Robot versus laparoscopic nerve-sparing radical hysterectomy for cervical cancer: a comparison of the intraoperative and perioperative results of a single surgeon's initial experience. Int J Gynecol Cancer. 2013;23:1145-1149. [PMID: 23748178 DOI: 10.1097/igc.0b013e31829a5db0]

Comparison of surgical outcomes between robot-assisted and conventional laparoscopic nerve-sparing modified radical hysterectomy for deep endometriosis

PURPOSE

Drug resistance and severe pelvic pain often warrant surgical intervention for treating deep endometriosis (DE); however, damage to the autonomic nervous system can occur because of anatomical considerations. We aimed to investigate the advantages of robotic technology in enabling precise dissection, even in DE.

METHODS

We retrospectively compared the surgical outcomes of robot-assisted (RA) and conventional laparoscopic (CL) nerve-sparing modified radical hysterectomies (NSmRHs) for DE.

RESULTS

Between the two groups (RA-NSmRH group, n = 50; CL-NSmRH group, n = 18), no differences were identified based on patient demographics, such as age, body mass index, previous surgery, revised American Society of Reproductive Medicine classification, Enzian classification, uterine weight, number of removed DE lesions, and concomitant procedures. All patients in both groups achieved complete removal of the DE lesions with complete bilateral pelvic autonomic nerve preservation. The mean operative time (OT) was significantly longer (130 ± 46 vs. 98 ± 22 min, p < 0.01), and estimated blood loss (EBL) was lower (35 ± 44 vs. 131 ± 49 ml, p < 0.01) in the RA-NSmRH group than in the CL-NSmRH group. The hospitalization days (4.3 ± 1.3 vs. 4.1 ± 0.2 days, p = 0.45) and perioperative complications with Clavien-Dindo classification ≥ grade III (0% vs. 0%) were not significant in both the groups. None of the patients required self-catheterization after surgery.

CONCLUSION

Compared with CL-NSmRH, RA-NSmRH was associated with longer OT and lower EBL, whereas the number of hospitalization days and complications were similar in both groups. Our results imply that nerve-sparing surgery can be safely and reproducibly performed using conventional or robotic laparoscopic modalities to treat DE.

Key Anatomical Concepts, Landmarks, and Proposed Terminology for Nerve-Sparing Gynecologic Surgery: A Narrative Review

OBJECTIVE

To synthesize the terminology utilized in nerve-sparing surgical literature and propose standardized and nonconflicting terms to allow for consistent vocabulary.

DESIGN

We performed a literature search on PubMed using the search terms "pelvis" and "nerve-sparing." Nongynecologic surgery and animal studies were excluded. A narrative review was performed, focusing on nerves, fasciae, ligaments, and retroperitoneal spaces. Terms from included papers were discussed by all authors, who are surgeons versed in nerve-sparing procedures and one anatomist, and recommendations were made regarding the most appropriate terms based on the frequency of occurrence in the literature and the possibility of overlapping names with other structures.

RESULTS

224 articles were identified, with 81 included in the full-text review. Overall, 48% of articles focused on cervical cancer and 26% on deeply infiltrating endometriosis. Findings were synthesized both narratively and visually. Inconsistencies in pelvic anatomical nomenclature were prevalent across publications. The structure with the most varied terminology was the rectal branch of the inferior hypogastric plexus with 14 names. A standardized terminology for pelvic autonomic nerve structures, fasciae, ligaments, and retroperitoneal spaces was proposed to avoid conflicting terms.

CONCLUSION

Surgeons and anatomists should use consistent terminology to facilitate increased uptake of nerve-sparing techniques in gynecologic surgery through a better understanding of surgical technique description. We have proposed a standardized terminology believed to facilitate this goal.

Comparison of survival outcomes between robotic and laparoscopic radical hysterectomies for early-stage cervical cancer: a systemic review and meta-analysis

OBJECTIVE

Survival outcomes of robotic radical hysterectomy (RRH) remain controversial. Therefore, we performed a meta-analysis to evaluate survival outcomes between RRH) and laparoscopic radical hysterectomy (LRH) in patients with early-stage cervical cancer.

METHODS

Studies comparing between RRH and LRH published up to November 2022 were systemically searched in the PubMed, Cochrane Library, Web of Science, ScienceDirect, and Google Scholar databases. Manual searches of related articles and relevant bibliographies of the published studies were also performed. Two researchers independently extracted data. Studies with information on recurrence and death after minimally invasive radical hysterectomy were also included. The extracted data were analyzed using the Stata MP software package version 17.0.

RESULTS

Twenty eligible clinical trials were included in the meta-analysis. When all studies were pooled, the odds ratios of RRH for recurrence and death were 1.19 (95% confidence interval [CI]=0.91-1.55; p=0.613; I²=0.0%) and 0.96 (95% CI=0.65-1.42; p=0.558; I²=0.0%), respectively. In a subgroup analysis, the quality of study methodology, study size, country where the study was conducted, and publication year were not associated with survival outcomes between RRH and LRH.

CONCLUSION

This meta-analysis demonstrates that the survival outcomes are comparable between RRH and LRH.

TRIAL REGISTRATION

International Prospective Register of Systematic Reviews Identifier: CRD42023387916.

Effect of robotic versus laparoscopic surgery on postoperative wound infection in patients with cervical cancer: A meta-analysis

The objective of this research is to evaluate the risk of postoperative infection and other risks associated with robotic radical hysterectomy (RRH) compared with laparoscopic radical hysterectomy (LRH). Recent studies on RRH versus LRH have not been conclusive for cervical carcinoma. Our group attempted to use meta-analyses to evaluate the effects of both RRH and LRH on postoperative outcomes in order to make sure that the best operative method was used to prevent wound infections. We looked up Cochrane Library and published databases for this research and found 594 findings. Articles were screened by title and abstract and then carefully examined for inclusion and exclusion criteria. Data extraction was performed independently by two researchers. Comparison studies were used to describe the incidence of wound complications after surgery. The publication bias was assessed using Egger regression correlation analysis. There were six trials eligible for inclusion, of which 491 RRH and 807 LRH. Depending on surgery for cervical carcinoma, it is true that there is a difference in the way that surgery affects the postoperative complications. Our analysis demonstrated that the use of robotic operation can decrease the amount of blood loss during operation as compared with routine laparoscopy (MD, -77.69; 95% CI, -132.08, -23.30; p = 0.005). However, there were no statistical differences in the incidence of postoperative wound infections (OR, 0.54; 95% CI, 0.25, 1.19; p = 0.13) and intraoperative operative time (MD, 13.01; 95% CI, -41.38, 67.41; p = 0.64) among the two procedures. There was no statistically significant difference between these two groups of patients with severe postoperative complications. Unlike other research, the findings of this meta-analysis are not consistent with the findings of the present study, which suggest that robotic operations cannot lower the rate of postoperative wound infections. However, because of the limitations and the retrospective character of the trials covered, these findings should be interpreted with care and more extensive research is required.

