Robot-assisted versus total laparoscopic radical hysterectomy in early cervical cancer, a review

Comparison of survival outcome of open, total laparoscopic, and laparoscopy-assisted radical vaginal hysterectomy for stage IB2 cervical cancer patients: A multicenter retrospective study

The aim of this study was to compare survival outcomes of 3 different radical hysterectomy (RH) types, namely total abdominal radical hysterectomy (TARH), total laparoscopic radical hysterectomy (TLRH), and laparoscopy-assisted radical vaginal hysterectomy (LARVH), in patients with FIGO stage IB2 cervical cancer. We retrospectively identified a cohort of patients who underwent RH for cervical cancer between 2010 and 2017. Patients with stage IB2 cervical cancer were included and were classified into TARH, TLRH, and LARVH treatment groups. Survival outcomes were estimated by the Kaplan-Meier method and compared with the log-rank test. Cox proportional hazards models were fit to estimate the independent association of RH technique with outcome. 194 patients were included in this study: 79 patients in the TARH group, 55 in the TLRH group, and 60 in the LARVH group. No significant differences were found in clinicopathological characteristics between the 3 RH groups. On comparing survival outcomes with TARH, both TLRH and LARVH showed no significant difference in terms of 5-year overall survival (TARH vs TLRH, P = .121 and TARH vs LARVH, P = .436). Conversely, compared to the TARH group, 5-year progression-free survival (PFS) was significantly worse in the TLRH group (P = .034) but not in the LARVH group (P = .288). Multivariate analysis showed that TLRH surgical approach (hazard ratio, 3.232; 95% confidence interval, 1.238-8.438; P = .017) was an independent prognostic factor for PFS in patients with IB2 cervical cancer. Our study suggests that in patients with FIGO stage IB2 cervical cancer, among the minimally invasive RH approaches, TLRH and LARVH, only TLRH approach was associated with worse PFS when compared with the TARH approach.

Effect of robotic versus laparoscopic surgery on postoperative wound infection in patients with cervical cancer: A meta-analysis

The objective of this research is to evaluate the risk of postoperative infection and other risks associated with robotic radical hysterectomy (RRH) compared with laparoscopic radical hysterectomy (LRH). Recent studies on RRH versus LRH have not been conclusive for cervical carcinoma. Our group attempted to use meta-analyses to evaluate the effects of both RRH and LRH on postoperative outcomes in order to make sure that the best operative method was used to prevent wound infections. We looked up Cochrane Library and published databases for this research and found 594 findings. Articles were screened by title and abstract and then carefully examined for inclusion and exclusion criteria. Data extraction was performed independently by two researchers. Comparison studies were used to describe the incidence of wound complications after surgery. The publication bias was assessed using Egger regression correlation analysis. There were six trials eligible for inclusion, of which 491 RRH and 807 LRH. Depending on surgery for cervical carcinoma, it is true that there is a difference in the way that surgery affects the postoperative complications. Our analysis demonstrated that the use of robotic operation can decrease the amount of blood loss during operation as compared with routine laparoscopy (MD, -77.69; 95% CI, -132.08, -23.30; p = 0.005). However, there were no statistical differences in the incidence of postoperative wound infections (OR, 0.54; 95% CI, 0.25, 1.19; p = 0.13) and intraoperative operative time (MD, 13.01; 95% CI, -41.38, 67.41; p = 0.64) among the two procedures. There was no statistically significant difference between these two groups of patients with severe postoperative complications. Unlike other research, the findings of this meta-analysis are not consistent with the findings of the present study, which suggest that robotic operations cannot lower the rate of postoperative wound infections. However, because of the limitations and the retrospective character of the trials covered, these findings should be interpreted with care and more extensive research is required.

Systematic Review and Meta-analysis of laparoscopic radical hysterectomy vs. Robotic assisted radical hysterectomy for early stage cervical cancer

OBJECTIVE

Following compelling evidence that open techniques may be related to better survival and disease free survival rates, many gynecologic oncologists in the US have turned away from performing laparoscopic radical hysterectomy (LRH) and robotic radical hysterectomy (RRH) for the treatment of early-stage cervical cancer. While this may be warranted as a safety concern, there is little high-quality data on the head-to-head comparison of LRH and RRH and therefore little evidence to answer the question of where this decrease in patient survival is originating from. In our systematic review, we aimed to compare the complications and outcomes of LRH against those of RRH.

DATA SOURCES

We searched PubMed, Cochrane CENTRAL, Medline, ClinicalTrials.Gov, SCOPUS, and Web of Science from database inception until February 1st, 2022.

METHODS OF STUDY SELECTION

A total of 676 studies were identified and screened through a manual three-step process. Ultimately 33 studies were included in our final analysis. We included all studies that compared LRH and RRH and included at least one of our selected outcomes. We included retrospective cohorts, prospective cohorts, case-control, and randomized clinical trials.

TABULATION, INTEGRATION, AND RESULTS

Data was independently extracted manually by multiple observers and the analysis was performed using Review Manager Software. PRISMA guidelines were followed. We analyzed homogenous data using a fixed-effects model, while a random-effects model was used for heterogeneous outcomes. We found that following RRH, women had a decreased hospital stay (MD = 0.80[0.38,1.21],(P < 0.002). We found no differences in estimated blood loss (MD = 35.24[-0.40,70.89],(P = 0.05), blood transfusion rate ((OR = 1.32[0.86,2.02],(P = 0.20), rate of post-operative complications (OR = 0.84[0.60,1.17],(P = 0.30), the operative time (MD = 6.01[-4.64,16.66],(P = 0.27), number of resected lymph node (MD = -1.22[-3.28,0.84],(P = 0.25) intraoperative complications (OR = 0.78[0.51,1.19],(P = 0.25), five-year overall survival (OR = 1.37[0.51,3.69],(P = 0.53), lifetime disease free survival (OR = 0.89[0.59,1.32],(P = 0.55), intraoperative and postoperative mortality (within 30 days) (OR = 1.30[0.66,2.54],(P = 0.44), and recurrence (OR = 1.14[0.79,1.64],(P = 0.50).

