Davenport, W. B., M. P. Lowe, et al. (2012). “Outcomes of obese versus non-obese subjects undergoing robotic-assisted hysterectomy: a multi-institutional study.” Journal of Robotic Surgery: 1-6.
The goal of our study was to determine whether there was a difference in operative outcomes in obese versus non-obese subjects undergoing robotic-assisted hysterectomies of varying levels of difficulty. Secondarily, we sought to analyze the published outcomes between robotic-assisted hysterectomy and total laparoscopic hysterectomy in obese women at each of these levels of difficulty. This was a multi-institutional retrospective cohort study of all patients undergoing robotic-assisted hysterectomy by five gynecologic oncologists at four geographically separate locations from April 2003 to March 2008. The cohort was stratified into obese vs. non-obese groups, and defined surgical outcomes compared between groups, then further divided into three subgroups based on case difficulty level. Univariate analysis and regression analysis using SAS 9.1 was performed. We then conducted a literature search of total laparoscopic hysterectomy outcomes in obese women, dividing the resulting studies into three comparative subgroups based on surgical difficulty levels for comparison with our robotic-assisted hysterectomy results. Our cohort had 228 obese and 323 non-obese subjects. Overall, the obese group had higher blood loss and longer operative time. When further stratified by level of difficulty, obese subjects also had a higher average blood loss and longer operative time in the hysterectomy-alone subgroup. No clinically significant differences in operative outcomes exist between obese and non-obese women when utilizing the da Vinci robotic system to perform a hysterectomy, independent of case difficulty level. More prospective, controlled studies which compare the two surgical approaches of robotic-assisted and laparoscopic hysterectomy approaches are needed. © 2012 Springer-Verlag London Ltd.
Liu, H., D. Lu, et al. (2012). “Robotic surgery for benign gynaecological disease.” Cochrane Database of Systematic Reviews 2: CD008978.
BACKGROUND: Robotic surgery is the latest innovation in the field of minimally invasive surgery. In the case of robotic surgery, instead of directly moving the instruments the surgeon uses a robotic system to control the instruments for surgical procedures. Robotic surgical systems have been used in various gynaecological surgeries for benign disease, such as hysterectomy (removal of the uterus), myomectomy (removal of uterine leiomyomas) and tubal reanastomosis (the reuniting of a divided tube). The mounting evidence demonstrates the feasibility and safety of robotic surgery in benign gynaecological disease. Robotic surgery is advertised as having promising advantages including more precise vision and procedures, improved ergonomics and shorter length of hospital stay. However, the main disadvantages of the robotic surgical system should not be overlooked, including the high cost of disposable instruments and retraining for both surgeons and nurses. OBJECTIVES: To assess the effectiveness and safety of robot-assisted surgery in the treatment of benign gynaecological disease. SEARCH METHODS: We searched the Cochrane Menstrual Disorders and Subfertility Group’s Trial Register, the Cochrane Central Register of Controlled Trials (CENTRAL) (Issue 2, 2011), MEDLINE and EMBASE up to November 2011 and citation lists of relevant publications. SELECTION CRITERIA: All randomised controlled trials (RCTs) comparing robotic surgery for benign gynaecological disease to laparoscopic or open surgical procedures. RCTs comparing different types of robotic assistants were also included. We contacted study authors for unpublished information, but failed in obtaining a response. DATA COLLECTION AND ANALYSIS: Two review authors independently screened studies for inclusion. The domains assessed for risk of bias were allocation concealment, blinding, incomplete outcome data and selective outcome reporting. Odds ratios (OR) were used for reporting dichotomous data with 95% confidence intervals (CI), whilst mean differences (MD) were determined for continuous data. Statistical heterogeneity was assessed using the I(2) statistic. We contacted the primary authors for missing data but failed in obtaining a response. MAIN RESULTS: Two trials involving 158 participants were included. Since one included trial was published in conference proceedings, limited usable data were available for further analysis. The only analysis in this trial showed comparable rates of conversions to open surgery between the robotic group and the laparoscopic group (OR 1.41, 95% CI 0.22 to 9.01; P = 0.72). One RCT showed longer operation time (MD 66.00, 95% CI 40.93 to 91.07; P < 0.00001), higher cost (MD 1936.00, 95% CI 445.69 to 3426.31; P = 0.01) in the robotic group compared with the laparoscopic group. Also, both studies reported that robotic and laparoscopic surgery seemed comparable regarding intraoperative outcome, complications, length of hospital stay and quality of life. AUTHORS’ CONCLUSIONS: Currently, the limited evidence showed that robotic surgery did not benefit women with benign gynaecological disease in effectiveness or in safety. Further well-designed RCTs with complete reported data are required to confirm or refute this conclusion.
