INTRODUCTION
Hysterectomy for benign uterine pathology is one of the most commonly performed surgical procedures worldwide [1]. According to the World Health Organization (WHO), approximately 1.54 million women underwent hysterectomy in 2016 [2]. Minimally invasive surgery (MIS) is recommended as the preferred approach for hysterectomy by the American College of Obstetricians and Gynecologists (ACOG) [3]. The use of MIS techniques has increased in recent years due to their well-documented benefits, including reduced blood loss, shorter hospital stays, and faster recovery.
Studies indicate that patient-reported outcomes typically return to baseline within 6 weeks after both robotic and laparoscopic hysterectomy [4]. While laparoscopic hysterectomy has been shown to provide superior short- and long-term quality of life (QOL) compared with abdominal hysterectomy, data directly comparing laparoscopic and robotic approaches remain limited, especially in the early postoperative period (<6 weeks) [4,5]. Some research suggests that patients undergoing robotic hysterectomy report favorable long-term QOL and high satisfaction with their surgical choice [4]. However, robust evidence addressing short-term QOL and satisfaction differences between laparoscopic and robotic hysterectomy is lacking.
In India, hysterectomy is among the most common gynaecological surgeries, with a substantial proportion of women still undergoing open procedures [1]. Although MIS approaches such as laparoscopic and robotic hysterectomy are increasingly adopted due to their advantages, there is limited evidence on their comparative outcomes in the Indian population, particularly in the early recovery phase. Cultural factors also influence recovery patterns, as women are often encouraged to take prolonged rest following surgery, reflecting decades of reliance on open hysterectomy.
Our study seeks to address this knowledge gap by evaluating and comparing early postoperative recovery and quality of life between patients undergoing robotic-assisted and laparoscopic hysterectomy for benign indications in the Indian context. These findings may provide valuable insights for surgical planning, patient counseling, and improving recovery outcomes.
MATERIALS AND METHODS
Study design
This retrospective study analyzed prospectively collected data conducted in the Department of Gynaecology and Robotic Surgery, Apollo Health City, Hyderabad, between December 2023 and November 2024. During this period, 63 women underwent hysterectomy via conventional laparoscopy, and 102 women underwent hysterectomy using the da Vinci Xi Robotic System (Intuitive Surgical, Sunnyvale, CA, USA). All surgeries were performed by two experienced surgeons proficient in laparoscopic and robotic-assisted gynaecologic surgeries.
Outcomes measured
The primary objective of the study was to evaluate the QOL and recovery during the early postoperative period (<6 weeks after surgery) in patients who underwent robotic and laparoscopic hysterectomy for benign pathology. The secondary objective was to compare surgical outcomes, QOL, and postoperative recovery between the two groups.
Inclusion criteria
Patients who underwent laparoscopic or robotic-assisted hysterectomy using the da Vinci Xi Robotic System for benign uterine pathology were included in the study. Benign indications included fibroids, endometriosis, adenomyosis, atypical endometrial hyperplasia, chronic pelvic pain, abnormal uterine bleeding or postmenopausal bleeding with atypical endometrial hyperplasia or endometrial polyp.
Exclusion criteria
Patients were excluded if they underwent hysterectomy for malignant pathology, had a vaginal or open approach, were unable to provide consent, or could not complete the questionnaire.
Ethical considerations
The study was approved by the institutional ethics committee, and all clinical protocols adhered to its ethical standards (IEC reference No. AHJ-C-S-019/09-24). Written informed consent was obtained from all participants prior to surgery.
Data collection
Demographic and medical history data were retrieved from patient case records. Intraoperative details collected included the surgical procedure performed, operative findings, and operative time, which was measured from induction to extubation. For robotic surgeries, console time was also recorded. The uterine weight was measured by weighing the excised uterus immediately after removal. Estimated blood loss was calculated by determining the difference in fluid volume between irrigation and suction. Additionally, data regarding blood transfusions, organ injuries, and any conversions to open surgery were collected.
Key postoperative metrics included length of hospital stay, defined as the number of days from surgery to discharge, and time to resume normal activities. Pain scores were assessed using the visual analogue scale, and intravenous analgesic usage, including dosage and duration, was documented. Postoperative complications, such as fever, infection, bleeding, or the need for re-surgery, were recorded. Other recovery data included readmission rates and the time it took for patients to return to work. QOL was assessed using validated questionnaires designed for the study, which were completed by patients at various points during their recovery.
QOL assessment
QOL was assessed using validated questionnaires, which were reviewed by consultant surgeons before patient use. The questionnaires were completed at three time points: day 1, in the hospital; week 1, during the follow-up visit; week 6, completed by patients using Google Forms (Google, Mountain View, CA, USA) sent via e-mail.
Details of questionnaires used
EuroQOL 5D questionnaire (EQ-5D)
A health-related quality of life questionnaire assessing five dimensions: mobility, self-care, usual activities, pain/discomfort, and anxiety/depression [6].