CONCLUSIONS

RRH seems to result in the patient leaving the hospital sooner after surgery. We were unable to find any differences in our ten other outcomes related to complications or efficacy. These findings suggest that the decreased survival seen in minimally invasive RH in previous studies could be due to factors inherent to both LRH and RRH.

PROSPERO PROSPECTIVE REGISTRATION NUMBER

CRD42022273727.

Artificial Intelligence and Machine Learning Based Intervention in Medical Infrastructure: A Review and Future Trends

People in the life sciences who work with Artificial Intelligence (AI) and Machine Learning (ML) are under increased pressure to develop algorithms faster than ever. The possibility of revealing innovative insights and speeding breakthroughs lies in using large datasets integrated on several levels. However, even if there is more data at our disposal than ever, only a meager portion is being filtered, interpreted, integrated, and analyzed. The subject of this technology is the study of how computers may learn from data and imitate human mental processes. Both an increase in the learning capacity and the provision of a decision support system at a size that is redefining the future of healthcare are enabled by AI and ML. This article offers a survey of the uses of AI and ML in the healthcare industry, with a particular emphasis on clinical, developmental, administrative, and global health implementations to support the healthcare infrastructure as a whole, along with the impact and expectations of each component of healthcare. Additionally, possible future trends and scopes of the utilization of this technology in medical infrastructure have also been discussed.

A Comparative Analysis of Robotic Single-Site Surgery and Laparoendoscopic Single-Site Surgery as Therapeutic Options for Stage IB1 Cervical Squamous Carcinoma

Purpose

To compare perioperative outcomes between robotic single-site surgical technique and conventional laparoendoscopic single-site surgical technique.

Methods

This was a retrospective cohort study involving 67 patients who received robotic single-site surgery or laparoendoscopic single-site surgery for the treatment of stage IB1 cervical squamous carcinoma. The robotic single-site radical hysterectomy technique combined with pelvic lymph node dissections were performed in 32 patients while the laparoendoscopic single-site radical hysterectomy technique combined with pelvic lymph node dissections were performed in 35 patients.

Results

The enrolled patients had been diagnosed with stage IB1 cervical squamous carcinoma. The perioperative outcomes were mean age (51.63±8.32 years in the lymph node dissection (RSS group) and 53.14±8.14 years in the lymph node dissection (LESS group), p=0.453); BMIs (23.76±2.72 in the RSS group and 23.46±2.28 in the LESS group, p=0.629); shorter operative times (223.56±15.43 min in the RSS group and 248.61±20.89 min in the LESS group, p<0.01) and less estimated blood loss (217.25±16.77 mL in the RSS group and 294.74±24.00 mL in the LESS group, p<0.01). None of the study participants exhibited postoperative pain. There were no statistically significant differences in the length of hospital stay (p=0.865), perioperative complications (p=0.602), duration of closure and removal of catheter (p=0.518) as well as in pathological diagnoses between the two groups.

Conclusion

Robotic single-site surgery can be used in the treatment of early stage cervical cancer as it exhibits acceptable operative times and perioperative outcomes. This surgical technique is feasible and safe.

Robotic single-site versus multiport radical hysterectomy in early stage cervical cancer: An analysis of 62 cases from a single institution

Background

This study aimed to compare the surgical outcomes and cost of robotic single‐site radical hysterectomy (RSSRH) versus robotic multiport radical hysterectomy (RMPRH) with pelvic lymph node dissection in early stage cervical cancer.

Methods

Sixty‐two patients with early stage cervical cancer were recruited between November 2011 and July 2017 and underwent RSSRH (20 patients) and RMPRH (42 patients) for early stage cervical cancer using the da Vinci Si Surgical System (Intuitive Surgical).

Results

There were no significant difference between the two groups in most of parameters. However, postoperative hospital discharge and total hospital costs for RSSRH were significantly shorter than RMPRH (both p < 0.001). However, lymph node retrieval of RMPRH was significantly higher than RSSRH in (18.0 vs. 9.5, respectively; p < 0.001).

Conclusions

RSSRH has comparable surgical outcomes to the RMPRH method. RSSRH could be considered a surgical option in a well‐selected patient group.

Comparison of long-term survival of total abdominal radical hysterectomy and laparoscopy-assisted radical vaginal hysterectomy in patients with early cervical cancer: Korean multicenter, retrospective analysis

PURPOSE

The aim of this study was to compare survival outcomes of total abdominal radical hysterectomy (TARH) versus laparoscopy-assisted radical vaginal hysterectomy (LARVH) in stage IA2-IB2 cervical cancer.

METHODS

812 patients who underwent RH between 2008 and 2017 were evaluated in 3 institutions. Progression-free survival (PFS) and overall survival (OS) were analyzed with Kaplan-Meier method and compared by log-rank test. The clinical noninferiority of the LARVH to TARH was assessed with a margin of -7.2%. Noninferiority was demonstrated if the low limit of 95% confidence interval (CI) exceeded its predefined margin.

RESULTS

258 patients were treated with TARH and 252 patients with LARVH. TARH and LARVH group had similar 5-year PFS (84.4% vs 86.6%, p = 0.467) and OS rates (85.8% vs 88.0%, p = 0.919). Noninferiority of LARVH to TARH were confirmed with 5-year PFS and OS difference rates of 2.2% (95% CI -2.9-7.3, p = 0.001) and 2.2% (95% CI -2.7-7.1, p = 0.001), respectively. In subgroup of patients with tumors size >2 cm, 5-year PFS (77.6% vs 79.0%, p = 0.682) and OS rates (79.2% vs 81.5%, p = 0.784) did not differ statistically between the two groups. Noninferiority of LARVH to TARH were also confirmed with 5-year PFS and OS difference rates of 1.4% (95% CI -7.0-9.8, p = 0.046) and 2.3% (95% CI -5.8-10.4, p = 0.027), respectively.

CONCLUSION

LARVH showed significant noninferiority for PFS and OS versus TARH in early cervical cancer, suggesting the potential oncologic safety of LARVH.

