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Citation: Jeong, S.Y.; Kim, K.;
Ryu, J.W.; Cha, J.; Park, S.T.;
Park, S.H. Comparison of Surgical
Outcomes of Robotic Versus
Conventional Laparoscopic
Hysterectomy of Large Uterus with
Gynecologic Benign Disease. J. Pers.
Med. 2022,12, 2042. https://
doi.org/10.3390/jpm12122042
Academic Editor: Antonio Raffone
Received: 14 November 2022
Accepted: 8 December 2022
Published: 10 December 2022
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Journal of
Personalized
Medicine
Article
Comparison of Surgical Outcomes of Robotic versus
Conventional Laparoscopic Hysterectomy of Large Uterus with
Gynecologic Benign Disease
Soo Young Jeong, Kyoungseon Kim, Ji Won Ryu, Jieum Cha, Sung Taek Park and Sung Ho Park *
Department of Obstetrics and Gynecology, Kangnam Sacred-Heart Hospital, Hallym University Medical Center,
Hallym University College of Medicine, Seoul 07441, Republic of Korea
*Correspondence: vth2000@hallym.or.kr or vth2000@naver.com; Tel.: +82-2-829-5151
Abstract:
Hysterectomy is commonly performed for benign gynecological diseases. Minimally
invasive surgical approaches offer several advantages. Unfortunately, few studies have compared the
outcomes of different types of minimally invasive surgeries. Therefore, this study aimed to compare
the surgical outcomes of robotic hysterectomy (RH) and conventional laparoscopic hysterectomy
(CLH) in benign gynecologic diseases. We performed a retrospective cohort study at a single
center between January 2014 and July 2022. A total of 397 patients (RH: 197 and CLH: 200) who
underwent minimally invasive hysterectomy for benign diseases with uterine size exceeding 250 g
were enrolled, and factors related to the surgical outcomes were compared. The median age was
46 (range, 35–74) years
, and the median uterine weight was 400 (range, 250–2720) g. There were
no significant differences between the two groups regarding age, body mass index, uterine weight,
hospital stay, estimated blood loss, or operating time. Intraoperative and postoperative complication
rates were not significantly different between the two groups. RH was not inferior to CLH in terms of
perioperative and immediate postoperative outcomes in our study.
Keywords: robotic hysterectomy; conventional laparoscopic hysterectomy; surgical outcome
1. Introduction
Hysterectomy is commonly performed for benign gynecologic diseases such as uterine
myoma, adenomyosis, endometriosis, genital prolapse, pelvic pain, and other symptoms
associated with pelvic organs. [
1
]. The prevalence of hysterectomy in the reproductive years
(ages 18–44 years) has reached about 18% and that of remaining ages reached about 48% in
the United States. These prevalence rates showed a consistency through
1997–2005 [2]
. An
extensive study about unadjusted all-age hysterectomy prevalence using the Behavioral
Risk Factor Surveillance System, providing national representative trends, revealed that
it ranged from 21.4% in 2006 to 21.1% in 2016 [
3
]. Similar trends were noted in the
Republic of Korea. Although overall rates of hysterectomy have been decreasing, 329.6 of
100,000 women
in Korea underwent hysterectomy in 2010, according to health data from
the Organization for Economic Cooperation and Development [4].
For hysterectomy, surgeons usually choose a surgical approach based on the clinical
circumstances or personal preferences. Abdominal or vaginal hysterectomy has tradition-
ally been performed. However, minimally invasive approaches including conventional
laparoscopy, 3D laparoscopy, and robotic surgery are being increasingly applied in benign
gynecological surgery [
5
,
6
]. Of all the hysterectomies in USA in 2003, the most common
method was abdominal (66.1%), followed by vaginal (21.8%) and laparoscopic hysterec-
tomy (11.8%) for benign disease [
7
]. By 2009, the tendency had shifted toward laparoscopic
(20.4%) and robotic surgery (4.5%) [
8
]. However, in Korea, the change was rapid; laparo-
scopic hysterectomy in benign cause accounted for 52.0% by 2009, with a significantly
increasing trend (p< 0.001) [9].
J. Pers. Med. 2022,12, 2042. https://doi.org/10.3390/jpm12122042 https://www.mdpi.com/journal/jpm
J. Pers. Med. 2022,12, 2042 2 of 7
This was inevitable for minimally invasive surgical approaches as they offer several
important advantages such as less pain, reduced blood loss, shorter duration of hospital-
ization, faster postoperative recovery, smaller scars, and fewer complications than open
methods [
10
,
11
]. Therefore, the abdominal hysterectomy rates fell short of minimally
invasive surgery in 2012 [12].
