The impact of robotics on practice management of endometrial cancer: transitioning from traditional surgery

The Role of Robotic Visceral Surgery in Patients with Adhesions: A Systematic Review and Meta-Analysis

Abdominal adhesions are a risk factor for conversion to open surgery. An advantage of robotic surgery is the lower rate of unplanned conversions. A systematic review was conducted using the terms “laparoscopic” and “robotic”. Inclusion criteria were: comparative studies evaluating patients undergoing laparoscopic and robotic surgery; reporting data on conversion to open surgery for each group due to adhesions and studies including at least five patients in each group. The main outcomes were the conversion rates due to adhesions and surgeons’ expertise (novice vs. expert). The meta-analysis included 70 studies from different surgical specialities with 14,329 procedures (6472 robotic and 7857 laparoscopic). The robotic approach was associated with a reduced risk of conversion (OR 1.53, 95% CI 1.12–2.10, p = 0.007). The analysis of the procedures performed by “expert surgeons” showed a statistically significant difference in favour of robotic surgery (OR 1.48, 95% CI 1.03–2.12, p = 0.03). A reduced conversion rate due to adhesions with the robotic approach was observed in patients undergoing colorectal cancer surgery (OR 2.62, 95% CI 1.20–5.72, p = 0.02). The robotic approach could be a valid option in patients with abdominal adhesions, especially in the subgroup of those undergoing colorectal cancer resection performed by expert surgeons.

Rate of conversion to an open procedure is reduced in patients undergoing robotic colorectal surgery: A single-institution experience

Background

Robotic-assisted surgery is becoming increasingly used in colorectal operations. It has many advantages over laparoscopic surgery including three-dimensional viewing, motion scaling, improved dexterity and ergonomics as well as increased precision. However, there are also disadvantages to robotic surgery such as lack of tactile feedback, cost as well as limitations on multi-quadrant surgeries. The purpose of this study was to compare the rate of conversion to an open surgery in patients undergoing robotic-assisted colorectal surgery and traditional laparoscopic surgery.

Methods

Patients undergoing minimally invasive colorectal surgery for neoplastic and dysplastic disease from 2009 to 2016 were identified and examined retrospectively. The statistical software SAS, manufactured by SAS Institute, Cary, North Carolina. Continuous variables were analysed using analysis of variance test. Chi-square test was used to analyse categorical variables. P <0.05 was considered statistically significant.

Results

Two hundred and thirty-five patients were identified that underwent minimally invasive colorectal surgery. One hundred and sixty-four underwent laparoscopic resection and 71 underwent robotic-assisted resection. There was no statistical difference in gender or race between the two groups (both P > 0.05). Patients that underwent robotic-assisted resection were slightly younger than patients that underwent laparoscopic resection (61.6 years vs. 65.6 years; P= 0.02). When examining conversion to an open procedure, patients that underwent robotic-assisted resection had a significantly lower chance of conversion than did the patients undergoing a laparoscopic approach (11.27% vs. 29.78%; P= 0.0018).

Conclusion

Conversion rates from a minimally invasive procedure to an open procedure appear to be lower with robotic-assisted surgery compared to laparoscopic surgery.

The Impact of Corporate Payments on Robotic Surgery Research: A Systematic Review

OBJECTIVE

To quantify the influence of financial conflict of interest (COI) payments on the reporting of clinical results for robotic surgery.

DATA SOURCES AND STUDY SELECTION

A systematic search (Ovid MEDLINE databases) was conducted (May 2017) to identify randomized controlled trials (RCTs) and observational studies comparing the efficacy of the da Vinci robot on clinical outcomes. Financial COI data for authors (per study) were determined using open payments database.

MAIN OUTCOMES AND MEASURES

Primary outcomes assessed were receipt of financial COI payments and overall conclusion reported between robotic versus comparative approach. Quality/risk of bias was assessed using Newcastle-Ottawa Scale (NOS)/Cochrane risk of bias tool. Disclosure discrepancies were also analyzed.

DATA EXTRACTION AND SYNTHESIS

Study characteristics, surgical subspecialty, methodological assessment, reporting of disclosure statements, and study findings dual abstracted. The association of the amount of financial support received as a predictor of reporting positive findings associated robotic surgery was assessed at various cut-offs of dollar amount received by receiver operating curve (ROC).

RESULTS

Thirty-three studies were included, 9 RCTs and 24 observational studies. There was a median, 111 patients (range 10 to 6420) across studies. A little more than half (17/33) had a conclusion statement reporting positive results in support of robotic surgery, with 48% (16/33) reporting results not in favor [equivocal: 12/33 (36%), negative: 4/33 (12%)]. Nearly all (91%) studies had authors who received financial COI payments, with a median of $3364.46 per study (range $9 to $1,775,378.03). ROC curve demonstrated that studies receiving greater than $9557.31 (cutpoint) were more likely to report positive robotic surgery results (sensitivity: 0.65, specificity: 0.81, area under the curve: 0.73). Studies with financial COI payment greater than this amount were more likely to report beneficial outcomes with robotic surgery [(78.57% vs 31.58%, P = 0.013) with an odds ratio of 2.07 (confidence interval: 0.47-3.67; P = 0.011)]. Overall, studies were high quality/low risk of bias [median NOS: 8 (range 5 to 9)]; Cochrane risk: "low risk" (9/9, 100%)].

CONCLUSION AND RELEVANCE

Financial COI sponsorship appears to be associated with a higher likelihood of studies reporting a benefit of robotic surgery. Our findings suggest a dollar amount where financial payments influence reported clinical results, a concept that challenges the current guidelines, which do not account for the amount of COI funding received.

Nationwide Introduction of Minimally Invasive Robotic Surgery for Early-Stage Endometrial Cancer and Its Association With Severe Complications

Importance

Minimally invasive laparoscopic surgery (MILS) for endometrial cancer reduces surgical morbidity compared with a total abdominal hysterectomy. However, only a minority of women with early-stage endometrial cancer undergo MILS.

Objective

To evaluate the association between the Danish nationwide introduction of minimally invasive robotic surgery (MIRS) and severe complications in patients with early-stage endometrial cancer.

Design, Setting, and Participants

In this nationwide prospective cohort study of 5654 women with early-stage endometrial cancer who had undergone surgery during the period from January 1, 2005, to June 30, 2015, data from the Danish Gynecological Cancer Database were linked with national registers on socioeconomic status, deaths, hospital diagnoses, and hospital treatments. The women were divided into 2 groups; group 1 underwent surgery before the introduction of MIRS in their region, and group 2 underwent surgery after the introduction of MIRS. Women with an unknown disease stage, an unknown association with MIRS implementation, unknown histologic findings, sarcoma, or synchronous cancer were excluded, as were women who underwent vaginal or an unknown surgical type of hysterectomy. Statistical analysis was conducted from February 2, 2017, to May 4, 2018.

Exposure

Minimally invasive robotic surgery, MILS, or total abdominal hysterectomy.

Main Outcomes and Measures

Severe complications were dichotomized and encompassed death within 30 days after surgery and intraoperative and postoperative complications diagnosed within 90 days after surgery.

