Article Text
Abstract
Objective To establish the feasibility and safety of robotic interval debulking surgery following the MIRRORS protocol (robot-assisted laparoscopic assessment prior to robotic or open surgery) in women with advanced-stage ovarian cancer. MIRRORS is the first of three planned trials: MIRRORS, MIRRORS-RCT (pilot), and MIRRORS-RCT.
Methods The participants were patients with stage IIIc-IVb epithelial ovarian cancer undergoing neo-adjuvant chemotherapy, suitable for interval debulking surgery with a pelvic mass ≤8 cm. The intervention was robot-assisted laparoscopic assessment prior to robotic or open interval debulking surgery (MIRRORS protocol). The primary outcome was feasibility of recruitment, and the secondary outcomes were quality of life (EORTC QLQC30/OV28, HADS questionnaires), pain, surgical complications, complete cytoreduction rate (%), conversion to open surgery (%), and overall and progression-free survival at 1 year.
Results Overall, 95.8% (23/24) of patients who were eligible were recruited. Median age was 68 years (range 53–83). All patients had high grade serous histology and were BRCA negative. In total, 56.5% were stage IV, 43.5% were stage III, 87.0% had a partial response, while 13.0% had stable disease by RECIST 1.1. Median peritoneal cancer index was 24 (range 6–38). Following MIRRORS protocol, 87.0% (20/23) underwent robotic interval debulking surgery, and 13.0% (3/23) had open surgery. All patients achieved R<1 (robotic R0=47.4%, open R0=0%). No patients had conversion to open. Median estimated blood loss was 50 mL for robotic (range 20–500 mL), 2026 mL for open (range 2000–2800 mL) (p=0.001). Median intensive care length of stay was 0 days for robotic (range 0–8) and 3 days (range 3–13) for MIRRORS Open (p=0.012). The median length of stay was 1.5 days for robotic (range 1–17), 6 days for open (range 5–41) (p=0.012). The time to chemotherapy was as follows 18.5 days for robotic (range 13–28), 25 days for open (range 22–28) (p=0.139).
Conclusions Robotic interval debulking surgery appears safe and feasible for experienced robotic surgeons in patients with a pelvic mass ≤8 cm. A randomized controlled trial (MIRRORS-RCT) will determine whether MIRRORS protocol has non-inferior survival (overall and progression-free) compared with open interval debulking surgery.
- Ovarian Cancer
- Cytoreduction surgical procedures
- Surgical Oncology
- Fallopian Tube Neoplasms
- Quality of Life (PRO)/Palliative Care
Data availability statement
Data are available upon reasonable request. All data relevant to the study are included in the article or uploaded as supplementary information. The datasets generated from this current study will be available upon request from Christina Uwins (Christina.Uwins@nhs.net) as raw anonymized data for up to 5 years following completion of the study. Participants have given their consent for the information collected from this study to be used to support other research in the future and to be shared anonymously with other researchers.
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- Ovarian Cancer
- Cytoreduction surgical procedures
- Surgical Oncology
- Fallopian Tube Neoplasms
- Quality of Life (PRO)/Palliative Care
WHAT IS ALREADY KNOWN ON THIS TOPIC
Retrospective studies have suggested that minimally invasive interval debulking surgery is feasible. There are no prospective trials on robotic interval debulking surgery for advanced ovarian cancer.
WHAT THIS STUDY ADDS
MIRRORS is a prospective cohort study assessing the feasibility of robotic interval debulking surgery for advanced-stage ovarian cancer. MIRRORS demonstrated the feasibility and safety of robotic interval debulking surgery in advanced stage ovarian cancer. MIRRORS is the first in a series of three planned trials culminating in a multicenter international randomized controlled trial of MIRRORS protocol versus standard open interval debulking surgery (MIRRORS-RCT).
HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE, OR POLICY
In the UK and Europe, the majority of patients with advanced ovarian cancer have interval debulking surgery performed through an open approach. If non-inferiority of robotic interval debulking surgery with regards to survival (overall and progression-free) is confirmed by an adequately powered randomized controlled trial, this could lead to a significant change in practice.
