Robotic Hysterectomy and Pelvic–Aortic Lymphadenectomy for Endometrial Cancer

Is there a need for a technical certification system for gynecological robotic surgery? Questionnaire survey of members of the Japan Society of Gynecologic and Obstetric Endoscopy and Minimally Invasive Therapy

The Japan Society of Gynecologic and Obstetric Endoscopy and Minimally Invasive Therapy (JSGOE) introduced a system for the certification of laparoscopic surgeons in 2002 and a system for the certification of facilities in 2014. We examined the opinions of the members of the Japan Society of Gynecologic and Obstetric Endoscopy and Minimally Invasive Therapy (JSGOE) regarding the necessity of a certification training system and a technical certification system for robotic surgery skills in Japan. Members of the JSGOE were surveyed with two questionnaires. Overall, 870 and 519 participants responded to the first and second questionnaires, respectively. Half of the respondents indicated that both systems were necessary. The breakdown by age and qualifications showed that this was especially true for the younger generation and respondents with more experience with robotic surgery. Overall, 40% of the respondents judged that a certification system for robotic surgery alone (with or without certification in laparoscopic surgery but with a requirement of experience in laparoscopic surgery) would be necessary. The opinions of the JSGOE members on making a certification system for robotic surgery were split into two clear-cut camps. Thus, we must further seek the extent of public demand for using a public survey so that a final decision can be made on whether to establish this system.

Intraoperative Complications and Conversion to Laparatomy in Gynecologic Robotic Surgery

INTRODUCTION

In this study our objective was to document complications encountered during our initial experience with the robotic system and also state the cases in which conversion to laparotomy was necessary.

MATERIAL AND METHODS

This study is a retrospective analysis of robotically performed gynecological and gynecologic oncology procedures at a single center from July 2016 to July 2018. Patient demographics and preoperative indications were obtained from the electronic medical records.

RESULTS

The patients had a mean age of 53.6 years (range, 25-84 years). The operative time ranged from 1 h and 50 min to 9 h (mean, 5 h and 2 min). Most of the complications were managed within minutes and with robotic assisted suturing when necessary. Five patients out of 83 patients needed a surgical conversion from robotic surgery. Conversion rate was 6.02%.

CONCLUSION

During the study period we were able to manage complications uneventfully without requiring conversion to laparotomy most of the time. Vascular complications encountered during robotic surgery can be managed without requiring conversion to laparatomy.

Robotic versus laparoscopic hysterectomy in morbidly obese women for endometrial cancer

Surgery is the mainstay treatment for endometrial cancer and complex atypical endometrial hyperplasia. These conditions are more common in the obese women and as such these patients pose additional risks and challenges to surgery. Laparoscopic hysterectomy (LH) is preferred over open surgery in obese patients as it reduces surgical morbidity. However, more recently, robotic-assisted hysterectomy (RH) has been used in morbidly obese patients to overcome the limitations of conventional laparoscopy. To compare the surgical outcomes of morbidly obese patients undergoing LH or RH for endometrial cancer or complex atypical hyperplasia. A retrospective analysis of morbidly obese patients (BMI > 40 kg/m²) who underwent LH or RH for endometrial cancer or complex atypical hyperplasia at the Chris O'Brien Lifehouse Gynaecological Oncology Unit from 2015 to 2019 was performed. Data was collected from the prospectively maintained gynaecology oncology database and descriptive analysis was performed. 33 (51.6%) underwent LH and 31 (48.4%) had RH. More LHs were performed 2015-2017 period, whereas there were more RHs performed in 2018-2019 period (p = 0.01). The difference between theatre time use and operating time for LH surgery compared to RH was significantly shorter (45.7 for LH versus 61.9 min for RH, p = 0.009). RH was performed more commonly when BMI was > 50 kg/m² (p = 0.02). There has been an increase in the use of RH in morbidly obese patients, particularly for women with a BMI > 50 kg/m².

Robotic vs Open Surgery for Endometrial Cancer in Elderly Patients: Surgical Outcome, Survival, and Cost Analysis

OBJECTIVE

This study aimed to compare robotic and open surgery in elderly women diagnosed as having endometrial cancer, in terms of costs, survival, surgical outcome, and operating time.

METHODS

Women 70 years or older undergoing open and robotic surgery for endometrial cancers were included consecutively before and after the introduction of robotic surgery at a tertiary center. Costs were calculated using the case-costing system, cost per patient, including the first 30 postoperative days. Relative and overall survival outcomes were obtained from the Swedish National Cancer Registry and analyzed using the Kaplan-Meier method. Surgical outcomes including operating and anesthesia times, estimated blood loss, hospital stay, and intraoperative and postoperative complications were reviewed.

RESULTS

In all, 137 and 141 women 70 years or older were identified to have undergone open and robotic surgery, respectively. The groups showed similar body mass index, comorbidities, and tumor characteristics. No statistically significant differences were seen in costs (robotic &OV0556;11,874 vs open &OV0556;11,521, P = 0.463) or 5-year survival outcomes (robotic 94% [95% confidence interval {CI}, 84-105] vs open 87% [95% CI, 78-98], P = 0.529). Robotic surgery was associated with significantly lower estimated blood loss (P < 0.001) and shorter hospital stay (P < 0.001) but longer anesthesia time (186 vs 174 minutes; P < 0.05) and operating theater time (205 vs 190 minutes; P < 0.05). There were no significant differences in intraoperative complications, but robotic surgery resulted in fewer postoperative Clavien-Dindo grade II complications.

CONCLUSIONS

Elderly women can safely undergo robotic surgery for endometrial cancer and could be offered this technique to the same extent as younger patients. They may benefit from shorter hospital stay, decreased blood loss, and postoperative complications, without resulting in higher costs to the health care system or jeopardizing their survival.

Setting Benchmarks for the New User: Training on the Robotic Simulator

Background and Objectives:

Data showing the impact of the robotic simulator on fellowship training are limited. This study was conducted to determine whether simulator scores reflect the experience of the robotic gynecologic surgeon and to develop a simulator curriculum for trainees in gynecologic oncology.