Results

A total of 3091 women (mean [SD] age, 67 [10] years) were allocated to group 1, and a total of 2563 women (mean [SD] age, 68 [10] years) were allocated to group 2. In multivariate logistic regression analyses, the odds of severe complications were significantly higher in group 1 than in group 2 (odds ratio [OR], 1.39; 95% CI, 1.11-1.74). The proportion of women undergoing MILS was 14.1% (n = 436) in group 1 and 22.2% in group 2 (n = 569). The proportion of women undergoing MIRS in group 2 was 50.0% (n = 1282). In group 2, multivariate logistic regression analyses demonstrated that a total abdominal hysterectomy was associated with increased odds of severe complications compared with MILS (OR, 2.58; 95% CI, 1.80-3.70) and MIRS (OR, 3.87; 95% CI, 2.52-5.93). No difference was found for MILS compared with MIRS (OR, 1.50; 95% CI, 0.99-2.27).

Conclusions and Relevance

The national introduction of MIRS changed the surgical approach for early-stage endometrial cancer from open surgery to minimally invasive surgery. This change in surgical approach was associated with a significantly reduced risk of severe complications.

Robotic vs Open Surgery for Endometrial Cancer in Elderly Patients: Surgical Outcome, Survival, and Cost Analysis

OBJECTIVE

This study aimed to compare robotic and open surgery in elderly women diagnosed as having endometrial cancer, in terms of costs, survival, surgical outcome, and operating time.

METHODS

Women 70 years or older undergoing open and robotic surgery for endometrial cancers were included consecutively before and after the introduction of robotic surgery at a tertiary center. Costs were calculated using the case-costing system, cost per patient, including the first 30 postoperative days. Relative and overall survival outcomes were obtained from the Swedish National Cancer Registry and analyzed using the Kaplan-Meier method. Surgical outcomes including operating and anesthesia times, estimated blood loss, hospital stay, and intraoperative and postoperative complications were reviewed.

RESULTS

In all, 137 and 141 women 70 years or older were identified to have undergone open and robotic surgery, respectively. The groups showed similar body mass index, comorbidities, and tumor characteristics. No statistically significant differences were seen in costs (robotic &OV0556;11,874 vs open &OV0556;11,521, P = 0.463) or 5-year survival outcomes (robotic 94% [95% confidence interval {CI}, 84-105] vs open 87% [95% CI, 78-98], P = 0.529). Robotic surgery was associated with significantly lower estimated blood loss (P < 0.001) and shorter hospital stay (P < 0.001) but longer anesthesia time (186 vs 174 minutes; P < 0.05) and operating theater time (205 vs 190 minutes; P < 0.05). There were no significant differences in intraoperative complications, but robotic surgery resulted in fewer postoperative Clavien-Dindo grade II complications.

CONCLUSIONS

Elderly women can safely undergo robotic surgery for endometrial cancer and could be offered this technique to the same extent as younger patients. They may benefit from shorter hospital stay, decreased blood loss, and postoperative complications, without resulting in higher costs to the health care system or jeopardizing their survival.

Robot-assisted surgery in gynaecology

BACKGROUND

This is an updated merged review of two originally separate Cochrane reviews: one on robot-assisted surgery (RAS) for benign gynaecological disease, the other on RAS for gynaecological cancer. RAS is a relatively new innovation in laparoscopic surgery that enables the surgeon to conduct the operation from a computer console, situated away from the surgical table. RAS is already widely used in the United States for hysterectomy and has been shown to be feasible for other gynaecological procedures. However, the clinical effectiveness and safety of RAS compared with conventional laparoscopic surgery (CLS) have not been clearly established and require independent review.

OBJECTIVES

To assess the effectiveness and safety of RAS in the treatment of women with benign and malignant gynaecological disease.

SEARCH METHODS

For this update, we searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE via Ovid, and EMBASE via Ovid, on 8 January 2018. We searched www.ClinicalTrials.gov. on 16 January 2018.

SELECTION CRITERIA

Randomised controlled trials (RCTs) comparing RAS versus CLS or open surgery in women requiring surgery for gynaecological disease.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed studies for inclusion and risk of bias, and extracted study data and entered them into an Excel spreadsheet. We examined different procedures in separate comparisons and for hysterectomy subgrouped data according to type of disease (non-malignant versus malignant). When more than one study contributed data, we pooled data using random-effects methods in RevMan 5.3.

MAIN RESULTS

We included 12 RCTs involving 1016 women. Studies were at moderate to high overall risk of bias, and we downgraded evidence mainly due to concerns about risk of bias in the studies contributing data and imprecision of effect estimates. Procedures performed were hysterectomy (eight studies) and sacrocolpopexy (three studies). In addition, one trial examined surgical treatment for endometriosis, which included resection or hysterectomy. Among studies of women undergoing hysterectomy procedures, two studies involved malignant disease (endometrial cancer); the rest involved non-malignant disease.• RAS versus CLS (hysterectomy)Low-certainty evidence suggests there might be little or no difference in any complication rates between RAS and CLS (risk ratio (RR) 0.92, 95% confidence interval (CI) 0.54 to 1.59; participants = 585; studies = 6; I² = 51%), intraoperative complication rates (RR 0.77, 95% CI 0.24 to 2.50; participants = 583; studies = 6; I² = 37%), postoperative complications (RR 0.81, 95% CI 0.48 to 1.34; participants = 629; studies = 6; I² = 44%), and blood transfusions (RR 1.94, 95% CI 0.63 to 5.94; participants = 442; studies = 5; I² = 0%). There was no statistical difference between malignant and non-malignant disease subgroups with regard to complication rates. Only one study reported death within 30 days and no deaths occurred (very low-certainty evidence). Researchers reported no survival outcomes.Mean total operating time was longer on average in the RAS arm than in the CLS arm (mean difference (MD) 41.18 minutes, 95% CI -6.17 to 88.53; participants = 148; studies = 2; I² = 80%; very low-certainty evidence), and the mean length of hospital stay was slightly shorter with RAS than with CLS (MD -0.30 days, 95% CI -0.53 to -0.07; participants = 192; studies = 2; I² = 0%; very low-certainty evidence).• RAS versus CLS (sacrocolpopexy)Very low-certainty evidence suggests little or no difference in rates of any complications between women undergoing sacrocolpopexy by RAS or CLS (RR 0.95, 95% CI 0.21 to 4.24; participants = 186; studies = 3; I² = 78%), nor in intraoperative complications (RR 0.82, 95% CI 0.09 to 7.59; participants = 108; studies = 2; I² = 47%). Low-certainty evidence on postoperative complications suggests these might be higher with RAS (RR 3.54, 95% CI 1.31 to 9.56; studies = 1; participants = 68). Researchers did not report blood transfusions and deaths up to 30 days.Low-certainty evidence suggests that RAS might be associated with increased operating time (MD 40.53 min, 95% CI 12.06 to 68.99; participants = 186; studies = 3; I² = 73%). Very low-certainty evidence suggests little or no difference between the two techniques in terms of duration of stay (MD 0.26 days, 95% CI -0.15 to 0.67; participants = 108; studies = 2; I² = 0%).• RAS versus open abdominal surgery (hysterectomy)A single study with a total sample size of 20 women was included in this comparison. For most outcomes, the sample size was insufficient to show any possible differences between groups.• RAS versus CLS for endometriosisA single study with data for 73 women was included in this comparison; women with endometriosis underwent procedures ranging from relatively minor endometrial resection through hysterectomy; many of the women included in this study had undergone previous surgery for their condition. For most outcomes, event rates were low, and the sample size was insufficient to detect potential differences between groups.

