Prospective randomized study comparing robotic-assisted hysterectomy and regional lymphadenectomy with traditional laparotomy for staging of endometrial carcinoma -initial Indian experience

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.

Robotic-assisted surgery for endometrial cancer: a comparison of surgical and oncologic outcomes in patients with low and high BMI at an Indian tertiary care center

The robotic-assisted surgery for endometrial cancer (EC) is becoming increasingly important, owing to the superior surgical outcomes. However, efficacy data from India is limited, particularly for older women who are obese. We undertook this study to compare the surgical outcomes of robotic-assisted surgery among Indian EC patients with a BMI of < 30 and ≥ 30 kg/m2. A retrospective chart review was conducted for the period of May 2016 to October 2020. Data on patient demographics, medical history, clinical characteristics, and perioperative outcomes were collected by a single senior surgeon, followed by statistical analysis. A total of 99 patients; 39 in the BMI group < 30 and 60 in the BMI group ≥ 30 kg/m2 were included in the study. The mean age of the BMI groups < 30 and ≥ 30 kg/m2 was 60.92 ± 10.43 and 58.90 ± 8.52 years respectively (P = 0.2944). The mean total operating time was slightly higher in the BMI group < 30 kg/m2 (P = 0.8552) but the difference was not statistically significant. Similarly, the mean blood loss (P = 0.2041), length of hospital stays (P = 0.6564), early (P = 0.7758) and delayed complications (P = 0.1878) were less in the BMI group < 30 kg/m2 but the difference was not statistically significant either. At a median follow-up of 22.3 months, the number of recurrences (5.13% vs 3.33%) and deaths (2.56% vs 1.67%) were more in BMI < 30 kg/m2 group. Our study suggests that obese older women predisposed to multiple medical co-morbidities and surgical complications would especially benefit from robotic-assisted technology regardless of their BMI.

Survival outcomes of robotic-assisted laparoscopy versus conventional laparoscopy and laparotomy for endometrial cancer: A systematic review and meta-analysis

OBJECTIVE

Robotic-assisted laparoscopy (RALS) has gained widespread acceptance in the field of gynecological oncology. However, whether the prognosis of endometrial cancer after RALS is superior to conventional laparoscopy (CLS) and laparotomy (LT) remains inconclusive. Therefore, the aim of this meta-analysis was to compare the long-term survival outcomes of RALS with CLS and LT for endometrial cancer.

METHODS

A systematic literature search was conducted on electronic databases (PubMed, Cochrane, EMBASE and Web of Science) until May 24, 2022, followed by a manual search. Based on inclusion and exclusion criteria, publications investigating long-term survival outcomes after RALS vs CLS or LT in endometrial cancer patients were collected. The primary outcomes included overall survival (OS), disease-specific survival (DSS), recurrence-free survival (RFS) and disease-free survival (DFS). Fixed effects models or random effects models were employed to calculate the pooled hazard ratios (HRs) and 95% confidence intervals (CIs) as appropriate. Heterogeneity and publication bias were also assessed.

RESULTS

RALS and CLS had no difference in OS (HR = 0.962, 95% CI: 0.922-1.004), RFS (HR = 1.096, 95% CI: 0.947-1.296), and DSS (HR = 1.489, 95% CI: 0.713-3.107) for endometrial cancer; however, RALS was significantly associated with favorable OS (HR = 0.682, 95% CI: 0.576-0.807), RFS (HR = 0.793, 95% CI: 0.653-0.964), and DSS (HR = 0.441, 95% CI: 0.298-0.652) when compared with LT. In the subgroup analysis of effect measures and follow-up length, RALS showed comparable or superior RFS/OS to CLS and LT. In early-stage endometrial cancer patients, RALS had similar OS but worse RFS than CLS.

CONCLUSIONS

RALS is safe in the management of endometrial cancer, with long-term oncological outcomes equivalent to CLS and superior to LT.