Methods:

All faculty and fellows in the Department of Gynecologic Oncology and Reproductive Medicine were asked to participate. For phase 1, all participants were divided into 2 groups based on robotic surgical experience: beginner (0–50 cases) and experienced (>50 cases). Each participant completed 9 modules 3 times each to establish baseline data. Median module scores for the experienced group defined the benchmarks scores. In phase 2, all trainees who did not meet the benchmark score on a module were asked to repeat the module until they reached the score twice.

Results:

Twenty-four participants were included: 18 beginners and 6 experienced surgeons. For all modules, experienced surgeons received higher median scores than beginners. There was a significant difference between the scores of the 2 groups in the Energy Switching 1 (87.5 vs 92.5; P = .002) and Suture Sponge 2 (75.0 vs 87.3; P = .011) modules. Thirteen trainees participated in phase 2. For 8 of 9 of the modules, >75% of trainees met proficiency, with a median of 3 to 6 attempts (range, 2–24).

Conclusion:

Based on the findings, scores reflected each surgeon's experience. With repetition, most of the trainees were able to reach the benchmark scores. Further study is needed to determine the impact of surgical simulation on true intraoperative performance.

Robotic-assisted vs traditional laparoscopic surgery for endometrial cancer: a randomized controlled trial

BACKGROUND

Previous studies comparing robotic-assisted laparoscopic surgery to traditional laparoscopic or open surgery in gynecologic oncology have been retrospective. To our knowledge, no prospective randomized trials have thus far been performed on endometrial cancer.

OBJECTIVE

We sought to prospectively compare traditional and robotic-assisted laparoscopic surgery for endometrial cancer.

STUDY DESIGN

This was a randomized controlled trial. From December 2010 through October 2013, 101 endometrial cancer patients were randomized to hysterectomy, bilateral salpingo-oophorectomy, and pelvic lymphadenectomy either by robotic-assisted laparoscopic surgery or by traditional laparoscopy. The primary outcome measure was overall operation time. The secondary outcome measures included total time spent in the operating room, and surgical outcome (number of lymph nodes harvested, complications, and recovery). The study was powered to show at least a 25% difference in the operation time using 2-sided significance level of .05. The differences between the traditional laparoscopy and the robotic surgery groups were tested by Pearson χ² test, Fisher exact test, or Mann-Whitney test.

RESULTS

In all, 99 patients were eligible for analysis. The median operation time in the traditional laparoscopy group (n = 49) was 170 (range 126-259) minutes and in the robotic surgery group (n = 50) was 139 (range 86-197) minutes, respectively (P < .001). The total time spent in the operating room was shorter in the robotic surgery group (228 vs 197 minutes, P < .001). In the traditional laparoscopy group, there were 5 conversions to laparotomy vs none in the robotic surgery group (P = .027). There were no differences as to the number of lymph nodes removed, bleeding, or the length of postoperative hospital stay. Four (8%) vs no (0%) patients (P = .056) had intraoperative complications and 5 (10%) vs 11 (22%) (P = .111) had major postoperative complications in the traditional and robotic surgery groups, respectively.

CONCLUSION

In patients with endometrial cancer, robotic-assisted laparoscopic surgery was faster to perform than traditional laparoscopy. Also total time spent in the operation room was shorter in the robotic surgery group and all conversions to laparotomy occurred in the traditional laparoscopy group. Otherwise, the surgical outcome was similar between the groups. Robotic surgery offers an effective and safe alternative in the surgical treatment of endometrial cancer.

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.

Comparison of lymphedema incidence between 2 lymphadenectomy techniques in patients with uterine cancer undergoing robotic staging

OBJECTIVE

This study aimed to compare the incidence of lower extremity lymphedema in patients with uterine cancer after robotic staging using the following 2 methods: standard and selective pelvic lymphadenectomy.

MATERIALS AND METHODS

Three hundred forty-four consecutive patients who presented with endometrial cancer from March 2007 to October 2012 underwent robotic staging. Surgeon A performed standard pelvic lymphadenectomy and surgeon B performed selective lymphadenectomy. Selective pelvic lymphadenectomy spared the lateral chain of the external iliac lymph nodes (LNs). The incidence of lymphedema and staging adequacy between the 2 groups were analyzed.

RESULTS

Standard pelvic lymphadenectomy was performed in 238/344 (69.2%) patients and selective pelvic lymphadenectomy was performed in 106/344 (30.8%) patients. Conversion to laparotomy occurred in 2/344 cases (0.6%). Mean age for 344 patients was 63.6 (10) years and body mass index was 34.8 (10.1) kg/m(2). The mean operative time was 162.3 (54.6) minutes. Postoperative hospitalization was 1.62 (1.93) days. Histology included 80.8% endometrioid adenocarcinomas and 19.2% clear cell, serous, and carcinosarcomas. Mean pelvic LN counts for the standard and selective pelvic lymphadenectomy groups were 16 (8.6) and 15.5 (7.1), respectively (P = 0.31). Mean numbers of para-aortic LNs retrieved for the standard and selective lymphadenectomy groups were 3.1 (4.1) and 4.9 (4.5), respectively (P < 0.01).Median follow-up was 29.3 months (interquartile range, 15.6-43.1 months). The difference in the incidence of lower extremity lymphedema was statistically significant: 4.6% (11/238 patients) in the standard lymphadenectomy group versus 0.9% (1/106 patients) in the selective lymphadenectomy group (P = 0.03).

CONCLUSIONS

When compared to the standard technique, selective pelvic lymphadenectomy with sparing of the lateral chain of the external iliac LNs is adequate and results in a lower incidence of lower extremity lymphedema.

Incorporating resident/fellow training into a robotic surgery program

With the rapid uptake of the robotic approach in gynecologic surgery, a thorough understanding of the technology, including its uses and limitations, is critical to maximize patient outcomes and safety. This review discusses the role of training modalities and development of curricula for robotic surgery. Furthermore, methods for incorporating the entire surgical team and the process of credentialing/maintaining privileges are described.

