Robotic-assisted surgery in gynecologic oncology Abdulrahman K. Sinno, M.D., and Amanda N. Fader, M.D. The Kelly Gynecologic Oncology Service, Department of Gynecology and Obstetrics, Johns Hopkins Medicine, Baltimore, Maryland
The quest for improved patient outcomes has been a driving force for adoption of novel surgical innovations across surgical subspecialties. Gynecologic oncology is one such surgical discipline in which minimally invasive surgery has had a robust and evolving role in defining standards of care. Robotic-assisted surgery has developed during the past two decades as a more technologically advanced form of minimally invasive surgery in an effort to mitigate the limitations of conventional laparoscopy and improved patient outcomes. Robotically assisted technology offers potential advantages that include improved three-dimensional stereoscopic vision, wristed instruments that improve surgeon dexterity, and tremor canceling software that improves surgical precision. These technological advances may allow the gynecologic oncology surgeon to perform increasingly radical oncologic surgeries in complex patients. However, the platform is not without limitations, including high cost, lack of haptic feedback, and the requirement for additional training to achieve competence. This review describes the role of robotic-assisted surgery in the management of endometrial, cervical, and ovarian cancer, with an emphasis on comparison with laparotomy and conventional laparoscopy. The literature on novel robotic innovations, special patient populations, cost effectiveness, and fellowship training is also appraised critically in this regard. (Fertil SterilÒ 2014;102:922–32. Ó2014 by American Society Use your smartphone for Reproductive Medicine.) to scan this QR code Key Words: Robotic surgery, cervical cancer, endometrial cancer, ovarian cancer, single site, and connect to the sentinel lymph node Discuss: You can discuss this article with its authors and with other ASRM members at http:// fertstertforum.com/sinnoa-robotic-surgery-gynecologic-oncology/
M
inimally invasive surgery is the standard of care for the treatment of a variety of benign (1–4) and malignant (5–7) gynecologic conditions. Approximately half of the estimated 500,000 hysterectomies performed annually in the United States are carried out with vaginal, laparoscopic, or roboticassisted surgical approaches. Level I studies demonstrate the benefits of minimally invasive surgery compared with laparotomy, including improved perioperative outcomes, shorter hospital stays, improved quality of life, and a faster return to daily functions and the workforce. In addition, in gynecologic oncology patients, minimally invasive surgery appears oncologically
safe when performed in women with apparent early stage disease or in women who have isolated tumor recurrences (5–8). The da Vinci surgical system (Intuitive Surgical) was initially approved by the Food and Drug Administration in 2005 for use in gynecologic surgery. Since then there has been a growing body of published reports evaluating the utility of robotic-assisted surgery in gynecologic oncology. Accordingly, robotic-assisted surgical approaches have been used increasingly in the setting of risk-reducing uterine and adnexal surgery, and for the treatment of endometrial cancer (5–7, 9, 10), cervical cancer (9, 11–16), adnexal masses, and ovarian cancer (17–21).
Received June 1, 2014; revised and accepted August 12, 2014. A.K.S. has nothing to disclose. A.N.F. has nothing to disclose. Reprint requests: Amanda N. Fader, M.D., Gynecology and Obstetrics, Division of Gynecologic Oncology, 600 North Wolfe Street, Phipps 281, Johns Hopkins Medicine, Baltimore, Maryland 21281 (E-mail: [email protected]). Fertility and Sterility® Vol. 102, No. 4, October 2014 0015-0282/$36.00 Copyright ©2014 American Society for Reproductive Medicine, Published by Elsevier Inc. http://dx.doi.org/10.1016/j.fertnstert.2014.08.020 922
discussion forum for this article now.*
* Download a free QR code scanner by searching for “QR scanner” in your smartphone’s app store or app marketplace.
Robotic-assisted surgical technology addresses several of the limitations associated with conventional laparoscopy, including lack of depth perception, two-dimensional optics, camera instability, limited range of motion, and steep learning curves. Robotically assisted technology offers advantages that include improved three-dimensional stereoscopic vision, wristed instruments that improve dexterity, and tremor canceling software that improves surgical precision. However, the platform is not without limitations, including high cost, lack of haptic feedback, and the requirement for additional training to achieve competence. Furthermore, and of particular interest to the gynecologic oncologist, the platform is not intended for simultaneous multiple quadrant surgery. Despite these limitations, the technology has been widely adopted and has achieved considerable penetrance within the US gynecologic oncology surgeon community. It VOL. 102 NO. 4 / OCTOBER 2014
Fertility and Sterility® remains unclear in comparison studies, however, whether robotic-assisted surgery is truly superior to conventional laparoscopy for the treatment of oncologic conditions. Randomized controlled trials comparing these surgical approaches are lacking. The purpose of this review is to assess the current state of robotic-assisted surgery in gynecologic oncology and to conduct a critical appraisal of the published literature on the use of robotic-assisted surgery in the treatment of gynecologic malignancies. This was achieved by performing a PubMed search to identify published English language manuscripts that included the key words robotic, robotic surgery and ovarian cancer, cervical cancer, and endometrial cancer. Relevant articles were then analyzed in detail for inclusion in this review.
