Laparoscopic versus open radical hysterectomy for elderly patients with early-stage cervical cancer

Comparison of 2D 4K vs. 3D HD laparoscopic imaging systems in bariatric surgery: study protocol for a randomized controlled prospective trial

BACKGROUND

Vision is an important and defining element of laparoscopy and significantly affects the outcome of surgery in terms of time, error, and precision. Several new imaging systems have become available for laparoscopic surgery, including three-dimensional (3D) high-definition (HD) and two-dimensional (2D) ultra-high-resolution (4K) monitors. 3D HD systems offer a number of potential benefits to surgeons and patients over traditional 2D systems, including reduced operating time, blood loss, and hospital stay. However, the performance of 3D systems against the new, ultra-high definition 4K systems is barely known and highly controversial. There is a paucity of studies comparing them in clinical settings. The aim of this study is to compare 2D 4K and 3D HD perspectives in gastric bypass surgery.

METHODS

Forty-eight patients with an indication for gastric bypass will be randomized to receive laparoscopic gastric bypass surgery using either 2D 4K or 3D HD systems. The operations will be performed by a well-coordinated team of three senior surgeons. The primary outcome is operative time. Secondary outcomes include intraoperative complications, blood loss, operator workload as assessed by the validated Surg-TLX questionnaire, and postoperative complications according to the Clavien-Dindo classification. An interim analysis is planned after enrollment of 12 participants for each group.

DISCUSSION

This prospective, randomized trial is designed to test the hypothesis that the use of a 3D HD system will result in a significant improvement in operative time compared to a 2D 4K system in bariatric surgery. The objective is to provide clinical evidence for new laparoscopic imaging systems and to evaluate potential benefits.

TRIAL REGISTRATION

This trial is registered at clinicaltrials.gov under the identifier NCT05895058. Registered 30 May 2023. BASEC2023-D0014 [Registry ID Swissethics, approved 3 May 2023]. SNCTP000005489 [SNCTP study register, last updated 13 July 2023].

Laparoscopic Versus Abdominal Radical Hysterectomy for Cervical Cancer: A Meta-analysis of Randomized Controlled Trials

BACKGROUND

Laparoscopic radical hysterectomy (LRH) and open abdominal radical hysterectomy (ARH) have been used for cervical cancer treatment. We aimed to perform a meta-analysis to compare the efficacy and safety of LRH and ARH in the treatment of cervical cancer to provide reliable evidence to the clinical cervical cancer treatment.

METHODS

Two investigators independently searched PubMed and other databases for randomized controlled trials (RCTs) comparing LRH and ARH for cervical cancer treatment up to May 31, 2022. The risk of bias assessment tool recommended by Cochrane library was used for quality assessment. RevMan 5.3 software was used for meta-analysis.

RESULTS

Fourteen RCTs with a total of 1700 patients with cervical cancer were finally included. Meta-analyses indicated that compared with ARH, LRH reduced the intraoperative blood loss (mean difference [MD]=-58.08; 95% CI, -70.91, -45.24), the time to first passage of flatus (MD=-14.50; 95% CI, -16.55, -12.44) (all P <0.05), and increase the number of lymph nodes removed (MD=3.47; 95% CI, 0.51, 6.43; P =0.02). There were no significant differences in the duration of surgery (MD=27.62; 95% CI, -6.26, 61.49), intraoperative complications (odd ratio [OR]=1.10; 95% CI, 0.17, 7.32), postoperative complications (OR=0.78; 95% CI, 0.33, 1.86), relapse rate (OR=1.45; 95% CI, 0.56, 3.74), and survival rate (OR=0.75; 95% CI, 0.52, 1.08) between LRH group and ARH group (all P >0.05).

CONCLUSIONS

LRH has more advantages over ARH in the treatment of cervical cancer. Still, the long-term effects and safety of LRH and ARH need more high-quality, large-sample RCTs to be further verified.

Evaluation of Surgical Outcomes of Abdominal Radical Hysterectomy and Total Laparoscopic Radical Hysterectomy for Cervical Cancer: A Retrospective Analysis of Data Collected before the LACC Trial

Although a surgical approach is one of the key treatments for stages IA1-IIA2, results of the Laparoscopic Approach to Cervical Cancer (LACC) published in 2018 radically changed the field, since minimally invasive surgery was associated with a four-fold higher rate of recurrence and a six-fold higher rate of all-cause death compared to an open approach. We aimed to evaluate surgical outcomes of abdominal radical hysterectomy (ARH) and total laparoscopic radical hysterectomy (TLRH) for cervical cancer, including data collected before the LACC trial. In our retrospective analysis, operative time was significantly longer in TLRH compared to ARH (p < 0.0001), although this disadvantage could be considered balanced by lower intra-operative estimated blood loss in TLRH compared with ARH (p < 0.0001). In addition, we did not find significant differences for intra-operative (p = 0.0874) and post-operative complication rates (p = 0.0727) between ARH and TLRH. This was not likely to be influenced by age and Body Mass Index, since they were comparable in the two groups (p = 0.0798 and p = 0.4825, respectively). Finally, mean number of pelvic lymph nodes retrieved (p = 0.153) and nodal metastases (p = 0.774), as well as death rate (p = 0.5514) and recurrence rate (p = 0.1582) were comparable between the two groups. Future studies should be aimed at assessing whether different histology/grades of cervical cancer, as well as particular subpopulations, may have significantly different outcomes using minimally invasive surgery or laparotomy, with or without neoadjuvant chemotherapy.