Systematic Review and Meta-analysis of laparoscopic radical hysterectomy vs. Robotic assisted radical hysterectomy for early stage cervical cancer

OBJECTIVE

Following compelling evidence that open techniques may be related to better survival and disease free survival rates, many gynecologic oncologists in the US have turned away from performing laparoscopic radical hysterectomy (LRH) and robotic radical hysterectomy (RRH) for the treatment of early-stage cervical cancer. While this may be warranted as a safety concern, there is little high-quality data on the head-to-head comparison of LRH and RRH and therefore little evidence to answer the question of where this decrease in patient survival is originating from. In our systematic review, we aimed to compare the complications and outcomes of LRH against those of RRH.

DATA SOURCES

We searched PubMed, Cochrane CENTRAL, Medline, ClinicalTrials.Gov, SCOPUS, and Web of Science from database inception until February 1st, 2022.

METHODS OF STUDY SELECTION

A total of 676 studies were identified and screened through a manual three-step process. Ultimately 33 studies were included in our final analysis. We included all studies that compared LRH and RRH and included at least one of our selected outcomes. We included retrospective cohorts, prospective cohorts, case-control, and randomized clinical trials.

TABULATION, INTEGRATION, AND RESULTS

Data was independently extracted manually by multiple observers and the analysis was performed using Review Manager Software. PRISMA guidelines were followed. We analyzed homogenous data using a fixed-effects model, while a random-effects model was used for heterogeneous outcomes. We found that following RRH, women had a decreased hospital stay (MD = 0.80[0.38,1.21],(P < 0.002). We found no differences in estimated blood loss (MD = 35.24[-0.40,70.89],(P = 0.05), blood transfusion rate ((OR = 1.32[0.86,2.02],(P = 0.20), rate of post-operative complications (OR = 0.84[0.60,1.17],(P = 0.30), the operative time (MD = 6.01[-4.64,16.66],(P = 0.27), number of resected lymph node (MD = -1.22[-3.28,0.84],(P = 0.25) intraoperative complications (OR = 0.78[0.51,1.19],(P = 0.25), five-year overall survival (OR = 1.37[0.51,3.69],(P = 0.53), lifetime disease free survival (OR = 0.89[0.59,1.32],(P = 0.55), intraoperative and postoperative mortality (within 30 days) (OR = 1.30[0.66,2.54],(P = 0.44), and recurrence (OR = 1.14[0.79,1.64],(P = 0.50).

CONCLUSIONS

RRH seems to result in the patient leaving the hospital sooner after surgery. We were unable to find any differences in our ten other outcomes related to complications or efficacy. These findings suggest that the decreased survival seen in minimally invasive RH in previous studies could be due to factors inherent to both LRH and RRH.

PROSPERO PROSPECTIVE REGISTRATION NUMBER

CRD42022273727.

The incidence of perioperative lymphatic complications after radical hysterectomy and pelvic lymphadenectomy between robotic and laparoscopic approach : a systemic review and meta-analysis

BACKGROUND

Although many studies have reported perioperative complications after radical hysterectomy and pelvic lymph node dissection using robotic and laparoscopic approaches, the risk of perioperative lymphatic complications has not been well identified. The aim of this meta-analysis is to compare the risks of perioperative lymphatic complications after robotic radical hysterectomy and lymph node dissection (RRHND) with laparoscopic radical hysterectomy and lymph node dissection (LRHND) for early uterine cervical cancer.

MATERIALS AND METHODS

The authors searched the PubMed, Cochrane Library, Web of Science, ScienceDirect, and Google Scholar databases for studies published up to July 2022 comparing perioperative lymphatic complications after RRHND and LRHND while treating early uterine cervical cancer. Related articles and bibliographies of relevant studies were also checked. Two reviewers independently performed the data extraction.

RESULTS

A total of 19 eligible clinical trials (15 retrospective studies and 4 prospective studies) comprising 3079 patients were included in this analysis. Only 107 patients (3.48%) had perioperative lymphatic complications, of which the most common was lymphedema ( n =57, 1.85%), followed by symptomatic lymphocele ( n =30, 0.97%), and lymphorrhea ( n =15, 0.49%). When all studies were pooled, the odds ratio for the risk of any lymphatic complication after RRHND compared with LRHND was 1.27 (95% CI: 0.86-1.89; P =0.230). In the subgroup analysis, study quality, country of research, and publication year were not associated with perioperative lymphatic complications.

CONCLUSIONS

A meta-analysis of the available current literature suggests that RRHND is not superior to LRHND in terms of perioperative lymphatic complications.

Laparoscopic nerve‑sparing radical hysterectomy for the treatment of cervical cancer: a meta-analysis of randomized controlled trials

Background

The effects and safety of laparoscopic nerve‑sparing radical hysterectomy (LNSRH) and laparoscopic radical hysterectomy (LRH) in cervical cancer treatment remain unclear. This article aims to evaluate the role of LNSRH versus LRH in the treatment of cervical cancer. This is because the updated meta-analysis with synthesized data may provide more reliable evidence on the role of LNSRH and LRH.

Methods

We searched Pubmed et al. databases for randomized controlled trials (RCTs) involving laparoscopic nerve‑sparing radical hysterectomy (LNSRH) and laparoscopic radical hysterectomy (LRH) for cervical cancer treatment from the inception of databases to June 15, 2021. The RevMan 5.3 software was used for data analyses. This meta-analysis protocol had been registered online (available at: https://inplasy.com/inplasy-2021-9-0047/).

Results

Thirteen RCTs involving a total of 1002 cervical cancer patients were included. Synthesized results indicated that the duration of surgery of the LNSRH group was significantly longer than that of the LRH group [SMD 1.11, 95% CI (0.15 ~ 2.07), P = 0.02]. The time to intestinal function recovery [SMD −1.27, 95% CI (−1.84 ~ −0.69), P < 0.001] and the time to postoperative urinary catheter removal of the LNSRH group [SMD −1.24, 95% CI (−1.62 ~ −0.86), P < 0.001] were significantly less than that of the LRH group. There were no significant differences in the estimated blood loss [SMD 0.10, 95% CI (−0.14 ~ 0.34), P = 0.41], the length of parauterine tissue resection [SMD −0.10, 95% CI (−0.25 ~ 0.05), P = 0.19], length of vaginal excision [SMD 0.04, 95% CI (−0.26 ~ 0.34), P = 0.78], and incidence of intraoperative adverse events [RR 0.97, 95% CI (0.44 ~ 2.13), P = 0.94] between the LNSRH group and the LRH group.

Conclusions

LNSRH significantly results in earlier bladder and bowel function after surgery. Limited by sample size, LNSRH should be considered with caution in the future.

