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Natarajan P, Delanerolle G, Dobson L, Xu C, Zeng Y, Yu X, Marston K, Phan T, Choi F, Barzilova V, Powell SG, Wyatt J, Taylor S, Shi JQ, Hapangama DK. Surgical Treatment for Endometrial Cancer, Hysterectomy Performed via Minimally Invasive Routes Compared with Open Surgery: A Systematic Review and Network Meta-Analysis. Cancers (Basel) 2024; 16:1860. [PMID: 38791939 PMCID: PMC11119247 DOI: 10.3390/cancers16101860] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2024] [Revised: 04/06/2024] [Accepted: 04/27/2024] [Indexed: 05/26/2024] Open
Abstract
Background: Total hysterectomy with bilateral salpingo-oophorectomy via minimally invasive surgery (MIS) has emerged as the standard of care for early-stage endometrial cancer (EC). Prior systematic reviews and meta-analyses have focused on outcomes reported solely from randomised controlled trials (RCTs), overlooking valuable data from non-randomised studies. This inaugural systematic review and network meta-analysis comprehensively compares clinical and oncological outcomes between MIS and open surgery for early-stage EC, incorporating evidence from randomised and non-randomised studies. Methods: This study was prospectively registered on PROSPERO (CRD42020186959). All original research of any experimental design reporting clinical and oncological outcomes of surgical treatment for endometrial cancer was included. Study selection was restricted to English-language peer-reviewed journal articles published 1 January 1995-31 December 2021. A Bayesian network meta-analysis was conducted. Results: A total of 99 studies were included in the network meta-analysis, comprising 181,716 women and 14 outcomes. Compared with open surgery, laparoscopic and robotic-assisted surgery demonstrated reduced blood loss and length of hospital stay but increased operating time. Compared with laparoscopic surgery, robotic-assisted surgery was associated with a significant reduction in ileus (OR = 0.40, 95% CrI: 0.17-0.87) and total intra-operative complications (OR = 0.38, 95% CrI: 0.17-0.75) as well as a higher disease-free survival (OR = 2.45, 95% CrI: 1.04-6.34). Conclusions: For treating early endometrial cancer, minimal-access surgery via robotic-assisted or laparoscopic techniques appears safer and more efficacious than open surgery. Robotic-assisted surgery is associated with fewer complications and favourable oncological outcomes.
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Affiliation(s)
- Purushothaman Natarajan
- Department of Women’s & Children’s Health, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool L8 7SS, UK
- Liverpool Women’s Hospital NHS Foundation Trust, Liverpool L8 7SS, UK
| | - Gayathri Delanerolle
- Institute of Applied Health Research, College of Medicine, University of Birmingham, Vincent Drive, Edgbaston B15 2TT, UK
| | - Lucy Dobson
- Department of Women’s & Children’s Health, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool L8 7SS, UK
- Liverpool Women’s Hospital NHS Foundation Trust, Liverpool L8 7SS, UK
| | - Cong Xu
- Department of Statistics and Data Science, Southern University of Science and Technology, Shenzhen 518055, China
| | - Yutian Zeng
- Department of Statistics and Data Science, Southern University of Science and Technology, Shenzhen 518055, China
| | - Xuan Yu
- Department of Statistics and Data Science, Southern University of Science and Technology, Shenzhen 518055, China
| | - Kathleen Marston
- Department of Women’s & Children’s Health, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool L8 7SS, UK
| | - Thuan Phan
- Department of Women’s & Children’s Health, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool L8 7SS, UK
| | - Fiona Choi
- Department of Women’s & Children’s Health, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool L8 7SS, UK
- Liverpool Women’s Hospital NHS Foundation Trust, Liverpool L8 7SS, UK
| | - Vanya Barzilova
- Department of Women’s & Children’s Health, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool L8 7SS, UK
| | - Simon G. Powell
- Department of Women’s & Children’s Health, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool L8 7SS, UK
| | - James Wyatt
- Department of Women’s & Children’s Health, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool L8 7SS, UK
| | - Sian Taylor
- Liverpool Women’s Hospital NHS Foundation Trust, Liverpool L8 7SS, UK
| | - Jian Qing Shi
- Department of Statistics and Data Science, Southern University of Science and Technology, Shenzhen 518055, China
- National Center for Applied Mathematics Shenzhen, Shenzhen 518038, China
| | - Dharani K. Hapangama
- Department of Women’s & Children’s Health, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool L8 7SS, UK
- Liverpool Women’s Hospital NHS Foundation Trust, Liverpool L8 7SS, UK
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Massimello F, Cela V. Role of single port robotic surgery in gynecology. Best Pract Res Clin Obstet Gynaecol 2024:102497. [PMID: 38653650 DOI: 10.1016/j.bpobgyn.2024.102497] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Revised: 03/18/2024] [Accepted: 04/13/2024] [Indexed: 04/25/2024]
Abstract
Robot-assisted Single-Site Laparoscopy (R-LSS) is a rapidly evolving minimally invasive technique. Although it is a very recent technology, the use of R-LSS have been increasingly report in gynecology, for both benign and malignant indications. This review aims to summarize the evolution of this innovative technique and to examine its feasibility and safety for gynecological surgical procedures. We evaluated studies dealing about R-LSS in gynecological surgery. We performed a comprehensive literature research on PubMed and the Cochrane Library in February 2024. Based on the study reviewed, R-LSS seems to be a feasible and effective alternative to other mini-invasive approach in gynecological surgery. R-LSS combine the advantages of robotics surgery with the aesthetic result of a single incision. Compare to Single-Site Laparoscopy, it restore triangulation of the instrument and improve visualization and ergonomic. R-LSS seems to be related to favourable intra-e post-operative outcomes. Although, further studies would be necessary allow us to draw any final conclusion.
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Affiliation(s)
- F Massimello
- Department of Clinical and Experimental Medicine, Division of Obstetrics and Gynecology, University of Pisa, Pisa, Italy
| | - V Cela
- Department of Clinical and Experimental Medicine, Division of Obstetrics and Gynecology, University of Pisa, Pisa, Italy.
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Cheng X, Huang C, Jia W, Guo Z, Shi Y, Song Z, Feng H, Huang H, Xu S, Li H, Wang S, Zhang Y, Zhang T, Liu K, Ji X, Zhao R. Clinical status and future prospects of single-incision robotic-assisted surgery: a review. Int J Surg 2023; 109:4221-4237. [PMID: 37988410 PMCID: PMC10720873 DOI: 10.1097/js9.0000000000000944] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Accepted: 11/13/2023] [Indexed: 11/23/2023]
Abstract
Since the advent of conventional multiport laparoscopic surgery, the prosperity of minimally invasive surgery has been thriving on the advancement of endoscopic techniques. Cosmetic superiority, recovery benefits, and noninferior surgical outcomes weigh single-incision laparoscopic surgery as a promising modality. Although there are surgical challenges posed by steep learning curve and technological difficulties, such as instruments collision, triangulation loss and limited retraction, the establishment of robotic surgical platform as a solution to all is inspiring. Furthermore, with enhanced instrument maneuverability and stability, robotic ergonomic innovations adopt the advantages of single-incision laparoscopic surgery and surmount its recognized barriers by introducing a novel combination, single-incision robotic-assisted surgery. As was gradually diffused in general surgery and other specialties, single-incision robotic-assisted surgery manifests privileges in noninferior clinical outcomes an satisfactory cosmetic effect among strictly selected patients, and has the potential of a preferable surgical option for minimally invasive surgery.
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Affiliation(s)
- Xi Cheng
- Department of General Surgery
- Shanghai Institute of Digestive Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Chenhao Huang
- Department of General Surgery
- Shanghai Institute of Digestive Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Wenqing Jia
- Department of General Surgery
- Shanghai Institute of Digestive Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Zichao Guo
- Department of General Surgery
- Shanghai Institute of Digestive Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yiqing Shi
- Department of General Surgery
- Shanghai Institute of Digestive Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Zijia Song
- Department of General Surgery
- Shanghai Institute of Digestive Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Haoran Feng
- Department of General Surgery
- Shanghai Institute of Digestive Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Haiyan Huang
- Department of General Surgery
- Shanghai Institute of Digestive Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Shuiyu Xu
- Department of General Surgery
- Shanghai Institute of Digestive Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Haosheng Li
- Department of General Surgery
- Shanghai Institute of Digestive Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Shaodong Wang
- Department of General Surgery
- Shanghai Institute of Digestive Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yaqi Zhang
- Department of General Surgery
- Shanghai Institute of Digestive Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Tao Zhang
- Department of General Surgery
- Shanghai Institute of Digestive Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Kun Liu
- Department of General Surgery
- Shanghai Institute of Digestive Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Xiaopin Ji
- Department of General Surgery
- Shanghai Institute of Digestive Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Ren Zhao
- Department of General Surgery
- Shanghai Institute of Digestive Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
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Thigpen B, Connell P, Erfani H, Koythong T, Sunkara S, Guan X. Robotic-assisted vaginal natural orifice transluminal endoscopic surgery versus robotic-assisted single-site port for benign hysterectomy: a comparison of surgical outcomes. J Robot Surg 2023; 17:2487-2494. [PMID: 37523047 DOI: 10.1007/s11701-023-01680-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2023] [Accepted: 07/17/2023] [Indexed: 08/01/2023]
Abstract
The objective of this study is to evaluate the surgical outcomes for robotic-assisted vaginal natural orifice transluminal endoscopic surgery (R-VNOTES) hysterectomy versus robotic-assisted single-site port (RSSP) hysterectomy when performed for benign indications. This is a retrospective chart review in an academic tertiary setting. 404 patients underwent hysterectomy for benign indications. R-VNOTES hysterectomy and RSSP hysterectomy were performed by a single minimally invasive gynecologic surgeon from January 2015 to August 2022. The primary outcome of our study was total operative time (minutes). Secondary outcomes included estimated blood loss (mL), length of hospital stay (days), and postoperative pain score. Other intraoperative and postoperative surgical complications were also compared. 159 patients underwent R-VNOTES hysterectomy, and 269 patients underwent RSSP hysterectomy. Median length of surgery (minutes) demonstrated a statistically significant shorter operative time in the R-VNOTES hysterectomy group when compared to the RSSP hysterectomy group, (132 min versus 146 min, respectively, p = 0.0001). Additionally, patients in the R-VNOTES hysterectomy group experienced decreased postoperative pain levels at week 1 (6 versus 7, respectively, p = 0.01) and week 3 (1.5 versus 2.5, respectively, p = 0.01) after surgery. There were no statistically significant differences between the two groups when comparing length of hospital stay, estimated blood loss, and weight of the uterus. There was no difference in rates of urinary tract infection, blood transfusion, bowel injury, readmission, reoperation, conversion, deep surgical site infection, and venous thromboembolism between both groups. However, there was a higher rate of superficial SSI in the RSSP hysterectomy group (0.6% versus 4.5%, respectively, p = 0.03). When compared to RSSP hysterectomy, R-VNOTES hysterectomy is safe and feasible, as both approaches have comparable surgical outcomes. Patients undergoing R-VNOTES hysterectomy had shorter length of surgery, decreased postoperative pain, and lower rates of superficial surgical site infections.
