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Robotically assisted tubal sterilization reversal: Surgical technique and cost effectiveness versus conventional surgery

2004; Elsevier BV; Volume: 82; Linguagem: Inglês

10.1016/j.fertnstert.2004.07.034

1556-5653

Sejal Dharia, Michael P. Steinkampf, Scott J. Whitten, B.A. Malizia, Meredith L. Kilgore,

Reproductive Health and Technologies

ObjectiveReversal of surgical sterilization is commonly performed through a laparotomy incision. Although laparoscopy offers quicker recovery and comparable success rates, the technical difficulty of this approach has limited its acceptance among surgeons. Robotic technology has the potential to overcome this challenge through the fine motor precision of wristed instruments and three-dimensional vision. However, the incorporation of new technology is limited by significant operating costs. The purpose of our study was to describe our technique for robotic tubal reanastomosis, and to examine the cost effectiveness of robotic assisted tubal reanastomoses compared to open surgery in a fellowship training program.DesignA prospective cohort studyMaterials and methodsBetween February 2003-January 2004, we performed robotic assisted laparoscopic tubal reanastomoses using the daVinci surgical system® (Intuitive Surgical, Sunnyvale, CA) in 18 patients who desired sterilization reversal. The outcomes of these patients were compared to 10 patients who underwent an open microsurgical tubal reanastomosis between November 2002-February 2003. Each case was performed by the same faculty mentor and the fellow in training. Main outcome measures included cost per live birth incorporating costs from admission to discharge, recovery, and post-operative testing and treatment. Four weeks after surgery, each patient was interviewed to obtain the time to return to independent activities of daily living (IADLS), employment and analgesia requirements. Charges were obtained from the hospital billing department and were converted to costs using a ratio provided by the hospital administration. Statistical analysis utilized Chi square and Fisher exact test.ResultsPatients who underwent an open tubal renastomoses (OPEN; n=10) and patients who underwent robotically assisted surgery (ROBOT; n=18) were comparable for age, body mass index, parity, type of reanastomosis and tubal length. The mean operative time for robotic reanastomoses was significantly longer than for open surgery (ROBOT: 201 minutes, OPEN: 155.3 minutes; P=0.0011), but the mean hospitalization time was shorter (ROBOT: 3 hours, OPEN: 34.7 hours; P<0.0001). Hospital costs for the procedure were $13,773.55 per case in robotic reanastomoses and $11,742.97 per case in open surgery. Post-operatively, recovery times were shorter after robotic procedures with respect to return to IADLS (ROBOT 11.1 days, OPEN 28.1 days; P=0.0001) and employment (ROBOT 22 days, OPEN 45.8 days P=0.0016), and post-operative analgesic requirements were significantly reduced (ibuprofen: ROBOT 29.3 tablets, OPEN 90 tablets, P<0.0001; hydrocodone: ROBOT 16.6 tablets, OPEN 36 tablets, P=0.0003). In all non-pregnant patients, patency was established in at least one tube by hysterosalpingogram. Pregnancy rates (ROBOT 62.5%, OPEN 50%) and live birth rates (ROBOT 28%, OPEN 30%) were comparable as was the cost per delivery (ROBOT: $92,488.00, OPEN $92,205.90).ConclusionRobotically assisted microsurgical tubal reanastomosis is equally cost effective to open surgery. Increased operative times and equipment costs for robotic surgery is counterbalanced by increased hospitalization and recovery time in open surgery. ObjectiveReversal of surgical sterilization is commonly performed through a laparotomy incision. Although laparoscopy offers quicker recovery and comparable success rates, the technical difficulty of this approach has limited its acceptance among surgeons. Robotic technology has the potential to overcome this challenge through the fine motor precision of wristed instruments and three-dimensional vision. However, the incorporation of new technology is limited by significant operating costs. The purpose of our study was to describe our technique for robotic tubal reanastomosis, and to examine the cost effectiveness of robotic assisted tubal reanastomoses compared to open surgery in a fellowship training program. Reversal of surgical sterilization is commonly performed through a laparotomy incision. Although laparoscopy offers quicker recovery and comparable success rates, the technical difficulty of this approach has limited its acceptance among surgeons. Robotic technology has the potential to overcome this challenge through the fine motor precision of wristed instruments and three-dimensional vision. However, the incorporation of new technology is limited by significant operating costs. The purpose of our study was to describe our technique for robotic tubal reanastomosis, and to examine the cost effectiveness of robotic assisted tubal reanastomoses compared to open surgery in a fellowship