Minimally invasive comprehensive surgical staging for endometrial cancer: Robotics or laparoscopy?

Management of early stage, high-risk endometrial carcinoma: preoperative and surgical considerations

Endometrial cancer is the most common gynecologic malignancy in the developed world. Most cases are diagnosed at an early stage and have low-grade histology, portending an overall excellent prognosis. There exists a subgroup of patients with early, high-risk disease, whose management remains controversial, as current data is clouded by inclusion of early stage tumors with different high-risk features for recurrence, unstandardized protocols for surgical staging, and an evolving staging system by which we are grouping these patients. Here, we present preoperative and intraoperative considerations that should be taken into account when planning surgical management for this population of patients.

Integration of robotics into two established programs of minimally invasive surgery for endometrial cancer appears to decrease surgical complications

Objective

To compare peri- and postoperative outcomes and complications of laparoscopic vs. robotic-assisted surgical staging for women with endometrial cancer at two established academic institutions.

Methods

Retrospective chart review of all women that underwent total hysterectomy with pelvic and para-aortic lymphadenectomy by robotic-assisted or laparoscopic approach over a four-year period by three surgeons at two academic institutions. Intraoperative and postoperative complications were measured. Secondary outcomes included operative time, blood loss, transfusion rate, number of lymph nodes retrieved, length of hospital stay and need for re-operation or re-admission.

Results

Four hundred and thirty-two cases were identified: 187 patients with robotic-assisted and 245 with laparoscopic staging. Both groups were statistically comparable in baseline characteristics. The overall rate of intraoperative complications was similar in both groups (1.6% vs. 2.9%, p=0.525) but the rate of urinary tract injuries was statistically higher in the laparoscopic group (2.9% vs. 0%, p=0.020). Patients in the robotic group had shorter hospital stay (1.96 days vs. 2.45 days, p=0.016) but an average 57 minutes longer surgery than the laparoscopic group (218 vs. 161 minutes, p=0.0001). There was less conversion rate (0.5% vs. 4.1%; relative risk, 0.21; 95% confidence interval, 0.03 to 1.34; p=0.027) and estimated blood loss in the robotic than in the laparoscopic group (187 mL vs. 110 mL, p=0.0001). There were no significant differences in blood transfusion rate, number of lymph nodes retrieved, re-operation or re-admission between the two groups.

Conclusion

Robotic-assisted surgery is an acceptable alternative to laparoscopy for staging of endometrial cancer and, in selected patients, it appears to have lower risk of urinary tract injury.

Robot-assisted hysterectomy compared to open and laparoscopic approaches: systematic review and meta-analysis

PURPOSE

To review the safety and effectiveness of robot-assisted hysterectomy compared to traditional open and conventional laparoscopic surgery, differentiating radical, simple total with node staging, and simple total hysterectomy.

METHODS

Medline, Embase, the Cochrane library, and the Journal of Robotic Surgery were searched for controlled trials and observational studies with historic or concurrent controls. Data were pooled using random effects meta-analysis.

RESULTS

Compared to open surgery, robot-assisted radical hysterectomy is associated with reduced hospital stay and blood transfusions. For simple total hysterectomy with node staging, robot-assisted surgery is associated with reduced hospital stay, complications, and blood transfusions compared to open surgery. Compared to conventional laparoscopic surgery, robot-assisted simple total hysterectomy with node staging is associated with complications and conversions.

CONCLUSIONS

Compared to open surgery, robot-assisted hysterectomy offers benefits for reduced length of hospital stay and blood transfusions. The best evidence of improved outcomes is for simple total hysterectomy with node staging. Study quality was poor.

Analysis of disease recurrence and survival for women with uterine malignancies undergoing robotic surgery

OBJECTIVES

To evaluate recurrence-free survival (RFS) and overall survival (OS) for patients who underwent robotic-assisted laparoscopic hysterectomy (RALH) for uterine malignancies.

METHODS

Medical records from 372 patients with uterine malignancies who underwent RALH from 3/06 to 3/09 at two institutions were reviewed for clinico-pathologic data, adjuvant therapies, disease recurrence, and survival. Median follow-up for survival analysis was 31 ± 14 months. Thirty (8.1%) patients were lost to follow-up before 12 months and censored from the recurrence analysis.

