Robotic Surgery In Gynecologic Oncology Research Articles

Asian Society for Gynecologic Robotic Surgery consensus guidelines on robotic surgery in gynecological cancer

This document outlines guidelines drafted by the Consensus Panel for Gynecologic Oncology of the Asian Society for Gynecologic Robotic Surgery (ASGRS) based on review of contemporaneous data on robotic surgery and related issues such as sentinel node biopsy and surgery for cervical cancer. These guidelines were also the basis of the Consensus Statement on robotic surgery in gynecologic oncology made at the Asian Summit on Robotic Surgery, November 2022.

Mandate to evaluate robotic surgery implementation: a 12-year retrospective analysis of impact and future implications.

The introduction of robotic surgery in hospitals has raised much debate given the various effects on care, costs, education and medical advancement. Purchasing discussions are often approached with more questions than answers and there is a need for reports that provide a case for whether or not such technologies are advantageous from multiple perspectives, and offer insights into ways such devices can be introduced into a hospital setting. This report provides an evidence-based review of a university-affiliated tertiary care hospital's 12-year experience with robotic surgery in gynecologic oncology and delves into the various takeaways and challenges of implementing robotic surgery. Key findings were that robotic surgery significantly reduced complication rates, lengths of hospital stays for patients and overall hospital costs. Key obstacles were large upfront costs and the need for significant leadership and collaboration. Ongoing challenges to evaluating robotics include assessing long-term survival data, making comparisons with concurrently changing hospital conditions and determining how data can be generalized to other departments and institutions.

Using Regression Models to Predict Surgery Duration for Robotic-Assisted Total Laparoscopic Hysterectomy in Endometrial Cancer

Study Objective To develop regression models using preoperative variables that can accurately predict the operating room time of robotic surgery for endometrial cancer. Design A retrospective review using preoperative variables including age, BMI, ASA score, surgery start time, preoperative diagnosis, number of previous abdominal surgeries, parity, and uterine volume were used to develop regression models. These regression models were compared to institutional models that used preoperative estimations of operating room times based on historical averages. Setting An urban, academic hospital. Patients or Participants 348 patients undergoing robotic-assisted total laparoscopic hysterectomy with staging for endometrial cancer between 2016-2020 by six surgeons. Interventions N/A Measurements and Main Results The mean operating room time was 234 minutes (range: 130 – 484). The mean preoperative estimated operating room time was 223 minutes (range: 120 – 390). Linear, ridge, lasso, and elastic net models had relatively similar performance measures, and all models outperformed preoperative estimated operating room duration. Ultimately, the elastic net model performed the best. Elastic net had the smallest median root mean square error (RMSE) 57.97 (CI of 54.44-61.72) and greatest median R-squared 0.22 (CI 0.18-0.26). Surgery start time and preoperative diagnosis were found to be most influential variables in predicting operating room time followed by BMI, uterine volume, and number of prior surgeries. Age, ASA, parity and surgery type were not important in predicting operating room time. Conclusion Regression modeling more accurately predicted operating room time than the institutional standard that used historical averages for robotic-assisted hysterectomy with staging for endometrial cancers. This study is novel in its application to the field of robotic surgery in gynecologic oncology as it builds off of previous work from other disciplines demonstrating improved OR time predictions with regression models. Further studies are needed with expanded databases and more robust variable sets to refine the models ability to account for variance.

Interview with Prof. Walter Gotlieb: a pioneer of robotic surgery in gynecologic oncology in Canada

Interview with Prof. Walter Gotlieb: a pioneer of robotic surgery in gynecologic oncology in Canada

Role of Robotic Surgery in Gynecologic Oncology in India

Role of Robotic Surgery in Gynecologic Oncology in India

Walter Gotlieb: a pioneer of robotic surgery in gynecologic oncology in Canada

Walter H. Gotlieb, Division of Gynecologic Oncology, Segal Cancer Center, Lady Davis Institute of Research, Jewish General Hospital, McGill University, Montreal, Canada.

