Cost-Effectiveness of Robotic Versus Laparoscopic-Assisted Vaginal Natural Orifice Transluminal Surgery (vNOTES) for Hysterectomy

INTRODUCTION: Vaginal natural orifice transluminal endoscopic surgery (vNOTES) is a minimally invasive technique that eliminates abdominal incisions and is associated with reduced postoperative pain, though it is limited by challenges in instrument triangulation, caudal-to-cephalic visualization, and restricted instrument length. Recent integration of robotic assistance has facilitated the application of vNOTES to more complex gynecologic procedures and for surgeons predominantly trained in robotic surgery; nevertheless, the principal criticism of this approach remains the potential for increased procedural costs. OBJECTIVE: This study aims to compare the operative characteristics and costs of robotic versus laparoscopic vNOTES. METHODS: This is a retrospective study that was conducted at a single tertiary medical center including 72 women who underwent vaginal natural orifice transluminal endoscopic surgery (vNOTES) hysterectomy. Patients were divided into two groups based on the surgical approach: the study group underwent robot-assisted laparoscopy, while the control group underwent conventional laparoscopy. Both groups were evaluated for operative characteristics and surgery-specific costs to compare the outcomes of the two techniques. Shared equipment costs used across both groups were excluded from the analysis. The primary outcome was the total cost per procedure, incorporating the cost of approach-specific equipment and procedure duration. Both groups were evaluated for operative characteristics and surgery-specific costs to compare the outcomes of the two techniques. Shared equipment costs used across both groups were excluded from the analysis. The primary outcome was the total cost per procedure, incorporating the cost of approach-specific equipment and procedure duration. RESULTS: Of the 72 women included in the study, 35 (49%) underwent robotic vNOTES and 37 (51%) underwent conventional laparoscopic vNOTES. Baseline characteristics, including age, body mass index (BMI), parity, and history of cesarean deliveries, were comparable between the two groups. In both groups, the most common indication for surgery was symptomatic fibroids causing abnormal uterine bleeding. Specimen weights were similar between groups [200 g (range 97–290) vs 218 g (range 90–358); p=0.93]. Procedure duration, measured from intubation to extubation, was slightly shorter in the robotic group, with a median time of 114 minutes (range 91–134) compared to 129 minutes (range 100–152) in the laparoscopic group, although this difference was not statistically significant (p=0.15). Cost analysis was performed for each case, incorporating the cost of procedure-specific equipment and operative time. Operative time was monetized at a standard institutional rate of $57.76 per minute, which included operating room, anesthesia, and surgeon fees. The total cost of robotic vNOTES was calculated at $8,559.09, compared to $7,753.19 for laparoscopic vNOTES. The difference in total cost between the two approaches was not statistically significant (p=0.32). CONCLUSIONS: Robotic vNOTES is a feasible and efficient approach with operative times and overall costs comparable to conventional laparoscopic vNOTES. These findings suggest that the addition of robotic assistance does not impose a significant financial burden while potentially offering enhanced surgical dexterity and precision, supporting its broader adoption for minimally invasive hysterectomy.