Berger, J. L. and P. T. Ramirez (2012). “Surgical management of cervical carcinoma.” Hematology/Oncology Clinics of North America 26(1): 63-78.
Cervical cancer is the second most common cancer in women worldwide. In developed countries screening programs have decreased the incidence of this disease and improved the detection of early-stage disease amenable to surgical intervention. This article discusses the scope of surgical treatment of cervical carcinoma, including conization for the earliest-stage and lowest-risk patients, radical hysterectomy with lymphadenectomy, radical trachelectomy for appropriately selected patients who desire future fertility, and pelvic exenteration for recurrent disease. In addition, current surgical advances such as surgical staging methods and minimally invasive approaches are discussed. © 2012 Elsevier Inc.
Boruta Ii, D. M., W. B. Growdon, et al. (2011). “Evolution of surgical management of early-stage endometrial cancer.” American Journal of Obstetrics and Gynecology 205(6): 565.e561-565.e566.
Objective: We sought to examine the evolution of surgical care for early-stage endometrial cancers and factors affecting use of laparoscopy. Study Design: Women with surgically managed early-stage endometrial cancer were divided into 2 groups corresponding to before and after addition of faculty with formal fellowship training in laparoscopic staging and access to a robotic surgery platform. Results: In all, 502 women were identified. Laparoscopic management increased from 24-69% between time periods (P <.0001). Performance of comprehensive surgical staging, and lymph node counts, increased (P <.0001) despite an increase in median body mass index (P =.001). A traditional “straight stick” technique was performed in 72% of laparoscopic cases during the later period. Laparoscopy patients had lower estimated blood losses and shorter hospital stays (each P <.0001) compared to laparotomy patients. Conclusion: Addition of faculty with formal fellowship training in laparoscopic staging and access to a robotic surgery platform shifted management of early-stage endometrial cancer toward laparoscopy. © 2011 Mosby, Inc.
Dennis, T., C. De Mendona, et al. (2012). “Study of surplus cost of robotic assistance for radical hysterectomy, versus laparotomy and standard laparoscopy.” Étude du surcoût de la cœlioscopie assistée par robot dans l’hystérectomie élargie 40(2): 77-83.
Objectives: The study purpose was to compare the costs among robotic, laparoscopic and open radical hysterectomy for cervical cancer. Patients and methods: Thirty-seven patients underwent robotic radical hysterectomy for cervical cancer. Cases were performed by three surgeons, at two institutions, and were retrospectively reviewed to perform a cost comparison between all three modalities. We included costs for edible materials in anesthesia and surgery, but costs for staff and indirect financial expenses were excluded. Those data are compared to open and laparoscopic radical hysterectomy data. Results: The average cost for robotic assistance presented a surplus of 1796 euros compare to laparotomy and 1313 euros compare to standard laparoscopy in 2008, and 1320 and 837 euros respectively. Discussion and conclusion: The average cost for radical hysterectomy was highest for robotic, followed by standard laparoscopy, and least for laparotomy. However, over only 2 years of use, this difference tends to decrease. Medico-economic impact is the main restraint for robotic assistance development, and needs to be assessed permanently. © 2011 Elsevier Masson SAS. All rights reserved.