Improvement in quality of life after robotic surgery results in patient satisfaction

BackgroundThere are well-described benefits to minimally invasive surgery including decreased blood loss, shorter hospital-stay, and faster recovery. The role of robotic surgery in gynecologic oncology has become increasingly prominent; however limited data are available on quality of life (QOL) after robotic surgery. MethodsIn this prospective, IRB-approved study, women scheduled for robotic surgery for a gynecologic indication between May 2008 and February 2012 completed validated QOL measures at baseline, 6weeks (6wk), and 4months postoperative (4mo). Functional status (SF-12), symptom severity and interference (MDASI), sexual function (FSFI), and satisfaction with decision (SWD) were assessed at relevant time points. Differences between groups were evaluated using the Mann–Whitney test. ResultsAmong 408 women who underwent robotic surgery 278 (68%) completed the QOL measures. Median age was 55.6years (range 25.7–85.1). Median BMI was 31.3kg/m2. The majority of patients were white (75%). The most common indication for surgery was endometrial cancer/hyperplasia (59.7%). While physical functioning declined from baseline to 6wk (51.4 to 41.6, p<0.001), it improved by 4mo (53.5). Mental functioning improved over time (baseline 48.6, 6wk 52.8, and 4mo 55.6, p<0.001). Symptom severity decreased over time (p<0.001) as did symptom interference (p<0.001). Sexual function improved significantly from baseline (8.6) to 4mo (20.2, p<0.001). Patients were satisfied with their decision making (SWD=30). ConclusionIn this prospective study, general health, symptom burden and sexual function returned to or improved beyond baseline levels within 6weeks of surgery. Overall, women were satisfied with their decision to undergo robotic surgery.

Cost-effectiveness of robotic surgery in gynecologic oncology.

Robotically assisted surgeries have flourished in the United States, especially in gynecological procedures. Current robotic systems have high upfront and procedure costs that have led many in the medical community to question the new technology's cost-effectiveness. Recent research continues to find that robotically assisted gynecological cancer treatments have comparable outcomes to traditional laparoscopy and similar or better outcomes than that of laparotomy in the cases studied. However, robotic surgery costs remain higher than that of traditional laparoscopy. Under the current reimbursement climate, practicing physicians and hospitals should collaborate on identifying cost-effective uses of robotic systems and pushing manufacturers to lower purchase and procedure costs to a level that may be accepted by all stakeholders.

Robotic Surgery in Gynecologic Oncology: Updates and Innovations

Surgical advances in minimally invasive surgery, including laparoscopic and robotics, have revolutionized the practice of medicine and surgery in gynecologic oncology. During this time, an emphasis has been made to improve quality metrics such as complications, readmissions, and length of stay. The Institute for Healthcare Improvement has recommended health systems and surgeons to improve performance focused on better care, better quality, and better cost. Minimally invasive surgery may help to achieve these measures and serve as the foundation upon which these goals are reached. Despite the availability of laparoscopic tools at many hospitals, the majority of patients who had gynecologic cancer surgery in the United States had a laparotomy prior to the introduction of robot-assisted surgery. Reasons for this have been attributed to limitations of laparoscopy, which include 2D vision and rigid instruments without articulation. One of the greatest advancements in gynecologic surgery occurred in 2005, when the FDA approved the da Vinci surgical platform (Intuitive Surgical Inc, Sunnyvale, CA, USA) for use in gynecologic surgery. This platform provides a 3D vision system paired with wristed articulating instruments. Together, these enhancements may overcome some of the limitations of laparoscopy allowing for surgeons to perform less open surgery. The introduction of robotics in 2005 has led to an increase in minimally invasive surgery and significantly less open surgery – especially for the gynecologic oncology patient. This review will focus on recent advancements in robotic surgery in the field of gynecology oncology. It will also discuss the role for standardizing education and training through the development of training and educational networks to improve surgical outcomes.

