Comparing Single-Site and Multiport Robotic Hysterectomy with Sentinel Lymph Node Mapping for Endometrial Cancer: Surgical Outcomes and Cost Analysis

Robotic single site versus robotic multiport hysterectomy in endometrial cancer: a systematic review and meta-analysis

OBJECTIVE

This meta-analysis aims to compare the safety and efficacy of robotic single-site hysterectomy (RSSH) with robotic multiport hysterectomy (RMPH) in treating endometrial cancer.

METHODS

We conducted a comprehensive literature search across several databases, including PubMed, the Cochrane Central Register of Controlled Trials (CENTRAL), Embase, the Chinese National Knowledge Infrastructure (CNKI), Wan Fang, and the Chinese Science and Technology Journal Full Text Database (VIP). The search covered literature from inception until October 17, 2024. The primary outcomes included intraoperative complications, postoperative complications, postoperative pain scores, and satisfaction with cosmetic outcomes. The secondary outcomes included operative time (min), estimated blood loss (ml), hemoglobin drop, blood transfusion, conversion, postoperative hospital stay, lymph nodes harvested, sentinel lymph node identification, recurrence, and mortality during follow-up. Data analysis was performed using random-effects or fixed-effects models, calculating combined risk ratios (RR), weighted mean difference (WMD), and 95% confidence intervals (95% CI).

RESULTS

Five studies describing a total of 448 patients were retained and included for this meta-analysis. No significant differences were found between RSSH and RMPH regarding intraoperative complications, postoperative complications, and postoperative pain scores. There were also no differences in terms of operation time, estimated blood loss, hemoglobin drop, blood transfusion, conversion, postoperative hospital stay, lymph nodes harvested, and sentinel lymph node identification.

CONCLUSION

This systematic review and meta-analysis provides evidence that RSSH is effective and safe for the treatment of endometrial cancer, as it is generally equivalent to RMPH regarding perioperative outcomes.

Surgical Outcomes in Laparoscopic Hysterectomy, Robotic-Assisted, and Laparoscopic-Assisted Vaginal Hysterectomy for Uterine and Cervical Cancers: A Systematic Review

BACKGROUND/OBJECTIVES

This systematic review aimed to evaluate the outcomes of minimally invasive techniques in gynecological cancer surgery, specifically laparoscopic hysterectomies (LHs), robotic-assisted hysterectomies (RHs), and laparoscopic-assisted vaginal hysterectomies (LAVHs).

METHODS

We conducted a comprehensive search of electronic databases including PubMed and MedLine from January 2010 to August 2024. The search included randomized controlled trials (RCTs) and observational studies. Studies were selected based on inclusion criteria such as a focus on LHs, RHs, or LAVHs, and reporting on key outcomes like recovery rates, overall survival (OS) rates, disease-free survival (DFS), postoperative complications, and surgery time. Exclusion criteria were applied to omit non-randomized studies, non-English publications, and those lacking relevant data.

RESULTS

The analysis included 35 studies on gynecological cancers and surgical procedures, conducted across multiple countries. Among them, 8 were RCTs from countries like the Netherlands and Italy, while 20 were retrospective cohort studies from China and the USA. The studies varied in design, cancer type, and participant age, highlighting diverse surgical approaches and the adaptation of minimally invasive techniques in gynecological cancer treatment. LH and RH demonstrated similar oncological safety with comparable OS and DFS rates. RH was associated with reduced blood loss, but longer operative times compared to LH. LAVH showed favorable perioperative outcomes, including shorter hospital stays and faster recovery, but was less frequently studied in advanced-stage cancers. Complication rates were generally lower in minimally invasive surgeries compared to open procedures. The findings support the efficacy of LH and RH as viable alternatives to open surgery, with specific advantages depending on patient and disease characteristics.

CONCLUSIONS

Minimally invasive techniques in gynecological cancer surgery offer significant advantages in terms of recovery and complication rates. Despite these benefits, further research is needed to confirm their oncological safety and overall effectiveness compared to traditional open surgeries.