The early surgical period in robotic radical hysterectomy is related to the recurrence after surgery in stage IB cervical cancer

Objective: To identify the pattern of recurrence and assess the clinicopathologic prognostic factors for survival after robotic radical hysterectomy (RRH) in the treatment of stage IB cervical cancer. Methods: From December 2008 to March 2018, 64 cervical cancer patients who underwent RRH with pelvic lymph node dissection by a single surgeon were enrolled in this retrospective historical cohort timeline study. The patient's status was estimated in terms of operative outcomes, pathologic results, and survival outcomes. Results: The median follow-up was 63 months. The recurrence rate was 9.4% (6/64). There were two recurrences at the vaginal vault, two in the pelvic cavity, and two at the peritoneum in the intraabdominal cavity. The overall survival rate was 95.3% (61/64). When patients were divided into three groups in order based on surgery date, the first surgical period showed significantly higher recurrence rate (21%) compared to both the second (10%) and the third period (0%) (p=0.037). Multivariate analysis showed that the early period of RRH (p=0.025) and clinical tumor size more than 3 cm (p=0.003) were prognostic factors related to the recurrence. Although there was no statistical significance, there has been no recurrence since a uterine manipulator was not used. Conclusion: The early surgical period and large tumor were related to the disease recurrence after RRH. We suggest that the achievement of proficiency and appropriate patient selection are critical for prognosis after RRH in stage IB cervical cancer.

A retrospective assessment of the safety and efficacy of laparoscopic radical hysterectomy in Japan during the early years following its introduction: a Japanese Gynecologic Oncology Group study (JGOG1081S)

OBJECTIVE

To evaluate the safety and efficacy of laparoscopic radical hysterectomy (LRH) for cervical cancer, in terms of morbidity and short-term oncologic outcome following LRH's introduction into Japan.

METHODS

We conducted a retrospective analysis of patients with early-stage cervical cancer (FIGO staging IA2, IB1, and IIA1) who underwent LRH from Dec 2014 to Dec 2016. We assessed the morbidity, overall survival (OS) and recurrence-free survival (RFS), and prognostic factors for RFS.

RESULTS

A total of 251 patients were included from 22 facilities across Japan. There were 8 cases of stage IA2 cervical cancer, 226 of IB1, and 17 of IIA1. The median operating time was 343 min and the median blood loss was 190 ml. Two patients (0.8%) had a postoperative complication with a Clavien-Dindo classification of grade 3 or higher. After a median follow-up time of 15.6 months, the 2-year RFS was 87.4%, and the 2-year OS was 97.8%. When the 2-year RFS rate was compared with whether the patient pathologically had tumors of less than 2 cm, versus 2 cm or more, the RFS was 95.8% and 80.4%, respectively. Multivariate analysis found that tumor size and the route of lymph node removal were independent prognostic factors for recurrence.

CONCLUSION

When LRH was first introduced into Japan, we found that the route of lymph node removal was an independent prognostic factor for recurrence in addition to large tumors (≥ 2 cm). Our results suggest that prognosis may be secured by paying attention to the lymph node removal route.

Comparative analysis of robotic vs laparoscopic radical hysterectomy for cervical cancer

BACKGROUND

Cervical cancer is the most common gynecological malignancy, ranking first in female reproductive malignancies with more than 500000 new cases and 275000 deaths each year. Traditionally, open radical hysterectomy is considered the standard surgical procedure for the treatment of resectable cervical cancer. The latest guidelines from the National Comprehensive Cancer Network and the European Society of Gynecological Oncology suggest that open surgery and laparoscopic surgery (using traditional laparoscopic or robotic techniques) are the main surgical approaches for radical hysterectomy for patients with stage IA2-IIA cervical cancer. Robotic surgery has been increasingly used in abdominal surgery and has shown more beneficial effects.

AIM

To analyse the perioperative conditions, complications, and short-term and long-term effects in patients undergoing robotic radical hysterectomy (RRH) and laparoscopic radical hysterectomy (LRH) to compare their clinical efficacy, safety, and feasibility.

METHODS

The perioperative data of patients undergoing RRH and LRH were extracted and collected from the database of surgical treatments for cervical cancer for statistical analysis.

RESULTS

Of the patients, 342 underwent LRH for cervical cancer, and 216 underwent RRH. The total complication rate was 9.65% (20 patients) in the RRH group and 17.59% (60 patients) in the LRH group. The complication rate was significantly lower in the RRH group than in the LRH group. There was no significant difference in the follow-up period (P = 0.658). The total recurrence rates were 15.7% and 12% in the RRH and LRH groups, respectively. The progression-free survival time was 28.91 ± 15.68 mo and 28.34 ± 15.13 mo in the RRH and LRH groups, respectively (P = 0.669). The overall survival (OS) rates were 92.13% and 94.45% in the RRH and LRH groups, respectively (P = 0.292). The OS time was 29.87 ± 15.92 mo and 29.41 ± 15.14 mo in the RRH and LRH groups, respectively (P = 0.732). The survival curves and the progression-free survival curves were not statistically significantly different between the two groups (P = 0.407 and 0.28, respectively).

CONCLUSION

RRH is associated with significantly less operative time and blood loss than LRH. The two procedures have similar complication rates, OS, and progression-free survival time.

Safety and effectiveness of robotic hysterectomy versus conventional laparoscopic hysterectomy in patients with cervical cancer in China

OBJECTIVE

The aim of this study was to compare the safety and effectiveness of robotic hysterectomy (RH) with conventional laparoscopic hysterectomy (LH) for the treatment of cervical cancer using multivariate regressions.

METHODS

We designed a retrospective single-center study and consecutively collected patients with cervical cancer from February 2014 to October 2017. Data extraction was performed by two independent researchers. The surgical outcomes include operative time, estimated blood loss, number of lymph nodes, time to first flatus, time to a full diet, time to remove drainage tube, length of hospital stay, and postoperative complication.

RESULTS

A total of 152 patients with cervical cancer were collected in our study including 92 patients who underwent RH and 60 patients who underwent LH. Both groups have similar characteristics. The RH group showed shorter operative time (Coe - 42.89; 95% CI - 74.39 to 11.39; P = 0.008) and more number of lymph nodes (Coe 6.06; 95% CI 2.46-9.66; p = 0.001) than the LH group. As for the postoperative parameters, the RH group showed shorter time to remove drainage tube (Coe - 0.89; 95% CI -1.62 to -0.15; p = 0.019) and length of hospital stay (Coe - 6.40; 95% CI - 10.19 to - 2.95; p = 0.001). No significant difference was found between the groups in estimated blood loss (Coe 34.64; 95% CI - 33.08 to 102.37; p = 0.314), time to first flatus (Coe 0.11; 95% CI - 0.38 to 0.61; p = 0.652), time to a full diet (Coe - 0.24; 95% CI - 0.54 to 0.06, p = 0.118), and postoperative complication (OR 0.84; 95% CI 0.35-1.98; p = 0.685).

CONCLUSION

The results from this study suggest that RH is safe and effective as LH but robotic surgery significantly contributed to the feasibility of alternative treatment options for cervical cancer patients.

Nerve-sparing radical hysterectomy compared to standard radical hysterectomy for women with early stage cervical cancer (stage Ia2 to IIa)

BACKGROUND

Radical hysterectomy is one of the standard treatments for stage Ia2 to IIa cervical cancer. Bladder dysfunction caused by disruption of the pelvic autonomic nerves is a common complication following standard radical hysterectomy and can affect quality of life significantly. Nerve-sparing radical hysterectomy is a modified radical hysterectomy, developed to permit resection of oncologically relevant tissues surrounding the cervical lesion, while preserving the pelvic autonomic nerves.

