Perioperative Outcomes of 3-Arm Versus 4-Arm Robotic Radical Hysterectomy in Patients with Cervical Cancer

Automated performance metrics, learning curve and robotic colorectal surgery

BACKGROUND

The aim of this study was to evaluate the usefulness of Automated Performance Metrics (APMs) in assessing the learning curve.

METHODS

A retrospective review of 85 consecutive patients who underwent total robotic colorectal surgery at a single institution between August 2020 and October 2022 was performed. Patient demographics, operation type, and APMs were collected and analysed. Cumulative summation technique (CUSUM) was used to construct learning curves of surgeon console time (SCT), use of the fourth arm, clutch activation, instrument off screen (number and duration), and cut electrocautery activation.

RESULTS

Two phases with 50 and 35 cases were identified from the CUSUM graph for SCT. The SCT was significantly different between the two phases (176 and 251 min, p < 0.002). After adjustment for SCT, the APMs were not significantly different between the two phases.

CONCLUSIONS

Most APMs do not offer additional learning curve information when compared with SCT analysis alone.

Urological Complications in Radical Surgery for Cervical Cancer: A Comparative Meta-Analysis before and after LACC Trial

BACKGROUND

After the LACC trial publication in 2018, the minimally invasive approach (MIS) has severely decreased in favor of open surgery: MIS radical hysterectomy was associated with worse oncological outcomes than open surgery, but urological complications were never extensively explored in pre- versus post-LACC eras, even if they had a great impact on post-operative QoL. The purpose of this meta-analysis is to compare functional and organic urological complication rates before and after LACC trial.

METHODS

An independent search of the literature was conducted 4 years before and after the LACC trial and 50 studies were included.

RESULTS

The overall rate of urologic complications was higher in pre-LACC studies while no differences were found for organic urological complications. Conversely, the overall risk of dysfunctional urological complications showed a higher rate in the pre-LACC era. This is probably related to a sudden shift to open surgery, with potential lower thermal damage to the urinary tract autonomic nervous fibers.

CONCLUSIONS

This meta-analysis showed that the incidence of urological complications in radical cervical cancer surgery was higher before the LACC trial, potentially due to the shift to open surgery. Nevertheless, further studies are needed to shed light on the connection between minimally invasive surgery and urological damage.

Comparing surgical outcomes of da Vinci SP and da Vinci Xi for endometrial cancer surgical staging in a propensity score-matched study

The number of studies comparing robotic systems in endometrial cancer staging is limited. This retrospective study analyzed the medical records of 42 consecutive endometrial cancer patients, who underwent robotic staging using the da Vinci SP (SP) system, and 126 propensity score-matched patients who underwent staging using the da Vinci Xi (Xi) system. Median console and total operation times were longer in the SP group than those in the Xi group (125 vs. 77 min, p < 0.001; 225 vs. 154.5 min, p < 0.001, respectively). Notably, the median console time of the first 10 cases using SP was 184 min; it subsequently decreased to 99.5 min in the fourth 10 cases. SP had lesser postoperative hemoglobin (Hb) change (0.6 ± 0.7 g/dL vs. 1.8 ± 0.9 g/dL in Xi, p < 0.001) and lower median pain score at 6 h after surgery (2 vs. 3 in Xi, p = 0.046). Moreover, median postoperative hospital stay was shorter in the SP group (2 days) than that in the Xi group (6 days) (p < 0.001). Although SP was correlated with lower postoperative Hb change, shorter postoperative hospital stay, and lower pain score than those in Xi, it required longer operation times. Further prospective randomized studies are needed to validate the benefits of SP compared to other robotic platforms.

Improving ergonomics for the bedside assistant in robotic colorectal surgery

The aim of the study was to document when significant bedside assistant (BA) and robotic arm collisions occurred during robotic colorectal surgery (RCS). An observational study of 10 consecutive RCS cases, from May 2022 to September 2022, was performed. Situations when there was significant collision between BA arm and robotic arm (to cause inadvertent movement of the assistant instrument) were documented. The assistant port was randomly placed to the right or the left side of the camera port. Situations which led to detrimental BA ergonomics include dissection at the most peripheral working field, proximity of the target (mesenteric vessels), small bowel retraction, placement of the assistant port in the medial position (on the left side of the camera port), during intra-corporeal suturing and robotic stapler use. The robotic console surgeon can predictably identify and avoid situations when injury to the BA may occur.