RESULTS

Mean age and BMI of 372 patients was 61.8 ± 9.8 years and 32.2 ± 8.4 kg/m(2) (range 19-70). Robotic procedures included RALH 16 (4.3%), RALH with pelvic lymphadenectomy (PL) 96 (25.8%), and RALH with pelvic-and-aortic lymphadenectomy (PAL) 252 (67.7%) cases. Histology included 319 (85.8%) endometrioid and 53 (12.6%) high-risk histologies. Mean pelvic and aortic lymph node counts were 16.8 ± 8.7 and 8.4 ± 4.5, respectively. Lymph node metastases were identified in 26 (7.3%) cases. Adjuvant therapies were prescribed for 108 (29.1%) of patients: 7.8% brachytherapy, 1.9% pelvic radiation+brachytherapy, 7.8% chemotherapy, 11.6% chemotherapy+radiation. Risk of recurrence for all patients was 8.3% and 17 (4.6%) patients died of disease. The estimated 3-year recurrence-free survival (RFS) for the entire study group was 89.3% and the estimated 5-year overall survival (OS) was 89.1%, compared to 92.5% and 93.4% for the endometrioid sub-set.

CONCLUSIONS

Patients with endometrial cancer undergoing robotic hysterectomy with staging lymphadenectomies during our 3-years of robotic experience had low-risk for recurrence and excellent disease-specific survival at a median follow-up time of 31 months.

Clinical outcomes in endometrial cancer care when the standard of care shifts from open surgery to robotics

INTRODUCTION

In Singapore, the standard of care for endometrial cancer staging remains laparotomy. Since the introduction of gynecologic robotic surgery, there have been more data comparing robotic surgery to laparoscopy in the management of endometrial cancer. This study reviewed clinical outcomes in endometrial cancer in a program that moved from laparotomy to robotic surgery.

METHODS

A retrospective review was performed on 124 consecutive endometrial cancer patients. Preoperative data and postoperative outcomes of 34 patients undergoing robotic surgical staging were compared with 90 patients who underwent open endometrial cancer staging during the same period and in the year before the introduction of robotics.

RESULTS

There were no significant differences in the mean age, body mass index, rates of diabetes, hypertension, previous surgery, parity, medical conditions, size of specimens, histologic type, or stage of cancer between the robotic and the open surgery groups. The first 20 robotic-assisted cases had a mean (SD) operative time of 196 (60) minutes, and the next 14 cases had a mean time of 124 (64) minutes comparable to that for open surgery. The mean number of lymph nodes retrieved during robot-assisted staging was smaller than open laparotomy in the first 20 cases but not significantly different for the subsequent 14 cases. Robot-assisted surgery was associated with lower intraoperative blood loss (110 [24] vs 250 [83] mL, P < 0.05), a lower rate of postoperative complications (8.8% vs 26.8%, P = 0.032), a lower wound complication rate (0% vs 9.9%, P = 0.044), a decreased requirement for postoperative parenteral analgesia (5.9% vs 51.1, P < 0.001), and shorter length of hospitalization (2.0 [1.1] vs 6.0 [4.5] days, P < 0.001) compared to patients in the open laparotomy group.

CONCLUSIONS

Our series shows that outcomes traditionally associated with laparoscopic endometrial cancer staging are achievable by laparoscopy-naive gynecologic cancer surgeons moving from laparotomy to robot-assisted endometrial cancer staging after a relatively small number of cases.

The place of robotics in gynecologic surgery

Robot-assisted laparoscopic gynecologic surgery has undergone widespread development in recent years. The surgical literature on this subject continues to grow. The goal of this article is to summarize the principal indications for robotic assistance in gynecologic surgery and to offer a general overview of the principal articles dealing with robotic surgery for both benign and malignant disease.

The commercialization of robotic surgery: unsubstantiated marketing of gynecologic surgery by hospitals

OBJECTIVE

We analyzed the content, quality, and accuracy of information provided on hospital web sites about robotic gynecologic surgery.

STUDY DESIGN

An analysis of hospitals with more than 200 beds from a selection of states was performed. Hospital web sites were analyzed for the content and quality of data regarding robotic-assisted surgery.

RESULTS

Among 432 hospitals, the web sites of 192 (44.4%) contained marketing for robotic gynecologic surgery. Stock images (64.1%) and text (24.0%) derived from the robot manufacturer were frequent. Although most sites reported improved perioperative outcomes, limitations of robotics including cost, complications, and operative time were discussed only 3.7%, 1.6%, and 3.7% of the time, respectively. Only 47.9% of the web sites described a comparison group.