OBJECTIVES

To evaluate the benefits and harms of nerve-sparing radical hysterectomy in women with stage Ia2 to IIa cervical cancer.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL; 2018, Issue 4), MEDLINE via Ovid (1946 to May week 2, 2018), and Embase via Ovid (1980 to 2018, week 21). We also checked registers of clinical trials, grey literature, reports of conferences, citation lists of included studies, and key textbooks for potentially relevant studies.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) evaluating the efficacy and safety of nerve-sparing radical hysterectomy compared to standard radical hysterectomy for women with early stage cervical cancer (stage Ia2 to IIa).

DATA COLLECTION AND ANALYSIS

We applied standard Cochrane methodology for data collection and analysis. Two review authors independently selected potentially relevant RCTs, extracted data, evaluated risk of bias of the included studies, compared results and resolved disagreements by discussion or consultation with a third review author, and assessed the certainty of evidence.

MAIN RESULTS

We identified 1332 records as a result of the search (excluding duplicates). Of the 26 studies that potentially met the review criteria, we included four studies involving 205 women; most of the trials had unclear risks of bias. We identified one ongoing trial.The analysis of overall survival was not feasible, as there were no deaths reported among women allocated to standard radical hysterectomy. However, there were two deaths in among women allocated to the nerve-sparing technique. None of the included studies reported rates of intermittent self-catheterisation over one month following surgery. We could not analyse the relative effect of the two surgical techniques on quality of life due to inconsistent data reported. Nerve-sparing radical hysterectomy reduced postoperative bladder dysfunctions in terms of a shorter time to postvoid residual volume of urine ≤ 50 mL (mean difference (MD) -13.21 days; 95% confidence interval (CI) -24.02 to -2.41; 111 women; 2 studies; low-certainty evidence) and lower volume of postvoid residual urine measured one month following operation (MD -9.59 days; 95% CI -16.28 to -2.90; 58 women; 2 study; low-certainty evidence). There were no clear differences in terms of perioperative complications (RR 0.55; 95% CI 0.24 to 1.26; 180 women; 3 studies; low-certainty evidence) and disease-free survival (HR 0.63; 95% CI 0.00 to 106.95; 86 women; one study; very low-certainty evidence) between the comparison groups.

AUTHORS' CONCLUSIONS

Nerve-sparing radical hysterectomy may lessen the risk of postoperative bladder dysfunction compared to the standard technique, but the certainty of this evidence is low. The very low-certainty evidence for disease-free survival and lack of information for overall survival indicate that the oncological safety of nerve-sparing radical hysterectomy for women with early stage cervical cancer remains unclear. Further large, high-quality RCTs are required to determine, if clinically meaningful differences of survival exist between these two surgical treatments.

Efficacy of robotic radical hysterectomy for cervical cancer compared with that of open and laparoscopic surgery: A separate meta-analysis of high-quality studies

BACKGROUND

To perform a meta-analysis of high-quality studies comparing robotic radical hysterectomy (RRH) vs laparoscopic radical hysterectomy (LRH), and open radical hysterectomy (ORH) for the treatment of cervical cancer.

METHODS

A systematic search of PubMed, Embase, Cochrane Library, and Web of Science was performed to identify studies that compared RRH with LRH or ORH. The selection of high-quality, nonrandomized comparative studies was based on a validated tool (methodologic index for nonrandomized studies) since no randomized controlled trials have been published. Outcomes of interest included conversion rate, operation time, intraoperative estimated blood loss (EBL), length of hospital stay (LOS), morbidity, mortality, number of retrieved lymph nodes (RLNs), and long-term oncologic outcomes.

RESULTS

Twelve studies assessing RRH vs LRH or ORH were included for this meta-analysis. In comparison with LRH, there was no difference in operation time, EBL, conversion rate, intraoperative or postoperative complications, LOS, and tumor recurrence (P > .05). Compared with ORH, patients underwent RRH had less EBL (weighted mean difference [WMD] = -322.59 mL; 95% confidence interval [CI]: -502.75 to -142.43, P < .01), a lower transfusion rate (odds ratio [OR] = 0.14, 95% CI: 0.06-0.34, P < .01), and shorter LOS (WMD = -2.71 days; 95% CI: -3.74 to -1.68, P < .01). There was no significant difference between RRH and LRH with respect to the operation time, intraoperative or postoperative complications, RLN, and tumor recurrence (P > .05).

CONCLUSION

Our results indicate that RRH is safe and effective compared to its laparoscopic and open counterpart and provides favorable outcomes in postoperative recovery.

Robotic-Assisted Radical Hysterectomy Results in Better Surgical Outcomes Compared With the Traditional Laparoscopic Radical Hysterectomy for the Treatment of Cervical Cancer

Objective

The aim of this study was to compare the surgical outcomes of robotic-assisted radical hysterectomy (RRH) with traditional laparoscopic radical hysterectomy (TLRH) for the treatment of early-stage cervical cancer in a large retrospective cohort of a total of 933 patients.

Methods

We have enrolled 100 patients into the RRH and 833 patients into the TLRH group. The surgical outcomes include operating time, blood loss, transfusion rate, pelvic lymph node yield, hospitalization days, duration of bowel function recovery, catheter removal before and after 3 weeks, conversion to laparotomy, and intraoperative and postoperative complications. Follow-up results were also analyzed for all patients.

Results

Both groups have similar patient and tumor characteristics but patients with a larger lesion size were preferably enrolled in the TLRH treatment group. The treatment with RRH was generally superior to TLRH with respect to operating time, blood loss, length of hospitalization, duration of bowel function recovery, and postoperative complications. On follow-up of patients, there were no relapses reported in the RRH group compared with 4% of relapse cases and 2.9% of deaths because of metastasis in the TLRH group. No conversion of laparotomy occurred in the RRH group. No significant difference was found with respect to intraoperative complications and blood transfusion between both groups.

Conclusions

The results from this study suggest that RRH is superior to TLRH with regard to surgical outcome and may pose a safe and feasible alternative to TLRH. The operating time and lymph node yield is acceptable. Our study is one of the largest single-center studies of surgical outcomes comparing RRH with TLRH during cervical cancer treatment and will significantly contribute to the safety of alternative treatment options for patients. Furthermore, the difference detected between TLRH and RRH group is further strengthened by the great expertise of the surgeon performing laparoscopic surgeries.

Robotic versus laparoscopic radical hysterectomy in early cervical cancer: A case matched control study

BACKGROUND

This study aims at evaluating the feasibility, surgical outcome and oncological results observed after robotic radical hysterectomy (RH) compared to laparoscopy for patients with early stage cervical cancer (ECC) patients.

METHODS

Between January 2010 and October 2016, 210 patients underwent RH for treatment of ECC: 70 underwent robotic approach (Cases), and 140 underwent laparoscopic approach (Controls).

RESULTS

There was no statistically significant difference between the two approaches with regard to clinical patient characteristics and in terms of extent of RH and rate of pelvic and aortic lymphadenectomy. Operative time was significantly longer in the robotic versus laparoscopic group (median = 243 min, range 90-612 versus median = 210 min, range 80-660; p value = 0.008). Conversion to laparotomy was necessary in 4 patients (1.9%) in the whole series. No difference was found in terms of intraoperative and postoperative complications between the two groups. Overall, during the observation period, 34 (16.2%) patients experienced any grade postoperative complications, and 21 (10.0%) had >G2 complications. The 3-yr DFS was 88.0% versus 84.0% in robotic and laparoscopic group, respectively (p value = 0.866). Central and/or lateral pelvic disease represented the most common site of relapse. The 3-yr OS was 90.8% in patients underwent robotic RH versus 94.0% in patients underwent laparoscopic RH (p value = 0.924).

