Health-related quality of life after robotic-assisted laparoscopic hysterectomy for women with endometrial cancer — A prospective cohort study

Prospective cohort study investigating quality of life outcomes following multi-speciality robotic-assisted surgery

INTRODUCTION

Despite recent evidence on the surgical outcomes of robotic-assisted surgery (RAS), other patient centre outcomes, including quality of life (QOL), are lacking. This study aims to examine changes in QoL trajectories following RAS across different surgical specialities.

PATIENTS AND METHODS

A prospective cohort study was conducted for patients undergoing urologic, cardiothoracic, colorectal or benign gynaecological RAS, between June 2016 and January 2020 at a tertiary referral hospital in Australia. QoL was measured using the 36-item Short-Form Health Survey at pre-operative, 6 weeks and 6 months postoperatively. Physical and mental summary scores and utility index were primary outcomes, and sub-domains were secondary outcomes.

STATISTICAL ANALYSIS USED

Mixed-effects linear regressions were used to determine changes in QoL trajectories.

RESULTS

Of the 254 patients undergoing RAS, 154 underwent urologic, 36 cardiothoracic, 24 colorectal and 40 benign gynaecological surgery. Overall, the average age was 58.8 years and most patients were male (75.1%). Physical summary scores significantly decreased from pre-operative to 6 weeks' post-operative in urologic and colorectal RAS; with all surgical specialities at least returning to pre-operative levels within 6 months postoperatively. Mental summary scores consistently increased from pre-operative to 6 months postoperatively for colorectal and gynaecological RAS.

CONCLUSIONS

RAS contributed to positive changes in QoL, with physical health returning to the pre-operative level and mental health improvements across specialities, in the short term. While degrees of post-operative changes varied amongst specialities, significant improvements demonstrate benefits in RAS.

Robotic and laparoscopic gynaecological surgery: a prospective multicentre observational cohort study and economic evaluation in England

OBJECTIVE

To compare the health-related quality of life and cost-effectiveness of robot-assisted laparoscopic surgery (RALS) versus conventional 'straight stick' laparoscopic surgery (CLS) in women undergoing hysterectomy as part of their treatment for either suspected or proven gynaecological malignancy.

DESIGN

Multicentre prospective observational cohort study.

SETTING

Patients aged 16+ undergoing hysterectomy as part of their treatment for gynaecological malignancy at 12 National Health Service (NHS) cancer units and centres in England between August 2017 and February 2020.

PARTICIPANTS

275 patients recruited with 159 RALS, 73 CLS eligible for analysis.

OUTCOME MEASURES

Primary outcome was the European Organisation for Research and Treatment of Cancer Quality of Life measure (EORTC). Secondary outcomes included EuroQol-5 Dimension (EQ-5D-5L) utility, 6-minute walk test (6MWT), NHS costs using pounds sterling (£) 2018-2019 prices and cost-effectiveness. The cost-effectiveness evaluation compared EQ-5D-5L quality adjusted life years and costs between RALS and CLS.

RESULTS

No difference identified between RALS and CLS for EORTC, EQ-5D-5L utility and 6MWT. RALS had unadjusted mean cost difference of £556 (95% CI -£314 to £1315) versus CLS and mean quality adjusted life year (QALY) difference of 0.0024 (95% CI -0.00051 to 0.0057), non-parametric incremental cost-effectiveness ratio of £231 667per QALY. For the adjusted cost-effectiveness analysis, RALS dominated CLS with a mean cost difference of -£188 (95% CI -£1321 to £827) and QALY difference of 0.0024 (95% CI -0.0008 to 0.0057).

CONCLUSIONS

Findings suggest that RALS versus CLS in women undergoing hysterectomy (after adjusting for differences in morbidity) is cost-effective with lower costs and QALYs. Results are highly sensitive to the usage of robotic hardware with higher usage increasing the probability of cost-effectiveness. Non-inferiority randomised controlled trial would be of benefit to decision-makers to provide further evidence on the cost-effectiveness of RALS versus CLS but may not be practical due to surgical preferences of surgeons and the extensive roll out of RALS.

Health-related quality of life after robotic surgery for endometrial cancer: a prospective longitudinal one-year follow-up study

PURPOSE

This study aimed to explore how patients treated for endometrial cancer (EC) with robotic surgery are affected in symptoms of anxiety and depression and HRQoL in the long term.

METHODS

Women scheduled for primary robotic surgery for EC were included (n = 64), in this single-center study. Socioeconomic variables were obtained at baseline. The European Organization for Research and Treatment of Cancers Quality of Life Questionnaire Core 30 (QLQ-C30), its module for EC (EN24), the Generalized Anxiety Disorder Scale (GAD-7), and the Patient Health Questionnaire Depression Scale (PHQ-9) were followed prospectively from baseline to 2 weeks, 3 months and 1 year postoperatively.

