Robot-assisted Surgery in Gynecologic Cancers

The Influence of Surgical Complexity and Center Experience on Postoperative Morbidity After Minimally Invasive Surgery in Gynecologic Oncology: Lessons Learned from the ROBOGYN-1004 Trial

BACKGROUND

This study was a secondary analysis of the ROBOGYN-1004 trial conducted between 2010 and 2015. The study aimed to identify factors that affect postoperative morbidity after either robot-assisted laparoscopy (RL) or conventional laparoscopy (CL) in gynecologic oncology.

METHODS

The study used two-level logistic regression analyses to evaluate the prognostic and predictive value of patient, surgery, and center characteristics in predicting severe postoperative morbidity 6 months after surgery.

RESULTS

This analysis included 368 patients. Severe morbidity occurred in 49 (28 %) of 176 patients who underwent RL versus 41 (21 %) of 192 patients who underwent CL (p = 0.15). In the multivariate analysis, after adjustment for the treatment group (RL vs CL), the risk of severe morbidity increased significantly for patients who had poorer performance status, with an odds ratio (OR) of 1.62 for the 1-point difference in the WHO performance score (95 % CI 1.06-2.47; p = 0.027) and according to the type of surgery (p < 0.001). A focus on complex surgical acts showed significant more morbidity in the RL group than in the CL group at the less experienced centers (OR, 3.31; 95 % CI 1.0-11; p = 0.05) compared with no impact at the experienced centers (OR, 0.87; 95 % CI 0.38-1.99; p = 0.75).

CONCLUSION

The findings suggest that the center's experience may have an impact on the risk of morbidity for patients undergoing complex robot-assisted surgical procedures.

Utilization of robotics in pediatric surgical oncology

Despite increasing implementation of robotic surgery and minimally invasive techniques within adult surgical oncology and pediatric general surgery, the utilization of robotic-assisted resections for pediatric tumors has been met with controversy. The robotic platform affords numerous advantages over conventional surgical techniques. However, limited data and guidelines regarding patient selection, indications for the robotic approach, and long-term oncologic outcomes have delayed the widespread adoption of robotic-assisted resection of pediatric tumors. This paper reviews the benefits, limitations, and existing guidelines and data regarding the utilization of robotics in pediatric surgical oncology.

Robot-Assisted Surgery in Gynecology

The advancement of robotics-based procedures in the medical industry is the subject of this review article. The purpose of the surgical robot is to increase surgical abilities and address human shortcomings. The robot's success has been predicated on its ability to accurately and consistently repeat tasks. The following are a few objectives and quantifiable benefits of robotic technology improving surgical maneuverability and physical capabilities. In 2005, the FDA granted gynecological surgery approval for the Da Vinci surgical system. It has been quickly embraced and has already taken on a significant role at many of the locations where it is offered. It consists of a cart with robotic branches next to the patient and a high-resolution three-dimensional (3D) vision system. This study covers laparoscopy via robots in benign gynecological surgeries, myomectomy surgery, hysterectomies, endometriosis, tubal anastomosis, and sacrocolpopexy. The appropriate published studies were evaluated after a PubMed search was conducted. Additionally, procedures that may be used in the future are highlighted. In benign gynecological illness, most currently available research does not show a substantial benefit over traditional laparoscopic surgery. Robotics, however, does provide help in more complicated operations. Compared to laparoscopy, robotic assistance has a lower conversion rate to open procedures. Endo wrist movement of an automated machine during myomectomy surgery can perform proper and better suturing than traditional laparoscopy. The automated program is a noticeable improvement over laparoscopic surgery and, if price issues are resolved, can gain popularity among gynecological surgeons around the globe.

Surgical and Oncologic Outcomes of Robotic and Conventional Nipple-Sparing Mastectomy with Immediate Reconstruction: International Multicenter Pooled Data Analysis

BACKGROUND

Robotic nipple-sparing mastectomy (RNSM) has been developed to reduce conspicuous scar and increase the quality of life in women. This study aimed to evaluate the surgical and oncologic outcomes of RNSM with immediate breast reconstruction (IBR) compared with conventional nipple-sparing mastectomy (CNSM).