THE GYNECOLOGIC ONCOLOGY PATIENT The diversity in the characteristics of patients afflicted with gynecologic malignancies is a function of the different etiologic factors associated with these diseases. Because of these differences, various surgical approaches, often by roboticassisted surgery or other minimally invasive techniques, are used. Women diagnosed with cervical cancer are often young, have been exposed to the human papilloma virus, and require radical or fertility sparing surgery with curative intent. On the other hand, ovarian and endometrial cancer are diseases of the elderly and obese (22), and special consideration for surgical intervention with regard to recovery and complication rates is warranted. Age should never be considered as an independent, isolated contraindication to surgery, as performance status and the presence of comorbid medical conditions are more predictive of surgical complication rates (23–25). Older patients, however, are more likely to have associated comorbidities such as hypertension, cardiac, and pulmonary disease (26). Furthermore, obesity and diabetes are often present in patients with gynecologic cancer, and this further compounds the perioperative risk, including but not limited to, deep vein thrombosis and surgical site infections (27, 28). As such, this patient population may especially benefit from minimally invasive surgical interventions. In addition, robotic-assisted surgery, in particular, may offer advantages versus other minimally invasive modalities in the morbidly obese. The surgically complex patient will be explored in the following sections.
PENETRANCE OF ROBOTIC-ASSISTED SURGERY IN GYNECOLOGIC ONCOLOGY At present, more than 2,100 robotics have been installed in the United States (29). In fact, only 4 years after its clearance for gynecologic applications, 24% of gynecologist oncologists reported using robotic-assisted surgery, with 66% indicating that they planned to increase their use of the procedure in the next year (30). Similar to physicians who adopted laparoscopy early on in its development, gynecologic oncologists who completed their training less than 5 years before the present study were more likely to adopt robotic-assisted surgery than those who completed fellowship more than 15 years ago. Another survey, published in 2010, noted that 95% of gynecologic oncology fellows have a robotic VOL. 102 NO. 4 / OCTOBER 2014
platform at their institutions, and 95% were trained to use it (31). In this same study, 74% of fellows were trained to perform robotic-assisted lymph node dissection and 44% performed radical hysterectomies (31). These and other studies contributed to the Society of Gynecologic Oncology's robotic task force position statement that acknowledged that roboticassisted surgery has indeed ‘‘markedly changed’’ the practice patterns in the US gynecologic oncologist community (32).
ROBOTIC-ASSISTED SURGERY IN CERVICAL CANCER Background Despite recent advances in Papanicolaou smear (Pap) screening and human papilloma virus vaccination, cervical carcinoma remains a significant cause of morbidity and mortality worldwide. In the United States, 12,000 cases of cervical carcinoma are diagnosed annually and 4,000 deaths are attributed to this preventable disease (22). Cervical carcinoma is the second most common indication for the use of roboticassisted surgery (32). Abdominal radical hysterectomy (ARH) has been the traditional standard of care for patients with early disease (FIGO stage 1A2-IIA), with 5-year overall survival rates of 62%–90% (33). The intricacies of radical hysterectomy, which include a sophisticated dissection of the parametria, unroofing of the ureter from the ureteric canal within the cardinal ligament, and an en block resection of the uterus, cervix, parametria, and uterosacral ligaments, make it an ideal surgery for adoption into the robotic platform, especially as only a small number of surgeons adopted the laparoscopic technique for this complex procedure.
