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Pain and type of hysterectomy.

I have some problems with the article that summarized the findings of a study by Dr. Megan Wasson ("More pain meds used after robotic hysterectomies," January 2014, p.6).

Among the many limitations of the study that make it of almost no value is the fact that most patients in the nonrobotic group underwent supracervical hysterectomy. In the first instance, supracervical hysterectomy is a procedure of greatly dubious benefit for most women. Irrespective of that, the two groups in Dr. Wasson's study underwent fundamentally different surgeries for which the expectation of pain is completely different.

The study is of very limited quality because supracervical hysterectomy (67% of the nonrobotic group) and total hysterectomy (98.7% of the robotic group) are not the same surgery! The anatomy and surgical considerations are fundamentally different.

A more pressing question is this: Why were so many supracervical hysterectomies, which represents an unfinished surgery for most women, being performed after 2009?

Antonio R. Pizarro, M.D.

Shreveport, La.

We asked our medical editor for Master Class on Gynecologic Surgery, Dr. Charles E. Miller, to respond: This past November at the Global Congress of the AAGL, Dr. Wasson reported on the findings of a retrospective study comparing analgesia requirements in women undergoing robotically assisted laparoscopic hysterectomy and conventional hysterectomy.

Although Dr. Wasson and her colleagues noted no difference in oral oxycodone equivalents utilized postoperatively in either the robotically assisted or conventional groups, the use of parenteral oxycodone equivalents and the combined oral and parenteral oxycodone requirements were statistically greater in the robotically assisted laparoscopic hysterectomy group. As a result, Dr. Wasson concluded that the outcome of this study could help determine use of robotic assistance versus a conventional approach when postoperative pain is a consideration.

While Dr. Wasson and her colleagues need to be congratulated on their interesting study and their important contribution to minimally invasive gynecologic surgery, especially the ongoing evaluation of the place of robotic-assisted surgery, I believe that she and her colleagues are premature in their conclusion that conventional laparoscopic hysterectomy is indeed associated with less postoperative pain.

In the past year, two studies have been published comparing postoperative pain following conventional laparoscopic surgery and robotic-assisted surgery. Presented at the AAGL Global Congress of Minimally Invasive Gynecology in 2011, Dr. Raymond E. Betcher and associates performed a retrospective case control analysis of robotic (first 100 consecutive) versus traditional (last 100 consecutive) total laparoscopic hysterectomy procedures (J. Robot. Surg. 2014;8:35-41).

Even through the surgeons were early in their robotic careers, the patients undergoing conventional laparoscopic hysterectomy were noted to have higher visual analog scale pain scores postoperatively and used more narcotics. This was despite the fact that the robotic-assisted cases were associated with more procedures, more ports, total incision size, and longer operative time. In their discussion, the authors noted that their findings were consistent with those found by Dr. Abraham R. Shashoua and associates (JSLS 2009;13:364-9).

In 2013, Dr. Lena El Hachem and colleagues Dr. Uchenna Acholonu and Dr. Farr Nezhat performed a prospective, nonrandomized analysis of patients undergoing conventional laparoscopy versus robotically assisted laparoscopy. In this study, 42% of conventional laparoscopy patients and 64% of robotically assisted patients underwent concurrent hysterectomy, respectively. The authors found no significant differences in mean Numeric Rating Scale pain scores over time or mean narcotic requirements. The authors concluded that robotically assisted laparoscopy is equivalent to conventional laparoscopy in terms of subjective and objective measures of postoperative pain (Obstet. Gynecol. 2013;121:547-53).

Even in a randomized controlled trial comparing 40 robotic-assisted and 38 conventional laparoscopic sacrocolpopexy procedures by Dr. Marie Fidela R. Paraiso and associates, patients in the robotically assisted group had higher visual analog scale pain scores at rest and with normal activities from weeks 3-5 postoperatively, but their narcotic use and return to normal activity were similar to the conventional group (Obstet. Gynecol. 2011;118:1005-13).

Ultimately, I believe it will take a large, multicenter, randomized controlled trial comparing robotically assisted hysterectomy to conventional laparoscopically hysterectomy to answer the question raised by Dr. Wasson and her colleagues.

Furthermore, as one critically appraises Dr. Wassons study, it can be quickly ascertained that it compares two different procedures. In the conventional laparoscopy group, only 38 of 116 patients underwent total laparoscopic hysterectomy, while virtually all of the 237 (234) robotically assisted hysterectomies were total hysterectomies.

Ever since I began performing laparoscopic supracervical hysterectomy nearly 20 years ago, I have counseled my patients that postoperative pain and recovery would be less, compared with total laparoscopic hysterectomy.

In a 2011 article, Dr. Jon I. Einarsson and associates concluded that supracervical laparoscopic hysterectomy appears to provide greater improvement in short-term postoperative quality of life, compared with total laparoscopic hysterectomy. Although there was no significant difference in use of pain medications, bodily pain was greater in the total laparoscopic hysterectomy group (J. Minim. Invasive Gynecol. 2011;18:617-21).

Dr. Miller is clinical associate professor at the University of Illinois at Chicago, immediate past president of the International Society for Gynecologic Endoscopy (, and a past president of the AAGL ( He is a reproductive endocrinologist and minimally invasive gynecologic surgeon in private practice in Naperville, III, and Schaumburg, III, and the director of minimally invasive gynecologic surgery at Advocate Lutheran General Hospital in Park Ridge, Ill.

Note: Dr. Wasson could not be reached for comment.
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Title Annotation:LETTER
Author:Pizarro, Antonio R.
Publication:OB GYN News
Article Type:Letter to the editor
Date:Apr 1, 2014
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