RESULTS

The number of patients scoring above the clinical threshold for anxiety decreased from 17 (27.0%) at baseline to 4 (7.0%) at 2 weeks (p = 0.012). Depressive symptoms were reported in 20% of patients at baseline and did not change significantly during the one-year follow-up (p = 0.58). A significant decrease in Global health status was seen at 2 weeks (from 69.8 to 62.7; p = 0.048), with return to baseline levels after 3 months (68.5; p = 0.32) and stable at 1 year. Unemployment, low income, and adjuvant therapy correlated with lower Global health status at 3 months.

CONCLUSION

The significant proportion of patients with anxiety symptoms preoperatively reduced prompt after surgery, while the proportion with depression remained constant, indicating that the primary treatment has no long-term negative effect on patients' mental health. At 3 months, there is no obvious remaining negative impact on patients' HRQoL, and these results are consistent after 1 year.

Comparison of health-related quality of life of women undergoing robotic surgery, laparoscopic surgery or laparotomy for gynecologic conditions: A cross-sectional study

OBJECTIVE

To assess and compare the health-related quality of life of women undergoing robotic gynecologic surgery, laparoscopic gynecologic surgery or laparotomy for benign and cancerous conditions.

METHODS

Cross-sectional study design was used. The present study was carried out with 240 women, who underwent gynecologic surgery (robotic 48, laparoscopic 96, and laparotomy 96) in a tertiary care hospital. Instruments included a participant description questionnaire and Medical Outcomes Study Short Form-36. The data were collected 4 weeks after surgery, at the first postoperative visit of women to the clinic. Pearson χ² test, one-way analysis of variance, and regression analysis were used to assess the data.

RESULTS

Over half of the women in each group had surgery because of gynecologic cancer. All the subscale scores of Medical Outcomes Study Short Form-36 were significantly higher in the robotic group than the other surgical groups (P < 0.05). Women in the robotic group had better quality of life in terms of both the physical component and the mental component after surgery.

CONCLUSIONS

Knowledge of health-related quality of life in the recovery period after surgery is important for healthcare providers to provide adequate preventive measures, information, and follow up.

Functional recovery in older women undergoing surgery for gynaecological malignancies: A systematic review and narrative synthesis

OBJECTIVES

Older women are increasingly undergoing surgery for gynaecological malignancies. Although survival data is available other outcomes such as functional recovery are less well described. This systematic review and narrative synthesis describes functional recovery after gynaeoncology surgery with respect to baseline characteristics.

MATERIALS AND METHODS

Systematic search of MEDLINE and EMBASE databases and Cochrane Library between 1974 to 2018. Two reviewers independently reviewed abstracts/papers for inclusion against the following criteria: Results analysed and presented using narrative synthesis.

RESULTS

Fifteen studies identified (8 Endometrial, 2 Ovarian, 2 Vulval, 3 mixed cancer types). 1/15 used a standalone functional assessment tool, 14/15 used Health-Related Quality of Life tools (EORTC QLQ C30 (8), FACT-G (3), SF-36 (3)) comprising items describing function. More studies showed full recovery to baseline (n = 13) than incomplete recovery (n = 2). Four studies reported a negative association between older age and functional trajectory. Recovery was more likely and occurred faster in minimally-invasive surgery. Few studies reported baseline characteristics including cognition, frailty or comorbidities and none examined associations with functional recovery.

CONCLUSION

There is inadequate data on functional recovery of older women following gynaeoncology surgery. Future studies are needed to identify factors associated with poorer/better outcomes. This may enable identification of opportunities for risk reduction, improve equity of access and better shared-decision making.

A prospective randomized assessment of quality of life between open and robotic hysterectomy in early endometrial cancer

OBJECTIVE

There are limited prospective data on the evaluation of quality of life in patients undergoing robotic hysterectomy for endometrial cancer. Our objective was to determine whether post-operative recovery differs between robotic and abdominal hysterectomy.

METHODS

At a Swedish tertiary referral university hospital, 50 women with low-risk endometrial cancer scheduled for surgery between February 2012 and May 2016 were included in a randomized trial. Surgery was performed according to principles for minimal invasive surgery. Anesthesia and peri-operative care followed a standardized enhanced recovery after surgery program in both groups. The EuroQol Group form EQ-5D and the Short Form-36 were used to evaluate patients' health-related quality of life. The Swedish Postoperative Symptoms Questionnaire assessed symptoms pre-operatively, daily for 7 days from the day of surgery, and then weekly until 6 weeks post-operatively. Data were analyzed by means of non-parametric tests and repeated measures ANOVA. To evaluate the time-dependent occurrence of complications, Kaplan-Meier survival and Cox proportional-hazard models were used.

RESULTS

A total of 50 women were enrolled in the study (25 robotic and 25 abdominal hysterectomy). Median age (68 years vs 67 years), estimated blood loss (50 mL vs 50 mL), length of hospital stay de facto (53 hours vs 51 hours), and time to meet discharge criteria (36 hours vs 36 hours) in the robotic and abdominal groups, respectively, did not differ significantly (p>0.05) Women in the robotic hysterectomy group recovered significantly faster (p=0.01) in the EQ-5D health index, and reached their pre-operative level after approximately 3 weeks, nearly 2 weeks earlier than the abdominal group. Differences regarding improvement in health-related quality of life (Short Form-36) were statistically significant in general health and social functioning only, and were in favor of robotic hysterectomy. Consumption of analgesics, pain intensity, and symptom sum score post-operatively were equal. Occurrence of complications was an independent risk factor and influenced significantly the EQ-5D health index, length of hospital stay, pain intensity, opioid consumption, and symptom sum score adversely.