Radical Hysterectomy for Cervical Cancer Multiple studies have assessed the feasibility and safety of robotic-assisted radical hysterectomy (RRH) (Table 1). In 2008, Boggess et al. (34) published a case series of 51 consecutive RRHs performed on patients with FIGO stage IA1-IIA cervical cancer diagnosed between June 2005 and November 2007, and compared them with 49 consecutive patients undergoing ARH who were matched for cancer type and stage. Significantly less blood loss (96 vs. 411 mL), less operative time (210 vs. 247 minutes), shorter hospital stay (1 vs. 3.1 days), and a significantly increased mean number of lymph nodes retrieved (33.8 vs. 23.3) was noted in the robotic-assisted cohort. Postoperative complications were less in the RRH group, but this was not statistically significant. The investigators concluded that RRH may have more favorable outcomes when compared with ARH and that the traditional laparoscopic radical hysterectomy experience was not required to use the robotic-assisted approach, as the surgeons did not have extensive experience in total laparoscopic radical hysterectomy (TLRH). These data were later corroborated by Magrina et al. (8), who compared the three approaches (RRH, TLRH, and ARH) to radical hysterectomy. The robotic-assisted approach was associated with less mean blood loss, operative time, and duration of hospital stay than both the open and traditional laparoscopic techniques. Another study (10) retrospectively 923
VIEWS AND REVIEWS
TABLE 1 Selected publications of robotic surgery in cervical cancer. No. of patients
Disease site
Boggess et al. 2008
100
Cervix
Margina et al. 2008
129
Cantrell et al. 2010
127
Soliman et al. 2011
Author(s)/year
Diaz-Feijoo et al. 2014
Cervix and corpus
Study groups RRH vs. RAH
Study design
Significance
Case control
First case series of radical abdominal hysterectomy. RRH associated with reduced OR time, EBL, LOS, and similar complication rates Boggess et al. did not have prior experience in laparoscopic radical hysterectomy First study comparing TLRH and RRH and showing improved outcomes for RRH vs. TLRH and RAH 94% progression-free survival and overall survival at 36 months RRH had similar overall and progression-free survival as ARH Less risk of conversion to laparotomy in RRH, shorter length of stay, less total IV opioid administration Robotic approach yielded a higher no. of aortic nodes (14 vs. 17 nodes, P< .05) and less blood loss (90 vs. 20 mL, P< .05) Operative time, hospital stay, and complication rates were the same in both groups
RRH vs. RAH vs. TLRH
Prospective cohort
Cervix
RRH vs. RAH
Retrospective cohort
95
Cervix
RRH vs. TLRH vs. RAH
Retrospective cohort
100
Cervix
Robotic vs. laparoscopic extraperitoneal lymphadenectomy
Matched case control
Note: EBL ¼ estimated blood loss; LOS ¼ length of surgery; OR ¼ operative time; RAH ¼ radical abdominal hysterectomy; RRH ¼ robotic radical hysterectomy; TLRH ¼ total laparoscopic radical hysterectomy. Sinno. Robotic-assisted surgery in gynecologic oncology. Fertil Steril 2014.
compared 99 women who received either RRH or TLRH and found a similar rate of mean blood loss, hospital stay, and complication rates. However, operative time was significantly longer in the robotic-assisted group (255 vs. 323 minutes; P< .05). This has been validated multiple times in the literature; similar complication rates (9, 15, 30, 35), improved operative outcomes, such as estimated blood loss and infections in the RRH groups (35–37), and variable operative times (9, 15, 36–48). In a retrospective review of a commercially available database, Wright et al. (39) reviewed 1,894 patients who underwent radical hysterectomy between 2006 and 2010. Overall, intraoperative and surgical site complications were not significantly different across modalities (P¼ .76 and P¼ .69, respectively) and both RRH and TLRH were associated with less transfusion requirements and shorter hospital stays than ARH (P< .05). Conversely, a meta-analysis (13) of 27 case series of TLRH versus RRH published in 2011, found that although the rate of intraoperative complications and the rate of reoperation was similar between the groups, RRH had a higher rate of major postoperative complications when compared with TLRH (9.6% vs. 5.4%; P< .01). It is important to note that 63.6% of the major complications in the RRH group were vaginal cuff dehiscences or abscesses. The investigators concluded that further experience beyond the learning curve phase may improve this complication rate (13). Another potential advantage of robotic-assisted procedures is that postoperative pain and return to function may 924
occur more quickly for patients than with other surgical procedures. It is postulated that decreased incisional pain may occur in robotic-assisted procedures because the instrument torque is not at the level of the abdominal wall (as it is with conventional laparoscopic instruments), but rather, downstream at the articulated wrists of the robotic instruments. Soliman et al. (37) retrospectively reviewed the records of 85 patients who underwent minimally invasive radical hysterectomy for stage IA1-IIB2 cervical cancer. Despite a higher median age in the RRH group (42 vs. 52 years; P¼ .001), RRH was associated with a significantly shorter length of stay (2 vs. 1 day; P¼ .005) and a significantly less total IV opioid administration (10.7 vs. 26.7 mg of morphine equivalents; P¼ .001) compared with the TLRH group. In a prospective analysis of patients undergoing RRH versus TLRH and ARH, Estape et al. (35) found that patients in the RRH and TLRH groups averaged 19 and 18 days less on pain medication than patients in the ARH group (P¼ .002) and returned to work 23 days sooner (P¼ .003).
