Benefits of Minimal Access Surgery in Elderly Patients with Pelvic Cancer

Surgery Advances in Gynecologic Tumors: The Evolution and Outcomes of Robotic Surgery for Gynecologic Cancers in a Tertiary Center

The integration of innovation into routine clinical practice is faced with many challenges. In 2007, we received the mandate to evaluate how the introduction of a robotic program in gynecologic oncology affected patient-centered care by studying its impact on clinical outcomes and hospital resource utilization. Here we summarize the history and experience of developing a robotic surgery program for gynecologic cancers over 16 years. Analysis of the data indicates that robotic surgery improved perioperative patient clinical parameters, decreased blood loss, complications, and hospital stay, maintained the oncologic outcome, and is cost-effective, resulting in it becoming the dominant surgical approach in gynecologic oncology in a tertiary cancer care institution.

Optimizing Total Laparoscopic Hysterectomy for the Geriatric Population: A Practical Case Study and Comprehensive Literature Review

Elderly patients represent a large cohort of patients requiring gynaecological surgery for benign and malignant indications. In recent years, several conventional gynaecological procedures have shifted towards minimally invasive alternatives such as laparoscopy, hysteroscopy, and robotic surgery. A recent Surveillance, Epidemiology, and End Results (SEER) analysis compared the outcomes of 25,000 women undergoing laparotomy versus laparoscopic approach to hysterectomy and found that laparoscopy is associated with a shorter duration of hospitalization (three days versus five days), less postoperative complications (76%), less requirement for blood transfusion, reduced operational costs, faster recovery, and an overall safer surgical experience. Although geriatric patients are affected by age-related comorbidities, physiologic changes, and altered pharmacodynamics and pharmacokinetics of administered drugs, these patients benefit most from minimally invasive surgery. In this paper, we present a comprehensive account of the interdisciplinary perioperative approaches employed to accomplish a total laparoscopic hysterectomy, bilateral salpingo-oophorectomy, and pelvic lymph node dissection in an 82-year-old patient who was diagnosed with grade I endometrial adenocarcinoma and multiple age-related medical comorbidities.

Feasibility of transthoracic esophagectomy with a next-generation surgical robot

Robot-assisted minimal access surgery (MAS), compared with conventional MAS, has shown a number of benefits across several therapeutic indications but its use for transthoracic esophagectomy (TTE) requires further evaluation. Here, we report the first-in-human series of major esophageal resections performed using a next-generation tele-operated robotic surgical system in a single center. Robot-assisted TTE was performed using the Versius Surgical System by a single surgeon to assess the robotic system's ability to achieve tumor clearance (measured by R0 resection rates) whilst reducing anastomotic leakage rates. Intra- and post-operative outcomes such as median operative time, length of hospitalization, intra-operative blood loss, and the number of complications were also assessed. Fifty-seven patients underwent robot-assisted TTE between August 2019 and June 2021. All procedures were completed successfully with no unplanned conversions to alternative surgical methods. Estimated blood loss was minimal, and no adverse events, complications or deaths were reported. Our experience with the Versius Surgical System demonstrates its safe adoption and implementation for TTE.

Rare complications of pessary use: A systematic review of case reports

Introduction

Pessaries are desirable for its overall safety profiles. Serious complications have been reported; however, there is little summative evidence. This systematic review aimed to consolidate all reported serious outcomes from pessaries usage to better identify and counsel patients who might be at higher risk of developing these adverse events.

Methods

We performed a systematic literature review using search terms such as ‘prolapse’, ‘stress urinary incontinence’ and ‘pessary or pessaries or pessarium’ on PubMed, Embase and CINAHL. A total of 36 articles were identified. Patient‐level data were extracted from case reports to further describe complications on an individual level.

Results

Overall median age of the patients was 82 years (range 62–98). The most frequent complications were vesicovaginal fistula (25%, n = 9/36), rectovaginal fistula (19%, n = 7/36), vaginal impaction (11%, n = 4/36) and vaginal evisceration of small bowel through vaginal vault (8%, n = 3/36). In the vesicovaginal fistula cohort, none of the patients had a history of radiation, and two had histories of total abdominal hysterectomy (22%). In the rectovaginal fistula cohort, one patient had a history of pelvic radiation for rectal squamous cell carcinoma, and another had a history of chronic steroid use for rheumatoid arthritis. No other risk factors were reported in the other groups. Ring and Gellhorn were the most represented pessary types among the studies, 16 (44%) and 12 (33%), respectively. No complications were reported with surgical and non‐surgical treatment of the complications.

Conclusion

Pessaries are a reasonable and durable treatment for POP with exceedingly rare reports of severe adverse complications. The ideal candidate for pessary should have a good self‐care index. Studies to determine causative factors of the more serious adverse events are needed; however, this may be difficult given the long follow‐up that is required.