AUTHORS' CONCLUSIONS

Evidence on the effectiveness and safety of RAS compared with CLS for non-malignant disease (hysterectomy and sacrocolpopexy) is of low certainty but suggests that surgical complication rates might be comparable. Evidence on the effectiveness and safety of RAS compared with CLS or open surgery for malignant disease is more uncertain because survival data are lacking. RAS is an operator-dependent expensive technology; therefore evaluating the safety of this technology independently will present challenges.

Robotic Versus Open Renal Transplantation in Obese Patients: Protocol for a Cost-Benefit Markov Model Analysis

Background

Recent studies have reported a significant decrease in wound problems and hospital stay in obese patients undergoing renal transplantation by robotic-assisted minimally invasive techniques with no difference in graft function.

Objective

Due to the lack of cost-benefit studies on the use of robotic-assisted renal transplantation versus open surgical procedure, the primary aim of our study is to develop a Markov model to analyze the cost-benefit of robotic surgery versus open traditional surgery in obese patients in need of a renal transplant.

Methods

Electronic searches will be conducted to identify studies comparing open renal transplantation versus robotic-assisted renal transplantation. Costs associated with the two surgical techniques will incorporate the expenses of the resources used for the operations. A decision analysis model will be developed to simulate a randomized controlled trial comparing three interventional arms: (1) continuation of renal replacement therapy for patients who are considered non-suitable candidates for renal transplantation due to obesity, (2) transplant recipients undergoing open transplant surgery, and (3) transplant patients undergoing robotic-assisted renal transplantation. TreeAge Pro 2017 R1 TreeAge Software, Williamstown, MA, USA) will be used to create a Markov model and microsimulation will be used to compare costs and benefits for the two competing surgical interventions.

Results

The model will simulate a randomized controlled trial of adult obese patients affected by end-stage renal disease undergoing renal transplantation. The absorbing state of the model will be patients' death from any cause. By choosing death as the absorbing state, we will be able simulate the population of renal transplant recipients from the day of their randomization to transplant surgery or continuation on renal replacement therapy to their death and perform sensitivity analysis around patients' age at the time of randomization to determine if age is a critical variable for cost-benefit analysis or cost-effectiveness analysis comparing renal replacement therapy, robotic-assisted surgery or open renal transplant surgery. After running the model, one of the three competing strategies will result as the most cost-beneficial or cost-effective under common circumstances. To assess the robustness of the results of the model, a multivariable probabilistic sensitivity analysis will be performed by modifying the mean values and confidence intervals of key parameters with the main intent of assessing if the winning strategy is sensitive to rigorous and plausible variations of those values.

Conclusions

After running the model, one of the three competing strategies will result as the most cost-beneficial or cost-effective under common circumstances. To assess the robustness of the results of the model, a multivariable probabilistic sensitivity analysis will be performed by modifying the mean values and confidence intervals of key parameters with the main intent of assessing if the winning strategy is sensitive to rigorous and plausible variations of those values.

A comparison of operative outcomes between standard and robotic laparoscopic surgery for endometrial cancer: A systematic review and meta-analysis

BACKGROUND

Evidence has been systematically assessed comparing robotic with standard laparoscopy for treatment of endometrial cancer.

METHODS

A search of Medline, Embase and Cochrane databases was performed until 30th October 2016.

RESULTS

Thirty-six papers including 33 retrospective studies, two matched case-control studies and one randomized controlled study were used in a meta-analysis. Information from a further seven registry/database studies were assessed descriptively. There were no differences in the duration of surgery but days stay in hospital were shorter in the robotic arm (0.46 days, 95%CI 0.26 to 0.66). A robotic approach had less blood loss (57.74 mL, 95%CI 38.29 to 77.20), less conversions to laparotomy (RR = 0.41, 95%CI 0.29 to 0.59), and less overall complications (RR = 0.82, 95%CI 0.72 to 0.93). A robotic approach had higher costs ($1746.20, 95%CI $63.37 to $3429.03).

CONCLUSION

A robotic approach has favourable clinical outcomes but is more expensive.

A Comparison of Outcomes Between Open Hysterectomy and Robotic-Assisted Hysterectomy for Endometrial Cancer Using the National Cancer Database

Purpose

The purpose of this study is to evaluate usage patterns and outcomes of women who underwent open hysterectomy (OH) versus robotic assisted-hysterectomy (RAH) for the treatment of endometrial cancer.

Methods

Women with nonmetastatic endometrial adenocarcinoma diagnosed between 2010 and 2012, who either underwent an OH or RAH, were selected from the National Cancer Database. The χ2, Fisher exact, or Mann-Whitney U tests were used where appropriate to compare outcomes between groups. Multivariable logistic regression was used to analyze for predictors for RAH and other outcome variables.

Results

A total of 43,985 women were included in this study with a median age of 61 years. Of these, 23,872 (54.3%) underwent RAH and 20,113 (45.7%) underwent OH. The usage of RAH increased from 43.0% in 2010 to 63.8% in 2012 (P < 0.001). Women receiving RAH were more commonly found to have a Charlson comorbidity score of 0 to 1, lower pathologic stage, nonblack race, treatment at a comprehensive center, and had insurance other than Medicaid. Robotic-assisted hysterectomy was associated with a shorter inpatient stay, lower readmission rates, and lower 30- and 90-day mortality rates (P < 0.001 for all comparisons). There was a significant improvement in overall survival favoring RAH, 96.1% versus 94.0%, which persisted on multivariable logistic regression (P < 0.001).

Conclusions

In this large, hospital-based analysis, RAH was associated with decreased length of stay, lower readmission rates, and less perioperative mortality. However, socioeconomic status continues to remain a barrier to equal treatment allocation. Overall survival was improved with RAH, but the follow-up is limited, and this finding must be interpreted with caution.