Among the minimally invasive surgeries, surgeons have usually chosen the conven-
tional laparoscopic technique for hysterectomy. It requires an endoscopic camera and
long instruments, with small abdominal incisions [
13
]. Since the approval of the da Vinci
robotic surgical system by the U.S. Food and Drug Administration in 2005, the number
of robotic surgeries has been increasing [
14
]. The advantages of robotic surgery include
three-dimensional (3D) visualization, tremor filtration, higher magnification, telestration,
and improved ergonomics by using EndoWrist instruments (Intuitive Surgical Inc., Sun-
nyvale, CA, USA) that provide freedom of articulation with improved visualization and
dissection precision [
15
,
16
]. Robotic hysterectomy occupied the highest rate (robotic, 36%;
conventional laparoscopic, 31%; abdominal, 24%; and vaginal, 8%) in 2013 among all
benign hysterectomies, and its contribution has been increasing rapidly [
12
]. Therefore, we
aimed to compare the surgical outcomes of robotic hysterectomy (RH) and conventional
laparoscopic hysterectomy (CLH) in benign gynecologic diseases.
2. Materials and Methods
2.1. Patient Selection and Data Collection
In this retrospective cohort study, data from women who underwent minimally inva-
sive hysterectomy at Kangnam Sacred-Heart Hospital, Seoul, Korea, between January 2014
and July 2022 were reviewed. As this was a retrospective study, direct written informed
consent from patients was not required, as per the ethical guidelines.
The inclusion criteria were (1) patients with a large uterus size over 250 g; (2) who
underwent minimally invasive hysterectomy; and (3) who had benign diseases. Patients
with gynecological cancers were excluded. A total of 403 patients were enrolled and
among these, six patients were excluded because other procedures such as cholecystec-
tomy or breast mass excision were also performed (Figure 1). Finally, 397 patients were
included in the study. Of these, 197 women underwent robotic surgery and 200 underwent
conventional surgery.
J. Pers. Med. 2022, 12, x FOR PEER REVIEW 2 of 8
terectomy (11.8%) for benign disease [7]. By 2009, the tendency had shifted toward lapa-
roscopic (20.4%) and robotic surgery (4.5%) [8]. However, in Korea, the change was rapid;
laparoscopic hysterectomy in benign cause accounted for 52.0% by 2009, with a signifi-
cantly increasing trend (p < 0.001) [9].
This was inevitable for minimally invasive surgical approaches as they offer several
important advantages such as less pain, reduced blood loss, shorter duration of hospital-
ization, faster postoperative recovery, smaller scars, and fewer complications than open
methods [10,11]. Therefore, the abdominal hysterectomy rates fell short of minimally in-
vasive surgery in 2012 [12].
Among the minimally invasive surgeries, surgeons have usually chosen the conven-
tional laparoscopic technique for hysterectomy. It requires an endoscopic camera and long
instruments, with small abdominal incisions [13]. Since the approval of the da Vinci ro-
botic surgical system by the U.S. Food and Drug Administration in 2005, the number of
robotic surgeries has been increasing [14]. The advantages of robotic surgery include
three-dimensional (3D) visualization, tremor filtration, higher magnification, telestration,
and improved ergonomics by using EndoWrist instruments (Intuitive Surgical Inc.,
Sunnyvale, CA, USA) that provide freedom of articulation with improved visualization
and dissection precision [15,16]. Robotic hysterectomy occupied the highest rate (robotic,
36%; conventional laparoscopic, 31%; abdominal, 24%; and vaginal, 8%) in 2013 among
all benign hysterectomies, and its contribution has been increasing rapidly [12]. Therefore,
we aimed to compare the surgical outcomes of robotic hysterectomy (RH) and conven-
tional laparoscopic hysterectomy (CLH) in benign gynecologic diseases.
2. Materials and Methods
2.1. Patient Selection and Data Collection
In this retrospective cohort study, data from women who underwent minimally in-
vasive hysterectomy at Kangnam Sacred-Heart Hospital, Seoul, Korea, between January
2014 and July 2022 were reviewed. As this was a retrospective study, direct written in-
formed consent from patients was not required, as per the ethical guidelines.
The inclusion criteria were (1) patients with a large uterus size over 250 g; (2) who
underwent minimally invasive hysterectomy; and (3) who had benign diseases. Patients
with gynecological cancers were excluded. A total of 403 patients were enrolled and
among these, six patients were excluded because other procedures such as cholecystec-
tomy or breast mass excision were also performed (Figure 1). Finally, 397 patients were
included in the study. Of these, 197 women underwent robotic surgery and 200 under-
went conventional surgery.