Long-term Outcomes There is a paucity of data regarding long-term outcomes in patients who receive robotic-assisted radical hysterectomy. Tinelli et al. (10) found an equivalent disease-free recurrence rate of 95% and 97% after 24 ad 48 months in the ARH and RRH groups. Another publication (38) showed a 94% overall survival at 36 months in 71 patients (8 patients were excluded VOL. 102 NO. 4 / OCTOBER 2014
Fertility and Sterility® from analysis) who underwent RRH because of recurrence and the death of 1 patient. This was statistically equivalent to a matched historic control of ARH. It should be noted that multiple reports (8, 34, 40) have established that the number of lymph nodes retrieved are at least equal, if not larger, in RRH compared with traditional approaches. A current randomized control trial (16) to better assess long-term outcomes and recurrence rates is underway.
Fertility-sparing Surgery and Ovarian Transposition Given that 40% of women diagnosed with cervical cancer have the desire to preserve fertility (41), fertility-sparing surgery in the form of vaginal radical trachelectomy using the Dargent technique, has been described since the late 1980s. This technique has been further developed into an abdominal approach and found to yield similar oncologic outcomes as radical hysterectomy, with the added benefit that 70%–95% of these carefully selected patients successfully maintained fertility (42–46). Radical trachelectomy is a complex procedure that requires mobilization of the ureter and identification of its path as it courses through the pelvis. After completion of ureteral dissection and mobilization, the vaginal branch of the uterine artery is ligated. Superior visualization and wristed hand motions offered by the robotic platform are particularly attractive in this setting. Review of the current literature reveals that 6 case reports and case series, with a total of 36 patients who have underwent robotic-assisted radical trachelectomy, have been reported (11, 47–52). Fertility preservation was successful in 81% of these patients and 10 of 36 successfully conceived. One report (49) noted a nerve-sparing technique and another (50) reported preservation of the uterine artery. Ovarian transposition is of particular significance in cervical cancer given that most patients are premenopausal and emerging evidence regarding the improved all-cause mortality when ovaries are conserved in women less than age 65 years (53). Furthermore it is well-known that the risk of metastasis of cervical cancer to the ovary is 0.5% in squamous cell carcinoma and 1.3% in adenocarcinoma (54). As such, many patients wish to avoid surgical or radiation-induced menopause and its associated symptoms. Two case reports (55, 56) of successful robotic-assisted laparoscopic ovarian transposition have been published. Given the ease of traditional laparoscopic ovarian transposition, we do not believe that a role for robotic assistance exists, except as an adjunct to robotic-assisted radical hysterectomy or para-aortic lymphadenectomy in the setting of locally advanced disease.
Extraperitoneal Lymphadenectomy Lymph node metastasis is a powerful predictor of overall prognosis and risk of recurrence in cervical carcinoma (14, 57). Furthermore, involvement of para-aorta may require extension of the radiation field to the lower abdomen to fully cover the sites of disease (58). Patients diagnosed with paraaortic lymph node metastasis may also be candidates for intensity-modulated radiation therapy, which has been VOL. 102 NO. 4 / OCTOBER 2014
shown to reduce the morbidity associated with abdominal radiation in this setting (59). Unfortunately, imaging with techniques have a maximum sensitivity of 84% in detecting para-aortic nodal metastasis (in the case of FDG-PET) (60). For these reasons, some surgeons recommend pretreatment surgical evaluation with extraperitoneal lymph node sampling to tailor radiation therapy to the individual patient (14). Diaz-Feijoo et al. (61) compared robotic extraperitoneal lymph node sampling to the conventional laparoscopic approach in 100 consecutive patients and published their findings in January of 2014. They identified that the robotic-assisted approach yielded a higher number of aortic nodes (14 vs. 17 nodes; P< .05) and less blood loss (90 vs. 20 mL; P< .05). Operative time, hospital stay, and complication rates were the same in both groups. In this and another study by Magrina et al. (62) reported that a 10- to 15degree rotation of the table avoided arm collision during the infrarenal dissection, which would have otherwise been a technical challenge to procedure completion. Other investigators (63, 64) have placed of the optical trocar in the lateral position and performed slight table rotation and Trendelenberg positioning of the patient to successfully overcome arm collision.