Robotic surgery in supermorbidly obese patients with endometrial cancer

OBJECTIVE

Morbid obesity is a known risk factor for the development of endometrial cancer. Several studies have demonstrated the overall feasibility of robotic-assisted surgical staging for endometrial cancer as well as the benefits of robotics compared with laparotomy. However, there have been few reports that have evaluated robotic surgery for endometrial cancer in the supermorbidly obese population (body mass index [BMI], ≥50 kg/m(2)). We sought to evaluate safety, feasibility, and outcomes for supermorbidly obese patients who undergo robotic surgery for endometrial cancer, compared with patients with lower body mass indices.

STUDY DESIGN

We performed a retrospective chart review of 168 patients with suspected early-stage endometrial adenocarcinoma who underwent robotic surgery for the management of their disease. Analysis of variance and univariate logistic regression were used to compare patient characteristics and surgical variables across all body weights. Cox proportional hazard regression was used to determine the impact of body weight on recurrence-free and overall survival.

RESULTS

The mean BMI of our cohort was 40.9 kg/m(2). Median follow up was 31 months. Fifty-six patients, 30% of which had grade 2 or 3 tumors, were supermorbidly obese with a BMI of ≥50 kg/m(2) (mean, 56.3 kg/m(2)). A comparison between the supermorbidly obese and lower-weight patients demonstrated no differences in terms of length of hospital stay, blood loss, complication rates, numbers of pelvic and paraaortic lymph nodes retrieved, or recurrence and survival. There was a correlation between BMI and conversion to an open procedure, in which the odds of conversion increased with increasing BMI (P = .02).

CONCLUSION

Offering robotic surgery to supermorbidly obese patients with endometrial cancer is a safe and feasible surgical management option. When compared with patients with a lower BMI, the supermorbidly obese patient had a similar outcome, length of hospital stay, blood loss, complications, and numbers of lymph nodes retrieved.

An economic analysis of robotically assisted hysterectomy

OBJECTIVE

To perform an econometric analysis to examine the influence of procedure volume, variation in hospital accounting methodology, and use of various analytic methodologies on cost of robotically assisted hysterectomy for benign gynecologic disease and endometrial cancer.

METHODS

A national sample was used to identify women who underwent laparoscopic or robotically assisted hysterectomy for benign indications or endometrial cancer from 2006 to 2012. Surgeon and hospital volume were classified as the number of procedures performed before the index surgery. Total costs as well as fixed and variable costs were modeled using multivariable quantile regression methodology.

RESULTS

A total of 180,230 women, including 169,324 women who underwent minimally invasive hysterectomy for benign indications and 10,906 patients whose hysterectomy was performed for endometrial cancer, were identified. The unadjusted median cost of robotically assisted hysterectomy for benign indications was $8,152 (interquartile range [IQR] $6,011-10,932) compared with $6,535 (IQR $5,127-8,357) for laparoscopic hysterectomy (P<.001). The cost differential decreased with increasing surgeon and hospital volume. The unadjusted median cost of robotically assisted hysterectomy for endometrial cancer was $9,691 (IQR $7,591-12,428) compared with $8,237 (IQR $6,400-10,807) for laparoscopic hysterectomy (P<.001). The cost differential decreased with increasing hospital volume from $2,471 for the first 5 to 15 cases to $924 for more than 50 cases. Based on surgeon volume, robotically assisted hysterectomy for endometrial cancer was $1,761 more expensive than laparoscopy for those who had performed fewer than five cases; the differential declined to $688 for more than 50 procedures compared with laparoscopic hysterectomy.

CONCLUSION

The cost of robotic gynecologic surgery decreases with increased procedure volume. However, in all of the scenarios modeled, robotically assisted hysterectomy remained substantially more costly than laparoscopic hysterectomy.

Impact of Body Mass Index on Surgical Outcomes and Analysis of Disease Recurrence for Patients With Endometrial Cancer Undergoing Robotic-Assisted Staging

Objective

This study aimed to evaluate the impact of body mass index (BMI) on the short- and long-term outcomes of patients with endometrial cancer who underwent robotic-assisted staging and to analyze disease recurrence and recurrence-free survival (RFS).

Materials and Methods

The charts of all consecutive patients with endometrial cancer who underwent robotic surgery from March 2007 to October 2012 were analyzed. Patients with follow-up less than 12 months after surgery were censored from the RFS analysis.

Results

Mean (SD) age for the 364 patients was 63.6 (10) years, and mean (SD) BMI was 34.8 (10.1) kg/m2. Conversions were in 3 (0.8%) of 364 cases. The mean (SD) operative time was 162.3 (54.6) minutes. Mean (SD) postoperative hospitalization was 1.6 (1.9) days. Histology included 80.5% endometrioid and 19.5% clear cell, serous, and carcinosarcomas. Mean (SD) pelvic and paraaortic lymph node counts were 15.9 (8.2) and 3.6 (4.3), respectively. Metastatic disease was diagnosed in 58 (16%) of 364 patients. The median follow-up was 29.3 months. The recurrence rates were 4.1% for the patients with endometrioid carcinoma and 14.1% for nonendometrioid histologies. Recurrences in patients with BMI less than 30 kg/m2 accounted for 68.2% of all recurrences (15/22 patients). The rest of recurrences (7/22 patients, 31.8%) were in obese patients. Moreover, when analyzed for each histologic subtype, recurrence rates were consistently higher for patients with BMI less than 30 kg/m2 when compared with patients with BMI greater than 30 kg/m2. The 3-year overall survival was 98.2%, and the 3-year RFS was 92%.

Conclusions

Obesity and morbid obesity did not affect adversely the operative outcomes for patients with endometrial cancer who were operated on using the robotic system. The recurrence rates were lower for patients with BMI greater than 30 kg/m2 compared with patients with BMI less than 30 kg/m2 for both endometrioid and nonendometrioid cancers.