An Australian, single-centre study of surgical management outcomes for early-stage cervical cancer

BACKGROUND

The Laparoscopic Approach to Cervical Cancer (LACC) trial is the first phase III randomised, multicentred trial to compare oncologic outcomes associated with open radical hysterectomy vs minimally invasive surgery (MIS) for treatment of early cervical cancer.

AIM

To evaluate our surgical experience in patients with early cervical cancer.

METHODS AND MATERIALS

The Lifehouse Gynaecologic Oncology database was queried based upon the eligibility criteria of the LACC study and included all FIGO 2009 stage (1A1 with lymph vascular space invasion, 1A2, 1B1) cervical cancer women from 2008-2018. Patients were also included in our study if they had abdominal radical trachelectomy (ART), laparoscopic radical hysterectomy (TLRH) and robotic radical trachelectomy (RRT).

RESULTS

Forty-six women were identified with four exclusions. Thirty-seven women had stage 1B1 disease, 24 had a squamous cell carcinoma, 15 had an adenocarcinoma and three had an adenosquamous carcinoma of the cervix. Of the 42 eligible patients, 32 underwent an open abdominal approach (26 total abdominal radical hysterectomy (TARH), six ART) and ten a MIS approach (nine TLRH and one RRT) with a mean follow-up of 4.8 years. All 42 women had a pelvic lymph node dissection, eight women had nodal metastases and 16 patients received adjuvant chemoradiation. Two of the nine women in the laparoscopic radical hysterectomy group had a recurrence. Both had adenocarcinoma, stage 1B1 disease. There were no recurrences in the TARH group or radical trachelectomy groups.

CONCLUSION

Our data, albeit limited in number, have reflected the results of the LACC trial that MIS was associated with a lower disease-free survival than open radical hysterectomy.

Perioperative Complications and Safety Evaluation of Robot-Assisted Radical Hysterectomy of Cervical Cancer After Neoadjuvant Chemotherapy

Purpose

To evaluate the perioperative complications of patients with cervical cancer who are treated with robot-assisted radical hysterectomy (RRH) and to further evaluate the safety of patients undergoing NACT.

Methods

A total of 805 consecutive cervical cancer patients undergoing RRH were involved in this report. Their clinical characteristics were retrieved from hospital medical records. Perioperative complications were subdivided into intraoperative and postoperative complications, which were graded according to the Clavien-Dindo classification (CDC), and the complications of grade III and above were defined as severe complications. Furthermore, the two-level logistic regression model was used to estimate the risk factors of perioperative and severe complications and to further confirm the relationship between NACT and perioperative and severe complications.

Results

The perioperative complication rate and severe complications were 45.09% and 7.83%, respectively. Poorly differentiated tumor and NACT were identified as independent risk factors for perioperative complications by multifactor analysis. Furthermore, we concentrated on the relations between NACT and complications. The risk of perioperative complications of the group with NACT (OR = 11.08, 95% CI: 5.70-21.54) was significantly higher than the group without NACT, especially in postoperative complications (OR=17.65, 95% CI: 8.63-36.08), even after adjusting confounding factors. However, there was no statistically significant difference in terms of severe complications (OR=1.68, 95% CI: 0.64-4.41) and intraoperative complications (OR=0.51, 95% CI: 0.18-1.41). Moreover, as the times of NACT increase, the impact on perioperative complications is more pronounced. A similar trend was observed in postoperative complications, while this statistical difference was still not observed in intraoperative and severe complications.

Conclusion

This result demonstrates the feasibility and safety of RRH of cervical carcinoma after NACT in generally, since it only causes mild complications, not severe complications.

Laparoscopic radical hysterectomy with transvaginal closure of vaginal cuff - a multicenter analysis

OBJECTIVE

Laparoscopic/robotic radical hysterectomy has been historically considered oncologically equivalent to open radical hysterectomy for patients with early cervical cancer. However, a recent prospective randomized trial (Laparoscopic Approach to Cervical Cancer, LACC) has demonstrated significant inferiority of the minimally invasive approach. The aim of this study is to evaluate the oncologic outcomes of combined laparoscopic-vaginal radical hysterectomy.

METHODS

Between August 1994 and December 2018, patients with invasive cervical cancer were treated using minimally-invasive surgery at the Universities of Jena, Charité Berlin (Campus CCM and CBF) and Cologne and Asklepios Clinic Hamburg. 389 patients with inclusion criteria identical to the LACC trial were identified. In contrast to the laparoscopic/robotic technique used in the LACC trial, all patients in our cohort underwent a combined transvaginal-laparoscopic approach without the use of any uterine manipulator.

RESULTS

A total of 1952 consecutive patients with cervical cancer were included in the analysis. Initial International Federation of Gynecology and Obstetrics (FIGO) stage was IA1 lymphovascular space invasion (LVSI+), IA2 and IB1/IIA1 in 32 (8%), 43 (11%), and 314 (81%) patients, respectively, and histology was squamous cell in 263 (68%), adenocarcinoma in 117 (30%), and adenosquamous in 9 (2%) patients. Lymphovascular invasion was confirmed in 106 (27%) patients. The median number of lymph nodes was 24 (range 2-86). Lymph nodes were tumor-free in 379 (97%) patients. Following radical hysterectomy, 71 (18%) patients underwent adjuvant chemoradiation or radiation. After a median follow-up of 99 (range 1-288) months, the 3-, 4.5-, and 10-year disease-free survival rates were 96.8%, 95.8%, and 93.1 %, and the 3-, 4.5-, and 10-year overall survival rates were 98.5%, 97.8%, and 95.8%, respectively. Recurrence location was loco-regional in 50% of cases with recurrence (n=10). Interestingly, 9/20 recurrences occurred more than 39 months after surgery.

CONCLUSION

The combined laparoscopic-vaginal technique for radical hysterectomy with avoidance of spillage and manipulation of tumor cells provides excellent oncologic outcome for patients with early cervical cancer. Our retrospective data suggest that laparoscopic-vaginal surgery may be oncologically safe and should be validated in further randomized trials.