Geisler, J. P., C. Orr, et al. (2011). “Robotically-assisted laparoscopic radical parametrectomy and radical vaginectomy.” European Journal of Gynaecological Oncology 32(6): 674-676.
Background: Radical parametrectomy is a technically challenging operation used for women found to have occult cervix cancer after a hysterectomy for benign reasons. A similar operation, radical vaginectomy, is rarely performed because of the its technical difficulty in getting adequate margins without an attached uterus. Case Reports: A 41-year-old woman was found to have a presumed surgical Stage IB1 squamous cell carcinoma of the cervix at time of surgery for uterine prolapse. The patient was offered multiple options of surgery and chemoradiation. A second case, a 55-year-old woman, was found to have 1 cm vaginal cancer nine years after a total vaginal hysterectomy for carcinoma in situ of the cervix. She was also offered chemoradiation versus surgery. For the robotically-assisted laparoscopic radical parametrectomy operating time was 186 minutes with an estimated blood loss of 250 ml. For the robotically-assisted laparoscopic radical vaginectomy operating time was 154 minutes with an estimated blood loss of 150 ml. Neither patient had a hospitalization over 24 hours. There were no intraoperative or postoperative complications. Conclusions: Robotically-assisted laparoscopic radical paremetrectomy and vaginectomy are both technically feasible procedures.
Köhler, C., S. Marnitz, et al. (2012). “Operative treatment for women with invasive cervical cancer.”Operative Therapie bei Frauen mit invasivem Zervixkarzinom: 1-10.
Currently there is a wide spectrum of possible operations available for patients with primary cervical cancer extending from conization (± sentinel lymphadenectomy) to primary exenteration. Therefore, exact knowledge of the tumor stage is essential to determine an individual treatment plan. Fertility-preserving operations in terms of radical vaginal trachelectomy can be offered to young patients with small tumors less than 2 cm in size and tumor-free lymph nodes with high oncologic safety. Only laparoscopic (extraperitoneal or transperitoneal) staging in patients with cervical cancer stages IA2-IIA allows those cases to be differentiated which should be treated by primary chemoradiation from those which should undergo radical hysterectomy in order to avoid the significantly higher toxicity of trimodal therapy. Various techniques of radical hysterectomy have been described ranging from abdominal nerve-sparing radical hysterectomy to total mesometrial resection (TMMR), laparoscopic-assisted radical vaginal hysterectomy (LARVH), total laparoscopic radical hysterectomy (TLRH) and robotic radical hysterectomy (RRH). All approaches seem to be oncologically adequate; however, no randomized studies comparing the various surgical techniques have yet been carried out. Patients with cervical cancer FIGO stage IVA should also be informed about the possibility of primary exenteration despite the lack of comparative data to primary chemoradiation. There is an absolute necessity for interdisciplinary cooperation (even preoperative) between radiooncologists, pathologists, hematooncologists and gynecologic oncologists within the framework of gynecologic-oncologic centers to define an optimal treatment plan for each patient with cervical cancer. © 2012 Springer-Verlag.
Leitao, M. M., Jr., G. Briscoe, et al. (2012). “Introduction of a computer-based surgical platform in the surgical care of patients with newly diagnosed uterine cancer: Outcomes and impact on approach.”Gynecologic Oncology.