Robot-assisted versus conventional laparoscopic surgery for endometrial cancer staging: A meta-analysis

This meta-analysis broadly compared the safety and efficacy of robot-assisted laparoscopy (RAL) with that of conventional laparoscopy (CL) for endometrial cancer staging. The advantages of RAL were evaluated through the outcomes in terms of conversion rates, complications, length of operation, blood loss, number of lymph nodes harvested, and length of hospitalization. Three electronic databases (PubMed, MEDLINE, and EmBASE) were searched to identify eligible studies. We selected all retrospective studies documenting a comparison between RAL and CL for endometrial cancer staging between 2005 and 2015, and tallied with meta-analyses criteria. Only studies published in English were included in this analysis. The outcomes of the extracted data were pooled and estimated by the Review Manager version 5.1 software. Seventeen studies met the eligibility criteria. Among the 2105 patients reported, 912 underwent RAL and the other 1193 underwent CL for endometrial cancer staging. Compared with CL, RAL had lower conversion rates [risk ratio, 0.4; 95% confidence interval (CI), 0.25-0.64; p = 0.0002]. Its complications were also less than that of CL (risk ratio, 0.72; 95% CI, 0.56-0.94; p = 0.02). RAL was associated with significantly less intraoperative blood loss (weighted mean difference, -79.2 mL; 95% CI, from -103.43 to -54.97; p < 0.00001) and a shorter length of hospitalization (weighted mean difference, -0.37 days; 95% CI, from -0.57 to -0.17; p = 0.0003). We found no significant differences in the length of operation and number of lymph nodes harvested between the two groups. From our meta-analysis results, RAL is a safe and effective alternative to CL for endometrial cancer staging. Further studies are required to determine potential advantages or disadvantages of RAL.

Robot-assisted Surgery in Gynecologic Cancers

Robotic-assisted surgery is a technological advancement that facilitates the application of minimally invasive techniques for complex operations in gynecologic oncology. The objective of this article was to review the literature regarding the role of robotic-assisted surgery to treat women with gynecologic cancers. The majority of publications on robotic surgery are still retrospective or descriptive in nature; however, the data for managing patients with a robotic-assisted approach show comparable, and at times improved, outcomes compared with both laparoscopy (2-dimensional) and laparotomy approaches. Robotic-assisted surgery has been used for patients with endometrial cancer and resulted in the increased use of minimally invasive surgery with improved outcomes compared with laparotomy and partially with laparoscopy. This has been shown in large cohorts of patients as well as in obese patients in whom the complication rates have significantly decreased. For early cervical cancer, robotic radical hysterectomy seems to be safe and feasible and to be preferable to laparotomy with seemingly comparable oncologic outcomes. Robotic-assisted surgery and conventional laparoscopy to stage women with early-stage ovarian cancer seem to have similar surgical and oncologic outcomes, with a shorter learning curve for robotic-assisted surgery. However, robotic-assisted surgery appears to be more expensive than laparotomy and traditional laparoscopy. In conclusion, robotic-assisted surgery appears to facilitate the surgical approach for complex operations to treat women with gynecologic cancers. Although randomized controlled trials are lacking to further elucidate the equivalence of robot-assisted surgery with conventional methods in terms of oncologic outcome and patients' quality of life, the technology appears to be safe and effective and could offer a minimally invasive approach to a much larger group of patients.

Robotic-assisted vs traditional laparoscopic surgery for endometrial cancer: a randomized controlled trial

BACKGROUND

Previous studies comparing robotic-assisted laparoscopic surgery to traditional laparoscopic or open surgery in gynecologic oncology have been retrospective. To our knowledge, no prospective randomized trials have thus far been performed on endometrial cancer.

OBJECTIVE

We sought to prospectively compare traditional and robotic-assisted laparoscopic surgery for endometrial cancer.

STUDY DESIGN

This was a randomized controlled trial. From December 2010 through October 2013, 101 endometrial cancer patients were randomized to hysterectomy, bilateral salpingo-oophorectomy, and pelvic lymphadenectomy either by robotic-assisted laparoscopic surgery or by traditional laparoscopy. The primary outcome measure was overall operation time. The secondary outcome measures included total time spent in the operating room, and surgical outcome (number of lymph nodes harvested, complications, and recovery). The study was powered to show at least a 25% difference in the operation time using 2-sided significance level of .05. The differences between the traditional laparoscopy and the robotic surgery groups were tested by Pearson χ² test, Fisher exact test, or Mann-Whitney test.

RESULTS

In all, 99 patients were eligible for analysis. The median operation time in the traditional laparoscopy group (n = 49) was 170 (range 126-259) minutes and in the robotic surgery group (n = 50) was 139 (range 86-197) minutes, respectively (P < .001). The total time spent in the operating room was shorter in the robotic surgery group (228 vs 197 minutes, P < .001). In the traditional laparoscopy group, there were 5 conversions to laparotomy vs none in the robotic surgery group (P = .027). There were no differences as to the number of lymph nodes removed, bleeding, or the length of postoperative hospital stay. Four (8%) vs no (0%) patients (P = .056) had intraoperative complications and 5 (10%) vs 11 (22%) (P = .111) had major postoperative complications in the traditional and robotic surgery groups, respectively.

CONCLUSION

In patients with endometrial cancer, robotic-assisted laparoscopic surgery was faster to perform than traditional laparoscopy. Also total time spent in the operation room was shorter in the robotic surgery group and all conversions to laparotomy occurred in the traditional laparoscopy group. Otherwise, the surgical outcome was similar between the groups. Robotic surgery offers an effective and safe alternative in the surgical treatment of endometrial cancer.

A population-based registry study evaluating surgery in newly diagnosed uterine cancer

INTRODUCTION

The aim was to evaluate surgical treatment of newly diagnosed uterine cancer in a Swedish population.

MATERIAL AND METHODS

Data in the GynOp registry from 2008 to 2014 were analyzed.

RESULTS

In total, 3443 cases were included: 430 (12%) were robotic-assisted laparoscopic, 272 (8%) laparoscopic, and 2741 (80%) abdominal operations. There was an increasing trend in minimally invasive surgery from 2008 to 2014 (41%). Women with lymph nodes removed in the robotic-assisted laparoscopic group experienced less blood loss (mean 105 vs. 377 mL), shorter length of hospital stay (2.4 vs. 4.1 days), and fewer days to normal activities of daily living (6.5 vs. 12.7 days) (all p < 0.001) compared with the abdominal group, but operating time did not differ. Similar results were found in women with no lymph node removal and in women with body mass index ≥35. Major complications during hospital stay, reoperations, and time to work were less in both minimally invasive groups. More lymph nodes were retrieved in the abdominal (mean 34.4) than in the robotic-assisted laparoscopic (mean 26.0) group, but the number of women with lymph node metastases did not differ, totaling 211/960 (21.9%; 95% CI 19.4-24.7%). Isolated para-aortic lymph node metastases were found in 3.9% (95% CI 2.4-5.6%) of women.

CONCLUSIONS

Minimally invasive surgery in uterine cancer patients reduces days to normal activities of daily living, number of days to return to work, length of hospital stay, and blood loss in patients without and with lymph node dissection and in obese patients.

Robot-assisted surgery versus conventional laparoscopic surgery for endometrial cancer: a systematic review and meta-analysis

PURPOSE

To compare perioperative outcomes between robot-assisted surgery (RAS) and conventional laparoscopic surgery (CLS) for the treatment of endometrial cancer by conducting a meta-analysis.

