Robotic single site versus robotic multiport hysterectomy in early endometrial cancer: a case control study

Role of single port robotic surgery in gynecology

Robot-assisted Single-Site Laparoscopy (R-LSS) is a rapidly evolving minimally invasive technique. Although it is a very recent technology, the use of R-LSS have been increasingly report in gynecology, for both benign and malignant indications. This review aims to summarize the evolution of this innovative technique and to examine its feasibility and safety for gynecological surgical procedures. We evaluated studies dealing about R-LSS in gynecological surgery. We performed a comprehensive literature research on PubMed and the Cochrane Library in February 2024. Based on the study reviewed, R-LSS seems to be a feasible and effective alternative to other mini-invasive approach in gynecological surgery. R-LSS combine the advantages of robotics surgery with the aesthetic result of a single incision. Compare to Single-Site Laparoscopy, it restore triangulation of the instrument and improve visualization and ergonomic. R-LSS seems to be related to favourable intra-e post-operative outcomes. Although, further studies would be necessary allow us to draw any final conclusion.

Efficacy of transumbilical laparoendoscopic single-site surgery versus multi-port laparoscopic surgery for endometrial cancer: a retrospective comparison study

Background

Although single-port laparoscopy surgery has been evaluated for several years, it has not been widely adopted by gynecologic oncologists. The objective was to compare the perioperative outcomes and survival of endometrial cancer (EC) patients undergoing transumbilical laparoendoscopic single-site surgery (TU-LESS) with multi-port laparoscopic surgery (MLS).

Materials and methods

This is a retrospective comparative monocentric study including patients treated between December 2017 and October 2021. The perioperative outcomes and survival of EC patients who had surgery via TU-LESS or MLS were compared, by propensity matching.

Results

A total of 156 patients were included (TU-LESS vs. MLS: 78 vs. 78). The conversion rate of TU-LESS and MLS was 5.13% and 2.56%, respectively (P=0.681). The operation time was comparable between the two groups [207.5min (180-251) vs. 197.5min (168.8-225), P=0.095]. There was no significant difference between the two groups in exhaustion time, perioperative complications, or postoperative complications. While, the TU-LESS group had a shorter out-of-bed activity time [36 hours (24-48) vs. 48 hours (48-72), P<0.001] and a lower visual analog pain scale 36 hours after surgery [1 (1-2) vs. 2 (1-2), P<0.001] than the MLS group. The length of hospital stay was similar in the two groups [5(4-6) vs. 5(4-5), P=0.599]. Following surgery, 38.5% of the TU-LESS patients and 41% of the MLS patients got adjuvant therapy (P=0.744). The median follow-up time for TU-LESS and MLS cohorts was 45 months (range: 20-66) and 43 months (range: 18-66), respectively. One TU-LESS patient and one MLS patient died following recurrence. The 4-year overall survival was similar in both groups (98.3% vs. 98.5%, P=0.875).

Conclusion

TU-LESS is a feasible and safe option with comparable perioperative outcomes and survival of MLS in endometrial cancer. With the growing acceptance of sentinel lymph node biopsy, TU-LESS of endometrial cancer may be a viable option for patients and surgeons.

Robot-Assisted Surgery in the Treatment of Gynecological Carcinoma and Malignancies: Introduction to the da Vinci Robotic Surgery System

Robotic surgery is a surgical intervention that was developed from traditional manual surgeries because of the intrusive procedures it uses. It is now accomplished in hospitals worldwide, and comprehensive programs for the application of technology in the management of gynecological cancer are being developed. Robotic surgery should be straightforwardly compared with manual and traditional laparoscopy to see if the higher indirect costs are justified by some improvements in patient studies. This paper aims to evaluate the procedure of robotic surgery and its implementation in gynecological cancer to verify its safeness, practicability, and effectiveness. A higher chance of infections is usually in classical surgery, particularly in comparison to laparoscopic or robotic surgery. Surgical and hospital stay are much less with any of these new technologies than the aforementioned; however, the drawbacks are the scarcity of robot systems, their high price, and the realization that it is only appropriate in learning institutions with infrastructure and highly skilled surgeons. In conclusion, tissue engineering constitutes a significant discovery and approach for treating gynecological cancer with improved methods than some other types of traditional surgery, and it will likely become dominant technology shortly.