Figure 1. Flowchart for the enrolled patients.
Figure 1. Flowchart for the enrolled patients.
A single gynecologic surgeon (S.H.P.), who has been performing laparoscopic and
robotic surgeries for 20 and 8 years, respectively, evaluated all patients enrolled in the study
preoperatively and performed all surgeries. He decided the surgical approach according
to the patient’s characteristics and clinical parameters. Hence, all surgeries had similar
perioperative management and intraoperative strategies. For CLH, a primary 10 mm
J. Pers. Med. 2022,12, 2042 3 of 7
port was positioned at the umbilicus and an additional two or mostly three 5 mm ports
were placed in the suprapubic region and at each side of the abdomen, resulting in a
diamond-shaped port placement. For RH, a primary 8 mm robotic port was positioned
at the umbilicus. Subsequently two more 8 mm robotic ports were placed lateral to the
primary port, each about 8 cm apart. The assistant’s port was placed on the right to one
of the additional ports, resulting in a linear port alignment. Except for port placement,
almost all of the surgical procedures were carried out in a similar manner including vaginal
retrieval of the specimen and intraabdominal stump suture. Even the suture material
was manufactured by the same company. For the energy device, Thunderbeat (Olympus,
Tokyo, Japan) and Fenestrated bipolar forceps (Intuitive Surgical Inc., Sunnyvale, CA, USA)
were utilized.
Data were retrieved from the patients’ electronic medical records. Operative time
was defined as the time from skin incision to skin closure, which included docking time
for RH. Drop in hemoglobin level was defined as the difference between the preoperative
and postoperative hemoglobin levels. Postoperative hemoglobin was measured in the
morning following surgery. Postoperative complications were classified according to the
Clavien–Dindo classification [17].
2.2. Statistical Analyses
Statistical analyses were performed using SPSS version 25.0 (SAS Institute, Cary, NC,
USA). The descriptive statistics were reported as median (range) for continuous variables
(age, body mass index [BMI], uterus weight, hospital days, estimated blood loss [EBL],
operative time, and drop in hemoglobin), and number (percentage) for categorical variables
(number of previous operations, uterine disease, pelvic adhesion, conversion to open
surgery, intraoperative complications, and postoperative complications). Clinical data
were compared using
χ
2 or Fisher’s exact tests for categorical variables and Student’s t-
or Wilcoxon rank-sum tests for continuous variables. Two-sided tests were applied and
p< 0.05 was considered statistically significant. Values were reported to the thousandths,
which were rounded up from the ten-thousandths.
3. Results
Consecutive participants (n= 403) were screened, but six were excluded because they
also underwent non-gynecologic surgery. The final cohort comprised 397 participants:
197 patients
in the RH group and 200 patients in the CLH group. The participants’ char-
acteristics are shown in Table 1. The median age was 46 years (range, 35–74), median
BMI was 23.6 kg/m
2
(range, 15.4–42.7), and the median uterus weight was 400 g (range,
250–2720). In RH, the median age was 47 years (range, 36–42), median BMI was 23.4 kg/m
2
(range, 17.7–42.7), the median weight of the uterus was 430 g (range, 250–2000). In CLH,
the median age was 47 years (range, 35–74), median BMI was 24.0 kg/m
2
(range, 15.4–40.9),
and the median weight of the uterus was 363 g (range, 250–2720). There were no significant
differences between the two groups in terms of age, BMI, and uterine weight. The two most
common indications in both groups were myoma (RH, 91.4%; LH, 94.5%) and adenomyosis
(RH, 64.5%; LH, 61.5%). There were no significant inter-group differences in the number of
previous operations or pelvic adhesions.
The surgical outcomes are presented in Table 2. The median hospital stay (5 days in
both groups), median EBL (RH, 100 mL; LH, 150 mL), and the drop in hemoglobin (1.6 g/dL
in both groups) were similar in both groups. Only one case was converted to laparotomy in
the CLH group. Intraoperative complications comprised two types: blood transfusion and
ureteral injury. Six patients in each group received blood transfusions. Additionally, four
patients in the robotic group and one patient in the laparoscopic group had ureteral injury.
Postoperative complications were classified using the Clavien–Dindo classification. Urinary
retention with catheterization was classified as a grade 1 complication, and there was no
significant difference between the two groups (RH, 4.1%; LH, 3.5%, p= 0.576). Postoperative
J. Pers. Med. 2022,12, 2042 4 of 7
transfusion and antibiotic use were classified as grade 2 complications, and there was no
significant difference between the two groups (RH, 8.1%; LH, 12.5%, p= 0.438).