Minimally Invasive Robotic Surgery for Gynecologic Cancers: A Review

Minimally invasive robotic surgery has become an effective surgical technique for the treatment of gynecologic malignancies. This article reviews the current utilization of robotic surgery and its role for future treatment in gynecologic oncology.

Concurrent Learning Curves of 3-Dimensional and Robotic-Assisted Laparoscopic Radical Hysterectomy for Early-Stage Cervical Cancer Using 2-Dimensional Laparoscopic Radical Hysterectomy as a Benchmark: A Single Surgeon's Experience

Background

For early-stage cervical cancers, radical hysterectomy (RH) with pelvic lymphadenectomy has been the standard care. This study compared the learning curves and intra-, peri-, and post-operative outcomes for 3-dimensional laparoscopic RH (3D-LRH) and robotic-assisted (RA)-LRH by a surgeon highly skilled in 2-dimensional (2D)-LRH for treatment of early-stage cervical cancer.

Material/Methods

Two hundred and thirty-nine patients with early-stage cervical cancer (FIGO stage: Ia2–IIa2) admitted to Shanghai Obstetrics and Gynecology Hospital, Fudan University were recruited into this prospective study: 54, 85, and 100 patients underwent 2D-, 3D-, and RA-LRH, respectively and were followed up. Patients’ demographic, clinical, and operative information was retrieved and compared. CUSUM (cumulative summation) analysis using a benchmark derived from previously performed 2D-LRHs.

Results

Both 3D- and RA-LRH had a steep learning curve. 3D-LRH was superior to 2D- and RA-LRH in terms of significantly shorter operating time. For all approaches, the operating time was associated with the uterus size of the patient and was not affected by other parameters. All approaches of LRH yielded comparable radicality and operative results other than operative time.

Conclusions

Both 3D- and RA-LRH approaches had similar radicality, and intra-operative and post-operative complication rates, however, 3D-LRH had the shortest operating time and lowest amount of blood loss. After reaching proficiency, RA-LRH had comparable operating time with that of 2D-LRH, and might be even shorter in cases where surgeon has acquired more experience. In countries where labor costs are low; 3D-LRH might be preferable to 2D- and RA-LRH for early-stage cervical cancer.

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.

Predictive factors of severe perioperative morbidity of radical hysterectomy with lymphadenectomy in early-stage cervical cancer: A French prospective multicentric cohort of 248 patients

OBJECTIVE

The purpose of this study was to assess the postoperative morbidity after radical hysterectomy (RH) for early-stage cervical cancer and to determine risk factors of severe perioperative morbidity.

METHODS

Data of two prospective trials on sentinel node biopsy for cervical cancer (SENTICOL I & II) were analysed. Patients having a radical hysterectomy were included between 2005 and 2012 from 25 French oncologic centers. Postoperative complications were prospectively recorded in a pre-specified analysis.

RESULTS

248 patients met the inclusion criteria. The median age was 44.5 years [25-85]. 88.7% of patients had a stage IB1 disease. There were 71.4% epidermoid carcinomas and 25% adenocarcinomas. 125 patients (50.4%) had a laparoscopic-assisted vaginal RH, 88 patients (35.5%) had a total laparoscopic RH, 26 patients (10.5%) had an open RH and 9 patients (3.6%) had a robotic-assisted RH. Sixteen patients (6.4%) had intraoperative complications. On a multivariate analysis, intraoperative complications were significantly associated with BMI >30 kg/m². The urinary, lymphovascular and neurologic complications rates were respectively 34.3%, 20.6% and 19.8%. 31 patients (12.5%) had severe postoperative complications (Clavien-Dindo ≥ 3 or CTCAE ≥ 3). On multivariate analysis, severe postoperative complications were associated with parametrial involvement, preoperative brachytherapy and inclusion in low surgical skills center.

CONCLUSIONS

This study based on prospective data showed that RH has low severe postoperative complications. The main complications were urinary infections and lower limb lymphedema. Patients with early-stage cervical cancer should be referred to expert center to ensure best surgical outcomes.

Robotic Radical Hysterectomy for Cervical Cancer: A Population-Based Study of Adoption and Immediate Postoperative Outcomes in the United States

STUDY OBJECTIVE

To compare the use of robotic radical hysterectomy (RRH) and abdominal radical hysterectomy (ARH) in the United States, with secondary outcomes of perioperative complications, hospital length of stay (LOS), immediate postoperative mortality, cost and a subanalysis compared with laparoscopic radical hysterectomy (LRH).

DESIGN

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

SETTING

Data from the National Inpatient Sample (NIS), a government-funded database of hospitalization in the United States.

PATIENTS AND INTERVENTIONS

All women with cervical cancer undergoing RH between 2008 and 2015 in the United States and included in the NIS database.

MEASUREMENTS AND MAIN RESULTS

Trends in surgical modality, baseline characteristics, LOS, perioperative outcomes, mortality, and hospital charges were compared between RRH and ARH. Regression models were adjusted for baseline characteristics. Among 41,317 women with cervical cancer, 3563 underwent RH, including 21.0% with a robotic procedure, 6.5% with a laparoscopic procedure, and 72.5% with open surgery. The annual rates of ARH declined significantly over the study period, whereas those of RRH increased. Baseline characteristics were comparable between the RRH and ARH groups. Compared with the ARH group, women undergoing RRH had a lower rate of cumulative postoperative complications (18.16% vs 21.21%; odds ratio [OR], 0.81; 95% confidence interval [CI], 0.6-1.0; p = .05), including lower rates of wound infection (0.27% vs 1.82%; OR, 0.14; 95% CI, 0.03-0.6; p < .01), sepsis (0.27% vs 1.20%; OR, 0.22; 95% CI, 0.05-0.9; p = .03), fever (1.87% vs 4.06%; OR, 0.44, 95% CI, 0.3-0.8; p < .01), and ileus (2.8% vs 9.13%; OR, 0.28; 95% CI, 0.12-0.4; p < .01). The LOS was significantly shorter in the RRH group (median, 2 days vs 4 days; p < .01). The total median hospitalization charge was $47,218 for the RRH group, compared with $38,877 for the ARH group (p < .01).