[Malignant Diseases in the Elderly]

A majority of patients with newly diagnosed malignant disease are 70 years old or older. Frailty - i. e. increased vulnerability towards stressors at older age - is a major challenge during the oncological work-up and treatment in the elderly. Therefore, older cancer patients should receive a systematic assessment of frailty by use of standard tools. Assessment results should be carefully considered during oncological treatment decisions, e. g. in interdisciplinary tumor conferences. Moreover, they are prerequisite to initiate geriatric co-management for which there is emerging new evidence. Advances in tumor surgery and irradiation as well as personalized precision medicine with novel targeted drugs have facilitated the treatment of cancer even in old age and frailty. However, patients with such characteristics are at increased risk of complications compared to younger subjects. Physicians and medical staff involved in treatment must therefore co-operate well. This article provides an overview of the current evidence and highlights key aspects of diagnosis and treatment of malignant diseases in the elderly.

Using end-user feedback to optimize the design of the Versius Surgical System, a new robot-assisted device for use in minimal access surgery

Background

Robot-assisted minimal access surgery (MAS) reduces blood loss, recovery time, intraoperative and postoperative complications and pain. However, uptake of robotic MAS remains low, suggesting there are barriers to its use. To overcome these barriers, a new surgical robot system, Versius, was developed based on the needs and feedback of surgeons and surgical teams.

Methods

The surgical robot prototype was designed based on observations in the operating room (OR) and previous interviews with surgeons. Formative studies with surgeons and surgical teams were used to refine the prototype design, resulting in modifications to all components, including the arms, instruments, handgrips and surgeon console. Proof-of-concept cadaver studies were used to further optimize its design by assessing its usability during surgical procedures.

Results

Feedback led to the development of a novel, mobile design with independent arm carts and surgical console, linked by supported serial or parallel connections, providing maximum flexibility in the OR. Instrument tips were developed based on surgeons’ preferred designs and wristed at the tip providing seven degrees of freedom within the patient. Multiple handgrip designs were assessed by surgeons; of these, a ‘game controller’ design was rated most popular and usable. An open surgical console design allowing multiple working positions was rated highest by surgeons and the surgical teams.

Conclusions

This surgical robot system has been developed using feedback from end users throughout the design process and aims to minimize barriers to robotic MAS uptake. Additionally, these studies demonstrate system success in the surgical procedures it was designed for. The studies reported here, and further studies of the Versius Surgical System, are intended to align with IDEAL (Idea, Development, Exploration, Assessment, Long-term study) Framework guidance.

Management of endometrial cancer in patients aged 80 years and older: Identifying patients who may benefit from a curative treatment

OBJECTIVE

The goal of this study was to evaluate the demographic characteristics, pathology, treatment, prognostic factors and survival rates in elderly patients with endometrial cancer, and to compare their results with those of younger ones, in order to define the specific characteristics of this malignancy in this population.

STUDY DESIGN

Retrospective analysis of all endometrial cancer patients managed at the University Hospital of the Canary Islands (Spain) between 1990 and 2016. Survival curves were calculated by using the Kaplan-Meier method and compared with the log-rank test. Logistic regression analysis was used to assess the independent effect of different variables on cancer-specific survival. Statistical significance was considered for p < 0.05.

RESULTS

The study included 1799 endometrial cancer patients; 170 of them (9.4%) were 80 years old or older. Elderly patients received less surgery (68.2% vs. 92.4%), lymphadenectomy (10.3% vs. 26.2%) and adjuvant treatment (37.1% vs. 51.2%) than younger ones, and presented higher probability of receiving palliative treatment (27.6% vs. 4%). Endometrioid tumors were more frequently diagnosed in younger patients (78.8% vs. 62.9%), while type 2-endometrial cancer was more frequently diagnosed in elderly ones (37.1% vs. 21.2%). Cancer-specific survival in older patients was significantly poorer than in younger ones, with a mean of 61.4 months (95%CI 51.7-71.1) versus 226 months (95%CI 218.9-233.1), respectively. In a multivariate analysis: age, FIGO stage, histology, tumor differentiation and adjuvant treatment were independently associated with survival.

CONCLUSION

Although endometrial cancer is more aggressive in older patients, they are less likely to receive optimal treatment, which negatively affects their survival. Specific guidelines for the management of this population, including a comprehensive geriatric assessment, should be developed to improve their prognosis.

Management of pelvic organ prolapse in the elderly - is there a role for robotic-assisted sacrocolpopexy?

Abdominal sacrocolpopexy is considered the gold standard treatment for symptomatic pelvic organ prolapse (POP). Since its introduction, robotic-assisted sacrocolpopexy has emerged as a popular minimally invasive alternative to open repair. Epidemiologic data suggest that the number of women seeking surgical treatment for POP will increase to ~50% by 2050, and many of these women will be elderly. Advanced age should not preclude elective POP surgery. Substantial data suggest that medical comorbidities and other preoperative markers may be more important than age in predicting adverse surgical outcomes. POP surgery in the elderly has been extensively studied and found to be safe, but there is a paucity of information regarding robotic-assisted sacrocolpopexy in this population. Data are only beginning to emerge regarding the safety and efficacy of robotic surgery in the elderly, with most studies focusing on oncologic procedures. Preliminary studies in this setting suggest that elderly patients may benefit from a minimally invasive approach, although given their limited physiologic reserves, appropriate patient selection is essential. The purpose of this review article is to evaluate the stepwise management of POP in the elderly female, with a focus on the safety and feasibility of a robotic approach.