DISCUSSION
Main findings
Robotic gynaecological surgery was sporadically used in England between
in 2006 and 2010. Since then, there has been a steady increase in its
uptake, especially for hysterectomies and adnexal surgeries. However,
there was wide regional variation with only about half of the English
NHS hospitals being involved. Robotic assistance was used in 1152
procedures between 1st April 2017 and
31st March 2018 to carry out hysterectomy, adnexal and
urogynaecological surgery which constituted 2.6% of the total number of
these procedures carried out in the English NHS 16.
Strengths:
To our knowledge this is the first study of the uptake of robotic
gynaecological surgery in the whole of English NHS since 2006, following
the FDA approval of da Vinci surgical system for use in gynaecology
(2005) up to March 2018. Our population included over half a million
patient undergoing elective gynaecological procedures.
HES data is subject to rigorous quality assurance processes and its use
in research had been validated 17-19. Using national
hospital data, we underwent a comprehensive review of both benign and
malignant gynaecological hysterectomy/ adnexal surgery cases as well as
urogynaecological procedures approached abdominally. It has been argued
that independent evaluation of robotic surgery is challenging as it is
an “operator-dependent expensive technology” 6.
However, our results derived from national administrative data from NHS
hospitals that provide 95% of inpatient care in England are independent
of both surgeons and the industry 20.
Limitations:
Our study was limited by its retrospective nature and we could only
examine outcomes available in HES data.
Interpretation in light of other
evidence:
The upward trend in the use of robotic gynaecological surgery in England
is in line with the results observed elsewhere and in other specialties.
Wright and colleagues demonstrated a rise in the total number of robotic
procedures in the United States (US) from ~ 21,000 to
34,000 between 2009 and 2012 with 4.5 fold increase in robotic general
surgical procedures during the same period 21.
Similarly, Stewart et al studied a US population of ~
150,000 general surgical oncology patients between 2010 and 2014, and
showed 5-fold increase in the number of robotic procedures during the
study period, which was significantly larger than the increase in
laparoscopic (1.1-fold) and open (1.2-fold)
procedures22. Damle et al studied diffusion trends of
robotic colorectal procedures in the US (2011-2015) and demonstrated
increase in robotic procedure numbers (from 2.6% to 6.6% of total
procedures), centres offering them (from 105 to 140) as well as
significant increase patient complexity23. Papalekas
and colleagues studied routes of hysterectomy done for both benign and
malignant conditions for over 5000 patients at a community and a
teaching hospital in the US between 2010 and 2014, and demonstrated a
60% and 20% increase in the robotic approach at those hospitals
respectively24.
Marcus et al compared diffusion trends of robotic prostatectomy, partial
nephrectomy and hysterectomy in the UK using HES data between 2006 and
2014. They concluded that diffusion of these procedures was rapid,
moderate and slow respectively, attributing this to institutional,
surgeon and patient specific factors25. This agrees
with our findings that the proportion of elective robotic gynaecological
procedures took over a decade to rise from negligible levels to 2.6% of
total number of procedures studied.
Mapping robotic procedure numbers to geographical English regions
suggest clustering around areas that are likely to represent cancer
centres26. Factors related to the funding, surgical
expertise and the role of specific centres in gynaecological training
are likely to have contributed to this regional variation.
Our evidence on outcomes is very similar to the results of the most
recent Cochrane review on robotic gynaecological surgery
(2019)6. However, it is important to note that the
rate of conversion to laparotomy that we observed, which included both
intraoperative conversions to laparotomies and those after return to
theatre, was much lower than those reported in observational studies
with rates of intraoperative conversions to laparotomy ranging from 2.4
to 8.7% 27, 28.
We did not find changes in outcomes over time, in contrast to others28. The variation in median LOS for hysterectomy,
adnexal surgery and total procedures was statistically but not
clinically significant (table 1). It has to be taken into account that
we only studied a small range of outcomes and that the statistical power
to assess the impact of a ‘learning curve’ was limited.