training program. DesignA prospective cohort study A prospective cohort study Materials and methodsBetween February 2003-January 2004, we performed robotic assisted laparoscopic tubal reanastomoses using the daVinci surgical system® (Intuitive Surgical, Sunnyvale, CA) in 18 patients who desired sterilization reversal. The outcomes of these patients were compared to 10 patients who underwent an open microsurgical tubal reanastomosis between November 2002-February 2003. Each case was performed by the same faculty mentor and the fellow in training. Main outcome measures included cost per live birth incorporating costs from admission to discharge, recovery, and post-operative testing and treatment. Four weeks after surgery, each patient was interviewed to obtain the time to return to independent activities of daily living (IADLS), employment and analgesia requirements. Charges were obtained from the hospital billing department and were converted to costs using a ratio provided by the hospital administration. Statistical analysis utilized Chi square and Fisher exact test. Between February 2003-January 2004, we performed robotic assisted laparoscopic tubal reanastomoses using the daVinci surgical system® (Intuitive Surgical, Sunnyvale, CA) in 18 patients who desired sterilization reversal. The outcomes of these patients were compared to 10 patients who underwent an open microsurgical tubal reanastomosis between November 2002-February 2003. Each case was performed by the same faculty mentor and the fellow in training. Main outcome measures included cost per live birth incorporating costs from admission to discharge, recovery, and post-operative testing and treatment. Four weeks after surgery, each patient was interviewed to obtain the time to return to independent activities of daily living (IADLS), employment and analgesia requirements. Charges were obtained from the hospital billing department and were converted to costs using a ratio provided by the hospital administration. Statistical analysis utilized Chi square and Fisher exact test. ResultsPatients who underwent an open tubal renastomoses (OPEN; n=10) and patients who underwent robotically assisted surgery (ROBOT; n=18) were comparable for age, body mass index, parity, type of reanastomosis and tubal length. The mean operative time for robotic reanastomoses was significantly longer than for open surgery (ROBOT: 201 minutes, OPEN: 155.3 minutes; P=0.0011), but the mean hospitalization time was shorter (ROBOT: 3 hours, OPEN: 34.7 hours; P<0.0001). Hospital costs for the procedure were $13,773.55 per case in robotic reanastomoses and $11,742.97 per case in open surgery. Post-operatively, recovery times were shorter after robotic procedures with respect to return to IADLS (ROBOT 11.1 days, OPEN 28.1 days; P=0.0001) and employment (ROBOT 22 days, OPEN 45.8 days P=0.0016), and post-operative analgesic requirements were significantly reduced (ibuprofen: ROBOT 29.3 tablets, OPEN 90 tablets, P<0.0001; hydrocodone: ROBOT 16.6 tablets, OPEN 36 tablets, P=0.0003). In all non-pregnant patients, patency was established in at least one tube by hysterosalpingogram. Pregnancy rates (ROBOT 62.5%, OPEN 50%) and live birth rates (ROBOT 28%, OPEN 30%) were comparable as was the cost per delivery (ROBOT: $92,488.00, OPEN $92,205.90). Patients who underwent an open tubal renastomoses (OPEN; n=10) and patients who underwent robotically assisted surgery (ROBOT; n=18) were comparable for age, body mass index, parity, type of reanastomosis and tubal length. The mean operative time for robotic reanastomoses was significantly longer than for open surgery (ROBOT: 201 minutes, OPEN: 155.3 minutes; P=0.0011), but the mean hospitalization time was shorter (ROBOT: 3 hours, OPEN: 34.7 hours; P<0.0001). Hospital costs for the procedure were $13,773.55 per case in robotic reanastomoses and $11,742.97 per case in open surgery. Post-operatively, recovery times were shorter after robotic procedures with respect to return to IADLS (ROBOT 11.1 days, OPEN 28.1 days; P=0.0001) and employment (ROBOT 22 days, OPEN 45.8 days P=0.0016), and post-operative analgesic requirements were significantly reduced (ibuprofen: ROBOT 29.3 tablets, OPEN 90 tablets, P<0.0001; hydrocodone: ROBOT 16.6 tablets, OPEN 36 tablets, P=0.0003). In all non-pregnant patients, patency was established in at least one tube by hysterosalpingogram. Pregnancy rates (ROBOT 62.5%, OPEN 50%) and live birth rates (ROBOT 28%, OPEN 30%) were comparable as was the cost per delivery (ROBOT: $92,488.00, OPEN $92,205.90). ConclusionRobotically assisted microsurgical tubal reanastomosis is equally cost effective to open surgery. Increased operative times and equipment costs for robotic surgery is counterbalanced by increased hospitalization and recovery time in open surgery. Robotically assisted microsurgical tubal reanastomosis is equally cost effective to open surgery. Increased operative times and equipment costs for robotic surgery is counterbalanced by increased hospitalization and recovery time in open surgery.