degrees of freedom, thus allowing the surgeon to more readily suture and perform difficult dissections. Critics of robotic surgery are quick to discuss the time factor for learning and performing robotic surgery and the cost of robotic surgery. This retrospective review analyzes all endometrial cancer staging procedures performed by a single surgeon at a single institution via traditional laparotomy, standard laparoscopy, and robotic surgery.

Section snippets

Methods

A retrospective chart review was performed on all endometrial cancer staging procedures done by a single board certified gynecologic oncologist at a single institution. The practice of this surgeon is a private practice without ob/gyn residents. The dates of accrual for patients were from May 2000 to June 2007. During the study period, the surgeon started performing standard laparoscopic hysterectomies with nodes in 2003, and robotic hysterectomies with nodes in 2005. Once the surgeon started

Results

The demographic data indicate that women who underwent laparotomy were oldest with a mean age of 72.3 years. This was significantly higher than the mean age of women who underwent standard laparoscopy (mean age 68.4 years), and women who underwent robotic staging (mean age of 63.0 years). The body mass index was highest for women who underwent robotic staging with a mean BMI of 33.0, but this was not statistically different from the laparoscopic group with an average BMI of 31.9, and the

Discussion

The conversion to minimally invasive surgery for endometrial cancer has increased in the field of gynecologic oncology. Barakat et al. published their analysis of the technique used for endometrial cancer. They found that there was an increase in the use of laparoscopy for staging between 1995–2004 [2]. Likewise, Naumann et al. surveyed the Society of Gynecologic Oncologists and found that about 50% of gynecologic oncologists utilize laparoscopy for endometrial cancer staging [3]. As robotic

Complications

Our data indicate that the peri-operative complications are significantly higher for laparotomy procedures than compared to robotic surgery. Furthermore, robotic surgery had resulted in fewer complications than standard laparoscopy. This is similar to other investigators. Frigerio et al. compared laparoscopic assisted hysterectomy with staging to laparotomy and found fewer post-operative complications in the Laparoscopic Assisted Vaginal Hysterectomy group (6 vs. 11 cases; p < 0.001) [4].

Length of stay

Our data, like others, demonstrate a significant decrease in hospital stay for both standard laparoscopy and robotic cases compared to laparotomy. Frigerio et al. demonstrated a shorter hospital stay for laparoscopic assisted surgery compared to laparotomy (4 vs. 8.5 days; p < 0.001) [4]. Obermair found the mean post-operative hospital stay was 4.4 (+/− 3.9) days in the Total Laparoscopic Hysterectomy group and 7.9 (+/− 3.0) days in the Total Abdominal Hysterectomy group (P < 0.0001) [7].

Cost

Certainly, the length of stay is directly related to the cost, and length of stay is the driving force behind the increased cost of laparotomy. Actual cost to the institution is difficult to obtain. Charges are more readily obtainable and should reflect the cost but may not. In our data, both charge data and cost data rank laparotomy as the most expensive modality followed by robotic and laparoscopy. The validity of charge comparisons, however, depends upon the charge structure of the health

Conflicts of interest statement

The authors have no conflicts of interest to declare.

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