The value of surgical admissions for malignant uterine cancer. A comparative analysis of robotic, laparoscopic, and laparotomy surgery in a university hospital

Background

Robotic surgery for malignant uterine cancer raises issue of economic sustainability for providers. The objective of this study was to assess the value of surgical admissions for malignant uterine cancer in a University Hospital through an analysis of their costs and outcomes by comparing three different surgical approaches (laparotomy, laparoscopic, and robotic surgery).

Methods

Hospitalizations between 1 January 2019 and 31 October 2021 for malignant uterine cancer surgery were selected and stratified. For each surgical approach, mean values (with 95% confidence intervals, CI) were calculated for cost items. Moreover, 30-day readmission frequency was calculated for the three approaches compared to each other. ANOVA and Student's t-test and relative risk (RR) were used for statistical analysis. A break-even analysis was carried out by evaluating the volume of robotic and non-robotic surgical admissions.

Results

A total of 1,336 hospitalizations were included in the study, 366 with robotic, 591 with laparoscopic, and 379 with laparotomy surgery. Robotic surgery, compared to laparoscopic and laparotomy ones, showed a statistically significant difference (p < 0.001) in the economic margin, which was largely negative (-1069.18 €; 95%CI:-1240.44--897.92 €) mainly due to devices cost, and a lower percentage of 30-day readmissions (1.4%; 95%CI: 0.2-2.6%), with a statistically significant difference only vs. laparotomy (p = 0.029). Laparoscopic compared to laparotomy surgery showed a significantly (p < 0,001) more profitable economic margin (1692.21 €; 95%CI: 1531.75 €-1852.66 €) without a significant difference for 30-day readmissions. Break-even analysis showed that, on average, for each malignant uterine cancer elective surgery performed laparoscopically, 1.58 elective robotic surgeries are sustainable for the hospital (95% CI: 1.23-2.06).

Conclusion

Break-even analysis could be a useful tool to support hospital management in planning and governance of malignant uterine cancer surgery. Systematic application of this tool will allow defining over time right distribution of robotic, laparoscopic, and laparotomy surgeries' volumes to perform to ensure both quality and economic-financial balance and therefore value of uterine oncological surgery. Concerning research, this study paves the way for a multicentric study, the extension of outcomes of malignant uterine surgery to be considered and assessed, and the future inclusion of other therapeutic interventions in the analysis.

Impact of Surgeon-Controlled Suction During Robotic Prostatectomy to Reduce Dependence on Bedside Assistance

Background: Suction during robotic surgery has traditionally been performed by a bedside assistant. Adequately skilled assistants are not always available. We assessed a purpose-designed robotic surgeon-controlled suction catheter for efficiency and safety by comparing with historic cases of suction controlled by a dedicated bedside assistant using standard rigid laparoscopic suction. Methods: Beginning in February 2019, the remotely operated suction irrigation (ROSI) device was used in all robotic prostatectomy procedures, which is a flexible suction catheter manipulated by the surgeon such that a bedside assistant is never required for suction. The initial 300 consecutive cases performed with ROSI were compared with the 300 immediately previous procedures using bedside assistant suction (BAS). Results: There were no statistically significant differences between groups in age, body mass index, American Anesthesiologist Association score, prostate specific antigen, or pathologic stage. Lymph node dissection was performed in all 600 patients. All 300 ROSI cases were completed without requiring switching to BAS. Estimated blood loss (102.7 vs 120.2 mL, p = 0.001) and operative time (156.1 vs 149.3 minutes, p < 0.001) were slightly lower in the ROSI group. There was no statistical difference in the 90-day complication rate (Clavien ≥III) between groups, with both having 3% of patients readmitted or seen in the emergency department within 90 days of surgery. Conclusion: Surgeon-controlled suction allowed more surgeon autonomy without a negative impact on efficiency or safety issues requiring "bailout" suctioning by the bedside assistant whether urgent or otherwise. Robotic surgeons without access to skilled bedside assistants should consider suctioning for themselves not unlike the norm for many laparoscopic surgeons.

Comparative Survival Outcome of Robot-Assisted Staging Surgery Using Three Robotic Arms versus Open Surgery for Endometrial Cancer

PURPOSE

There is lack of data on direct comparison of survival outcomes between open surgery and robot-assisted staging surgery (RSS) using three robotic arms for endometrial cancer. The purpose of this study was to compare the overall survival (OS) and disease-free survival (DFS) between open surgery and RSS using three robotic arms for endometrial cancer.