METHODS

We searched the Cochrane Central Register of Controlled Trials, PubMed, and EMBASE up to January 8, 2016. Studies clearly documenting a comparison between RAS and CLS for patients with endometrial cancer were included. The perioperative outcomes of interest included intraoperative visceral injuries, postoperative complications, operation time, estimated blood loss (EBL), blood transfusion, total lymph nodes harvested (TLNH), conversion to laparotomy, and length of hospital stay. The weighted mean difference (WMD) and odds ratio (OR) were pooled with either a fixed-effects or a random-effects model.

RESULTS

A total of 19 studies were included in the analysis, involving 3056 patients. The pooled analysis showed that RAS was associated with lower EBL (WMD -77.65; 95 % confidence interval [CI] -105.58 to -49.72), lower conversion rate (OR 0.29; 95 % CI 0.18-0.46), and shorter hospital stay (WMD -0.48; 95 % CI -0.70 to -0.26) compared to CLS. The incidence of intraoperative visceral injuries, operation time, transfusion rate, and TLNH showed no significant differences between RAS and CLS.

CONCLUSIONS

RAS is a feasible and effective surgical approach that may be superior to CLS for the treatment of endometrial cancer, with lower EBL and lower conversion rate. Further prospective randomized trials are required to validate our findings.

Robotic surgery: disruptive innovation or unfulfilled promise? A systematic review and meta-analysis of the first 30 years

Background

Robotic surgery has been in existence for 30 years. This study aimed to evaluate the overall perioperative outcomes of robotic surgery compared with open surgery (OS) and conventional minimally invasive surgery (MIS) across various surgical procedures.

Methods

MEDLINE, EMBASE, PsycINFO, and ClinicalTrials.gov were searched from 1990 up to October 2013 with no language restriction. Relevant review articles were hand-searched for remaining studies. Randomised controlled trials (RCTs) and prospective comparative studies (PROs) on perioperative outcomes, regardless of patient age and sex, were included. Primary outcomes were blood loss, blood transfusion rate, operative time, length of hospital stay, and 30-day overall complication rate.

Results

We identified 99 relevant articles (108 studies, 14,448 patients). For robotic versus OS, 50 studies (11 RCTs, 39 PROs) demonstrated reduction in blood loss [ratio of means (RoM) 0.505, 95 % confidence interval (CI) 0.408–0.602], transfusion rate [risk ratio (RR) 0.272, 95 % CI 0.165–0.449], length of hospital stay (RoM 0.695, 0.615–0.774), and 30-day overall complication rate (RR 0.637, 0.483–0.838) in favour of robotic surgery. For robotic versus MIS, 58 studies (21 RCTs, 37 PROs) demonstrated reduced blood loss (RoM 0.853, 0.736–0.969) and transfusion rate (RR 0.621, 0.390–0.988) in favour of robotic surgery but similar length of hospital stay (RoM 0.982, 0.936–1.027) and 30-day overall complication rate (RR 0.988, 0.822–1.188). In both comparisons, robotic surgery prolonged operative time (OS: RoM 1.073, 1.022–1.124; MIS: RoM 1.135, 1.096–1.173). The benefits of robotic surgery lacked robustness on RCT-sensitivity analyses. However, many studies, including the relatively few available RCTs, suffered from high risk of bias and inadequate statistical power.

Conclusions

Our results showed that robotic surgery contributed positively to some perioperative outcomes but longer operative times remained a shortcoming. Better quality evidence is needed to guide surgical decision making regarding the precise clinical targets of this innovation in the next generation of its use.

Benefits of Minimal Access Surgery in Elderly Patients with Pelvic Cancer

An increasing proportion of patients requiring treatment for malignancy are elderly, which has created new challenges for oncologic surgeons. Aging is associated with an increasing prevalence of frailty and comorbidities that may affect the outcome of surgical procedures. By decreasing complications and shortening length of hospital stay without affecting oncologic safety, surgery performed using the robot, rather than traditional laparotomy, improves the chances of a better outcome in our growing elderly populations. In addition to age, surgeons should take into account factors, such as frailty and comorbidities that correlate with outcome.

Peer Review and Surgical Innovation: Robotic Surgery and Its Hurdles

The peer review processes as outlined in the Health Care Quality Improvement Act (HCQIA) is meant ensure quality standard of care through a self-policing mechanism by the medical community. This process grants immunity for people filing a peer review, which is meant to protect whistleblowers. However, it also creates a loophole that can be used maliciously to hinder competition. This is accentuated when surgeons are integrating new technologies, such as robotic surgery, into their practice. With more than 2000 da Vinci robots in use and more than 300 new units being shipped each year, robotic surgery has become a mainstay in the surgical field. The applications for robots continue to expand as surgeons discover their expanding capability. We need a better peer review process. That ensures the peer review is void of competitive bias. Peer reviewers need to be familiar with the procedure and the technology. The current process could stymie innovation in the name of competition.

Comparison of Laparoscopic-Assisted Operations and Laparotomy Operations for the Treatment of Hirschsprung Disease: Evidence From a Meta-Analysis

The purpose of this meta-analysis is to compare the relative merits among laparoscopic-assisted operations and laparotomy operations for patients with Hirschsprung disease. PubMed, Web of Science, and Wanfang databases were searched for the related articles. We analyzed dichotomous variables by estimating odds ratios (ORs) with their 95% confidence intervals (CIs) and continuous variables using the weighted mean difference (WMD) with the 95% CI. The random-effects model (REM) was used to combine the results. The outcome measures included operating time (OT), estimated blood loss (EBL), length of hospital stay (LOHS), mean first bowel movement (MFBM), and number of complications. Sixteen articles were included in the meta-analysis. These studies involved a total of 774 patients, 396 of whom underwent laparoscopic-assisted operations and 378 of whom underwent laparotomy operations. The EBL (WMD = -1.48, 95% CI = -1.82, -1.13), LOHS (WMD = -0.67, 95% CI = -0.86, -0.49), MFBM (WMD = -0.83, 95% CI = -1.05, -0.61), and number of complications (OR = 0.60, 95% CI = 0.40, 0.89) were significantly lower in laparoscopic-assisted operations than in laparotomy operations. The OT (WMD = 0.12, 95% CI = -0.05, 0.28) showed no significant differences between laparoscopic-assisted operations and laparotomy operations. Compared with laparotomy operations, laparoscopic-assisted operations are generally safer and more reliable for patients with Hirschsprung disease.

Same-day discharge is feasible and safe in patients undergoing minimally invasive staging for gynecologic malignancies

OBJECTIVE

The objective of the study was to evaluate the feasibility and safety of same-day discharge of patients undergoing minimally invasive comprehensive surgical staging for endometrial and cervical cancer.

STUDY DESIGN

We performed a retrospective review of consecutive patients from January 2008 to December 2011 undergoing comprehensive staging for endometrial or cervical cancer by traditional laparoscopy or robotic-assisted laparoscopy and intended for same-day discharge. Patients accomplishing same-day discharge were compared with those who required admission. Clinical and demographic data, perioperative outcomes, and postoperative patient contacts within 6 weeks were collected. Multivariate logistic regression modeling was used to determine factors associated with admission and unscheduled patient contacts within 2 weeks of surgery.

