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

Surgical Treatment for Endometrial Cancer, Hysterectomy Performed via Minimally Invasive Routes Compared with Open Surgery: A Systematic Review and Network Meta-Analysis

Background: Total hysterectomy with bilateral salpingo-oophorectomy via minimally invasive surgery (MIS) has emerged as the standard of care for early-stage endometrial cancer (EC). Prior systematic reviews and meta-analyses have focused on outcomes reported solely from randomised controlled trials (RCTs), overlooking valuable data from non-randomised studies. This inaugural systematic review and network meta-analysis comprehensively compares clinical and oncological outcomes between MIS and open surgery for early-stage EC, incorporating evidence from randomised and non-randomised studies. Methods: This study was prospectively registered on PROSPERO (CRD42020186959). All original research of any experimental design reporting clinical and oncological outcomes of surgical treatment for endometrial cancer was included. Study selection was restricted to English-language peer-reviewed journal articles published 1 January 1995-31 December 2021. A Bayesian network meta-analysis was conducted. Results: A total of 99 studies were included in the network meta-analysis, comprising 181,716 women and 14 outcomes. Compared with open surgery, laparoscopic and robotic-assisted surgery demonstrated reduced blood loss and length of hospital stay but increased operating time. Compared with laparoscopic surgery, robotic-assisted surgery was associated with a significant reduction in ileus (OR = 0.40, 95% CrI: 0.17-0.87) and total intra-operative complications (OR = 0.38, 95% CrI: 0.17-0.75) as well as a higher disease-free survival (OR = 2.45, 95% CrI: 1.04-6.34). Conclusions: For treating early endometrial cancer, minimal-access surgery via robotic-assisted or laparoscopic techniques appears safer and more efficacious than open surgery. Robotic-assisted surgery is associated with fewer complications and favourable oncological outcomes.

Impact of artificial intelligence on the diagnosis, treatment and prognosis of endometrial cancer

Endometrial cancer is one of the most prevalent tumours in females and holds an 83% survival rate within 5 years of diagnosis. Hypoestrogenism is a major risk factor for the development of endometrial carcinoma (EC) therefore two major types are derived, type 1 being oestrogen-dependent and type 2 being oestrogen independent. Surgery, chemotherapeutic drugs, and radiation therapy are only a few of the treatment options for EC. Treatment of gynaecologic malignancies greatly depends on diagnosis or prognostic prediction. Diagnostic imaging data and clinical course prediction are the two core pillars of artificial intelligence (AI) applications. One of the most popular imaging techniques for spotting preoperative endometrial cancer is MRI, although this technique can only produce qualitative data. When used to classify patients, AI improves the effectiveness of visual feature extraction. In general, AI has the potential to enhance the precision and effectiveness of endometrial cancer diagnosis and therapy. This review aims to highlight the current status of applications of AI in endometrial cancer and provide a comprehensive understanding of how recent advancements in AI have assisted clinicians in making better diagnosis and improving prognosis of endometrial cancer. Still, additional study is required to comprehend its strengths and limits fully.

Robotic surgery in endometrial cancer: first Polish experience

In Poland, robotic surgery is nowadays perceived as a new method of surgical treatment in endometrial cancer patients. We aim to present the first Polish group of endometrial cancer patients treated using robotic surgery. The analysis was based on 79 patients with mean age of 59.72 ± 11.709 (range 27-83) years and endometrial cancer scheduled for surgical treatment. Mean BMI was 31.38 ± 8.78 (range 19.03-65.97) kg/m2. The data were collected based on a questionnaire consisting of 19 questions concerning the patient's perception of robotic surgery before the procedure. Patients with a family history of neoplastic diseases indicate precision of movements as the most important reason for choosing robotic surgery (p = 0.0035). Patients after surgery procedures in the past named shorter hospitalization as a major benefit (p = 0.0037). Patients who chose robotic surgery for financial reasons stressed the cosmetic effect as a priority (p = 0.0319). Shorter length of hospital stay, less blood loss, enlarged view, and good visualization were statistically significant reasons for choosing robotic surgery (p < 0.05). Women who consider work, good material status, and well-being as the most important aspects of their lives cited the cosmetic effect as a benefit of robotic surgery (p = 0.0029 vs. p = 0.0074 vs. p = 0.01745, respectively). In the follow-up after operations, no patients regretted choosing robotic surgery. Good visualization, precise movements, less blood loss, and cosmetic effects are the most frequent reasons for choosing robotic surgery. Even patients after other types of surgery in the past decided on robot-assisted radical hysterectomy because of the clear benefits of this approach.