Comparing surgical outcomes of da Vinci SP and da Vinci Xi for endometrial cancer surgical staging in a propensity score-matched study

The number of studies comparing robotic systems in endometrial cancer staging is limited. This retrospective study analyzed the medical records of 42 consecutive endometrial cancer patients, who underwent robotic staging using the da Vinci SP (SP) system, and 126 propensity score-matched patients who underwent staging using the da Vinci Xi (Xi) system. Median console and total operation times were longer in the SP group than those in the Xi group (125 vs. 77 min, p < 0.001; 225 vs. 154.5 min, p < 0.001, respectively). Notably, the median console time of the first 10 cases using SP was 184 min; it subsequently decreased to 99.5 min in the fourth 10 cases. SP had lesser postoperative hemoglobin (Hb) change (0.6 ± 0.7 g/dL vs. 1.8 ± 0.9 g/dL in Xi, p < 0.001) and lower median pain score at 6 h after surgery (2 vs. 3 in Xi, p = 0.046). Moreover, median postoperative hospital stay was shorter in the SP group (2 days) than that in the Xi group (6 days) (p < 0.001). Although SP was correlated with lower postoperative Hb change, shorter postoperative hospital stay, and lower pain score than those in Xi, it required longer operation times. Further prospective randomized studies are needed to validate the benefits of SP compared to other robotic platforms.

Surgical Outcomes Following Robotic Single-Site Versus Multiport Hysterectomy for Treatment of Endometrial Cancer: A Systematic Review and Meta-Analysis

Robotic single-site hysterectomy (RSSH) has emerged as a novel surgical approach for the treatment of endometrial cancer and atypical endometrial hyperplasia (AEH). Current research regarding the benefits of RSSH compared to robotic multiport hysterectomy (RMPH) for these indications has been inconclusive. Our team sought to compare surgical outcomes between these two approaches of robotic hysterectomy via systematic review and meta-analysis to ensure optimal surgical practices. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 Checklist guided our review. MEDLINE, Clinicaltrials.gov, and Cochrane Library were searched, yielding 59 results. Articles were filtered by title and abstract and then reviewed in full for inclusion and exclusion criteria. Inclusion criteria required that (1) studies compared outcomes for RSSH and RMPH, (2) hysterectomy was indicated for endometrial cancer or hyperplasia with atypia, and (3) studies were available in English. Excluded studies (1) compared single-site and multiport laparoscopic approaches, (2) compared robotic approaches to laparoscopic or abdominal (open) techniques, and (3) employed hysterectomy for benign conditions. Publication bias was assessed using the Egger Regression Correlation analysis. Four studies complied with the selection criteria, comprising 138 patients in the RSSH group and 259 in the RMPH group. Similar outcomes were noted across all measures, including conversion rate (relative risk [RR] = 1.84 and confidence interval [CI] = 0.99-3.43), blood loss (Cohen's d = 1.05 and Z = 18.62), operating time (Cohen's d = 0.29 and Z = 4.38), and length of hospital stay (Cohen's d = 1.06 and Z = 3.86). Publication bias was deemed minimal as indicated by Egger regression values of less than 0.05. These findings suggest that either a surgical approach or AEH with the proper standard of care can provide patients with endometrial cancer.

Ultra-minimally invasive approaches for endometrial cancer treatment: review of the literature

INTRODUCTION

We conducted a systematic review to evaluate the outcomes and role of ultra-minimally invasive surgical approaches for treatment of women diagnosed with endometrial cancer. Although, there is no agreed definition of the term "ultraminimal," we considered the hysteroscopic surgery, single-port surgery, mini/microlaparoscopy and percutaneous laparoscopy as surgical approaches that would best fit this description.

EVIDENCE ACQUISITION

The current systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) Guidelines. We performed a literature search using MEDLINE (PubMed), EMBASE and Cochrane Library databases for English-language studies published before August 1, 2020. We used the following keywords including "endometrial cancer," "endometrial malignancy," "fertility-sparing or preserving," "hysteroscopy," "hysteroscopic resection," "dilatation and curettage," "ultra-minimally invasive surgery," "progestin therapy," "hormone therapy," "single port," "single-site," "minilaparoscopy," "microlaparoscopy," "percutaneous" and "3 mm laparoscopy."