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Affiliation(s)
- Brooke Thigpen
- Division of Minimally Invasive Gynecologic Surgery, Department of Obstetrics and Gynecology, Baylor College of Medicine, 6651 Main Street, Suite F1020, Houston, TX, 77030, USA
| | - Phillip Connell
- Division of Minimally Invasive Gynecologic Surgery, Department of Obstetrics and Gynecology, Baylor College of Medicine, 6651 Main Street, Suite F1020, Houston, TX, 77030, USA
| | - Hadi Erfani
- Division of Minimally Invasive Gynecologic Surgery, Department of Obstetrics and Gynecology, Baylor College of Medicine, 6651 Main Street, Suite F1020, Houston, TX, 77030, USA
| | - Tamisa Koythong
- Division of Minimally Invasive Gynecologic Surgery, Department of Obstetrics and Gynecology, Baylor College of Medicine, 6651 Main Street, Suite F1020, Houston, TX, 77030, USA
| | - Sowmya Sunkara
- Division of Minimally Invasive Gynecologic Surgery, Department of Obstetrics and Gynecology, Baylor College of Medicine, 6651 Main Street, Suite F1020, Houston, TX, 77030, USA
| | - Xiaoming Guan
- Division of Minimally Invasive Gynecologic Surgery, Department of Obstetrics and Gynecology, Baylor College of Medicine, 6651 Main Street, Suite F1020, Houston, TX, 77030, USA.
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Chen Y, Zheng Y, Wang P, Wang Q, Yang F, Zhou S. Single-port robotic surgery using the EDGE SP1000 surgical system in gynaecology: Initial experience of a single institution. Int J Med Robot 2023:e2578. [PMID: 37727013 DOI: 10.1002/rcs.2578] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Revised: 08/22/2023] [Accepted: 09/05/2023] [Indexed: 09/21/2023]
Abstract
BACKGROUND The EDGE SP1000 is a newly developed single-port (SP) robotic surgical system whose clinical evaluation in gynaecology has not yet been addressed. METHODS This is a single-arm clinical trial evaluating the perioperative outcomes of patients receiving EDGE SP1000 assisted surgeries. Patients with either benign or malignant gynaecological diseases suitable for robotic surgery were included, and their data were prospectively collected. RESULTS Eighteen patients were included and 8 of them had malignant conditions. The total operative time was 190.1 ± 83.3 min for benign diseases and 254.4 ± 59.4 min for malignant diseases. The mean estimated blood loss was 25 mL (range, 5-100). No assistant ports or conversions were required. No perioperative complications occurred. Overall satisfaction with the umbilical wounds was expressed at the 1-month follow-up. CONCLUSION EDGE SP1000 SP robotic surgical system is technically feasible and safe in various gynaecological surgeries with good cosmetic effects.
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Affiliation(s)
- Yu Chen
- Department of Gynecologic Oncology, West China Second University Hospital, Sichuan University, Chengdu, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Chengdu, China
| | - Ying Zheng
- Department of Gynecologic Oncology, West China Second University Hospital, Sichuan University, Chengdu, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Chengdu, China
| | - Ping Wang
- Department of Gynecologic Oncology, West China Second University Hospital, Sichuan University, Chengdu, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Chengdu, China
| | - Qiao Wang
- Department of Gynecologic Oncology, West China Second University Hospital, Sichuan University, Chengdu, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Chengdu, China
| | - Fan Yang
- Department of Gynecologic Oncology, West China Second University Hospital, Sichuan University, Chengdu, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Chengdu, China
| | - Shengtao Zhou
- Department of Gynecologic Oncology, West China Second University Hospital, Sichuan University, Chengdu, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Chengdu, China
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You X, Wang Y, Zheng Y, Yang F, Wang Q, Min L, Wang K, Wang N. Efficacy of transumbilical laparoendoscopic single-site surgery versus multi-port laparoscopic surgery for endometrial cancer: a retrospective comparison study. Front Oncol 2023; 13:1181235. [PMID: 37700843 PMCID: PMC10495218 DOI: 10.3389/fonc.2023.1181235] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Accepted: 07/28/2023] [Indexed: 09/14/2023] Open
Abstract
Background Although single-port laparoscopy surgery has been evaluated for several years, it has not been widely adopted by gynecologic oncologists. The objective was to compare the perioperative outcomes and survival of endometrial cancer (EC) patients undergoing transumbilical laparoendoscopic single-site surgery (TU-LESS) with multi-port laparoscopic surgery (MLS). Materials and methods This is a retrospective comparative monocentric study including patients treated between December 2017 and October 2021. The perioperative outcomes and survival of EC patients who had surgery via TU-LESS or MLS were compared, by propensity matching. Results A total of 156 patients were included (TU-LESS vs. MLS: 78 vs. 78). The conversion rate of TU-LESS and MLS was 5.13% and 2.56%, respectively (P=0.681). The operation time was comparable between the two groups [207.5min (180-251) vs. 197.5min (168.8-225), P=0.095]. There was no significant difference between the two groups in exhaustion time, perioperative complications, or postoperative complications. While, the TU-LESS group had a shorter out-of-bed activity time [36 hours (24-48) vs. 48 hours (48-72), P<0.001] and a lower visual analog pain scale 36 hours after surgery [1 (1-2) vs. 2 (1-2), P<0.001] than the MLS group. The length of hospital stay was similar in the two groups [5(4-6) vs. 5(4-5), P=0.599]. Following surgery, 38.5% of the TU-LESS patients and 41% of the MLS patients got adjuvant therapy (P=0.744). The median follow-up time for TU-LESS and MLS cohorts was 45 months (range: 20-66) and 43 months (range: 18-66), respectively. One TU-LESS patient and one MLS patient died following recurrence. The 4-year overall survival was similar in both groups (98.3% vs. 98.5%, P=0.875). Conclusion TU-LESS is a feasible and safe option with comparable perioperative outcomes and survival of MLS in endometrial cancer. With the growing acceptance of sentinel lymph node biopsy, TU-LESS of endometrial cancer may be a viable option for patients and surgeons.
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Affiliation(s)
- Xiaolin You
- Department of Obstetrics and Gynaecology, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Yanyun Wang
- Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China
- Laboratory of Molecular Translational Medicine, Center for Translational Medicine, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Ying Zheng
- Department of Obstetrics and Gynaecology, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Fan Yang
- Department of Obstetrics and Gynaecology, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Qiao Wang
- Department of Obstetrics and Gynaecology, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Ling Min
- Department of Obstetrics and Gynaecology, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Kana Wang
- Department of Obstetrics and Gynaecology, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Na Wang
- Department of Obstetrics and Gynaecology, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China
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Kang OJ, Nam JH, Park JY. Laparo-endoscopic single-site versus conventional laparoscopic surgery for early-stage endometrial cancer: A randomized controlled non-inferiority trial. Gynecol Oncol 2023; 173:74-80. [PMID: 37105060 DOI: 10.1016/j.ygyno.2023.04.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2023] [Revised: 04/09/2023] [Accepted: 04/10/2023] [Indexed: 04/29/2023]
Abstract
OBJECTIVE To evaluate the feasibility and safety of laparo-endoscopic single-site surgery (LESS) compared with conventional laparoscopic surgery (CLS) for early-stage endometrial cancer. METHODS Patients with clinical stage IA, IB, grade 1-3 endometrial cancer were randomly assigned to undergo LESS or CLS. The primary endpoint was the non-inferiority of LESS to CLS in terms of operation time and the number of resected pelvic lymph nodes. We set the non-inferior margin of the operation time as within 15% (24 min) and the number of resected pelvic lymph nodes as within 20% (5.2 lymph nodes). RESULTS There was no significant difference between the LESS group (n = 53) and the CLS group (n = 54) in terms of age, weight, body mass index, parity, menopausal status, history of abdominal surgery, and preoperative CA-125 levels. The total operation time was comparable between the two groups. On average, 4.6 fewer pelvic lymph nodes were retrieved in the LESS group, which was within the non-inferiority margin. There were no significant differences in the incidence of intra- and postoperative complications, estimated blood loss, and postoperative hospital stay between the two groups. After a median follow-up time of 34 months (range, 2-242), the progression-free survival rates were 96.2% and 98.1% (P = 0.55) in the LESS group and the CLS group, and the overall survival rates were 98.1% and 100.0% (P = 0.31), respectively. CONCLUSION LESS surgical staging was non-inferior to CLS and had acceptable feasibility, safety, and efficacy for the surgical management of early-stage endometrial cancer. TRIAL REGISTRATION Clinicaltrial.gov identifier number: NCT01679522.
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Affiliation(s)
- Ok-Ju Kang
- Department of Obstetrics and Gynecology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Joo-Hyun Nam
- Department of Obstetrics and Gynecology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Jeong-Yeol Park
- Department of Obstetrics and Gynecology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea.
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Gardella B, Dominoni M, Gritti A, Mereu L, Bogliolo S, Torella M, Fanfani F, Malzoni M, Couso A, Zapico A, Zapardiel I. Comparison between Robotic Single-Site and Laparoendoscopic Single-Site Hysterectomy: Multicentric Analysis of Surgical Outcomes. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:medicina59010122. [PMID: 36676747 PMCID: PMC9866110 DOI: 10.3390/medicina59010122] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Revised: 01/04/2023] [Accepted: 01/06/2023] [Indexed: 01/11/2023]
Abstract
Background and Objectives: Minimally invasive surgery, especially the single-site approach, has demonstrated several advantages in the gynaecological setting. The aim of this study was to compare the surgical outcomes of single-site hysterectomy for benign conditions between the traditional laparoendoscopic approach and robotic surgery. MATERIALS AND METHODS We consecutively enrolled 278 women between 2012 and 2019 in this multicentre trial. The patients underwent robotic single-site hysterectomy (RSSH) or laparoendoscopic single-site hysterectomy (LESSH) procedures with or without salpingo-oophorectomy for benign indications. Surgical parameters and surgical outcomes were analysed. RESULTS There was a statistical difference between the two surgical techniques for total operative time (p = 0.001), set-up time (p = 0.013), and anaesthesia time (p = 0.001). Significant differences in intraoperative blood loss were observed (p = 0.001), but no differences were shown for blood transfusion or intraoperative or postoperative complications in the two groups. CONCLUSIONS LESSH outperformed RSSH in terms of surgical performance and clinical outcomes, with no differences in adverse events.