CONCLUSIONS

The present study shows the equivalence of robotic and laparoscopic approaches to radical surgery of ECC patients, in terms of perioperative and postoperative outcomes with equivalent survival figures, and thus the choice of approach can be tailored to the choice of patient and surgeon.

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.

Perioperative Outcomes of 3-Arm Versus 4-Arm Robotic Radical Hysterectomy in Patients with Cervical Cancer

STUDY OBJECTIVE

To investigate and compare surgical outcomes of the 3 versus 4 robotic arm approaches for robotic surgery in patients with cervical cancer.

DESIGN

A retrospective analysis of prospectively collected data (Canadian Task Force classification II-2).

SETTING

An academic tertiary hospital.

PATIENTS

A total of 142 patients with stage 1A1 to IIB cervical carcinoma who underwent robotic surgery were included for analysis. The subjects were divided according to the surgical approach (i.e., the number of robotic arms), and the 2 groups were compared in terms of intraoperative data and postoperative outcomes.

INTERVENTIONS

Robotic radical hysterectomy (RRH) with lymphadenectomy using 3 robotic arms (n = 101) versus 4 robotic arms (n = 41).

MEASUREMENTS AND MAIN RESULTS

Perioperative surgical outcomes. The 3-arm robotic approach consisted of a camera arm, 2 robotic arms, and 1 conventional assistant port. An additional robotic arm was placed on the right side of the patient's abdomen for the 4-arm robotic approach. The mean age, body mass index, cell type, Fédération Internationale de Gynécologie et d'Obstétrique stage, and type of surgery were not significantly different between the 2 cohorts. The 3-arm approach showed favorable outcomes over the 4-arm approach in terms of postoperative pain at 6 and 24 hours (3.8 ± 1.8 vs 4.5 ± 1.7 and 2.8 ± 1.7 vs 3.4 ± 1.6, respectively; p = .033 and .049) and postoperative hemoglobin difference (1.8 ± 0.9 vs 2.6 ± 1.3 and 1.9 ± 1.1 vs 2.4 ± 0.9 on days 1 and 3, respectively; p = .002 and .004). The median length of postoperative hospital stay, total operative time, docking time, lymph node yield, and intraoperative and postoperative complication rates were comparable between the 2 cohorts.

CONCLUSION

Surgical outcomes and complications rates of RRH for cervical cancer using the 4-arm approach were comparable with that of the 3-arm approach with decreased early postoperative pain in the 3-arm group. Cost-benefit analysis and the impact on surgical training are needed in the future.

Role of robotic surgery in cervical malignancy

Surgical treatment is the mainstay of the management of early-stage cervical cancer. Abdominal radical hysterectomy and trachelectomy have long been the standard surgical approach to early-stage cervical cancer, achieving excellent survival outcomes. Recently, laparoscopic radical hysterectomy and trachelectomy have become the preferred alternative to abdominal surgery because laparoscopic approaches lead to better surgical outcomes without compromising survival outcomes. Since the robotic surgery platform was approved for the use of gynaecologic surgery in 2005, robotic radical hysterectomy and trachelectomy have been increasingly used in the surgical management of early-stage cervical cancer. However, the role of robotic surgery is poorly defined. This review examines the role of robotic surgery in the surgical management of cervical cancer by comparing the published data on its use with those of abdominal and laparoscopic surgeries.

Superiority of robotic surgery for cervical cancer in comparison with traditional approaches: A systematic review and meta-analysis

OBJECTIVES

To review the safety and effectiveness of da Vinci robotic surgery for cervical cancer in comparison with the traditional open surgery and conventional laparoscopic operation.

METHODS

Based on Medline, the Cochrane library, Embase, and the Journal of Robotic Surgery prior to December 30st, 2015, we searched for controlled trials and observational studies. A systematic review with meta-analyses was conducted to compare the clinical efficacy between the da Vinci robotic surgery, open surgery, and laparoscopic surgery for cervical cancer. Data were pooled using the random effects meta-analysis.

RESULTS

Compared with the open surgery, the robotic surgery for cervical cancer would be advantageous in terms of the length of hospital stay, incidence of complications, volume of blood loss and blood transfusion. The operative time of robotic surgery was longer than that of the open surgery, but the prediction intervals indicated that they could be shorter in future studies. Meanwhile, compared with conventional laparoscopic surgery, the robotic surgery could offer more benefits in terms of the length of hospital stay, while no difference was found in terms of the incidence of complications and the volume of blood loss.

CONCLUSIONS

Compared to open surgery, the robotic surgery would be advantageous for cervical cancer patients in terms of the length of hospital stay, the incidence of complications, blood loss and blood transfusion. Compared with conventional laparoscopic surgery, the robotic surgery would result in longer OT, more BL and shorter LOS. The study quality was poor.

Robot-assisted Surgery in Gynecologic Cancers

Robotic-assisted surgery is a technological advancement that facilitates the application of minimally invasive techniques for complex operations in gynecologic oncology. The objective of this article was to review the literature regarding the role of robotic-assisted surgery to treat women with gynecologic cancers. The majority of publications on robotic surgery are still retrospective or descriptive in nature; however, the data for managing patients with a robotic-assisted approach show comparable, and at times improved, outcomes compared with both laparoscopy (2-dimensional) and laparotomy approaches. Robotic-assisted surgery has been used for patients with endometrial cancer and resulted in the increased use of minimally invasive surgery with improved outcomes compared with laparotomy and partially with laparoscopy. This has been shown in large cohorts of patients as well as in obese patients in whom the complication rates have significantly decreased. For early cervical cancer, robotic radical hysterectomy seems to be safe and feasible and to be preferable to laparotomy with seemingly comparable oncologic outcomes. Robotic-assisted surgery and conventional laparoscopy to stage women with early-stage ovarian cancer seem to have similar surgical and oncologic outcomes, with a shorter learning curve for robotic-assisted surgery. However, robotic-assisted surgery appears to be more expensive than laparotomy and traditional laparoscopy. In conclusion, robotic-assisted surgery appears to facilitate the surgical approach for complex operations to treat women with gynecologic cancers. Although randomized controlled trials are lacking to further elucidate the equivalence of robot-assisted surgery with conventional methods in terms of oncologic outcome and patients' quality of life, the technology appears to be safe and effective and could offer a minimally invasive approach to a much larger group of patients.