Multi-Institutional Trends in Gynecological Robotic Surgery in India: A Real-World Scenario

Background Robot-assisted laparoscopic surgery in gynecology has grown exponentially compared to laparoscopic surgery. The probable reasons for the increased uptake of robotics are a shorter learning curve, three-dimensional vision, and increased dexterity compared to laparoscopic surgery, and precise surgery as compared to open surgery. This study compares the time trends of various parameters in robotic gynecological surgery in India over a decade. Material and methods In India, a retrospective analysis of all robot-assisted laparoscopic surgery for gynecologic diseases in five tertiary care hospitals was conducted between July 2011 and June 2021. Data were collected regarding demographic profiles, clinical and disease characteristics, and indications for surgery. Details related to surgery were collected, such as the number of ports, console and docking time, the procedure performed, total operative time, average blood loss, blood transfusion, and length of hospital stay. All the parameters collected were grouped into five years, and a comparison was made between the first five years (2011-2015) and the second five years (2016-2021). Statistical analysis, including descriptive statistics and trend analysis, was performed. Results During the 10 years, the total number of cases included was 1,501, out of which 764 were benign cases and 737 were pre-malignant/malignant cases. The common indications were uterine leiomyoma (31.2%) and carcinoma endometrium (28%). The mean age for benign cases was significantly lower than that for malignant cases (40.84 years and 55.42 years, respectively). Mean blood loss was significantly lower for benign indications (97.48 mL) than for oncological surgery (184.67 mL) and needed fewer transfusions. The mean length of stay (LOS) for benign (2.07 days) and malignant/ pre-malignant cases (2.32 days) and the mean BMI for benign (28.40) and for oncological patients (28.47) were similar in both groups. The docking time reduced significantly in the last five years. Conclusion The current retrospective study demonstrates an increasing uptake of robotic technology in gynecological surgery in India. Of the total cohort of cases, 70.9% of patients underwent gynecological robotic surgery in the last five years. A burst of adaptability happened for malignant cases in 2017 and benign cases in 2018, probably due to the increased availability of robotic platforms and improved awareness of technology and training among medical professionals. The number of cases has grown exponentially over the last five years in both benign and malignant/ pre-malignant scenarios; however, there has been a downward trend in the robotic surgery performed in the previous couple of years due to the uncertainty of the COVID pandemic.

A prospective observational study assessing the feasibility and factors affecting same-day discharge in patients undergoing robotic-assisted surgery for gynecological cancers

Although robotic-assisted surgery is being increasingly used in the management of gynecologic cancers, most surgeons discharge patients on the next day of surgery citing concerns about immediate post-operative complications. Present study was conducted to evaluate the safety, factors influencing and quality of life for gynaecological cancer patients undergoing same-day discharge after robotic-assisted surgery. This is single institutional prospective observational study as pragmatic cohort including all well-selected gynecological cancer patients undergoing robotic-assisted surgery from September 2017 to June 2019. Patients were divided into two study groups [Same-day discharge (SDD) group vs. Next-day discharge (NDD) group] according to day of discharge. The entire cohort included 152 patients (38 in SDD group and 114 in NDD group). The difference between both SDD vs. NDD was significant for parameters including Age ≥ 70 years (0% vs. 18.4%, p: 0.010); Operative time > 60 min (39.5% vs. 60.5%, p: 0.024); patients with third-party insurance covering surgery (2.6% vs. 25.4%, p: 0.005) and place of residence ≥ 60 km from hospital (13.1% vs. 51.8%, p: < 0.0001). The quality of life was similar in both groups and none of the patients required readmission or emergency room visits. Same-day discharge after robot-assisted surgery in gynecologic cancer patients is a safe and feasible option. Younger patients, short surgical time, surgery early in the day, no claim for third-party insurance, residing nearby hospital within 60 km radius were influencing factors favouring same-day discharge.