Prospective randomized study comparing robotic-assisted hysterectomy and regional lymphadenectomy with traditional laparotomy for staging of endometrial carcinoma -initial Indian experience

Robotic assisted hysterectomy with regional lymphadenectomy is increasingly used for the treatment of endometrial carcinoma. In the present study we evaluated the feasibility and technique of robotic assisted hysterectomy and lymphadenectomy in patients with endometrial carcinoma. A prospective randomized study was undertaken from July 2011 to June 2012, in 50 consecutive patients with carcinoma endometrium. Demographic (age, BMI) and perioperative data (operating time, estimated blood loss, total number of lymph nodes retrieved, hospital stay, conversion to open procedure, intraoperative and postoperative complications) of robotic assisted surgery were compared with open staging procedure. Mean age of the patient and BMI in both groups were comparable with no significant difference. Estimated blood loss (81.28 ml), hospital stay (1.94 days) and perioperative complications were significantly less in robotic assisted group in comparison to open method. Mean number of lymph nodes removed were 30.56 versus 27.6 which is suggestive of significant difference statistically. Operative time decreased as the experience of the surgeon increased but still significantly remained higher than the open procedure after 25 robotic assisted surgeries. All robotic surgeries were completed successfully without converting to open method. Robotic assisted staging procedure for endometrial carcinoma is feasible without converting to open method, with the advantages of decreased blood loss, short duration of hospital stay and less postoperative minor complications. Operative time will decrease further as the experience of surgeon increases. Para-aortic lymph node dissection is easily done and with a better ergonomics for surgeon.

Conversion from robotic surgery to laparotomy: a case-control study evaluating risk factors for conversion

OBJECTIVES

To determine risk factors associated with conversion to laparotomy for women undergoing robotic gynecologic surgery.

METHODS

The medical records of 459 consecutive robotic surgery cases performed between December 2006 and October 2011 by 8 different surgeons at a single institution were retrospectively reviewed. Cases converted to laparotomy were compared to those completed robotically. Descriptive statistics were used to summarize the demographic and clinical characteristics.

RESULTS

Forty of 459 (8.7%, 95% CI 6.3%-11.7%) patients had conversion to open surgery. Reason for conversion included poor visualization due to adhesions (13), inability to tolerate Trendelenburg (7), enlarged uterus (7), extensive peritoneal disease (5), bowel injury (2), ureteral injury (1), vascular injury (1), bladder injury (1), technical difficulty with the robot (2), and inability to access abdominal cavity (1). 5% of cases were converted prior to docking the robot. On univariate analysis, preoperative diagnosis (p=0.012), non-White race (p=0.004), history of asthma (p=0.027), ASA score (p=0.032), bowel injury (p=0.012), greater BMI (p<0.001), need for blood transfusion (p<0.001), and expected blood loss (p<0.001) were associated with conversion. On multivariate analysis, non-White race (OR 2.88, 95% CI 1.39-5.96, p=0.004), bowel injury (OR 35.40, 95% CI 3.00-417.28, p=0.005), and increasing BMI (OR 1.06, 95% CI 1.03-1.09, p<0.001) were significantly associated with increased risk for conversion. Prior surgery was not associated with conversion to open surgery (p=0.347).

CONCLUSION

Conversion to laparotomy was required for 8.7% of patients undergoing robotic surgery for a gynecologic indication. Increasing BMI and non-white race were identified as the two preoperative risk factors associated with conversion.

Robotic microsurgical training and evaluation

Robotic surgery has expanded rapidly over the past two decades and is in widespread use among the surgical subspecialties. Clinical applications in plastic surgery have emerged gradually over the last few years. One of the promising applications is robotic-assisted microvascular anastomosis. Here the authors first describe a process by which an assessment instrument they developed called the Structured Assessment of Robotic Microsurgical Skills (SARMS) was validated. The instrument combines the previously validated Structured Assessment of Microsurgical Skills (SAMS) with other skill domains in robotic surgery. Interrater reliability for the SARMS instrument was excellent for all skill areas among four expert, blinded evaluators. They then present a process by which the learning curve for robotic-assisted microvascular anastomoses was measured and plotted. Ten study participants performed five robotic microanastomoses each that were recorded, deidentified and scored. Trends in SARMS scores were plotted. All skill areas and overall performance improved significantly for each participant over the five microanastomotic sessions, and operative time decreased for all participants. The results showed an initial steep ascent in technical skill acquisition followed by more gradual improvement, and a steady decrease in operative times for the cohort. Participants at all levels of training, ranging from minimal microsurgical experience to expert microsurgeons gained proficiency over the course of five robotic sessions.

Impact of robotics on the outcome of elderly patients with endometrial cancer

OBJECTIVE

To evaluate the impact of introducing a robotics program on clinical outcome of elderly patients with endometrial cancer.

METHODS

Evaluation and comparison of peri-operative morbidity and disease-free interval in 163 consecutive elderly patients (≥70years) with endometrial cancer undergoing staging procedure with traditional open surgery compared to robotic surgery.

RESULTS

All consecutive patients ≥70years of age with endometrial cancer who underwent robotic surgery (n=113) were compared with all consecutive patients ≥70years of age (n=50) before the introduction of a robotic program in December 2007. Baseline patient characteristics were similar in both eras. Patients undergoing robotic surgery had longer mean operating times (244 compared with 217minutes, p=0.009) but fewer minor adverse events (17% compared with 60%, p<0.001). The robotics cohort had less estimated mean blood loss (75 vs 334mL, p<0.0001) and shorter mean hospital stay (3 vs 6days, p<0.0001). There was no difference in disease-free survival (p=0.61) during the mean follow-up time of 2years.

CONCLUSION

Transitioning from open surgery to a robotics program for the treatment of endometrial cancer in the elderly has significant benefits, including lower minor complication rate, less operative blood loss and shorter hospitalization without compromising 2-year disease-free survival.