RESULTS

A total of 141 patients were identified. One hundred eighteen patients (83.7%) underwent same-day discharge and 23 (16.3%) required overnight admission. The variables that significantly predicted overnight admission were severe pain in the postanesthesia care unit (odds ratio [OR], 6.81; 95% confidence interval [CI], 1.74-26.6; P = .006), delayed ability to tolerate oral intake (OR, 9.3; 95% CI, 2.25-38.6, P = .002), traditional laparoscopic vs robotic-assisted surgical approach (OR, 9.05; 95% CI, 2.34-35.1; P = .001), and surgery start time at 2:00 pm or later (OR, 36.8; 95% CI, 6.19-219.3; P < .0001). There was no difference in the readmission rate between patients undergoing same-day discharge compared with overnight admission (11% vs 17%, P = .48). No variables significantly predicted unscheduled patient contact within 2 weeks of surgery at P < .01.

CONCLUSION

Same-day discharge for patients undergoing laparoscopic or robotic-assisted laparoscopic staging for endometrial or cervical cancer is feasible and safe. There are low complication rates and few readmissions or unscheduled patient contacts within 2 weeks of surgery.

WITHDRAWN: Robotic assisted surgery for gynaecological cancer

This review is being withdrawn as now superceded by a new review covering both malignant an benign disease: Lawrie TA, Liu H, Lu D, Dowswell T, Song H, Wang L, Shi G. Robot‐assisted surgery in gynaecology. Cochrane Database of Systematic Reviews 2019, Issue 4. Art. No.: CD011422. DOI: 10.1002/14651858.CD011422.pub2 (https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD011422.pub2/full )

The editorial group responsible for this previously published document have withdrawn it from publication.

Robot-assisted surgery in gynaecology

BACKGROUND

This is an updated merged review of two originally separate Cochrane reviews: one on robot-assisted surgery (RAS) for benign gynaecological disease, the other on RAS for gynaecological cancer. RAS is a relatively new innovation in laparoscopic surgery that enables the surgeon to conduct the operation from a computer console, situated away from the surgical table. RAS is already widely used in the United States for hysterectomy and has been shown to be feasible for other gynaecological procedures. However, the clinical effectiveness and safety of RAS compared with conventional laparoscopic surgery (CLS) have not been clearly established and require independent review.

OBJECTIVES

To assess the effectiveness and safety of RAS in the treatment of women with benign and malignant gynaecological disease.

SEARCH METHODS

For this update, we searched the Cochrane Central Register of Controlled Trials (CENTRAL) (2014, Issue 5) and the Cochrane Gynaecological Cancer Review Group Trials Register. We also searched MEDLINE and EMBASE databases, to complement the searches of the original malignant and benign disease reviews (conducted up to July 2010 and November 2011, respectively), from July 2010 to June 2014.

SELECTION CRITERIA

Randomised controlled trials (RCTs) of RAS compared with CLS or open surgery in women requiring surgery for gynaecological disease.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed the studies for inclusion and risk of bias, and extracted study data and entered them into an Excel spreadsheet. We subgrouped data according to type of procedure and pooled data using random-effects methods in RevMan 5.3. We performed sensitivity analyses by excluding studies at high risk of bias.

MAIN RESULTS

We included six RCTs involving 517 women. Most were at low to moderate overall risk of bias; one was at high risk of bias. Four studies evaluated RAS for hysterectomy (371 women), and two studies evaluated RAS for sacrocolpopexy (146 women). All studies compared RAS with CLS, except for one study, which compared RAS with CLS or a vaginal surgical approach for hysterectomy. Confidence intervals for the risk of intraoperative and postoperative complications included benefits with either approach when they were analysed together (risk ratio (RR) 0.95, 95% confidence interval (CI) 0.46 to 1.99; participants = 513; studies = 6; I(2) = 74%) and separately (low-quality evidence). Moderate-quality evidence was found for the effects of RAS on intraoperative injury when compared with CLS (RR 1.23, 95% CI 0.44 to 3.46; participants = 415; studies = 5; I(2) = 0%), along with low-quality evidence for bleeding and infection complications.Mean total operating time was consistent across procedures and on average was about 42 minutes longer in the RAS arm compared with the CLS arm (95% CI 17 to 66 minutes; participants = 294; studies = 4; I(2) = 82%; moderate-quality evidence). Mean hospital stay for hysterectomy procedures was on average about seven hours shorter in the RAS arm than in the CLS arm (mean difference (MD) -0.30 days, 95% CI -0.54 to -0.06; participants = 217; studies = 2; I(2) = 0%; low-quality evidence). The estimated effect of conversion with RAS compared with CLS was imprecise (RR 1.28, 95% CI 0.40 to 4.12; participants = 337; studies = 4; I(2) = 0%; moderate-quality evidence). Limited data from two studies suggest that RAS for sacrocolpopexy may be associated with increased postoperative pain compared with CLS; this needs further investigation. We identified five ongoing trials-four of cancer surgery.

AUTHORS' CONCLUSIONS

We are uncertain as to whether RAS or CLS has lower intraoperative and postoperative complication rates because of the imprecision of the effect and inconsistency among studies when they are used for hysterectomy and sacrocolpopexy. Moderate-quality evidence suggests that these procedures take longer with RAS but may be associated with a shorter hospital stay following hysterectomy. We found limited evidence on the effectiveness and safety of RAS compared with CLS or open surgery for surgical procedures performed for gynaecological cancer; therefore its use should be limited to clinical trials. Ongoing trials are likely to have an important impact on evidence related to the use of RAS in gynaecology.

Comparison of robotic surgery with laparoscopy and laparotomy for treatment of endometrial cancer: a meta-analysis

Purpose

To compare the relative merits among robotic surgery, laparoscopy, and laparotomy for patients with endometrial cancer by conducting a meta-analysis.

Methods

The MEDLINE, Embase, PubMed, Web of Science, and Cochrane Library databases were searched. Studies clearly documenting a comparison between robotic surgery and laparoscopy or between robotic surgery and laparotomy for endometrial cancer were selected. The outcome measures included operating time (OT), number of complications, length of hospital stay (LOHS), estimated blood loss (EBL), number of transfusions, total lymph nodes harvested (TLNH), and number of conversions. Pooled odds ratios and weighted mean differences with 95% confidence intervals were calculated using either a fixed-effects or random-effects model.

Results

Twenty-two studies were included in the meta-analysis. These studies involved a total of 4420 patients, 3403 of whom underwent both robotic surgery and laparoscopy and 1017 of whom underwent both robotic surgery and laparotomy. The EBL (p = 0.01) and number of conversions (p = 0.0008) were significantly lower and the number of complications (p<0.0001) was significantly higher in robotic surgery than in laparoscopy. The OT, LOHS, number of transfusions, and TLNH showed no significant differences between robotic surgery and laparoscopy. The number of complications (p<0.00001), LOHS (p<0.00001), EBL (p<0.00001), and number of transfusions (p = 0.03) were significantly lower and the OT (p<0.00001) was significantly longer in robotic surgery than in laparotomy. The TLNH showed no significant difference between robotic surgery and laparotomy.