Prospective Quality of Life Outcomes Following Robotic Surgery in Gynecologic Oncology

PurposeTo characterize the health-related quality of life (HRQL) of patients undergoing robotic surgery for the treatment of gynecologic cancers. Methods211 patients completed a quality of life questionnaire before surgery. Postoperative questionnaires, consisting of the same assessment with the addition of postoperative questions, were given at 1week, 3weeks, 3, 6, and 12months after surgery. The Functional Assessment of Cancer Therapy—General (FACT-G) and its subscales were used to evaluate HRQL. Patient-rated body image was evaluated using the Body Image Scale. Statistical significance was measured by the Wilcoxon signed-rank test. Minimally important difference (MID) values were analyzed to evaluate clinical significance. ResultsOverall HRQL and body image decreased at 1week after surgery and returned to baseline by 3weeks. Physical and functional well-being decreased at 1week after surgery and returned to baseline by 3months after surgery. However, using MID criteria, physical well-being returned to baseline by 3weeks. Social well-being did not change significantly. Emotional well-being increased immediately by 1week after surgery. ConclusionPatient reported HRQL outcomes following robotic surgery for the treatment of gynecologic cancers suggests a rapid return to pre-surgery values.

Successful incorporation of robotic surgery into gynecologic oncology fellowship training

BackgroundThe increasing role of robotic surgery in gynecologic oncology may impact fellowship training. The purpose of this study was to review the proportion of robotic procedures performed by fellows at the console, and compare operative times and lymph node yields to faculty surgeons. MethodsA prospective database of women undergoing robotic gynecologic surgery has been maintained since 2008. Intra-operative datasheets completed include surgical times and primary surgeon at the console. Operative times were compared between faculty and fellows for simple hysterectomy (SH), bilateral salpingo-oophorectomy (BSO), pelvic (PLND) and paraaortic lymph node dissection (PALND) and vaginal cuff closure (VCC). Lymph nodes counts were also compared. ResultsTimes were recorded for 239 SH, 43 BSOs, 105 right PLNDs, 104 left PLNDs, 34 PALND and 269 VCC. Comparing 2008 to 2011, procedures performed by the fellow significantly increased; SH 16% to 83% (p<0.001), BSO 7% to 75% (p=0.005), right PLND 4% to 44% (p<0.001), left PLND 0% to 56% (p<0.001), and VCC 59% to 82% (p=0.024). Console times (min) were similar for SH (60 vs. 63, p=0.73), BSO (48 vs. 43, p=0.55), and VCC (20 vs. 22, p=0.26). Faculty times (min) were shorter for PLND (right 26 vs. 30, p=0.04, left 23 vs. 27, p=0.02). Nodal counts were not significantly different (right 7 vs. 8, p=0.17 or left 7 vs. 7, p=0.87). ConclusionsRobotic surgery can be successfully incorporated into gynecologic oncology fellowship training. With increased exposure to robotic surgery, fellows had similar operative times and lymph node yields as faculty surgeons.

Improvement in quality of life after robotic surgery results in patient satisfaction

Objective: There are well-described benefits to minimally invasive surgery, including shorter hospital stay and recovery period and decreased blood loss. The role of robotic surgery in gynecologic oncology has become increasingly prominent, but limited data are available on quality of life (QOL) after robotic surgery.

Radical hysterectomy: A comparison of surgical approaches after adoption of robotic surgery in gynecologic oncology

ObjectiveTo compare intra-operative, postoperative and pathologic outcomes of three surgical approaches to radical hysterectomy and bilateral pelvic lymph node dissection over a three year time period during which all three approaches were used. MethodsWe reviewed all patients who underwent radical hysterectomy with pelvic lymph node dissection between 1/2007 and 11/2010. Comparison was made between robotic, laparoscopic and open procedures in regard to surgical times, complication rates, and pathologic findings. ResultsA total of 95 radical hysterectomy procedures were performed during the study period: 30 open (RAH), 31 laparoscopic (LRH) and 34 robotic (RRH). There were no differences in age, body mass index or other demographic factors between the groups. Operative time was significantly shorter in the RAH compared to LRH and RRH (265 vs 338 vs 328min, p=0.002). Estimated blood loss was significantly lower in LRH and RRH compared with RAH (100 vs 100 vs 350mL, p<0.001). Thirteen (24%) of RAH required blood transfusion. Conversion rates were higher in the LRH (16%) compared to RRH (3%) although not significant (p=0.10). Median length of stay was significantly shorter in RRH (1day) vs LRH or RAH (2 vs 4days, p<0.01). Pathologic findings were similar among all groups. ConclusionMinimally invasive surgery has made a significant impact on patients undergoing radical hysterectomy including decrease in blood loss and transfusion rates however; operative times were significantly longer compared to open radical hysterectomy. Our findings suggest that the robotic approach may have the added benefit of even shorter length of stay compared to traditional laparoscopy.