Research quality and transparency, outcome measurement and evidence for safety and effectiveness in robot-assisted surgery: systematic review

BACKGROUND

Robot-assisted surgery (RAS) has potential panspecialty surgical benefits. High-quality evidence for widespread implementation is lacking. This systematic review aimed to assess the RAS evidence base for the quality of randomized evidence on safety and effectiveness, specialty 'clustering', and outcomes for RAS research.

METHODS

A systematic review was undertaken according to PRISMA guidelines. All pathologies and procedures utilizing RAS were included. Studies were limited to RCTs, the English language and publication within the last decade. The main outcomes selected for the review design were safety and efficacy, and study purpose. Secondary outcomes were study characteristics, funding and governance.

RESULTS

Searches identified 7142 titles, from which 183 RCTs were identified for data extraction. The commonest specialty was urology (35·0 per cent). There were just 76 unique study populations, indicating significant overlap of publications; 103 principal studies were assessed further. Only 64·1 per cent of studies reported a primary outcome measure, with 29·1 per cent matching their registration/protocol. Safety was assessed in 68·9 per cent of trials; operative complications were the commonest measure. Forty-eight per cent of trials reported no significant difference in safety between RAS and comparator, and 11 per cent reported RAS to be superior. Efficacy or effectiveness was assessed in 80·6 per cent of trials; 43 per cent of trials showed no difference between RAS and comparator, and 24 per cent reported that RAS was superior. Funding was declared in 47·6 per cent of trials.

CONCLUSION

The evidence base for RAS is of limited quality and variable transparency in reporting. No patterns of harm to patients were identified. RAS has potential to be beneficial, but requires continued high-quality evaluation.

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.

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.

Gynecological cancers: A summary of published Indian data

Gynecological cancers are among the most common cancers in women and hence an important public health issue. Due to the lack of cancer awareness, variable pathology, and dearth of proper screening facilities in developing countries such as India, most women report at advanced stages, adversely affecting the prognosis and clinical outcomes. Ovarian cancer has emerged as one of the most common malignancies affecting women in India and has shown an increase in the incidence rates over the years. Although cervical cancer is on a declining trend, it remains the second most common cancer in women after breast cancer. Many researchers in India have published important data in the field of gynecologic oncology, covering all domains such as basic sciences, preventive oncology, pathology, radiological imaging, and clinical outcomes. This work has given us an insight into the in-depth understanding of these cancers as well as the demographics and survival rates in the Indian population. This aim of this review is to discuss the important studies done in India for all gynecological cancers.

Total (Transthoracic and Transabdominal) Robotic Radical Three-Stage Esophagectomy-Initial Indian Experience

This study aims to evaluate the safety and technical feasibility of total robot-assisted three-stage esophagectomy. From July 2011 to June 2014, 35 histologically proven resectable carcinoma esophagus patients underwent robot-assisted transthoracic and transperitoneal three-stage esophagectomy. In the initial ten cases, total docking time, thoracic docking time, total operative time, thoracic-phase operative time, and blood loss were 67.9 ± 13.24, 32.2 ± 9.74, 429.2 ± 57.65, and 96.6 ± 20.33 min and 433.20 ± 48.72 ml, respectively. In the subsequent 25 cases, all parameters decreased significantly (33.20 ± 4.16, 13.76 ± 3.43, 321.13 ± 13.75, and 57.04 ± 9.15 min and 256.32 ± 17.52 ml, respectively). Median numbers of lymph node dissected were 32. One case was converted to open method, and there was no in-hospital or 30-day mortality. Two cases required ventilator support for 1 day, with ICU stay for 1 day in 15 patients and 2 days in five patients. Two patients had major complications. Median hospital stay was 8 days. All had microscopic negative resection margins. Robot-assisted three-stage esophagectomy has the benefits of minimally invasive surgery and immediate oncological outcomes are comparable to conventional open surgery. Therefore, it is a safe and feasible technique for the treatment of esophageal cancer in selected patients.