The effect of obesity on clinical and economic outcomes in robotic endometrial cancer surgery

Proficiency-based progression training in robot-assisted laparoscopy for endometrial cancer: peri-operative and survival outcomes from an observational cohort study

Introduction

Over the last decade there has been a transition from traditional laparoscopy to robotic surgery for the treatment of endometrial cancer. A number of gynecological oncology surgical fellowship programmes have adopted robot-assisted laparoscopy, but the effect of training on complications and survival has not been evaluated. Our aim was to assess the impact of a proficiency-based progression training curriculum in robot-assisted laparoscopy on peri-operative and survival outcomes for endometrial cancer.

Methods

This is an observational cohort study performed in a tertiary referral and subspecialty training center. Women with primary endometrial cancer treated with robot-assisted laparoscopic surgery between 2015 and 2022 were included. Surgery would normally include a hysterectomy and salpingo-oophorectomy with some form of pelvic lymph node dissection (sentinel lymph nodes or lymphadenectomy). Training was provided according to a training curriculum which involves step-wise progression of the trainee based on proficiency to perform a certain surgical technique. Training cases were identified pre-operatively by consultant surgeons based on clinical factors. Case complexity matched the experience of the trainee. Main outcome measures were intra- and post-operative complications, blood transfusions, readmissions < 30 days, return to theater rates and 5-year disease-free and disease-specific survival for training versus non-training cases. Mann-Witney U, Pearson's chi-squared, multivariable regression, Kaplan-Meier and Cox proportional hazard analyses were performed to assess the effect of proficiency-based progression training on peri-operative and survival outcomes.

Results

Training cases had a lower BMI than non-training cases (30 versus 32 kg/m2, p = 0.013), but were comparable in age, performance status and comorbidities. Training had no influence on intra- and post-operative complications, blood transfusions, readmissions < 30 days, return to theater rates and median 5-year disease-free and disease-specific survival. Operating time was longer in training cases (161 versus 137 min, p = < 0.001). The range of estimated blood loss was smaller in training cases. Conversion rates, critical care unit-admissions and lymphoedema rates were comparable.

Discussion

Proficiency-based progression training can be used safely to teach robot-assisted laparoscopic surgery for women with endometrial cancer. Prospective trails are needed to further investigate the influence of distinct parts of robot-assisted laparoscopic surgery performed by a trainee on endometrial cancer outcomes.

Economic evaluation of different routes of surgery for the management of endometrial cancer: a retrospective cohort study

OBJECTIVES

The benefits of minimally invasive surgery (MIS) for endometrial carcinoma (EC) are well established although the financial impact of robotic-assisted hysterectomy (RH) compared with laparoscopic hysterectomy (LH) is disputed.

DESIGN

Retrospective cohort study.

SETTING

English National Health Service hospitals 2011-2017/2018.

PARTICIPANTS

35 304 women having a hysterectomy for EC identified from Hospital Episode Statistics.

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary outcome was the association between route of surgery on cost at intervention, 30, 90 and 365 days for women undergoing an open hysterectomy (OH) or MIS (LH/RH) for EC in England. The average marginal effect was calculated to compare RH versus OH and RH versus LH which adjusted for any differences in the characteristics of the surgical approaches. Secondary outcomes were to analyse costing data for each surgical approach by age, Charlson Comorbidity Index (CCI) and hospital MIS rate classification.

RESULTS

A total of 35 304 procedures were performed, 20 405 (57.8%) were MIS (LH: 18 604 and RH: 1801), 14 291 (40.5%) OH. Mean cost for LH was significantly less than RH, whereas RH was significantly less than OH at intervention, 30, 90 and 365 days (p<0.001). Over time, patients who underwent RH had increasing CCI scores and by the 2015/2016 year had a higher average CCI than LH. Comparing the cost of LH and RH against CCI score identified that the costs closely reflected the patients' CCI. Increasing disparity was also seen between the MIS and OH costs with rising age. When exploring the association between provider volume, MIS rate and surgical costs, there was an association with the higher the MIS rate the lower the average cost.

CONCLUSIONS

Further research is needed to investigate costs in matched patient cohorts to determine the optimum surgical modality in different populations.

Introducing robotic radical hysterectomy for stage 1bi cervical cancer-A prospective evaluation of clinical and economic outcomes in a single UK institution

BACKGROUND

We have assessed the impact of introducing robotics for a stage 1b cervical cancer service on laparotomy rates, complications, and costs.

METHODS

Data were collected prospectively from 90 consecutive patients who had a radical hysterectomy between 1 April 2010 and 31 December 2017.

RESULTS

There were 37 women before the first robotic procedure and 53 after. The laparotomy rate reduced from 75% (9/12) in 2010 to 0% (0/18) in 2017. The length of stay reduced from 6 days (range 3-39) to 3 days (range 1-15) (P < 0.0001). The complication rate before robotics was 68% (25/37) compared with 45% (24/53) afterwards (P = 0.0493). The blood transfusion rate reduced from 43% (16/37) to 11% (6/53) (P = 0.0007). There were no differences between the total costs before and after the introduction of robotics or between each route.

CONCLUSIONS

In this series, introducing robotics for cervical carcinoma reduced hospital stay and complications. No cost differences were demonstrated.

A comparison of operative outcomes between standard and robotic laparoscopic surgery for endometrial cancer: A systematic review and meta-analysis

BACKGROUND

Evidence has been systematically assessed comparing robotic with standard laparoscopy for treatment of endometrial cancer.

METHODS

A search of Medline, Embase and Cochrane databases was performed until 30th October 2016.

RESULTS

Thirty-six papers including 33 retrospective studies, two matched case-control studies and one randomized controlled study were used in a meta-analysis. Information from a further seven registry/database studies were assessed descriptively. There were no differences in the duration of surgery but days stay in hospital were shorter in the robotic arm (0.46 days, 95%CI 0.26 to 0.66). A robotic approach had less blood loss (57.74 mL, 95%CI 38.29 to 77.20), less conversions to laparotomy (RR = 0.41, 95%CI 0.29 to 0.59), and less overall complications (RR = 0.82, 95%CI 0.72 to 0.93). A robotic approach had higher costs ($1746.20, 95%CI $63.37 to $3429.03).

CONCLUSION

A robotic approach has favourable clinical outcomes but is more expensive.