Introduction
Epithelial ovarian cancer, including cancers of the fallopian tube and peritoneum, is the sixth most common cancer in women in the UK, with around 7500 women diagnosed each year. More than 70% of women present with advanced stage disease (FIGO ≥stage III), and many are older and or frail, as incidence increases with age.1 Standard treatment involves surgery and platinum-based chemotherapy. Complete resection of all visible tumor deposits (R0) is the strongest predictor of improved overall and progression-free survival. Best outcomes are seen in women where it is possible to remove all visible tumor deposits during primary surgery.2
Neoadjuvant chemotherapy is recommended in women with advanced stage disease, where upfront surgery would be unlikely to achieve removal of all visible disease, or when patients are not fit for primary surgery. Interval debulking surgery has been shown to have equivalent outcomes to primary surgery with reduced patient morbidity and mortality.3 4 The ongoing TRUST trial is seeking to establish whether primary cytoreductive surgery is superior to interval debulking surgery in patients with advanced ovarian cancer.5
While surgical complications may prevent or delay patients from commencing chemotherapy,6–11 minimally invasive surgery is associated with quicker recovery, shorter inpatient stay, reduced blood loss and need for transfusion, fewer wound complications, lower risk of thromboembolism and high dependency care requirements, and lower 30-day mortality in comparison with laparotomy.6 12
Methods
Trial Design
MIRRORS (Minimally Invasive Robotic surgery, Role in optimal debulking Ovarian cancer, Recovery and Survival) is a prospective cohort feasibility study of robotic interval debulking surgery in women with advanced-stage epithelial ovarian cancer. MIRRORS is a stage 2a development study following the IDEAL framework.13
Patients with stage IIIC-IVb epithelial ovarian cancer (following review of imaging in the gynecological oncology multidisciplinary team meeting), and identified as suitable for interval debulking surgery having responded to neoadjuvant chemotherapy, were offered inclusion in the study. Patients with progressive disease on CT were excluded. Surgery commenced with an open entry laparoscopy using an Alexis wound protector (Applied Medical, Rancho Santa Margarita, CA, USA). A laparoscopic assessment of the abdomen and pelvis was performed using the Da Vinci robot endoscopic camera (Intuitive Surgical, Sunnyvale, CA, USA) by an experienced gynecological oncologist and robotic surgeon, followed by proceeding immediately to robotic or open interval debulking surgery (MIRRORS protocol). The decision to proceed with robotic interval debulking surgery or to proceed with an open approach was made by the lead operating surgeon, based on the laparoscopic findings. Cases such as those with extensive dense adhesions preventing safe port entry and full visualization of the abdomen, peritoneal disease covering the entire anterior abdominal wall around port sites, or extensive bowel mesenteric disease considered resectable via an open approach may be best suited to an open surgical approach. The aim of surgery was to remove all visible disease with conversion to open surgery if required. Robotic surgery was performed using the Da Vinci Si and Xi systems (Intuitive Surgical, Sunnyvale, CA, USA) (Figures 1 and 2).
Setting
MIRRORS was based at Royal Surrey NHS Foundation Trust, UK a gynecological cancer center and Intuitive Robotic Epicenter. Recruitment occurred between June 2020 and May 2021. The publication of this feasibility study was delayed due to both professional and academic commitments. MIRRORS was presented at both the British Gynecological Cancer Society Academic Meeting and International Gynecologic Cancer Society Conference in 2022. Following this, a successful grant application for MIRRORS-RCT (pilot), a follow-up study to MIRRORS, required time to complete sponsorship, ethics applications, and site set-up. The findings of MIRRORS presented here have contributed to the design of MIRRORS-RCT (pilot) and are informing the final design of MIRRORS-RCT.
Participants
Inclusion criteria
Women ≥18 years with Stage IIIc–IVb epithelial ovarian cancer suitable for interval debulking surgery with a pelvic mass ≤8cm.
Exclusion criteria
Women who lacked capacity to complete trial documentation or were not medically fit for laparoscopy, and women who required specialist surgical support whose recommendation was open surgery were excluded.
Outcomes
Primary outcome was recruitment (%). Recruitment (%) was defined as the number of patients consented for the MIRRORS study compared with the number identified by multidisciplinary team as eligible for inclusion in the study, expressed as a percentage. Secondary outcomes included surgical and post-operative complications, rate of conversion to open surgery once robot docked, rate of complete cytoreduction (R0) (percentage), pain, quality of life, and progression-free and overall survival.
Assessment of surgical and post-operative complications included both intraoperative and post-operative (classified by Clavien-Dindo classification) complications assessed at close of trial (15 months±7 days (recruitment and follow-up period)), with success being defined as complication rate not higher than for open interval debulking surgery.