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Affiliation(s)
- Barbara Gardella
- Department of Clinical, Surgical, Diagnostic and Paediatric Sciences, University of Pavia, 27100 Pavia, Italy
- Department of Obstetrics and Gynecology, IRCCS Foundation Policlinico San Matteo, 27100 Pavia, Italy
| | - Mattia Dominoni
- Department of Clinical, Surgical, Diagnostic and Paediatric Sciences, University of Pavia, 27100 Pavia, Italy
- Department of Obstetrics and Gynecology, IRCCS Foundation Policlinico San Matteo, 27100 Pavia, Italy
- Correspondence: ; Tel.: +39-038-250-3267; Fax: +39-038-250-3146
| | - Andrea Gritti
- Department of Clinical, Surgical, Diagnostic and Paediatric Sciences, University of Pavia, 27100 Pavia, Italy
- Department of Obstetrics and Gynecology, IRCCS Foundation Policlinico San Matteo, 27100 Pavia, Italy
| | - Liliana Mereu
- Maternal and Child Department, Obstetrics and Gynecology, Cannizzaro Hospital, 95122 Catania, Italy
- Department of Obstetrics and Gynecology, S Chiara Hospital, 38122 Trento, Italy
| | - Stefano Bogliolo
- Department of Clinical, Surgical, Diagnostic and Paediatric Sciences, University of Pavia, 27100 Pavia, Italy
- Department of Obstetrics and Gynecological Oncology, P.O del Tigullio Hospital-ASL4, Metropolitan Area of Genoa, 16043 Genoa, Italy
| | - Marco Torella
- Obstetrics and Gynecology Unit, Department of Woman, Child and General and Specialized Surgery, University of Campania Luigi Vanvitelli, 80138 Naples, Italy
| | - Francesco Fanfani
- Gynecologic Oncology Unit, Department of Women, Children and Public Health Sciences, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy
- Dipartimento Scienze della Vita e Sanità Pubblica, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
| | - Mario Malzoni
- Endoscopica Malzoni-Center for Advanced Endoscopic Gynecological Surgery, 83100 Avellino, Italy
| | - Aldina Couso
- Gynecology Department, Principe de Asturias University Hospital, 28805 Madrid, Spain
| | - Alvaro Zapico
- Gynecology Department, Principe de Asturias University Hospital, 28805 Madrid, Spain
| | - Ignacio Zapardiel
- Gynecologic Oncology Unit, La Paz University Hospital, 28046 Madrid, Spain
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Perioperative and Survival Outcomes of Robotic-Assisted Surgery, Comparison with Laparoscopy and Laparotomy, for Ovarian Cancer: A Network Meta-Analysis. JOURNAL OF ONCOLOGY 2022; 2022:2084774. [PMID: 35535312 PMCID: PMC9078848 DOI: 10.1155/2022/2084774] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Accepted: 04/04/2022] [Indexed: 02/08/2023]
Abstract
Objective We aimed to compare the perioperative and survival outcomes of robotic-assisted surgery, traditional laparoscopy, and laparotomy approaches in ovarian cancer. Methods PubMed, Cochrane Library, Embase, Web of Science, and Chinese National Knowledge Infrastructure (CNKI) were searched using multiple terms for ovarian cancer surgeries, including comparative studies in Chinese and English. Literatures are published before August 31, 2021. The outcomes include operating time, estimated blood loss, length of hospital stay, postoperative/intraoperative/total complications, pelvic/para-aortic/total lymph nodes, transfusion, and five-year overall survival rate. The dichotomous data, continuous data, and OS data were pooled and reported as relative risk, standardized mean differences, and hazard ratio HRs with 95% confidence intervals, respectively. The Newcastle–Ottawa Scale was used to evaluate the risk of bias of included studies. Results Thirty-eight studies, including 8,367 patients and three different surgical approaches (robotic-assisted laparoscopy surgery, traditional laparoscopy, or laparotomy approaches), were included in this network meta-analysis. Our analysis shows that the operating time of laparotomy was shorter than laparoscopy. The robotic-assisted laparoscopy has the least estimated blood loss during the surgery, followed by laparoscopy, and finally laparotomy. Compared with laparotomy, the incidence of blood transfusion was lower in the robotic-assisted laparoscopy and laparoscopy groups, and the length of hospital stay is shorter. Laparotomy had a significantly higher incidence of total complications than robotic-assisted laparoscopy and laparoscopy and higher postoperative complications than laparoscopy. For the number of pelvic/para-aortic/total lymph nodes removed by different surgical approaches, our analysis revealed no statistical difference. Our analysis also revealed no significant differences in intraoperative complications and 5-year OS among the three surgical approaches. Conclusion Compared with laparotomy, robotic-assisted laparoscopy and laparoscopy had a shorter hospital stay, decreased blood loss, fewer complications, and transfusion happened. The 5-year OS of ovarian cancer patients has no difference between robotic-assisted laparoscopy, laparoscopy, and laparotomy groups.
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Robotic single-site surgery versus laparoendoscopic single-site surgery in early-stage endometrial cancer: a case-control study. Wideochir Inne Tech Maloinwazyjne 2021; 16:597-603. [PMID: 34691311 PMCID: PMC8512518 DOI: 10.5114/wiitm.2021.103955] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2020] [Accepted: 12/22/2020] [Indexed: 11/17/2022] Open
Abstract
Introduction Laparoendoscopic single-site surgery (LESS) can reduce the limited invasiveness of conventional laparoscopy while providing superior cosmetic results. Robotic single-site surgery (RSSS) can overcome this shortcoming to a certain extent. Aim To evaluate the advantages of RSSS in treating early-stage endometrial cancer by comparing RSSS with LESS. Material and methods From January 2018 to August 2018, patients diagnosed with endometrial cancer from endometrial curettage and imaging studies were selected for this prospective cohort study, with 22 undergoing RSSS and 18 undergoing LESS. All surgical procedures were performed using the conventional da Vinci Si surgical system with the Lagiport single port or a conventional laparoendoscopic instrument with the Lagiport single port. Operative time was recorded electronically. Intraoperative parameters and postoperative parameters were recorded and further analyzed. Results The operation was successfully completed, and a pure single-point approach was adopted. There were no laparotomy or intraoperative complications. Compared with the LESS group, the RSSS group had significantly longer pre-surgical time, significantly lower median operation time, significantly lower median blood loss, and significantly lower vaginal cuff closure time. The median length of hospital stay in the RSSS group was significantly lower than that in the LESS group. There was no significant difference in the incidence of early and late complications between the two groups. No recurrence events were observed in either the RSSS or the LESS group. Conclusions RSSS is feasible and safe in patients with early-stage endometrial cancer. RSSS can reduce operating time, blood loss and length of hospital stay compared with LESS.
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Laparoendoscopic Single Site Hysterectomy: Literature Review and Procedure Description. J Clin Med 2021; 10:jcm10102073. [PMID: 34066002 PMCID: PMC8151169 DOI: 10.3390/jcm10102073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Revised: 04/25/2021] [Accepted: 05/10/2021] [Indexed: 11/16/2022] Open
Abstract
Laparoendoscopic single site surgery (LESS) refers to a spectrum of surgical techniques that allow the performance of laparoscopic surgery through consolidation of all ports into one surgical incision. LESS has emerged as a potentially less invasive alternative to multiport laparoscopy and in the last year in gynecology; hence, this approach has been largely applied for selective indications to perform total hysterectomy. We performed a literature review on single site hysterectomy and described indications and technique, highlighting practical problems, pointers, limitations and recent technical development as robotic assistance.
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LA Russa M, Liakou C, Burbos N. Ultra-minimally invasive approaches for endometrial cancer treatment: review of the literature. Minerva Med 2020; 112:31-46. [PMID: 33205639 DOI: 10.23736/s0026-4806.20.07073-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
INTRODUCTION We conducted a systematic review to evaluate the outcomes and role of ultra-minimally invasive surgical approaches for treatment of women diagnosed with endometrial cancer. Although, there is no agreed definition of the term "ultraminimal," we considered the hysteroscopic surgery, single-port surgery, mini/microlaparoscopy and percutaneous laparoscopy as surgical approaches that would best fit this description. EVIDENCE ACQUISITION The current systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) Guidelines. We performed a literature search using MEDLINE (PubMed), EMBASE and Cochrane Library databases for English-language studies published before August 1, 2020. We used the following keywords including "endometrial cancer," "endometrial malignancy," "fertility-sparing or preserving," "hysteroscopy," "hysteroscopic resection," "dilatation and curettage," "ultra-minimally invasive surgery," "progestin therapy," "hormone therapy," "single port," "single-site," "minilaparoscopy," "microlaparoscopy," "percutaneous" and "3 mm laparoscopy." EVIDENCE SYNTHESIS A total of 21 studies, reporting on 229 patients were included. 219 (95.6%) of the patients were premenopausal. Among premenopausal women, complete disease response was reported in 186 (84.9%) patients. The complete response rate was 77.1% in patients who underwent focal or extensive endometrial resection, 90.9% in patients who had the two-step approach and 88.9% in the group of patients treated with the three-step technique. Among 98 women who wished and attempted to conceive, 65 (66.3%) women became pregnant. Recurrent disease was diagnosed in 26 of 219 (11.9%) patients. No surgical complications were reported. In 10 postmenopausal patients that underwent hysteroscopic resection, no recurrences were detected after 5 years of follow-up. We identified 11 studies that reported on the use single-port laparoscopic surgery and included a total of 447 patients. The rate of intraoperative and postoperative complications was 2.6% and 5.2%, respectively. The majority of the studies did not report on the duration of follow-up or oncological outcomes. Ten studies, including 296 patients, investigated the role of single-port robotic-assisted laparoscopy. The overall rate of intraoperative and postoperative complications was 1.0% and 7.1%, respectively. Two studies, including 38 patients, reported on the role of minilaparoscopy. None of these cases required conversion to laparotomy. Data on overall survival in the cohort of patients that underwent minilaparoscopy were not reported. We found only one publication reporting on the use of percutaneous laparoscopy. This prospective study included 30 patients. No complication was reported, and with a median follow-up time of 14 months (range 12-36) no recurrences were diagnosed. CONCLUSIONS Several ultra-minimally invasive surgical techniques have been developed and implemented in selected patients with endometrial cancer. The results of this review support the feasibility and perioperative safety of these approaches, while long-term outcomes are not adequately studied. However, further work is required in standardization of the techniques, in determining the learning curve of the operator and establishing their oncological safety.
