“Robotically assisted hysterectomy in patients with large uteri: outcomes in five community practices.”
Payne, T. N., F. R. Dauterive, et al. (2010).
Obstet Gynecol 115(3): 535-542.
OBJECTIVE:: To examine outcomes of robotically assisted laparoscopic hysterectomy in patients with benign conditions involving high uterine weight and complex pathology. METHODS:: A multicenter study was undertaken in five community practice settings across the United States. All patients who had minimally invasive laparoscopic hysterectomy with robotic assistance March 2006 through July 2009 and uterine weights of at least 250 g were included. Retrospective chart review identified outcomes including skin-to-skin operative time, conversion to an exploratory laparotomy, blood loss, complications, and hospital duration of stay. The effect of uterine weight on skin-to-skin time and blood loss also was examined. RESULTS:: Data were analyzed for 256 patients with uteri weighing 250 to 3,020 g (median 453 g). Most patients were obese or had a history of pelvic or abdominal surgery. Median operative time was 145 minutes. Duration of surgery in patients with uteri 500 g or greater was significantly longer than in patients with uteri less than 500 g (167 compared with 126 minutes, P<.001). Median estimated blood loss also was greater in women with uteri weighing 500 g or more (100 compared with 50 mL, P<.001). Multivariable linear regression analysis confirmed the independent effect of uterine weight on operative time and blood loss. Median duration of hospital stay was 1 day. The conversion rate was 1.6%, the minor complication rate was 1.6%, and major complications occurred in 2.0% of patients. CONCLUSION:: Women with large uteri may successfully undergo robotically assisted hysterectomy with low morbidity, low blood loss, and minimal risk of conversion to laparotomy. Results were reproducible among general gynecologists from geographically diverse community settings. LEVEL OF EVIDENCE:: III.
“Robot-assisted total laparoscopic hysterectomy in obese and morbidly obese women.”
Rebeles, S. A., H. G. Muntz, et al. (2009).
Journal of Robotic Surgery 3(3): 141-147.
Total laparoscopic hysterectomy (TLH) in obese patients is challenging. We sought to evaluate whether total laparoscopic hysterectomies using the da Vinci robotic system in obese patients, in comparison with non-obese patients, is a reasonable surgical approach. One-hundred consecutive robot-assisted TLHs were performed over a 17-month period. Obesity was not a contraindication to robotic surgery, assuming adequate respiratory function to tolerate Trendelenburg position and, for cancer cases, a small enough uterus to allow vaginal extraction without morcellation. Data were prospectively collected on patient characteristics, total operative time, hysterectomy time, estimated blood loss, length of stay, and complications. Outcomes with non-obese and obese women were compared. The median age, weight, and BMI of the 100 patients who underwent robot-assisted TLH was 57. 6 years (30.0-90.6), 82.1 kg (51.9-159.6), and 30.2 kg/m<sup>2</sup> (19.3-60.2), respectively. Fifty (50%) patients were obese (BMI ≥ 30); 22 patients were morbidly obese (BMI ≥ 40). There was no increase in complications (p = 0.56) or blood loss (p = 0.44) with increasing BMI. While increased BMI was associated with longer operative times (p = 0.05), median time increased by only 36 min when comparing non-obese and morbidly obese patients. Median length of stay was one day for all weight categories (p = 0.42). Robot-assisted TLH is feasible and can be safely performed in obese patients. More data are needed to compare robot-assisted TLH with other hysterectomy techniques in obese patients. Nonetheless, our results are encouraging. Robot-assisted total laparoscopic hysterectomy may be the preferred technique for appropriately selected obese patients. © Springer-Verlag London Ltd 2009.
“Survival outcomes for women undergoing type III robotic radical hysterectomy for cervical cancer: A 3-year experience.”
Cantrell, L. A., A. Mendivil, et al. (2010).
OBJECTIVES.: To assess progression-free (PFS) and overall survival (OS) for women with cervical cancer who underwent type III robotic radical hysterectomy (RRH). METHODS.: A retrospective analysis of women who underwent RRH from 2005 to 2008 was performed. The data analyzed included patient demographics, histology, clinical stage, surgical margins, lymph node and disease status. Comparison was made to a group of historical open radical hysterectomies. Survival statistics were analyzed using the Kaplan-Meier method. RESULTS.: Seventy-one women underwent attempted RRH during the study period. Eight were excluded from analysis, 4 for non-cervical primary and 4 cases aborted due to extent of disease. Squamous was the most common histology (62%) followed by adenocarcinoma (32%). Median patient age was 43 years. There was one intraoperative complication (asystole after induction) and two postoperative complications (ICU admission to rule out myocardial infarction and reoperation for cuff dehiscence). Of the patients who underwent RRH, 32% received whole-pelvis radiation with chemo sensitization. The median follow-up was 12.2 months (range 0.2-36.3 months). Kaplan-Meier survival analysis demonstrated 94% PFS and OS at 36 months due to the recurrence and death of one patient. Compared with a historical cohort at our institution, there was no statistically significant difference in PFS (P=0.27) or OS (P=0.47). CONCLUSIONS.: RRH is safe and feasible and has been shown to be associated with improved operative measures. This study shows that at 3 years, RRH appears to have PFS and OS equivalent to that of traditional laparotomy. Longer follow-up is needed, but early data are supportive of at least equivalent oncologic outcomes compared with other surgical modalities.