Conclusions

Robotic surgery is generally safer and more reliable than laparoscopy and laparotomy for patients with endometrial cancer. Robotic surgery is associated with significantly lower EBL than both laparoscopy and laparotomy; fewer conversions but more complications than laparoscopy; and shorter LOHS, fewer complications, and fewer transfusions but a longer OT than laparoscopy. Further studies are required.

Laparoscopic vs robotic-assisted surgery for endometrial carcinoma in a centre with long laparoscopic experience

Surgical outcomes and costs of laparoscopic and robotic hysterectomy for the treatment of endometrial carcinoma were compared in a centre with lengthy experience with laparoscopic surgery. The robotic cohort (n = 67) had a longer operative time than the laparoscopic cohort (n = 150) (p < 0.0001). Lymph node yields were similar for both surgical modalities, but the median of estimated blood loss was lower in the robotic group (50 ml vs 100 ml; p < 0.0001). The proportion of patients with hospital stay > 2 days and rate of overall complications were similar in both groups. Operative costs were (Euros) €1,680 and €3,860 for the laparoscopic and robotic procedure, respectively. We conclude that robotic technology is feasible but does not provide short-term benefits for the treatment of endometrial carcinoma in a centre where laparoscopy has been established as the standardised minimally invasive surgical method.

Impact of robotics on the outcome of elderly patients with endometrial cancer

OBJECTIVE

To evaluate the impact of introducing a robotics program on clinical outcome of elderly patients with endometrial cancer.

METHODS

Evaluation and comparison of peri-operative morbidity and disease-free interval in 163 consecutive elderly patients (≥70years) with endometrial cancer undergoing staging procedure with traditional open surgery compared to robotic surgery.

RESULTS

All consecutive patients ≥70years of age with endometrial cancer who underwent robotic surgery (n=113) were compared with all consecutive patients ≥70years of age (n=50) before the introduction of a robotic program in December 2007. Baseline patient characteristics were similar in both eras. Patients undergoing robotic surgery had longer mean operating times (244 compared with 217minutes, p=0.009) but fewer minor adverse events (17% compared with 60%, p<0.001). The robotics cohort had less estimated mean blood loss (75 vs 334mL, p<0.0001) and shorter mean hospital stay (3 vs 6days, p<0.0001). There was no difference in disease-free survival (p=0.61) during the mean follow-up time of 2years.

CONCLUSION

Transitioning from open surgery to a robotics program for the treatment of endometrial cancer in the elderly has significant benefits, including lower minor complication rate, less operative blood loss and shorter hospitalization without compromising 2-year disease-free survival.

Vaginal Vault Dehiscence After Robotic Hysterectomy for Gynecologic Cancers: Search for Risk Factors and Literature Review

Introduction

Vaginal vault dehiscence following robotic-assisted hysterectomy for gynecologic cancer may be attributed to surgical techniques and postoperative therapeutic interventions. We searched for risk factors in patients with gynecologic cancers and complemented this with a literature review.

Methods

Evaluation of prospectively gathered information on all consecutive robotic surgeries for gynecologic cancers was performed in a tertiary academic cancer center between December 2007 and March 2012. The literature was reviewed for articles relevant to “gynecologic oncology” and “robotics” with “vaginal cuff dehiscence” in the English and French languages. Respective authors were contacted to complete relevant information.

Results

Seven dehiscences were identified of 441 cases with established gynecologic cancers. The closures in these 7 were performed using interrupted 1-Vicryl (Ethicon Inc) (3/167; 1.8%), combination of interrupted 1-Vicryl and 1-Biosyn (Covidien Inc) (3/156, 1.9%), and V-Loc (Covidien Inc) (1/118, 0.8%) sutures. Associated risk factors included adjuvant chemotherapy and/or brachytherapy, early resumption of sexual activity, and low body mass index (mean, 23 ± 3.23 kg/m2). Dehiscences occurred regardless of suturing by staff or trainees. Review of operative videos did not reveal a detectable etiologic factor, such as excessive cautery damage to the vaginal cuff or shallow tissue sutured. All 7 colporrhexis repairs were performed through a vaginal approach without the need of laparoscopy or laparotomy.

Conclusions

Postoperative chemotherapy, brachytherapy, and early resumption of sexual activities are risk factors for vaginal vault dehiscence. Surgical technique, particularly the use of delayed absorbable sutures, deserves further evaluation

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.

Robotic surgical staging for obese patients with endometrial cancer

OBJECTIVE

To compare surgical outcomes for robotic vs laparotomy staging in obese endometrial cancer patients.

STUDY DESIGN

This was a retrospective cohort study of patients with body mass index ≥30 kg/m(2) staged in a community gynecologic oncology practice. Patients undergoing robotic staging were compared with historic laparotomy controls.

RESULTS

One hundred twenty-nine patients underwent robotic staging, compared with 110 laparotomy patients. The robotic cohort had fewer abdominal wound complications (13.9% vs 32.7%, P < .001), but more vaginal cuff complications (4.7% vs 0%, P = .032). Blood loss was lower in the robotic group (P < .001), as was length of stay (P < .001). Surgical times were longer in the robotic group (P < .001). There was no difference in terms of percentage of patients undergoing pelvic or paraaortic lymph node dissection.

CONCLUSION

Robotic staging for endometrial cancer is feasible in obese women, with fewer abdominal wound complications, but more vaginal cuff complications.

[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.

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.

Comparison between 155 cases of robotic vs. 150 cases of open surgical staging for endometrial cancer

OBJECTIVE

To compare the outcomes of 155 cases of endometrial cancer who had robot-assisted surgical staging to 150 open cases.

METHODS

Retrospective chart review of cases of endometrial cancer that underwent staging two different ways by two surgeons at an academic institution.

RESULTS

Mean age was 62.4 years in the robotic arm and 65 (P=0.04) in the open arm. Mean body mass index was 34.5 Kg/m(2) in the robotic arm and 33 Kg/m(2) in the open arm (P=0.2). Pelvic and para-aortic lymph node dissection were performed in 94.8% and 67.7% of the robotic cases versus 95.3% and 74% of the open cases, respectively. Mean operative time was 127 min in the robotic arm, and 141 min in the open arm (P=0.0001). Mean lymph node count was 20.3 in the robotic arm, and 20 in the open arm (P=0.567). Mean estimated blood loss was 119 ml in the robotic arm and 185 in the open arm (P=0.015). Mean hospital stay was 1.5 days in the robotic arm, and 4 days in the open arm (P=0.0001). The incidence of postoperative ileus (0.6% vs. 10.7%, P=0.0001), infections (5.2% vs. 24%, P=0.0001), anemia/transfusion (1.3% vs. 7.7%, P=0.005), and cardiopulmonary complications (3.2% vs.14.7%, P=0.003) was significantly lower in the robotic arm vs. the open arm. There was one death in the robotic arm attributed to pre-existing cardiac condition.

CONCLUSION

Robotic-assisted staging reaps the benefits of minimally invasive surgery without compromising the adequacy of the procedure. Dedication to the technique shortens the operative time.