Comparison of 2D 4K vs. 3D HD laparoscopic imaging systems using a pelvitrainer model: a randomized controlled study

Laparoscopic surgery provides well-known benefits, but it has technological limitations. Depth perception is particularly crucial, with three-dimensional (3D) imaging being superior to two-dimensional (2D) HD imaging. However, with the introduction of 4K resolution monitors, 2D rendering is capable of providing higher-quality visuals. Therefore, this study aimed to compare 3D HD and 2D 4K imaging using a pelvitrainer model. Eight experts and 32 medical students were performing the same four standardized tasks using 2D 4K and 3D HD imaging systems. Task completion time and the number of errors made were recorded. The Wilcoxon test and mixed-effects models were used to analyze the results. Students were significantly faster in all four tasks when using the 3D HD perspective. The median difference ranged from 18 s in task 3 (P < 0.003) up to 177.5 s in task 4 (P < 0.001). With the exception of task 4, students demonstrated significantly fewer errors in all tasks involving 3D HD imaging. The experts’ results confirmed these findings, as they were also faster in all four tasks using 3D HD, which was significant for task 1 (P < 0.001) and task 4 (P < 0.006). The expert group also achieved better movement accuracy using the 3D HD system, with fewer mistakes made in all four tasks, which was significant in task 4 (P < 0.001). Participants in both groups achieved better results with the 3D HD imaging system than with the 2D 4K system. The 3D HD image system should be used when available. Trial registration: this trial is registered at research registry under the identifier researchregistry6852.

Laparoscopic versus open radical hysterectomy in women with early stage cervical cancer: A systematic review and meta-analysis

This review aimed to evaluate the short term and long-term outcomes of laparoscopic radical hysterectomy (LRH) versus abdominal radical hysterectomy (ARH) for early-stage cervical cancer. A search of PubMed, Medline and Scopus databased from 2000 to 2018 was conducted. Thirty studies were retrieved including 22 retrospective cohort studies and 8 prospective cohort studies. LRH was comparable with ARH in 5-year overall survival (RR = 1.0. 95%CI 0.98-1.03; p = 0.33) and 5-year disease-free survival (RR = 1.02 95%CI 0.97-1.06; p = 0.98). The majority of included studies reported the negative cancer factors which drive adjuvant therapy were similar between two approaches. LRH was associated with lower blood loss and blood transfusion, less postoperative complication, shorter hospital stays and similar intraoperative complication rate compared to ARH. Our data suggested LRH for early-stage cervical cancer was as safe and effective in terms of long-term outcomes, but with lower surgical morbidities.

Comparison of oncological outcomes and major complications between laparoscopic radical hysterectomy and abdominal radical hysterectomy for stage IB1 cervical cancer with a tumour size less than 2 cm

OBJECTIVE

To compare the oncological outcomes and major complications of laparoscopic radical hysterectomy (LRH) and abdominal radical hysterectomy (ARH) for stage IB1 cervical cancer (FIGO 2009) with a tumour size less than 2 cm.

METHODS

We retrospectively compared the oncological outcomes and major complications of 1207 stage IB1 cervical cancer patients with a tumour size less than 2 cm who received LRH (n = 546) or ARH (n = 661) in 37 hospitals.

RESULTS

(1) There was no significant difference in 3-year overall survival (OS; 97.3% vs. 98.5%, P = 0.288) or 3-year disease-free survival (DFS; 95.1% vs. 95.4%, P = 0.792) between LRH (n = 546) and ARH (n = 661).(2) The rate of any 1 complication refers to the incidence of one or more complications in a patient, which was higher with LRH than ARH (OR = 4.047, 95% CI = 2.035-8.048, P < 0.001). Additionally, intraoperative complications occurred with LRH (OR = 12.313, 95% confidence intervals [CI] = 1.571-96.493, P = 0.017), and postoperative complications (OR = 3.652, 95% CI = 1.763-7.562, P < 0.001) were higher with LRH than ARH. The ureteral injury rate was higher with LRH than with ARH (1.50% vs. 0.20%, OR = 9.814, 95% CI = 1.224-78.712, P = 0.032). The ureterovaginal fistula rate was higher with LRH than ARH. The rates of obturator nerve injury, bladder injury, vesicovaginal fistula, rectovaginal fistula, venous thromboembolism, bowel obstruction, chylous leakage, pelvic haematoma, and haemorrhage were similar between the groups.

CONCLUSIONS

The oncological outcomes of LRH and ARH for stage IB1 cervical cancer patients with a tumour size less than 2 cm do not differ significantly. However, incidences of any 1 complication, intraoperative complications, and postoperative complications were higher with LRH than ARH, with complications manifesting mainly as ureteral injury and uterovaginal fistula.

Survival After Minimally Invasive vs Open Radical Hysterectomy for Early-Stage Cervical Cancer: A Systematic Review and Meta-analysis

Importance

Minimally invasive techniques are increasingly common in cancer surgery. A recent randomized clinical trial has brought into question the safety of minimally invasive radical hysterectomy for cervical cancer.

Objective

To quantify the risk of recurrence and death associated with minimally invasive vs open radical hysterectomy for early-stage cervical cancer reported in observational studies optimized to control for confounding.

Data Sources

Ovid MEDLINE, Ovid Embase, PubMed, Scopus, and Web of Science (inception to March 26, 2020) performed in an academic medical setting.

Study Selection

In this systematic review and meta-analysis, observational studies were abstracted that used survival analyses to compare outcomes after minimally invasive (laparoscopic or robot-assisted) and open radical hysterectomy in patients with early-stage (International Federation of Gynecology and Obstetrics 2009 stage IA1-IIA) cervical cancer. Study quality was assessed with the Newcastle-Ottawa Scale and included studies with scores of at least 7 points that controlled for confounding by tumor size or stage.

Data Extraction and Synthesis

The Meta-analysis of Observational Studies in Epidemiology (MOOSE) checklist was used to abstract data independently by multiple observers. Random-effects models were used to pool associations and to analyze the association between surgical approach and oncologic outcomes.

Main Outcomes and Measures

Risk of recurrence or death and risk of all-cause mortality.

