Robotic radical hysterectomy

Instituting a robot-assisted surgery programme at a tertiary care cancer centre

BACKGROUND

The initial experience of a gynaecological oncology robotic surgery programme at a tertiary care cancer centre is described.

METHODS

A retrospective study was performed to evaluate the perioperative outcomes of 76 patients offered robot-assisted surgery.

RESULTS

Seventy-three patients underwent robot-assisted surgery; three cases were converted to laparotomy; 51% of patients underwent treatment for endometrial cancer; 18% had ovarian cancer risk reduction surgery; and 8% were treated for uterine leiomyomata. Median body mass index (BMI) was 30. Median estimated blood loss, operative time, and length of stay were 150 ml, 195 min and 1 day, respectively. The total major complication rate was 6.8% and the total minor complication rate was 15.1%.

CONCLUSION

Robot-assisted surgery is safe and appropriate for gynaecological patients undergoing surgical management. A gynaecological oncology robot-assisted programme can be easily established in a tertiary care cancer centre.

Reduced-force closed trocar entry technique: analysis of trocar insertion force using a mechanical force gauge

BACKGROUND AND OBJECTIVES

Trocar insertion injury has a high morbidity, mortality, and cost. The purpose of this study was to compare standard trocar entry with our reduced-force closed trocar entry technique by measuring trocar insertion force using a mechanical force gauge.

METHODS

In the operating room, the force gauge was inserted into a sterile glove and connected to the proximal portion of the trocar to measure insertion force. Through one incision, we used a standard closed trocar entry, while through the other incision, we used our reduced-force closed trocar entry technique. After making the skin incision and before trocar entry, we spread and dilated the skin, subcutaneous tissue, fascia, and muscle with a hemostat.

RESULTS

Twenty-five patients entered the trial and none were excluded. Median trocar insertion force was 3.3lb (range, 1.6 to 5.4) with our reduced-force trocar entry technique versus 6.5lb (range, 2.0 to 14.0) with the standard trocar entry (P=.001). No complications occurred with the reduced-force trocar entry technique.

CONCLUSION

Our reduced-force trocar entry technique decreases trocar insertion force by 50%, requires no additional instruments or cost and is fast and safe. Reduced-entry force pressure may decrease the risk of trocar insertion injury.

Role of Robot-Assisted Surgery in Cervical Cancer

Background:

The development of robotic technology has facilitated the application of minimally invasive techniques for complex operations in gynecologic oncology.

Objectives:

The objective of the study was to assess and summarize the current literature on the role of robot-assisted surgery in cervical cancer in terms of its utility and outcome.

Methods:

Literature review concerning the use of robot-assisted technology in the management of cervical cancer, including radical hysterectomy, trachelectomy, parametrectomy, pelvic and aortic lymphadenectomy, and pelvic exenteration, was performed.

Results:

To date, 12 articles addressing radical hysterectomy, 5 articles of radical trachelectomy, and 6 articles of surgical procedure in advanced or recurrent cervical cancer, all performed robotically, are published in the literature. The advantages of the robotic system include 3-dimensional vision, tremor reduction, motion downscaling, improved ergonomics, and greater dexterity with instrument articulation. Because of these benefits, the robotic technology seems to facilitate the surgical approach for technically challenging operations performed to treat primary, early or advanced, and recurrent cervical cancer as evidenced by the current literature.

Conclusions:

Surgical management of cervical cancer may be one of the gynecologic oncology surgeries that can take full advantage of robotic assistance in a minimally invasive manner. Continued research and clinical trials are needed to further elucidate the equivalence or superiority of robot-assisted surgery to conventional methods in terms of oncological outcome and patient's quality of life.

The twenty-first century role of Piver-Rutledge type III radical hysterectomy and FIGO stage IA, IB1, and IB2 cervical cancer in the era of robotic surgery: a personal perspective

Type III radical hysterectomy reported in 1974 by Piver, Rutledge, and Smith is considered worldwide by many as the standard surgical therapy for invasive cervical carcinoma stage IB and IIA. With the increasing number of robotic surgeries being performed for early stage cervical cancer worldwide, the purpose of the paper is to present our personal perspective of the 21st century role of Piver-Rutledge type III radical hysterectomy for stage IB cervical cancer in the era of robotic surgery using the da Vinci robot.

A case-control study of robotic radical hysterectomy and pelvic lymphadenectomy using 3 robotic arms compared with abdominal radical hysterectomy in cervical cancer

OBJECTIVE

The purpose of this study was to compare surgical outcomes of robotic radical hysterectomy (RRH) using 3 robotic arms with those of abdominal radical hysterectomy (ARH) in the treatment of early-stage cervical cancer.