Pelvic Exenteration Pelvic exenteration is one the most radical procedure a gynecologic oncologist will perform. It includes en bloc resection of the bladder, pelvic ureters, rectum, sigmoid, peritoneum, and any residual pelvic lymph nodes (65). First described in 1948 by Brunschwig (66), the indications for pelvic exenteration have continued to evolve and become more restrictive given the high morbidity of the procedure. Currently, pelvic exenteration is performed for recurrent cervical cancer when isolated recurrences (
The quest for improved patient outcomes has been a driving force for adoption of novel surgical innovations across surgical subspecialties. Gynecologic oncology is one such surgical discipline in which minimally invasive surgery has had a robust and evolving role in defining standards of care. Robotic-assisted surgery has developed during the past two decades as a more technologically advanced form of minimally invasive surgery in an effort to mitigate the limitations of conventional laparoscopy and improved patient outcomes. Robotically assisted technology offers potential advantages that include improved three-dimensional stereoscopic vision, wristed instruments that improve surgeon dexterity, and tremor canceling software that improves surgical precision. These technological advances may allow the gynecologic oncology surgeon to perform increasingly radical oncologic surgeries in complex patients. However, the platform is not without limitations, including high cost, lack of haptic feedback, and the requirement for additional training to achieve competence. This review describes the role of robotic-assisted surgery in the management of endometrial, cervical, and ovarian cancer, with an emphasis on comparison with laparotomy and conventional laparoscopy. The literature on novel robotic innovations, special patient populations, cost effectiveness, and fellowship training is also appraised critically in this regard. (Fertil SterilÒ 2014;102:922–32. Ó2014 by American Society Use your smartphone for Reproductive Medicine.) to scan this QR code Key Words: Robotic surgery, cervical cancer, endometrial cancer, ovarian cancer, single site, and connect to the sentinel lymph node Discuss: You can discuss this article with its authors and with other ASRM members at http:// fertstertforum.com/sinnoa-robotic-surgery-gynecologic-oncology/
M
inimally invasive surgery is the standard of care for the treatment of a variety of benign (1–4) and malignant (5–7) gynecologic conditions. Approximately half of the estimated 500,000 hysterectomies performed annually in the United States are carried out with vaginal, laparoscopic, or roboticassisted surgical approaches. Level I studies demonstrate the benefits of minimally invasive surgery compared with laparotomy, including improved perioperative outcomes, shorter hospital stays, improved quality of life, and a faster return to daily functions and the workforce. In addition, in gynecologic oncology patients, minimally invasive surgery appears oncologically
safe when performed in women with apparent early stage disease or in women who have isolated tumor recurrences (5–8). The da Vinci surgical system (Intuitive Surgical) was initially approved by the Food and Drug Administration in 2005 for use in gynecologic surgery. Since then there has been a growing body of published reports evaluating the utility of robotic-assisted surgery in gynecologic oncology. Accordingly, robotic-assisted surgical approaches have been used increasingly in the setting of risk-reducing uterine and adnexal surgery, and for the treatment of endometrial cancer (5–7, 9, 10), cervical cancer (9, 11–16), adnexal masses, and ovarian cancer (17–21).
Received June 1, 2014; revised and accepted August 12, 2014. A.K.S. has nothing to disclose. A.N.F. has nothing to disclose. Reprint requests: Amanda N. Fader, M.D., Gynecology and Obstetrics, Division of Gynecologic Oncology, 600 North Wolfe Street, Phipps 281, Johns Hopkins Medicine, Baltimore, Maryland 21281 (E-mail: [email protected]). Fertility and Sterility® Vol. 102, No. 4, October 2014 0015-0282/$36.00 Copyright ©2014 American Society for Reproductive Medicine, Published by Elsevier Inc. http://dx.doi.org/10.1016/j.fertnstert.2014.08.020 922
discussion forum for this article now.*
* Download a free QR code scanner by searching for “QR scanner” in your smartphone’s app store or app marketplace.
Robotic-assisted surgical technology addresses several of the limitations associated with conventional laparoscopy, including lack of depth perception, two-dimensional optics, camera instability, limited range of motion, and steep learning curves. Robotically assisted technology offers advantages that include improved three-dimensional stereoscopic vision, wristed instruments that improve dexterity, and tremor canceling software that improves surgical precision. However, the platform is not without limitations, including high cost, lack of haptic feedback, and the requirement for additional training to achieve competence. Furthermore, and of particular interest to the gynecologic oncologist, the platform is not intended for simultaneous multiple quadrant surgery. Despite these limitations, the technology has been widely adopted and has achieved considerable penetrance within the US gynecologic oncology surgeon community. It VOL. 102 NO. 4 / OCTOBER 2014
Fertility and Sterility® remains unclear in comparison studies, however, whether robotic-assisted surgery is truly superior to conventional laparoscopy for the treatment of oncologic conditions. Randomized controlled trials comparing these surgical approaches are lacking. The purpose of this review is to assess the current state of robotic-assisted surgery in gynecologic oncology and to conduct a critical appraisal of the published literature on the use of robotic-assisted surgery in the treatment of gynecologic malignancies. This was achieved by performing a PubMed search to identify published English language manuscripts that included the key words robotic, robotic surgery and ovarian cancer, cervical cancer, and endometrial cancer. Relevant articles were then analyzed in detail for inclusion in this review.