MD Anderson Symptom Inventory (MDASI)
Evaluates symptom severity over the preceding 24 hours and measures symptom interference in six daily activities (general activity, mood, work, relationships, walking, and enjoyment of life). Items are scored from 0 to 10, where 0 indicates no symptom burden and 10 indicates the greatest symptom burden. Higher scores reflect worse symptoms [7].
Statistical analysis
Descriptive statistics were used to summarize patient demographics, clinical characteristics, and surgical outcomes. Continuous variables were presented as mean±standard deviation, while categorical variables were expressed as frequencies and percentages. Comparative analysis between laparoscopic and robotic hysterectomy groups was conducted using Z-tests to compare outcome measures between groups. A P-value <0.05 was considered statistically significant.
RESULT
The analysis highlights key differences between patients undergoing laparoscopic and robotic surgeries. The mean age was similar in both groups (45.75±6.80 years for laparoscopic vs. 46.08±8.10 years for robotic), with the majority of patients in the 41–50 age group.
Obesity was more prevalent in robotic surgery patients (51.9%) than in laparoscopic patients (41.2%), while mean parity was slightly higher in the laparoscopic group (1.8±0.7 vs. 1.6±0.7). Heavy menstrual bleeding was the most common symptom in both groups (73% in laparoscopic and 72.5% in robotic), while dysmenorrhea was more frequent in robotic cases (52.9%) and abdominal pain was more common in laparoscopic cases (42.8%) (Fig. 1). Hypertension and hypothyroidism were the predominant comorbidities, with higher prevalence in laparoscopic patients (28.5% and 28.57%, respectively) compared to robotic patients (16.6% and 11.76%) (Fig. 2).
Additionally, robotic surgery patients had a higher incidence of prior caesarean sections. Overall, robotic surgery was more commonly performed in obese patients and those with a history of higher parity, highlighting its suitability for managing complex cases (Table 1).
Outcome parameters
The analysis highlights key differences between laparoscopic and robotic surgeries. Uterine size was larger in robotic cases (13.67±5.41 cm) compared to laparoscopic (12.19±4.46 cm), with no significant difference (P=0.06). Blood loss was lower in robotic surgeries, with 73.5% of cases losing less than 100 mL compared to 55.5% in laparoscopic, though the mean difference was not significant (P=0.44). Specimen weight was significantly higher in robotic cases (393.3±341.8 g vs. 288.6±230.8 g; P=0.02). Hospital stays were shorter for robotic surgeries (1.39±0.67 days vs. 1.84±0.80 days; P<0.01). The operative time for robotic cases is significantly higher than laparoscopic (Z=1.88, P=0.03).
Resumption of activities, including sexual, household, and office work, showed no significant differences between groups. Robotic surgery demonstrated advantages in reduced blood loss, shorter recovery times, and larger specimen weights, supporting its suitability for more complex cases.
Overall, robotic surgery demonstrated advantages in terms of reduced blood loss, shorter hospital stays, and higher specimen weights, indicating its efficacy in complex cases, although resumption of activities was comparable between the two techniques (Table 2).
Comparison of QOL in the early postoperative period on the basis of EQ-5D
The EQ-5D descriptive system is a preference-based health-related quality of life measure that includes one question for each of five dimensions: mobility, self-care, usual activities, pain/discomfort, and anxiety/depression. The responses for each dimension were categorized as “No problems”, “Some problems”, and “Unable to perform”, and were recorded at day 1, week 1, and week 6 post-surgery.
The EQ-5D questionnaire responses indicate faster recovery in robotic surgery patients across all domains. Mobility improved significantly, with 97.1% of robotic patients reporting no issues by week 1 compared to 84.1% in laparoscopic cases (P<0.0001 for day 1). Self-care showed similar trends, with 97.1% of robotic patients reporting no problems by week 1, while laparoscopic patients lagged (88.9%, P<0.0001 for day 1). For usual activities, robotic patients recovered fully by week 6 (100% no problems), outperforming laparoscopic cases (93.7%, P<0.0001 for day 1). Pain and discomfort were resolved earlier in robotic patients, with 94.1% reporting no pain by week 1 versus 79.4% in laparoscopic cases (P=0.0002 for day 1). Emotional recovery was also better, as 91.2% of robotic patients were not anxious or depressed on day 1, compared to 79.4% in laparoscopic cases (P=0.042).
Overall, robotic surgery demonstrated significant advantages in mobility, pain management, self-care, and emotional well-being, supporting its efficacy in enhancing post-operative recovery and quality of life (Table 3).
Comparison of satisfaction level on the basis of MDASI symptom severity index
The MDASI was used to evaluate symptom severity over the preceding 24 hours and to assess symptom interference with six daily activities. The evaluated symptoms included pain, nausea, feeling distressed or upset, shortness of breath, memory problems, lack of appetite, drowsiness, dry mouth, sadness, and vomiting. Symptom severity was rated on a scale from 0 to 10 at 1 day, 1 week, and 6 weeks post-surgery, where 0 represents no symptom burden and 10 represents the greatest symptom burden.