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Affiliation(s)
- Mariaclelia LA Russa
- Department of Gynecological Oncology, Norfolk and Norwich University Hospital, Norwich, UK -
| | - Chrysoula Liakou
- Department of Gynecological Oncology, Norfolk and Norwich University Hospital, Norwich, UK
| | - Nikolaos Burbos
- Department of Gynecological Oncology, Norfolk and Norwich University Hospital, Norwich, UK
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Capozzi VA, Armano G, Rosati A, Tropea A, Biondi A. The robotic single-port platform for gynecologic surgery: a systematic review of the literature and meta-analysis. Updates Surg 2020; 73:1155-1167. [PMID: 32472402 DOI: 10.1007/s13304-020-00812-8] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2019] [Accepted: 05/19/2020] [Indexed: 02/07/2023]
Abstract
Since the first robotic single-site hysterectomy was performed, the research focused on the use of robotic single-site surgery (RSSS) for all gynecological conditions. This review aims to examine the studies available in the literature on RSSS in gynecology both for benign and malignant indications. The systematic review was carried out in agreement with the preferred reporting items for systematic reviews and meta-analyses statement (PRISMA). All the articles were grouped into three sets based on the surgical indication (Group 1, 2, and 3 for benign, malignant, and mixed diseases, respectively). Two hundred and fifty total studies were analyzed, and 27 articles were included in the review. A total of 1065 patients were included in the analysis. Of these, 605 patients were included in group 1, 260 in group 2, and 200 in group 3. Ten (1.7%) patients with benign pathology, 16 (6.2%) patients with malignant disease, and 5 (2.5%) patients with both diseases developed major complications. Two (0.3%) patients in group 1, 3 (1.2%) patients in group 2 and 5 (2.5%) in group 3 were converted to a different type of surgery. No significant differences were found between groups for BMI (p = 0.235), operative time (p = 0.723), estimated blood loss (EBL) (p = 0.342), and hospital stay (p = 0.146). The complications and conversions incidence through pooled analysis showed a higher general conversion rate (p = 0.012) in group 3 (3.0%) and higher complications rate (p = 0.001) in group 2 (5.3%) compared to the other groups. RSSS seems to be a feasible and safe procedure for all gynecological surgical procedures. A long-term analysis would be necessary before considering the RSSS oncologically safe for patients with malignant disease.
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Affiliation(s)
- Vito Andrea Capozzi
- Department of Gynecology and Obstetrics of Parma, University of Parma, via Gramsci, 14, 43125, Parma, Italy.
| | - Giulia Armano
- Department of Gynecology and Obstetrics of Parma, University of Parma, via Gramsci, 14, 43125, Parma, Italy
| | - Andrea Rosati
- Department of Woman, Child and Public Health, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Alessandro Tropea
- Department for the Treatment and Study of Abdominal Diseases and Abdominal Transplantation, IRCCS-ISMETT (Istituto Mediterraneo per i Trapianti E Terapie Ad Alta Specializzazione), University of Pittsburgh Medical Center Italy, Palermo, Italy
| | - Antonio Biondi
- Department of General Surgery and Medical Surgical Specialties, University of Catania, Catania, Italy
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Chen CW, Chang HC, Huang TF, Liao CC, Huang RL, Lai HC. Transition from multiport to single-site surgery: A single institution experience in robotic supracervical hysterectomy for benign gynecological diseases. Taiwan J Obstet Gynecol 2020; 58:514-519. [PMID: 31307743 DOI: 10.1016/j.tjog.2019.05.015] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/02/2019] [Indexed: 10/26/2022] Open
Abstract
OBJECTIVE To share our experience of transition from multiport to single-site robotic surgery for benign gynecological conditions as well as to assess the selection criteria of candidates for robotic single-site supracervical hysterectomy (RSSH). MATERIALS AND METHODS A retrospective review was conducted on patients undergoing robotic supracervical hysterectomy by a single surgeon in a single institute between June 2014 and December 2017. Patients who underwent additional procedures along with supracervical hysterectomy and who had unexpectant corpus malignancy proved pathologically were excluded from comparisons between patients undergoing RSSH and robotic multiport supracervical hysterectomy (RMSH). RESULTS Between June 2014 and December 2017, we accomplished 26 RSSH and 57 RMSH. There were no conversions, intraoperative complications, and readmissions within 30 days after surgery. In the RSSH group, the mean uterine weight was 264.6 ± 140.9 g with mean docking time of 15.8 ± 5.5 min, mean console time of 61.1 ± 35.6 min and mean operative time of 140.3 ± 34.4 min. In comparison to the RMSH group, the percentage of overweight/obese patients was lower (p = 0.018) and the uterine size was smaller (p < 0.001) with adenomyosis diagnosed more frequently (p = 0.002) in the RSSH group. While the operative time in the RSSH group was significantly shorter (p = 0.002), the RSSH group took longer time in docking (p < 0.001) and comparable time in console (p = 0.254). In view of chronological change, docking time and console time in the RMSH group remained steady, whereas steep decreases were observed in the RSSH group. The intraoperative blood loss and hemoglobin drop were comparable. The length of hospital stay was significantly shorter in the RSSH group (p = 0.005). CONCLUSION Transition from multiport to single-site surgery can be smooth for a surgical team experienced in the conventional multiport robotic system. RSSH is safe and feasible in properly selected patients.
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Affiliation(s)
- Chien-Wen Chen
- Department of Obstetrics and Gynecology, Shuang Ho Hospital, Taipei Medical University, New Taipei, Taiwan
| | - Heng-Cheng Chang
- Department of Obstetrics and Gynecology, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Tzu-Fei Huang
- Department of Obstetrics and Gynecology, Shuang Ho Hospital, Taipei Medical University, New Taipei, Taiwan
| | - Chi-Chun Liao
- Department of Obstetrics and Gynecology, Shuang Ho Hospital, Taipei Medical University, New Taipei, Taiwan
| | - Rui-Lan Huang
- Department of Obstetrics and Gynecology, Shuang Ho Hospital, Taipei Medical University, New Taipei, Taiwan; Department of Obstetrics and Gynecology, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Hung-Cheng Lai
- Department of Obstetrics and Gynecology, Shuang Ho Hospital, Taipei Medical University, New Taipei, Taiwan; Department of Obstetrics and Gynecology, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan.
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15
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Cianci S, Rosati A, Rumolo V, Gueli Alletti S, Gallotta V, Turco LC, Corrado G, Vizzielli G, Fagotti A, Fanfani F, Scambia G, Uccella S. Robotic Single-Port Platform in General, Urologic, and Gynecologic Surgeries: A Systematic Review of the Literature and Meta-analysis. World J Surg 2019; 43:2401-2419. [PMID: 31187247 DOI: 10.1007/s00268-019-05049-0] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Robotic platforms have recently acquired progressive importance in different surgical fields, such as urology, gynecology, and general surgery. Through the years, new surgical robots have become available as single-port robotic platform. The study is aimed to value the single-port robotic platform characteristics in different surgical specialties. METHODS The terms "LESS" OR "single port" OR "single site" AND "robot" OR "robotic" were systematically used to search the PubMed and Scopus databases. A total of 57 studies were considered eligible for the present review. The articles included were divided according to the surgical field in which the study was conducted: General surgery (29 articles), Gynecology (18 articles), Urology (10 articles). RESULTS Most part of the articles showed the feasibility of robotic single-port surgical procedures and described advantages in terms of cosmetic, hospital stay, and in some series even cost reduction. A meta-analysis was conducted, showing a significant increment of complications using RSP if compared with SLPS and a trend (P = 0.008) when RSP was compared with LESS. The comparison of different techniques in terms of conversion to laparotomy did not show any significant difference. CONCLUSION Robotic single port potentially furnishes an important surgical and post-operatory improvement; however, some limits still prolong the surgical time and complication rate.
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Affiliation(s)
- S Cianci
- Unità Operativa Ginecologia Oncologica, Dipartimento Scienze della Salute della Donna e del Bambino, Fondazione Policlinico Univeristario A. Gemelli, IRCCS, Rome, Italy.
