The future of robotic-assisted laparoscopic gynaecologic surgery in Australia - A time and a place for everything

Australian trends in the treatment of pelvic organ prolapse in the non-mesh era

BACKGROUND

To assess the contemporary trends in the types and incidence of pelvic organ prolapse (POP) surgery in Australia after the removal of transvaginal mesh from the Australian market.

METHODS

This was a retrospective Australian cohort study utilizing three large Governmental databases covering all private and public POP procedures in Australia. All females ≥25 years old undergoing POP procedures between 2005 and 2021 were included.

RESULTS

From 2005-2006 to 2020-2021 there have been a total of 408 881 POP procedures in Australia. The total number of procedures peaked in 2005-2006 at 537.8 procedures per 100 000 age-standardized female population, decreasing by an average of 3.5% per year to 329.0 procedures per 100 000 in 2018-2019, an overall 38.8% decrease (P < 0.001). A sudden growth in private operative procedures was noted between 2019-2020 and 2020-2021, from 218.2 to 268.6 procedures per 100 000 population, a 23.1% increase (P < 0.001). Laparoscopic and abdominal POP repair has seen a 115.8% increase from 13.7 procedures to 29.6 per 100 000 between 2005-2006 and 2020-2021. Over the last 15 years, the most common age group to undergo a procedure has changed from the 55 to 64 years demographic to a later decade of 65 to 74 years.

CONCLUSION

Over the last 15 years, the total number of POP procedures performed has significantly decreased. There has however been a recent rise in interventions seen in the private sector and the utilization of laparoscopic or abdominal POP repair has increased, which has implications for procedural credentialing to ensure patient safety.

Robotic Surgery: Advancements and Inflection Points in the Field of Gynecology

Robotics has become an essential part of the surgical armamentarium for a growing number of surgeons around the world. New companies seek to compete with established robotic systems that have dominated the market to date. Evolving robotic surgery platforms have introduced technologic and design advancements to optimize ergonomics, improve visualization, provide haptic feedback, and make systems smaller and cheaper. With the introduction of any new technology in the operating room, it is imperative that safeguards be in place to ensure its appropriate use. Current processes for granting of hospital robotic surgery privileges are inadequate and must be strengthened and standardized.

Detailed cost of robotic-assisted surgery in the Australian public health sector: from implementation to a multi-specialty caseload

Background

A barrier to the uptake of robotic-assisted surgery (RAS) continues to be the perceived high costs. A lack of detailed costing information has made it difficult for public hospitals in particular to determine whether use of the technology is justified. This study aims to provide a detailed description of the patient episode costs and the contribution of RAS specific costs for multiple specialties in the public sector.

Methods

A retrospective descriptive costing review of all RAS cases undertaken at a large public tertiary referral hospital in Sydney, Australia from August 2016 to December 2018 was completed. This included RAS cases within benign gynaecology, cardiothoracic, colorectal and urology, with the total costs described utilizing various inpatient costing data, and RAS specific implementation, maintenance and consumable costs.

Results

Of 211 RAS patients, substantial variation was found between specialties with the overall median cost per patient being $19,269 (Interquartile range (IQR): $15,445 to $32,199). The RAS specific costs were $8828 (46%) made up of fixed costs including $4691 (24%) implementation and $2290 (12%) maintenance, both of which are volume dependent; and $1848 (10%) RAS consumable costs. This was in the context of 37% robotic theatre utilisation.

Conclusions

There is considerable variation across surgical specialties for the cost of RAS. It is important to highlight the different cost components and drivers associated with a RAS program including its dependence on volume and how it fits within funding systems in the public sector.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-021-06105-z.

A laparoscopic study investigating 3D vs 2D imaging systems using a pelvitrainer model with experts, non-experts, and students

BACKGROUND

Vision is an essential element of laparoscopic surgery that defines the outcome of an operation in regards to time, mistakes and precision. A 3-dimensional (3D) perspective may improve vision during an operation. Therefore, this study was designed to compare 3D versus 2-dimensional (2D) perspectives using a pelvitrainer model.

METHODS

Fifty candidates were divided into 3 categories based on different experience levels. The candidates were randomised into two groups, with each group performing the same 4 standardised tasks. Group A approached the tasks first with 3D high definition and in a second turn with 2D high definition. Group B carried out the tasks with the systems in reverse order. Task completion time and the number of mistakes made for each task were recorded. After completing the tasks, participants answered questions concerning the two systems.

RESULTS

Group A was, on average, 20% faster at all four tasks and made approximately 18% fewer mistakes in two of the tasks in comparison to group B. The experts significantly benefited from the 3D system in terms of accuracy compared to non-experts and students. The students demonstrated a significantly greater benefit from the 3D system when performing non-linear, continuous movements. Loss of concentration occurred at the same rate for subjects using the 2D and 3D systems. Nausea and dizziness were reported only when working with the 3D system. 91% found the 3D system advantageous for accomplishing the tasks.

CONCLUSIONS

Irrespective of experience level, 3D laparoscopy shows advantages in saving time, increasing accuracy and reducing mistakes. These benefits were also accompanied by subjective advantages that were noted by the participants. However, the more complex the task, the less significant the benefit of the 3D system and some people feel handicapped by the eyewear.