THE GYNECOLOGIC ONCOLOGY PATIENT The diversity in the characteristics of patients afflicted with gynecologic malignancies is a function of the different etiologic factors associated with these diseases. Because of these differences, various surgical approaches, often by roboticassisted surgery or other minimally invasive techniques, are used. Women diagnosed with cervical cancer are often young, have been exposed to the human papilloma virus, and require radical or fertility sparing surgery with curative intent. On the other hand, ovarian and endometrial cancer are diseases of the elderly and obese (22), and special consideration for surgical intervention with regard to recovery and complication rates is warranted. Age should never be considered as an independent, isolated contraindication to surgery, as performance status and the presence of comorbid medical conditions are more predictive of surgical complication rates (23–25). Older patients, however, are more likely to have associated comorbidities such as hypertension, cardiac, and pulmonary disease (26). Furthermore, obesity and diabetes are often present in patients with gynecologic cancer, and this further compounds the perioperative risk, including but not limited to, deep vein thrombosis and surgical site infections (27, 28). As such, this patient population may especially benefit from minimally invasive surgical interventions. In addition, robotic-assisted surgery, in particular, may offer advantages versus other minimally invasive modalities in the morbidly obese. The surgically complex patient will be explored in the following sections.
PENETRANCE OF ROBOTIC-ASSISTED SURGERY IN GYNECOLOGIC ONCOLOGY At present, more than 2,100 robotics have been installed in the United States (29). In fact, only 4 years after its clearance for gynecologic applications, 24% of gynecologist oncologists reported using robotic-assisted surgery, with 66% indicating that they planned to increase their use of the procedure in the next year (30). Similar to physicians who adopted laparoscopy early on in its development, gynecologic oncologists who completed their training less than 5 years before the present study were more likely to adopt robotic-assisted surgery than those who completed fellowship more than 15 years ago. Another survey, published in 2010, noted that 95% of gynecologic oncology fellows have a robotic VOL. 102 NO. 4 / OCTOBER 2014
platform at their institutions, and 95% were trained to use it (31). In this same study, 74% of fellows were trained to perform robotic-assisted lymph node dissection and 44% performed radical hysterectomies (31). These and other studies contributed to the Society of Gynecologic Oncology's robotic task force position statement that acknowledged that roboticassisted surgery has indeed ‘‘markedly changed’’ the practice patterns in the US gynecologic oncologist community (32).
ROBOTIC-ASSISTED SURGERY IN CERVICAL CANCER Background Despite recent advances in Papanicolaou smear (Pap) screening and human papilloma virus vaccination, cervical carcinoma remains a significant cause of morbidity and mortality worldwide. In the United States, 12,000 cases of cervical carcinoma are diagnosed annually and 4,000 deaths are attributed to this preventable disease (22). Cervical carcinoma is the second most common indication for the use of roboticassisted surgery (32). Abdominal radical hysterectomy (ARH) has been the traditional standard of care for patients with early disease (FIGO stage 1A2-IIA), with 5-year overall survival rates of 62%–90% (33). The intricacies of radical hysterectomy, which include a sophisticated dissection of the parametria, unroofing of the ureter from the ureteric canal within the cardinal ligament, and an en block resection of the uterus, cervix, parametria, and uterosacral ligaments, make it an ideal surgery for adoption into the robotic platform, especially as only a small number of surgeons adopted the laparoscopic technique for this complex procedure.
