Robotic-assisted vs traditional laparoscopic surgery for endometrial cancer: a randomized controlled trial

A comparison of operative outcomes between standard and robotic laparoscopic surgery for endometrial cancer: A systematic review and meta-analysis

BACKGROUND

Evidence has been systematically assessed comparing robotic with standard laparoscopy for treatment of endometrial cancer.

METHODS

A search of Medline, Embase and Cochrane databases was performed until 30th October 2016.

RESULTS

Thirty-six papers including 33 retrospective studies, two matched case-control studies and one randomized controlled study were used in a meta-analysis. Information from a further seven registry/database studies were assessed descriptively. There were no differences in the duration of surgery but days stay in hospital were shorter in the robotic arm (0.46 days, 95%CI 0.26 to 0.66). A robotic approach had less blood loss (57.74 mL, 95%CI 38.29 to 77.20), less conversions to laparotomy (RR = 0.41, 95%CI 0.29 to 0.59), and less overall complications (RR = 0.82, 95%CI 0.72 to 0.93). A robotic approach had higher costs ($1746.20, 95%CI $63.37 to $3429.03).

CONCLUSION

A robotic approach has favourable clinical outcomes but is more expensive.

[Primary management of endometrial carcinoma. Joint recommendations of the French society of gynecologic oncology (SFOG) and of the French college of obstetricians and gynecologists (CNGOF)]

OBJECTIVES

The management of endometrial carcinoma is constantly evolving. The SFOG and the CNGOF decided to jointly update the previous French recommendations (Institut national du cancer 2011) and to adapt to the French practice the 2015 recommendations elaborated at the time of joint European consensus conference with the participation of the three concerned European societies (ESGO, ESTRO, ESMO).

MATERIAL AND METHODS

A strict methodology was used. A steering committee was put together. A systematic review of the literature since 2011 has been carried out. A first draft of the recommendations has been elaborated, with emphasis on high level of evidence. An external review by users representing all the concerned discipines and all kinds of practice was completed. Three hundred and four comments were sent by 54 reviewers.

RESULTS

The management of endometrial carcinoma requires a precise preoperative workup. A provisional estimate of the final stage is provided. This estimation impact the level of surgical staging. Surgery should use a minimal invasive approach. The final pathology is the key of the decision concerning adjuvant therapy, which involves surveillance, radiation therapy, brachytherapy, or chemotherapy.

CONCLUSION

The management algorithms allow a fast, state of the art based, answer to the clinical questions raised by the management of endometrial cancer. They must be used only in the setting of a multidisciplinary team at all stages of the management.

Costs of Robotic-Assisted Versus Traditional Laparoscopy in Endometrial Cancer

OBJECTIVES

The purpose of this study was to compare the costs of traditional laparoscopy and robotic-assisted laparoscopy in the treatment of endometrial cancer.

METHODS AND MATERIALS

A total of 101 patients with endometrial cancer were randomized to the study and operated on starting from 2010 until 2013, at the Department of Obstetrics and Gynecology of Tampere University Hospital, Tampere, Finland. Costs were calculated based on internal accounting, hospital database, and purchase prices and were compared using intention-to-treat analysis. Main outcome measures were item costs and total costs related to the operation, including a 6-month postoperative follow-up.

RESULTS

The total costs including late complications were 2160 &OV0556; higher in the robotic group (median for traditional 5823 &OV0556;, vs robot median 7983 &OV0556;, P < 0.001). The difference was due to higher costs for instruments and equipment as well as to more expensive operating room and postanesthesia care unit time. Traditional laparoscopy involved higher costs for operation personnel, general costs, medication used in the operation, and surgeon, although these costs were not substantial. There was no significant difference in in-patient stay, laboratory, radiology, blood products, or costs related to complications.

CONCLUSIONS

According to this study, robotic-assisted laparoscopy is 37% more expensive than traditional laparoscopy in the treatment of endometrial cancer. The cost difference is mainly explained by amortization of the robot and its instrumentation.

Health care cost consequences of using robot technology for hysterectomy: a register-based study of consecutive patients during 2006-2013

The objective of this study is to examine the costs attributable to robotic-assisted laparoscopic hysterectomy from a broad healthcare sector perspective in a register-based longitudinal study. The population in this study were 7670 consecutive women undergoing hysterectomy between January 2006 and August 2013 in public hospitals in Denmark. The interventions in the study were total and radical hysterectomy performed robotic-assisted laparoscopic hysterectomy (RALH), total laparoscopic hysterectomy (TLH), or open abdominal hysterectomy (OAH). Service use in the healthcare sector was evaluated 1 year before to 1 year after the surgery. Tariffs of the activity-based remuneration system and the diagnosis-related grouping case-mix system were used for valuation of primary and secondary care, respectively. Costs attributable to RALH were estimated using a difference-in-difference analytical approach and adjusted using multivariate linear regression. The main outcome measure was costs attributable to OAH, TLH, and RALH. For benign conditions RALH generated cost savings of € 2460 (95% CI 845; 4075) per patient compared to OAH and non-significant cost savings of € 1045 (95% CI -200; 2291) when compared with TLH. In cancer patients RALH generated cost savings of 3445 (95% CI 415; 6474) per patient when compared to OAH and increased costs of € 3345 (95% CI 2348; 4342) when compared to TLH. In cancer patients undergoing radical hysterectomy, RALH generated non-significant extra costs compared to OAH. Cost consequences were primarily due to differences in the use of inpatient service. There is a cost argument for using robot technology in patients with benign disease. In patients with malignant disease, the cost argument is dependent on comparator.