| | - A Rosati
- Unità Operativa Ginecologia Oncologica, Dipartimento Scienze della Salute della Donna e del Bambino, Fondazione Policlinico Univeristario A. Gemelli, IRCCS, Rome, Italy
| | - V Rumolo
- Unità Operativa Ginecologia Oncologica, Dipartimento Scienze della Salute della Donna e del Bambino, Fondazione Policlinico Univeristario A. Gemelli, IRCCS, Rome, Italy
| | - S Gueli Alletti
- Unità Operativa Ginecologia Oncologica, Dipartimento Scienze della Salute della Donna e del Bambino, Fondazione Policlinico Univeristario A. Gemelli, IRCCS, Rome, Italy
| | - V Gallotta
- Unità Operativa Ginecologia Oncologica, Dipartimento Scienze della Salute della Donna e del Bambino, Fondazione Policlinico Univeristario A. Gemelli, IRCCS, Rome, Italy
| | - L C Turco
- Unità Operativa Ginecologia Oncologica, Dipartimento Scienze della Salute della Donna e del Bambino, Fondazione Policlinico Univeristario A. Gemelli, IRCCS, Rome, Italy
| | - G Corrado
- Unità Operativa Ginecologia Oncologica, Dipartimento Scienze della Salute della Donna e del Bambino, Fondazione Policlinico Univeristario A. Gemelli, IRCCS, Rome, Italy
| | - G Vizzielli
- Unità Operativa Ginecologia Oncologica, Dipartimento Scienze della Salute della Donna e del Bambino, Fondazione Policlinico Univeristario A. Gemelli, IRCCS, Rome, Italy
| | - A Fagotti
- Unità Operativa Ginecologia Oncologica, Dipartimento Scienze della Salute della Donna e del Bambino, Fondazione Policlinico Univeristario A. Gemelli, IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - F Fanfani
- Unità Operativa Ginecologia Oncologica, Dipartimento Scienze della Salute della Donna e del Bambino, Fondazione Policlinico Univeristario A. Gemelli, IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - G Scambia
- Unità Operativa Ginecologia Oncologica, Dipartimento Scienze della Salute della Donna e del Bambino, Fondazione Policlinico Univeristario A. Gemelli, IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - S Uccella
- Obstetrics and Gynecology Department, Nuovo Ospedale degli Infermi, Biella, Italy
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16
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Does surgical platform impact recurrence and survival? A study of utilization of multiport, single-port, and robotic-assisted laparoscopy in endometrial cancer surgery. Am J Obstet Gynecol 2019; 221:243.e1-243.e11. [PMID: 31075245 DOI: 10.1016/j.ajog.2019.04.038] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2019] [Revised: 04/26/2019] [Accepted: 04/30/2019] [Indexed: 11/23/2022]
Abstract
BACKGROUND Minimally invasive hysterectomy is the standard of care in the majority of women diagnosed with endometrial cancer via robotic-assisted, multiport, and single-port laparoscopy technology. Although safe and efficacious, it is unclear how oncologic outcomes are impacted by surgical platform. OBJECTIVE To identify differences in progression-free survival and overall survival in women undergoing minimally invasive surgery for endometrial cancer staging via either multiport, single-port, or robotic-assisted laparoscopy. STUDY DESIGN A multicenter, single-institution retrospective cohort study was performed in women with a diagnosis of endometrial cancer who underwent minimally invasive surgery from 2009 to 2015. Data were collected for demographics, pathologic information, adjuvant treatment, and disease status. Pearson χ2 and Fisher exact tests were used to evaluate risk factors for outcomes, Kaplan-Meier estimates and Cox proportional hazards were used to evaluate differences in time to progression or death, and multivariate regression analysis was performed. RESULTS In total, 1150 women with endometrial cancer underwent robotic-assisted laparoscopy (n=652), multiport laparoscopy (n=214), or single-port laparoscopy (n=284). The median age and body mass index of women was 62.0 years and 33.5 kg/m2, respectively. The majority of patients had endometrioid histology (88.1%), stage IA (74.7%) or IB disease (13.1%) and International Federation of Gynecology and Obstetrics grade 1 (57.4%) or 2 (26.0%) histology. Lymphovascular space invasion was present in 24.7% (n=283). Adjuvant radiation was given in 34.2% of cases, with 21.9% receiving vaginal brachytherapy, 6.6% pelvic radiation, and 5.4% both. For the entire cohort, there were no differences in progression-free survival at 2, 3, and 5 years for multiport laparoscopy (94.2%, 91.4%, 87.4%), robotic-assisted laparoscopy (94.5%, 92.9%, 88.8%), and single-port laparoscopy (93.6%, 91.2%, 90.0%) (P=.93), respectively. Similarly, there were no differences in overall survival at 2, 3, and 5 years for multiport laparoscopy (94.4%, 91.8%, 91.8%), robotic-assisted laparoscopy (95.6%, 93.4%, 90.7%), and single-port laparoscopy (95.0, 93.1, 91.8) (P=.99), respectively. Among women with stage IA and IB disease, no difference existed for progression-free survival at 2, 3, and 5 years for multiport laparoscopy (94.2%, 91.4%, 87.4%), robotic-assisted laparoscopy (94.5%, 92.9%, 88.8%), and single-port laparoscopy (93.6, 91.2, 90.0) (P=.93), respectively. Similarly, among women with stage I disease, there was no difference in overall survival at 2, 3, and 5 years for multiport laparoscopy (96.2%, 95.0%, 95.0%), robotic-assisted laparoscopy (96.6%, 95.4%, 93.3%), and single-port laparoscopy (96.6%, 95.0%, 93.4%) (P=.89). Rather, progression-free survival and overall survival were predicted by age >65 years, stage, grade, and histology (P<.05). On multivariate analysis, modality of surgery did not impact overall survival or progression-free survival (robotic-assisted laparoscopy, hazard ratio, 1.28, P=.50; single-port laparoscopy, hazard ratio, 0.84, P=.68 vs multiport laparoscopy). Age >65 years (hazard ratio, 5.42, P<.001) and advanced stage disease (P=.003) were associated with decreased overall survival. CONCLUSION In this retrospective cohort, there was no difference in progression-free survival or overall survival in women undergoing surgery for endometrial cancer via robotic-assisted laparoscopy, single-port laparoscopy, or multiport laparoscopy.
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Matanes E, Lauterbach R, Boulus S, Amit A, Lowenstein L. Robotic laparoendoscopic single-site surgery in gynecology: A systematic review. Eur J Obstet Gynecol Reprod Biol 2018; 231:1-7. [PMID: 30317138 DOI: 10.1016/j.ejogrb.2018.10.006] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2018] [Revised: 09/27/2018] [Accepted: 10/01/2018] [Indexed: 12/20/2022]
Abstract
Robotic laparoendoscopic single-site (R-LESS) seems to be the next route in advancing minimal invasive surgery, with the potential for better cosmetic results and reduced patient morbidity compared with multi-port surgery. This review describes the history and development of (R-LESS) gynecologic surgery and outlines the latest advancements in the realm of gynecology. The review was conducted according to the PRISMA guidelines. Pubmed and ClinicalTrials.gov (www.clinicaltrials.gov) were the main search engines utilized for retrieval of study data (1990 - present). The following subject headings and keywords were searched: "robotic laparoscopic single incision", "robotic laparoendoscopic single site", "single incision robotic surgery" and "single-port robotic surgery". All original research articles including randomized, non-randomized controlled trials, cohort studies, patient series, and case reports were included. The search produced a total of 1127 results. After duplicate removal, 452 remained, and each title and abstract was reviewed by 2 reviewers. Subsequently, 56 full texts were selected for full review and an additional 20 excluded, leaving 36 studies that were included in the final review. Based on the data gathered we reached the conclusion that R-LESS surgery is feasible, safe and has equivalent surgical outcomes as conventional LESS surgery; in addition to shorter recovery times, less postoperative pain and better cosmetic outcomes than robotic multi-port surgery. To conclude, R-LESS is a feasible approach with low complication rates, minimal blood loss and postsurgical pain, fast recovery, and virtually scar-free results. However, the lack of large comparative prospective randomized controlled studies prevents drawing absolute conclusions.
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Affiliation(s)
- Emad Matanes
- Department of Obstetrics and Gynecology, Rambam Health Care Campus, Haifa, Israel; Ruth and Bruce Rappaport Faculty of Medicine, Technion, Haifa, Israel.
| | - Roy Lauterbach
- Department of Obstetrics and Gynecology, Rambam Health Care Campus, Haifa, Israel; Ruth and Bruce Rappaport Faculty of Medicine, Technion, Haifa, Israel
| | - Sari Boulus
- Department of Obstetrics and Gynecology, Rambam Health Care Campus, Haifa, Israel; Ruth and Bruce Rappaport Faculty of Medicine, Technion, Haifa, Israel
| | - Amnon Amit
- Department of Obstetrics and Gynecology, Rambam Health Care Campus, Haifa, Israel; Ruth and Bruce Rappaport Faculty of Medicine, Technion, Haifa, Israel
| | - Lior Lowenstein
- Department of Obstetrics and Gynecology, Rambam Health Care Campus, Haifa, Israel; Ruth and Bruce Rappaport Faculty of Medicine, Technion, Haifa, Israel
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18
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Mereu L, Pellegrini A, Carlin R, Terreno E, Prasciolu C, Tateo S. Feasibility of sentinel lymph node fluorescence detection during robotic laparoendoscopic single-site surgery in early endometrial cancer: a prospective case series. ACTA ACUST UNITED AC 2018. [DOI: 10.1186/s10397-018-1046-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Abstract
Background
In the last few decades, the introduction of technologies such as single-site surgery, robotics, and sentinel lymph node detection has reduced invasiveness in the treatment and staging of endometrial cancer patients. The goal of the present prospective cohort study is to evaluate the feasibility of lymph node fluorescence detection with robotic single-site approach in low-risk endometrial cancer.
Results
Fifteen non consecutive low-risk endometrial atypical hyperplasia (EAH) patients underwent sentinel lymph node (SLN) biopsy and total hysterectomy utilizing the Da Vinci Si Single-Site Surgical. System and Firefly 3D imaging. Indications for surgery included eight (53.3%) IA FIGO stage G1 EC, three (20%) IA FIGO stage G2 EC, and four (26.6%) EAH. Mean operative time was 155 min (range 112–175). One vaginal laceration was the only perioperative complication encountered, and all patients were discharged within 48 h of surgery.
SLN was detected in 86.6% of cases; 1/29 (3.4%) SLN results were positive for isolated tumor cells (ITCs) at immunohistochemical analysis.
Conclusions
The present study demonstrates the feasibility and applicability of robotic single-site approach with SLN fluorescence detection for the staging of low-risk endometrial cancer.
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Cela V, Marrucci E, Angioni S, Freschi L. Robot-assisted laparoscopic single-site hysterectomy: our experience and multicentric comparison with single-port laparoscopy. ACTA ACUST UNITED AC 2018; 70:621-628. [PMID: 29856186 DOI: 10.23736/s0026-4784.18.04197-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND Analysis of perioperative outcomes of robotic single-site technique and to compare surgical outcomes with a new laparo-endoscopic single-port surgery (LESS) technique for total hysterectomy. METHODS Perioperative data from 12 women undergone robotic single-site hysterectomy (RSSH) for benign or oncologic disease were compared with data from 15 patients who underwent total laparo-endoscopic single-site hysterectomy (LESSH) for benign disease using the new X-Cone (Karl Storz, Tuttlingen, Germany). The CUSUM technique for quantitative assessment of the learning curve was then performed. RESULTS The mean operative time (OT) was 85±33 minutes for RSSH group and 100±20 minutes for LESSH group. Mean blood loss was 80±18 mL and 92±21 mL for RSSH and LESSH, respectively. For each group, the CUSUM learning curves identified two phases with a highly significant decrease of mean OT between phase 1 and phase 2 in both groups. The OT of both groups during phase 2 was significantly lower than during phase 1. CONCLUSIONS This study confirms the safety and reproducibility of the RSS. The comparison between RSS and LESS techniques has shown that RSS has important advantages over the LESS, like deeper learning curve, lower OT not correlated with age and uterus size.
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Affiliation(s)
- Vito Cela
- Division of Gynecology and Obstetrics, University of Pisa, Pisa, Italy
| | - Elena Marrucci
- Division of Gynecology and Obstetrics, University of Pisa, Pisa, Italy
| | - Stefano Angioni
- Division of Obstetrics and Gynecology, University Medical School of Cagliari, Cagliari, Italy
| | - Letizia Freschi
- Division of Gynecology and Obstetrics, University of Pisa, Pisa, Italy -
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Abstract
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.