CONCLUSION

Robotic hysterectomy in the setting of an enhanced recovery after surgery program led to faster recovery in health-related quality of life compared with abdominal hysterectomy.

New insights into early recovery after robotic surgery for endometrial cancer

OBJECTIVE

To assess early recovery of physical health after robotic minimally invasive surgery (RMIS) for early-stage endometrial cancer using the European Organisation of Research and Treatment of Cancer Computer Adaptive Test Core questionnaire (EORTC CAT Core). The EORTC CAT Core provides individualised measurements while maintaining comparability. A hypothesis of individual complete recovery to baseline within three post-surgical weeks was evaluated.

METHODS

Ninety-four women who underwent RMIS for early-stage endometrial cancer were included consecutively. The EORTC CAT Core was distributed before surgery and prospectively every week during the first post-operative month. Repeated measures models were fitted for each of the four domains (physical functioning, role function, fatigue, and pain) and tested for impact of age, ASA score, minor/major surgery, and the individual baseline scores (poorest, intermediate, best).

RESULTS

Women with the lowest physical functioning, lowest role function, highest fatigue level, and highest pain level at baseline all recovered within three weeks. Women with the highest physical functioning, highest role function, lowest level of fatigue, and lowest level of pain at baseline did not reach their individual baselines within the first post-operative month but had the most favourable domain-scores three weeks post-operatively.

CONCLUSION

The individual woman's physical health baseline score is predictive for her postoperative recovery following RMIS for early-stage endometrial cancer. Women with the best physical health had the best postoperative functions and lowest level of symptoms; however their recovery to baseline was prolonged. Computer adaptive testing may be a valuable tool for individualised pre-operative information and supportive care during surveillance.

Is robotic hepatectomy cost-effective? In view of patient-reported outcomes

BACKGROUND

Robotic hepatectomy has been accepted as an alternative for patients needing surgery. However, few reports addressed the patient-reported outcomes and long-term quality of life (QoL) of patients having undergone robotic liver surgery.

METHODS

This study presented the QoL and cost-effectiveness associated with robotic and open hepatectomy by performing a comparative survey using two standardized questionnaires (Short Form-36 and Gastrointestinal Quality of Life Index).

RESULTS

One hundred patients completed the study. The robotic group tended to experienced longer operation time but shorter length of hospital stay compared to open group. Moreover, the robotic group had faster return to daily activities, less need of patient-controlled anesthesia, and less wound-related complaints in long-term follow-up. The robotic group incurred higher peri-operative expenses; however, the cost of inpatient care was lower.

CONCLUSIONS

Our study suggested that robotic hepatectomy provided good post-operative QoL and recovery of daily activity. However, efforts for lowering the financial burden of medical care by reducing the cost of robotic surgery is necessary for further application.

Impact of Laparoscopic Hysterectomy on Quality of Life

There is an ongoing debate regarding the benefits and drawbacks of the various routes of hysterectomy. A number of studies have examined overall quality of life outcomes as well as specific patient-reported outcomes including physical, psychosocial, and sexual functioning after hysterectomy. Existing studies have used varied methodologies with widely heterogeneous results, but patient satisfaction appears to be very high after laparoscopic hysterectomy, with many studies favoring the laparoscopic approach over other routes of hysterectomy. There are many opportunities for further investigation into the impact of laparoscopic hysterectomy on quality of life-an outcome measure that may be 1 of the most important in surgeries for benign indications.

Robotic surgery in gynecology

Robotic surgery is the most dynamic development in the sector of minimally invasive operations currently. It should not be viewed as an alternative to laparoscopy, but as the next step in a process of technological evolution. The advancement of robotic surgery, in terms of the introduction of the Da Vinci Xi, permits the variable use of optical devices in all four trocars. Due to the new geometry of the "patient cart," an operation can be performed in all spatial directions without re-docking. Longer instruments and the markedly narrower mechanical elements of the "patient cart" provide greater flexibility as well as access similar to those of traditional laparoscopy. Currently, robotic surgery is used for a variety of indications in the treatment of benign gynecological diseases as well as malignant ones. Interdisciplinary cooperation and cooperation over large geographical distances have been rendered possible by telemedicine, and will ensure comprehensive patient care in the future by highly specialized surgery teams. In addition, the second operation console and the operation simulator constitute a new dimension in advanced surgical training. The disadvantages of robotic surgery remain the high costs of acquisition and maintenance as well as the laborious training of medical personnel before they are confident with using the technology.

Robot-assisted hysterectomy for endometrial and cervical cancers: a systematic review

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.