CONCLUSION

RRH is being increasingly performed in the United States and is associated with shorter LOS and less postoperative morbidity; however, long-term oncologic outcomes require additional attention.

Cost effectiveness of preoperative screening for healthy patients undergoing robotic hysterectomy

The objective of this study was to determine whether routine preoperative type and screen blood testing is cost effective and medically warranted for benign diagnosis in healthy patients undergoing robotic hysterectomy. The study was designed as a cross sectional retrospective descriptive study. Four hundred and twenty two medical records of American Society of Anesthesiologists (ASA) Classifications I and II patients undergoing robotically-assisted laparoscopic hysterectomy between 1 June 2011 and 31 May 2014 at a 211 bed regional medical center were analysed. The results from this study paralleled the findings of other published research. Preoperative type and screen testing was performed on 249 (59%) of the patients in the study. Ten patients (2.4% of the group) converted to open laparotomy. Mean estimated blood loss was 59.59ml. No perioperative transfusions were required. The results indicate that preoperative type and screen testing is not warranted for patients meeting the inclusion criteria.

The comparison of surgical outcomes and learning curves of radical hysterectomy by laparoscopy and robotic system for cervical cancer: an experience of a single surgeon

Objective

The aim of this study was to compare and determine the feasibility, surgical outcomes, learning curves of robotic radical hysterectomy with lymph node dissection (RRHND) to conventional laparoscopic radical hysterectomy with lymph node dissection (LRHND) performed by a single surgeon, in patients with cervical cancer.

Methods

Between April 2009 and March 2013, 22 patients underwent LRHND and 19 patients underwent RRHND. Variables such as age, body mass index, International Federation of Gynecology and Obstetrics stage, histological results, number of dissected lymph nodes, operative time, estimated blood loss, days of hospitalization and complications were reviewed. Learning curves of operation time was obtained using cumulative sum (CUSUM) method.

Results

Both groups showed similar patient and tumor characteristics. In surgical outcome analysis, RRHND (51.8±10.4 minutes) showed longer preparing time than LRHND (42.5±14.1 minutes). In the LRHND group, 8 patients experienced postoperative complications (5 void difficulty, 1 postoperative bleeding, 1 right basal ganglia infarction, 1 fever). On the other hand, in the RRHND group, 4 patients experienced a postoperative complication (2 bleeding, 1 peritonitis, 1 dehiscence of trocar site). Using CUSUM method, the learning curves were obtained by plotting the cumulative sequential differences between each data point and the average operation time, and showed two distinct phases in both type of operations.

Conclusion

RRHND would be appropriate surgical approach in patients with cervical cancer with favorable outcome of less voiding difficulty. A minimum of 13 cases of robotic radical hysterectomies are required to achieve surgical improvement in the treatment of cervical cancer.

Efficacy and safety outcomes of robotic radical hysterectomy in Chinese older women with cervical cancer compared with laparoscopic radical hysterectomy

Background

Recently, as a complex integrating a number of modern high-tech means, robotic surgery system is a well-deserved revolutionary tool in globally minimally invasive surgical field. For the first time in China, the objective of this study was to evaluate the efficacy and safety outcomes of robotic radical hysterectomy (RRH) in Chinese older women with cervical cancer compared with laparoscopic radical hysterectomy (LRH).

Methods

In this prospective, randomized and double-blinded study, 60 Chinese older women with cervical cancer were evenly divided to accept the RRH or LRH. Follow-up period lasted for 24 months.

Results

Median age for the entire cohort was 65 (range: 61-69) years. There was no difference in International Federation of Gynecology and Obstetrics (FIGO) stages and cell types between two groups (p > 0.05 for all). Uterine size, tumor size, vaginal length and numbers of left and right pelvic lymph nodes did not differ between two groups (p > 0.05 for all). No difference was observed in numbers of left and right lymph node metastasis (p > 0.05 for all). All patients had negative margins without conversion to laparotomy. There were significantly less postoperative complications in the RRH group than in the LRH group (p < 0.05). Shorter indwelling time of bladder and drain catheters was observed in the RRH group than in the LRH group (p < 0.05 for all). Length of postoperative hospital stay in the RRH group was significantly shorter compared with that in the LRH group (p < 0.05). Patients in two groups similarly experienced the recurrence and death (p > 0.05 for all).

Conclusions

This study demonstrated that RRH provided additional benefits for Chinese older women with cervical cancer because of less complications and faster recovery compared with LRH. Meanwhile, this study supported an equivalence of surgical qualities and survival outcomes of RRH to LRH. Robotics-assisted surgical method is effective, safe and feasible for Chinese older women with cervical cancer.

New Developments in Minimally Invasive Gynecologic Oncology Surgery

Minimally invasive surgery continues to transform the field of gynecologic oncology and has now become the standard of care for many early-stage malignancies. The proven benefits of minimally invasive surgery are driving the rapid introduction and dissemination of novel technologies and the increasing ability to perform even the most complex procedures less invasively. In this article, we will review the current literature on traditional multiport laparoscopy, robotic-assisted laparoscopy, laparoendoscopic single-site surgery as well as robotic-assisted laparoendoscopic single-site surgery, with a specific focus on their role in the treatment of gynecologic malignancies.

Comparison of Robotic and laparoscopic Radical type-B and C hysterectomy for cervical cancer: Long term-outcomes

STUDY OBJECTIVE

To compare the clinical and oncologic outcomes of Robotic radical hysterectomy (RRH) vs Laparoscopic radical hysterectomy (TLRH) in patients with cervical carcinoma.

DESIGN

Long term follow-up in a prospective study between March 2010 to March 2016.

SETTING

Oncological referral center, department of gynecology and obstetrics of Alessandro Manzoni Hospital, department of gynecology, University of San Gerardo Monza, Milan.

PATIENTS

52 patients with cervical carcinoma, matched by age, body mass index, tumor size, International Federation of Gynecology and Obstetrics (FIGO) stage, comorbidity, previous neoadjuvant chemotherapy, histology type, and tumor grade to obtain homogeneous samples.