“Surgical outcomes of robotic-assisted surgical staging for endometrial cancer are equivalent to traditional laparoscopic staging at a minimally invasive surgical center.”
Cardenas-Goicoechea, J., S. Adams, et al. (2010).
OBJECTIVE: To compare peri- and post-operative complications and outcomes of robotic-assisted surgical staging with traditional laparoscopic surgical staging for women with endometrial cancer. METHODS: A retrospective chart review of cases of women undergoing minimally invasive total hysterectomy and pelvic and para-aortic lymphadenectomy by a robotic-assisted approach or traditional laparoscopic approach was conducted. Major intraoperative complications, including vascular injury, enterotomy, cystotomy, or conversion to laparotomy, were measured. Secondary outcomes including operative time, blood loss, transfusion rate, number of lymph nodes retrieved, and the length of hospitalization were also measured. RESULTS: 275 cases were identified-102 patients with robotic-assisted staging and 173 patients with traditional laparoscopic staging. There was no significant difference in the rate of major complications between groups (p=0.13). The mean operative time was longer in cases of robotic-assisted staging (237 min vs. 178 min, p<0.0001); however, blood loss was significantly lower (109 ml vs. 187 ml, p<0.0001). The mean number of lymph nodes retrieved were similar between groups (p=0.32). There were no significant differences in the time to discharge, re-admission, or re-operation rates between the two groups. CONCLUSION: Robotic-assisted surgery is an acceptable alternative to laparoscopy for minimally invasive staging of endometrial cancer. In addition to the improved ease of operation, visualization, and range of motion of the robotic instruments, robotic surgery results in a lower mean blood loss, although longer operative time. More data are needed to determine if the rates of urinary tract injuries and other surgical complications can be reduced with the use of robotic surgery.
“Comparison of a novel surgical approach for radical hysterectomy: Robotic assistance versus open surgery.”
Feuer, G., B. Benigno, et al. (2009).
Journal of Robotic Surgery 3(3): 179-186.
To report the learning curve and perioperative outcomes for robotic radical hysterectomy using a unilateral surgical approach transferred directly from one surgeon’s open radical hysterectomy experience, thirty-two consecutive robotic radical hysterectomy cases (10/2006-1/2009) were contrasted to a cohort of 20 consecutive open radical hysterectomies (2/2005-2/2008). Perioperative characteristics compared included operative time, number of nodes, estimated blood loss, length of hospital stay, and complications. Robotic operative times were significantly longer than for open (122.1 ± 33.0 versus 67.5 ± 16.2 min, P < 0.0001), but decreased with experience, going from 156. 0 min for the first eight robotic cases to 95.0 min for the last eight cases (P < 0.05). Blood loss (99.2 ± 46.2 mL versus 275.0 ± 206.0 mL, P < 0.0001) and length of hospital stay (1.7 versus 5.2 days, P < 0.001) were significantly lower for the robotic cohort. Lymph node yield in the robotic cohort was equivalent to that for the open cohort (11.5 versus 9.2, P = 0.1446), and complication rates were 21.9% for robotic and 30.0% for open radical hysterectomy. Implementing a unilateral approach to maximize surgical efficiency greatly reduced surgical times without compromising patient morbidity, bringing robotic operative times while still within the learning curve close to those for open radical hysterectomy. Thus, robotic radical hysterectomy may soon be considered the preferred standard front-line therapy for cervical cancer. © Springer-Verlag London Ltd 2009.
“Letter to the Editor regarding “a case matched analysis of robotic radical hysterectomy with lymphadenectomy compared with laparoscopy and laparotomy”.”
Hall, J. B. (2010).
Gynecol Oncol 116(3): 588-589; author reply 590-581.
“Robotic approach for cervical cancer: Comparison with laparotomy. A case control study.”
Minig, L., V. Zanagnolo, et al. (2010).