PATIENTS AND METHODS

This international multicenter, pooled analysis of individual patient-level data enrolled a total of 755 procedures in 659 women (609 had breast cancer and 50 underwent risk-reducing mastectomy) who underwent nipple-sparing mastectomy with IBR. Surgical and oncologic outcomes, including 30-days postoperative (POD 30d) complication rate, nipple necrosis rate, grade of Clavien-Dindo classification, disease-free survival, and overall survival, were evaluated. Propensity score-matched analyses were performed to adjust for confounding factors.

RESULTS

The median age of both the RNSM and CNSM groups was 45 years. The RNSM group had lower body mass index (BMI) and a higher proportion of benign disease compared with the CNSM group. POD 30d complications and postoperative complication grade III rates were lower in the RNSM group than in the CNSM group (p < 0.05). The nipple necrosis rate was 2.2% and 7.8% for RNSM and CNSM, respectively (p = 0.002). After propensity score matching, significantly lower rates of POD 30d complications, nipple necrosis, and postoperative complication grade III occurred in the RNSM group than in the CNSM group (all p < 0.05). Oncologic outcomes were not significantly different between the two groups.

CONCLUSION

RNSM can provide better cosmetic results with favorable surgical and oncologic outcomes for women with early breast cancer or BRCA mutation.

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.

Robotic-assisted thoracic surgery reduces perioperative complications and achieves a similar long-term survival profile as posterolateral thoracotomy in clinical N2 stage non-small cell lung cancer patients: a multicenter, randomized, controlled trial

Background

Our previous study demonstrated the safety and short-term efficacy of robotic-assisted thoracic surgery (RATS) in clinical N2 (c-N2) stage non-small cell lung cancer (NSCLC) patients. From this, the present study was devised, in which the follow-up time and sample size were both extended to explore the long-term efficacy and potential benefit in survival of RATS compared with lobectomy in c-N2 stage NSCLC patients.

Methods

Patients with c-N2 NSCLS were randomly assigned in a 1:1 ratio to accept operation through thoracotomy or RATS. The da Vinci Surgical System (Si/Xi) was applied in the RATS group, while conventional lobectomy with a rib-spreading incision was applied in the posterolateral thoracotomy group. Primary endpoint was defined as disease free survival and overall survival (OS) of all recruited patients.

Results

Compared with posterolateral thoracotomy group (N=72), the RATS group (N=76) had a reduced blood loss (P<0.001), decreased drainage duration (P=0.002), and decreased postoperative pain visual analog score (all P<0.001), but increased overall cost (P<0.001). Meanwhile, no difference in the other postoperative complications (such as air leakage, subcutaneous emphysema, atrial fibrillation etc.) was found between the RATS group and the posterolateral thoracotomy group (all P>0.05). Regarding long-term outcome, no difference in disease-free survival (DFS; P=0.925) or OS (P=0.853) was observed between the RATS group and posterolateral thoracotomy group. Subgroup analyses and multivariable Cox regression analyses also found no difference in DFS or OS between the RATS group and posterolateral thoracotomy groups.

Conclusions

RATS reduced intraoperative bleeding, drainage duration, postoperative pain, and achieved similar long-term survival outcomes compared with posterolateral thoracotomy in c-N2 stage NSCLC patients.

Trial registration

Chinese Clinical Trial Registry ChiCTR-INR-17012777.

Endometrial cancer in the morbidly obese: a review

PURPOSE OF REVIEW

With a worldwide increase in obesity, there has been an increase in obesity-related diseases. Endometrial cancer is a common cause of cancer for women worldwide. Incidence of endometrial cancer has risen worldwide. Accompanying these patients are risk factors and challenges that may prevent standard of care from being delivered.

RECENT FINDINGS

The current article describes recent literature describing surgical approaches to the obese patient and special considerations in this population. This article also reviews bariatric surgery and endometrial cancer as well as new updates in radiation, chemotherapy and hormonal therapy research in the obese population.

SUMMARY

The current article reviews therapeutics and surgery in the morbidly obese for the treatment of endometrial cancer.

A modified technique to perform para-aortic lymphadenectomy up to the renal vein

OBJECTIVE

To investigate the safety and feasibility of our modified technique to perform lymph node excision up to the renal vein in cases of gynecological cancer.

