Robotic radical hysterectomy for stage 1B1 cervical cancer: A case series of survival outcomes from a leading UK cancer centre

An optimized robotic surgical technique for cervical cancer: investigating whether the use of the pulling robotic arm has better surgical outcomes

Objective

The evidence for adopting the 3^rd robotic arm (RA) called the pulling RA rather than a uterine manipulator to manipulate the uterus in the robotic radical hysterectomy (RRH) for cervical cancer is still limited. We present a single-center retrospective experience comparing using the pulling RA to replace a uterine manipulator vs. using a uterine manipulator to manipulate the uterus in RRH.

Methods

106 patients diagnosed with IA, IB1-IB2 and IIA1 cervical cancer were retrospectively included for intraoperative and postoperative parameters analysis. 50 patients received RRH by adopting the pulling RA instead of a uterine manipulator to pull the uterus (3-RA RRH group), and another 56 patients were performed RRH with a uterine manipulator (2-RA RRH group). RRH with the pulling RA consisted of a camera arm, 3 RAs including a pulling RA, and 2 conventional assistant arms (3-RA RRH group). In comparison, RRH with a uterine manipulator included 2 RAs and 2 conventional assistant arms (2-RA RRH group). Besides, 3-RA' RRH group was selected from the 25^th-50^th cases in the 3-RA RRH group based on the learning curve and was compared with the 2-RA RRH group in terms of intraoperative and postoperative parameters.

Results

The patients' early post-operative complication (≤7 days) (p=0.022) and post-operative anemia (p < 0.001) of the 3-RA RRH were significantly lower than that in the 2-RA RRH group. The results of comparing the 2-RA RRH group with the 3-RA' RRH group were consistent with the aforementioned results, except for the operative time (220.4 vs. 197.4 minutes, p=0.022) and hospital stay (7.8 vs. 8.7 days, p=0.034). The median follow-up in the 3-RA RRH and 2-RA RRH groups was 29 and 50 months till March 2023. The 3-RA RRH and 2-RA RRH groups' recurrence rates were 2% (1/50) and 5.4% (3/56), respectively. The mortality in the 3-RA RRH and 2-RA RRH groups was 2% (1/50) and 3.5% (2/56), respectively.

Conclusion

Our study suggested that replacing the uterine manipulator via the 3^rd RA is viable; the results showed comparable surgical outcomes between the two methods. Thus, 3-RA RRH could be considered a well-executed surgical option in well-selected patients.

Minimally invasive pelvic exenteration for gynaecological malignancy: A single-centre case series and review of the literature

For those with certain recurrent gynaecological cancers where primary management such as chemo-radiotherapy has failed, or in cases of recurrence following primary surgery, pelvic exenteration (PE) is considered the only curative option. Whilst initially considered a morbid procedure, improved surgical techniques, advancing technology, and nuanced reconstructive options have facilitated more radical resections and improved morbidity and mortality. Open PE remains the gold standard approach, however, minimally invasive techniques for PE may lessen morbidity whilst achieving the same oncological outcomes. The objective of this study was to assess the feasibility and safety of minimally invasive PE with a laparoscopic or robot-assisted approach. We also performed a review of the literature on robot-assisted PE which has not been widely reported for cases of recurrent gynaecological malignancy. Between 2015 and 2021six minimally invasive PE were performed. All patients underwent extensive multi-disciplinary assessment and counselling pre-operatively. Patient characteristics, treatment indication, perioperative data, short-term complications, and histological outcomes were recorded. There were two anterior exenterations, three posterior exenterations and one total exenteration performed. The primary cancer stage varied from stage 1a-3b. Five out of six patients had pre-operative chemo-radiotherapy. The average operative time (including surgical docking) was 600 min. Mean blood loss was 400 mL and the average length of stay was eight days. Enhanced recovery practices were used where possible. There were no intraoperative complications and one major post-operative complicationwhich was breakdown of an inferior gluteal artery perforator flap perineal reconstruction. All patients had negative margins at post-operative histopathology. All patients are alive and recurrence free at follow-up, but long-term outcome data is needed. This initial case series suggest that minimally invasive pelvic exenterationcan feasibly be performed in place of open pelvic exenteration. Furthermore, our findings suggest this may be a safe alternative as we report similar findings to the existing literature, however no firm conclusions can be drawn at such an early stage. Long term follow-up data and a larger cohort study will be needed to establish non-inferiority to open PE.

Laparoscopic and Robotic Surgery for Endometrial and Cervical Cancer

Minimally invasive surgery (MIS) has many benefits, in the form of reduced postoperative morbidity, improved recovery and reduced inpatient stay. It is imperative, however, when new techniques are adopted, in the context of treating oncology patients, that the oncological efficacy and safety are established rigorously rather than assumed based on first principles. Here we have attempted to provide a comprehensive review of all the contentious and topical themes surrounding the use of MIS in the treatment of endometrial and cervix cancer following a thorough review of the literature. On the topic of endometrial cancer, we cover the role of laparoscopy in both early and advanced disease, together with the role and unique benefits of robotic surgery. The surgical challenge of patients with a raised body mass index and the frail and elderly are discussed and finally the role of sentinel lymph node assessment. For cervical cancer, the role of MIS for staging and primary treatment is covered, together with the interesting and highly specialist topics of fertility-sparing treatment, ovarian transposition and the live birth rate associated with this. We end with a discussion on the evidence surrounding the role of adjuvant hysterectomy following radical chemoradiation and pelvic exenteration for recurrent cervical cancer. MIS is the standard of care for endometrial cancer. The future of MIS for cervix cancer, however, remains uncertain. Current recommendations, based on the available evidence, are that the open approach should be considered the gold standard for the surgical management of early cervical cancer and that MIS should only be adopted in the context of research. Careful counselling of patients on the current evidence, discussing in detail the risks and benefits to enable them to make an informed choice, remains paramount.