Robotic radical parametrectomy with pelvic lymphadenectomy: Our experience and review of the literature

Long-term oncological outcome in patients with cervical cancer after 3 trimodality treatment (radiotherapy, platinum-based chemotherapy, and robotic surgery)

Cervical cancer represents a general health issue spread all over the globe, which prompts the surge of scientific survey toward the rise of survival and condition of life of these patients. American and European guidelines suggest the open surgery, laparoscopic, and robotic surgery are the main therapeutic approaches for radical hysterectomy for patients with cervical cancer. This is the first survey to analyze the long-term oncological outcome of an extensive series of subjects cared for with multimodality treatment, here comprising robotic surgery.This study intents to evaluate the long-term oncological result in patients diagnosed with cervical cancer treated with radiotherapy (±chemotherapy) and robotic surgery compared with open surgery. Medical files of 56 patients diagnosed with cervical cancer who underwent a robotic hysterectomy and radiotherapy ± chemotherapy were retrospectively analyzed.The median age at diagnosis was 50.5 (range: 23-70). Eleven patients (19.6%) presented in an early stage (IB-IIA) and 80.4% advanced stage (IIB-IVA). Overall response rate after radiotherapy and chemoradiotherapy was 96.2%. Pathologic complete response was obtained in 64% of patients. After a median follow-up of 60 months (range: 6-105 months), 8 patients (14.2%) presented local recurrence or distant metastases. Disease-free survival (DFS) was 92% at 2 years and 84% at 3 and 5 years. Overall survival (OS) rates at 2, 3, and 5 years for patients with robotic surgery were 91%, 78%, and 73%, median OS not reached. OS was lower in the arm of open surgery (2, 3, and 5 years 87%, 71%, and 61%, respectively; median OS was 72 months P = .054). The multivariate analysis regarding the outcome of patients revealed an advantage for complete versus partial response (P < .002), for early versus advanced stages (P = .014) and a 10% gained in DFS at 3 years for patients in whom chemoradiotherapy was administered (DFS at 3 years 75% vs 85%) in patients with advanced stages.Robotic surgery has a favorable oncological outcome when associated with multimodal therapy.

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 in Patients With Locally Advanced Cervical Cancer After Neoadjuvant Chemotherapy: Survival Outcomes

AIM

To evaluate the survival outcomes of consecutive patients with locally advanced cervical cancer (LACC) who underwent comprehensive robotic surgery after neoadjuvant chemotherapy (NACT).

MATERIALS AND METHODS

Since 2009, patients with LACC (FIGO [International Federation of Gynecology and Obstetrics] stages IB2-IIB) were submitted to robotic surgical staging after 3 cycles of NACT. Clinical objective tumor response was assessed according to the Response Evaluation Criteria in Solid Tumors, whereas pathologic responses were defined according to the criteria of the European study SNAP01. Univariable and multivariable analyses were performed to assess potential clinicopathologic prognostic factors affecting progression-free survival and overall survival (OS).

RESULTS

During the study period, 32 patients meeting the inclusion criteria were managed. The median (range) age and body mass index were 47.3 (8.6-75.5) years and 22.7 (17.5-37.1) kg/m(2), respectively. Overall, 28.0 (range, 12-58) lymph nodes were retrieved. According to the final pathologic examination, 6 (18.8%) women had positive pelvic lymph nodes, whereas 16 (50.0%) patients achieved an optimal pathological response. After a median follow-up of 36.3 (range, 5.2-71.1) months, 6 (18.8%) patients had a recurrence and subsequently died of disease.Positive nodal status was the only independent predictor of both progression-free survival (12.5 [2.3-69.1]; P < 0.0001) and OS (12.0 [2.0-60.4]; P < 0.0001) at multivariable analysis.

CONCLUSIONS

Nodal status represents the strongest predictor of survival in women with LACC. Similarly, NACT including 3 agents (TIP [paclitaxel 175 mg/m(2) + ifosfamide 5 g/m(2) + cisplatin 75 mg/m(2)] and TEP [paclitaxel 175 mg/m(2) + epirubicin 80 mg/m(2) + cisplatin 75 mg/m(2)] regimens) warranted better OS than those achieved by other schedules.

Occult invasive cervical cancer after simple hysterectomy: a multi-center retrospective study of 89 cases

Background

Occult invasive cervical cancer (OICC) is sometimes incidentally found in surgical specimens after a simple hysterectomy (SH). This study was aimed at identifying a subset of patients with OICC who have a favorable prognosis. This patient group may not require adjuvant radiotherapy and other procedures.

Methods

The medical records of women in whom OICC was detected after an inadvertent SH were retrospectively reviewed. The relevant data, including clinicopathological characteristics, treatment and clinical outcome were evaluated. The primary and secondary endpoints were overall survival (OS) and relapse-free survival (RFS), respectively.