MATERIALS AND METHODS

87 patients with endometrial or ovarian neoplasms underwent laparoscopic para-aortic lymphadenectomy (LPAL) up to the left renal vein were enrolled prospectively. During surgery, the surgeon was positioned to the right side of the patient and an additional trocar was introduced into the upper right abdomen. The laparoscopic video screen was placed to the side of the patient's head. Three-fan retractor forceps were used to hold up the duodenum and small bowel. The rest of the procedure was the same as conventional LPAL.

RESULTS

The median operating time for LPAL was 72 min (range: 40-115 min) and the median estimated blood loss was 45 ml (range: 15-1000 mL). There were two cases of intra-operative vascular injury. The median number of retrieved para-aortic lymph nodes (PALNs) was 18 (range: 10-37). Of the 87 patients, 11 patients had positive PALNs. None of the cases required laparotomy.

CONCLUSION

Our findings demonstrate that our modified LPAL technique is feasible, reproducible, can achieve good exposure and reduces surgical difficulty.

Can artificial intelligence overtake human intelligence on the bumpy road towards glioma therapy?

Gliomas are one of the most devastating primary brain tumors which impose significant management challenges to the clinicians. The aggressive behaviour of gliomas is mainly attributed to their rapid proliferation, unravelled genomics and the blood-brain barrier which protects the tumor cells from chemotherapeutic regimens. Suspects of brain tumors are usually assessed by magnetic resonance imaging and computed tomography. These images allow surgeons to decide on the tumor grading, intra-operative pathology, feasibility of surgery, and treatment planning. All these data are compiled manually by physicians, wherein it takes time for the validation of results and concluding the treatment modality. In this context, the arrival of artificial intelligence in this era of personalized medicine, has proven promising performance in the diagnosis and management of gliomas. Starting from grading prediction till outcome evaluation, artificial intelligence-based forefronts have revolutionized oncological research. Interestingly, this approach has also been able to precisely differentiate tumor lesion from healthy tissues. However, till date, their utility in neuro-oncological field remains limited due to the issues pertaining to their reliability and transparency. Hence, to shed novel insights on the "clinical utility of this novel approach on glioma management" and to reveal "the black-boxes that have to be solved for fruitful application of artificial intelligence in neuro-oncology research", we provide in this review, a succinct description of the potential gear of artificial intelligence-based avenues in glioma treatment and the barriers that impede their rapid implementation in neuro-oncology.

Utilization and perioperative outcome of minimally invasive pelvic exenteration in gynecologic malignancies: A national study in the United States

OBJECTIVE

To examine characteristics and short-term perioperative outcomes related to minimally invasive pelvic exenteration for gynecologic malignancy.

METHODS

This comparative effectiveness study is a retrospective population-based analysis of the National Inpatient Sample from 10/2008-9/2015. Women with cervical, uterine, vaginal, and vulvar malignancies who underwent pelvic exenteration were evaluated based on the use of laparoscopic or robotic-assisted surgery. Patient demographics and intraoperative/postoperative complications related to a minimally invasive surgical approach were assessed.

RESULTS

Among 1376 women who underwent pelvic exenteration, 49 (3.6%) had the procedure performed via a minimally invasive approach. The majority of minimally invasive cases were robotic-assisted (51.0%). Women in the minimally invasive group were more likely to be old, white, have cervical/uterine cancers, and receive urinary diversion, but less frequently received vaginal reconstruction or colostomy when compared to those in the open surgery group (P < 0.05). Overall perioperative complication rates were similar between the minimally invasive and open surgery groups (79.6% versus 77.7%, P = 0.862), but the minimally invasive group had a decreased risk of high-risk complications compared to the open surgery group (adjusted-odds ratio 0.19, 95% confidence interval 0.07-0.51). Specifically, a minimally invasive approach was associated with decreased incidence of sepsis and thromboembolism compared to an open approach (P < 0.05). The minimally invasive group had a shorter length of stay (median, 9 versus 14 days) and lower total charge (median, $127,875 versus $208,591) compared to the open surgery group (P < 0.05).

CONCLUSION

Laparotomy remains the main surgical approach for pelvic exenteration for gynecologic malignancy and minimally invasive surgery was infrequently utilized during the study period in the United States. Before widely adopting this surgical approach, the utility and role of minimally invasive pelvic exenteration requires further investigation.