Table 1. The patients’ characteristics by the type of hysterectomy.
Entire Cohort
(n= 397)
Robotic Hysterectomy
(n= 197)
Laparoscopic Hysterectomy
(n= 200) p-Value
Median age (yr) 46 (35–74) 47 (36–62) 47 (35–74)
Median BMI 1(kg/m2)23.6 (15.4–42.7) 23.4 (17.7–42.7) 24.0 (15.4–40.9)
Median weight of uterus (g) 400 (250–2720) 430 (250–2000) 363 (250–2720)
Number of previous
operations 0.171
0 213 (53.7%) 111 (56.3%) 102 (51.0%)
1 92 (23.2%) 49 (24.9%) 43 (21.5%)
2 76 (19.1%) 29 (14.7%) 47 (23.5%)
≥3 16 (4.0%) 8 (4.1%) 8 (4.0%)
Uterus characteristics
Myoma 369 (92.9%) 180 (91.4%) 189 (94.5%) 0.223
Adenomyosis 250 (63.0%) 127 (64.5%) 123 (61.5%) 0.540
Endometriosis 10 (2.5%) 5 (2.5%) 5 (2.5%) 0.981
Pelvic adhesion 104 (26.2%) 47 (23.9%) 57 (28.5%) 0.293
1BMI, body mass index.
Table 2. Surgical outcomes by the surgery type of hysterectomy.
Entire Cohort
(n= 397)
Robotic Hysterectomy
(n= 197)
Laparoscopic Hysterectomy
(n= 200) p-Value
Hospital days 5 (4–11) 5 (4–11) 5 (5–9)
EBL (ml) 1100 (10–3000) 100 (20–3000) 150 (10–1000)
Operative time (min) 120 (60–460) 120 (70–375) 120 (60–460)
Drop in hemoglobin (g/dL) 1.6 (−1.2–6.5) 1.6 (−0.9–6.5) 1.6 (−1.2–5.3)
Conversion to laparotomy 1 (0.3%) 0 (0%) 1 (0.5%) 0.320
Intraoperative complication
Blood transfusion 12 (3.0%) 6 (3.0%) 6 (3.0%) 0.979
Ureter injury 5 (1.3%) 4 (2.0%) 1 (0.5%) 0.172
Postoperative complications 20.464
I 195 (49.1%) 101 (51.3%) 94 (47.0%)
II 41 (10.3%) 16 (8.1%) 25 (12.5%)
III (IIIa, IIIb) 3 (0.8%) 2 (1.0%) 1 (0.5%)
IV, V 0 (0%) 0 (0%) 0 (0%)
1
EBL, estimated blood loss.
2
Postoperative complications were classified as per the Clavien–Dindo classification.
4. Discussion
Minimally invasive surgery has become a tremendously important surgical tech-
nique over the past three decades. It was proven with strong evidence that it has better
surgical and patient outcomes—a reduction in hospital days, EBL, postoperative pain,
postoperative morbidities, and cost—than open approaches [
18
,
19
]. Additionally, since
the FDA approved the da Vinci robotic surgical system in 2005, the number of RH has
been increasing annually. However, the benefits of RH compared to CLH are still being
debated [
20
,
21
]. This retrospective study demonstrated that RH is not inferior to CLH in
terms of operation outcomes.
In two randomized controlled trials, RH was found to require a significantly longer
operative time [
22
,
23
]. Operating time is influenced by patient-related or surgeon-related
factors. Patient-related factors including older age, higher BMI, increased uterine weight,
and adhesions can increase the operating time. We established that patient-related factors
were not different enough to affect the findings on that matter. Surgeon-related factors in-
cluding surgical approach, technique, and surgeon expertise can also increase the operating
J. Pers. Med. 2022,12, 2042 5 of 7
time [
24
]. In particular, the surgeon’s expertise is the most important contributing factor to
operating time [
25
]. In this study, we excluded all surgeries performed by surgeons other
than S.H.P.; therefore, the effect of expertise could be eliminated. Additionally, the exact
docking time of RH was not stated in the electronic medical records, thus we calculated the
operating time including docking time. All the procedures related to robotic docking were
conducted under supervision by S.H.P. Despite including docking time in the operating
time, there was no significant difference between RH and CLH groups, thereby indicating
that RH is not inferior to CLH in terms of operating time.