INTERVENTIONS

Patients with FIGO stage IA2 or IB1 with a tumor size less than or equal to 2 cm underwent RR type B. RR-Type C1 was performed in stage IB1, with a tumor size larger than 2 cm, or in patients previously treated with NACT (IB2). In all cases Pelvic lymphadenectomy was performed for the treatment of cervical cancer.

MEASUREMENTS AND MAIN RESULTS

Surgical time was similar for both the 2 groups. RRH was associated with significantly less (EBL) estimated blood loss (P=0,000). Median number pelvic lymph nodes was similar, but a major number of nodes was observed in RRH group (35.58 vs 24.23; P=0,050). The overall median length of follow-up was 59 months (range: 9-92) and 30 months (range: 90-6) for RRH and TLRH group respectively. Overall survival rate (OSR) was 100% for RRH group and 83.4% for LTRH group. The DFS (disease free survival rate) was of 97% and 89% in RRH and LTRH group respectively. No significant difference was reported in HS (hospital stay).

CONCLUSIONS

RRH is safe and feasible and is associated with an improved intraoperative results and clinical oncological outcomes. The present study showed that robotic surgery, in comparison to laparoscopic approach, was associated with better perioperative outcomes because of a decrease of EBL, and similar operative time, HS and complication rate, without neglecting the long-term optimal oncologic outcomes.

Robot-assisted gynaecological cancer surgery-complications and prevention

Ever since the US Food and Drug Administration approval of the use of da Vinci surgical systems (Intuitive Surgical Inc., Sunnyvale, California) in gynaecology in 2005, robot-assisted surgery has been widely adopted in different countries. Some of the applications in benign and oncological gynaecology include myomectomy, sacrocolpopexy, tubal anastomosis, simple hysterectomy, radical hysterectomy, radical trachelectomy, pelvic and/or para-aortic lymphadenectomy and even debulking surgery for ovarian cancer and pelvic exenteration for recurrent cervical and vaginal cancer. Although there is robust evidence on the safety and treatment outcomes in robot-assisted surgery, complications still rarely occur. Team approach is particularly important in robotic surgery and thorough communication between the bedside assistant and the console surgeon cannot be stressed any more. Thus, complications can be due to miscommunication between the console surgeon and bedside assistant, positioning of the patients, the length of the operations, the malfunction of the instrument and the risks specific to the types of anaesthesia and surgery per se, leading to thromboembolism, haemorrhage, organ damage, and so on. The most important strategies that can prevent complications are to have thorough preoperative assessment of the patients' fitness, good communication between surgical team members, caution regarding the positioning, a good knowledge of the pelvic and abdominal anatomy, careful and meticulous manipulation of the instrument and early recognition of the complications. In this article, different types of complications and the preventive measures are described.

Robotic Radical Hysterectomy After Concomitant Chemoradiation in Locally Advanced Cervical Cancer: A Prospective Phase II Study

STUDY OBJECTIVE

To assess the feasibility of total robotic radical surgery (TRRS) in patients with locally advanced cervical cancer (LACC) who receive chemoradiation therapy (CT/RT).

DESIGN

A prospective (preplanned) study of a nonrandomized controlled trial (Canadian Task Force classification level 2).

SETTING

Catholic University of the Sacred Hearth, Rome, Italy.

PATIENTS

Between September 2013 and January 2016, a total of 40 patients with LACC (Fédération Internationale de Gynécologie et d'Obstétrique stage IB2-III) were enrolled in the study.

INTERVENTIONS

Robotic radical hysterectomy (RRH) plus pelvic and/or aortic lymphadenectomy was attempted within 6 weeks after CT/RT. The feasibility of TRRS as well as the rate, pattern, and severity of early and late postoperative complications were analyzed.

MEASUREMENTS AND MAIN RESULTS

After CT/RT, 29 patients (72.5%) underwent type B2 RRH, and 11 (27.5%) underwent type C1 RRH. Pelvic lymphadenectomy was performed in all cases. TRRS was successful in 39 of 40 cases (feasibility rate = 97.5%). In patients successfully completing TRRS, the median operating time was 185 minutes (range, 100-330 minutes), and the median blood loss was 100 mL (range, 50-300 mL). The median time of hospitalization counted from the first postoperative day was 2 days (range, 1-4 days). No intraoperative complications were recorded. During the observation period (median = 18 months; range, 4-28 months), 9 of 40 (22.5%) experienced postoperative complications, for a total number of 12 complications. As of April 2016, recurrence of disease was documented in 5 cases (12.5%).

CONCLUSION

TRRS is feasible in LACC patients administered preoperative CT/RT, providing perioperative outcomes comparable with those registered in early-stage disease, and LACC patients receiving neoadjuvant chemotherapy.

Robot-assisted versus open radical hysterectomy: A multi-institutional experience for early-stage cervical cancer

OBJECTIVE

To compare perioperative and clinico-pathological outcomes of patients with early-stage cervical cancer who underwent robot-assisted radical hysterectomy (RRH) and open radical hysterectomy (ORH).

METHODS

This retrospective multi-center study abstracted demographic, clinico-pathological and perioperative outcomes data from medical records of 491 cervical cancer patients treated with RRH (n = 259) ORH (n = 232) between 2005 and 2011 at two American and one Norwegian University Cancer Centres.

RESULTS

Mean estimated blood loss (EBL) and transfusion rates were less for RRH than for ORH (97 vs. 49 mL, p < 0.001, and 3% vs. 7%, p = 0.018, respectively). Mean length of hospital stay (LOS) was significantly shorter in RRH versus ORH (1.8 vs. 5.1 days, p < 0.001). Mean operative time was longer for RRH than ORH (220 vs. 156 min, p < 0.001). Although overall complications were similar (p = 0.49), intra-operative complications were less common in the RRH group than ORH (4% vs. 10%, p = 0.004). In multivariate regression analyses longer operative time, less EBL and intra-operative complications, shorter LOS, and more pre-operative cone were significantly associated with RRH versus ORH. Recurrence and death rates were not statistically different for the two groups at a mean follow-up time of 39 months (p = 1.00 and p = 0.48, respectively).