EVIDENCE SYNTHESIS

A total of 21 studies, reporting on 229 patients were included. 219 (95.6%) of the patients were premenopausal. Among premenopausal women, complete disease response was reported in 186 (84.9%) patients. The complete response rate was 77.1% in patients who underwent focal or extensive endometrial resection, 90.9% in patients who had the two-step approach and 88.9% in the group of patients treated with the three-step technique. Among 98 women who wished and attempted to conceive, 65 (66.3%) women became pregnant. Recurrent disease was diagnosed in 26 of 219 (11.9%) patients. No surgical complications were reported. In 10 postmenopausal patients that underwent hysteroscopic resection, no recurrences were detected after 5 years of follow-up. We identified 11 studies that reported on the use single-port laparoscopic surgery and included a total of 447 patients. The rate of intraoperative and postoperative complications was 2.6% and 5.2%, respectively. The majority of the studies did not report on the duration of follow-up or oncological outcomes. Ten studies, including 296 patients, investigated the role of single-port robotic-assisted laparoscopy. The overall rate of intraoperative and postoperative complications was 1.0% and 7.1%, respectively. Two studies, including 38 patients, reported on the role of minilaparoscopy. None of these cases required conversion to laparotomy. Data on overall survival in the cohort of patients that underwent minilaparoscopy were not reported. We found only one publication reporting on the use of percutaneous laparoscopy. This prospective study included 30 patients. No complication was reported, and with a median follow-up time of 14 months (range 12-36) no recurrences were diagnosed.

CONCLUSIONS

Several ultra-minimally invasive surgical techniques have been developed and implemented in selected patients with endometrial cancer. The results of this review support the feasibility and perioperative safety of these approaches, while long-term outcomes are not adequately studied. However, further work is required in standardization of the techniques, in determining the learning curve of the operator and establishing their oncological safety.

A Comparison of Surgical Outcomes between Single-Site Robotic, Multiport Robotic and Conventional Laparoscopic Techniques in Performing Hysterectomy for Benign Indications

Objectives:

Minimally invasive gynecologic surgery (MIGS) is the standard of care in performing hysterectomy for benign conditions. However, the choice of laparoscopic modality is largely dependent on surgeon's discretion, experience, and equipment availability. The objective of this study is: To compare outcomes between different minimally invasive approaches available for benign hysterectomies and to evaluate patient factors that influence the use of one approach over another. With this study, we sought to provide some objective criteria while deciding the appropriate MIGS technique.

Materials and Methods:

This is a retrospective study comparing perioperative outcomes between three techniques of minimally invasive hysterectomy: laparoscopy (LSC), multiport daVinci (MP-Rob) and single-site daVinci (SS-Rob). Patients undergoing benign hysterectomy (daVinci or conventional LSC) from January 2015 to July 2016 were included. 129 patients were identified and divided into: LSC (n = 44), MP-Rob (n = 36) and SS-Rob (n = 49).

Results:

There were statistically significant differences in age (MP-Rob46 ≠ LSC39), body mass index (BMI) (MP-Rob33 ≠ LSC27 or SS-Rob26.8), uterus weight (MP-Rob144 ≠ LSC102 or SS-Rob105) and operative time (LSC192 ≠ SS-Rob162.3 or MP-Rob163). Chi-square analyses revealed history of endometriosis and clinical endometriosis was statistically less common while leiomyomas were more common indications of MP-Rob. There was no statistically significant difference noted between length of stay, estimated blood loss, intraoperative, and post-operative complications between different surgical types.

Conclusion:

Patients with higher age, BMI, uterus weight and abnormal uterine bleeding were noted to undergo MP-Rob surgery. Patients with history of endometriosis were more likely to undergo LSC or SS-Rob surgery. Operative time was significantly less for daVinci hysterectomies (SS-Rob and MP-Rob) as compared to conventional LSC.

