Successful incorporation of robotic surgery into gynecologic oncology fellowship training

A fellow-run clinic achieves similar patient outcomes as faculty clinics: A safe and feasible model for gynecologic oncology fellow education

OBJECTIVES

Fellow involvement in patient care is important for education, but effect on patient care is unclear. Our aim was to compare patient outcomes in gynecologic oncology attending clinics versus a fellow training clinic at a large academic medical center.

METHODS

A retrospective review of consecutive gynecologic oncology patients from six attending clinics and one faculty-supervised fellow clinic was used to analyze differences based on patient demographics, cancer characteristics, and practice patterns. Primary outcome was overall survival (OS); secondary outcomes included recurrence-free survival (RFS), postoperative complications and chemotherapy within the last 30 days of life. Survival analyses were performed using Kaplan-Meier curves with log-rank tests.

RESULTS

Of 159 patients, 76 received care in the attending clinic and 83 in the fellow clinic. Patients in the fellow clinic were younger, less likely to be Caucasian, and more overweight, but cancer site and proportion of advanced stage disease were similar. Both clinics had similar rates of moderate to severe adverse events related to surgery (15% vs. 8%, p = .76), chemotherapy (21% vs. 23%, p = .40), and radiation (14% vs. 17%, p = .73). There was no difference in median RFS in the fellow compared to attending clinic (38 vs. 47 months, p = .78). OS on both univariate (49 months-fellow clinic, 60 months-attending clinic vs. p = .40) and multivariate analysis [hazard ratio 1.3 (0.57, 2.75), P = .58] was not significantly different between groups.

CONCLUSIONS

A fellow-run gynecologic oncology clinic designed to provide learning opportunities does not compromise patient outcomes and is a safe and feasible option for fellow education.

Minimally Invasive Robotic Surgery for Gynecologic Cancers: A Review

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

Pedagogic Approach in the Surgical Learning: The First Period of "Assistant Surgeon" May Improve the Learning Curve for Laparoscopic Robotic-Assisted Hysterectomy

Background

Hysterectomy is the most frequent surgery done with robotic assistance in the world and has been widely studied since its emergence. The surgical outcomes of the robotic hysterectomy are similar to those obtained with other minimally invasive hysterectomy techniques (laparoscopic and vaginal) and appear as a promising surgical technique in gynecology surgery. The aim of this study was to observe the learning curve of robot-assisted hysterectomy in a French surgical center, and was to evaluate the impact of the surgical mentoring.

Methods

We retrospectively collected the data from the files of the robot-assisted hysterectomies with the Da Vinci^® Surgical System performed between March 2010 and June 2014 at the Foch hospital in Suresnes (France). We first studied the operative time according to the number of cases, independently of the surgeon to determine two periods: the initial learning phase (Phase 1) and the control of surgical skills phase (Phase 2). The phase was defined by mastering the basic surgical tasks. Secondarily, we compared these two periods for operative time, blood losses, body mass index (BMI), days of hospitalizations, and uterine weight. We, finally, studied the difference of the learning curve between an experimented surgeon (S1) who practiced first the robot-assisted hysterectomies and a less experimented surgeon (S2) who first assisted S1 and then operated on his own patients.

Results

A total of 154 robot-assisted hysterectomies were analyzed. Twenty procedures were necessary to access to the control of surgical skills phase. There was a significant decrease of the operative time between the learning phase (156.8 min) compared to the control of surgical skills phase (125.8 min, p = 0.003). No difference between these two periods for blood losses, BMI, days of hospitalizations and uterine weight was demonstrated. The learning curve of S1 showed 20 procedures to master the robot-assisted hysterectomies with a significant decrease of the operative time, while the learning curve of S2 showed no improvement in operative time with respect to case number.

Conclusion

Twenty robot-assisted hysterectomies are necessary to achieve control of surgical skills. The companionship to learn robotic surgery seems also promising, by improving the learning phase for this surgical technique.

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

STUDY OBJECTIVE

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

DESIGN

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

SETTING

Catholic University of the Sacred Hearth, Rome, Italy.

PATIENTS

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

INTERVENTIONS

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

MEASUREMENTS AND MAIN RESULTS

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

CONCLUSION

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

Robotic-Assisted Surgery in Gynecological Oncology

BACKGROUND

Robotic-assisted surgery is a technological advancement, and its use is rapidly expanding into the field of gynecological oncology. However, a paucity of evidence exists to prove its superiority over standard laparoscopy. Its cost is also high and it lacks haptic feedback.

METHODS

A systematic review of the relevant literature was undertaken to understand the use of robotic-assisted surgery in gynecological oncology.

RESULTS

Robotic-assisted surgery is being used for select cases of endometrial cancer and has resulted in the increased utilization of minimally invasive surgery for such patients. Use of robotic-assisted surgery among patients who are obese has led to decreased complication rates. Robotic-assisted surgery appears to be more expensive than traditional laparoscopy; however, there are potential cost savings to robotic-assisted surgery, including shorter hospital stays and fewer complications, compared with laparotomy.

CONCLUSIONS

The gynecological oncology community is rapidly accepting the use of robotic-assisted surgery. Although randomized controlled trials are lacking, the technology appears to be safe and effective, and it has equivalent oncological outcomes in this patient population.

Make New Friends But Keep the Old: Minimally Invasive Surgery Training in Gynecologic Oncology Fellowship Programs

OBJECTIVES

To evaluate the role of minimally invasive surgery (MIS) in gynecologic oncology fellowship training and fellows' predictions of their use of MIS in their future practice.

METHODS

All fellows-in-training in American Board of Obstetrics and Gynecology-approved training programs were surveyed in 2012 through an online or mailed-paper survey. Data were analyzed and compared to results of a similar 2007 survey.

RESULTS

Of 172 fellows, 69 (40%) responded. Ninety-nine percent of respondents (n = 68) indicated that MIS was either very important or important in gynecologic oncology, a proportion essentially unchanged from 2007 (100%). Compared to 2007, greater proportions of fellows considered laparoscopic radical hysterectomy and node dissection for cervical cancer (87% vs 54%; P < 0.0001) and trachelectomy and staging for cervical cancer (83% vs 32%; P < 0.0001) appropriate for MIS. Of the respondents, 92% believed that maximum or some emphasis should be placed on robotic-assisted surgery and 89% on traditional laparoscopy during fellowship training. Ten percent rated their fellowship training in laparoendoscopic single-site surgery as very poor; 44% said that the question was not applicable. Most respondents (60%) in 2012 performed at least 11 procedures per month, whereas most respondents (45%) in 2007 performed 6 to 10 procedures per month (P = 0.005). All respondents at institutions where robotic surgery was used were allowed to operate at the robotic console, and 63% of respondents reported that in robotic-assisted surgery cases when a fellow sat at the robot, the fellow performed more than 50% of the case at the console.

CONCLUSIONS

These findings indicate that MIS in gynecologic oncology is here to stay. Fellowship programs should develop a systematic approach to training in MIS and in individual MIS platforms as they become more prevalent. Fellowship programs should also develop and apply an objective assessment of minimum proficiency in MIS to ensure that programs are adequately preparing trainees.