METHODS

Thirty-two patients with stage IA2-IIB cervical carcinoma according to the International Federation of Gynecology and Obstetrics underwent RRH between June 2006 and February 2009. Patient outcomes were compared with those of a historic cohort of 32 patients who underwent ARH, who were matched for age, stage according to the International Federation of Gynecology and Obstetrics, and type of radical surgery.

RESULTS

All RRHs were completed robotically with no conversions to laparotomy. Robotic radical hysterectomy showed favorable outcomes over ARH in terms of the mean length of hospital stay (11.6 vs 16.9 days, P < 0.001) and the mean estimated blood loss (220 vs 531 mL, P = 0.002). The mean operating time and the number of lymph node retrievals were comparable. There were no significant differences in the incidence of postoperative complications between the 2 groups. The mean follow-up time was 15.3 months, and 2 patients in the RRH group had recurrences.

CONCLUSIONS

Robotic radical hysterectomy and pelvic lymphadenectomy using 3 robotic arms is feasible and preferable over ARH for the treatment of cervical cancer patients. Prospective randomized trials should be completed to confirm the potential benefits associated with RRH.

Laparoscopic cytoreduction for primary advanced ovarian cancer

Laparoscopic-assisted cytoreduction for primary advanced ovarian cancer was found to be a feasible intervention technique with minimal morbidity.

Introduction:

We evaluated the feasibility of laparoscopic cytoreduction for primary advanced ovarian cancer.

Methods:

All patients with presumed stage 3/4 primary ovarian cancer underwent attempted laparoscopic cytoreduction. All patients had CT evidence of omental metastasis and ascites. A 5-port (5-mm) transperitoneal approach was used. A bilateral salpingo-oophorectomy, supracervical hysterectomy, and omentectomy were performed with PlasmaKinetic (PK) cutting forceps. A laparoscopic 5-mm Argon-Beam Coagulator was used to coagulate tumor in the pelvis, abdominal peritoneum, intestinal mesentery, and diaphragm.

Results:

Nine of 11 cases (82%) were successfully de-bulked laparoscopically without conversion to laparotomy. Median operative time was 2.5 hours, and median blood loss was 275 mL. All tumors were debulked to <2 cm and 45% had no residual disease. Stages were 1–3B, 7–3C, and 1–4. Median length of stay was one day. Median VAS pain score was 4 (discomforting). Two of 11 patients (18%) had postoperative complications.

Conclusion:

Laparoscopic cytoreduction was successful and resulted in minimal morbidity. Because of our small sample size, additional studies are needed.

From open radical hysterectomy to robot-assisted laparoscopic radical hysterectomy for early stage cervical cancer: aspects of a single institution learning curve

We analysed the introduction of the robot-assisted laparoscopic radical hysterectomy in patients with early-stage cervical cancer with respect to patient benefits and surgeon-related aspects of a surgical learning curve. A retrospective review of the first 14 robot-assisted laparoscopic radical hysterectomies and the last 14 open radical hysterectomies in a similar clinical setting with the same surgical team was conducted. Patients were candidates for a laparoscopic sentinel node procedure, pelvic lymph node dissection and open radical hysterectomy (RH) before August 2006 and were candidates for a laparoscopic sentinel node procedure, pelvic lymph node dissection and robot-assisted laparoscopic radical hysterectomy (RALRH) after August 2006. Overall, blood loss in the open cases was significantly more compared with the robot cases. Median hospital stay after RALRH was 5 days less than after RH. The median theatre time in the learning period for the robot procedure was reduced from 9 h to less that 4 h and compared well to the 3 h and 45 min for an open procedure. Three complications occurred in the open group and one in the robot group. RALRH is feasible and of benefit to the patient with early stage cervical cancer by a reduction of blood loss and reduced hospital stay. Introduction of this new technique requires a learning curve of less than 15 cases that will reduce the operating time to a level comparable to open surgery.

Transvaginal application of a laparoscopic bipolar cutting forceps to assist vaginal hysterectomy in extremely obese endometrial cancer patients

INTRODUCTION

The purpose of this report is to evaluate our experience with transvaginal application of a laparoscopic bipolar cutting forceps to assist vaginal hysterectomy in extremely obese women with endometrial cancer in whom obesity precluded LAVH/BSO and lymphadenectomy and vaginal obesity limited visualization and exposure.

MATERIALS AND METHODS

We performed a retrospective review and identified 6 consecutive cases. No cases were excluded. A laparoscopic 33-cm Plasma Kinctic (PK) cutting forceps with a 5-mm diameter was applied transvaginally to coagulate and cut the uterosacral and cardinal ligaments, uterine vasculature, and ovarian ligaments. The uterus was delivered vaginally. Staging lymphadenectomy was not performed.

