Objectives: This is a retrospective cost analysis of vaginal natural orifice transluminal endoscopic surgery (vNOTES) hysterectomy versus robotic-assisted total laparoscopic hysterectomy (RATLH). The robotic approach is now increasingly used for complex cases, e.g. large uteri, prior abdominal surgeries and adnexal masses. Robotic hysterectomies have been associated with longer operative times and higher costs, largely due to high purchase price and expensive disposables. vNOTES is a new, innovative approach to minimally invasive gynecologic surgery. In the most recent Cochrane review, vaginal hysterectomy, including vNOTES, was deemed superior to abdominal or laparoscopic routes. The vaginal approach can be limited, however, by poor visualization or difficult manipulation of the uterus. vNOTES is a valuable approach for such cases as it provides the advantages of both a laparoscopic and vaginal approach. Both the vNOTES and the robotic approach utilize disposable surgical equipment, which is a driver in increasing surgical costs. There are very limited studies on vNOTES and the majority have been performed outside the US. There are no data that directly compare the cost of the robotic versus vNOTES for benign indications. This study aims to investigate a large cohort of cases at one hospital.
Methods: Patient data were obtained from chart review via Epic EMR, and financial data was obtained from the hospital. The primary focus of this study is the total operative cost of vNOTES compared to RATLH. The hypothesis was that vNOTES would be less costly than RATLH. Secondary outcomes included an analysis of all operation costs, PACU costs, inpatient costs, pre-operative diagnosis, conversion rate to laparotomy, uterine weight, concomitant gynecologic procedures, length of stay, estimated blood loss, requirement of transfusion, and intraoperative complications. In addition, operative time and length of stay were also studied as these have been identified as significant factors associated with increased costs in multiple studies.
Results: All vNOTES and robotic cases from April 2021 to November 2023 at a single institution were included in the study. There were 309 vNOTES cases and 150 robotic cases. Preliminary analysis demonstrates a 39% reduction in operative time and a 13% reduction in total OR time for the vNOTES group compared to the RATLH group. Length of stay in hours was not significantly different. Cost analysis using a two-sided T-test demonstrated a statistically significant decrease in cost (p = 0.02). The average cost for vNOTES was $3,339 and the average cost of RATLH was $5,191.
Conclusions: In conclusion, preliminary data suggests a significant cost savings for vNOTES hysterectomy compared with RATLH. Further analysis is needed to confirm these initial findings.
