Costs of Robotic-Assisted Versus Traditional Laparoscopy in Endometrial Cancer:

Robot-assisted versus conventional laparoscopic surgery for endometrial cancer: long-term comparison of outcomes

Objective

There is a lack of multi-institutional large-volume and long-term follow-up data on comparisons between robot-assisted surgery and conventional laparoscopic surgery. This study compared the surgical and long-term survival outcomes between patients who underwent robot-assisted or conventional laparoscopic surgery for endometrial cancer.

Methods

We retrospectively reviewed the data of patients from five large academic institutions who underwent either robot-assisted or conventional laparoscopic surgery for the treatment of endometrial cancer between 2012 and 2017, ensuring at least 5 years of potential follow-up. Intra- and postoperative outcomes, long-term disease-free survival, and overall survival were compared.

Results

The study cohort included 1,003 unselected patients: 551 and 452 patients received conventional laparoscopic and robot-assisted surgery, respectively. The median follow-up duration was 57 months. Postoperative complications were significantly less likely to occur in the robot-assisted surgery group compared to the laparoscopic surgery group (7.74% vs. 13.79%, P = 0.002), primarily limited to minor complications. There were no significant differences in survival: 5-year disease-free survival was 91.2% versus 90.0% (P = 0.628) and overall survival was 97.9% versus 96.8% (P = 0.285) in the robot-assisted and laparoscopic surgery cohorts, respectively. Cox proportional hazard regression models demonstrated that the mode of surgery was not associated with disease-free survival (hazard ratio, 0.897; confidence interval, 0.563-1.429) or overall survival (hazard ratio, 0.791; confidence interval, 0.330-1.895) after adjusting for confounding factors.

Conclusion

Robot-assisted surgery for endometrial cancer demonstrates comparable long-term survival outcomes and a reduced incidence of postoperative minor complications when compared to conventional laparoscopic surgery.

Clinical Relevance of Uterine Manipulation on Oncologic Outcome in Robot-Assisted versus Open Surgery in the Management of Endometrial Cancer

In this study, we investigated the impact of uterine manipulation on endometrial cancer survival outcomes. We analyzed patients with endometrial cancer who underwent robot-assisted staging and open staging surgery between 2010 and 2020. Either uterine manipulators or vaginal tubes were utilized in robot-assisted staging. Propensity score matching was performed to correct baseline characteristics. Progression-free survival (PFS) and overall survival (OS) were analyzed using Kaplan-Meier curve analysis. In total, 574 patients, including those undergoing robot-assisted staging with a uterine manipulator (n = 213) or vaginal tube (n = 147) and staging laparotomy (n = 214), were analyzed. Propensity score matching was performed for age, histology, and stage as covariates. Before matching, Kaplan-Meier curve analysis showed that PFS and OS were significantly different among the three groups (p < 0.001 and p = 0.009, respectively). In the propensity-matched cohorts of 147 women, the previously suggested differences in PFS and OS were not observed in patients undergoing robot-assisted staging with a uterine manipulator or vaginal tube or open surgery. In conclusion, robotic surgery using a uterine manipulator or vaginal tube did not compromise survival outcomes in endometrial cancer management.

Laparotomic versus robotic surgery in elderly patients with endometrial cancer: A systematic review and meta-analysis

Background

Although robotics has been shown to improve outcomes in some high‐difficulty surgical category patients, it is unclear if such an approach may improve outcomes in elderly patients with endometrial carcinoma (EC).

Objective

To compare robotic and laparotomic surgery in the treatment and staging of elderly EC patients.

Materials and methods

A systematic review and meta‐analysis was performed assessing the risk of overall, intra‐operative, and peri‐operative complications associated with the surgical approach (laparotomic vs robotic) for elderly patients with EC by relative risk (RR). Pooled means ± standard deviation of length of stay were compared with the unpaired t test. Subgroup analyses for overall complications were performed based on different age cut‐offs (>70, >65, and >75 years) and severity of complications (minor and major). A value of P less than 0.05 was considered significant.

Results

Five studies with 7629 EC patients were included. Pooled RR for robotic compared with laparotomic surgery was 0.40 (P < 0.001) for overall, 0.46 (P = 0.18) for intra‐operative, and 0.43 (P < 0.001) for peri‐operative complications. Pooled difference between means ± standard deviation of length of stay for robotic versus laparotomic surgery was −3.34 (P < 0.001). At subgroup analyses, pooled RR of overall complications for robotic surgery versus laparotomic surgery was 0.34 (P < 0.001) in the >70 years, 0.51 (P < 0.01) in the >65 years, 0.20 (P = 0.12) in the >75 years groups. Pooled RR was 0.50 (P = 0.1) in the minor complications subgroup, and 0.42 (P = 0.002) in the major complications subgroup.

Conclusion

Robotics might be a viable alternative to the laparotomic approach for EC in elderly patients because it significantly decreases the risk of overall and peri‐operative complications (mainly major complications), and the length of stay when compared with laparotomy. The decrease in risk of overall complications is greater with increasing patient age.