RESULTS

Median age was 51 years, median weight was 405 lbs, and median BMI was 66 kg/m². Five of 6 cases were successfully performed vaginally (83%). Median operative time was 1 hour 10 minutes, median blood loss was 500 mL, and pain was only discomforting. All patients were discharged the day after surgery. There were no complications. At median follow-up of 1 year, all patients were alive with no evidence of disease.

CONCLUSION

It is our opinion that the transvaginal application of a laparoscopic bipolar cutting forceps can successfully assist vaginal hysterectomy in extremely obese endometrial cancer patients who cannot tolerate LAVH/BSO and lymphadenectomy and vaginal obesity limits visualization and exposure.

Recent advances of robotic surgery and single port laparoscopy in gynecologic oncology

Two innovative approaches in minimally invasive surgery that have been introduced recently are the da Vinci robotic platform and single port laparoscopic surgery (SPLS). Robotic surgery has many advantages such as 3-dimensional view, the wrist like motion of the robotic arm and ergonomically comfortable position for the surgeon. Numerous literatures have demonstrated the feasibility of robotic surgery in gynecologic oncology. However, further research should be performed to demonstrate the superiority of robotic surgery compared to conventional laparoscopy. Additionally, cost reduction of robotic surgery is needed to adopt robotic surgery into gynecologic oncology worldwide. SPLS has several possible benefits including reduced operative complications, reduced postoperative pain, and better cosmetic results compared to conventional laparoscopy. Although several authors have indicated that SPLS is a feasible approach for gynecologic surgery, there have been few reports demonstrating the potential advantages over conventional laparoscopy. Moreover, technical difficulties of SPLS still exist. Therefore, the advantages of a single port approach compared to conventional laparoscope should be evaluated with comparative study, and further technologic development for SPLS is also needed. These two progressive technologies take the lead in the development of MIS and further studies should be performed to evaluate the benefits of robot surgery and SPLS.

Current status of robotic assisted pelvic surgery and future developments

AIMS

The aim of this review is to assess the role of robotics in pelvic surgery in terms of outcomes. We have also highlighted the issues related to training and future development of robotic systems.

MATERIALS AND METHODS

We searched MEDLINE, EMBASE and the Cochrane Databases from 1980 to 2009 for systematic reviews of randomised controlled trials, prospective observational studies, retrospective studies and case reports assessing robotic surgery.

RESULTS

During the last decade, there has been a tremendous rise in the use of robotic surgical systems for all forms of precision operations including pelvic surgery. The short-term results of robotic pelvic surgery in the fields of urology, colorectal surgery and gynaecology have been shown to be comparable to the laparoscopic and open surgery. Robotic surgery offers an opportunity where many of these obstacles encountered during open and laparoscopic surgery can be overcome.

CONCLUSIONS

Robotic surgery is a continually advancing technology, which has opened new horizons for performing pelvic surgery with precision and accuracy. Although its use is rapidly expanding in all surgical disciplines, particularly in pelvic surgery, further comparative studies are needed to provide robust guidance about the most appropriate application of this technology within the surgical armamentarium.

Complications of laparoscopic radical hysterectomy and pelvic lymphadenectomy--experience of 117 patients

OBJECTIVE

To describe the combined surgical technique of laparoscopic radical hysterectomy and pelvic lymphadenectomy (LRH + LPL) for cervical cancers and summarize our experiences in prevention and treatment of complications, so as to provide strategies to prevent and appropriately manage the complications that may occur during these procedures.

METHODS

A retrospective study was conducted on LRH + LPL in 117 cases of cervical cancer with International Federation of Gynecology and Obstetrics stages Ib (n = 96) and II a (n = 21) from August 1998 to December 2006. The intraoperative and postoperative complications were analyzed.

RESULTS

The overall conversion rate was 1.7% (2/117). Four patients had vessel injuries, 3 of which were treated laparoscopically. One patient had a common iliac vein laceration that could not be controlled laparoscopically after failing to deal with the injured branch of common iliac vein. Cystotomy occurred in 5 patients. One case of stage IIa with a bladder laceration longer than 3 cm was converted to laparotomy during the early stages of the learning curve. The remaining 4 were managed laparoscopically. Postoperative complications occurred in 38.5% (n = 45) of the patients, including 38 patients with urinary retention who exhibited complete resolution within 6 months by intermittent training and catheterization, 4 with lymphocyst who underwent conservation treatment, 1 with ureteral fistula that was treated by cystoscopic placement of double-J ureteral stents, 1 with mild adynamic bowel obstruction who received conservative management, and 1 with vesicovaginal fistula that was closed by conservative treatment.