Results

Forty-nine studies were identified, of which 15 were included in the meta-analysis. Of 9499 patients who underwent radical hysterectomy, 49% (n = 4684) received minimally invasive surgery; of these, 57% (n = 2675) received robot-assisted laparoscopy. There were 530 recurrences and 451 deaths reported. The pooled hazard of recurrence or death was 71% higher among patients who underwent minimally invasive radical hysterectomy compared with those who underwent open surgery (hazard ratio [HR], 1.71; 95% CI, 1.36-2.15; P < .001), and the hazard of death was 56% higher (HR, 1.56; 95% CI, 1.16-2.11; P = .004). Heterogeneity of associations was low to moderate. No association was found between the prevalence of robot-assisted surgery and the magnitude of association between minimally invasive radical hysterectomy and hazard of recurrence or death (2.0% increase in the HR for each 10-percentage point increase in prevalence of robot-assisted surgery [95% CI, -3.4% to 7.7%]) or all-cause mortality (3.7% increase in the HR for each 10-percentage point increase in prevalence of robot-assisted surgery [95% CI, -4.5% to 12.6%]).

Conclusions and Relevance

This systematic review and meta-analysis of observational studies found that among patients undergoing radical hysterectomy for early-stage cervical cancer, minimally invasive radical hysterectomy was associated with an elevated risk of recurrence and death compared with open surgery.

Minimally Invasive Radical Hysterectomy for Cervical Cancer: A Systematic Review and Meta-analysis

OBJECTIVE

To compare recurrence rate, progression-free survival (PFS), and overall survival for early-stage cervical cancer after minimally invasive (MIS) vs abdominal radical hysterectomy.

DATA SOURCES

MEDLINE, Embase, Cochrane Central Register of Controlled Trials, and Cochrane Library databases.

METHODS OF STUDY SELECTION

We identified studies from 1990 to 2020 that included women with stage I or higher cervical cancer treated with primary radical hysterectomy and compared recurrence and/or PFS and overall survival with MIS vs abdominal radical hysterectomy. (The review protocol was registered with the International Prospective Register of Systematic Reviews: CRD4202173600).

TABULATION, INTEGRATION, AND RESULTS

We performed random-effects meta-analyses overall and by length of follow-up. Fifty articles on 40 cohort studies and 1 randomized controlled trial that included 22 593 women with cervical cancer met the inclusion criteria. Twenty percent of the studies had <36 months of follow-up, and 24% had more than 60 months of follow-up. The odds of PFS were worse for women undergoing MIS radical hysterectomy (odds ratio 1.54; 95% CI [confidence interval], 1.24-1.94; 14 studies). When limited to studies with longer follow-up, the odds of PFS were progressively worse with MIS radical hysterectomy (HR [hazard ratio] 1.48 for >36 months; 95% CI, 1.21-1.82; 10 studies; HR 1.69 for >48 months; 95% CI, 1.26-2.27; 5 studies; and HR 2.020 for >60 months; 95% CI, 1.36-3.001; 3 studies). For overall survival, the odds were not significantly different for MIS vs abdominal hysterectomy (odds ratio 0.94; 95% CI, 0.66-1.35; 14 studies) (HR 0.99 for >36 months; 95% CI, 0.66-1.48; 9 studies; HR 1.05 for >48 months; 95% CI, 0.57-1.94; 4 studies; and HR 1.35 for >60 months; 95% CI, 0.73-2.51; 3 studies).

CONCLUSION

In our meta-analysis of 50 studies, MIS radical hysterectomy was associated with worse PFS than open radical hysterectomy for early-stage cervical cancer. The emergence of this finding with longer follow-up highlights the importance of long-term, high-quality studies to guide cancer and surgical treatments.

A laparoscopic study investigating 3D vs 2D imaging systems using a pelvitrainer model with experts, non-experts, and students

BACKGROUND

Vision is an essential element of laparoscopic surgery that defines the outcome of an operation in regards to time, mistakes and precision. A 3-dimensional (3D) perspective may improve vision during an operation. Therefore, this study was designed to compare 3D versus 2-dimensional (2D) perspectives using a pelvitrainer model.

METHODS

Fifty candidates were divided into 3 categories based on different experience levels. The candidates were randomised into two groups, with each group performing the same 4 standardised tasks. Group A approached the tasks first with 3D high definition and in a second turn with 2D high definition. Group B carried out the tasks with the systems in reverse order. Task completion time and the number of mistakes made for each task were recorded. After completing the tasks, participants answered questions concerning the two systems.

RESULTS

Group A was, on average, 20% faster at all four tasks and made approximately 18% fewer mistakes in two of the tasks in comparison to group B. The experts significantly benefited from the 3D system in terms of accuracy compared to non-experts and students. The students demonstrated a significantly greater benefit from the 3D system when performing non-linear, continuous movements. Loss of concentration occurred at the same rate for subjects using the 2D and 3D systems. Nausea and dizziness were reported only when working with the 3D system. 91% found the 3D system advantageous for accomplishing the tasks.

CONCLUSIONS

Irrespective of experience level, 3D laparoscopy shows advantages in saving time, increasing accuracy and reducing mistakes. These benefits were also accompanied by subjective advantages that were noted by the participants. However, the more complex the task, the less significant the benefit of the 3D system and some people feel handicapped by the eyewear.

Survival After Minimally Invasive vs. Open Radical Hysterectomy for Cervical Cancer: A Meta-Analysis

Background: The comparison of survival outcomes between minimally invasive surgery and open surgery for cervical cancer patients remains controversial. We evaluated the survival outcomes of cervical cancer patients who underwent different surgical approaches.

Methods: A literature search was performed in PubMed, Embase, and Cochrane databases up to February 2020, using the MESH terms “minimally invasive surgical procedures” and “Uterine Cervical Neoplasms.” Included were all original comparative studies and trials both published and unpublished in English that were related to minimally invasive surgery and open surgery for cervical cancer patients with International Federation of Gynecology and Obstetrics (FIGO) 2009 stage < IIB. Begg's and Egger's regressions were used to evaluate publication bias.