Robot-assisted surgery for women with endometrial cancer: Surgical and oncologic outcomes within a Belgium gynaecological oncology group cohort

OBJECTIVE

To evaluate surgical and oncologic outcomes of patients treated by robot-assisted surgery for endometrial cancer within the Belgium Gynaecological Oncology Group (BGOG).

STUDY DESIGN

We performed a retrospective analysis of women with clinically Stage I endometrial cancer who underwent surgical treatment from 2007 to 2018 in five institutions of the BGOG group.

RESULTS

A total of 598 consecutive women were identified. The rate of conversion to laparotomy was low (0.8%). The mean postoperative Complication Common Comprehensive Index (CCI) score was 3.4. The rate of perioperative complications did not differ between age groups, however the disease-free survival was significantly lower in patients over 75 years compared to patients under 65 years of age (p=0.008). Per-operative complications, conversion to laparotomy rate, post-operative hospital stay, CCI score and disease-free survival were not impacted by increasing BMI.

CONCLUSION

Robot-assisted surgery for the surgical treatment of patients suffering from early-stage endometrial cancer is associated with favourable surgical and oncologic outcomes, particularly for unfavourable groups such as elderly and obese women, thus permitting a low morbidity minimally-invasive surgical approach for the majority of patients in expert centres.

Bowel injury in robotic gynecologic surgery: risk factors and management options. A systematic review

OBJECTIVE

We sought to analyze the published literature on bowel injuries in patients undergoing gynecologic robotic surgery with the aim to determine its incidence, predisposing factors, and treatment options.

DATA SOURCES

Studies included in this analysis were identified by searching PubMed Central, OVID Medline, EMBASE, Cochrane, and ClinicalTrials.gov databases. References for all studies were also reviewed. Time frame for data analysis spanned from November 2001 through December 2014.

STUDY ELIGIBILITY CRITERIA

All English-language studies reporting the incidence of bowel injury or complications during robotic gynecologic surgery were included. Studies with data duplication, not in English, case reports, or studies that did not explicitly define bowel injury incidence were excluded.

STUDY APPRAISAL AND SYNTHESIS METHODS

The Guidelines for Meta-Analyses and Systematic Reviews of Observational Studies were used to complete the systematic review with the exception of scoring study quality and a single primary reviewer.

RESULTS

In all, 370 full-text articles were reviewed and 144 met the inclusion criteria. There were 84 bowel injuries recorded in 13,444 patients for an incidence of 1 in 160 (0.62%; 95% confidence interval, 0.50-0.76%). There were no significant differences in incidence of bowel injury by procedure type. The anatomic location of injury, etiology, and management were rarely reported. Of the bowel injuries, 87% were recognized intraoperatively and the majority (58%) managed via a minimally invasive approach. Of 13,444 patients, 3 (0.02%) (95% confidence interval, 0.01-0.07%) died in the immediate postoperative period and no deaths were a result of a bowel injury.

CONCLUSION

The overall incidence of bowel injury in robotic-assisted gynecologic surgery is 1 in 160. When the location of bowel injuries were specified, they most commonly occurred in the colon and rectum and most were managed via a minimally invasive approach.

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.

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.

Influence of Morbid Obesity on Surgical Outcomes in Robotic-Assisted Gynecologic Surgery

Objective: The aim of this research was to estimate the impact of body mass index (BMI) on surgical outcomes in patients undergoing robotic-assisted gynecologic surgery. Materials and Methods: This study was a retrospective review of prospectively collected cohort data for a consecutive series of patients undergoing gynecologic robotic surgery in a single institution. BMI, expressed as kg/m2, was abstracted from the medical charts of all patients undergoing robotic hysterectomy. Data on estimated blood loss (EBL), hemoglobin (Hb) drop, procedure time, length of hospital stay, uterine weight, pain-medication use, and complications were also extracted. Results: Two hundred and eighty-one patients underwent robotic operations. Types of procedures were total hysterectomy with or without adnexal excision, and total hysterectomies with lymphadenectomies. Eighty-four patients who were classified as morbidly obese (BMI>35) were compared with 197 patients who had a BMI of<35 (nonmorbidly obese). For patients with BMI<35, and BMI>35, the mean BMI was 27.1 and 42.5 kg/m2 (p<0.05), mean age was 49 and 50 (p=0.45), mean total operative time was 222 and 266 minutes (p<0.05), console time 115 and 142 minutes (p<0.05), closing time (from undocking until port-site fascia closure) was 30 and 41 minutes (p<0.05), EBL was 67 and 79 mL (p=0.27), Hb drop was 1.6 and 1.4 (p=0.28), uterine weight was 196.2 and 227 g (p=0.52), pain-medication use 93.7 and 111 mg of morphine (p=0.46), and mean length of stay was 1.42 and 1.43 days (0.9), all respectively. No statistically significant difference was noted between the 2 groups for EBL, Hb drop, LOS, uterine weight, pain-medication use, or complications. The only statistically significant difference was seen in operating times and included docking, console, closing, and procedure times. There were no perioperative mortalities. Morbidity occurred in 24 patients (8%). In the morbidly obese group, there were 6 complications (7%) and, in the nonmorbidly obese group, there were 18 complications (9%). Conclusions: Morbid obesity does not appear to be associated with an increased risk of morbidity in patients undergoing robotically assisted gynecologic surgery. Morbid obesity is associated with increased procedure time, but otherwise appears to have no difference in outcomes. Robotic surgery offered an ideal approach, allowing minimally invasive surgery in these technically challenging patients, with no significant increase in morbidity. J GYNECOL SURG 30:81).