Results

Eighty-nine patients who met the inclusion criteria were included for analysis, and the risk of OICC was found to be 1.9 %. Finding an invasive cancer in a hysterectomy specimen after a conization procedure that shows positive margins was the most common reason (41.6 %) for the performance of inadvertent SH. In the univariate analysis, a tumor width > 20 mm, deep stromal invasion, and lymph node metastasis (LNM) were adversely associated with relapse (P < 0.001, < 0.001, and = 0.001, respectively) and survival (P = 0.003, 0.004, and 0.027, respectively), although these parameters were not independently associated with patient prognoses in the multivariate analysis. In patients with a tumor width ≤ 20 mm and superficial stromal invasion in the observation subgroup, the 5-year RFS and 5-year OS were both 100 %, whereas they were 57.1 % and 66.7 %, respectively, in patients with a tumor size > 20 mm and deep stromal invasion in the radiotherapy or chemotherapy subgroup (P < 0.001, and = 0.008, respectively).

Conclusions

Simple observation after a lymphadenectomy procedure may be feasible in OICC patients with a tumor width ≤ 20 mm, superficial stromal invasion, a negative section margin in hysterectomy specimens, and no LNM.

Robotic-assisted radical parametrectomy in patients with malignant gynecological tumors

We describe the operative technique of robotic-assisted laparoscopic radical parametrectomy and analyze perioperative data including adequacy of resections, pathology, and complications in our initial cases. A retrospective study was performed of seven patients with gynecological cancers involving the cervix who had previously been treated with simple hysterectomies and then underwent robotic-assisted radical parametrectomies. Pathology from the initial hysterectomies and the radical parametrectomies was reviewed. Postoperative complications, operative times, estimated blood loss, and length of hospital stay were assessed. The upper part of the vagina, parametrial tissue, and bilateral pelvic lymph nodes of all seven patients who had undergone a previous simple hysterectomy were removed. The mean age was 56.4 (SD ± 10.7) years. Diagnoses from hysterectomy specimens were invasive squamous carcinoma (n = 4), endometrial adenocarcinoma (n = 2), and clear-cell papillary adenocystic cervical carcinoma (n = 1). The median number of lymph nodes removed was 8 (min 4, max 29), and one patient had nodal metastasis. The mean operative time was 228.6 (SD ± 38.9) min, estimated blood loss was 147 (SD ± 58.2) ml, and length of hospital stay was five (SD ± 2.3) days. One intraoperative complication (cystotomy) occurred and was successfully repaired. One postoperative fistula developed on postoperative day 10. This early experience demonstrates that the basic surgical and anatomical principles of radical parametrectomy can be applied to robotic-assisted laparoscopic surgery. Genitourinary fistulae are always a concern with this procedure, and minimization of electrocautery near the bladder and ureters may further reduce complications.

Robotic radical hysterectomy following neoadjuvant chemotherapy in FIGO stage IIIB cervical cancer: a case report

BACKGROUND

The management of advanced cervical cancer is challenging. The administration of neoadjuvant chemotherapy (NACT) followed by radical hysterectomy has proved to be safe in selected cases. Nevertheless, data on the use of minimally invasive surgery is lacking with this clinical application.

METHODS

A 31 year-old woman was diagnosed with a FIGO stage IIIB squamous cell cervical carcinoma. During multidisciplinary consultation it was decided that she should receive NACT, followed by robotic hysterectomy.

RESULTS

After three cycles of TIP (paclitaxel, ifosfamide and cisplatin), the patient achieved a complete clinical and radiological response. She underwent robotic type III/C2 radical hysterectomy with bilateral salpingo-oophorectomy and bilateral systematic pelvic lymphadenectomy. No complications were recorded. The complete response was confirmed at pathological examination. Two additional cycles of adjuvant chemotherapy were administered, and the patient is currently without evidence of disease at 18 months of follow-up.

CONCLUSIONS

In selected patients, robotics is a viable option to accomplish radical hysterectomy, including cases of advanced cervical cancer. Further experiences are needed to confirm our findings.

Robotic surgical staging for endometrial and cervical cancers in medically ill patients

OBJECTIVES

Patients with high anesthesiological risk due to old age, obesity and severe co-morbidities alone or in combination are considered as poor candidates for extensive surgical staging procedures, especially if through minimally invasive approach. We aimed to evaluate the feasibility and safety of robotic surgical staging of endometrial and cervical cancers in the medically ill patient.

METHODS

Between 07-2007 and 12-2012, consecutive patients scheduled for staging for endometrial or cervical cancer were directed towards robotic staging and divided into two groups according to their starting score in the American Society for Anaesthesiologists (ASA): Group 1 (ASA 1-2) and Group 2 (ASA ≥3).

RESULTS

Overall, 169 (71.9%) patients had ASA 1-2 whereas 66 (28.1%) had ASA ≥3. ASA ≥3 were older (p<0.0001) with a greater proportion of co-morbidities (p<0.0001), as well as of Class II (4.7% vs 19.7%; p=0.0007) and Class III obesity (2.4% vs 31.8%; p<0.0001). No differences were found between groups in terms of operative time, blood loss, intra- and post-operative complications, conversion rate and hospitalization. No differences were recorded either in terms of staging procedures performed or in terms of number of pelvic (p=0.72) and para-aortic (p=0.86) lymph nodes retrieved.

CONCLUSIONS

Despite theoretical concerns about the performance of robotic surgery in patients with high anesthesiological risk, our experience showed that robotics is a feasible, safe and viable option for the management of endometrial and cervical cancers also in this more vulnerable group of patients.