Robotic laparoendoscopic single-site compared with robotic multi-port sacrocolpopexy for apical compartment prolapse

BACKGROUND

Sacrocolpopexy is a commonly performed procedure for repair of apical compartment prolapse. A Y-shaped mesh is attached to the prolapsed cervix or vagina and suspended to the anterior longitudinal ligament of the sacrum. In addition to conventional laparoscopic and multi-port robotic routes, the robotic laparoendoscopic single-site approach has emerged as a viable, feasible, and widely applicable minimally invasive approach to sacrocolpopexy.

OBJECTIVE

To compare robotic laparoendoscopic single-site with multi-port robotic sacrocolpopexy for women with either utero-vaginal or vaginal apical prolapse.

MATERIALS AND METHODS

In this single-center randomized controlled trial, 70 women at Pelvic Organ Prolapse Quantitative stages 2-4 were assigned randomly to undergo sacrocolpopexy by robotic laparoendoscopic single-site or multi-port robotic approaches from August 2017 to November 2018. Of 35 women randomized to each group, 32 underwent sacrocolpopexy. Operating time was the primary outcome of the trial. Secondary outcomes included intraoperative bleeding, length of hospitalization, pain during the first postoperative 24 hours (according to a 0-10 visual analogue scale), need for analgesics, and intraoperative and postoperative adverse events. At 6 weeks and 6 months after surgery, patients underwent a physical examination according to Pelvic Organ Prolapse Quantitative measurements, to assess the anatomical success of the surgery. The Pelvic Floor Distress Inventory-20 and Pelvic Organ Prolapse/Urinary Incontinence Sexual-12 questionnaires were administered prior to surgery and at 6-month follow-up. The Patient Scar Assessment Questionnaire and the Activity Assessment Scale were administered at 6 weeks and 6 months after the surgery. Exclusion criteria included contraindication to general anesthesia, a history of prior sacrocolpopexy, suspicious adnexal masses, suspicious thickened endometrium, and morbid obesity (body mass index of 40 kg/m² or more).

RESULTS

The mean age of the patients was 58.4 years. More than half of the patients (54%) had stage III prolapse. Mean total operative times were 181.3 ± 32.6 and 157.5 ± 42 minutes for robotic laparoendoscopic single-site and multi-port robotic sacrocolpopexy, respectively; the difference was 23.8 minutes (95% confidence interval, 4.2-43.4, P = .018). The mean differences in duration between the procedures were as follows: 29.8 minutes, 95% confidence interval, 9.2-50.4, P = .005 for anesthesia time; 33.1 minutes, 95% confidence interval, 16.5-49.7, P < .0001 for console time; 8.6 minutes, 95% confidence interval, 1.1-16.3, P = .025 for supracervical hysterectomy time; 8.3 minutes, 95% confidence interval, 1.8-14.8, P = 0.03 for mesh suturing and fixation to the promontory; and 4.7 minutes, 95% confidence interval, 1.5-7.7, P = .004 for peritoneum suturing. Statistically significant differences were not observed between the groups in regard to estimated blood loss, intraoperative complications, and demand for analgesics during hospital stay. Quality-of-life parameters were similar. Patients' assessments of their scars were more favorable in the robotic laparoendoscopic single-site group.

CONCLUSION

For sacrocolpopexy, the operative time was longer for the robotic laparoendoscopic single-site than for the multi-port robotic approach. Both approaches are feasible, and short-term outcomes, quality-of-life parameters, and anatomic repair are comparable. Our results are generalizable only to the specific robotic platforms used in the study.

Comparison of Intraoperative Outcomes between Single-incision Robotic Cholecystectomy and Multi-incision Robotic Cholecystectomy

Background

The aim of this study was to evaluate the differences in the key surgical factors for single-incision robotic cholecystectomy (SIRC) and multi-incision robotic cholecystectomy (MIRC).

Methods

A retrospective data review from August 2013 to April 2018 consisting of 104 SIRC and 105 MIRC cases was done considering factors including patient gender, age, operating time (skin incision to skin closure), robotic console time (docking to undocking), the preoperative diagnosis for surgery, any complications in surgery, length of stay (LOS), and estimated blood loss (EBL). Procedures with conversion away from original robotic cholecystectomy approach were excluded. Chi-square analysis (p-value: 0.05) was run between the two data sets.