Pain was assessed using a numeric rating scale (NRS11), mental well-being using the hospital anxiety and depression scale (HADS) and quality of life using the patient-reported outcome measure European Organization for Research and Treatment of Cancer (EORTC) validated quality of life questionnaire for ovarian cancer (QLQ-C30/QLQ-OV28) and analysed as per the EORTC scoring manual.14 15 Unadjusted mean scores were compared between MIRRORS Open and MIRRORS Robot at each time point using linear regression (Stata Statistical Software Release 16), with results presented graphically. Questionnaires were completed at baseline, at day 1 post-surgery, 3–4 weeks post surgery, and 3 months post-surgery. Data were analysed in Microsoft Excel and IBM SPSS Statistics 26.
Kaplan-Meier survival curves were generated from date of diagnosis until date of first recurrence or death in months. Progression was defined as radiographic evidence of disease progression as per the Response Evaluation Criteria in Solid Tumors (RECIST) version 1.1, or by progressive serial elevation of CA125, as per the recommendations of the Gynecological Cancer Intergroup (GCIG), with the earliest date recorded.16–18 As a prospective feasibility study there was no control arm. To provide reassurance that we were not seeing an increased number of early recurrences, a concurrent cohort (Not-MIRRORS, n=11) consisting of all women undergoing interval debulking surgery not recruited to MIRRORS, and a historical cohort (n=37), consisting of women who had undergone open interval debulking surgery in the 12 months immediately prior to MIRRORS were identified. Follow-up was for a minimum of 1 year for survival.
Study Size
The sample size was set pragmatically to balance precision in the estimate of the pre-defined feasibility success criteria; at least 20% of those eligible accepting inclusion in the study, complication rate not higher for robotic interval debulking surgery than for open, and the conversion to open surgery rate not greater than 50% of the patient group deemed suitable for robotic interval debulking surgery following initial diagnostic laparoscopy. Inclusion of a minimum of 20 women in this initial feasibility study was targeted as sufficient to ensure these rates can be estimated within a standard error of less than 10%, providing maximal confidence intervals for percentage estimates of ±20%.
Trial Registration
Registered prior to first patient recruited at ClinicalTrials.gov: NCT04402333 (https://clinicaltrials.gov/ct2/show/study/NCT04402333). In accordance with the journal’s guidelines, we will provide our data for independent analysis by a team selected by the Editorial Team for the purposes of additional data analysis, or for the reproducibility of this study in other centers, if such is requested.
Results
During the recruitment period 35 of 44 women considered were found to be eligible for interval debulking surgery (one was later found unfit). Of these 35, 24 women fulfilled the inclusion/exclusion criteria for MIRRORS (68.6%). Overall, 23 of 24 eligible women were recruited (95.8%). Median age was 68 years (range 53–83). All patients recruited had high grade serous tumors and were BRCA negative, and 13 (56.5%) had stage IV disease (IVa: n=3, 13.0%; IVb: n=10, 43.5%). Following MIRRORS protocol, 20 women (87.0%) proceeded with robotic surgery and 3 (13.0%) with open surgery. There were no conversions to open surgery.
None of the patients had a complete response to chemotherapy by RECIST 1.1. The median peritoneal cancer index score was 24 (range 6–38) The diagnosis of stage IVb disease was based on the presence of extra abdominal lymph nodes on pre-operative imaging. In addition, of these patients presenting with stage IVb disease, one was diagnosed based on a supraclavicular lymph node biopsy, one had a biopsy-proven high-grade serous tumor breast metastasis, one had a histology-proven full thickness diaphragmatic deposit, another had a liver deposit resected involving the liver parenchyma on histology, and lastly, one had tumor in the resected umbilicus on histology. Peritoneal cancer index score was documented before and after surgery. MIRRORS did not find that the addition of a CT scan within 4 weeks of surgery improved on this assessment (Tables 1 and 2).
Two patients recruited to MIRRORS proved to have high-grade serous endometrial cancer (open: n=1, robotic: n=1). Of those confirmed to have epithelial ovarian cancer, complete cytoreduction (R0) was achieved in 47.4%, who had robotic interval debulking surgery. None of the open surgery cases achieved R0. Median estimated blood loss for the robotic group was 50 mL (range 20–500) versus 2026 mL (range 2000–2800) for the open surgery group (p=0.001). Median operating time was 358 min for robotic (range 168–698), 338 min for open (range 310–360), and 353 min for MIRRORS overall (range 168–698) (p=0.763). Robotic interval debulking procedures included bowel resection with stapled anastomosis (3/20, 15.0%), diaphragmatic stripping (12/20, 60.0%), full thickness diaphragmatic resection (1/20, 5.0%), and pelvic peritoneal stripping (14/20, 70.0%) (Figure 2B).