Systematic review of robotic surgery in gynecology: robotic techniques compared with laparoscopy and laparotomy

The Society of Gynecologic Surgeons Systematic Review Group performed a systematic review of both randomized and observational studies to compare robotic vs nonrobotic surgical approaches (laparoscopic, abdominal, and vaginal) for treatment of both benign and malignant gynecologic indications to compare surgical and patient-centered outcomes, costs, and adverse events associated with the various surgical approaches. MEDLINE and the Cochrane Central Register of Controlled Trials were searched from inception to May 15, 2012, for English-language studies with terms related to robotic surgery and gynecology. Studies of any design that included at least 30 women who had undergone robotic-assisted laparoscopic gynecologic surgery were included for review. The literature yielded 1213 citations, of which 97 full-text articles were reviewed. Forty-four studies (30 comparative and 14 noncomparative) met eligibility criteria. Study data were extracted into structured electronic forms and reconciled by a second, independent reviewer. Our analysis revealed that, compared with open surgery, robotic surgery consistently confers shorter hospital stay. The proficiency plateau seems to be lower for robotic surgery than for conventional laparoscopy. Of the various gynecologic applications, there seems to be evidence that renders robotic techniques advantageous over traditional open surgery for management of endometrial cancer. However, insofar as superiority, conflicting data are obtained when comparing robotics vs laparoscopic techniques. Therefore, the specific method of minimally invasive surgery, whether conventional laparoscopy or robotic surgery, should be tailored to patient selection, surgeon ability, and equipment availability.

Learning curve analysis of robot-assisted radical hysterectomy for cervical cancer: initial experience at a single institution

OBJECTIVE

The aim of this study was to evaluate the learning curve and perioperative outcomes of robot-assisted laparoscopic procedure for cervical cancer.

METHODS

A series of 65 cases of robot-assisted laparoscopic radical hysterectomies with bilateral pelvic lymph node dissection for early stage cervical cancer were included. Demographic data and various perioperative parameters including docking time, console time, and total operative time were reviewed from the prospectively collected database. Console time was set as a surrogate marker for surgical competency, in addition to surgical outcomes. The learning curve was evaluated using cumulative summation method.

RESULTS

The mean operative time was 190 minutes (range, 117 to 350 minutes). Two unique phases of the learning curve were derived using cumulative summation analysis; phase 1 (the initial learning curve of 28 cases), and phase 2 (the improvement phase of subsequent cases in which more challenging cases were managed). Docking and console times were significantly decreased after the first 28 cases compared with the latter cases (5 minutes vs. 4 minutes for docking time, 160 minutes vs. 134 minutes for console time; p<0.001 and p<0.001, respectively). There was a significant reduction in blood loss during operation (225 mL vs. 100 mL, p<0.001) and early postoperative complication rates (28% vs. 8.1%, p=0.003) in phase 2. No conversion to laparotomy occurred.

CONCLUSION

Improvement of surgical performance in robot-assisted surgery for cervical cancer can be achieved after 28 cases. The two phases identified by cumulative summation analysis showed significant reduction in operative time, blood loss, and complication rates in the latter phase of learning curve.

Successful incorporation of robotic surgery into gynecologic oncology fellowship training

BACKGROUND

The increasing role of robotic surgery in gynecologic oncology may impact fellowship training. The purpose of this study was to review the proportion of robotic procedures performed by fellows at the console, and compare operative times and lymph node yields to faculty surgeons.

METHODS

A prospective database of women undergoing robotic gynecologic surgery has been maintained since 2008. Intra-operative datasheets completed include surgical times and primary surgeon at the console. Operative times were compared between faculty and fellows for simple hysterectomy (SH), bilateral salpingo-oophorectomy (BSO), pelvic (PLND) and paraaortic lymph node dissection (PALND) and vaginal cuff closure (VCC). Lymph nodes counts were also compared.

RESULTS

Times were recorded for 239 SH, 43 BSOs, 105 right PLNDs, 104 left PLNDs, 34 PALND and 269 VCC. Comparing 2008 to 2011, procedures performed by the fellow significantly increased; SH 16% to 83% (p<0.001), BSO 7% to 75% (p=0.005), right PLND 4% to 44% (p<0.001), left PLND 0% to 56% (p<0.001), and VCC 59% to 82% (p=0.024). Console times (min) were similar for SH (60 vs. 63, p=0.73), BSO (48 vs. 43, p=0.55), and VCC (20 vs. 22, p=0.26). Faculty times (min) were shorter for PLND (right 26 vs. 30, p=0.04, left 23 vs. 27, p=0.02). Nodal counts were not significantly different (right 7 vs. 8, p=0.17 or left 7 vs. 7, p=0.87).

CONCLUSIONS

Robotic surgery can be successfully incorporated into gynecologic oncology fellowship training. With increased exposure to robotic surgery, fellows had similar operative times and lymph node yields as faculty surgeons.

Integration of robotics into two established programs of minimally invasive surgery for endometrial cancer appears to decrease surgical complications

Objective

To compare peri- and postoperative outcomes and complications of laparoscopic vs. robotic-assisted surgical staging for women with endometrial cancer at two established academic institutions.

Methods

Retrospective chart review of all women that underwent total hysterectomy with pelvic and para-aortic lymphadenectomy by robotic-assisted or laparoscopic approach over a four-year period by three surgeons at two academic institutions. Intraoperative and postoperative complications were measured. Secondary outcomes included operative time, blood loss, transfusion rate, number of lymph nodes retrieved, length of hospital stay and need for re-operation or re-admission.

Results

Four hundred and thirty-two cases were identified: 187 patients with robotic-assisted and 245 with laparoscopic staging. Both groups were statistically comparable in baseline characteristics. The overall rate of intraoperative complications was similar in both groups (1.6% vs. 2.9%, p=0.525) but the rate of urinary tract injuries was statistically higher in the laparoscopic group (2.9% vs. 0%, p=0.020). Patients in the robotic group had shorter hospital stay (1.96 days vs. 2.45 days, p=0.016) but an average 57 minutes longer surgery than the laparoscopic group (218 vs. 161 minutes, p=0.0001). There was less conversion rate (0.5% vs. 4.1%; relative risk, 0.21; 95% confidence interval, 0.03 to 1.34; p=0.027) and estimated blood loss in the robotic than in the laparoscopic group (187 mL vs. 110 mL, p=0.0001). There were no significant differences in blood transfusion rate, number of lymph nodes retrieved, re-operation or re-admission between the two groups.