Radical Hysterectomy for Cervical Cancer Multiple studies have assessed the feasibility and safety of robotic-assisted radical hysterectomy (RRH) (Table 1). In 2008, Boggess et al. (34) published a case series of 51 consecutive RRHs performed on patients with FIGO stage IA1-IIA cervical cancer diagnosed between June 2005 and November 2007, and compared them with 49 consecutive patients undergoing ARH who were matched for cancer type and stage. Significantly less blood loss (96 vs. 411 mL), less operative time (210 vs. 247 minutes), shorter hospital stay (1 vs. 3.1 days), and a significantly increased mean number of lymph nodes retrieved (33.8 vs. 23.3) was noted in the robotic-assisted cohort. Postoperative complications were less in the RRH group, but this was not statistically significant. The investigators concluded that RRH may have more favorable outcomes when compared with ARH and that the traditional laparoscopic radical hysterectomy experience was not required to use the robotic-assisted approach, as the surgeons did not have extensive experience in total laparoscopic radical hysterectomy (TLRH). These data were later corroborated by Magrina et al. (8), who compared the three approaches (RRH, TLRH, and ARH) to radical hysterectomy. The robotic-assisted approach was associated with less mean blood loss, operative time, and duration of hospital stay than both the open and traditional laparoscopic techniques. Another study (10) retrospectively 923
VIEWS AND REVIEWS
TABLE 1 Selected publications of robotic surgery in cervical cancer. No. of patients
Disease site
Boggess et al. 2008
100
Cervix
Margina et al. 2008
129
Cantrell et al. 2010
127
Soliman et al. 2011
Author(s)/year
Diaz-Feijoo et al. 2014
Cervix and corpus
Study groups RRH vs. RAH
Study design
Significance
Case control
First case series of radical abdominal hysterectomy. RRH associated with reduced OR time, EBL, LOS, and similar complication rates Boggess et al. did not have prior experience in laparoscopic radical hysterectomy First study comparing TLRH and RRH and showing improved outcomes for RRH vs. TLRH and RAH 94% progression-free survival and overall survival at 36 months RRH had similar overall and progression-free survival as ARH Less risk of conversion to laparotomy in RRH, shorter length of stay, less total IV opioid administration Robotic approach yielded a higher no. of aortic nodes (14 vs. 17 nodes, P< .05) and less blood loss (90 vs. 20 mL, P< .05) Operative time, hospital stay, and complication rates were the same in both groups
RRH vs. RAH vs. TLRH
Prospective cohort
Cervix
RRH vs. RAH
Retrospective cohort
95
Cervix
RRH vs. TLRH vs. RAH
Retrospective cohort
100
Cervix
Robotic vs. laparoscopic extraperitoneal lymphadenectomy
Matched case control
Note: EBL ¼ estimated blood loss; LOS ¼ length of surgery; OR ¼ operative time; RAH ¼ radical abdominal hysterectomy; RRH ¼ robotic radical hysterectomy; TLRH ¼ total laparoscopic radical hysterectomy. Sinno. Robotic-assisted surgery in gynecologic oncology. Fertil Steril 2014.
compared 99 women who received either RRH or TLRH and found a similar rate of mean blood loss, hospital stay, and complication rates. However, operative time was significantly longer in the robotic-assisted group (255 vs. 323 minutes; P< .05). This has been validated multiple times in the literature; similar complication rates (9, 15, 30, 35), improved operative outcomes, such as estimated blood loss and infections in the RRH groups (35–37), and variable operative times (9, 15, 36–48). In a retrospective review of a commercially available database, Wright et al. (39) reviewed 1,894 patients who underwent radical hysterectomy between 2006 and 2010. Overall, intraoperative and surgical site complications were not significantly different across modalities (P¼ .76 and P¼ .69, respectively) and both RRH and TLRH were associated with less transfusion requirements and shorter hospital stays than ARH (P< .05). Conversely, a meta-analysis (13) of 27 case series of TLRH versus RRH published in 2011, found that although the rate of intraoperative complications and the rate of reoperation was similar between the groups, RRH had a higher rate of major postoperative complications when compared with TLRH (9.6% vs. 5.4%; P< .01). It is important to note that 63.6% of the major complications in the RRH group were vaginal cuff dehiscences or abscesses. The investigators concluded that further experience beyond the learning curve phase may improve this complication rate (13). Another potential advantage of robotic-assisted procedures is that postoperative pain and return to function may 924
occur more quickly for patients than with other surgical procedures. It is postulated that decreased incisional pain may occur in robotic-assisted procedures because the instrument torque is not at the level of the abdominal wall (as it is with conventional laparoscopic instruments), but rather, downstream at the articulated wrists of the robotic instruments. Soliman et al. (37) retrospectively reviewed the records of 85 patients who underwent minimally invasive radical hysterectomy for stage IA1-IIB2 cervical cancer. Despite a higher median age in the RRH group (42 vs. 52 years; P¼ .001), RRH was associated with a significantly shorter length of stay (2 vs. 1 day; P¼ .005) and a significantly less total IV opioid administration (10.7 vs. 26.7 mg of morphine equivalents; P¼ .001) compared with the TLRH group. In a prospective analysis of patients undergoing RRH versus TLRH and ARH, Estape et al. (35) found that patients in the RRH and TLRH groups averaged 19 and 18 days less on pain medication than patients in the ARH group (P¼ .002) and returned to work 23 days sooner (P¼ .003).