Robotic surgery in gynecologic oncology

The objective of this article is to review the recently published literature on the use of robotic surgery in the management of gynecologic malignancies. Retrospective data collected from many institutions support the use of robotic surgery in the management of cervical, endometrial, and early-stage ovarian cancer. Benefits to robotic surgery include decreased blood loss, fewer perioperative complications, and decreased length of hospital stay, especially when compared to an open cohort. Disadvantages include costs associated with the robotic system and disposable equipment, accessibility to robotic surgical systems, loss of haptic sensation with the device, and lack of prospective trials validating its use in gynecologic oncology. Current evidence establishes a role for the use of robotic surgery in the treatment of gynecologic malignancies. Further research should be implemented to validate the use of robotic surgery in gynecologic malignancies and to compare its outcomes to those of open and laparoscopic surgery.

Anesthesia considerations for robotic surgery in gynecologic oncology.

Robot-assisted gynecologic surgery is performed with a pneumoperitoneum and prolonged maximum Trendelenburg position which can result in adverse physiologic effects. The purpose of this study was to assess the feasibility of robot-assisted gynecologic oncology procedures and to identify anesthesia-related peri-operative adverse events. This is a case series performed on the first 133 patients who underwent a robot-assisted gynecologic oncology procedure at a tertiary care facility. Data was collected from electronically archived patient charts and from a prospective surgical database. Patient demographics were recorded and significant intra-operative and post-operative adverse events were reviewed. Robot-assisted surgery for gynecologic oncologic surgery with the use of extreme Trendelenburg in all patients was safely and successfully performed across a wide range of ages, American Society of Anesthesiologists physical status scores and body mass indices. Although most patients developed various degree of facial edema, only 5% of patients had a delayed extubation. Transient intra-operative hypoxemia (O2 saturation<90%) occurred in 3.75% (5/133) of patients and hypercapnia (CO2>45mmHg) in 18% (24/133). The mean duration of surgery was 254min and median hospital stay was 1day. Anesthetic and peri-operative complications are rare for patients undergoing robot-assisted gynecologic oncology surgeries despite the prolonged use of maximum Trendelenburg positioning and pneumoperitoneum. Although there are new anesthetic challenges, these surgeries were safely performed in a wide range of patients with minimal blood loss, short hospital stay and no significant cardiopulmonary complications.

Da Vinci robotic-assisted radical hysterectomy procedural guide.

The Da Vinci robotic surgical platform has rapidly been adopted by skilled surgeons for procedures in gynecologic oncology. The lack of specific procedural guides and surgical atlases for robotic surgery in gynecologic oncology produces challenges in the education of trainees in their role both as the assistant and as the console surgeon. This procedural guide was developed in order to facilitate trainee education in the technical aspects of radical hysterectomy for cervical cancer using the Da Vinci robotic surgical platform. Patient selection, preparation, and the technical aspects of robotic radical hysterectomy are described from both the standpoint of the console surgeon and the bedside assistant.

Robotic surgery in gynecologic oncology

The goal of this paper is to review the current data documenting the advantages of robotic surgery over open or laparoscopic surgery. The aim of this study is to compare the complications and perioperative outcome of robotic surgery with open and laparocopic surgery, in gynecologic oncology. The terms radical robotic or robot- assisted hysterectomy in PubMed search lead to 41 references. We excluded one review of literature, ten studies with benign and malignant cases, eight cases reports, one letter to the editor. We kept the prospective studies and comparative studies (total abdominal hysterectomy (TAH) vs. total robotic hysterectomy (TRH), total laparoscopic hysterectomy (TLH) vs. TRH or TAH vs. TRH vs. TLH). The results are separated for endometrial cancers, early cervical cancers, pelvic and paraaortic lymph node dissections, radical parametrectomy and trachelectomy, and pelvic exenteration. The literature on robotic-assisted radical hysterectomy supports its safety and feasibility for the surgical management of early cervical cancer and endometrial cancer. However, the results of a phase III randomized clinical trial testing the equivalence of outcomes after laparoscopic or robotic radical hysterectomy with abdominal radical hysterectomy are expected.