Results: This meta-analysis included 28 studies enrolling 18,961 patients with cervical cancer. The overall analyses indicated that cervical cancer patients with FIGO 2009 stage < IIB who underwent minimally invasive surgery had a lower rate of OS (HR = 1.43, 95% CI = 1.06–1.92, P = 0.019) and DFS (HR = 1.50, 95% CI = 1.21–1.85, P < 0.001) than those who underwent open surgery. Moreover, minimally invasive surgery could lower OS (HR = 2.30, 95% CI = 1.50–3.52, P < 0.001) and DFS (HR = 1.94, 95% CI = 1.36–2.76, P < 0.001) of cervical cancer patients with FIGO 2009 stage ≤ IB1 compared to open surgery. However, there were no significant differences in OS (HR = 1.07, 95% CI = 0.65–1.76, P = 0.801) and DFS (HR = 1.20, 95% CI = 0.65–2.19, P = 0.559) in patients with tumors < 2 cm between the two groups.

Conclusions: Minimally invasive radical hysterectomy was associated with poor survival outcomes compared to open surgery. Patients with FIGO 2009 stage ≤ IB1 cervical cancer who underwent minimally invasive surgery have lower OS and DFS rates than those who underwent open surgery. Therefore, open surgery should be performed for cervical cancer patients. However, patients with tumors < 2 cm might take the most advantage of minimally invasive surgery without increasing poor prognosis. There are some limitations in the meta-analysis, which needs further high-quality multicenter studies to confirm and update our findings.

Characteristics and Treatments of Patients Aged 65 Years or Over with Cervical Cancer

Purpose

Although the mortality of elderly women with cervical cancer is high, their characteristics and prognosis have not attracted sufficient attention. This study aims to clarify the prognostic factors of cervical cancer patients aged ≥65.

Patient and Methods

The incidences and characteristics of patients diagnosed with cervical cancer (aged ≥65 and <65) during 2004–2015 were obtained through the Surveillance, Epidemiology, and End Results Program (SEER) database. The differences of distributions of characteristics between two age groups were compared by chi-squared (χ²) test. Kaplan–Meier survival method, Log-rank test, Cox-regression and visual nomogram were utilized for survival analysis.

Results

The annual incidences of two age groups with cervical cancer were (5.5–7.5)/100,000 and (3.4–3.9)/100,000, respectively, during 2004–2015. The 1-year and 5-year cancer-specific survival rates of old patients were both lower than those of young patients (P <0.001). The proportions of unmarried state and advanced International Federation of Gynecology and Obstetrics (FIGO) stage in old patients were higher than those in relatively young patients, and fewer elderly patients received surgery. Univariate and multivariate survival analysis showed non-squamous cell carcinoma, poor differentiation and late FIGO stage were independent poor prognostic factors for patients aged ≥65. Treatments improved the outcomes of elderly patients, and the effect of surgery was better than non-surgical treatment on elderly patients with FIGO I. Besides, geriatric score and survival probability could be accomplished by our nomogram with a c-index of 0.7945.

Conclusion

Delayed diagnosis and insufficient treatment were two distinct features of elderly patients and correlated with their poor clinical outcomes. More attention and active treatments should be adopted in elderly women based on their general condition.

Assessment of treatment factors and clinical outcomes in cervical cancer in older women compared to women under 65 years old

OBJECTIVE

This study aims to understand the treatment patterns and clinical outcomes of older women with cervical cancer compared to younger women.

METHODS

Women undergoing care for cervical cancer between 2000 and 2013 at two academic institutions were identified. The cohort of older patients was defined as >65 years old at diagnosis. Patient charts were retrospectively reviewed, and clinical variables were extracted. Fisher's exact tests, logistic regression, and Kaplan-Meier analyses were performed.

RESULTS

From 2000 to 2013 1119 women with cervical cancer were identified. Of these, 191 (17.0%) were >65 years old at the time of diagnosis. Older women were more likely to present with higher stage disease (p < 0.001). Controlling for stage, older women were less likely to undergo surgery during their treatment course (38% versus 70%, p < 0.001) and more likely to undergo radiation (77% versus 52%, p < 0.001), but no more likely to receive chemotherapy (p = 0.34). If they did undergo surgery, older women were less likely to have a pelvic lymph node dissection performed (41% versus 61%, p = 0.04), though the rate of positive pelvic lymph nodes was not different (p = 0.80). Overall survival was decreased in the older cohort (p < 0.001). A multivariate model identified age > 65 (HR 1.76, 95%CI 1.30-2.40), stage (HR 2.77, 95%CI 2.40-3.21), and ever undergoing surgery (HR 0.60, 95%CI 0.44-0.82) as independently associated with overall survival.

CONCLUSIONS

Women over age 65 with cervical cancer are less likely to undergo surgical management and were observed to have a decreased overall survival, even when controlling for use of surgery and stage of disease.

Long-Term Oncological Outcomes After Laparoscopic Versus Abdominal Radical Hysterectomy in Stage IA2 to IIA2 Cervical Cancer: A Matched Cohort Study

OBJECTIVE

The aim of the study was to investigate the long-term oncological outcomes of laparoscopic radical hysterectomy (LRH) and abdominal radical hysterectomy (ARH) for treatment of stage IA2 to IIA2 cervical cancer.

METHODS

We matched stage IA2 to IIA2 cervical cancer patients with known risk factors for recurrence who underwent ARH or LRH.