CONCLUSION

Marketing of robotic gynecologic surgery is widespread. Much of the content is not based on high-quality data, fails to present alternative procedures, and relies on stock text and images.

Minimally invasive surgery in gynecologic oncology: a review of modalities and the literature

Minimally invasive surgery is one of the newest and most exciting areas of development in procedural medicine. This field shows tremendous potential to increase therapeutic benefit while minimizing some of the painful or dangerous side effects of surgical interventions. Minimally invasive surgery has strong historic ties to the field of gynecology and has come a long way as technology and techniques have improved. This has increasingly allowed the application of laparoscopy to more complex procedures and the treatment of gynecologic malignancies. Three laparoscopic approaches, traditional laparoscopy, robotic assisted laparoscopy and laparoendoscopic single-site surgery are reviewed here. We discuss the basic approaches to these three laparoscopic techniques, and then review their applications in gynecologic oncology. We also touch on the evidence behind outcomes associated with their use.

Robotic-assisted gynecologic/oncologic surgery: experience of early cases in a Saudi Arabian tertiary care facility

We report early experience of a case-mix series of robotic-assisted (RA) gynecologic/oncologic surgery in an Arabian population from a tertiary care facility, and discuss the emergence/growth of robotic surgery in the Arab world (Middle East). From December 2005 to December 2010, 60 consecutive patients [benign with complex pathology (BN, n = 34) and 26 cases with various malignancies; i.e., endometrial cancer (EC, n = 13), ovarian cancer (OC, n = 4), cervical cancer (CC, n = 1), and other cancers (OTH, n = 8), underwent RA procedures for the diagnosis/treatment/management of gynecologic/oncologic diseases at a single institution using the da Vinci(®) Surgical System. Data were analyzed for demographics, clinico-pathologic and peri/post-operative factors using intent-to-treat analysis. Despite continuous growth in the number of cases performed each year, the establishment of the robotic surgery program at our institution has been rather challenging due to patient acceptance, public awareness, and administrative resistance. The mean age of the case-mix was 43 ± 15 years (distribution: BN 39 ± 14, EC 61 ± 6, OC 36 ± 15, CC 50, OTH 41 ± 12 years). The body mass index for the case-mix was 30.3 ± 6.9 kg/m(2) (distribution: BN 29.7 ± 6.2, EC 34.0 ± 3.6, OC 20.0 ± 1.7, CC 48, OTH 30.2 ± 6.2 kg/m(2)). The histology of most EC cases was endometrioid adenocarcinoma. The mean operative time was case-mix 95 ± 43, BN 77 ± 26, EC 156 ± 30, OC 80 ± 35, CC 150, OTH 79 ± 23 min. Mean blood loss was case-mix 126, BN 129, EC 177, OC 67, CC 50, OTH 71 min. Two cases (3.3%) were converted to laparotomy (one each in EC and BN groups). Mean hospital length of stay was 2 days. Four cases (6.7%) experienced complications. Only 4/26 (15.4%) of cancer cases required adjuvant therapy. The data suggest that RA gynecologic/oncologic procedures are feasible and satisfactory to our Arabian patient population and comparable to the existing literature for Caucasian counterparts. We believe this report is the first (and perhaps largest) case-mix series on the early experience of RA surgery for gynecologic/oncologic cases from the Middle East.

Robotic surgery applications in the management of gynecologic malignancies

This review evaluates the use of robotic-assisted laparoscopic surgery in the treatment of gynecologic malignancies and objectively evaluates the use of these systems in performing radical hysterectomies and surgical staging of gynecologic malignancies. The review focuses on surgical length, blood loss, complications, recovery time, and adequacy of surgical staging of robotic-assisted surgery compared to abdominal and non-robotically assisted laparoscopic surgery for malignancies.