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Single-site port robotic-assisted hysterectomy: an update. J Robot Surg 2018; 12:201-213. [PMID: 29453728 DOI: 10.1007/s11701-018-0789-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2017] [Accepted: 02/11/2018] [Indexed: 02/08/2023]
Abstract
Single-incision approach in robotic gynecology is a relatively new concept. The role of single-port systems in robotic hysterectomy, their advantages and disadvantages, as well as the technical challenges, are still under investigation. A systematic review was performed by searching in PubMed and Scopus databases. In 810 out of 1225 patients, hysterectomy was performed for non-neoplastic disease. Single-Site® was the most common port system. Duration of the procedure and relative blood loss ranged from 60 to 311 min and 7 to 750 ml, respectively. The weight of the removed uteri ranged from 39 to 520 g. 4.9% of the included patients presented complications, among which bleeding, vaginal haematoma, laceration and dehiscence, umbilical hernia, and visceral injuries. Conversion rate to laparotomy reached 2.8%. Although some technical difficulties are still described in the literature, the single-port approach is becoming more standardized nowadays and performed by more surgeons. The initial phase of the learning curve can be achieved after five cases, while a proficiency in intracorporeal cuff suturing after 14 cases. Uterus weight and previous abdominal surgical history can still be limitations of the technique. Compared to our previous study, we can see that the technique has been used in more elderly or obese patients. The complication rate can reach 4.9% while the conversion rate can reach 2.8%. However, we consider that complication and conversion rates as well as surgical time could be improved with experience. Regarding post-operative pain and cosmetic outcomes, the lack of information do not allow us to draw any safe conclusions.
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The Patient and Observer Scar Assessment Scale to Evaluate the Cosmetic Outcomes of the Robotic Single-Site Hysterectomy in Endometrial Cancer. Int J Gynecol Cancer 2018; 28:194-199. [DOI: 10.1097/igc.0000000000001130] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
ObjectiveThe objective of this study was to evaluate the cosmetic outcome of robotic single-site hysterectomy (RSSH) in early-stage endometrial cancer.MethodsWe prospectively collected patient demographics, operative times, complications, pathologic results, and length of stay on all patients who underwent RSSH for early-stage endometrial cancer. The Patient and Observer Scar Assessment Scale (POSAS) was used for the evaluation of the cosmetic outcome.ResultsForty-five patients were included in our study from January 2012 to October 2015. The median age of patients was 63 years (range, 35–84 years), and the median body mass index was 26.5 kg/m2 (range, 18–39 kg/m2). No laparoscopic/laparotomic conversion was registered. The median docking time, console time, and total operative time were 7 minutes (range, 4–14 minutes), 46 minutes (range, 20–100 minutes), and 90 minutes (range, 45–150 minutes), respectively. The median blood loss was 50 mL (range, 10–150 mL). Nine patients underwent pelvic lymphadenectomy, and the median number of pelvic lymph nodes was 13 (range, 10–32). The median time to discharge was 3 days (range, 2–6 days). No intraoperative complications occurred, whereas we did observe 1 early postoperative complication. The oncological outcome was directly comparable to the literature. Patients reported low pain scores and high satisfaction in terms of postoperative scarring. The POSAS scores confirmed excellent cosmetic outcome of RSSH.ConclusionRobotic single-site hysterectomy provided an efficient option for gynecologic oncologic surgery. The POSAS revealed high objective and patient-evaluated outcome, and patients were highly satisfied with the overall outcome of the appearance of their scars.
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Lucidi A, Chiantera V, Gallotta V, Ercoli A, Scambia G, Fagotti A. Role of robotic surgery in ovarian malignancy. Best Pract Res Clin Obstet Gynaecol 2017; 45:74-82. [PMID: 28602522 DOI: 10.1016/j.bpobgyn.2017.05.005] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2017] [Accepted: 05/03/2017] [Indexed: 01/05/2023]
Abstract
As part of minimally invasive surgery, robotic-assisted approach is becoming increasingly popular in gynecologic oncology. It has been shown to be effective and feasible for staging and treating endometrial and cervical cancer, but its role in the context of primary and recurrent ovarian cancers is presently debated. Scanty data are available in the literature, and the level of evidence supporting its use in ovarian cancer is quite low. However, from a retrospective case-control series, robotic surgery seems to be safe and feasible for early-stage ovarian cancer. Its use in treating patients with advanced-stage or relapsed ovarian cancer is still highly controversial, suggesting the choice of robotic approach in a highly selected population.
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Affiliation(s)
- A Lucidi
- Gynecologic Oncology, Armas Civico, University of Palermo, Palermo, Italy
| | - V Chiantera
- Gynecologic Oncology, Armas Civico, University of Palermo, Palermo, Italy
| | - V Gallotta
- Gynecologic Oncology, Fondazione Policlincio A. Gemelli, Catholic University Sacred Heart, Rome, Italy
| | - A Ercoli
- SCDU Obstetrics and Gynecology, Maggiore Hospital, Eastern Piedmont University, Novara, Italy
| | - G Scambia
- Gynecologic Oncology, Fondazione Policlincio A. Gemelli, Catholic University Sacred Heart, Rome, Italy
| | - A Fagotti
- Gynecologic Oncology, Fondazione Policlincio A. Gemelli, Catholic University Sacred Heart, Rome, Italy.
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Corrado G, Cutillo G, Mancini E, Baiocco E, Patrizi L, Saltari M, di Luca Sidozzi A, Sperduti I, Pomati G, Vizza E. Robotic single site versus robotic multiport hysterectomy in early endometrial cancer: a case control study. J Gynecol Oncol 2017; 27:e39. [PMID: 27171672 PMCID: PMC4864515 DOI: 10.3802/jgo.2016.27.e39] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2015] [Revised: 01/28/2016] [Accepted: 03/29/2016] [Indexed: 11/30/2022] Open
Abstract
Objective To compare surgical outcomes and cost of robotic single-site hysterectomy (RSSH) versus robotic multiport hysterectomy (RMPH) in early stage endometrial cancer. Methods This is a retrospective case-control study, comparing perioperative outcomes and costs of RSSH and RMPH in early stage endometrial cancer patients. RSSH were matched 1:2 according to age, body mass index, comorbidity, the International Federation of Gynecology and Obstetric (FIGO) stage, type of radical surgery, histologic type, and grading. Mean hospital cost per discharge was calculated summarizing the cost of daily hospital room charges, operating room, cost of supplies and length of hospital stay. Results A total of 23 women who underwent RSSH were matched with 46 historic controls treated by RMPH in the same institute, with the same surgical team. No significant differences were found in terms of age, histologic type, stage, and grading. Operative time was similar: 102.5 minutes in RMPH and 110 in RSSH (p=0.889). Blood loss was lower in RSSH than in RMPH (respectively, 50 mL vs. 100 mL, p=0.001). Hospital stay was 3 days in RMPH and 2 days in RSSH (p=0.001). No intraoperative complications occurred in both groups. Early postoperative complications were 2.2% in RMPH and 4.3% in RSSH. Overall cost was higher in RMPH than in RSSH (respectively, $7,772.15 vs. $5,181.06). Conclusion Our retrospective study suggests the safety and feasibility of RSSH for staging early endometrial cancer without major differences from the RMPH in terms of surgical outcomes, but with lower hospital costs. Certainly, further studies are eagerly warranted to confirm our findings.
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Affiliation(s)
- Giacomo Corrado
- Surgical Oncology Department, Gynecologic Oncology Unit, Regina Elena National Cancer Institute, Rome, Italy.
| | - Giuseppe Cutillo
- Surgical Oncology Department, Gynecologic Oncology Unit, Regina Elena National Cancer Institute, Rome, Italy
| | - Emanuela Mancini
- Surgical Oncology Department, Gynecologic Oncology Unit, Regina Elena National Cancer Institute, Rome, Italy
| | - Ermelinda Baiocco
- Surgical Oncology Department, Gynecologic Oncology Unit, Regina Elena National Cancer Institute, Rome, Italy
| | - Lodovico Patrizi
- Surgery Department, Section of Gynecology and Obstetrics, Tor Vergata University, Rome, Italy
| | - Maria Saltari
- Surgery Department, Section of Gynecology and Obstetrics, Tor Vergata University, Rome, Italy
| | - Anna di Luca Sidozzi
- Surgical Oncology Department, Gynecologic Oncology Unit, Regina Elena National Cancer Institute, Rome, Italy
| | - Isabella Sperduti
- Scientific Direction, Regina Elena National Cancer Institute, Rome, Italy
| | - Giulia Pomati
- Surgery Department, Section of Gynecology and Obstetrics, Tor Vergata University, Rome, Italy
| | - Enrico Vizza
- Surgical Oncology Department, Gynecologic Oncology Unit, Regina Elena National Cancer Institute, Rome, Italy
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Corrado G, Mereu L, Bogliolo S, Cela V, Freschi L, Carlin R, Gardella B, Mancini E, Tateo S, Spinillo A, Vizza E. Robotic single site staging in endometrial cancer: A multi-institution study. Eur J Surg Oncol 2016; 42:1506-11. [DOI: 10.1016/j.ejso.2016.08.014] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2016] [Revised: 07/05/2016] [Accepted: 08/18/2016] [Indexed: 01/14/2023] Open
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Corrado G, Cutillo G, Pomati G, Mancini E, Baiocco E, Patrizi L, Saltari M, Barletta F, Patani F, Vizza E. Single-access laparoscopic approach in the surgical treatment of endometrial cancer: A single-institution experience and review of literature. J Minim Access Surg 2016; 12:360-5. [PMID: 27609329 PMCID: PMC5022519 DOI: 10.4103/0972-9941.186690] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND: The aim of this study was to assess the surgical and oncological outcome for the management of endometrial cancer (EC) by laparoendoscopic single-site surgery (LESS). PATIENTS AND METHODS: We performed a retrospective chart review of patients who underwent a LESS for EC. All the patients were treated by the same surgical team between July 2009 and June 2013 at the Gynaecologic Oncologic Unit, Regina Elena National Cancer Institute, Rome, Italy. RESULTS: A total of 50 women were included, with a median age of 45 years (range, 39-84 years) and a median body mass index (BMI) of 21.8 kg/m2 (range, 19-48 kg/m2). Median operative time was 100 min (range, 50-240 min), median blood loss was 90 mL (range, 10-300 mL) and median hospital stay was 3 days (range, 2-9 days). The median number of pelvic lymph nodes retrieved was 14 (range, 5-20). No intraoperative complications occurred, but there were 4 postoperative complications. Two patients required a laparoscopic conversion. The median follow-up was 36 months (range, 16-62 months) and no recurrence occurred. CONCLUSION: Our report showed that the LESS approach in the treatment of early EC can be a safe and reliable technique in terms of surgical and oncological outcomes.