Robotics-Assisted Pediatric Oncology Surgery-A Preliminary Single-Center Report and a Systematic Review of Published Studies

AIM

The use of robotics-assisted surgery in oncology has been proved effective and safe in adults. Despite these results, the use of robotics has been rarely reported for pediatric oncology. Our review aims to evaluate the safety and feasibility of robotics-assisted surgery in this field, analyzing our experience and performing a systematic review of the most recent studies.

METHODS

We reviewed all patients affected by an oncological disease who underwent a robotics-assisted procedure at our institute. We performed a systematic review of the literature from 2012 to 2021 on the subjects.

FINDINGS

A total of 14 patients underwent robotics-assisted tumor resection. Eleven procedures (median age 13.2-years old) were carried out in children with adnexal lesions (seven tumor excision and four ovariectomies). Histological diagnosis was mature teratoma (six), serous papillary cystadenofibromas of the fallopian tube (two), ovarian serous cystadenoma (one), ovarian mucinous cystadenoma (one), and ovarian seromucinous cystadenoma. The median length of stay was 2 days. No recurrences or complications at a median follow-up of 2.1-years were observed. A 5-year-old girl underwent a complete posterior resection of a type 3 sacrococcygeal tumor with a robotics-assisted approach for the dissection of a possible intraabdominal residual component of the lesion. No intra- and postoperative complications were recorded. Complete excision of a recurrent differentiating neuroblastoma of the left para-renal region was performed on a 9-year-old girl. An idiopathic anaphylactic shock occurred 1 day after the procedure. At 9 months' follow-up, no local recurrences of the lesion were observed. Overall, we reported no conversion to open surgery. Lastly, a robotic excision of a growing left superior mediastinal intermixed ganglioneuroblastoma was performed on an 8-year-old girl with no postoperative complications. Follow-up was uneventful (7 months). In the literature, the rate of complications ranges from 0 to 28%, mainly related to difficult dissection and impaired anatomy. Conversion is reported in 5% of all oncological procedures, due to more invading tumors and altered anatomical features. No robotics-related complications were reported.

CONCLUSION

Robotics-assisted surgery in pediatric oncology has proven to be feasible. Nevertheless, its use should be limited to selected cases and performed by highly trained oncological surgeons. Preparation and patient positioning, alongside a correct port placement, are crucial to carrying out these procedures. Further innovations in robotics may allow a wider application of this technology in pediatric oncology.

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.

Robotic Surgery Is Less Physically Demanding Than Laparoscopic Surgery: Paired Cross Sectional Study

OBJECTIVE

To study musculoskeletal workload in experienced surgeons during laparoscopic surgery (LS) compared with robotic assisted laparoscopy (RALS).

BACKGROUND

70-90% of surgeons who regularly perform LS report musculoskeletal symptoms, mainly in neck and shoulders. Data regarding the potential ergonomic benefits of RALS in a clinical setting is very limited.

METHODS

Twelve surgeons with advanced experience in both LS and RALS each performed 2 hysterectomies on the same day. LS was performed standing, RALS sitting, the latter allowing forearm and head support. Bipolar surface electromyogram (EMG) was recorded from several muscles and was expressed relative to EMG during maximum contractions (%EMGmax). Gaps per minute plus static (p0.1), mean (p0.5), and peak (p0.9) muscle activation were calculated. Perceived exertion was rated before and just after each surgery.

RESULTS

Neck muscle activity (p0.1 4.7 vs. 3.0%EMGmax, p0.5 7.4 vs. 5.3%EMGmax, p0.9 11.6 vs. 8.2%EMGmax, all P < 0.05) and static shoulder muscle activity (p0.1 5.7 vs. 2.8%EMGmax, P < 0.05) were higher for LS than for RALS. Both a higher level of gaps during RALS and a lower rating of perceived exertion, also for the legs, after RALS supported these observations. However, low back muscle activity was higher for RALS.

CONCLUSIONS

RALS is significantly less physically demanding than LS, and also feels less strenuous for the surgeons. However, for both types of surgeries, there still is room for improvement of working conditions. To further optimize these, we suggest a scheme to regularly observe and advise the surgeons.

Choosing the most appropriate minimally invasive approach to treat gynecologic cancers in the context of an enhanced recovery program: Insights from a comprehensive cancer center

Objective

The aim of the study was to compare the characteristics of procedures for gynecologic cancers conducted with conventional laparoscopy (CL) or robotically assisted laparoscopy (RAL) in the context of an enhanced recovery program (ERP).