CONCLUSIONS

RRH had improved clinical outcomes compared to ORH in the treatment of early-stage cervical cancer in terms of EBL, intra-operative complications, transfusion rates, LOS, and pre-operative cone. Disease recurrence and survival were comparable for the two procedures.

Robot-Assisted Radical Hysterectomy in Cervical Carcinoma: The Belgian Experience

Objective

The purpose of this study was to report the experience and oncological outcome of robot-assisted radical hysterectomies (RRHs) for cervical cancer performed in Belgium.

Methods

Patients undergoing RRH for cervical cancer (n = 109) were prospectively collected between July 2007 and April 2014 in the 5 Belgian centers performing RRH for cervical cancer.

Results

The median age of the patients was 46 years (range, 31–80 years). Histological types included squamous cell carcinoma in 61 patients, adenocarcinoma in 22 patients, adenosquamous in 8 patients, endometrioid carcinoma in 2 patients, and other types (n = 16). The International Federation of Gynecology and Obstetrics stage distribution was IA (n = 9), stage IB1 (n = 71), stage IB2 (n = 4), stage II (n = 24), and unknown (n = 1). Twenty-four patients received adjuvant therapy, 17 patients underwent radiochemotherapy, and 7 underwent adjuvant radiation. Eighteen patients relapsed, and 5 died of disease. The median follow-up was 27.5 months (range, 3–82 months). The 2- and 5-year overall survivals were 96% and 89%, respectively. The 2- and 5-year disease-free survivals (DFSs) were 88% and 72%, respectively. The 2-year DFS per stage was 100% for IA, 88% for IB1, 100% for IB2, and 83% for II. The 5-year DFS per stage was 100% for stage IA and 75% for IB1. The complications were as expected for radical hysterectomy.

Conclusions

This series confirms the feasibility and safety of RRH not only in cervical cancer stage IA to IB1, but also after neoadjuvant chemotherapy in stage IB2 to IIB.

Laparoscopic radical hysterectomy in cervical cancer as total mesometrial resection (L-TMMR): a multicentric experience

OBJECTIVE

To analyze the feasibility of total mesometrial resection by laparoscopy (L-TMMR) in a multicentric series of early stage cervical cancer.

METHOD

We prospectively evaluated a consecutive series of cervical cancer patients with pre-operative FIGO stages IA2-IB1 at the Catholic University in Rome and in Campobasso and the Charitè University in Berlin. All cases were assessed at pre-operative MRI scan and clinically confirmed by investigation under anesthesia, adhering strictly to the FIGO criteria. The surgical and post-surgical data were collected.

RESULTS

104 women with cervical cancer were admitted between July 2013 and August 2014 and among them 71 patients with pre-operative FIGO stages IA2-IB1 were treated with L-TMMR. One laparotomic conversion was registered. The median operative time was 260min (120-670min), estimated blood loss was 100cm(3) (25-900cm(3)), and the median length of hospital stay was 6days (2-26days). We observed 8 intra-operative complications including a vascular injury of the left internal iliac vein that caused conversion, 6 vesical injuries and 1 ureteral injury managed laparoscopically. Two vescico-vaginal fistula and one hemoperitoneum were observed as major post-operative complications (4.2%).

CONCLUSION

L-TMMR can be safely performed in selected cervical cancer patients. Further larger prospective trials are needed to evaluate the oncological outcome of patients undergoing this surgical procedure.

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.

The use of robotics in surgery: a review

IMPORTANCE

There is an ever-increasing drive to improve surgical patient outcomes. Given the benefits which robotics has bestowed upon a wide range of industries, from vehicle manufacturing to space exploration, robots have been highlighted by many as essential for continued improvements in surgery.

OBJECTIVE

The goal of this review is to outline the history of robotic surgery, and detail the key studies which have investigated its effects on surgical outcomes. Issues of cost-effectiveness and patient acceptability will also be discussed.

RESULTS AND CONCLUSION

Robotic surgery has been shown to shorten hospital stays, decrease complication rates and allow surgeons to perform finer tasks, when compared to the traditional laparoscopic and open approaches. These benefits, however, must be balanced against increased intraoperative times, vast financial costs and the increased training burden associated with robotic techniques. The outcome of such a cost-benefit analysis appears to vary depending on the procedure being conducted; indeed the strongest evidence in favour of its use comes from the fields of urology and gynaecology. It is hoped that with the large-scale, randomised, prospective clinical trials underway, and an ever-expanding research base, many of the outstanding questions surrounding robotic surgery will be answered in the near future.

Robotic Versus Laparoscopic Radical Hysterectomy in Cervical Cancer Patients: A Matched-Case Comparative Study

Objective

This study aimed to compare initial surgical outcomes and complication rates of patients with early-stage cervical cancer who underwent robotic radical hysterectomy (RRH) and conventional laparoscopic radical hysterectomy (LRH).

Methods

Patients diagnosed with invasive cervical cancer (International Federation of Gynecology and Obstetrics stage I-IIA) who underwent RRH (n = 23) at Samsung Medical Center from January 2008 to May 2013 were compared with matched patients who underwent LRH (n = 69) during the same period. The 2 surgical groups were matched 3:1 for variables of age, body mass index, International Federation of Gynecology and Obstetrics stage, histological subtype, tumor size, and node positivity. All patient information and surgical and postoperative follow-up data were retrospectively collected.

Results

Operating time was significantly longer (317 vs 236 minutes; P < 0.001) in the RRH group compared with the LRH group but mean estimated blood loss was significantly reduced in the RRH group (200 vs 350 mL; P = 0.036). Intraoperative and postoperative complications were not significantly different between the 2 groups (4.3% for RRH vs 1.45% for LRH; P = 0.439). Recurrences were 2 (8.7%) in the RRH and 7 (10.1%) in the LRH group. The overall 3-year recurrence-free survival was 91.3% in RRH group and 89.9% in the LRH group (P = 0.778).

