Evidence for the use of robotically assisted surgery in gynecologic cancers

The Influence of Surgical Complexity and Center Experience on Postoperative Morbidity After Minimally Invasive Surgery in Gynecologic Oncology: Lessons Learned from the ROBOGYN-1004 Trial

BACKGROUND

This study was a secondary analysis of the ROBOGYN-1004 trial conducted between 2010 and 2015. The study aimed to identify factors that affect postoperative morbidity after either robot-assisted laparoscopy (RL) or conventional laparoscopy (CL) in gynecologic oncology.

METHODS

The study used two-level logistic regression analyses to evaluate the prognostic and predictive value of patient, surgery, and center characteristics in predicting severe postoperative morbidity 6 months after surgery.

RESULTS

This analysis included 368 patients. Severe morbidity occurred in 49 (28 %) of 176 patients who underwent RL versus 41 (21 %) of 192 patients who underwent CL (p = 0.15). In the multivariate analysis, after adjustment for the treatment group (RL vs CL), the risk of severe morbidity increased significantly for patients who had poorer performance status, with an odds ratio (OR) of 1.62 for the 1-point difference in the WHO performance score (95 % CI 1.06-2.47; p = 0.027) and according to the type of surgery (p < 0.001). A focus on complex surgical acts showed significant more morbidity in the RL group than in the CL group at the less experienced centers (OR, 3.31; 95 % CI 1.0-11; p = 0.05) compared with no impact at the experienced centers (OR, 0.87; 95 % CI 0.38-1.99; p = 0.75).

CONCLUSION

The findings suggest that the center's experience may have an impact on the risk of morbidity for patients undergoing complex robot-assisted surgical procedures.

Impact of obesity on surgical and oncologic outcomes in patients with endometrial cancer treated with a robotic approach

AIM

The surgical treatment of endometrial cancer (EC) can be more complicated in obese patients. Robotic surgery could simplify the surgical approach in these patients. The aim of our study was to compare the outcomes of robotic surgery in obese (body mass index ≥30 kg/m² ) and nonobese patients.

METHODS

We performed a retrospective study on patients with EC benefitting from a robotic approach in our institution. The primary outcome was the 5-year overall survival (OS). We also assessed the 5-year recurrence-free survival (RFS), type of surgery, laparotomy conversion rate, adjuvant treatment and postoperative morbidity.

RESULTS

We analyzed 175 consecutive patients with EC who underwent robotic surgery, 42 patients with obesity and 133 patients without. The median follow-up length was 37 months [1-120]. The OS rate was 97% in the whole population and the RFS was 74%. Obesity did not impact prognosis. Laparotomy conversion rate was low in both groups (5% in patients with obesity vs 3%, P = 0.619). There were no significant differences in terms of postoperative complications (5 vs 9%, P = 0.738). There were significantly less pelvic lymphadenectomies in patients with obesity (5 vs 12%, P = 0.005). In the subgroup of patients with high-risk EC, rate of lymphadenectomy and of adjuvant treatments did not differ between patients with or without obesity.

CONCLUSION

Obese patients with EC can be safely treated with a robotic approach, with a low complication rate and similar oncological outcomes compared to nonobese patients.

Pelvic exenteration by robotically-assisted laparoscopy: A feasibility series of 6 cases

After concomitant chemo-radiation therapy, 20 to 30% of advanced cervical cancers recur in irradiated territory. Pelvic exenteration remains a therapeutic option for selected patients. However, this procedure remains complex because of tissue fragility after radiotherapy and their associated co-morbidities. Minimally invasive surgery such as robotically assisted laparoscopy may overcome these surgical challenges. The objective of this study was to evaluate the feasibility of pelvic exenteration with robotically assisted laparoscopy.

Patients who underwent this procedure between 2015 and 2016 were included. Patients characteristics, treatment indication, intraoperative events, immediate and late complications, and histological outcomes were recorded.

The data of 6 patients were analyzed. The primary cancer staging ranged from IB1 to IIB. All cases were loco-regional recurrence and 2 cases presented with with vesico-vaginal fistula. All patients had a history of pelvic irradiation. The mean operative time was 6.7 h. No complications occurred during surgery. The average hospital stay was 11.5 days. Immediate complications were mostly represented by urinary tract infections (4/5). Histological margins were clear in 67% (4/6), and a focal involvement was found in 33% (2/6) of cases. Late complications occurred within 82 days on average and included stenosis of ileal anastomosis, wound infection, acute renal failure, and pulmonary embolism. Revision surgery was necessary in 2 cases. There were 3 local recurrences occurring within an average of 215 days.

In the light of these results, pelvic exenteration by robotically assisted laparoscopy may represent a valuable treatment modality of recurrent cervical cancer with low immediate postoperative morbidity.

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Robotic-assisted laparoscopy improve surgical performance in pelvic exenterations.

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Robotic-assisted laparoscopy is associated with good post-operative results.

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Robotic-assisted laparoscopy is associated with good histological results.

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This series described 6 real pelvic exenterations contrary to other smaller series.

Trends in Sentinel Lymph Node Mapping and Adjuvant Therapy in Endometrial Carcinoma

We analyzed 54,039 women with uterine cancer in the National Cancer Database from 2013 to 2014 including 38,453 (71.2%) who underwent lymphadenectomy, 1929 (3.6%) who underwent sentinel lymph node (SLN) mapping, and 13,657 (25.3%) who did not undergo nodal assessment. SLN mapping increased from 2.8% in 2013 to 4.3% in 2014 (P < 0.001). Patients treated in 2014 and those at community centers were more likely to undergo SLN biopsy, while women with advanced-stage disease, sarcomas, and grade 3 tumors were less likely to undergo SLN mapping (P < 0.05). There was no association between use of SLN biopsy and use of radiation (aRR = 0.92; 95% CI, 0.82-1.05).

Minimally Invasive Surgery to Treat Gynecological Cancer: Conventional Laparoscopy and/or Robot-Assisted Surgery

Robotic-assisted surgery is a technological advancement derived from conventional laparoscopy, which facilitates the application of minimally invasive techniques for complex operations in the field of gynecological oncology. However, its introduction in gynecological cancer has been scarce in most hospitals worldwide. Most publications on robotic surgery are still retrospective or descriptive in nature. Some studies compare robotic-assisted laparoscopy with open procedures, which is a questionable analysis, because the advantages of minimally invasive surgery have been already well established. Robotic surgery should be directly compared with conventional laparoscopy to determine whether its additional direct and indirect costs are in accordance with some improvements within patient clinical outcomes. On the other hand, the role of robotic-assisted surgery in allowing more patients to receive the benefits of the minimally invasive approach should also be considered. The objective of this article was, therefore, to review the literature regarding the role of conventional and robotic-assisted laparoscopy to treat women with gynecologic cancer.