Safety and Cost Considerations during the Introduction Period of Laparoscopic Radical Hysterectomy

Objective. To compare the safety, efficacy, and direct cost during the introduction of laparoscopic radical hysterectomy within an enhanced recovery pathway. Methods. A 1 : 1 single centre retrospective case control study of 36 propensity matched pairs of patients receiving open or laparoscopic surgery for early cervical cancer. Results. There were no significant differences in the baseline characteristics of the two cohorts. Open surgery cohort had significantly higher intraoperative blood loss (189 versus 934 mL) and longer postoperative hospital stay (2.3 versus 4.1 days). Although no significant difference in the intraoperative or postoperative complications was found more urinary tract injuries were recorded in the laparoscopic cohort. Laparoscopic surgery had significantly longer duration (206 versus 159 minutes), lower lymph node harvest (12.6 versus 16.9), and slower bladder function recovery. The median direct hospital cost was £4850 for laparoscopic radical hysterectomy and £4400 for open surgery. Conclusions. Laparoscopic radical hysterectomy can be safely introduced in an enhanced recovery environment without significant increase in perioperative morbidity. The 10% higher direct hospital cost is not statistically significant and is expected to even out when indirect costs are included.

Bowel injury in robotic gynecologic surgery: risk factors and management options. A systematic review

OBJECTIVE

We sought to analyze the published literature on bowel injuries in patients undergoing gynecologic robotic surgery with the aim to determine its incidence, predisposing factors, and treatment options.

DATA SOURCES

Studies included in this analysis were identified by searching PubMed Central, OVID Medline, EMBASE, Cochrane, and ClinicalTrials.gov databases. References for all studies were also reviewed. Time frame for data analysis spanned from November 2001 through December 2014.

STUDY ELIGIBILITY CRITERIA

All English-language studies reporting the incidence of bowel injury or complications during robotic gynecologic surgery were included. Studies with data duplication, not in English, case reports, or studies that did not explicitly define bowel injury incidence were excluded.

STUDY APPRAISAL AND SYNTHESIS METHODS

The Guidelines for Meta-Analyses and Systematic Reviews of Observational Studies were used to complete the systematic review with the exception of scoring study quality and a single primary reviewer.

RESULTS

In all, 370 full-text articles were reviewed and 144 met the inclusion criteria. There were 84 bowel injuries recorded in 13,444 patients for an incidence of 1 in 160 (0.62%; 95% confidence interval, 0.50-0.76%). There were no significant differences in incidence of bowel injury by procedure type. The anatomic location of injury, etiology, and management were rarely reported. Of the bowel injuries, 87% were recognized intraoperatively and the majority (58%) managed via a minimally invasive approach. Of 13,444 patients, 3 (0.02%) (95% confidence interval, 0.01-0.07%) died in the immediate postoperative period and no deaths were a result of a bowel injury.

CONCLUSION

The overall incidence of bowel injury in robotic-assisted gynecologic surgery is 1 in 160. When the location of bowel injuries were specified, they most commonly occurred in the colon and rectum and most were managed via a minimally invasive approach.

Surgical and clinical safety and effectiveness of robot-assisted laparoscopic hysterectomy compared to conventional laparoscopy and laparotomy for cervical cancer: A systematic review and meta-analysis

AIM

This study aimed to evaluate the surgical safety and clinical effectiveness of RH versus LH and laparotomy for cervical cancer.

METHODS

We searched Ovid-Medline, Ovid-EMBASE, and the Cochrane library through May 2015, and checked references of relevant studies. We selected the comparative studies reported the surgical safety (overall; peri-operative; and post-operative complications; death within 30 days; and specific morbidities), and clinical effectiveness (survival; recurrence; length of stay [LOS]; estimated blood loss [EBL]; operative time [OT]) and patient-reported outcomes.

RESULTS

Fifteen studies comparing RH with OH and 11 comparing RH with LH were identified. No significant differences were found in survival outcomes. The LOS was shorter and transfusion rate was lower with RH compared to OH or LH. EBL was significantly reduced with RH compared to OH. Compared to OH, overall complications, urinary infection, wound infection, and fever were significantly less frequent with RH. The overall, peri-operative, and post-operative complications were similar in other comparisons. Several patient-reported outcomes were improved with RH, though each outcome was reported in only one study.

CONCLUSIONS

RH appears to have a positive effect in reducing overall complications, individual adverse events including wound infection, fever, urinary tract infection, transfusion, LOS, EBL, and time to diet than OH for cervical cancer patients. Compared to LH, the current evidence is not enough to clearly determine its clinical safety and effectiveness. Further rigorous prospective studies with long-term follow-up that overcome the many limitations of the current evidence are needed.

Cost analysis of minimally invasive hysterectomy vs open approach performed by a single surgeon in an Italian center

Despite the rapid uptake of robotic surgery, the effectiveness of robotically assisted hysterectomy (RAH) remains uncertain, due to the costs widely variable. Observed the different related costs of robotic procedures, in different countries, we performed a detailed economic analysis of the cost of RAH compared with total laparoscopic (TLH) and open hysterectomy (OH). The three surgical routes were matched according to age, BMI, and comorbidities. Hysterectomy costs were collected prospectively from September 2014 to September 2015. Direct costs were determined by examining the overall medical pathway for each type of intervention. Surgical procedure cost for RAH was €3598 compared with €912 for TLH and €1094 for OH. The cost of the robot-specific supplies was €2705 per intervention. When considering overall medical surgical care, the patient treatment average cost of a RAH was €4695 with a hospital stay (HS) of 2 days (range 2-4) compared with €2053 for TLH and €2846 for OH. The main driver of additional costs is disposable instruments of the robot, which is not compensated by the hospital room costs and by an experienced team staff. Implementation of strategies to reduce the cost of robotic instrumentation is due. No significant cost difference among the three procedures was observed; however, despite the optimal operative time, the experienced, surgeon and the lower HS, RAH resulted 2, 3 times and 1, 6 times more expensive in our institution than TLH and OH, respectively.

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.

Complication reports for robotic surgery using three arms by a single surgeon at a single institution

BACKGROUND:

The aim of this study is to evaluate perioperative complications related to robotic-assisted laparoscopic surgery for management of gynaecologic disorders.

MATERIALS AND METHODS:

Eight hundred and fifty-one women who underwent robotic procedures between December 2011 and April 2015 were retrospectively included for analysis. Patient demographics, surgical outcomes and complications were evaluated.

RESULTS:

The overall complication rate was 5.5%, whereas the rate of complications for oncologic cases was 8.4%. Intra-operative complications (n = 7, 0.8%) consisted of five cases of bowel lacerations, one case of ureter laceration and one case of bladder injury. Early and late post-operative complications were 4.0% (n = 34) and 0.8% (n = 6), respectively. Six patients (0.7%) experienced Grade III complications based on the Clavien-Dindo classification and required further surgical intervention.

CONCLUSION:

Robotic-assisted laparoscopic surgery is a feasible approach for management of gynaecologic disorders; the complication rates for this type of procedure are acceptable.

Laparoscopic Nerve-Sparing Radical Hysterectomy for Cervical Carcinoma: Emphasis on Nerve Content in Removed Cardinal Ligaments

Objective

To evaluate the histopathology of autonomic nerve removal within the cardinal ligaments (CLs), patients’ postoperative urinary function, and the feasibility and safety of laparoscopic nerve-sparing radical hysterectomy (LNSRH) for treatment of early-stage cervical cancer.