Comparative Survival Outcome of Robot-Assisted Staging Surgery Using Three Robotic Arms versus Open Surgery for Endometrial Cancer

PURPOSE

There is lack of data on direct comparison of survival outcomes between open surgery and robot-assisted staging surgery (RSS) using three robotic arms for endometrial cancer. The purpose of this study was to compare the overall survival (OS) and disease-free survival (DFS) between open surgery and RSS using three robotic arms for endometrial cancer.

MATERIALS AND METHODS

Consecutive women with endometrial cancer who underwent surgery between May 2006 and May 2018 were identified. Robotic procedures were performed using the da Vinci robotic system, and the robotic approach consisted of three robotic arms including a camera arm. Propensity score matching, as well as univariate and multivariate Cox regression of OS and DFS were performed according to clinicopathologic data and surgical method.

RESULTS

The study cohort included 423 unselected patients with endometrial cancer, of whom 218 underwent open surgery and 205 underwent RSS using three robotic arms. Propensity score-matched cohorts of 146 women in each surgical group showed no significant differences in survival: 5-year OS of 91% vs. 92% and DFS of 86% vs. 89% in the open and robotic cohorts, respectively (hazard ratio, 1.02; 95% confidence interval, 0.82-1.67). In the univariate analysis with OS as the endpoint, surgical method, age, stage, type II histology, grade, and lymph node metastasis were independently associated with survival. Surgical stage, grade, and type II histology were found to be significant independent predictors for OS in the multivariate analysis.

CONCLUSION

RSS using three robotic arms and laparotomy for endometrial carcinoma had comparable survival outcomes.

Nationwide Comparison of Surgical and Oncologic Outcomes in Endometrial Cancer Patients Undergoing Robotic, Laparoscopic, and Open Surgery: A Population-Based Cohort Study

Purpose

Population-based comparisons between minimally invasive surgery (MIS) (robotic surgery [RS] and laparoscopic surgery [LS]) and open surgery (OS) for managing endometrial cancer are lacking. This study aimed to compare surgical and oncologic outcomes between endometrial cancer patients who underwent surgical staging via MIS or OS.

Materials and Methods

A population-based retrospective cohort study was performed using claims data from the Korean National Health Insurance database from January 2012 to December 2016. All patients who underwent hysterectomy under diagnosis of endometrial cancer were identified. Patients were classified into RS, LS, and OS groups. Operative and oncologic outcomes were compared among the three groups after adjustments for age group, risk group (adjuvant therapy status), modified Charlson comorbidity index, income level, insurance type, and index year using propensity scores obtained via the inverse probability of treatment weighted method.

Results

After adjustment, 5,065 patients (RS, n=315; LS, n=3,248; OS, n=1,503) were analyzed. Patient demographics were comparable. Hospital stay, postoperative complications, and cost were more favorable in the RS and LS groups than in the OS group (all p < 0.001). Five-year overall survival was significantly longer in the RS and LS groups than in the OS group (94.8%, 91.9%, and 86.9%, respectively; p < 0.001). Moreover, the survival benefit of RS was shown in the subgroup analysis of low-risk endometrial cancer patients.

Conclusion

Our study provides further evidence for the RS being a safe surgical alternative to the LS and OS, especially in low-risk endometrial cancer patients, offering surgical and oncologic outcomes equivalent to other surgical approaches.

How to train practising gynaecologists in total laparoscopic hysterectomy: protocol for the stepped-wedge IMAGINE trial

INTRODUCTION

Hysterectomy is the most common major gynaecological procedure in women and minimally invasive approaches should be used wherever possible; total laparoscopic hysterectomy (TLH) is one such surgical approach which allows removal of the uterus entirely laparoscopically. However, lack of surgical training opportunities is impeding its increased adoption. This study will formally test a surgical outreach training model to equip surgeons with the skills to provide TLH as an alternative to total abdominal hysterectomy (TAH).

METHODS AND ANALYSIS

Stepped wedge implementation trial of a surgical training programme for practising obstetrician gynaecologist specialists in four hospitals.

PRIMARY OUTCOMES

Change in the proportion of hysterectomies performed by TAH, measured between preintervention and postintervention; we aim to reduce TAH by at least 30% in 75% of the trainees.

SECONDARY OUTCOMES

(1) Number of hospitals screened, eligible, agree to training and complete the training; (2) number of surgeons screened for eligibility, eligible, agree to training, who complete training and achieve proficiency; (3) proportion of trainees achieving proficiency in correct theatre setup, vascular exposure, mobilisation and surgery closure; change in proportion proficient over time; (4) adverse events (conversion from TLH to TAH, anaesthetic incident, intraoperative visceral injury, red cell transfusions, hospital stay >7 days, incidental finding of malignancy, unplanned readmission, admission to intensive care, return to theatre, postoperative pulmonary embolism or deep vein thrombosis, development of a fistula, vault haematoma, vaginal vault dehiscence or pelvic infection); (5) hospital length-of-stay; (6) cost-effectiveness and (7) trainee surgeon proficiency with TLH.

ETHICS AND DISSEMINATION

The study has been approved by the Royal Brisbane and Women's Hospital Human Research Ethics Committee and has received site-specific approval from all participating hospitals. Results will be submitted for publication in a peer-reviewed journal.

TRIAL REGISTRATION NUMBER

NCT03617354; Pre-results.