Methods

This is a secondary analysis of prospectively collected data from a cohort study conducted between 2016 (when the ERP was first implemented at the Institut Paoli-Calmettes, a comprehensive cancer center in France) and 2018. We included patients who had undergone minimally invasive surgery for gynecological cancers and followed our ERP. The endpoints were the analysis of postoperative complications, the length of postoperative hospitalization (LPO), and the proportion of combined procedures depending on the approach (RAL or CL). Combined procedures were defined by the association of at least two of the following operative items: hysterectomy, pelvic lymphadenectomy, and para-aortic lymphadenectomy.

Results

A total of 362 women underwent either CL (n = 187) or RAL (n = 175) for gynecologic cancers and followed our ERP. The proportion of combined procedures performed by RAL was significantly higher (85/175 [48.6%]) than that performed by CL (23/187 [12.3%]; p < 0.001). The proportions of postoperative complications were similar between the two groups (19.4% versus 17.1%; p = 0.59). Logistic regression analysis revealed a statistically insignificant trend in the association of RAL with a reduced likelihood of an LPO > 3 days after adjusting for predictors of prolonged hospitalization (adjusted OR = 0.573 [0.236–1.388]; p = 0.217).

Conclusion

Experts from our cancer center preferentially choose RAL to perform gynecologic oncological procedures that present elements of complexity. More studies are needed to determine whether this strategy is efficient in managing complex procedures in the framework of an ERP.

Laparoscopic metroplasty for unicornuate uterus with a functional noncommunicating rudimentary horn

OBJECTIVE

To evaluate the feasibility of laparoscopic metroplasty for the treatment of unicornuate uterus with a functional noncommunicating rudimentary horn.

METHODS

Laparoscopic metroplasty was performed in one patient using traditional laparoscopy and four patients using robot-assisted laparoscopy from December 2013 to December 2017 at the Obstetrics and Gynecology Hospital of Fudan University. The records of the five patients were analyzed retrospectively.

RESULTS

In all five patients the unicornuate uterus and functional noncommunicating rudimentary horn were unified into a single cavity without intraoperative or postoperative complications. Average operative time was 281 minutes (range, 204-330 minutes) and average blood loss was 180 mL (range, 100-300 mL). Postoperative hospital stay was 7 days (range, 5-11 days) and there was no re-admission. All patients were relieved of pain and had regular menstruation after surgery. Average follow-up time was 44 months (range, 22-70 months). One patient conceived by in vitro fertilization and embryo transfer 2 years after the operation and delivered twins by cesarean at 33 weeks.

CONCLUSION

Laparoscopic metroplasty, with or without robotic assistance, is an acceptable alternative to resection for a noncommunicating rudimentary horn with a functional endometrium.

Robotic-assisted resection of ovarian tumors in children: A case report and review of literature

BACKGROUND

Ovarian tumors are common gynecological diseases in children, and the most commonly seen ovarian tumors are germ cell tumors. Robotic surgery is the new access for children ovarian tumors.

CASE SUMMARY

From June to October 2017, 4 children with ovarian tumors were admitted and treated in the Department of Pediatric Surgery of People’s Liberation Army General Hospital. The mean age, height, and weight of these patients were 7.5 (1-13) years old, 123.75 (71-164) cm, and 36.8 (8.5-69.5) kg, respectively. Robotic-assisted resection of ovarian tumors was performed for all 4 patients. The 3-port approach was used for robotic manipulation. The surgical procedures were as follows. After creation of the pneumoperitoneum, the robotic scope was placed to explore and find the left ovarian tumor. The trocars for robotic arms 1 and 2 were placed at the sites to the lower right and left of the port of the scope. The tumor capsule in the fallopian tube was incised, and the tumor was completely stripped by an electric hook along the junction of the tumor and the capsule. The resected tumor was completely removed using an endobag. The average docking time of the robotic system was 18.5 min, the average operative time was 120 min, and the average blood loss was 20 mL. No drainage tube was placed except in one patient with a mucinous tumor of the ovary. No fever, pelvic fluid, or intestinal obstruction was reported after surgery. No antibiotics were used during the perioperative period, and the average length of hospital stay after surgery was 3 d.