Methods

Perioperative and postoperative parameters were compared between patients with biopsy-proven, early-stage cervical carcinoma treated with LNSRH (n = 64) versus those treated with laparoscopic radical hysterectomy (LRH, n = 42) in a retrospective study. Nerves within CLs were identified by hematoxylin-eosin staining. Rates of the following complications were compared: bladder function, sexual dysfunction, and defecation problems.

Results

Duration of surgery, intraoperative blood loss, duration of hospitalization, and morbidity did not differ significantly between the LNSRH and LRH groups. Patients who underwent LNSRH had a significantly earlier return of bladder and bowel functions, with an average time to achieve residual urine of 50 mL or less of 10.22 days and a mean first defecation time of 3.58 days. Nerves were observed mainly in the CLs of the LRH group. Disease-free survival rate did not differ between the LNSRH (90.6%) and LRH (88.1%) groups (P = 0.643).

Conclusions

The LNSRH is a safe, feasible, and easy procedure for trained laparoscopic surgeons. Patients who underwent LNSRH had a more satisfactory quality of life than patients who underwent LRH.

Robot-Assisted Radical Hysterectomy in Cervical Carcinoma: The Belgian Experience

Objective

The purpose of this study was to report the experience and oncological outcome of robot-assisted radical hysterectomies (RRHs) for cervical cancer performed in Belgium.

Methods

Patients undergoing RRH for cervical cancer (n = 109) were prospectively collected between July 2007 and April 2014 in the 5 Belgian centers performing RRH for cervical cancer.

Results

The median age of the patients was 46 years (range, 31–80 years). Histological types included squamous cell carcinoma in 61 patients, adenocarcinoma in 22 patients, adenosquamous in 8 patients, endometrioid carcinoma in 2 patients, and other types (n = 16). The International Federation of Gynecology and Obstetrics stage distribution was IA (n = 9), stage IB1 (n = 71), stage IB2 (n = 4), stage II (n = 24), and unknown (n = 1). Twenty-four patients received adjuvant therapy, 17 patients underwent radiochemotherapy, and 7 underwent adjuvant radiation. Eighteen patients relapsed, and 5 died of disease. The median follow-up was 27.5 months (range, 3–82 months). The 2- and 5-year overall survivals were 96% and 89%, respectively. The 2- and 5-year disease-free survivals (DFSs) were 88% and 72%, respectively. The 2-year DFS per stage was 100% for IA, 88% for IB1, 100% for IB2, and 83% for II. The 5-year DFS per stage was 100% for stage IA and 75% for IB1. The complications were as expected for radical hysterectomy.

Conclusions

This series confirms the feasibility and safety of RRH not only in cervical cancer stage IA to IB1, but also after neoadjuvant chemotherapy in stage IB2 to IIB.

Robotic hysterectomy using the Vessel Sealer for myomatous uteri: technique and clinical outcome

OBJECTIVE

Robotic procedures using the Vessel Sealer are not well reported in the literature, especially given the advantages of sealing devices already studied in standard laparoscopic procedures. This study reports our experience with the EndoWrist(®) One™ Vessel Sealer in robotic hysterectomy for myomatous uteri.

STUDY DESIGN

In this retrospective cohort study of the first 50 consecutive patients with myomatous uteri undergoing a robotic hysterectomy, we report our experience with the EndoWrist(®) One™ Vessel Sealer (Intuitive Surgical Inc., Sunnyvale, CA) during this procedure. The learning curve was evaluated, and the operative times as well as the complications were recorded.

RESULTS

After the first 10 cases, the median console and total (skin-to-skin) operative time dropped significantly from 110 to 60min and from 158 to 105min, respectively (p=0.018 and p=0.008 respectively). The body mass index (≤ or >30kg/m(2)), uterine weight (≤ or >250g), and uterine size had no statistical significant effect on the total operative time. Median blood loss during surgery was 63mL in all cases (range: 0-400mL). The morbidity was low, and approximately 50% of cases could be discharged from the hospital after one to two days.

CONCLUSION

Robotic hysterectomy using the Vessel Sealer has, after a short learning curve of 10 cases, similar operative times than other published reports on robotic hysterectomy or laparoscopic hysterectomy using a sealing device for myomatous or large uteri.

Robotic radical hysterectomy in early stage cervical cancer: A systematic review and meta-analysis

OBJECTIVE

To compare intraoperative and short-term postoperative outcomes of robotic radical hysterectomy (RRH) to laparoscopic and open approaches in the treatment of early stage cervical cancer.

METHODS

A search of MEDLINE, EMBASE (using Ovid interface) and SCOPUS databases was conducted from database inception through February 15, 2014. We included studies comparing surgical approaches to radical hysterectomy (robotic vs. laparoscopic or abdominal, or both) in women with stages IA1-IIA cervical cancer. Intraoperative outcomes included estimated blood loss (EBL), operative time, number of pelvic lymph nodes harvested and intraoperative complications. Postoperative outcomes were hospital stay and surgical morbidity. The random effects model was used to pool weighted mean differences (WMDs) and odds ratios (OR).

RESULTS

Twenty six nonrandomized studies were included (10 RRH vs abdominal radical hysterectomy [ARH], 9 RRH vs laparoscopic radical hysterectomy [LRH] and 7 compared all 3 approaches) enrolling 4013 women (1013 RRH, 710 LRH and 2290 ARH). RRH was associated with less EBL (WMD=384.3, 95% CI=233.7, 534.8) and shorter hospital stay (WMD=3.55, 95% CI=2.10, 5.00) than ARH. RRH was also associated with lower odds of febrile morbidity (OR=0.43, 95% CI=0.20-0.89), blood transfusion (OR=0.12, 95% CI 0.06, 0.25) and wound-related complications (OR=0.31, 95% CI=0.13, 0.73) vs. ARH. RRH was comparable to LRH in all intra- and postoperative outcomes.

CONCLUSION

Current evidence suggests that RRH may be superior to ARH with lower EBL, shorter hospital stay, less febrile morbidity and wound-related complications. RRH and LRH appear equivalent in intraoperative and short-term postoperative outcomes and thus the choice of approach can be tailored to the choice of patient and surgeon.

The surgical management of cervical cancer: an overview and literature review

IMPORTANCE

Surgery has evolved into the standard therapy for nonbulky carcinoma of the cervix. The mainstay of surgical management is radical hysterectomy; however, less radical procedures have a small but important role in the management of cervical tumors.

OBJECTIVE

Our objective was to discuss the literature behind the different procedures utilized in the management of cervical cancer, emphasizing the radical hysterectomy. In addition, we aimed to discuss ongoing trials looking at the utility of less radical surgeries as well as emerging technologies in the management of this disease.

EVIDENCE ACQUISITION

We performed a PubMed literature search for articles in the English language that pertained to the topic of surgical techniques and their outcomes in the treatment of cervical cancer.

RESULTS

The minimally invasive approaches to radical hysterectomy appear to reduce morbidity without affecting oncological outcomes, although further data are needed looking at long-term outcomes with the robotic platform. Trials are currently ongoing looking at the role of less radical surgery for patients with low-risk disease and the feasibility of sentinel lymph node mapping.