RESULTS

After matching, a total of 203 patient pairs (LRH-ARH) were included. The LRH and ARH group had similar 5-year recurrence-free survival (RFS) rates (91.3% vs 90.4%, P = 0.83) and overall survival (OS) rates (93.2% vs 92.1%, P = 0.94). Patients with different tumor size (≤2, 2-4, >4 cm) had similar 5-year OS and RFS. Even in patients with pelvic lymph node metastasis, the 5-year RFS (69.20% vs 69.20%, P = 0.87) and OS (77.4% vs 76.3%, P = 0.83) did not differ statistically between the 2 groups. The LRH and ARH group had similar mean time to recurrence (16.29 vs 22.15 months, P = 0.68) and pattern of recurrence (P = 0.63). Compared with ARH, LRH resulted in significantly shorter operating time, less blood loss, and shorter hospital stay. The intraoperative complications rate was similar between the 2 groups (P = 0.72). The rate of postoperative complications was significantly lower in the LRH group than in the ARH group (P = 0.004).

CONCLUSIONS

Laparoscopic radical hysterectomy was associated with fewer operating time, blood loss, postoperative complication, and earlier recovery. Laparoscopic radical hysterectomy is an oncologically safe alternative to ARH.

Robotic Surgery in Elderly and Very Elderly Gynecologic Cancer Patients

STUDY OBJECTIVE

To investigate the feasibility, safety, and short-term outcomes of robotic surgery (RS) for gynecologic oncologic indications (cervical, endometrial, and ovarian cancer) in elderly patients, especially women age 65 to 74 years (elderly group [EG]) compared with women age ≥75 years (very elderly group [VEG]).

DESIGN

Retrospective cohort study (Canadian Task Force classification II-2).

SETTING

Catholic University of the Sacred Heart, Rome, Italy.

PATIENTS

Between May 2013 and April 2017, 204 elderly and very elderly patients underwent RS procedures for gynecologic malignancies.

RESULTS

The median age was 71 years (range, 65-74 years) in the EG and 77 years (range, 75-87 years) in the VEG. The incidence of cardiovascular disease was higher in the VEG (p = .038). The EG and VEG were comparable in terms of operative time, blood loss, and need for blood transfusion. Almost all (98.5%) of the patients underwent total/radical hysterectomy, 109 patients (55.6% of the EG vs 48.3% of the VEG) underwent pelvic lymphadenectomy, and 19 patients (10.5% of the EG vs 6.7% of the VEG) underwent aortic lymphadenectomy. A total of 7 (3.4%) conversions to open surgery were registered. Only 3 patients required postoperative intensive care unit admission. The median length of hospital stay was 2 days in each group. A total of 11 patients (5.6%) had early postoperative complications. Four patients (2.8%) in the EG and 2 patients (3.3%) in the VEG experienced grade ≥2 complications. At the time of analysis, median follow-up was 18 months (range, 6-55 months). Eleven patients (5.6%) experienced disease relapse, 2 (1%) died of disease, and 3 (1.5%) died of cardiovascular disease.

CONCLUSIONS

This study demonstrates the feasibility, safety, and good short-term outcomes of RS in elderly and very elderly gynecologic cancer patients. No patient can be considered too old for a minimally invasive robotic approach, but a multidisciplinary approach is the best management pathway; efforts to reduce associated morbidity are essential.

Role of robotic surgery in cervical malignancy

Surgical treatment is the mainstay of the management of early-stage cervical cancer. Abdominal radical hysterectomy and trachelectomy have long been the standard surgical approach to early-stage cervical cancer, achieving excellent survival outcomes. Recently, laparoscopic radical hysterectomy and trachelectomy have become the preferred alternative to abdominal surgery because laparoscopic approaches lead to better surgical outcomes without compromising survival outcomes. Since the robotic surgery platform was approved for the use of gynaecologic surgery in 2005, robotic radical hysterectomy and trachelectomy have been increasingly used in the surgical management of early-stage cervical cancer. However, the role of robotic surgery is poorly defined. This review examines the role of robotic surgery in the surgical management of cervical cancer by comparing the published data on its use with those of abdominal and laparoscopic surgeries.

Performance of Kymerax© precision-drive articulating surgical system compared to conventional laparoscopic instruments in a pelvitrainer model

BACKGROUND

The Kymerax© Precision-Drive Articulating Surgical System by Terumo© is a handheld laparoscopic robot which permits motion in two additional degrees of freedom (deflection and rotation in the instrument tip). In a pelvitrainer model, we compared the performance of participants with different laparoscopic experiences and compared Kymerax© to conventional laparoscopic instruments.

METHODS

20 expert surgeons, performing more than 50 laparoscopic procedures per year, and 25 medical students without any experience in surgery at all were selected. Each participant was randomized into two groups: Group TK performed the tasks using the traditional laparoscopic Instruments (TLI) first and Kymerax© thereafter, group KT vice versa. Six standardized tasks were used: Two instructional exercises and four tasks where time, number of mistakes, and overall precision were measured. Finally, a questionnaire had to be answered.

RESULTS

All four tasks were performed significantly more slowly with the Kymerax© device. Improved needle control in stitches towards the surgeon, significantly less deviation while cutting along different lines as well as a significantly reduced fraying of the cutting edge were found when participants were using Kymerax©. By questionnaire more than 90% of the participants indicated clear advantages using Kymerax©. However, participants needed more training time and had an earlier loss of concentration with Kymerax©. Further complaints about Kymerax© were its limitations in rotation and deflection, the impaired view as well as the non-ergonomic instrument handle. Rotation force, instrument weight, digital instrument-tip control, and needle fixation were rated as accurate.

CONCLUSIONS

This study shows that more time is needed to solve tasks with Kymerax© compared to conventional laparoscopic instruments. Kymerax© is superior to conventional laparoscopy for suturing at difficult angles and cutting along complex structures. Kymerax© can potentially bring benefits for certain laparoscopic tasks, but as seen in this study, further developments are necessary. Terumo© meanwhile closed down its Kymerax

[Initial experience in the laparoscopic treatment of benign and malignant gynaecological diseases in the Hospital Regional de Alta Especialidad in Oaxaca]

BACKGROUND

The history of laparoscopic surgery in gynaecological diseases progressed with the advances of Semm, as well as with the development of tools, equipment, and energy that led to its development in all surgical areas, including oncology.