MATERIALS AND METHODS

Consecutive women with endometrial cancer who underwent surgery between May 2006 and May 2018 were identified. Robotic procedures were performed using the da Vinci robotic system, and the robotic approach consisted of three robotic arms including a camera arm. Propensity score matching, as well as univariate and multivariate Cox regression of OS and DFS were performed according to clinicopathologic data and surgical method.

RESULTS

The study cohort included 423 unselected patients with endometrial cancer, of whom 218 underwent open surgery and 205 underwent RSS using three robotic arms. Propensity score-matched cohorts of 146 women in each surgical group showed no significant differences in survival: 5-year OS of 91% vs. 92% and DFS of 86% vs. 89% in the open and robotic cohorts, respectively (hazard ratio, 1.02; 95% confidence interval, 0.82-1.67). In the univariate analysis with OS as the endpoint, surgical method, age, stage, type II histology, grade, and lymph node metastasis were independently associated with survival. Surgical stage, grade, and type II histology were found to be significant independent predictors for OS in the multivariate analysis.

CONCLUSION

RSS using three robotic arms and laparotomy for endometrial carcinoma had comparable survival outcomes.

Application of da Vinci robot with the"3 + 2" mode in radical gastrectomy for gastric cancer

The aim of this study is to investigate the feasibility and advantages of the da Vinci robotic system with the "3 + 2" mode (3 robotic arms and 2 assistants) in radical gastrectomy for gastric cancer.The clinical data of 65 patients who underwent da Vinci robotic gastrectomy with the "3 + 2" mode from July 2016 to October 2019 were grouped into an observation group. An additional 65 patients who underwent robotic gastrectomy under the classic mode during the same period were grouped into a control group. The short-term surgical outcomes were compared between 2 different groups.Compared with the control group, the observation group had a significantly shorter operative time (176.18 ± 15.49 vs 203.85 ± 12.77 minutes, P < .001) and lower operation costs ($2761.19 ± $191.91 vs $3690.91 ± $162.82; P < .001). No statistical differences in other outcomes were observed (P > .05).We show that robotic gastrectomy with "3 + 2" mode is a safe and beneficial surgical procedure in new robotic surgery institutions.

From Da Vinci Si to Da Vinci Xi: realistic times in draping and docking the robot

Robot-assisted surgery is assumed to be time consuming partially due to extra time needed in preparing the robot. The objective of this study was to give realistic times in Da Vinci Xi draping and docking and to analyse the learning curve in the transition from the Si to the Xi in an experienced team. This prospective study was held in a hospital with a high volume of robot-assisted surgery in general surgery, urology and gynaecology. Times from the moment patients entered the operating room until the surgeon took place behind console were precisely recorded during the first 6 weeks after the implementation of the Xi. In total, 65 procedures were performed and documented. The learning curve for the process of draping and docking the robot was reached after 21 and 18 cases, respectively. Mean times after completion of the learning curve were 5 min for draping and 7 min for docking and were statistically different from mean times before completion of the learning curve (p values < 0.01). In dedicated teams netto extra time needed for preparing the Xi can even be reduced to just the time needed for docking. Thus, setting up the robot should have limited impact on overall time spent in the operation room.

Safety and effectiveness of the da Vinci robot with the "3+2" mode for distal pancreatectomy

BACKGROUND

Recently, no relevant research has focused on the relationship between the clinical efficacy of da Vinci robotic distal pancreatectomy (RDP) and the number of mechanical arms and assistants used for RDP. The aim of this study was to evaluate the safety, efficacy, and advantages of RDP with the "3 + 2" mode.

METHODS

Clinical data from 53 patients (observation group) who received RDP using the "3 + 2" mode in our department, from March 2016 to September 2018, were reviewed. An additional 53 patients who received RDP using the classical mode were chosen at random for the control group. Short-term outcomes for the two groups were compared.

RESULTS

There were no statistically significant differences between the two groups for estimated blood loss, postoperative day of flatus passage, postoperative hospital stay, and postoperative complication (P > 0.05). Compared with the control group, the observation group had a significantly shorter operative time (166.9 ± 13.3 vs 192.6 ± 11.1 minutes, P < 0.001), lower surgical costs ($2827.79 ± $173.02 vs $3900.63 ± $317.29, P < 0.001).

CONCLUSIONS

The RDP using the "3 + 2" mode can increase the exposure of surgical field, improve cooperation between assistants, lower the surgical costs, and shorten the operative time and learning curve. Moreover, the clinical effect is equal to that of RDP using the classical mode. These findings indicate that RDP using the "3 + 2" mode is safe and feasible for institutions that are equipped for robot-assisted surgery.