CONCLUSIONS AND RELEVANCE

Radical hysterectomy with pelvic lymphadenectomy has evolved into the standard therapy for nonbulky disease, and there is a clear advantage in the use of minimally invasive techniques to perform these procedures. However, pending ongoing trials, less radical surgery in patients with low-risk invasive disease as well as sentinel lymph node mapping may emerge as standards of care in selected patients with cervical carcinoma.

Perioperative complications of robot-assisted laparoscopic surgery using three robotic arms at a single institution

PURPOSE

The aim of this study was to evaluate perioperative complications of robot-assisted laparoscopic surgery in gynecology.

MATERIALS AND METHODS

Patients who underwent elective robot-assisted laparoscopic surgery between February 2006 and December 2013 were identified. Robotic procedures were performed using the da Vinci robotic system. Patient demographic data and operative outcomes were prospectively collected in a computerized database and extracted for this study.

RESULTS

Two hundred and ninety eight patients were identified during the study period. One case was converted to conventional laparoscopy due to mechanical failure of the robot system before the procedure and excluded from review. The median age and body mass index of patients were 48 years and 23.0 kg/m², respectively. The majority (n=130, 43.6%) of operative procedures was radical hysterectomy, followed by endometrial cancer staging (n=112, 37.6%), total hysterectomy (n=39, 13.1%), and myomectomy (n=17, 5.7%). The median operative time, estimated blood loss, and postoperative hospital stay were 208.5 min, 184.8 mL, and 8.9 days, respectively. The overall complication rate was 18.8% and that for only oncologic cases was 16.1%. Intraoperative complications (n=5, 1.7%) consisted of three vessel injuries, one bowel content leakage during an appendectomy during endometrial cancer staging and one case of bladder injury during radical hysterectomy. Early and late postoperative complications were 14.4% and 2.7%, respectively. Five patients (1.7%) experienced grade 3 complications according to Clavien-Dindo classification and therefore needed further intervention.

CONCLUSION

Robot-assisted laparoscopic surgery is a feasible approach in gynecology with acceptable complications.

Implementation of laparoscopic approach for type B radical hysterectomy: a comparison with open surgical operations

OBJECTIVE

To investigate the safety, feasibility and effectiveness of laparoscopic approach in the management patients undergoing modified radical hysterectomy for early stage cervical cancer.

METHODS

Consecutive data of 157 women who had class II radical hysterectomy, for stage IA2 and stage IB1 <2 cm cervical cancer, were prospectively collected. Data of patients undergoing surgery via laparoscopy (LRH) were compared with those undergoing open surgical operations (RAH). A propensity-matched comparison (1:1) was carried out to minimize as possible selection biases. Post-operative complications were graded per the Clavien-Dindo classification. Five-year survival outcomes were assessed using Kaplan-Meier model.

RESULTS

After the exclusion of 37 (23.5%) patients on the basis of propensity-matching, 60 patients undergoing LRH were compared with 60 patients undergoing RAH. No between-group differences in baseline, disease and pathological variables were observed (p > 0.05). Patients undergoing surgery via laparoscopy experienced longer operative time than patients undergoing RAH; while LRH correlated whit shorter length of hospitalization and lower blood loss in comparison to RAH. Intra- and post-operative complication rate was similar between groups (p = 1.00). The execution of LRH or RAH did not influence site of recurrence (p > 0.2) as well as survival outcomes, in term of 5-year disease-free (p = 0.29, log-rank test) and overall survivals (p = 0.50, log-rank test).

CONCLUSION

Laparoscopic approach is a safe procedure, upholds the results of RAH, reducing invasiveness of open surgical operations. Further large prospective investigations are warranted.

Nerve-Sparing Versus Conventional Laparoscopic Radical Hysterectomy: A Minimum 12 Months’ Follow-up Study

Objective

The objective of this study was to determinate whether the introduction of nerve-sparing (NS) procedure influences surgical and survival outcomes of cervical cancer patients undergoing laparoscopic radical hysterectomy (LRH).

Methods

Data of consecutive patients undergoing minimally invasive radical with or without NS surgery for cervical cancer were enrolled in the study.

Results

Sixty-three patients (66%) who had LRH were compared with 33 women (34%) undergoing NS-LRH. Among the NS group, 19 patients (57.6%) had surgery via minilaparoscopy (using 3-mm instruments). Baseline characteristics were similar between groups. Patients undergoing NS-LRH had shorter operative time (210 vs 257 minutes; P = 0.005) and higher number of pelvic lymph nodes yielded (29 [26–38] vs 22 [8–49]; P < 0.001) than patient in the control group. No differences in blood loss, complications, and parametrial width were observed. Patients were catheterized with an indwelling Foley catheter for a median of 3.5 days (2–7 days) and 5.5 days (4–7 days) in NS and non-NS groups, respectively (P = 0.01). Voiding dysfunctions occurred in 1 patient (3%) and 12 patients (19%) who underwent NS-LRH and standard LRH, respectively (P = 0.03). No differences in 3-year disease-free survival (P = 0.72) and overall survival (P = 0.71) were recorded.

Conclusions

The beneficial effects (in terms of operative time and number of nodes harvested) of NS-LRH are likely determined by the expertise of the surgeon because NS approach was introduced after having acquired adequate background in conventional LRH. Our data show that in experienced hands NS-LRH is safe and feasible. Moreover, NS technique reduces catheterization time and the rate of postoperative urinary dysfunction.

Clinical efficacy and safety of nerve-sparing radical hysterectomy for cervical cancer: a systematic review and meta-analysis

Backgroud and Objective

Nerve-sparing radical hysterectomy (NSRH) may be associated with lower postoperative morbidity than radical hysterectomy (RH). We aimed to compare the clinical efficacy and safety of abdominal or laparoscopic NSRH and RH for treating cervical cancer through systematic review and meta-analysis.

Methods

PubMed, EMBASE, The Cochrane Library and the Chinese National Knowledge Infrastructure databases were systematically searched for all relevant studies. Data were abstracted independently by two reviewers. A meta-analysis was performed to compare intra- and postoperative outcomes for the two techniques.

Results

A total of 17 clinical trials were identified. Meta-analysis showed that although operating time was significantly longer for abdominal or laparoscopic NSRH than for RH, NSRH based on laparotomy or laparoscopy proved more effective for postoperative recovery of bladder function. NSRH was also associated with lower bladder dysfunction morbidity and fewer postoperative complications. Two abdominal trials and one laparoscopic study further suggested that NSRH was associated with shorter time to recovery of anal/rectal function. In contrast, RH and NSRH based on laparotomy or laparoscopy were similar in terms of extent of resection, recurrence rate, survival rate, blood loss and frequency of intraoperative complications. The meta-analysis showed that abdominal NSRH was not significantly different from RH in length of hospital stay, while one trial suggested that length of hospital stay was shorter after laparoscopic NSRH than after the corresponding RH.

Conclusion

NSRH may be a reliable technique for treating early cervical cancer. Available evidence suggests that it is better than RH for postoperative recovery of pelvic organ function and postoperative morbidity, while the two techniques involve similar clinical safety and extent of resection. These results should be considered preliminary since they are based on a relatively small number of controlled trials, most of which were non-randomized. The findings should be verified in larger, well-designed studies.