Median length of stay was 1.5 days (range 1–17) for robotic interval debulking surgery (n=20) and 6 days (range 5–41) for MIRRORS Open (n=3) (p=0.012). Median intensive care length of stay was 0 days for robotic (range 0–8) and 3 days (range 3–13) for MIRRORS Open (p=0.012). Median time to chemotherapy for robotic interval debulking surgery was 18.5 days (range 13–28), 25 days for open surgery (range 22–28), and 20.0 days (range 13–28) for the entire MIRRORS cohort (p=0.139).
There were no returns to the operating room, and the 30-day and 90-day mortality rates were zero. The most common reported minor complications were urinary tract infection in 5/23 (21.7%) patients (none culture-proven, as patients were treated empirically by their general practitioner), and surgical emphysema, which occurred in the first 4/20 (20.0%) patients undergoing robotic interval debulking surgery. Our surgical approach was subsequently adapted so that the patient was only in a steep head down position for resection of disease in the pelvis, and was then moved to a completely flat position for resection of disease in the upper abdomen. This successfully prevented further significant surgical emphysema.
Three women enrolled in MIRRORS experienced Clavien-Dindo complications ≥grade 3. One patient in the open group suffered a superficial wound breakdown, requiring vacuum-assisted wound closure therapy. In the robot group, one patient had a chest drain inserted on day 1 post-surgery to treat a pneumothorax following diaphragmatic stripping, and subsequently tested positive for SARS-CoV-2 day 3 post-surgery. A second patient in the robot group suffered a fractured neck of femur on day 46 post-surgery, and was readmitted for surgery (Table 1).
Median pain scores for robotic interval debulking surgery were lower than open across all time points. Overall (MIRRORS cohort n=23) median scores for anxiety and depression were in the normal range at all-time points across the study. Analysis of the EORTC validated quality of life questionnaires (QLQ) for ovarian cancer (QLQ-C30/QLQ-OV28) found the symptom scores for nausea (p=0.032) and pain (p=0.030) to be significantly lower in the robot group than in the open group (Figure 3).
Overall survival and progression-free survival for MIRRORS patients confirmed to have epithelial ovarian cancer was compared with the concurrent cohort Not-MIRRORS (n=11) and the historical cohort (n=37), and is presented in Figure 3C. No significant difference in overall (p=0.39) or progression-free survival (p=0.54) was observed.
Discussion
Summary of Main Results
MIRRORS has confirmed the feasibility of robotic interval debulking surgery for women with advanced (stage IIIc-IVb) epithelial ovarian cancer with a pelvic mass ≤8 cm. The initial clinical assessment of suitability for robotic interval debulking surgery using the Da Vinci robot endoscopic camera proved accurate when performed immediately prior to the cytoreductive procedure, eliminating the need to arrange an additional surgical procedure, with 87.0% of MIRRORS cases undergoing robotic surgery with no conversions.
Women who underwent robotic interval debulking surgery described less pain and nausea post-operatively and spent less time in hospital with few requiring any intensive or high dependency care. Time to chemotherapy following surgery was shorter (18.5 days) for those undergoing robotic interval debulking surgery than for those undergoing open surgery (25 days). Overall time to chemotherapy for MIRRORS was 20 days. The findings of previous studies showing reduced blood loss and post-operative pain were confirmed.19–23
Results in the Context of Published Literature
Ovarian cancer management varies considerably both within the UK and internationally.24 25 Retrospective studies have suggested that minimally invasive interval debulking surgery is feasible.19 22 23 There are no prospective trials assessing the role of robotic interval debulking surgery for advanced ovarian cancer. The recently published CILOVE study, a phase II prospective multicenter feasibility study of laparoscopic interval debulking surgery, found that of 41 patients eligible for cytoreductive surgery, 32 (78.0%) were assessed as suitable for laparoscopy, and 9 (22.0%) suitable for open. Of these, 29/32 patients successfully underwent laparoscopic interval debulking surgery, with a conversion rate of 9.4%.26 Up to 10 ports were used to achieve a very high rate of R0 of 97%. No benefit in reduction of length of stay or time to chemotherapy was found.