CONCLUSION

Robotic-assisted resection of ovarian tumors is a simple, safe, and effective surgical procedure for selected patients.

Safety and effectiveness of robotic hysterectomy versus conventional laparoscopic hysterectomy in patients with cervical cancer in China

OBJECTIVE

The aim of this study was to compare the safety and effectiveness of robotic hysterectomy (RH) with conventional laparoscopic hysterectomy (LH) for the treatment of cervical cancer using multivariate regressions.

METHODS

We designed a retrospective single-center study and consecutively collected patients with cervical cancer from February 2014 to October 2017. Data extraction was performed by two independent researchers. The surgical outcomes include operative time, estimated blood loss, number of lymph nodes, time to first flatus, time to a full diet, time to remove drainage tube, length of hospital stay, and postoperative complication.

RESULTS

A total of 152 patients with cervical cancer were collected in our study including 92 patients who underwent RH and 60 patients who underwent LH. Both groups have similar characteristics. The RH group showed shorter operative time (Coe - 42.89; 95% CI - 74.39 to 11.39; P = 0.008) and more number of lymph nodes (Coe 6.06; 95% CI 2.46-9.66; p = 0.001) than the LH group. As for the postoperative parameters, the RH group showed shorter time to remove drainage tube (Coe - 0.89; 95% CI -1.62 to -0.15; p = 0.019) and length of hospital stay (Coe - 6.40; 95% CI - 10.19 to - 2.95; p = 0.001). No significant difference was found between the groups in estimated blood loss (Coe 34.64; 95% CI - 33.08 to 102.37; p = 0.314), time to first flatus (Coe 0.11; 95% CI - 0.38 to 0.61; p = 0.652), time to a full diet (Coe - 0.24; 95% CI - 0.54 to 0.06, p = 0.118), and postoperative complication (OR 0.84; 95% CI 0.35-1.98; p = 0.685).

CONCLUSION

The results from this study suggest that RH is safe and effective as LH but robotic surgery significantly contributed to the feasibility of alternative treatment options for cervical cancer patients.

Prediction of perioperative complications after robotic-assisted radical hysterectomy for cervical cancer using the modified surgical Apgar score

BACKGROUND

Although there has been marked development in surgical techniques, there is no easy and fast method of predicting complications in minimally invasive surgeries. We evaluated whether the modified surgical Apgar score (MSAS) could predict perioperative complications in patients undergoing robotic-assisted radical hysterectomy.

METHODS

All patients with cervical cancer undergoing robotic-assisted radical hysterectomy at our institution between January 2011 and May 2017 were included. Their clinical characteristics were retrieved from their medical records. The surgical Apgar score (SAS) was calculated from the estimated blood loss, lowest mean arterial pressure, and lowest heart rate during surgery. We modified the SAS considering the lesser blood loss typical of robotic surgeries. Perioperative complications were defined using a previous study and the Clavien-Dindo classification and subdivided into intraoperative and postoperative complications. We analyzed the association of perioperative complications with low MSAS.

RESULTS

A total of 138 patients were divided into 2 groups: with (n = 53) and without (n = 85) complications. According to the Clavien-Dindo classification, 49 perioperative complications were classified under Grade I (73.1%); 13, under Grade II (19.4%); and 5, under Grade III (7.5%); 0, under both Grade IV and Grade V. Perioperative complications were significantly associated with surgical time (p = 0.026). The MSAS had a correlation with perioperative complications (p = 0.047). The low MSAS (MSAS, ≤6; n = 52) group had significantly more complications [40 (76.9%), p = 0.01]. Intraoperative complications were more correlated with a low MSAS than were postoperative complications [1 (1.2%) vs. 21 (40.4%); p < 0.001, 13 (15.1%) vs. 25 (48.1%); p = 0.29, respectively]. We also analyzed the risk-stratified MSAS in 3 subgroups: low (MSAS, 7-10), moderate (MSAS 5-6), and high risks (MSAS, 0-4). The prevalence of intraoperative complications significantly increased as the MSAS decreased p = 0.01).

CONCLUSIONS

This study was consistent the concept that the intuitive and simple MSAS might be more useful in predicting intraoperative complications than in predicting postoperative complications in minimally invasive surgeries, such as robotic-assisted radical hysterectomy for cervical cancer.