OBJECTIVE

To present the initial experience in the laparoscopic treatment of benign and malignant gynaecological disease in the Hospital Regional de Alta Especialidad in Oaxaca.

MATERIAL AND METHODS

An analysis was performed on a total of 44 cases, distributed into: type III radical hysterectomy for invasive cervical cancer, hysterectomy type I cervical cancer in situ, extrafascial hysterectomy for benign disease, routine endometrium, ovary and routine salpingo-oophorectomy. The variables included age, BMI, surgical time, bleeding, intraoperative and postoperative complications, conversion, hospital stay, and pathology report.

RESULTS

Hysterectomy type III; age 40.2 years, BMI 25.8kg/m², 238ml bleeding, operative time 228min, 2.6-day hospital stay, intraoperative or postoperative complications, tumour size 1.1cm, 14 lymph nodes dissected, vaginal and negative parametrical edge. Type I hysterectomy cervical cancer in situ: 51 years, BMI 23.8kg/m², 80ml bleeding, operative time 127minutes, uterus of 9cm, length of stay of 2 days, a conversion by external iliac artery injury, with bleeding of 1500ml. Routine endometrium: 50.3 years, BMI 30.3kg/m², 83ml bleeding, operative time 180minutes, uterus 12.6cm, length of stay 2.3 days, no complications.

CONCLUSION

The management of benign and malignant pelvic diseases using laparoscopy is feasible and safe, with shorter hospital stays and a prompt recovery to daily activities.

Laparoscopy versus laparotomy for the management of early stage cervical cancer

Background

The possible advantages of laparoscopic radical hysterectomy (LRH) versus open radical hysterectomy (RH) have not been well reviewed systematically. The aim of this study was to systematically review the comparative effectiveness between LRH and RH in the treatment of cervical cancer based on the evaluation of the Perioperative outcomes, oncological clearance, complications and long-term outcomes.

Methods

The systematic review was conducted by searching PubMed, MEDLINE, EMBASE, the Cochrane Library and BIOSIS databases. All original studies that compared LRH with RH were included for critical appraisal. Data were pooled and analyzed.

Results

A total of twelve original studies that compared LRH (n = 754) with RH (n = 785) in patients with cervical cancer fulfilled quality criteria were selected for review and meta-analysis. LRH compared with RH was associated with a significant reduction of intraoperative blood loss (weighted mean difference = −268.4 mL (95 % CI −361.6, −175.1; p < 0.01), a reduced risk of postoperative complications (OR = 0.46; 95 % CI 0.34–0.63) and shorter hospital stay (weighted mean difference = −3.22 days; 95 % CI–4.21, −2.23 days; p < 0.01). These benefits were at the cost of longer operative time (weighted mean difference = 26.9 min (95 % CI 8.08–45.82). The rate of intraoperative complications was similar in the two groups. Lymph nodes yield and positive resection margins were similar between the two groups. There were no significant differences in 5-year overall survival (HR 0.91, 95 % CI 0.48–1.71; p = 0.76) and 5-year disease-free survival (hazard ratio [HR] 0.97, 95 % CI 0.56–1.68; p = 0.91).

Conclusions

LRH shows better short term outcomes compared with RH in patients with cervical cancer. The oncologic outcome and 5-year survival were similar between the two groups.

Electronic supplementary material

The online version of this article (doi:10.1186/s12885-015-1818-4) contains supplementary material, which is available to authorized users.

Prognostic and Safety Roles in Laparoscopic Versus Abdominal Radical Hysterectomy in Cervical Cancer: A Meta-analysis

Objective: Studies comparing the prognostic results between laparoscopic radical hysterectomy (LRH) and abdominal radical hysterectomy (ARH) in cervical cancer reported contradictory results. We aimed to evaluate the prognostic and safety roles of LRH by pooling studies in a meta-analysis.

Materials and Methods: Original articles were searched in PubMed, EMBASE, and the Cochrane Library. The survival results (5-year disease-free survival [DFS], 5-year overall survival [OS], and recurrence rate [RR]), safety parameters (intra-, peri-, and postoperative complication rates and postoperative bowel or bladder recovery days), efficiency parameters (pelvic/para-aortic lymph nodes removed), and other parameters (operative time, estimated blood loss, and hospital of stay) between the two approaches were reviewed.

Results: For the 2922 cases identified, DFS, OS, and RR did not differ in balanced prognostic factors, including lymph node metastasis, Stage IIB or above, non–squamous cancer histology, grade G3, lymphovascular space invasion, tumor size ≥4 cm, and positive parametrial and vaginal margin rates. Meanwhile, LRH was associated with higher complication rates and a shorter time to the recovery of bowel or bladder function than for ARH. The number of removed pelvic or para-aortic lymph nodes did not significantly differ. Other parameters showed LRH was associated with a longer operative time, less blood loss, and a shorter length of hospital stay. The survival and prognostic results did not differ in balanced prognostic factors.

Conclusions: LRH is safe and has lower operative complication rates than ARH.

Asian Society of Gynecologic Oncology International Workshop 2014

The Asian Society of Gynecologic Oncology International Workshop 2014 on gynecologic oncology was held in Asan Medical Center, Seoul, Korea on the 23rd to 24th August 2014. A total of 179 participants from 17 countries participated in the workshop, and the up-to-date findings on the management of gynecologic cancers were presented and discussed. This meeting focused on the new trends in the management of cervical cancer, fertility-sparing management of gynecologic cancers, surgical management of gynecologic cancers, and recent advances in translational research on gynecologic cancers.