The MDASI symptom severity index showed faster symptom resolution in robotic surgery patients. Pain scores were lower in robotic cases by day 1 (3.1 vs. 3.8, P=0.001) and week 6 (1.0 vs. 1.9, P<0.0001). Nausea, distress, and sadness improved more rapidly in robotic patients, with significant differences by week 1. Shortness of breath and loss of appetite resolved earlier in robotic cases (P<0.01). While dry mouth and vomiting were initially higher in robotic patients, they normalized by week 6.
Robotic surgery consistently demonstrated better postoperative symptom management and faster recovery (Table 4).
Satisfaction level on decision for surgery
Patient satisfaction with the decision to undergo robotic surgery was evaluated using the 2-question SWD scale. The questions assessed satisfaction with the decision to choose the surgical procedure, both rated on a scale from 1 to 10.
Patient satisfaction with the chosen surgical procedure was significantly higher in the robotic surgery group compared to the laparoscopic group (mean satisfaction scores, 9.88±0.32 vs. 8.71±1.08; P=0.001). In the robotic group, 88.2% of patients rated their satisfaction as grade 10, compared to 36.5% in the laparoscopic group. Lower satisfaction grades (7 and 8) were exclusively reported by laparoscopic patients (Fig. 3).
These results highlight the higher satisfaction levels associated with robotic surgery, likely due to its advanced precision, faster recovery, and better postoperative outcomes (Table 5).
DISCUSSION
In the present study, QOL and recovery during the early postoperative period were better among patients who underwent robotic hysterectomy (RH) compared to those who underwent laparoscopic hysterectomy (LH). Robotic surgery was more frequently performed in obese patients and in those with prior surgeries or endometriosis, where adhesions are often encountered. These findings differ from those of Elessawy et al [8]., who reported no significant difference in early postoperative QOL between RH and LH when comparing patients with similar age, body mass index, and surgical indications.
Although uterine weight was higher in the RH group, outcomes remained favorable, with comparable blood loss, better postoperative symptom profiles, shorter hospital stays, and earlier discharge. The mean hospital stay was 1.3 days in the RH group versus 1.8 days in the LH group. In contrast, Takmaz and Güngör [9] observed no significant difference in hospital stay or analgesic use, reporting mean stays of 1.4 days for RH and 1.5 days for LH.
Operative times were longer in the RH group than in the LH group. However, this did not negatively affect postoperative recovery. The increased duration is likely explained by the inclusion of more complex cases and obese patients in the RH cohort. Similar findings were reported by Takmaz and Güngör [9], who noted longer operative times and higher uterine weights in RH compared with LH.
Patients undergoing RH experienced faster recovery and higher satisfaction, reflecting improved QOL. Within 1 week, 97% of RH patients were fully mobile and symptom-free, compared with 79% in the LH group. The mean time to resumption of all preoperative activities was 3.9 weeks in RH vs. 4.4 weeks in LH. Sarlos et al [10]. similarly reported return to activities at approximately 4 weeks for both groups.
Satisfaction with the surgical decision was also markedly higher in the RH group: 88% reported complete satisfaction compared with 36% in the LH group. This may be attributed to the greater precision of robotic surgery, which can enhance postoperative outcomes and speed recovery. Literature on early postoperative satisfaction remains sparse. Gitas et al [11]. reported no long-term difference in satisfaction between groups, although 96.8% of RH patients expressed willingness to undergo the procedure again if necessary.
Our findings therefore suggest that robotic hysterectomy may offer advantages in terms of short-term recovery, QOL, and patient satisfaction, despite longer operative times. These results carry clinical relevance for individualized surgical decision-making and patient counseling. However, real-world application must also account for operative duration and the higher cost associated with robotic surgery.
This study has several limitations. First, baseline differences existed between groups, as the RH cohort included more obese and complex cases, which may have contributed to longer operative times. Second, cost analysis was not performed, although financial considerations are highly relevant to the broader adoption of robotic surgery. Finally, due to limited published data on very early postoperative recovery, some aspects could not be compared in detail. Larger, multi-center studies with longer follow-up and inclusion of cost-effectiveness analyses are warranted to confirm and expand upon our findings.
This study provides a comparative evaluation of early postoperative recovery and QOL following robotic-assisted and laparoscopic hysterectomy for benign uterine pathology. While both approaches are minimally invasive and associated with favorable surgical outcomes, robotic surgery demonstrated advantages in selected parameters, including reduced blood loss, shorter hospital stay, and faster postoperative recovery. Patients undergoing robotic hysterectomy also reported higher satisfaction, quicker resolution of pain and discomfort, and better mobility and emotional well-being in the early postoperative period.
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