CONCLUSIONS

With the continuous skilled laparoscopic technology, mastering the tips of prevention, and treatment of complications, LRH + LPL will be widely performed in the future.

Evolving role and current state of robotics in minimally invasive gynecologic surgery

Advancements in conventional laparoscopy afford gynecologists the ability to treat disease with minimally invasive interventions. Procedures such as hysterectomy are still performed predominantly via laparotomy. Instrumentation, complex disease, and steep learning curves are often cited as obstacles to minimally invasive surgery. The advent of robotic technology may provide a means to overcome the limitations of conventional laparoscopy through the use of 3-dimensional imaging and more dextrous and precise instruments. Current studies clearly demonstrate the feasibility and safety of applying robotics to the entire spectrum of gynecologic procedures. Rigorous scientific studies and long-term data are needed to determine the appropriate applications of robotics in gynecology. Numerous questions still exist pertaining to costs, credentialing and privileging, and training.

Robotic approach for cervical cancer: comparison with laparotomy: a case control study

OBJECTIVE

To compare the surgical outcome of robotic radical hysterectomy (RRH) versus abdominal radical hysterectomy (ARH) for the treatment of early stage cervical cancer.

METHODS

A prospective collection of data of all RRH for stages IA2-IIA cervical cancer was done. The procedures were performed at the European Institute of Oncology, Milan, Italy, between November 1, 2006 and February 1, 2009.

RESULTS

A total of 40 RRH were analyzed, and compared with 40 historic ARH cases. The groups did not differ significantly in body mass index, stage, histology, or intraoperative complications, but in age (p=0.035). The mean (SD) operative time was significantly shorter for ARH than RRH, 199.6 (65.6) minutes and 272.27 (42.3) minutes respectively (p=0.0001). The mean (SD) estimated blood loss (EBL) was 78 ml (94.8) in RRH group and 221.8 ml (132.4) in ARH. This difference was statistically significant in favor of RRH group (p<0.0001). Statistically significantly higher number of pelvic lymph nodes was removed by ARH than by RRH, mean (SD) 26.2 (11.7) versus 20.4 (6.9), p<0.05. Mean length of stay was significantly shorter for the RRH group (3.7 versus 5.0 days, p<0.01). There was no significant difference in terms of postoperative complications between groups.

CONCLUSION

This study shows that RRH is safe and feasible. However, a comparison of oncologic outcomes and cost-benefit analysis is still needed and it has to be carefully evaluated in the future.

Robotic surgery in gynecologic oncology: impact on fellowship training

OBJECTIVES

To report the impact of a new robotic surgery program on the surgical training of gynecologic oncology fellows over a 12 month period of time.

METHODS

A robotic surgery program was introduced into the gynecologic oncology fellowship program at Northwestern University Feinberg School of Medicine in June 2007. A database of patients undergoing surgical management of endometrial and cervical cancer between July 2007 and July 2008 was collected and analyzed. Changes in fellow surgical training were measured and analyzed.

RESULTS

Fellow surgical training for endometrial and cervical cancer underwent a dramatic transition in 12 months. The proportion of patients undergoing minimally invasive surgery increased from 3.3% (4/110 patients) to 43.5% (47/108 patients). Fellow training transitioned from primarily an open approach (94.4%) to a minimally invasive approach (11% laparoscopic, 49% robotic, 40% open) for endometrial cancer stagings, and from an open approach (100%) to an open (50%) and robotic (50%) approach for radical hysterectomies. Fellow participation in robotic procedures increased from 45% in the first 3 months to 72% within 6 months, and 92% by 12 months. The role of the fellow in robotic cases transitioned from bedside assistant to console operator within 3 months.

CONCLUSIONS

Fellow surgical training underwent a dramatic change with the introduction of a robotic surgery program. The management of endometrial and cervical cancer was impacted the most by robotics. Robotic surgery broadened fellowship surgical training, but balanced surgical training and standardized fellow training modules remain challenges for fellowship programs.