[Robotic surgery in endometrial cancer: a review]

Robotic surgery has spread for a few years. This access is now important in urologic surgery, especially for prostatic procedures. Development of robotic surgery in gynecology is more recent. Gynecologic oncology is probably one of the most interesting fields of development of this access. Robotic surgery is frequently used in endometrial cancer. As no randomized study is available, it seems to be interesting to make a review of retrospective studies. Feasibility seems to be high and the learning curve is short (around 20 cases). Operative lengths are longer when compared to laparotomy, but are similar or shorter than laparoscopy. Robot setting increases the global length of the procedure, but decreases with experience. Operative blood loss, as well as transfusion rate are decreased when compared to laparotomy, but are similar to those of laparoscopy. The overall morbidity rate seems lower than with other approaches. Postoperative pain, hospital stay and time to recovery are decreased when compared to laparotomy as well as to laparoscopy for some authors. The main limit to the diffusion of robotic surgery is accessibility because of its important cost. Other limits are pointed out by the most trained teams.

Comparative effectiveness of robotic versus laparoscopic hysterectomy for endometrial cancer

PURPOSE

Use 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 METHODS

The 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.

RESULTS

We 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).

CONCLUSION

Despite 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.

Robotic assisted surgery for gynaecological cancer

BACKGROUND

Robotic surgery is the latest innovation in the field of minimally invasive surgery. Robotic surgical systems have been used to perform surgery for endometrial, cervical cancer and ovarian cancer. There is mounting evidence which demonstrates the feasibility and safety of robotic surgery for gynaecological oncology.

OBJECTIVES

To evaluate the evidence for and against robotic assisted surgery in gynaecological cancer.

SEARCH METHODS

We searched the Cochrane Gynaecological Cancer Review Group Trials Register, Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2010, Issue 2), MEDLINE and EMBASE (up to July 2010) and citation lists of relevant publications.

SELECTION CRITERIA

All randomised controlled trials (RCTs) comparing robotic assisted surgery for gynaecological cancer to laparoscopic or open surgical procedures as well as RCTs comparing different types of robotic assistants.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened studies for inclusion. No RCTs were identified, therefore data collection and analysis could not be performed.

MAIN RESULTS

No studies were found that met the inclusion criteria. Controlled clinical trials (CCTs) are summarised and analysed, but are not discussed in the main body of the review as they present a high risk of bias.

AUTHORS' CONCLUSIONS

Well-designed RCTs are required as only low quality evidence from CCTs is available. These studies support the use of robotic assisted surgery for endometrial cancer and cervical cancer, but these findings present a high risk of bias.

Evolution of surgical management of early-stage endometrial cancer

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.

Total laparoscopic hysterectomy versus da Vinci robotic hysterectomy: is using the robot beneficial?

OBJECTIVE

To compare the outcomes of total laparoscopic to robotic approach for hysterectomy and all indicated procedures after controlling for surgeon and other confounding factors.

METHODS

Retrospective chart review of all consecutive cases of total laparoscopic and da Vinci robotic hysterectomies between August 2007 and July 2009 by two gynecologic oncology surgeons. Our primary outcome measure was operative procedure time. Secondary measures included complications, conversion to laparotomy, estimated blood loss and length of hospital stay. A mixed model with a random intercept was applied to control for surgeon and other confounders. Wilcoxon rank-sum, chi-square and Fisher's exact tests were used for the statistical analysis.

RESULTS

The 124 patients included in the study consisted of 77 total laparoscopic hysterectomies and 47 robotic hysterectomies. Both groups had similar baseline characteristics, indications for surgery and additional procedures performed. The difference between the mean operative procedure time for the total laparoscopic hysterectomy group (111.4 minutes) and the robotic hysterectomy group (150.8 minutes) was statistically significant (p=0.0001) despite the fact that the specimens obtained in the total laparoscopic hysterectomy group were significantly larger (125 g vs. 94 g, p=0.002). The robotic hysterectomy group had statistically less estimated blood loss than the total laparoscopic hysterectomy group (131.5 mL vs. 207.7 mL, p=0.0105) however no patients required a blood transfusion in either group. Both groups had a comparable rate of conversion to laparotomy, intraoperative complications, and length of hospital stay.

CONCLUSION

Total laparoscopic hysterectomy can be performed safely and in less operative time compared to robotic hysterectomy when performed by trained surgeons.

