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.