[Robotic assistance in gynaecological surgery: State-of-the-art]

From the Automated Endoscopic System for Optimal Positioning (AESOP), a robotic arm which operates the laparoscope, to the robots Zeus and da Vinci, robotic assistance in gynaecological endoscopic surgery has continuously evolved for the last fifteen years or so. It has brought about new technical advancements: the last generation robots offer a steady three-dimensional image, improved instrument dexterity and precision, higher ergonomics and comfort for the surgeon. The da Vinci robotic system has been used without evincing any specific morbidity in various cases, notably for tubal reanastomosis, myomectomy, hysterectomy, pelvic and para-aortic lymphadenectomy or sacrocolpopexy amongst others. Robotic assistance in gynaecology is thus feasible. Like conventional laparoscopic surgery, it allows decreased blood loss and morbidity as well as shorter hospital stay, as compared to laparotomy. It might indeed allow many surgical teams to perform minimally invasive surgical procedures which they were not used to performing by laparoscopy. Randomized prospective studies are needed to define its indications more precisely. Besides, its medico-financial impact should be evaluated too.

A comparison of robot-assisted and traditional radical hysterectomy for early-stage cervical cancer

A robotics surgery program was introduced into the division of gynecologic oncology at Northwestern University Feinberg School of Medicine in June 2007. A prospective database of all patients undergoing a type III radical hysterectomy for stage IB1 cervical cancer between July 2007 and June 2008 was collected and analyzed. Demographic data and perioperative outcomes were analyzed between a traditional and robot-assisted approach. A total of 14 patients were identified who underwent a type III radical hysterectomy for stage IB1 cervical cancer. Seven patients underwent robotic surgery and seven patients underwent traditional surgery. There were no significant differences in median age or body mass index between the two groups. A significant difference in blood loss between robotic (75 cc) and traditional (700 cc) surgery was detected (P = 0.002). A significant difference in hospital stay between robotic (1 day) and traditional (5 days) surgery was observed (P = 0.0007). No significant difference in operative time (260 vs. 264 min) or lymph node yield (19 and 14) was identified between the robotic and traditional approaches. No major operative complications occurred with robotic radical hysterectomy. Robot-assisted radical hysterectomy was associated with a significant reduction in blood loss and hospital stay. Improved nodal yields, fewer operative complications, and less pain was observed with the robotic approach. Robot-assisted radical hysterectomy appears safe and feasible and further investigation is warranted in a prospective fashion.

Robotic gynecologic surgery

The objective of this article is to review the recent adoption, experience, and applications of robot-assisted laparoscopy in gynecologic surgery. The use of robotics in gynecologic surgery is increasing in the United States. Robotic-assisted laparoscopic surgeries in gynecology include benign hysterectomy, myomectomy, tubal reanastomoses, radical hysterectomy, lymph node dissections, and sacrocolpopexies. The majority of the current literature includes case series of various robotic surgeries. Recently, comparative retrospective and prospective studies have demonstrated the feasibility of this particular type of surgery. Although individual studies vary, robot-assisted gynecologic surgery is often associated with longer operating room time but generally similar clinical outcomes, decreased blood loss, and shorter hospital stay. Robot-assisted gynecologic surgery will likely continue to develop as more gynecologic surgeons are trained and more patients seek minimally invasive surgical options. Well-designed, prospective studies with well-defined clinical, long-term outcomes, including complications, cost, pain, return to normal activity, and quality of life, are needed to fully assess the value of this new technology.

Robotic surgery for cervical cancer

The development of robotic technology has facilitated the application of minimally invasive techniques for the treatment and evaluation of patients with early, advanced, and recurrent cervical cancer. The application of robotic technology for selected patients with cervical cancer and the data available in the literature are addressed in the present review paper. The robotic radical hysterectomy technique developed at the Mayo Clinic Arizona is presented with data comparing 27 patients who underwent the robotic procedure with 2 matched groups of patients treated by laparoscopic (N = 31), and laparotomic radical hysterectomy (N = 35). A few other studies confirmed the feasibility and safety of robotic radical hysterectomy and comparisons to either to the laparoscopic or open approach were discussed. Based on data from the literature, minimally invasive techniques including laparoscopy and robotics are preferable to laparotomy for patients requiring radical hysterectomy, with some advantages noted for robotics over laparoscopy. A prospective randomised trial is currently being performed under the auspices of the American Association of Gyneoclogic Laparoscopists comparing minimally invasive radical hysterectomy (laparoscopy or robotics) with laparotomy. For early cervical cancer radical parametrectomy and fertility preserving trachelectomy have been performed using robotic technology and been shown to be feasible, safe, and easier to perform when compared to the laparoscopic approach. Similar benefits have been noted in the treatment of advanced and recurrent cervical cancer where complex procedures such as extraperitoneal paraortic lymphadenectomy and pelvic exenteration have been required.

CONCLUSION

Robotic technology better facilitates the surgical approach as compared to laparoscopy for technically challenging operations performed to treat primary, early or advanced, and recurrent cervical cancer. Although patient advantages are similar or slightly improved with robotics, there are multiple advantages for surgeons.