Robotic surgery in gynecologic oncology

Robotic surgery for the management of gynecologic cancers allows for minimally invasive surgical removal of cancer-bearing organs and tissues using sophisticated surgeon-manipulated, robotic surgical instrumentation. Early on, gynecologic oncologists recognized that minimally invasive surgery was associated with less surgical morbidity and that it shortened postoperative recovery. Now, robotic surgery represents an effective alternative to conventional laparotomy. Since its widespread adoption, minimally invasive surgery has become an option not only for the morbidly obese but for women with gynecologic malignancy where conventional laparotomy has been associated with significant morbidity. As such, this paper considers indications for robotic surgery, reflects on outcomes from initial robotic surgical outcomes data, reviews cost efficacy and implications in surgical training, and discusses new roles for robotic surgery in gynecologic cancer management.

Operative and anesthetic outcomes in endometrial cancer staging via three minimally invasive methods

The aim of this work is to compare operative and anesthetic outcomes in patients undergoing minimally invasive endometrial cancer staging, with lymphadenectomy performed via transperitoneal, extraperitoneal, or robotic-assisted methods. Sixty-six consecutive patients (24 transperitoneal, 19 extraperitoneal, and 23 robotic) were identified who underwent laparoscopic-assisted endometrial cancer staging with pelvic and para-aortic lymphadenectomy. Patients were divided into three groups based on method of para-aortic lymphadenectomy. Anesthetic and surgical times were longest in the extraperitoneal group. Patients undergoing robotic surgery had the shortest hospital stay and lowest conversion rate to laparotomy. Patients undergoing robotic lymphadenectomy had more pelvic and para-aortic nodes removed compared with the transperitoneal method. There was no difference in number of para-aortic nodes removed in the robotic versus extraperitoneal methods. The extraperitoneal group had highest peak end-tidal CO2 levels and highest narcotic requirements, while patients in the robotic group had highest peak inflation pressures and lowest pain scores. There were no differences in complication rates amongst the three groups. Robotic-assisted staging is superior to other minimally invasive methods in terms of most operative outcomes. Extraperitoneal lymphadenectomy is equivalent to robotic surgery where number of aortic nodes is concerned, but is associated with higher end-tidal CO2 levels and narcotic requirements. Peak inflation pressures were highest in the robotic group, with no apparent adverse consequences.

Minimally invasive surgical approaches for patients with endometrial cancer

Over the past 10 years, multiple studies have shown that minimally invasive surgical approaches for the treatment of endometrial cancer reduce blood loss, length of hospital stay, and the incidence and severity of surgical complications compared with laparotomy. In addition, minimally invasive approaches result in better cosmesis and short-term patient quality of life. Although data from prospective studies have yet to mature, laparoscopic and open surgeries seem to be equivalent oncologically. In this article, we will review the current literature on traditional laparoscopy, robotically assisted laparoscopy, and single-port laparoscopy as surgical approaches for the treatment of endometrial cancer.

Are costs of robot-assisted surgery warranted for gynecological procedures?

The exponential use of robotic surgery is not the result of evidence-based benefits but mainly driven by the manufacturers, patients and enthusiastic surgeons. The present review of the literature shows that robot-assisted surgery is consistently more expensive than video-laparoscopy and in many cases open surgery. The average additional variable cost for gynecological procedures was about 1600 USD, rising to more than 3000 USD when the amortized cost of the robot itself was included. Generally most robotic and laparoscopic procedures have less short-term morbidity, blood loss, intensive care unit, and hospital stay than open surgery. Up to now no major consistent differences have been found between robot-assisted and classic video-assisted procedures for these factors. No comparative data are available on long-term morbidity and oncologic outcome after open, robotic, and laparoscopic gynecologic surgery. It seems that currently only for very complex surgical procedures, such as cardiac surgery, the costs of robotics can be competitive to open surgical procedures. In order to stay viable, robotic programs will need to pay for themselves on a per case basis and the costs of robotic surgery will have to be reduced.

The impact of surgical guidelines and periodic quality assessment on the staging of endometrial cancer

OBJECTIVE

To determine the impact of surgical guidelines and transparent periodic assessment of surgical quality on endometrial cancer (EC) staging by gynecologic oncologists in a single institution and to identify process-of-care, patient-specific, and disease-specific risk factors that influence surgical quality.

METHODS

In January 2004, a prospective treatment algorithm was implemented for EC at our institution. The number of nodes harvested was a surrogate, and staging quality from 2004 to 2008 (quality assessment [QA] interval) was compared with the previous 5 years (pre-QA interval). Since 2004, low-risk cases based on frozen section examination had not undergone lymphadenectomy and were excluded. Independent patient-specific, disease-specific, and surgery-related risk factors influencing lymphadenectomy quality during both intervals were identified with multivariable logistic regression analysis.