MISSION,21 a prospective feasibility trial from 2016, assessed the early complication rate of minimally invasive interval debulking surgery. MISSION included women with complete clinical response and ECOG performance status <2, and excluded those with body mass index >40 kg/m2 and ASA score III-IV. Of the 184 patients considered eligible for interval debulking surgery, 52 (28.3%) met the inclusion criteria. Of these, 30 (57.7%) patients had minimally invasive interval debulking surgery (26 laparoscopic and 4 robotic) with no conversions. Of the 30 patients undergoing minimally invasive surgery, median blood loss was 100 mL (range 50–200 mL) and median post-operative stay was 2 days (range 2–3). Feasibility was demonstrated in this select group, but the authors concluded that longer follow-up and larger numbers were required to show oncological equivalence.
The current LANCE trial is looking at the role of minimally invasive surgery (both standard laparoscopic and robotic) versus laparotomy in women with advanced high-grade epithelial ovarian cancer who have demonstrated complete or partial response to chemotherapy. LANCE excludes patients with ‘small bowel or gastric tumor involvement, colon or rectal tumor involvement, diaphragmatic tumor involvement, splenic or hepatic surface or parenchymal tumor involvement’.27 The initial pilot results of the first 100 randomized patients has been presented with promising results, indicating that the study is feasible, and enrolment is ongoing in a definitive trial.28 The unexpected findings of the LACC trial, finding lower rates of disease-free survival and overall survival in women undergoing minimally invasive radical hysterectomy for early stage cervical cancer, highlights the need for surgical randomized controlled trials.29
Complete resection of all visible disease and sensitivity to platinum-based chemotherapy is associated with the best survival outcomes.3 30 There has been a move towards more radical procedures to attain complete resection of all visible tumor deposits (R0). There is some debate as to whether achieving R0 is a reflection of tumor biology, case selection, or the surgeon. ‘Ultra-radical’ surgery is associated with increased patient morbidity and reduced numbers of patients considered for surgery.31 Many frail patients may not be suitable for such procedures but may benefit from a reduction in tumor burden. This group of women may have the most to gain from a robotic approach.
Strengths and Weaknesses
MIRRORS is a prospective cohort feasibility study of robotic interval debulking surgery. Recruitment proved to be feasible with a high rate of patient enrolment. With regards to intraoperative and post-operative complications, success for this feasibility study was pre-defined as the ‘complication rate for robotic interval debulking surgery not exceeding that observed for open interval debulking surgery’. Initially it was anticipated that up to 50% of patients would successfully undergo robotic interval debulking surgery. A higher than expected number of patients successfully underwent robotic interval debulking surgery (87.0%) with less than expected (13.0%) undergoing open interval debulking surgery. Those undergoing open interval debulking surgery had a greater burden of disease by pre-operative peritoneal cancer index (PCI) score (open: median PCI 27 (range 24–38); robotic: median PCI24 (range 6–31)). Intraoperatively there were no complications in the robotic group, in the open group all three patients had blood loss >1000 mL. Grade 3 post-operative Clavien-Dindo complications occurred in 1/20 of the MIRRORS Robotic cohort, and in 1/3 of the MIRRORS Open group. As this was a feasibility study it was not powered to detect efficacy effects. Nevertheless, despite the very small number of open cases performed (n=3) compared with robotic (n=20), there appeared to be a significant difference in estimated blood loss, length of stay, length of stay in intensive care, and symptom scores for nausea and pain in favor of robotic interval debulking surgery. A randomized controlled trial is required to assess whether there is a significant difference in outcomes for women undergoing surgery following the MIRRORS protocol compared with those undergoing standard open surgery.
For survival analysis, historical and contemporaneous control groups were used to provide some comparison and reassurance that there was no increase in early recurrences. This was reassuring with regards to immediate short-term surgical outcomes, but a randomized controlled trial is required to assess this. Retrospective analysis relies on the quality of input data, and may be subject to selection bias. Selection bias, with regards to the contemporaneous and historical comparative cohorts, has been limited, as operation notes for each procedure are produced within the dedicated database at the time of surgery.
Implications for Practice and Future Research
More randomized controlled trials are needed to assess the role of minimally invasive interval debulking surgery. The LANCE trial aims to answer this question for selected women undergoing either laparoscopic or robotic surgery who have demonstrated complete or partial response to chemotherapy.27 28 MIRRORS-RCT will look to assess the role of robotic interval debulking surgery in women with a pelvic mass ≤8 cm.
Conclusions
Robotic interval debulking surgery appears to be safe and feasible in women with a pelvic mass ≤8 cm. Extensive disease on the small bowel mesentery or serosa or on parts of the anterior abdominal wall next to ports may not be amenable to robotic resection. Where disease is limited to the pelvic peritoneum, the rectosigmoid colon, paracolic gutters, and diaphragmatic peritoneum, the robotic platform facilitates resection of disease particularly in patients with high body mass index.