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Affiliation(s)
- Giacomo Corrado
- Department of Surgical Oncology, Gynecologic Oncology Unit, "Regina Elena" National Cancer Institute, Rome, Italy
| | - Giuseppe Cutillo
- Department of Surgical Oncology, Gynecologic Oncology Unit, "Regina Elena" National Cancer Institute, Rome, Italy
| | - Giulia Pomati
- Department of Surgery, Section of Gynaecology and Obstetrics, Tor Vergata University, Rome, Italy
| | - Emanuela Mancini
- Department of Surgical Oncology, Gynecologic Oncology Unit, "Regina Elena" National Cancer Institute, Rome, Italy
| | - Ermelinda Baiocco
- Department of Surgical Oncology, Gynecologic Oncology Unit, "Regina Elena" National Cancer Institute, Rome, Italy
| | - Lodovico Patrizi
- Department of Surgery, Section of Gynaecology and Obstetrics, Tor Vergata University, Rome, Italy
| | - Maria Saltari
- Department of Surgery, Section of Gynaecology and Obstetrics, Tor Vergata University, Rome, Italy
| | - Francesco Barletta
- Department of Surgery, Gynecology and Obstetrics Unit, San Giovanni Hospital, Rome, Italy
| | - Fabiola Patani
- Department of Surgery, Section of Gynaecology and Obstetrics, Tor Vergata University, Rome, Italy
| | - Enrico Vizza
- Department of Surgical Oncology, Gynecologic Oncology Unit, "Regina Elena" National Cancer Institute, Rome, Italy
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Nevis IF, Vali B, Higgins C, Dhalla I, Urbach D, Bernardini MQ. Robot-assisted hysterectomy for endometrial and cervical cancers: a systematic review. J Robot Surg 2016; 11:1-16. [PMID: 27424111 DOI: 10.1007/s11701-016-0621-9] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2016] [Accepted: 06/27/2016] [Indexed: 12/31/2022]
Abstract
Total and radical hysterectomies are the most common treatment strategies for early-stage endometrial and cervical cancers, respectively. Surgical modalities include open surgery, laparoscopy, and more recently, minimally invasive robot-assisted surgery. We searched several electronic databases for randomized controlled trials and observational studies with a comparison group, published between 2009 and 2014. Our outcomes of interest included both perioperative and morbidity outcomes. We included 35 observational studies in this review. We did not find any randomized controlled trials. The quality of evidence for all reported outcomes was very low. For women with endometrial cancer, we found that there was a reduction in estimated blood loss between the robot-assisted surgery compared to both laparoscopy and open surgery. There was a reduction in length of hospital stay between robot-assisted surgery and open surgery but not laparoscopy. There was no difference in total lymph node removal between the three modalities. There was no difference in the rate of overall complications between the robot-assisted technique and laparoscopy. For women with cervical cancer, there were no differences in estimated blood loss or removal of lymph nodes between robot-assisted and laparoscopic procedure. Compared to laparotomy, robot-assisted hysterectomy for cervical cancer showed an overall reduction in estimated blood loss. Although robot-assisted hysterectomy is clinically effective for the treatment of both endometrial and cervical cancers, methodologically rigorous studies are lacking to draw definitive conclusions.
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Affiliation(s)
- Immaculate F Nevis
- Health Quality Ontario, 130 Bloor Street West, 10th Floor, Toronto, ON, M5S 1N5, Canada.
| | - Bahareh Vali
- Health Quality Ontario, 130 Bloor Street West, 10th Floor, Toronto, ON, M5S 1N5, Canada
| | - Caroline Higgins
- Health Quality Ontario, 130 Bloor Street West, 10th Floor, Toronto, ON, M5S 1N5, Canada
| | - Irfan Dhalla
- Health Quality Ontario, 130 Bloor Street West, 10th Floor, Toronto, ON, M5S 1N5, Canada
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, 30 Bond St, Toronto, ON, M5B 1W8, Canada
| | - David Urbach
- Toronto General Hospital, University of Toronto, Toronto, ON, M5G 2M9, Canada
| | - Marcus Q Bernardini
- Department of Gynecologic Oncology, Princess Margaret Hospital, University of Toronto, 610, University Avenue, Toronto, ON, M5G 2M9, Canada
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Boruta DM. Laparoendoscopic single-site surgery in gynecologic oncology: An update. Gynecol Oncol 2016; 141:616-623. [PMID: 26980644 DOI: 10.1016/j.ygyno.2016.03.014] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2016] [Revised: 03/09/2016] [Accepted: 03/10/2016] [Indexed: 12/14/2022]
Abstract
The preferred surgical approach for many gynecologic oncology procedures is now laparoscopy. Reduced morbidity, shorter hospitalization and a more rapid recovery have been associated with minimally invasive surgical approaches when compared to laparotomy. Incisional morbidity, including vascular and viscous injury, postoperative hernia, infection, and pain remain significant concerns. Use of fewer and smaller incisions during laparoscopy may be expected to further minimize these risks. Laparoendoscopic single-site surgery (LESS), or single incision laparoscopy, describes the use of one small skin incision to complete laparoscopic surgical procedures. Recent advances in instrumentation have allowed increasingly complex procedures in gynecologic cancer patients to be completed. This review will serve as an update in regards to implementation of LESS in gynecologic oncology. Technical challenges encountered during performance of LESS as well as strategies to overcome these challenges will be discussed.
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Affiliation(s)
- David M Boruta
- Department of Obstetrics and Gynecology, Massachusetts General Hospital, Yawkey Suite 9E, 55 Fruit Street, Boston, MA 02114, USA.
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A Comparison of Outcomes Between Robotic-Assisted, Single-Site Laparoscopy Versus Laparoendoscopic Single Site for Benign Hysterectomy. J Minim Invasive Gynecol 2016; 23:84-8. [DOI: 10.1016/j.jmig.2015.08.883] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2015] [Revised: 08/13/2015] [Accepted: 08/21/2015] [Indexed: 01/12/2023]
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Morelli L, Guadagni S, Di Franco G, Palmeri M, Di Candio G, Mosca F. Da Vinci single site© surgical platform in clinical practice: a systematic review. Int J Med Robot 2015; 12:724-734. [PMID: 26525827 DOI: 10.1002/rcs.1713] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2015] [Revised: 07/18/2015] [Accepted: 10/05/2015] [Indexed: 02/05/2023]
Abstract
BACKGROUND The Da Vinci single-site© surgical platform (DVSSP) is a set of single-site instruments and accessories specifically dedicated to robot-assisted single-site surgery. METHODS The PubMed database from inception to June 2015 was searched for English literature on the clinical use of DVSSP in general surgery, urology and gynecology. RESULTS Twenty-nine articles involving the clinical application of DVSSP were identified; 15 articles on general surgery (561 procedures), four articles on urology (48 procedures) and 10 articles on gynecology (212 procedures). All studies have proven the safety and feasibility of the use of DVSSP. The principal reported advantage is the restoration of intra-abdominal triangulation, while the main reported limitation is the lack of the endowrist. CONCLUSIONS Da Vinci systems have proven to be valuable assets in single-site surgery, owing to the combination of robot use with the dedicated single-incision platform. However, case-control or prospective trials are warranted to draw more definitive conc lusions. Copyright © 2015 John Wiley & Sons, Ltd.
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Affiliation(s)
- Luca Morelli
- General Surgery Department of Oncology, Transplantation and New Technologies, University of Pisa, Pisa, Italy.,EndoCAS (Center for Computer Assisted Surgery), University of Pisa, Pisa, Italy
| | - Simone Guadagni
- General Surgery Department of Oncology, Transplantation and New Technologies, University of Pisa, Pisa, Italy
| | - Gregorio Di Franco
- General Surgery Department of Oncology, Transplantation and New Technologies, University of Pisa, Pisa, Italy
| | - Matteo Palmeri
- General Surgery Department of Oncology, Transplantation and New Technologies, University of Pisa, Pisa, Italy
| | - Giulio Di Candio
- General Surgery Department of Oncology, Transplantation and New Technologies, University of Pisa, Pisa, Italy
| | - Franco Mosca
- EndoCAS (Center for Computer Assisted Surgery), University of Pisa, Pisa, Italy
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Fanfani F, Boruta DM, Fader AN, Vizza E, Growdon WB, Kushnir CL, Corrado G, Scambia G, Turco LC, Fagotti A. Feasibility and Surgical Outcome in Obese Versus Nonobese Patients Undergoing Laparoendoscopic Single-site Hysterectomy: A Multicenter Case-control Study. J Minim Invasive Gynecol 2015; 22:456-61. [DOI: 10.1016/j.jmig.2014.12.008] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2014] [Revised: 12/04/2014] [Accepted: 12/07/2014] [Indexed: 11/28/2022]
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Scheib SA, Fader AN. Gynecologic robotic laparoendoscopic single-site surgery: prospective analysis of feasibility, safety, and technique. Am J Obstet Gynecol 2015; 212:179.e1-8. [PMID: 25088863 DOI: 10.1016/j.ajog.2014.07.057] [Citation(s) in RCA: 66] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2014] [Revised: 07/07/2014] [Accepted: 07/30/2014] [Indexed: 02/06/2023]
Abstract
OBJECTIVE Multiple reports suggest that laparoendoscopic single-site surgery is technically feasible, safe, and effective in treating a variety of gynecological disease processes. The study purpose was to assess the feasibility and safety of a novel robotic single-site platform (R-LESS) for the surgical treatment of benign and malignant gynecological conditions. STUDY DESIGN A single-institution, prospective analysis of 40 women treated with R-LESS on the gynecology and gynecological oncology services from June 2013 through March 2014. Women undergoing hysterectomy or adnexal surgery for either a benign or malignant gynecological condition were offered robotic single-site surgery during the study period of June 1, 2013, through April 1, 2014. Patients underwent surgery through a single 2.5-3.0 cm umbilical incision with a multichannel port and utilizing the da Vinci robotic single-site platform. Two surgeons with extensive laparoendoscopic single-site experience participated. RESULTS Forty patients had R-LESS performed. Procedures included total laparoscopic hysterectomy, laparoscopic supracervical hysterectomy, salpingo-oophorectomy, ovarian cystectomy, excision of endometriosis, and a combined case of total laparoscopic hysterectomy and cholecystectomy. Median age and body mass index were 42 years and 28.2 kg/m(2), respectively. Median operating time, defined as the interval between incision start to closure, was 134 minutes (range, 84-311 minutes). Median vaginal cuff closure was 21 minutes (range, 9-77 minutes). Overall, there appeared to be a linear relationship between vaginal cuff closure time, console time, and operating time with number of cases performed. Procedures were successfully performed via R-LESS in 92.5% of cases; 2 cases required 1 additional port and there was 1 conversion to traditional multiport robotic surgery. There was 1 major postoperative complication (2.5%) and 1 readmission (2.5%). After a median follow-up period of 230 days (range, 61-256), there have been no postoperative hernias diagnosed. CONCLUSION We present one of the first series of robotic laparoendoscopic single-site surgery for the treatment of various gynecological conditions. When performed by experienced minimally invasive surgeons, R-LESS is feasible and safe in select patients. Further studies are needed to better define the ideal gynecological procedures to perform using robotic single-site surgery and to assess the benefits and costs of R-LESS compared with multiport robotic and conventional laparoscopic approaches.