RESULTS

Pelvic and para-aortic lymph node dissection (LND) in surgical EC management before QA (n=420) were 77.9% and 48.8% vs 89.3% and 83.4% during the QA (n=561) (P<.001). The median number of pelvic and para-aortic nodes harvested in LND was 29 and 10 before QA vs 34 and 16 during the QA interval (P<.001). With acceptance of stringent criteria for defining systematic LND (mean node count-1 SD) during the QA, systematic pelvic (≥22 nodes) and para-aortic (≥10 nodes) LNDs occurred in 57.4% and 25.7% of cases before QA vs 77.9% and 70.7% during the QA interval (P<.001). In patients with LND, rates of systematic pelvic and para-aortic LND were 73.7% and 53.0% before vs 87.2% and 84.8% after QA (P<.001). Multivariable logistic regression analysis showed independent factors influencing systematic pelvic and para-aortic LND (P<.01): surgeon and stage during the pre-QA interval vs surgical approach; intraoperative ascites; body mass index; surgeon; patient age; and myometrial invasion after QA implementation.

CONCLUSION

Inclusion of detailed surgical guidelines and transparent periodic assessment of surgical quality translated to dramatic improvement in quality of surgical EC staging. This implementation was associated with a transition to more patient-specific risk factors influencing systematic LND. Although surgical quality metrics were markedly enhanced during QA, persistent variability observed among surgeons and the change in surgical approach render continuous QA and improvement obligatory.

Robotic-assisted total laparoscopic hysterectomy and staging for the treatment of endometrial cancer: a comparison with conventional laparoscopy and abdominal approaches

The treatment of endometrial cancer using a minimally invasive approach provides benefits to the patient; however, there are currently few papers comparing robotic total laparoscopic hysterectomy with staging to conventional laparoscopic and abdominal approaches. Analyses of 102 consecutive patients undergoing robotic total hysterectomy were compared to historical cohorts of 104 patients undergoing laparoscopic total hysterectomy and 78 patients undergoing abdominal total hysterectomy (laparotomy). The majority of all patients were FIGO'88 stage IB. Patient characteristics were similar, except for lower age (P = 0.0236) and body mass index (P = 0.0134) in the laparoscopy group when compared to laparotomy. Operative time was longer for the robotic group at 108.7 min, compared to 79.4 min for laparoscopy (P = 0.0207) and 84.0 min for laparotomy (P < 0.0001). Lymph node yield was significantly higher in the robotic group (16.0 nodes) when compared to both laparoscopy (5.0 nodes, P < 0.0001) and laparotomy (11.4 nodes, P = 0.0006). The perioperative complication rates were significantly decreased in both the robotic (10.8%) and laparoscopy (6.7%) groups when compared to laparotomy at 25.6% (P = 0.0089; P = 0.0002). Hospital stay was significantly reduced in both the robotic (1.9 days, P < 0.0001) and laparoscopic (1.8 days, P < 0.0001) groups when compared to laparotomy (4.1 days). Both minimally invasive approaches reduced morbidity. Robotic assistance resulted in improved lymph node yield. Robotic surgery for endometrial cancer is at least equivalent to laparoscopic and open techniques and may be the preferred method for treatment of endometrial cancer.

Surgical outcomes in gynecologic oncology in the era of robotics: analysis of first 1000 cases

OBJECTIVE

We sought to examine outcomes in an expanding robotic surgery (RS) program.

STUDY DESIGN

In all, 1000 women underwent RS from May 2006 through December 2009. We analyzed patient characteristics and outcomes. A total of 377 women undergoing RS for endometrial cancer staging (ECS) were compared with the historical data of 131 undergoing open ECS.

RESULTS

For the entire RS cohort of 1000, the conversion rate was 2.9%. Body mass index increased over 3 time intervals: T1 = 26.2, T2 = 29.5, T3 = 30.1 (T1:T2, P = .01; T1:T3, P = .0001; T2:T3, P = .037). Increasing body mass index was not associated with increased major complications: T1 = 8.7%, T2 = 4.3%, T3 = 5.7%. In the ECS cohort, as compared with open ECS, women undergoing RS had lower blood loss (46.9 vs 197.6 mL, P < .0001), shorter hospitalization (1.4 vs 5.3 days, P < .0001), fewer major complications (6.4% vs 20.6%, P < .0001), with higher lymph node counts (15.5 vs 13.1, P = .007).