Conclusion

Robotic-assisted surgery is an acceptable alternative to laparoscopy for staging of endometrial cancer and, in selected patients, it appears to have lower risk of urinary tract injury.

Analysis of disease recurrence and survival for women with uterine malignancies undergoing robotic surgery

OBJECTIVES

To evaluate recurrence-free survival (RFS) and overall survival (OS) for patients who underwent robotic-assisted laparoscopic hysterectomy (RALH) for uterine malignancies.

METHODS

Medical records from 372 patients with uterine malignancies who underwent RALH from 3/06 to 3/09 at two institutions were reviewed for clinico-pathologic data, adjuvant therapies, disease recurrence, and survival. Median follow-up for survival analysis was 31 ± 14 months. Thirty (8.1%) patients were lost to follow-up before 12 months and censored from the recurrence analysis.

RESULTS

Mean age and BMI of 372 patients was 61.8 ± 9.8 years and 32.2 ± 8.4 kg/m(2) (range 19-70). Robotic procedures included RALH 16 (4.3%), RALH with pelvic lymphadenectomy (PL) 96 (25.8%), and RALH with pelvic-and-aortic lymphadenectomy (PAL) 252 (67.7%) cases. Histology included 319 (85.8%) endometrioid and 53 (12.6%) high-risk histologies. Mean pelvic and aortic lymph node counts were 16.8 ± 8.7 and 8.4 ± 4.5, respectively. Lymph node metastases were identified in 26 (7.3%) cases. Adjuvant therapies were prescribed for 108 (29.1%) of patients: 7.8% brachytherapy, 1.9% pelvic radiation+brachytherapy, 7.8% chemotherapy, 11.6% chemotherapy+radiation. Risk of recurrence for all patients was 8.3% and 17 (4.6%) patients died of disease. The estimated 3-year recurrence-free survival (RFS) for the entire study group was 89.3% and the estimated 5-year overall survival (OS) was 89.1%, compared to 92.5% and 93.4% for the endometrioid sub-set.

CONCLUSIONS

Patients with endometrial cancer undergoing robotic hysterectomy with staging lymphadenectomies during our 3-years of robotic experience had low-risk for recurrence and excellent disease-specific survival at a median follow-up time of 31 months.

Clinical outcomes in endometrial cancer care when the standard of care shifts from open surgery to robotics

INTRODUCTION

In Singapore, the standard of care for endometrial cancer staging remains laparotomy. Since the introduction of gynecologic robotic surgery, there have been more data comparing robotic surgery to laparoscopy in the management of endometrial cancer. This study reviewed clinical outcomes in endometrial cancer in a program that moved from laparotomy to robotic surgery.

METHODS

A retrospective review was performed on 124 consecutive endometrial cancer patients. Preoperative data and postoperative outcomes of 34 patients undergoing robotic surgical staging were compared with 90 patients who underwent open endometrial cancer staging during the same period and in the year before the introduction of robotics.

RESULTS

There were no significant differences in the mean age, body mass index, rates of diabetes, hypertension, previous surgery, parity, medical conditions, size of specimens, histologic type, or stage of cancer between the robotic and the open surgery groups. The first 20 robotic-assisted cases had a mean (SD) operative time of 196 (60) minutes, and the next 14 cases had a mean time of 124 (64) minutes comparable to that for open surgery. The mean number of lymph nodes retrieved during robot-assisted staging was smaller than open laparotomy in the first 20 cases but not significantly different for the subsequent 14 cases. Robot-assisted surgery was associated with lower intraoperative blood loss (110 [24] vs 250 [83] mL, P < 0.05), a lower rate of postoperative complications (8.8% vs 26.8%, P = 0.032), a lower wound complication rate (0% vs 9.9%, P = 0.044), a decreased requirement for postoperative parenteral analgesia (5.9% vs 51.1, P < 0.001), and shorter length of hospitalization (2.0 [1.1] vs 6.0 [4.5] days, P < 0.001) compared to patients in the open laparotomy group.

CONCLUSIONS

Our series shows that outcomes traditionally associated with laparoscopic endometrial cancer staging are achievable by laparoscopy-naive gynecologic cancer surgeons moving from laparotomy to robot-assisted endometrial cancer staging after a relatively small number of cases.

Enhancing Fundamental Robot-Assisted Surgical Proficiency by Using a Portable Virtual Simulator

Background. The development of a virtual reality (VR) training platform provides an affordable interface. The learning effect of VR and the capability of skill transfer from the VR environment to clinical tasks require more investigation. Methods. Here, 14 medical students performed 2 fundamental surgical tasks—bimanual carrying (BC) and peg transfer (PT)—in actual and virtual environments. Participants in the VR group received VR training, whereas participants in the control group played a 3D game. The learning effect was examined by comparing kinematics between pretraining and posttraining in the da Vinci Surgical System. Differences between VR and playing the 3D game were also examined. Results. Those who were trained with the VR simulator had significantly better performance in both actual PT ( P = .002) and BC ( P < .001) tasks. The time to task completion and the total distance traveled were significantly decreased in both surgical tasks in the VR group compared with the 3D game group. However, playing the 3D game showed no significant enhancement of fundamental surgical skills in the actual PT task. The difference between pretraining and posttraining was significantly larger in the VR group than in the 3D game group in both the time to task completion ( P = .002) and the total distance traveled ( P = .027) for the actual PT task. Participants who played the 3D game seemed to perform even worse in posttraining. Conclusions. Training with the portable VR simulator improved robot-assisted surgical skill proficiency in comparison to playing a 3D game.

Robotic surgical staging for obese patients with endometrial cancer

OBJECTIVE

To compare surgical outcomes for robotic vs laparotomy staging in obese endometrial cancer patients.