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.

Robotic surgery in gynecology: an updated systematic review

The introduction of da Vinci Robotic Surgery to the field of Gynecology has resulted in large changes in surgical management. The robotic platform allows less experienced laparoscopic surgeons to perform more complex procedures. In general gynecology and reproductive gynecology, the robot is being increasingly used for procedures such as hysterectomies, myomectomies, adnexal surgery, and tubal anastomosis. Among urogynecology the robot is being utilized for sacrocolopexies. In the field of gynecologic oncology, the robot is being increasingly used for hysterectomies and lymphadenectomies in oncologic diseases. Despite the rapid and widespread adoption of robotic surgery in gynecology, there are no randomized trials comparing its efficacy and safety to other traditional surgical approaches. Our aim is to update previously published reviews with a focus on only comparative observational studies. We determined that, with the right amount of training and skill, along with appropriate patient selection, robotic surgery can be highly advantageous. Patients will likely have less blood loss, less post-operative pain, faster recoveries, and fewer complications compared to open surgery and potentially even laparoscopy. However, until larger, well-designed observational studies or randomized control trials are completed which report long-term outcomes, we cannot definitively state the superiority of robotic surgery over other surgical methods.

The technique of robotic assisted laparoscopic surgery in gynaecology, its introduction into the clinical routine of a gynaecological department and the analysis of the perioperative courses - a German experience

OBJECTIVE

Robotic assisted surgery is an advancement on conventional laparoscopy. The first and single FDA-approved device is the da-Vinci™ system, which provides means to overcome the limitations of conventional laparoscopy. In Germany the use of the robotic system in gynaecology is at the threshold of a promising development. There is a wide spectrum of indications, such as simple and radical hysterectomies, including pelvic and paraaortic lymph node dissection. The introduction of the robotic system into the clinical routine is demonstrated.

MATERIAL AND METHODS

Robotic assisted laparoscopic interventions have been performed in the reporting hospital since April 2008. In the course of treatment of 172 cases, an increasing rise of complexity of surgical procedure has been achieved. The daVinci™ system is well adaptable in clinical routine. Hitherto, the clinical outcome has been favourable, higher-grade specific complications occurred very rarely. The short time advantages are a decrease of postoperative length of stay, a reduction of postinterventional need of analgetics and an overall accelerated period of recovery has been demonstrated compared to conventional abdominal procedures. It also shows that a drastic decrease of open conventional abdominal procedures concerning uterine pathologies appeared in the reporting department.

RESULTS

Perioperative advantages of robotic assisted laparoscopic interventions are, above all, the decrease of morbidity (concerning blood loss, need of analgetics, length of stay, etc.). Surgical advantages are the more complex applicability, improved precision, dexterity and vision (3D), a greater autonomy of the surgeon, a smaller learning curve and an increase of preparation consistent with the anatomical structures. In contrast, disadvantages concern an initial greater time investment, the potentially different management of complications, the limited applicability in multiquadrant surgery and the difficulty regarding cost coverage respective to recovery.

CONCLUSIONS

In conclusion, robotic assisted minimal invasive surgery has an enormous potential in gynaecology; by simplifying the essential surgical procedure. The advantages of this technique will be approachability for a majority of gynaecological patients. The feasibility of a multitude of gynaecological surgical interventions has already been approved partially in a small number of cases. The upcoming challenge now is to verify the short and long term advantages of robotic surgery in prospective trials, especially concerning gynaecological oncology.