Risk of port-site metastases in pelvic cancers after robotic surgery

Laparoscopic radical hysterectomy for cervical cancer by pulling the round ligament without a uterine manipulator

OBJECTIVE

To demonstrate the experience of laparoscopic radical hysterectomy for cervical cancer without the use of a uterine manipulator and investigate the feasibility and treatment effectiveness of this surgical approach.

MATERIALS AND METHODS

The laparoscopic radical hysterectomy for cervical cancer by pulling the round ligament without a uterine manipulator prevented the oppression of the uterine manipulator on the tumour. Vaginal ligation was performed below the lesion of cervical cancer, and the vagina was cut off below the ligation line. Consequently, the exposure of cancer tissues in the abdominal cavity was prevented, enabling a tumour-free operation. We reviewed the medical records of the 22 patients with stage IB1-IIA2 cervical squamous cell carcinoma who were treated at our hospital between May 2019 and February 2020. All the patients underwent the laparoscopic radical hysterectomy for cervical cancer by pulling the round ligament. All the patients were informed about the different therapeutic schemes and surgical approaches as well as their advantages and disadvantages. Information about operative time, intraoperative blood loss, hospitalisation duration, postoperative complications, postoperative adjuvant therapy, prognosis and other data were recorded.

RESULTS

All the surgical procedures were successfully completed without perioperative complications, such as vascular injury, pelvic injury and abdominal organ injury. The mean operative duration was 204 min, and the mean operative blood loss was 102 mL. The mean duration of postoperative hospital stay was 13 days. Nineteen patients received postoperative chemotherapy once before hospital discharge. Urinary retention was the major postoperative complication. All the patients were followed up for 14-23 months. The median follow-up time was 18 months. 21 of the 22 patients survived. No recurrence was detected in the patients during follow-up. One patient who had a pelvic lymph node metastasis but refused complete chemoradiotherapy died before the last follow-up.

CONCLUSIONS

This surgical approach appears to be safe and feasible for patients with cervical cancer. A larger sample size and longer follow-up period are required to confirm whether this surgical approach can actually and effectively improve the prognosis.

Survey of current practices and opinions of German Society of Gynecologic Endoscopy members regarding the treatment of ovarian neoplasia by robotic surgery

PURPOSE

As data on this topic are sparse and contradictory, we aimed to ascertain the opinions of the members of the German Society of Gynecologic Endoscopy (AGE) regarding the use of robotic surgery in the treatment of ovarian malignancies.

METHODS

In 2015, an anonymous questionnaire was sent to AGE members to assess their views on the treatment of ovarian malignancies by robotic surgery according to T stage and the current treatment practices in their facilities.

RESULTS

Of the 228 respondents, 132 (58%) were fellows or attending physicians and 156 (68%) worked at university hospitals or tertiary referral centers. Most [n = 218 (96%)] respondents reported treating < 10% of their patients using robotic surgery. Respondents felt that T1 and borderline ovarian tumors, but not T2 (51%) or T3/4 (76%) tumors, should and could be treated by robot surgery. 162 (71%) respondents considered the currently available data on this subject to be insufficient, and 42% indicated their willingness to participate in clinical studies on the applicability of robotic surgery to the treatment of T1/2 ovarian tumors.

CONCLUSION

The majority of AGE members surveyed considered robotic surgery to be an option for the treatment of T1 ovarian malignancies and borderline ovarian tumors. However, prospective randomized studies are needed to determine the relevance of robotic surgery in this context.

The Pathogenesis and Prevention of Port-Site Metastasis in Gynecologic Oncology

Port-site metastasis (PSM) is a specific and challenging complication of laparoscopic gynecologic oncologic procedures. Research has demonstrated that PSM is associated with significant morbidity and poor outcome. The exact pathogenesis of PSM in gynecologic patients is not clear. Several preventive measures of PSM have been addressed in the relevant literature, and novel approaches to prevent this uncommon complication keep emerging. In this review, we summarized the potential mechanisms of PSM and discuss the controversies and merits of proposed preventive measures of PSM in gynecologic oncology. We undertook a literature search using the Medline database to identify studies on the pathogenesis and prevention of laparoscopic PSM. Hypotheses of PSM pathogeneses center on the immune response, pneumoperitoneum, wound contamination, and surgical method. Cogent evidence of effective prevention of PSM after laparoscopic surgery is lacking. Traditional preventive actions such as irrigation and tumor manipulation should be taken individually. Insufflation of hyperthermic CO₂ and humidified CO₂ leads to a better outcome in patients with a malignant tumor who undergo a laparoscopic procedure compared with normal CO₂ pneumoperitoneum. Port-site resection shows no advantage in survival and results in more wound events. PSM prevention plays a crucial part in the overall care of patients with gynecologic malignancies who undergo laparoscopic procedures.

Robot-assisted Surgery in Gynecologic Cancers

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