OBJECTIVE: To assess the introduction of computer-based surgery (ie, robotic surgery [RBT]) in the treatment of patients with newly diagnosed uterine cancer. METHODS: We identified all patients who presented to our institution for initial surgical care of newly diagnosed uterine cancer from 5/1/07-12/31/10. Perioperative outcomes of laparotomy cases were compared to those of laparoscopic (LSC) or RBT cases. Complications within 30days of surgery were graded. RESULTS: Of 752 patients, the planned approach was laparotomy in 103 (14%), LSC in 302 (40%), and RBT in 347 (46%). The rate of laparotomy for any reason (planned or converted) was 39% in 2007 compared to 18% in 2010 (P<0.001). Preoperative characteristics for LSC and RBT cases were similar, except 10% versus 15%, respectively, were morbidly obese (P=0.049). The extent of procedure, total nodal counts, and overall complications were similar between the LSC and RBT cases. The median length of stay was shorter for RBT cases (P<0.001). The median total room and operative times were longer for RBT cases (P<0.001), mainly due to cases in which the surgeon had less than ~40 RBT cases of experience. CONCLUSIONS: Robotics can be efficiently introduced into the surgical care of patients with newly diagnosed uterine cancers. RBT cases require the same operative times as LSC cases after accounting for the 40-case learning curve. Both approaches result in similar excellent patient outcomes and remain reasonable approaches for this disease. The introduction of robotics may lead to further reduction in the rate of laparotomy.
Pilka, R., R. Marek, et al. (2011). “[Robot assisted laparoscopic staging of endometrial cancer--comparison with standard laparotomy].” Ceska Gynekologie 76(6): 462-468.
OBJECTIVE: To describe our initial experience with robotically assisted laparoscopic staging of endometrial cancer patients as compared with previous cases staged by standard laparotomy. DESIGN: Original article. SETTING: Department of Obstetrics and Gynecology, Faculty of Medicine and Dentistry, Palacky University and University Hospital Olomouc. METHODS: The first twenty patients with early stage endometrial cancer underwent hysterectomy, bilateral salpingo-oophorectomy, and pelvic/paraaortic lymphadenectomy using four-armed da Vinci S HD surgical system (TRH) and were compared with previous 20 cases of staging procedures as done by laparotomy (TAH). Age, body mass index (BMI), clinical stage of disease, grade, histopathology, nodal yield, operative time, estimated blood loss, hospital stay, recovery room stay and analgesic needs were documented and compared. RESULTS: Mean age of patients in the robotic surgery group was 64,55 (47-85) years and in the laparotomy group 62,95 years (35-79). BMI was 27,45 (19-34) in TRH and 32,2 (26-55) in TAH group. There was no difference in FIGO stage, grade and histopathology between both groups. Node yield was slightly higher in TRH (16,95) than in TAH (14,9) group. Operative time was 262,25 min. (170-390) for TRH and 141,6 min. (97-175) for TAH. Estimates of blood loss were 102 (10-300) ml in the robotic surgery group and 352,5 (200-500) ml for TAH group. The average hospital stay was longer for the laparotomy than the robot group (8,75 vs. 7,20 days respectively). There was one conversion to laparotomy in TRH group. Within the “learning curve” gradually shortening operation time, recovery time and lowering blood loss were observed with number of performed robotic operations. CONCLUSION: Robotic hysterectomy and staging is associated with lower blood loss, lower use of narcotics and shorter hospital stay than standard laparotomy during “learning curve” period.
Schorge, J. O., E. E. Eisenhauer, et al. (2012). “Current surgical management of ovarian cancer.”Hematology/Oncology Clinics of North America 26(1): 93-109.
Surgical management of ovarian cancer requires excellent judgment andmastery of a wide array of procedures. Involvement of a gynecologic oncologist improves outcomes. Staging of apparent stage I disease is important. Minimally invasive techniques provide advantages. Primary debulking surgery provides the best long-term survival of any strategy in advanced ovarian cancer. Aggressive surgical paradigms have the greatest success. Further cytoreductive surgery may be appropriate. Most relapsed patients require management of bowel obstruction at some point. Palliative intervention can enhance quality of life. Surgical correction may extend survival. For end-stage patients with progressive disease, the treating gynecologic oncologist must manage expectations. © 2012 Elsevier Inc.