Conclusions

Although operating time was longer in the RRH cases because of lesser experience on robotic platform, we showed that surgical outcomes and complication rate of RRH were comparable to those of LRH. In addition, surgical skills for LRH easily and safely translated to RRH in case of experienced laparoscopic surgeon.

Surgical outcomes of robotic radical hysterectomy using three robotic arms versus conventional multiport laparoscopy in patients with cervical cancer

PURPOSE

To compare surgical outcomes of robotic radical hysterectomy (RRH) using 3 robotic arms with those of conventional laparoscopy in patients with early cervical cancer.

MATERIALS AND METHODS

A retrospective cohort study included 102 patients with stage 1A1-IIA2 cervical carcinoma, of whom 60 underwent robotic and 42 underwent laparoscopic radical hysterectomy (LRH) with pelvic lymph node dissection performed between December 2009 and May 2013. Perioperative outcomes were compared between two surgical groups.

RESULTS

Robotic approach consisted of 3 robotic arms including the camera arm and 1 conventional assistant port. Laparoscopic approach consisted of four trocar insertions with conventional instruments. There were no conversions to laparotomy. Mean age, body mass index, tumor size, cell type, and clinical stage were not significantly different between two cohorts. RRH showed favorable outcomes over LRH in terms of estimated blood loss (100 mL vs. 145 mL, p=0.037), early postoperative complication rates (16.7% vs. 30.9%, p=0.028), and postoperative complications necessitating intervention by Clavien-Dindo classification. Total operative time (200.5±61.1 minutes vs. 215.6±83.1 minutes, p=0.319), mean number of lymph node yield (23.3±9.3 vs. 21.7±9.8, p=0.248), and median length of postoperative hospital stay (11 days vs. 10 days, p=0.129) were comparable between robotic and laparoscopic group, respectively. The median follow-up time was 44 months with 2 recurrences in the robotic and 3 in the laparoscopic cohort.

CONCLUSION

Surgical outcomes of RRH and pelvic lymphadenectomy were comparable to that of laparoscopic approach, with significantly less blood loss and early postoperative complications.

Robot versus laparoscopic nerve-sparing radical hysterectomy for cervical cancer: a comparison of the intraoperative and perioperative results of a single surgeon's initial experience

OBJECTIVE

The aim of the study was to compare the initial surgical outcomes and learning curve of nerve-sparing robotic radical hysterectomy (RRH) with nerve-sparing total laparoscopic radical hysterectomy (TLRH) for the treatment of early-stage cervical cancer in the first 50 cases.

METHODS

Between January 2008 and March 2012, 50 consecutive patients underwent nerve-sparing RRH. These patients were compared with a historic cohort of the first 50 consecutive patients who underwent nerve-sparing TLRH.

RESULTS

Both groups were similar with respect to patients and tumor characteristics. The mean operating time in the RRH group was significantly longer than that in the TLRH group (230.1 ± 35.8 vs 211.2 ± 46.7 minutes; P = 0.025). The mean blood loss for the robotic group was significantly lower compared with the laparoscopic group (54.9 ± 31.5 vs 201.9 ± 148.4 mL; P < 0.001). There was no significant difference in the mean pelvic lymph nodes between the 2 groups (25.0 ± 9.9 vs 23.1 ± 10.4; P = 0.361). The mean days to normal residual urine were 9.6 ± 6.4 in RRH and 11.0 ± 6.2 in TLRH (P = 0.291). The incidence of intraoperative complication was profoundly lower in RRH compared with that of TLRH (0% vs 8%; P = 0.041). Moreover, no intraoperative transfusion was required in RRH, whereas 4 (8%) were required in TLRH (P = 0.041). In both groups, we found no evidence of a learning effect during the first 50 cases.

CONCLUSIONS

During the first 50 cases, surgical outcomes and complication rates of nerve-sparing RRH were found to be comparable to those of nerve-sparing TLRH. Moreover, the mean blood loss and intraoperative complication rate in the robotic group were significantly lower than those in the laparoscopic group. Surgical skills for nerve-sparing TLRH easily and safely translated to nerve-sparing RRH in case of experienced laparoscopic surgeon.

Randomized study comparing use of THUNDERBEAT technology vs standard electrosurgery during laparoscopic radical hysterectomy and pelvic lymphadenectomy for gynecologic cancer

STUDY OBJECTIVE

To compare operative time with use of THUNDERBEAT (TB) vs standard electrosurgery (SES) during laparoscopic radical hysterectomy and pelvic lymphadenectomy to treat gynecologic tumors.

DESIGN

Evidence obtained from a properly designed, randomized, controlled trial (Canadian Task Force classification I).

SETTING

Gynecologic Oncology Unit of the Catholic University of the Sacred Heart in Rome, Italy.

PATIENTS

Fifty patients with early cervical cancer (FIGO stages IA2, IB1, IIA <2 cm) or locally advanced cervical cancer (FIGO stages IB2, IIA >2cm, IIB) who received neoadjuvant treatment (chemotherapy or radiochemotherapy) and demonstrated a complete or partial clinical response and early stage endometrioid endometrial cancer (FIGO stages IB, II) were randomly assigned to undergo TB (arm A) or SES (arm B).

INTERVENTION

Laparoscopic radical hysterectomy with bilateral pelvic lymphadenectomy, using an easily reproducible technique was performed.

MEASUREMENTS AND MAIN RESULTS

Fifty patients were available for analysis, with 25 women randomly assigned to TB (arm A) and 25 to SES (arm B). The median operative time was 85 minutes for TB vs 115 minutes for SES (p = .001). At multivariate analysis, endometrial cancer (p = .001) and TB (p = .001) were independently associated with shorter operating time. No differences in perioperative outcomes and postoperative complications were observed between the 2 arms. Patients who underwent TB reported less postoperative pain, both at rest (p = .005) and after the Valsalva maneuver (p = .008), with less additional analgesic therapy other than standard therapy required in patients who underwent SES (p = .02).

CONCLUSION

TB is associated with shorter operative time and less postoperative pain than is the standard technique (SES) in patients with uterine cancer.