Review of Robotic Surgery in Gynecology-The Future Is Here

The authors present a systematic review of randomized and observational, retrospective and prospective studies to compare between robotic surgery as opposed to laparoscopic, abdominal, and vaginal surgery for the treatment of both benign and malignant gynecologic indications. The comparison focuses on operative times, surgical outcomes, and surgical complications associated with the various surgical techniques. PubMed was the main search engine utilized in search of study data. The review included studies of various designs that included at least 25 women who had undergone robotic gynecologic surgery. Fifty-five studies (42 comparative and 13 non-comparative) met eligibility criteria. After careful analysis, we found that robotic surgery was consistently connected to shorter post-surgical hospitalization when compared to open surgery, a difference less significant when compared to laparoscopic surgery. Also, it seems that robotic surgery is highly feasible in gynecology. There are quite a few inconsistencies regarding operative times and estimated blood loss between the different approaches, though in the majority of studies estimated blood loss was lower in the robotic surgery group. The high variance in operative times resulted from the difference in surgeon's experience. The decision whether robotic surgery should become mainstream in gynecological surgery or remain another surgical technique in the gynecological surgeon's toolbox requires quite a few more randomized controlled clinical trials. In any case, in order to bring robotic surgery down to the front row of surgery, training surgeons is by far the most important goal for the next few years.

New Developments in Robotics and Single-site Gynecologic Surgery

Within the last 10 years there have been significant advances in minimal-access surgery. Although no emerging technology has demonstrated improved outcomes or fewer complications than standard laparoscopy, the introduction of the robotic surgical platform has significantly lowered abdominal hysterectomy rates. While operative time and cost were higher in robotic-assisted procedures when the technology was first introduced, newer studies demonstrate equivalent or improved robotic surgical efficiency with increased experience. Single-port hysterectomy has not improved postoperative pain or subjective cosmetic results. Emerging platforms with flexible, articulating instruments may increase the uptake of single-port procedures including natural orifice transluminal endoscopic cases.

Robotic surgery in gynecology

Robotic surgery is the most dynamic development in the sector of minimally invasive operations currently. It should not be viewed as an alternative to laparoscopy, but as the next step in a process of technological evolution. The advancement of robotic surgery, in terms of the introduction of the Da Vinci Xi, permits the variable use of optical devices in all four trocars. Due to the new geometry of the "patient cart," an operation can be performed in all spatial directions without re-docking. Longer instruments and the markedly narrower mechanical elements of the "patient cart" provide greater flexibility as well as access similar to those of traditional laparoscopy. Currently, robotic surgery is used for a variety of indications in the treatment of benign gynecological diseases as well as malignant ones. Interdisciplinary cooperation and cooperation over large geographical distances have been rendered possible by telemedicine, and will ensure comprehensive patient care in the future by highly specialized surgery teams. In addition, the second operation console and the operation simulator constitute a new dimension in advanced surgical training. The disadvantages of robotic surgery remain the high costs of acquisition and maintenance as well as the laborious training of medical personnel before they are confident with using the technology.

Classification of Postoperative Complications in Robotic-assisted Compared With Laparoscopic Hysterectomy for Endometrial Cancer

STUDY OBJECTIVE

To compare intraoperative and postoperative surgical complications and outcomes between robotic-assisted and laparoscopic surgical management of endometrial cancer using a standardized classification system.

DESIGN

A retrospective cohort study (Canadian Task Force classification II-2).

SETTING

An integrated health care system in Northern California.

PATIENTS

One thousand four hundred thirty-three women with a diagnosis of complex atypical hyperplasia and endometrial cancer managed by minimally invasive hysterectomy and surgical staging from January 2009 to January 2014.

INTERVENTIONS

Seven hundred forty-five robotic-assisted and 688 laparoscopic hysterectomies were evaluated.

MEASUREMENTS AND MAIN RESULTS

The primary outcome was intraoperative and postoperative complications within 30 days. All complications were categorized using the Clavien-Dindo classification system. Secondary outcomes included total operative time, estimated blood loss, transfusion rates, length of stay, conversion to laparotomy, and number of pelvic and para-aortic lymph nodes retrieved. The modality of hysterectomy was not associated with either overall intraoperative complications or major postoperative complications (p > .1). However, there were significantly fewer minor postoperative complications with robotic surgery (16.6% vs 25.6%, p < .01). Statistically significant differences were also noted in the following outcomes: decreased median operative time, length of stay, estimated blood loss, conversion to laparotomy, and median number of lymph nodes retrieved in the robotic group when compared with the laparoscopic group.

CONCLUSION

There was no difference in the rate of major complication between robotic and laparoscopic surgery using the Clavien-Dindo system of categorizing surgical complications; however, there were clinically significant differences favoring the robotic approach, including a lower rate of minor complications and conversion rate to laparotomy.