Robotic Surgery in Gynecologic Oncology

Robotic surgery for the management of gynecologic cancers allows for minimally invasive surgical removal of cancer-bearing organs and tissues using sophisticated surgeon-manipulated, robotic surgical instrumentation. Early on, gynecologic oncologists recognized that minimally invasive surgery was associated with less surgical morbidity and that it shortened postoperative recovery. Now, robotic surgery represents an effective alternative to conventional laparotomy. Since its widespread adoption, minimally invasive surgery has become an option not only for the morbidly obese but for women with gynecologic malignancy where conventional laparotomy has been associated with significant morbidity. As such, this paper considers indications for robotic surgery, reflects on outcomes from initial robotic surgical outcomes data, reviews cost efficacy and implications in surgical training, and discusses new roles for robotic surgery in gynecologic cancer management.

Overcoming technical challenges with robotic surgery in gynecologic oncology

The majority of data published on robotic surgery in gynecologic oncology has focused on patient outcomes and surgical data. We have found that technical challenges due to the complexity of the robotic technology create a separate set of issues, adding time and difficulty to the actual surgical procedure. This study focuses on these technical problems and identifies pitfalls and potential solutions in robotics. All patients who underwent robotic surgery for gynecologic oncology indications from August 2006 through July 2008 were eligible for inclusion in the study. Data collected prospectively included demographics, surgical and clinicopathologic data, and technical problems with the robotic equipment. One hundred thirty-seven patients underwent robotic surgery during the study period. A total of 11 cases (8.02%) were associated with problems with robotic technology: 2/11 (18.2%) involved malfunction of robotic arms, 2/11 (18.2%) involved light or camera cords, and the remainder included a variety of problems, including malfunction of Maylard bipolar instrument [1/11 (9.1%)], power failure requiring reboot of robot [1/11 (9.1%)], port problems [2/11 (18.2%)], and 3/1 (27.3%) had miscellaneous problems. An estimated average of 25 min was added to each of these 11 cases in order to solve robot-related technological problems. No cases required conversion to laparotomy. All problems were solved by the robotic surgeon with the assistance of robotic surgery staff. Surgeons performing robotic surgery must become familiar with troubleshooting robotic technology. Several issues related to technical problems may arise, delaying progression of the case, and potential solutions were identified. As this technology is implemented, robotic surgeons must be trained to solve problems related to the robotic technology and associated equipment. Failure to do so may add time and technical difficulty to robotic cases.

Robotic surgery in gynecologic oncology: Impact on fellowship training

Objectives To report the impact of a new robotic surgery program on the surgical training of gynecologic oncology fellows over a 12 month period of time. Methods A robotic surgery program was introduced into the gynecologic oncology fellowship program at Northwestern University Feinberg School of Medicine in June 2007. A database of patients undergoing surgical management of endometrial and cervical cancer between July 2007 and July 2008 was collected and analyzed. Changes in fellow surgical training were measured and analyzed. Results Fellow surgical training for endometrial and cervical cancer underwent a dramatic transition in 12 months. The proportion of patients undergoing minimally invasive surgery increased from 3.3% (4/110 patients) to 43.5% (47/108 patients). Fellow training transitioned from primarily an open approach (94.4%) to a minimally invasive approach (11% laparoscopic, 49% robotic, 40% open) for endometrial cancer stagings, and from an open approach (100%) to an open (50%) and robotic (50%) approach for radical hysterectomies. Fellow participation in robotic procedures increased from 45% in the first 3 months to 72% within 6 months, and 92% by 12 months. The role of the fellow in robotic cases transitioned from bedside assistant to console operator within 3 months. Conclusions Fellow surgical training underwent a dramatic change with the introduction of a robotic surgery program. The management of endometrial and cervical cancer was impacted the most by robotics. Robotic surgery broadened fellowship surgical training, but balanced surgical training and standardized fellow training modules remain challenges for fellowship programs.