STUDY DESIGN

This was a retrospective cohort study of patients with body mass index ≥30 kg/m(2) staged in a community gynecologic oncology practice. Patients undergoing robotic staging were compared with historic laparotomy controls.

RESULTS

One hundred twenty-nine patients underwent robotic staging, compared with 110 laparotomy patients. The robotic cohort had fewer abdominal wound complications (13.9% vs 32.7%, P < .001), but more vaginal cuff complications (4.7% vs 0%, P = .032). Blood loss was lower in the robotic group (P < .001), as was length of stay (P < .001). Surgical times were longer in the robotic group (P < .001). There was no difference in terms of percentage of patients undergoing pelvic or paraaortic lymph node dissection.

CONCLUSION

Robotic staging for endometrial cancer is feasible in obese women, with fewer abdominal wound complications, but more vaginal cuff complications.

Magnetic resonance or computerized tomography imaging to predict difficulty of robotic surgery for endometrial cancer

To determine if the difficulty of a robotic hysterectomy for endometrial cancer can be predicted by MRI, CT or other methods. All robotic cases from 1 August 2006 through 30 July 2009 were identified. Data collected prospectively included co-morbidities, body mass index, surgical times, estimated blood loss (EBL), uterine weight, and pre- and postoperative complications. Those patients who received an MRI or CT scan prior to robotic hysterectomy had additional data gathered from imaging, including uterine volume, pelvic measurements and abdominal wall thickness. Cases were labeled difficult for the following reasons: outliers greater than 2 SD from the mean EBL, hysterectomy time and total console time. Additional factors identifying difficult cases included the need to undock to remove the specimen or conversion to laparotomy. Data were analyzed for their possible role in causing difficulty in a robotic hysterectomy. Comparative statistics utilized included chi-square and t-test, ANOVA and logistic regression analysis.From 2 August 2006 through 30 July 2009, 119 patients underwent robotic surgery for endometrial cancer and are included in this study. Of these patients, 25/119 (20.0%) were identified as difficult cases. Difficulty was found in those patients with greater than 2 SD from the mean for hysterectomy time, >90.9 min (n = 3, 2.5%), total console time of >178.1 min (n = 6, 5.0%), EBL >232 cc (n = 7, 5.9%) and undocking to remove the uterine specimen in 8 (6.7%) cases; 1/119 (0.8%) was converted to laparotomy. Lymphadenectomy (P = 0.005) was associated with case difficulty. In a logistic regression analysis CT/MRI measurements of uterine volume greater than 793 cm³ and CT/MRI pelvimetry, as well as abdominal wall thickness were independent predictors of a difficult case (P = 0.0116). MRI and CT scans can detect the probability that a robotic surgery will be difficult by determining uterine volume and pelvimetry; however, these were not the strongest predictors in our study. A narrow pelvic outlet as measured on CT/MRI and uterine volume of greater than 793 cc should raise a flag of caution when planning robotic hysterectomy for endometrial cancer.

Dual-console robotic surgery compared to laparoscopic surgery with respect to surgical outcomes in a gynecologic oncology fellowship program

OBJECTIVE

Minimally invasive surgical techniques decrease surgical morbidity and recovery time. Studies demonstrate similar surgical outcomes comparing robotic to laparoscopic surgery. These studies have not accounted for the incorporation of fellow education. With the dual-console da Vinci Si Surgical System®, a two surgeon approach could be performed. We sought to compare surgical outcomes at a gynecologic oncology fellowship program of traditional laparoscopic to robotic surgeries using the dual-console system.

METHODS

We identified patients who underwent laparoscopic or robotic surgery performed by a gynecologic oncologist from November 2009-November 2010. Robotic surgeries were conducted using the dual-console, utilizing a two surgeon approach. Surgeries involved a staff physician with a gynecologic oncology fellow. Statistical analysis was performed using student t-test and chi-squared analysis.

RESULTS

A total of 222 cases were identified. Cases were analyzed in groups: all cases identified, all cancer cases, and endometrial cancer cases only. When analyzing all cases, no statistical difference was noted in total operating room time (172 vs. 175 min; p=0.6), pelvic lymph nodes removed (10.1 vs. 9.6; p=0.69), para-aortic lymph nodes dissected (3.7 vs. 3.8; p=0.91), or length of stay (1.5 vs. 1.3 days; p=0.3). There was a significant difference in total surgical time (131 vs.110 min; p<0.0001) and EBL (157 vs.94 ml; p<0.0001), favoring robotic surgery. When analyzing all cancer cases, the advantage in total surgical time for robotic surgery was lost. Complications were similar between cohorts.

CONCLUSION

Incorporating fellow education into robotic surgery does not adversely affect outcomes when compared to traditional laparoscopic surgery.

[Robotic surgery in endometrial cancer: a review]

Robotic surgery has spread for a few years. This access is now important in urologic surgery, especially for prostatic procedures. Development of robotic surgery in gynecology is more recent. Gynecologic oncology is probably one of the most interesting fields of development of this access. Robotic surgery is frequently used in endometrial cancer. As no randomized study is available, it seems to be interesting to make a review of retrospective studies. Feasibility seems to be high and the learning curve is short (around 20 cases). Operative lengths are longer when compared to laparotomy, but are similar or shorter than laparoscopy. Robot setting increases the global length of the procedure, but decreases with experience. Operative blood loss, as well as transfusion rate are decreased when compared to laparotomy, but are similar to those of laparoscopy. The overall morbidity rate seems lower than with other approaches. Postoperative pain, hospital stay and time to recovery are decreased when compared to laparotomy as well as to laparoscopy for some authors. The main limit to the diffusion of robotic surgery is accessibility because of its important cost. Other limits are pointed out by the most trained teams.