Peri-Operative Management of Older Adults with Cancer-The Roles of the Surgeon and Geriatrician

Optimal surgical management of older adults with cancer starts pre-operatively. The surgeon plays a key role in the appropriate selection of patients and procedures, optimisation of their functional status prior to surgery, and provision of more intensive care for those who are at high risk of post-operative complications. The literature, mainly based on retrospective, non-randomised studies, suggests that factors such as age, co-morbidities, pre-operative cognitive function and intensity of the surgical procedure all appear to contribute to the development of post-operative complications. Several studies have shown that a pre-operative geriatric assessment predicts post-operative mortality and morbidity as well as survival in older surgical cancer patients. Geriatricians are used to working in multidisciplinary teams that assess older patients and make individual treatment plans. However, the role of the geriatrician in the surgical oncology setting is not well established. A geriatrician could be a valuable contribution to the treatment team both in the pre-operative stage (patient assessment and pre-operative optimisation) and the post-operative stage (patient assessment and treatment of medical complications as well as discharge planning).

Total Laparoscopic Versus Laparotomic Radical Hysterectomy and Lymphadenectomy in Cervical Cancer: An Observational Study of 13-Year Experience

This article aims to review our 13-year experience in the treatment of patients with cervical cancer by comparing total laparoscopic radical hysterectomy and lymphadenectomy with laparotomy.We reviewed all patients undergoing total laparoscopic or laparotomic radical hysterectomy and lymphadenectomy because of cervical cancer between 2001 and 2014 in our hospital.In total, 154 eligible patients with International Federation of Gynecology and Obstetrics Ia-IIb were enrolled, including 106 patients undergoing total laparoscopic procedure and 48 patients undergoing laparotomic procedure. In the present study, patients in total laparoscopy group were associated with superior surgical outcomes, such as significantly lower blood transfusion compared to those in laparotomy group. Furthermore, patients had significantly lower postoperative complication rate in total laparoscopy group compared with that in laparotomy group (24.5% vs 52.1%) (P = 0.001). Three patients (2.8%) in total laparoscopy group had unplanned conversion to laparotomy. Disease-free survival rates were 89.7% and 88.9% in total laparoscopy and laparotomy groups (P = 0.39), respectively, and overall survival rates were 90.2% in total laparoscopy group and 91.3% in laparotomy group (P = 0.40).Total laparoscopic procedure is a surgically and oncologically safe and reliable alternative to laparotomic procedure in the treatment for cervical cancer.

The surgical management of cervical cancer: an overview and literature review

IMPORTANCE

Surgery has evolved into the standard therapy for nonbulky carcinoma of the cervix. The mainstay of surgical management is radical hysterectomy; however, less radical procedures have a small but important role in the management of cervical tumors.

OBJECTIVE

Our objective was to discuss the literature behind the different procedures utilized in the management of cervical cancer, emphasizing the radical hysterectomy. In addition, we aimed to discuss ongoing trials looking at the utility of less radical surgeries as well as emerging technologies in the management of this disease.

EVIDENCE ACQUISITION

We performed a PubMed literature search for articles in the English language that pertained to the topic of surgical techniques and their outcomes in the treatment of cervical cancer.

RESULTS

The minimally invasive approaches to radical hysterectomy appear to reduce morbidity without affecting oncological outcomes, although further data are needed looking at long-term outcomes with the robotic platform. Trials are currently ongoing looking at the role of less radical surgery for patients with low-risk disease and the feasibility of sentinel lymph node mapping.

CONCLUSIONS AND RELEVANCE

Radical hysterectomy with pelvic lymphadenectomy has evolved into the standard therapy for nonbulky disease, and there is a clear advantage in the use of minimally invasive techniques to perform these procedures. However, pending ongoing trials, less radical surgery in patients with low-risk invasive disease as well as sentinel lymph node mapping may emerge as standards of care in selected patients with cervical carcinoma.

Minimally invasive surgery as a treatment option for gastric cancer in the elderly: comparison with open surgery for patients 80 years and older

BACKGROUND

As life expectancy is increasing, the use of minimally invasive surgery (MIS) in the elderly is gaining interest. The aim of this study was to identify the impact of minimally invasive gastrectomy by comparing the procedure to open surgery in octogenarians. In addition, we also evaluated the role of gastrectomy in elderly gastric cancer patients by assessing long-term outcomes.

METHODS

We retrospectively analyzed data from 99 gastric cancer patients aged 80 years or older, who underwent gastrectomy by either MIS or open surgery from 2005 to 2010. Patient characteristics, operative outcomes, pathologic results, morbidity, mortality, and follow-up data (including survival) were compared.

RESULTS

Thirty patients underwent gastrectomy with MIS (19 laparoscopic and 11 robotic) and 69 patients underwent open gastrectomy. MIS demonstrated significantly less blood loss, lower analgesic consumption, faster time to first flatus and soft diet, and a shorter post-operative hospital stay. Multivariate analysis revealed that the type of operation had no effect on the occurrence of complications. There were two postoperative mortalities, both in the open group. Excluding these patients, the overall and disease-specific 5-year survival rates were 57.4 and 70.0 %, respectively. The overall (MIS 70.0 %; open 52.0 %) and disease-specific (MIS 81.8 %; open 65.1 %) 5-year survival rates were similar for the two groups. When we analyzed the 85 patients underwent curative resection only, the overall (MIS 71.4 %; open 58.4 %) and disease-specific (MIS 84.1 %; open 73.6 %) 5-year survival rates were similar for the two groups.

CONCLUSIONS

MIS for gastric cancer may be performed safely and maintains the advantages of minimal invasiveness, even in extremely old patients. Furthermore, gastrectomy by either by MIS or open surgery can reduce gastric cancer-related deaths, even in patients 80 years or older.