Several studies have compared the complication rates of RH and CLH. Most studies
have reported no difference in the complication rates between the two groups. In a cohort
study of 264,758 women in the U.S., the overall complication rates were similar for RH
and CLH (5.5% vs. 5.3%) [
26
]. However, one study showed a slightly higher complication
rate with CLH (17.59% in CLH vs. 9.65% in RH) [
27
]. Our study found no significant
differences between the two groups. Five patients experienced ureteral injury during
hysterectomy (four in RH and one in CLH). In all cases, it was confirmed that the ureteral
wall was weakened, not perforated or cut; therefore, it was resolved by inserting a double-J
catheter into the ureter. Several studies have reported major complications in RH such as
respiratory arrest; however, no other major complications occurred after hysterectomy in
this study [26,28].
The present study had several limitations. The study design was retrospective, and
the groups were not exactly comparable. However, the bias was in the direction of more
challenging cases being offered RH. Furthermore, the study was not a randomized study.
While our departmental policy is clear and one surgeon decided the surgical approach of
all cases, it is difficult to know the exact decision-making process for individual patients.
The main strength of this study is that all cases were operated on by a single surgeon
(S.H.P.), resulting in operative management such as bowel preparation, the use of pro-
phylactic antibiotics just before the incision of the skin, supplementation of fluid, and the
administration of analgesics for pain control being carried out in a similar way. Operations
had no important differences including the number of ports, although the port site of
RH differed from that of CLH, the intra-operative strategies, and the vaginal retrieval of
specimen. Hence, they eliminate any potential effect of the varying skill levels of surgeons
and different pre-, intra-, postoperative management that may have otherwise affected
the outcomes.
An individual surgeon-conducted study could also be a disadvantage. A study on the
surgical proficiency of RH using cumulative summation analysis showed that proficiency
was reached after 33 cases [
29
]. Another study by a single surgeon mentioned that a
significantly decreased operative time was obtained after 24–28 cases [
30
]. The surgeon
(S.H.P.) had already dealt with numerous laparoscopic cases before the introduction of
robotic surgery at this center. Considering the total number of RH as 197 cases in the
present study, those numbers are not to be neglected. Multiple surgeons whose expertise
are not significantly different between the RH and CLH based data analysis are required to
tackle this problem.
Although this study concludes that RH is not inferior to CLH, it may be difficult
for clinicians to determine the operational approach. Studies including the present study
are yet to find the appropriate choice of operation for a patient who has a certain clinical
circumstance. The surgical difficulties of the cases in this study varied. Factors such as the
weight of the uterus (ranging from 250 g to 2,720 g), the presence or location of mass like
myomas or other pelvic structures, which may have obscured the operational field of view,
and intraoperative degrees of pelvic adhesion were not classified objectively or subjectively
for further evaluation. A review study highlighted that there were no clear indications for
RH over other minimally invasive surgeries; however, the RH appeared to be non-inferior
to CLH in the hands of expert surgeons [31]
A recent study concluded that robot-assisted techniques did not produce significant
clinical enhancements compared to similar surgical techniques with identical outcomes,
J. Pers. Med. 2022,12, 2042 6 of 7
while their costs were much higher [
32
,
33
]. Sisters of Charity Hospital of NY, USA con-
ducted a study on the average surgical cost and revealed that RH cost EUR 4,067 compared
to EUR 2,151 for the CLH in July 2021 [
34
]. In a randomized controlled trial, RH was not
found to be advantageous for treating conditions when a vaginal approach was feasible
(USD 4,579 for vaginal hysterectomy; USD 7,059 for CLH; USD 8,052 for RH) [
35
]. Even at
our institution, RH costs more than 10 times that of CLH. Hence, a surgeon should also
take these factors into account when considering the surgical method, especially in centers
located in Korea.
5. Conclusions
When introducing robotic surgery, there are numerous concerns about the operation
being performed at the console rather than adjacent to the patient. However, several studies
have highlighted the advantages of robotic surgery, and the results of this study showed no
significant difference compared to those of conventional surgery. Nevertheless, large-scale
randomized controlled studies are required to confirm these findings.
Author Contributions:
Conceptualization, validation, S.H.P.; Methodology, formal analysis, S.Y.J.; In-
vestigation, K.K. and J.W.R.; Resources, S.H.P. and S.T.P.; Data curation, K.K. and J.C.;
Writing—original
draft preparation, review and editing, S.Y.J.; Supervision, S.H.P. All authors have read and agreed to
the published version of the manuscript.
Funding: This research received no external funding.
Institutional Review Board Statement:
The study was conducted in accordance with the Declaration
of Helsinki, and approved by the Institutional Review Board of Kangnam Sacred-Heart Hospital (No.
2020-01-015, date of approval 5 January 2020).
Informed Consent Statement: Not applicable.
Data Availability Statement: Not applicable.
Conflicts of Interest: The authors declare no conflict of interest.
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