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Akdemir A, Yildirim N, Zeybek B, Karaman S, Sendag F. Single Incision Trans-Umbilical Total Hysterectomy: Robotic or Laparoscopic? Gynecol Obstet Invest 2015; 80:93-8. [DOI: 10.1159/000370000] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2014] [Accepted: 11/18/2014] [Indexed: 11/19/2022]
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Robotic-assisted surgery in gynecologic oncology. Fertil Steril 2014; 102:922-32. [DOI: 10.1016/j.fertnstert.2014.08.020] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2014] [Revised: 08/12/2014] [Accepted: 08/12/2014] [Indexed: 12/17/2022]
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Comparison of robotic surgery with laparoscopy and laparotomy for treatment of endometrial cancer: a meta-analysis. PLoS One 2014; 9:e108361. [PMID: 25259856 PMCID: PMC4178241 DOI: 10.1371/journal.pone.0108361] [Citation(s) in RCA: 58] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2014] [Accepted: 08/22/2014] [Indexed: 01/04/2023] Open
Abstract
Purpose To compare the relative merits among robotic surgery, laparoscopy, and laparotomy for patients with endometrial cancer by conducting a meta-analysis. Methods The MEDLINE, Embase, PubMed, Web of Science, and Cochrane Library databases were searched. Studies clearly documenting a comparison between robotic surgery and laparoscopy or between robotic surgery and laparotomy for endometrial cancer were selected. The outcome measures included operating time (OT), number of complications, length of hospital stay (LOHS), estimated blood loss (EBL), number of transfusions, total lymph nodes harvested (TLNH), and number of conversions. Pooled odds ratios and weighted mean differences with 95% confidence intervals were calculated using either a fixed-effects or random-effects model. Results Twenty-two studies were included in the meta-analysis. These studies involved a total of 4420 patients, 3403 of whom underwent both robotic surgery and laparoscopy and 1017 of whom underwent both robotic surgery and laparotomy. The EBL (p = 0.01) and number of conversions (p = 0.0008) were significantly lower and the number of complications (p<0.0001) was significantly higher in robotic surgery than in laparoscopy. The OT, LOHS, number of transfusions, and TLNH showed no significant differences between robotic surgery and laparoscopy. The number of complications (p<0.00001), LOHS (p<0.00001), EBL (p<0.00001), and number of transfusions (p = 0.03) were significantly lower and the OT (p<0.00001) was significantly longer in robotic surgery than in laparotomy. The TLNH showed no significant difference between robotic surgery and laparotomy. Conclusions Robotic surgery is generally safer and more reliable than laparoscopy and laparotomy for patients with endometrial cancer. Robotic surgery is associated with significantly lower EBL than both laparoscopy and laparotomy; fewer conversions but more complications than laparoscopy; and shorter LOHS, fewer complications, and fewer transfusions but a longer OT than laparoscopy. Further studies are required.
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Falcone F, Balbi G, Di Martino L, Grauso F, Salzillo ME, Messalli EM. Surgical management of early endometrial cancer: an update and proposal of a therapeutic algorithm. Med Sci Monit 2014; 20:1298-313. [PMID: 25063051 PMCID: PMC4136932 DOI: 10.12659/msm.890478] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
In the last few years technical improvements have produced a dramatic shift from traditional open surgery towards a minimally invasive approach for the management of early endometrial cancer. Advancement in minimally invasive surgical approaches has allowed extensive staging procedures to be performed with significantly reduced patient morbidity. Debate is ongoing regarding the choice of a minimally invasive approach that has the most effective benefit for the patients, the surgeon, and the healthcare system as a whole. Surgical treatment of women with presumed early endometrial cancer should take into account the features of endometrial disease and the general surgical risk of the patient. Women with endometrial cancer are often aged, obese, and with cardiovascular and metabolic comorbidities that increase the risk of peri-operative complications, so it is important to tailor the extent and the radicalness of surgery in order to decrease morbidity and mortality potentially derivable from unnecessary procedures. In this regard women with negative nodes derive no benefit from unnecessary lymphadenectomy, but may develop short- and long-term morbidity related to this procedure. Preoperative and intraoperative techniques could be critical tools for tailoring the extent and the radicalness of surgery in the management of women with presumed early endometrial cancer. In this review we will discuss updates in surgical management of early endometrial cancer and also the role of preoperative and intraoperative evaluation of lymph node status in influencing surgical options, with the aim of proposing a management algorithm based on the literature and our experience.
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Affiliation(s)
- Francesca Falcone
- Department of Woman, Child, and General and Specialized Surgery, Second University of Naples, Naples, Italy
| | - Giancarlo Balbi
- Department of Woman, Child, and General and Specialized Surgery, Second University of Naples, Naples, Italy
| | - Luca Di Martino
- Department of Woman, Child, and General and Specialized Surgery, Second University of Naples, Naples, Italy
| | - Flavio Grauso
- Department of Woman, Child, and General and Specialized Surgery, Second University of Naples, Naples, Italy
| | - Maria Elena Salzillo
- Department of Woman, Child, and General and Specialized Surgery, Second University of Naples, Naples, Italy
| | - Enrico Michelino Messalli
- Department of Woman, Child and of General and Special Surgery, Second University of Naples, Naples, Italy
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Laparoendoscopic Single-Site Versus Conventional Laparoscopic Surgical Staging for Early-Stage Endometrial Cancer. Int J Gynecol Cancer 2014; 24:358-63. [DOI: 10.1097/igc.0000000000000046] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
ObjectiveThis study aims to compare the feasibility, safety, and efficacy of laparoendoscopic single-site (LESS) surgical staging for early-stage endometrial cancer with conventional laparoscopic surgical staging.Materials and MethodsThe prospective study group consisted of 37 consecutive patients who underwent LESS surgical staging including hysterectomy, bilateral salpingo-oophorectomy, and pelvic lymph node dissection. The historical control group consisted of 74 consecutive patients who underwent 4-port laparoscopic surgical staging including hysterectomy, bilateral salpingo-oophorectomy, and pelvic lymph node dissection. Surgical outcomes were compared between the 2 groups.ResultsNo patient in the LESS or conventional laparoscopic surgery group required an additional trocar or conversion to laparotomy. There were no intergroup differences in mean age, menopause status, body mass index, and previous history of abdominal surgery. Further, there were no inter-group differences in the number of total (LESS vs. conventional, 25.9 ± 10.6 vs. 24.6 ± 9.0, P = 0.497), pelvic (24.6 ± 0.497 vs. 23.3 ± 7.7, P = 0.459), and para-aortic (4.9 ± 2.5 vs. 6.9 ± 7.3, P = 0.494) lymph nodes retrieved; the operating time (183 ± 50 min vs. 173 ± 106, P = 0.388); estimated blood loss (194 ± 149 mL vs. 173 ± 106 mL, P = 0.394); number of patients requiring transfusion (5.4% vs. 8.1%, P = 0.717); postoperative hospital stay (5.0 ± 1.8 days vs. 5.1 ± 1.8 days, P = 0.911); intraoperative complications (2.7% vs. 0%, P = 0.333); and postoperative complications (0% vs. 1.4%, P > 0.999). The postoperative pain scores and analgesic requirements were significantly lower in the LESS surgical staging group.ConclusionsLaparoendoscopic single-site surgical staging was a feasible, safe, and efficacious procedure for surgical management of early-stage endometrial cancer. It was associated with less postoperative pain and analgesic requirements and was comparable to conventional laparoscopic surgical staging in perioperative outcomes.
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Boruta DM, Fagotti A, Bradford LS, Escobar PF, Scambia G, Kushnir CL, Michener CM, Fader AN. Laparoendoscopic single-site radical hysterectomy with pelvic lymphadenectomy: initial multi-institutional experience for treatment of invasive cervical cancer. J Minim Invasive Gynecol 2013; 21:394-8. [PMID: 24161887 DOI: 10.1016/j.jmig.2013.10.005] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2013] [Revised: 10/11/2013] [Accepted: 10/11/2013] [Indexed: 11/18/2022]
Abstract
STUDY OBJECTIVE To describe the feasibility, safety, and outcomes of women with stage I cervical cancer treated with laparoendoscopic single-site surgery radical hysterectomy (LESS-RH). DESIGN A retrospective descriptive study (Canadian Task Force classification III). SETTING Multiple academic teaching hospitals. PATIENTS Women with Fédération Internationale de Gynécologie et d'Obstétrique FIGO stage IA1 to IB1 cervical cancer. INTERVENTIONS LESS-RH as the primary therapy for cervical cancer performed by a gynecologic oncologist with expertise in LESS. A multichannel, single-port access device; a flexible-tipped 5-mm laparoscope; and a multifunctional instrument were used in all cases. Clinicopathologic, surgical, and perioperative outcomes were analyzed. MEASUREMENTS AND MAIN RESULTS Twenty-two women were identified in whom a LESS-RH was attempted; 20 (91%) successfully underwent the procedure, including 19 in whom pelvic lymphadenectomy (PLND) was completed. Of the 2 converted procedures, 1 patient underwent 2-port laparoscopy secondary to truncal obesity, and 1 patient underwent conversion to laparotomy secondary to external iliac vein laceration during PLND. The median age and body mass index were 46 years and 23.3 kg/m(2), respectively. The median number of pelvic lymph nodes removed was 22. One patient experienced an intraoperative complication, and no patient required reoperation. The margins of excision were negative. One patient with 2 positive pelvic nodes and 1 patient with microscopic parametrial disease received adjuvant chemosensitized radiation; 3 additional patients received adjuvant radiation therapy secondary to an intermediate risk for recurrence. After a median follow up of 11 months, no recurrences were detected. CONCLUSION LESS-RH/PLND is feasible and safe for select patients with stage I cervical cancer. Larger studies are needed to confirm whether the increased technical difficulty of this procedure justifies its use in routine gynecologic oncology practice.
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Affiliation(s)
- David M Boruta
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Massachusetts General Hospital, Boston, Massachusetts.
| | - Anna Fagotti
- Division of Minimally Invasive Gynecology, University of Perugia, St. Maria Hospital, Terni, Italy
| | - Leslie S Bradford
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Massachusetts General Hospital, Boston, Massachusetts
| | - Pedro F Escobar
- Division of Gynecologic Oncology, HIMA-San Pablo, Caguas, Puerto Rico; Division of Gynecologic Oncology, Cleveland Clinic, Cleveland, Ohio
| | - Giovanni Scambia
- Division of Gynecologic Oncology, Catholic University of the Sacred Heart, Rome, Italy
| | - Christina L Kushnir
- Division of Gynecologic Oncology, Johns Hopkins Hospital, Baltimore, Maryland
| | - Chad M Michener
- Division of Gynecologic Oncology, Cleveland Clinic, Cleveland, Ohio
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