Dual-console robotic surgery: a new teaching paradigm

Robotic surgery has emerged as an alternative option in minimally invasive gynecologic surgery. The development of the dual-console da Vinci Si Surgical System(®) has enabled modification of the training atmosphere. We sought to investigate operative times and surgical outcomes while operating with the dual-console model in a training environment for our first fifty cases. We identified the first fifty patients who underwent robot-assisted total hysterectomy (TRH), with or without bilateral salpingo-oophorectomy (BSO), with or without pelvic and para-aortic lymph node dissection (PPALND), by use of the dual-console robotic system. Records were reviewed for patient demographics and surgical details. All surgery was conducted using the dual-console system and performed by staff physicians and fellows. Operative time was calculated from robotic docking until completion of the procedure. Cases were identified from November 2009 through July 2010. Mean age was 56.2 years (SD 13.35, 95 % CI 52.46-59.86). Mean BMI was 29.5 (SD 7.67, 95 % CI 27.35-31.61). Seventy-eight percent of these patients were considered overweight, including 12 defined as obese (BMI 30-34.9) and 10 patients classified as morbidly obese (BMI ≥ 35). Surgery completed included PPALND alone (n = 1); radical hysterectomy (n = 1); TRH only (n = 3); TRH/BSO (n = 25); and TRH/BSO/PPALND (n = 20). Mean total operating room time was 188.8 min (SD 55.31, 95 % CI 173.45-204.11). Mean total surgical time for all cases was 118.1 min (SD 44.28, 95 % CI 105.87-130.41). Two vascular injuries were encountered, with one requiring conversion to laparotomy. These results compare favorably with historically reported outcomes from single-console systems. Utilizing the dual-console enables use of an integrated teaching and supervising environment without compromising operative times or patient outcomes.

Evolution of surgical management of early-stage endometrial cancer

OBJECTIVE

We sought to examine the evolution of surgical care for early-stage endometrial cancers and factors affecting use of laparoscopy.

STUDY DESIGN

Women with surgically managed early-stage endometrial cancer were divided into 2 groups corresponding to before and after addition of faculty with formal fellowship training in laparoscopic staging and access to a robotic surgery platform.

RESULTS

In all, 502 women were identified. Laparoscopic management increased from 24-69% between time periods (P < .0001). Performance of comprehensive surgical staging, and lymph node counts, increased (P < .0001) despite an increase in median body mass index (P = .001). A traditional "straight stick" technique was performed in 72% of laparoscopic cases during the later period. Laparoscopy patients had lower estimated blood losses and shorter hospital stays (each P < .0001) compared to laparotomy patients.

CONCLUSION

Addition of faculty with formal fellowship training in laparoscopic staging and access to a robotic surgery platform shifted management of early-stage endometrial cancer toward laparoscopy.

Robotic surgery in gynecology: an updated systematic review

The introduction of da Vinci Robotic Surgery to the field of Gynecology has resulted in large changes in surgical management. The robotic platform allows less experienced laparoscopic surgeons to perform more complex procedures. In general gynecology and reproductive gynecology, the robot is being increasingly used for procedures such as hysterectomies, myomectomies, adnexal surgery, and tubal anastomosis. Among urogynecology the robot is being utilized for sacrocolopexies. In the field of gynecologic oncology, the robot is being increasingly used for hysterectomies and lymphadenectomies in oncologic diseases. Despite the rapid and widespread adoption of robotic surgery in gynecology, there are no randomized trials comparing its efficacy and safety to other traditional surgical approaches. Our aim is to update previously published reviews with a focus on only comparative observational studies. We determined that, with the right amount of training and skill, along with appropriate patient selection, robotic surgery can be highly advantageous. Patients will likely have less blood loss, less post-operative pain, faster recoveries, and fewer complications compared to open surgery and potentially even laparoscopy. However, until larger, well-designed observational studies or randomized control trials are completed which report long-term outcomes, we cannot definitively state the superiority of robotic surgery over other surgical methods.

Robotic surgery in gynecologic oncology

Robotic surgery for the management of gynecologic cancers allows for minimally invasive surgical removal of cancer-bearing organs and tissues using sophisticated surgeon-manipulated, robotic surgical instrumentation. Early on, gynecologic oncologists recognized that minimally invasive surgery was associated with less surgical morbidity and that it shortened postoperative recovery. Now, robotic surgery represents an effective alternative to conventional laparotomy. Since its widespread adoption, minimally invasive surgery has become an option not only for the morbidly obese but for women with gynecologic malignancy where conventional laparotomy has been associated with significant morbidity. As such, this paper considers indications for robotic surgery, reflects on outcomes from initial robotic surgical outcomes data, reviews cost efficacy and implications in surgical training, and discusses new roles for robotic surgery in gynecologic cancer management.

Comparison of single-port laparoscopy, standard laparoscopy, and robotic surgery in patients with endometrial cancer

BACKGROUND

The aim of this study was to evaluate single-port laparoscopy (SPL) for the surgical treatment of presumed early-stage endometrial cancer and to compare surgical outcomes to laparoscopy and robotics.

METHODS

A multi-institutional, matched retrospective cohort study was performed. All patients with clinical stage I or occult stage II endometrial cancer who underwent SPL hysterectomy, bilateral salpingo-oophorectomy +/- lymphadenectomy from April 2009 to September 2010 were identified. Outcomes were compared with patients matched by age, body mass index (BMI), tumor histology, and grade, who underwent laparoscopy or robotic surgery. Data was analyzed using Kruskal-Wallis 1-way analysis of variance and chi-square test for frequency data. A P value of <.05 was considered significant.

RESULTS

A total of 90 matched patients (30 SPL, 30 LSC, and 30 robotic) were included in the study. There were no significant differences in median operating time or estimated blood loss between the 3 groups. The median number of pelvic lymph nodes obtained was significantly higher in the robotic (17.0 [8-36] and SPL group (16.0 [11-21]) compared with the laparoscopy group (13.0 [3-18]) P = .04. However, there was no significant difference in the median number of para-aortic nodes obtained between the 3 groups. There was no significant difference between the groups in length of hospital stay, comorbid conditions, complication rates, or operative times.

CONCLUSIONS

Our findings suggest SPL surgery for endometrial carcinoma is feasible with similar operating times, hospital length of stay, complication rates, and estimated blood loss when compared with laparoscopy and robotics.