Hospital level under-utilization of minimally invasive surgery in the United States: retrospective review

OBJECTIVE

To determine casemix adjusted hospital level utilization of minimally invasive surgery for four common surgical procedures (appendectomy, colectomy, total abdominal hysterectomy, and lung lobectomy) in the United States.

DESIGN

Retrospective review.

SETTING

United States.

PARTICIPANTS

Nationwide inpatient sample database, United States 2010.

METHODS

For each procedure, a propensity score model was used to calculate the predicted proportion of minimally invasive operations for each hospital based on patient characteristics. For each procedure, hospitals were categorized into thirds (low, medium, and high) based on their actual to predicted proportion of utilization of minimally invasive surgery.

MAIN OUTCOME MEASURES

The primary outcome measures were the actual and predicted proportion of procedures performed with minimally invasive surgery. Secondary outcome measures included surgical complications and hospital characteristics.

RESULTS

Mean hospital utilization of minimally invasive surgery was 71.0% (423/596) for appendectomy (range 40.9-93.1% (244-555)), 28.4% (154/541) for colectomy (6.7-49.8% (36/541-269/541)), 13.0% (65/499) for hysterectomy (0.0-33.6% (0/499-168/499)), and 32.0% (67/208) for lung lobectomy (3.6-65.7% (7.5/208-137/208)). Utilization of minimally invasive surgery was highly variable for each procedure type. There was noticeable discordance between actual and predicted utilization of the surgery (range of actual to predicted ratio for appendectomy 0-1.49; colectomy 0-3.88; hysterectomy 0-6.68; lung lobectomy 0-2.51). Surgical complications were less common with minimally invasive surgery compared with open surgery, respectively: overall rate for appendectomy 3.94% (1439/36,513) v 7.90% (958/12,123), P<0.001; for colectomy: 13.8% (1689/12,242) v 35.8% (8837/24,687), P<0.001; for hysterectomy: 4.69% (270/5757) v 6.64% (1988/29,940), P<0.001; and for lung lobectomy: 17.1% (367/2145) v 25.4% (971/3824), P<0.05. High utilization of minimally invasive surgery was associated with urban location (appendectomy: odds ratio 4.66, 95% confidence interval 1.17 to 18.5; colectomy: 4.59, 1.04 to 20.3; hysterectomy: 15.0, 2.98 to 75.0), large hospital size (hysterectomy: 8.70, 1.62 to 46.8), teaching hospital (hysterectomy: 5.41, 1.27 to 23.1), Midwest region (appendectomy: 7.85, 1.26 to 49.1), south region (appendectomy: 21.0, 3.79 to 117; colectomy: 10.0, 1.83 to 54.7), and west region (appendectomy: 9.33, 1.48 to 58.8).

CONCLUSION

Hospital utilization of minimally invasive surgery for appendectomy, colectomy, total abdominal hysterectomy, and lung lobectomy varies widely in the United States, representing a disparity in the surgical care delivered nationwide.

Laparoscopic surgical management of localized recurrent ovarian cancer: a single-institution experience

BACKGROUND

Optimally, secondary cytoreduction is acknowledged as a valid option in terms of oncologic outcome for patients with platinum-sensitive recurrent ovarian cancer. In cases of localized relapse, a laparoscopic approach has been attempted at various institutions, but studies on its role for this subset of patients still are limited. This report describes the authors' experience using laparoscopic secondary cytoreduction for patients with localized recurrent ovarian cancer. The results from a retrospective analysis of a prospective case series are reported.

METHODS

Between October 2011 and May 2013, 29 patients with localized recurrent ovarian cancer were selected for a laparoscopic cytoreduction. Two conversions to laparotomy occurred. The analyzed outcome variables included stage and site of disease, type of surgical procedure, operative time, blood loss, length of hospital stay, complications, and oncologic outcome.

RESULTS

The median operating time was 188 min. The median estimated blood loss was 150 mL, and the median hospital stay was 4 days. Complete debulking was achieved for 96.2% of the patients. No intraoperative complications occurred, and postoperative complications were noted in only one patient. The median disease-free survival time was 14 months.

CONCLUSIONS

For selected patients, laparoscopy is a feasible and safe approach to optimal cytoreduction for patients with localized recurrent ovarian cancer.

Single port gasless laparoscopy-assisted mini-laparotomic ovarian resection (SP-GLAMOR): reasonable treatment for large cystic ovarian tumors with suspicion of malignancy

OBJECTIVES

Recent improvements to both optical and laparoscopic instruments have enabled the use of laparoscopic surgery for gynecological procedures as opposed to open abdominal surgery. However, laparoscopic surgery has several potential limitations, including tumor rupture, spillage, incomplete resection of lesions, and trocar insertion site metastasis in surgeries involving large ovarian masses with suspicion of malignancy. Here, we report a case series of large ovarian cystic tumors that were successfully removed by single port gasless laparoscopy assisted mini-laparotomic ovarian resection (SP-GLAMOR), the limitations of which were successfully addressed.

METHODS

We reviewed the medical records of 31 women who visited St. Vincent Hospital from April 2006 until April 2011 and were diagnosed with a large cystic ovarian mass with suspicion of malignancy based on imaging studies and tumor markers. After diagnosis, all of the women underwent SP-GLAMOR.

RESULTS

The median maximal diameter of cysts, median incision size, median surgical duration and median volume of blood loss were 20 cm (range 10.7-45 cm), 3 cm (range 2.5-4 cm), 100 min (range 45-270 min) and 100mL (range 30-500 mL), respectively. Four cases were diagnosed as malignant disease on frozen sections obtained during the operation, and were converted to open abdominal surgery. No major complications were observed. The four patients diagnosed with malignant disease also underwent adjuvant chemotherapy. All patients were followed up to the time of this report.

CONCLUSIONS

The results of our study suggest that the SP-GLAMOR procedure is feasible, with potentially decreased perioperative morbidity and blood loss, faster recovery and better cosmetic results.