Postoperative Telephone-Based Questionnaire on Quality of Life after Robotic-Assisted Laparoscopic Hysterectomy versus Conventional Total Laparoscopic Hysterectomy

Aim: The objective of the study was to evaluate the benefits of robotic-surgery for hysterectomy compared to conventional laparoscopy for benign indications. A specially prepared telephone-based questionnaire was used postoperatively. Method: All women (n = 155) undergoing total laparoscopic hysterectomy for benign indications either by the robotic-assisted procedure (RALH) or conventional laparoscopy (CL) between 1 January 2013 and 31 December 2017 at the Department of the Gynecology, University Hospitals, Campus Kiel, Germany, were eligible for analysis. Intra-operative and postoperative parameters affecting the patients’ quality of life were assessed by a telephone-based questionnaire. The latter addressed postoperative pain, limitations of basic hygiene, daily activity, active pursuit of hobbies, sexual intercourse, and days of sick leave. All patients received the questionnaire by post at least three weeks prior to being contacted on the phone. Results: 78% of the contacted patients responded to the questionnaire; 96% (n = 115) of the patients said they would recommend the operation to other patients. Both groups needed 42 days to resume their regular hobbies. In whole 90.8% (n = 108) were total satisfied with the cosmetic result of the abdominal incision; the numbers in the respective groups were 80% (80% n = 36) in RALH and 97.3% (n = 72) in CL. The difference was significant on the Chi-square test (p = 0.002). 5% (n = 7) were dissatisfied with the scar (13.3%; n = 6) in the RALH group, and 1.4% (n = 1) in CL. In all 1.7 % of patients were dissatisfied with the position of the incisions; the respective numbers were 4.4 % (n = 2) in the RALH group and no patient in the CL group. 33% of patients experienced no limitations in regard of sexual intercourse after the operation. The median number of days taken to resume sexual intercourse after the operation was 56 days in the CL group, and 49 days in the RALH group. Nearly 30% (n = 25) were hesitant to resume intercourse. The median operating time was 145 min in the RALH group, which was significantly longer than the 117 min taken in the CL group (p < 0.001). Conclusions: The RALH procedure was associated with some minor advantages for the patients according to the results, however it does not have major significant advantages, especially in regard of early restoration of sexual function, while the CL shows shorter operating times and similar limitation. Postoperative counseling of patients should be aligned to their fears and expectations in regard of sexual function.

Quality of life in patients who undergo conventional or robotic-assisted total laparoscopic hysterectomy: Protocol for a systematic review of randomized controlled trials

BACKGROUND

Hysterectomy for benign gynecologic diseases, especially dysfunctional uterine bleeding, is one of the most common gynecologic interventions. The uterus can be removed using abdominal, vaginal, laparoscopic, or robotic-assisted laparoscopic hysterectomy. In a robotic-assisted procedure, the surgeon directs the robot while seated at a console in the operating room. This differs from laparoscopic hysterectomy because a "robot" performs the operation, while the surgeon watches a monitor. This systematic review will compare quality of life (QOL) in patients who undergo total robotic-assisted laparoscopic hysterectomy for benign indications and those who undergo conventional laparoscopic surgery.

METHODS

We will perform a systematic review according to the Cochrane Methodology for randomized controlled trials. The review will include studies reporting use of QOL metrics to assess patients who undergo total hysterectomy for benign indications using robotic-assisted technique or conventional laparoscopic surgery. QOL will be the primary outcome and will be measured using validated instruments. An overall search strategy will be developed and adapted for Embase, MEDLINE, LILACS, and CENTRAL databases. Two reviewers will independently select the eligible studies, assess the risk of bias, and extract the data from included studies. Similar outcomes measured in at least 2 trials will be plotted in the meta-analysis using Review Manager 5.3. The quality of evidence will be determined using the GRADE approach.

RESULTS

This systematic review is designed to provide high quality evidence on QOL in patients undergoing total hysterectomy for benign indications using either robotic-assisted or conventional laparoscopic surgery.

CONCLUSION

It is expected that high-quality evidence on QOL can be used to guide decision-making by institutions and clinicians to improve health care; the evidence can also be used in future studies.

PROSPERO REGISTRATION NUMBER

PROSPERO CRD 42019129913.

Outcomes in women undergoing robotic-assisted laparoscopic hysterectomy compared to conventional laparoscopic hysterectomy at a tertiary hospital in Western Australia

BACKGROUND

Robotic-assisted laparoscopic hysterectomy (RALH) is associated with improved outcomes compared to open surgery in patients with endometrial cancer but data are conflicting when comparing RALH to conventional total laparoscopic hysterectomy (TLH). In October 2014, a RALH program was established in Perth, Western Australia.

AIM

To compare outcomes in patients undergoing RALH with a matched cohort undergoing TLH.

MATERIALS AND METHODS

A retrospective matched cohort study compared outcomes in 45 patients who underwent RALH with 45 controls who were patients treated with TLH.

RESULTS

Mean operating time was longer in the RALH group compared to controls (75.42 min vs 53.18 min, mean difference 22.24 min, P < 0.001, 95% Cl, 11.07-33.42). No differences were observed in mean pain scores (RALH 1.47 vs TLH 1.84 P = 0.31), mean parenteral and oral opioid use (RALH 14.3 mg and 42.4 mg vs TLH 17.5 mg and 52.57 mg, P = 0.42 and 0.42, respectively), and mean length of stay (RALH 1.51 vs TLH 1.67 days, P = 0.49). Two patients in the RALH group and one patient in the TLH group sustained iatrogenic bladder injuries (P = 0.62).

CONCLUSION

The establishment of the RALH program at our institution appeared to be associated with equivalent morbidity, post-operative pain, opioid use and length of stay compared to conventional laparoscopy. A surgical learning curve for RALH was observed. Well-designed prospective studies are needed to further evaluate short- and long-term patient function, morbidity, quality of life and oncologic outcomes.