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.

Preemptive multimodal analgesia facilitates same-day discharge following robot-assisted hysterectomy

We aimed to determine whether early hospital discharge following minimally invasive surgery can be achieved through the use of preemptive multimodal analgesia without compromising patient safety or comfort. Data were retrospectively collected for 150 patients who underwent robotic-assisted laparoscopic hysterectomy for benign indications from 9 December 2009 to 6 October 2010 at Cox Health Systems (Springfield, MO, USA). One surgeon performed 100 consecutive cases with all patients receiving preemptive multimodal treatment with celecoxib and ropivacaine. These cases were compared with 50 patients treated with an opioid-based postoperative analgesia regimen by one of four other surgeons at the same center. Patient characteristics, perioperative outcomes, opioid requirement, and time to discharge were compared between groups. The patients in the multimodal group had significantly reduced opioid requirements intraoperatively (25.0 mg vs. 29.9 mg, P = 0.0077), postoperatively on the day of surgery (10.9 mg vs. 17.9 mg, P = 0.0030), and on the first postoperative day (3.1 mg vs. 15.3 mg, P = 0.0001). There were no differences in procedure time, transfusions, or readmission rates between groups. Time in the Post-Anesthesia Care Unit (PACU) was decreased in the multimodal group (72.0 min vs. 88.4 min, P < 0.0001), as was time to discharge from the hospital (8.5 h vs. 30.2 h, P < 0.0001). Age and body mass index were both significantly lower in the multimodal group; however, regression analyses demonstrated that analgesia regimen was the only parameter that predicted opioid requirement and time to discharge. Preemptive multimodal analgesia reduced the total dose of rescue opioids, facilitating same-day discharge without compromising patient comfort or safety.

Comparison of robotic-assisted surgery outcomes with laparotomy for endometrial cancer staging in Turkey

PURPOSE

To compare the results of patients on whom staging was applied by robotic-assisted laparoscopic surgery and laparotomy for endometrial cancer.

METHOD

The study included 10 patients who had undergone robotic-assisted endometrial staging (group 1) and 12 patients staged by open surgery (group 2). Demographical characteristics and operative outcomes of all patients were compared. Body mass index, age, previous abdominal surgeries, histopathologic characteristics, performed operative procedure, operation time, complications, hospitalization duration, estimated blood loss and number of resected lymph nodes were recorded for all patients.

RESULTS

Mean age of the patients in the robotic surgery group was 55.7 years (37-66) and in the laparotomy group 56.4 years (47-75). Body mass index was calculated as 32.7 kg/m² (24.5-40.3) in group 1 and 30.3 kg/m² (25.9-35.8) in group 2. Total duration of operation was 234.6 min (137-300) and 168.5 min (102-232) in group 1 and 2, respectively. Mean duration of hospitalization in group 1 was 2.8 days (2-5) and in group 2 was 8.8 days (6-13). Estimates of blood loss were 95 ml (20-210 ml) in the robotic surgery group and 255 ml (80-420) in the other group. The mean number of resected lymph nodes was 42 (13-86) and 46.5 (26-107) in the robotic-assisted surgery group and laparotomy group, respectively. None of the cases in the robotic-assisted endometrial staging group required transition to laparotomy.

CONCLUSION

Robotic surgery may be preferred over laparotomy with respect to the advantages observed in the duration of hospitalization, estimated amount of blood loss and complications. There was no significant difference between the two methods in terms of number of resected lymph nodes. Despite the limited number of patients in this study, these results are important as they represent the first data on robotic surgery in Turkey.

Robotic surgical management of endometrial cancer in octogenarians and nonagenarians: analysis of perioperative outcomes and review of the literature

The primary aim of this article is to report the outcomes of octogenarians and nonagenarians who have undergone robotic surgery for endometrial cancer. A multi-institutional research consortium was created to evaluate the utility of robotics for gynecologic surgery (benign and malignant). IRB approval was obtained at each institution. A multi-institutional HIPPA compliant database was then created and analyzed for all patients that underwent robotic-assisted surgery with staging for endometrial cancer between the April 2003 and January 2009. In total, 395 patients were identified. A subset of patients between the ages of 80 and 95 years were then identified and analyzed for demographic data and perioperative outcomes. Twenty-seven patients in this age group were identified who underwent robotic-assisted hysterectomy and staging. The median age was 84, and median body mass index was 28. Comorbidities such as diabetes mellitus and hypertension were identified in 22 and 74% of patients, respectively. Over one-half (56%) of the patients reported a prior abdominal surgery. Final pathological analysis demonstrated that 88% of all patients had either Stage I or II disease. The median operative time was 192 min. The median estimated blood loss was 50 cc, and the median lymph node count was 16. The median hospital stay was 1.0 day. The overall intraoperative and postoperative complication rate was 7.4 and 33%, respectively. No patient received a blood transfusion. There was one conversion to laparotomy (3.7%). A comparison of the outcomes of the elderly cohort to those of all patients in the database (control group) revealed that there was no statistically significant difference between the groups in terms of operative time, blood loss, hospital stay, nodal yield, or conversion rate. Intraoperative complications were statistically similar between the groups; however, postoperative complications were significantly higher in the elderly cohort. We conclude that robotic surgery is safe, feasible, and expands surgical options for octogenarians and nonagenarians diagnosed with endometrial cancer. Age should not be considered a contraindication for robotic surgical management of patients with endometrial cancer.

Surgical outcomes of robotic-assisted surgical staging for endometrial cancer are equivalent to traditional laparoscopic staging at a minimally invasive surgical center

OBJECTIVE

To compare peri- and post-operative complications and outcomes of robotic-assisted surgical staging with traditional laparoscopic surgical staging for women with endometrial cancer.

METHODS

A retrospective chart review of cases of women undergoing minimally invasive total hysterectomy and pelvic and para-aortic lymphadenectomy by a robotic-assisted approach or traditional laparoscopic approach was conducted. Major intraoperative complications, including vascular injury, enterotomy, cystotomy, or conversion to laparotomy, were measured. Secondary outcomes including operative time, blood loss, transfusion rate, number of lymph nodes retrieved, and the length of hospitalization were also measured.

RESULTS

275 cases were identified-102 patients with robotic-assisted staging and 173 patients with traditional laparoscopic staging. There was no significant difference in the rate of major complications between groups (p=0.13). The mean operative time was longer in cases of robotic-assisted staging (237 min vs. 178 min, p<0.0001); however, blood loss was significantly lower (109 ml vs. 187 ml, p<0.0001). The mean number of lymph nodes retrieved were similar between groups (p=0.32). There were no significant differences in the time to discharge, re-admission, or re-operation rates between the two groups.

CONCLUSION

Robotic-assisted surgery is an acceptable alternative to laparoscopy for minimally invasive staging of endometrial cancer. In addition to the improved ease of operation, visualization, and range of motion of the robotic instruments, robotic surgery results in a lower mean blood loss, although longer operative time. More data are needed to determine if the rates of urinary tract injuries and other surgical complications can be reduced with the use of robotic surgery.