The planned MIRRORS-RCT trial aims to establish whether survival, patient morbidity, and quality of life are non-inferior in women undergoing MIRRORS protocol (robot-assisted laparoscopic assessment proceeding to robotic or open interval debulking surgery) compared with standard open interval debulking surgery with a pelvic mass ≤8 cm. Should non-inferiority be confirmed, a significant change in practice could result.
Supplemental material
Data availability statement
Data are available upon reasonable request. All data relevant to the study are included in the article or uploaded as supplementary information. The datasets generated from this current study will be available upon request from Christina Uwins (Christina.Uwins@nhs.net) as raw anonymized data for up to 5 years following completion of the study. Participants have given their consent for the information collected from this study to be used to support other research in the future and to be shared anonymously with other researchers.
Ethics statements
Patient consent for publication
Ethics approval
MIRRORS was approved by the London Riverside Research Ethics Committee (Ref: 20/LO/0262 IRAS project ID: 261933). MIRRORS was performed in accordance with the Declaration of Helsinki. Written informed consent was obtained from all participants prior to them taking part. Historical and concurrent comparison data were assessed as part of a registered service evaluation project with Royal Surrey NHS Foundation Trust (No: SU-CA-21-22-037).
Acknowledgments
We are very grateful for the support of our Medical Director at the time; Dr M. Illsley who supported the opening of MIRRORS during the COVID 19 pandemic and Dr E. Donovan, Visiting Professor and Senior Adviser for the NIHR Research Design Service. We would also like to thanks members of Royal Surrey Research and Development team particularly K.Penhaligon, L.Gordon, F. De Beaux, S. Barnett, T. K. Madhuri and L. Moore and J. Davies. Lastly we would like to thank all the women who took part in MIRRORS and the GRACE charity women who provided their time to review the study protocol and participant information sheets.
References
Supplementary materials
Supplementary Data
This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.
Supplementary Data
This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.
Footnotes
X @christinauwins, @drjaychatt, @ssskene, @AgnMichael
Correction notice This article has been corrected since it was first published. Information was missing from the Acknowledgements and Ethics approval sections and has now been added.
Contributors Conceptualization: CU and SB-M. Study design: CU, SB-M, SSS, and AM. Data collection: CU, HA, JR, JC, JCh, PE, and SB-M. Data interpretation: CU, KB, AT, JC, JCh, PE, SS, AM, and SB-M. Drafting and/or editing manuscript: CU, HA, KB, JR, AT, JC, JCh, PE, SSS, AM, and SB-M. All authors approve and agree to be accountable for all aspects of the work. CU and SB-M are the guarantors and accept full responsibility for the finished work and the conduct of the study.
Funding MIRRORS was funded following open competition by both GRACE Charity (Gynae-oncology Research and Clinical Excellence) Registered Charity No. 1189729 https://grace-charity.org.uk/ and NIHR Applied Research Collaborations (ARC) Kent Surrey & Sussex (KSS) Greenshoots award. MIRRORS was also adopted on to the National Institute for Health Research (NIHR) portfolio. The NIHR portfolio consists of clinical research studies that are eligible for support from the NIHR clinical research network in England. The funders have played no role in conducting the research or the writing of this paper.
Competing interests CU is Vice President of the The Young European Advocates of Robotic Surgery (YEARS) which is part of the Society of European Robotic Gynaecological Surgery (SERGS) HA: none, KB: none, JR: none, AT: none, JC: none. JC is a proctor for Intuitive Surgical Ltd, the manufacturers of Da VinciTM surgical robots. As such, he has received payment and travel expenses within the past three years for surgical proctoring on robotic gynecological surgery at other hospitals around the UK, as he is an acknowledged expert in this field. He also occasionally gives paid lectures on behalf of pharmaceutical companies. PE: none, SSS: none, AM: Consulting or Advisory Role (EISA Pharma, GlaxoSmithKline, Ipsen) Research Funding (Merck) Travel, Accommodations, Expenses (Merck). SB-M is a proctor for Intuitive Surgical Ltd, the manufacturers of Da VinciTM surgical robots. As such, he has received payment and travel expenses within the past three years for surgical proctoring on robotic gynaecological surgery at other hospitals around the UK and in the EU, as he is an acknowledged expert in this field. SB-M has recently been appointed Vice President (President Elect) of the British and Irish Association of Robotic Gynaecological Surgeons (BIARGS).
Provenance and peer review Not commissioned; externally peer reviewed.
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