机器人辅助子宫切除术的应用显著增加

《美国医学会杂志》(JAMA)2月20日发表的一项研究显示，自问世以来，机器人手术平台在子宫切除术中的应用显著增加，目前美国所有的子宫切除术中有近10%是通过机器人手术平台完成。在美国进行机器人辅助子宫切除术的医院中，该类手术在3年内占到了子宫切除术的20%以上。然而，机器人辅助子宫切除术并不比腹腔镜子宫切除术有效，而且两者的围手术期发病率相似。此外，机器人辅助子宫切除术的费用比任何其他子宫切除术明显更高(JAMA 2013;309:689-98)。

Jason Wright博士

在这项人群分析中，纽约哥伦比亚大学的Jason D. Wright博士及其同事采用Perspective国家数据库的数据，对机器人辅助子宫切除术的应用情况进行了评估。分析对象是2007~2010年441家医院进行的264,758例治疗良性疾病的子宫切除术，包括123,288例经腹子宫切除术，54,912例经阴道子宫切除术，75,761例腹腔镜子宫切除术和10,797例机器人辅助子宫切除术。

结果显示，2007年第一季度，经阴道子宫切除术病例在所有手术病例中占的比例为21.7%，2010年第一季度降至19.8%。同样，经腹子宫切除手术率从53.6%降至40.1%。相比之下，腹腔镜子宫切除手术病例在2007年第一季度占所有手术病例的24.3%，2010年第一季度升至30.5%。机器人辅助子宫切除手术率从0.5%增至9.5%，增幅最大。

研究者通过比较腹腔镜子宫切除术组和机器人辅助子宫切除术组的并发症发生率发现，两组未校正的总并发症发生率非常相似(5.3% vs. 5.5%)；术中并发症(2.4% vs. 2.5%)、手术部位并发症(2.0% vs. 1.7%)、内科并发症(1.2% vs. 1.6%)、输血(1.8% vs. 1.4%)、再次手术(两组均为0.1%)、非常规出院(0.3% vs. 0.2%)和医院死亡率(两组均为0%)的发生率也相似。

然而，腹腔镜子宫切除术的中位费用为6,679美元，而机器人辅助子宫切除术为8,868美元。在排除机器人平台的固定成本而仅对可变费用进行分析后仍发现，机器人辅助子宫切除术是最昂贵的子宫切除术类型。曾有学者假设，如果完全用机器人辅助子宫切除术代替常规手术，医疗费用将增加25亿美元以上。

机器人妇科手术迅速增加的原因尚不清楚，可能与下列因素有关：由于机器人手术更类似于传统开放手术，因此比腹腔镜手术更易于学习。此外，在机器人辅助下，外科医生可进行技术上要求更高的手术。对于机器人手术的宣传和营销也是重要因素。

该分析的局限性在于，数据集未包括一些可能影响特定手术方法的选择的重要因素，如患者的体重指数、手术史及估计子宫重量。

该研究的资金部分来自美国国立癌症研究所。研究者声明无经济利益冲突。

随刊述评：费用差别大

布里格姆妇女医院外科与公共卫生中心的Joel S. Weissman博士和Michael Zinner博士评论指出，机器人辅助子宫切除术的费用显著高于所有其他手术，每例需多花2,000美元，因此并无明显优势。从目前的报销政策来看，不论是否采用机器人辅助，腹腔镜手术的偿付金额是相同的。(JAMA 2013;309:721-2)

Weissman博士声明从美国国家药物委员会获得研究资金，Zinner博士声明无经济利益冲突。

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By: MARY ANN MOON

The use of a robotic surgical platform to perform hysterectomy for benign disease has increased substantially since its introduction and now accounts for nearly 10% of all hysterectomies nationwide, according to a report in the Feb. 20 issue of JAMA.

At hospitals across the United States where robotically assisted hysterectomy is performed, the procedure has shown notably rapid uptake: Within 3 years it accounted for more than 20% of hysterectomies, said Dr. Jason D. Wright of Columbia University, New York, and his associates.
 
However, robotically assisted hysterectomy is no more effective than laparoscopic hysterectomy, and it has a similar perioperative morbidity profile. But it is markedly more expensive than any other modality of hysterectomy. "Our study indicates ... the robotic procedure offers little short-term benefit and is accompanied by significantly greater costs," the investigators wrote.