Wright, J. D., W. M. Burke, et al. (2012). “Comparative Effectiveness of Robotic Versus Laparoscopic Hysterectomy for Endometrial Cancer.” Journal of Clinical Oncology.
PURPOSEUse of robotics in oncologic surgery is increasing; however, reports of safety and efficacy are from highly experienced surgeons and centers. We performed a population-based analysis to compare laparoscopic hysterectomy and robotic hysterectomy for endometrial cancer. PATIENTS AND METHODSThe Perspective database was used to identify women who underwent a minimally invasive hysterectomy for endometrial cancer from 2008 to 2010. Morbidity, mortality, and cost were evaluated using multivariable logistic and linear regression models.ResultsWe identified 2,464 women, including 1,027 (41.7%) who underwent laparoscopic hysterectomy and 1,437 (58.3%) who underwent robotic hysterectomy. Women treated at larger hospitals, nonteaching hospitals, and centers outside of the northeast were more likely to undergo a robotic hysterectomy procedure, whereas black women, those without insurance, and women in rural areas were less likely to undergo a robotic hysterectomy procedure (P < .05 for all). The overall complication rate was 9.8% for laparoscopic hysterectomy versus 8.1% for robotic hysterectomy (P = .13). The adjusted odds ratio (OR) for any morbidity for robotic hysterectomy was 0.76 (95% CI, 0.56 to 1.03). After adjusting for patient, surgeon, and hospital characteristics, there were no significant differences in the rates of intraoperative complications (OR, 0.68; 95% CI, 0.42 to 1.08), surgical site complications (OR, 1.49; 95% CI, 0.81 to 2.73), medical complications (OR, 0.64; 95% CI, 0.40 to 1.01), or prolonged hospitalization (OR, 0.85; 95% CI, 0.64 to 1.14) between the procedures. The mean cost for robotic hysterectomy was $10,618 versus $8,996 for laparoscopic hysterectomy (P < .001). In a multivariable model, robotic hysterectomy was significantly more costly ($1,291; 95% CI, $985 to $1,597). CONCLUSIONDespite claims of decreased complications with robotic hysterectomy, we found similar morbidity but increased cost compared with laparoscopic hysterectomy. Comparative long-term efficacy data are needed to justify its widespread use.
Cronin, C., M. Hewitt, et al. (2012). “Robot-assisted laparoscopic cervical cerclage as an interval procedure.”Gynecological Surgery: 1-5.
Salamon, C. G. and P. J. Culligan (2012). “Subjective and objective outcomes 1 year after robotic-assisted laparoscopic sacrocolpopexy.” Journal of Robotic Surgery: 1-4.
We aimed to assess the subjective and objective outcomes 1 year after robotic sacrocolpopexy using a type I polypropylene mesh. This was a case series of 64 patients who underwent a robotic-assisted laparoscopic sacrocolpopexy using a type I monofilament polypropylene mesh coated with hydrophilic porcine collagen. Objective and subjective outcomes were assessed using the pelvic organ prolapse quantification (POP-Q), the short forms of the Pelvic Floor Impact Questionnaire (PFIQ 7) and the Pelvic Floor Distress Inventory (PFDI-20). Outcome measures were collected pre-operatively and 1 year post-operatively on all but one patient, who was lost to follow-up. Paired comparisons between pre- and post-operative outcomes were performed using the Wilcoxon signed rank test. At 1 year, POP-Q stage II or greater and loss of follow-up were considered to be surgical failure. The “surgical cure” rate was 89%. We observed three distal anterior failures, two distal posterior failures and one apical failure, and one patient was lost to follow-up. We found significant differences between pre- and post-operative POP-Q measurements (p < 0.001) and PFDI-20/PFIQ-7 total scores (p < 0.001). Robotic sacrocolpopexy using this polypropylene mesh resulted in significant improvements in subjective and objective outcome measures at 1 year. © 2012 Springer-Verlag London Ltd.