Long-term Outcomes There is a paucity of data regarding long-term outcomes in patients who receive robotic-assisted radical hysterectomy. Tinelli et al. (10) found an equivalent disease-free recurrence rate of 95% and 97% after 24 ad 48 months in the ARH and RRH groups. Another publication (38) showed a 94% overall survival at 36 months in 71 patients (8 patients were excluded VOL. 102 NO. 4 / OCTOBER 2014
Fertility and Sterility® from analysis) who underwent RRH because of recurrence and the death of 1 patient. This was statistically equivalent to a matched historic control of ARH. It should be noted that multiple reports (8, 34, 40) have established that the number of lymph nodes retrieved are at least equal, if not larger, in RRH compared with traditional approaches. A current randomized control trial (16) to better assess long-term outcomes and recurrence rates is underway.
Fertility-sparing Surgery and Ovarian Transposition Given that 40% of women diagnosed with cervical cancer have the desire to preserve fertility (41), fertility-sparing surgery in the form of vaginal radical trachelectomy using the Dargent technique, has been described since the late 1980s. This technique has been further developed into an abdominal approach and found to yield similar oncologic outcomes as radical hysterectomy, with the added benefit that 70%–95% of these carefully selected patients successfully maintained fertility (42–46). Radical trachelectomy is a complex procedure that requires mobilization of the ureter and identification of its path as it courses through the pelvis. After completion of ureteral dissection and mobilization, the vaginal branch of the uterine artery is ligated. Superior visualization and wristed hand motions offered by the robotic platform are particularly attractive in this setting. Review of the current literature reveals that 6 case reports and case series, with a total of 36 patients who have underwent robotic-assisted radical trachelectomy, have been reported (11, 47–52). Fertility preservation was successful in 81% of these patients and 10 of 36 successfully conceived. One report (49) noted a nerve-sparing technique and another (50) reported preservation of the uterine artery. Ovarian transposition is of particular significance in cervical cancer given that most patients are premenopausal and emerging evidence regarding the improved all-cause mortality when ovaries are conserved in women less than age 65 years (53). Furthermore it is well-known that the risk of metastasis of cervical cancer to the ovary is 0.5% in squamous cell carcinoma and 1.3% in adenocarcinoma (54). As such, many patients wish to avoid surgical or radiation-induced menopause and its associated symptoms. Two case reports (55, 56) of successful robotic-assisted laparoscopic ovarian transposition have been published. Given the ease of traditional laparoscopic ovarian transposition, we do not believe that a role for robotic assistance exists, except as an adjunct to robotic-assisted radical hysterectomy or para-aortic lymphadenectomy in the setting of locally advanced disease.
Extraperitoneal Lymphadenectomy Lymph node metastasis is a powerful predictor of overall prognosis and risk of recurrence in cervical carcinoma (14, 57). Furthermore, involvement of para-aorta may require extension of the radiation field to the lower abdomen to fully cover the sites of disease (58). Patients diagnosed with paraaortic lymph node metastasis may also be candidates for intensity-modulated radiation therapy, which has been VOL. 102 NO. 4 / OCTOBER 2014
shown to reduce the morbidity associated with abdominal radiation in this setting (59). Unfortunately, imaging with techniques have a maximum sensitivity of 84% in detecting para-aortic nodal metastasis (in the case of FDG-PET) (60). For these reasons, some surgeons recommend pretreatment surgical evaluation with extraperitoneal lymph node sampling to tailor radiation therapy to the individual patient (14). Diaz-Feijoo et al. (61) compared robotic extraperitoneal lymph node sampling to the conventional laparoscopic approach in 100 consecutive patients and published their findings in January of 2014. They identified that the robotic-assisted approach yielded a higher number of aortic nodes (14 vs. 17 nodes; P< .05) and less blood loss (90 vs. 20 mL; P< .05). Operative time, hospital stay, and complication rates were the same in both groups. In this and another study by Magrina et al. (62) reported that a 10- to 15degree rotation of the table avoided arm collision during the infrarenal dissection, which would have otherwise been a technical challenge to procedure completion. Other investigators (63, 64) have placed of the optical trocar in the lateral position and performed slight table rotation and Trendelenberg positioning of the patient to successfully overcome arm collision.
Pelvic Exenteration Pelvic exenteration is one the most radical procedure a gynecologic oncologist will perform. It includes en bloc resection of the bladder, pelvic ureters, rectum, sigmoid, peritoneum, and any residual pelvic lymph nodes (65). First described in 1948 by Brunschwig (66), the indications for pelvic exenteration have continued to evolve and become more restrictive given the high morbidity of the procedure. Currently, pelvic exenteration is performed for recurrent cervical cancer when isolated recurrences (