Dr. Wright and his colleagues performed a population-based analysis of the diffusion of robotically assisted hysterectomy using information from the Perspective national database, which measures resource utilization and quality. They focused on 264,758 hysterectomies for benign indications done at 441 hospitals in 2007-2010.

This included 123,288 abdominal hysterectomies, 54,912 vaginal hysterectomies, 75,761 laparoscopic hysterectomies, and 10,797 robotically assisted hysterectomies.

The rate of vaginal hysterectomy declined during the study period from 21.7% of all procedures in the first quarter of 2007 to 19.8% in the first quarter of 2010. Similarly, the rate of abdominal hysterectomy declined from 53.6% to 40.1%.

In contrast, the rate of laparoscopic hysterectomy increased during that time period, from 24.3% of all procedures in the first quarter of 2007 to 30.5% in the first quarter of 2010.

The rate of robotically assisted hysterectomy increased the most, from 0.5% to 9.5%, the investigators reported (JAMA 2013;309:689-98).

They compared complication rates between laparoscopic and robotically assisted hysterectomies, and found that the unadjusted rates of overall complications were very similar, at 5.3% and 5.5%, respectively. Also similar were the rates of intraoperative complications (2.4% vs. 2.5%), surgical site complications (2.0% vs. 1.7%), medical complications (1.2% vs. 1.6%), transfusion (1.8% vs. 1.4%), reoperation (0.1% in both groups), nonroutine hospital discharge (0.3% vs. 0.2%), and hospital mortality (0% in both groups).

However, the median cost for laparoscopic hysterectomy was $6,679, compared with $8,868 for robotically assisted hysterectomy. "Even when we excluded the fixed cost of the robotic platform and examined only variable costs, we noted that robotic hysterectomy remained the most costly modality for hysterectomy," Dr. Wright and his associates wrote (JAMA 2013;309:689-98).

Other researchers have posited that if robotically assisted hysterectomy replaced conventional surgery, health care costs would increase by more than $2.5 billion, Dr. Wright and his colleagues added.

Findings of the current investigation "highlight the importance of developing rational strategies to implement new surgical technologies," they said.

The reasons for the rapid uptake of robotic gynecologic surgery are not yet known, but several factors likely contributed. Robotic surgery may be easier to learn than laparoscopy "because it is more analogous to traditional open surgery." Also, robotic assistance may permit surgeons to perform "more technically demanding cases that would otherwise have required laparotomy," the investigators said.

And importantly, "robotic surgery has been the subject of extensive marketing, not only to surgeons and hospitals, but also to medical consumers," Dr. Wright and his colleagues noted.

They added that their analysis was limited because the data set didn’t include several important factors that likely influenced the selection of a given surgical approach, such as the patient’s body mass index and surgical history, as well as the estimated weight of the uterus.

This study was funded in part by the National Cancer Institute. No financial conflicts of interest were reported.

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Stark contrast in costs

Joel S. Weissman, Ph.D., and Dr. Michael Zinner comment: The "stark" contrast in costs between robotically assisted hysterectomy and all other approaches – $2,000 more per case, or nearly one-third of the total cost – comes without any significant advantage in clinical outcomes, said Joel S. Weissman, Ph.D., and Dr. Michael Zinner.

"Would it be a better use of resources to train more surgeons in laparoscopic techniques than to spend the money on more robot machines?" they asked.

"As reimbursement policies stand today, payments for laparoscopic surgery are the same whether or not the procedures are robotically assisted. Therefore, neither patients, physicians, nor hospitals have the motivation to pursue the less expensive option," Dr. Weissman and Dr. Zinner wrote.

Dr. Weissman is at the center for surgery and public health and the patient-centered comparative effectiveness research center at Brigham and Women’s Hospital, Boston. Dr. Zinner is also at Brigham and Women’s Hospital. They reported no potential financial conflicts of interest, except that Dr. Weissman has received a research grant from the National Pharmaceutical Council. These remarks were taken from their editorial accompanying Dr. Wright’s report (JAMA 2013;309:721-2).