CONCLUSION

RS is associated with favorable morbidity and conversion rates in an unselected cohort. Compared to laparotomy, robotic ECS results in improved outcomes.

Learning curve and surgical outcome for robotic-assisted hysterectomy with lymphadenectomy: case-matched controlled comparison with laparoscopy and laparotomy for treatment of endometrial cancer

STUDY OBJECTIVE

To determine the learning curve for robotic-assisted hysterectomy with lymphadenectomy for surgical treatment of endometrial cancer.

DESIGN

An analysis of robotic-assisted hysterectomy with lymphadenectomy vs total laparoscopic hysterectomy with lymphadenectomy and laparotomy with total abdominal hysterectomy with lymphadenectomy (Canadian Task Force classification II-1).

SETTING

Solo, experienced, minimally invasive gynecologic oncology practice in a tertiary hospital.

PATIENTS

One hundred forty-eight patients including 56 patients who underwent robotic-assisted hysterectomy with bilateral pelvic and paraaortic lymph node dissection, 56 patients who underwent total laparoscopic hysterectomy with bilateral pelvic and paraaortic lymph node dissection, and 36 patients who underwent traditional total abdominal hysterectomy with bilateral pelvic and paraaortic lymph node dissection performed by the same surgeon for treatment of endometrial cancer.

INTERVENTIONS

Robotic-assisted hysterectomy with bilateral lymphadenectomy, total laparoscopic hysterectomy with bilateral lymphadenectomy, and traditional total abdominal hysterectomy with bilateral lymphadenectomy were performed. Data were categorized by chronologic order of cases into groups of 20 patients each. The learning curve of the surgical procedure was estimated by measuring operative time with respect to chronologic order of each patient who had undergone the respective procedure.

MEASUREMENTS AND MAIN RESULTS

For the 3 surgical procedures, data analyzed included mean age, body mass index, operative time, blood loss, lymph node retrieval, and complications. Mean (SD); 95% confidence interval [CI]) operative time for the 3 procedures was statistically significant: 162.5 (53) minutes (95% CI, 148.6-176.4]), 192.3 (55.5) minutes (95% CI, 177.6-207.0), and 136.9 (32.3) minutes (95% CI, 126.3-147.5), respectively. Analysis of operative time for robotic-assisted hysterectomy with bilateral lymph node dissection with respect to chronologic order of each group of 20 cases demonstrated a decrease in operative time: 183.2 (69) minutes (95% CI; 153.0-213.4) for cases 1 to 20, 152.7 (39.8) minutes (95% CI, 135.3-170.1) for cases 21 to 40, and 148.8 (36.7) minutes (95% CI, 130.8-166.8) for cases 41 to 56. For the groups with laparoscopic hysterectomy with lymphadenectomy and traditional total abdominal hysterectomy with lymphadenectomy, there was no difference in operative time with respect to chronologic group order of cases. There was a difference between the number of lymph nodes retrieved between robotic-assisted hysterectomy with bilateral lymphadenectomy (26.7 [12.8]; 95% CI, 23.3-30.1) compared with laparoscopic hysterectomy with bilateral lymphadenectomy (45.1 [20.9]; 95% CI, 39.6-50.6) and traditional total abdominal hysterectomy with lymphadenectomy (55.8 [23.4]; 95% CI, 48.2-63.4). The rate of intraoperative complications for laparoscopic hysterectomy with bilateral lymphadenectomy was 12.5% (7 of 56) compared with 0 % for robotic-assisted hysterectomy with bilateral lymphadenectomy. The rate of postoperative complications was 14.3% (8 of 56), 21.4% (12 of 56), and 19.4% (7 of 36), respectively, for the 3 groups. There was less blood loss with robotic-assisted hysterectomy with bilateral lymphadenectomy (89.3 [45.4]; 95% CI, 77.4-101.2) compared with laparoscopic hysterectomy with bilateral lymphadenectomy (209.1 [91.8]; 95% CI, 185.1-233.1) and traditional total abdominal hysterectomy with lymphadenectomy (266.0 [145.1]; 95% CI, 218.6-313.4). Duration of hospitalization was shorter in the group with robotic-assisted hysterectomy with bilateral lymphadenectomy (1.6 [0.7]; 95% CI, 1.4-1.8) compared with the groups who underwent laparoscopic hysterectomy with bilateral lymphadenectomy (2.6 [0.9]; 95% CI, 2.4-2.8) or traditional total abdominal hysterectomy with lymphadenectomy (4.9 [1.9]; 95% CI, (4.3-5.5).