Results

A total of 209 robotic cholecystectomy cases were reviewed since 2013. We found significantly less time with single-incision compared to multi-incision (single incision = 94.0 minutes, multi-incision = 99.9 minutes, p = 0.016) and EBL (single-incision = 11.52 mL, multi-incision = 17.17 mL, p = 0.004). There was no significant difference in age or robotic console time. The most common indication was symptomatic cholelithiasis overall, with equal cases of dyskinesia in single-incision approach, although there was no significant difference in indication between the two approaches. Intraoperatively, there was marginally significant use of irrigation in multi-incision (multi-incision 45 [42.9%], single-incision 31 [29.8%], p = 0.0499) and no difference in Firefly, perforation, or intraoperative cholangiogram use. LOS results showed significant decreased stay in SIRC cases (single-incision 84 outpatients [80.8%], multi-incision 75 [71.4%]; p = 0.0379).

Conclusions

SIRC and MIRC are both safe and feasible ways to remove the inflamed/dysfunctional gallbladder. SIRC is associated with less operative time, less blood loss, and shorter hospital stay. 

Robotic laparoendoscopic single-site surgery in gynecology: A systematic review

Robotic laparoendoscopic single-site (R-LESS) seems to be the next route in advancing minimal invasive surgery, with the potential for better cosmetic results and reduced patient morbidity compared with multi-port surgery. This review describes the history and development of (R-LESS) gynecologic surgery and outlines the latest advancements in the realm of gynecology. The review was conducted according to the PRISMA guidelines. Pubmed and ClinicalTrials.gov (www.clinicaltrials.gov) were the main search engines utilized for retrieval of study data (1990 - present). The following subject headings and keywords were searched: "robotic laparoscopic single incision", "robotic laparoendoscopic single site", "single incision robotic surgery" and "single-port robotic surgery". All original research articles including randomized, non-randomized controlled trials, cohort studies, patient series, and case reports were included. The search produced a total of 1127 results. After duplicate removal, 452 remained, and each title and abstract was reviewed by 2 reviewers. Subsequently, 56 full texts were selected for full review and an additional 20 excluded, leaving 36 studies that were included in the final review. Based on the data gathered we reached the conclusion that R-LESS surgery is feasible, safe and has equivalent surgical outcomes as conventional LESS surgery; in addition to shorter recovery times, less postoperative pain and better cosmetic outcomes than robotic multi-port surgery. To conclude, R-LESS is a feasible approach with low complication rates, minimal blood loss and postsurgical pain, fast recovery, and virtually scar-free results. However, the lack of large comparative prospective randomized controlled studies prevents drawing absolute conclusions.

Single-site port robotic-assisted hysterectomy: an update

Single-incision approach in robotic gynecology is a relatively new concept. The role of single-port systems in robotic hysterectomy, their advantages and disadvantages, as well as the technical challenges, are still under investigation. A systematic review was performed by searching in PubMed and Scopus databases. In 810 out of 1225 patients, hysterectomy was performed for non-neoplastic disease. Single-Site^® was the most common port system. Duration of the procedure and relative blood loss ranged from 60 to 311 min and 7 to 750 ml, respectively. The weight of the removed uteri ranged from 39 to 520 g. 4.9% of the included patients presented complications, among which bleeding, vaginal haematoma, laceration and dehiscence, umbilical hernia, and visceral injuries. Conversion rate to laparotomy reached 2.8%. Although some technical difficulties are still described in the literature, the single-port approach is becoming more standardized nowadays and performed by more surgeons. The initial phase of the learning curve can be achieved after five cases, while a proficiency in intracorporeal cuff suturing after 14 cases. Uterus weight and previous abdominal surgical history can still be limitations of the technique. Compared to our previous study, we can see that the technique has been used in more elderly or obese patients. The complication rate can reach 4.9% while the conversion rate can reach 2.8%. However, we consider that complication and conversion rates as well as surgical time could be improved with experience. Regarding post-operative pain and cosmetic outcomes, the lack of information do not allow us to draw any safe conclusions.