Comparison between 155 cases of robotic vs. 150 cases of open surgical staging for endometrial cancer
Highlights
► A comparison between robotic and open surgical staging for endometrial cancer. ► A chart review of 155 robotic and 150 open cases performed by 2 different surgeons. ► Robotic arm had significantly less blood loss, hospital stay and complications.
Introduction
Endometrial cancer accounts for 6% of all cancers in women. It is the most common female genital tract malignancy in the United States, with an incidence of 40,100 new cases and 7470 deaths annually [1]. Most cases are readily diagnosed at an early stage by an endometrial biopsy following abnormal uterine bleeding. Surgery alone is often adequate for cure, and the five-year survival rates for localized, regional, and metastatic disease are 96, 66, and 24%, respectively [1].
According to the International Federation of Gynecology and Obstetrics (FIGO) total extrafascial hysterectomy and bilateral salpingo-oopherectomy with pelvic and paraaortic lymph node dissection is the standard staging procedure for endometrial cancer [2].
An increased interest in minimally invasive surgery has resulted in multiple studies comparing laparoscopic staging of endometrial cancer, confined to the uterus, to staging via laparotomy. A recent meta-analysis of four randomized controlled trials found laparoscopic staging to be as effective as open surgery and, except for a longer operative time, laparoscopy was shown to have an advantage in terms of blood loss, hospital stay, and postoperative complications [3]. In an update of the same meta-analysis, the authors concluded that the laparoscopic approach is an effective procedure for treating early stage endometrial cancer in terms of long term survivals [4]. A large Gynecologic Oncology Group randomized controlled study reached similar favorable conclusions regarding safety, feasibility and short term outcomes of laparoscopic staging of uterine cancer [5]. Survival outcomes, however, from this and other well designed studies are pending before definitive conclusions can be drawn.
The da Vinci Surgical System (Intuitive Surgical, Inc, Sunnyvale, CA) was approved by the U.S. Food and Drug Administration (FDA) for use in gynecologic procedures in 2005. Though some have concerns about the cost of acquiring and maintaining the robotic system as well as the time needed to train a surgeon, advantages of this minimally invasive technology include high definition 3-dimentional field of vision, instruments with wrist-like range of motion, tremor filtration, better ergonomics, and a faster learning curve compared to laparoscopy [6], [11]. This robotic surgical system hence offers many advantages over traditional laparoscopy, and has been widely, and rapidly, embraced in gynecologic oncology as it was shown to be feasible, safe, and facilitates performing complex procedures such as retroperitoneal lymph node dissection [[7], [8], [9]].
When compared to laparoscopy, robotic-assisted staging for endometrial cancer was more feasible in patients with higher BMI. It was associated with less operative time, blood loss, and length of operative stay. There was no significant difference in lymph node yield or in cost [6], [10].
When compared to laparotomy, robotic-assisted staging for endometrial cancer retained all the advantages of minimally invasive surgery while maintaining the achievability of the surgical procedure. While published studies reported equal number of retrieved lymph nodes, the robotic surgical system was associated with reduced blood loss, less peri-operative complications, shorter hospital stay, faster return to normal activity, and less cost [[6], [10], [11], [12], [13]]. Though some studies have shown an improvement with experience [7], [8], thus far robotic-assisted staging for endometrial cancer seems to have a longer reported operative time than laparotomy.
Our objective is to review the experience of a single surgeon with robotic-assisted surgical staging for endometrial cancer, and to compare patients treated with this modality to those treated with laparotomy by another surgeon. To our knowledge this is the largest series thus far reported by a single surgeon using the robotic system.
Section snippets
Methods
After acquiring approval from the Yale University Human Investigative Committee (HIC), we performed a retrospective chart review of one hundred-fifty five patients who underwent robotic-assisted surgical staging for endometrial cancer by a single surgeon (MA) from September 2006 to September 2010. The control group comprised one hundred-fifty consecutive cases of endometrial cancer that were surgically staged via a laparotomy by a different surgeon (TJR) during the same period. Both surgeons
Results
During the study period, one hundred-fifty five patients with endometrial cancer underwent robotic-assisted surgical staging by a single surgeon (MA). Comparison was made to one hundred fifty consecutive cases that were surgically staged via laparotomy by a different surgeon (TJR) during the same period. The mean age was 62.4 years in the robot group, and 65 years in the laparotomy group (p = 0.04). The mean BMI was 34.5 Kg/m2 in the robot group, which was comparable to a BMI of 33 Kg/m2 in the
Discussion
In this study we evaluated the outcomes of 155 cases of robotic surgical staging for endometrial cancer performed by a single experienced laparoscopic surgeon who has widely adopted robotics into his practice since 2006. We compared those cases to 150 laparotomy cases performed by another accomplished gynecologic oncologist who did not uniformly change his approach from laparotomy to laparoscopy. This, to our knowledge, is the largest number of robotic-assisted cases of endometrial cancer
Conflict of interest statement
The Authors have nothing to declare.
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