CONCLUSION

The learning curve for robotic-assisted hysterectomy with lymph node dissection seems to be easier compared with that for laparoscopic hysterectomy with lymph node dissection for surgical management of endometrial cancer.

Relationship Between Body Mass Index and Robotic Surgery Outcomes of Women Diagnosed With Endometrial Cancer

Objective:

This is a prospective evaluation of the outcome of minimal invasive surgery using robotics in function of the body mass index (BMI) of patients.

Methods:

This is a prospective cohort study of consecutive women undergoing surgery for endometrial cancer at a tertiary care facility since the initiation of a robotic program in December 2007. Surgical and personal outcome variables as well as quality of life and postoperative recovery were assessed using a combination of objective and subjective/self-report questionnaires. Women were divided into 3 groups based on their BMI. Comparative analyses among nonobese (n = 52), obese (n = 33) and morbidly obese (n = 23) women were performed on the outcome measures after surgery.

Results:

The mean BMI and the range in each of the BMI categories was 25 kg/m2 (18.7-29.4 kg/m2), 34 kg/m2 (30.1-38.4 kg/m2), and 46 kg/m2 (40.0-58.8 kg/m2). Women with higher BMI tended to be more frequently affected with comorbidities such as diabetes (15.4%, 26.0%, and 27.3%, respectively; P = 0.32) and hypertension (55.8%, 69.6%, and 69.7%, respectively; P = 0.19). Despite these differences, surgical console time (P = 0.20), major postoperative complications (P = 0.52), overall wound complications (P = 0.18), and median length of hospitalization in days (P = 0.17) were not statistically different among the 3 groups. Only 5.6% of women needed a mini laparotomy all of which were performed for the removal of their enlarged uterus, which could not be delivered safely via the vagina, at the end of the surgical procedure. There was no increased conversion to laparotomy due to increased BMI. Women in all 3 groups reported rapid resumption of hygiene regimens and chores, little need for narcotic analgesia, and high satisfaction with the procedure.

Conclusions:

Obese and morbidly obese patients with endometrial cancer are also good candidates for robotic surgery. These women benefit considerably from minimal invasive surgery and have little perioperative complications.

Racial disparities in surgical care for uterine cancer

OBJECTIVE

To evaluate the association of race and surgical approach for women who underwent surgical treatment for uterine cancer.

METHODS

The design was a retrospective cohort study of discharge data from nonfederal acute care hospitals in Maryland from 2000 to 2009. Women aged 18 and older who underwent hysterectomy for uterine cancer were included in the study population. The main outcome measure was receipt of lymphadenectomy. Secondary outcomes included receipt of minimally-invasive surgical approach, in-hospital mortality and individual surgeon and individual hospital annual uterine cancer case volume. The independent variable was race. We used logistic regression to calculate odds ratios and confidence intervals for each outcome of interest. Caucasians were the reference group.

RESULTS

Among 5470 women who underwent hysterectomy, 2727 (49.9%) underwent lymphadenectomy and 512 (9.4%) underwent surgery through a minimally-invasive approach. After adjusting for age, payer status and APR-DRG mortality risk score, African-Americans were more likely to be operated on by high-volume surgeons (adjusted OR=1.27, 95% CI: 1.09-1.49) yet were less likely to undergo minimally-invasive surgery (adjusted OR=0.60, 95% CI: 0.45-0.80). For the outcome of lymphadenectomy, there was no significant difference between Caucasians and African-Americans (OR=1.13, 95% CI: 0.98-1.30). There was no association between race and in-hospital mortality or between race and the odds of undergoing surgery at a high-volume hospital.

CONCLUSION

In this retrospective analysis of uterine cancer patients, race is associated with likelihood of undergoing surgery through a minimally-invasive approach. Further analysis using prospectively collected data with more detail regarding peri-operative parameters is needed to further clarify possible reasons for this disparity.

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.