Surgical outcomes of single-port vs multi-port laparoscopic hysterectomy for endometrial cancer: A systematic review and meta-analysis

OBJECTIVE

This study aimed to compare the surgical outcomes in patients with endometrial cancer who underwent either single-port laparoscopic hysterectomy (SPLH) or multi-port laparoscopic hysterectomy (MPLH).

METHODS

We conducted a systematic literature search from the earliest records available up to May 2023. The databases searched included PubMed, Embase, ClinicalTrials.gov, and the Cochrane Library.

RESULTS

A total of 12 studies were included in the analysis. Both the SPLH and MPLH groups had similar operative times (MD = -4.27, 95% CI [-35.75, 27.22], p = 0.98), conversion rates (odds ratio [OR] = 1.43, 95% CI [0.57, 3.59], p = 0.44), blood transfusion rates, intraoperative complications (bladder injury, bowel injury, and vascular injury), and postoperative complications (umbilical hernia, fever, fistula, lymphocyst, and wound-related issues). However, the SPLH group showed significant advantages in certain areas. There was a notable reduction in estimated intraoperative blood loss (EBL) compared to the MPLH group (mean difference [MD] = -23.80, 95% CI [-42.99, -4.62], p = 0.02) and a shorter hospital stay duration (MD = -0.33, 95% CI [-0.46, -0.20], p < 0.00001). Although there was some debate about postoperative pain, SPLH tended to have more favorable outcomes. Despite these advantages, the SPLH group was less efficient in para-aortic lymph node clearance compared to the MPLH group (MD = -0.96, 95% CI [-1.57, -0.35], p = 0.002). No significant differences were observed in overall lymph node dissection (MD = -0.91, 95% CI [-2.52, 0.70], p = 0.27) and pelvic lymph node dissection (MD = -1.22, 95% CI [-3.82, 1.27], p = 0.36) between the two groups. Additionally, both groups showed similar therapeutic results, with no significant differences in overall survival (OS) and progression-free survival (PFS).

CONCLUSION

SPLH and MPLH techniques are equally effective in treating endometrial cancer, with both showing low rates of surgical complications with similar rates of surgical complications and therapeutic outcomes. However, SPLH offers additional benefits, including smaller incisions, reduced estimated intraoperative blood loss, and shorter hospital stays, making it an increasingly popular option for treating endometrial cancer.

Role of single port robotic surgery in gynecology

Robot-assisted Single-Site Laparoscopy (R-LSS) is a rapidly evolving minimally invasive technique. Although it is a very recent technology, the use of R-LSS have been increasingly report in gynecology, for both benign and malignant indications. This review aims to summarize the evolution of this innovative technique and to examine its feasibility and safety for gynecological surgical procedures. We evaluated studies dealing about R-LSS in gynecological surgery. We performed a comprehensive literature research on PubMed and the Cochrane Library in February 2024. Based on the study reviewed, R-LSS seems to be a feasible and effective alternative to other mini-invasive approach in gynecological surgery. R-LSS combine the advantages of robotics surgery with the aesthetic result of a single incision. Compare to Single-Site Laparoscopy, it restore triangulation of the instrument and improve visualization and ergonomic. R-LSS seems to be related to favourable intra-e post-operative outcomes. Although, further studies would be necessary allow us to draw any final conclusion.

Clinical status and future prospects of single-incision robotic-assisted surgery: a review

Since the advent of conventional multiport laparoscopic surgery, the prosperity of minimally invasive surgery has been thriving on the advancement of endoscopic techniques. Cosmetic superiority, recovery benefits, and noninferior surgical outcomes weigh single-incision laparoscopic surgery as a promising modality. Although there are surgical challenges posed by steep learning curve and technological difficulties, such as instruments collision, triangulation loss and limited retraction, the establishment of robotic surgical platform as a solution to all is inspiring. Furthermore, with enhanced instrument maneuverability and stability, robotic ergonomic innovations adopt the advantages of single-incision laparoscopic surgery and surmount its recognized barriers by introducing a novel combination, single-incision robotic-assisted surgery. As was gradually diffused in general surgery and other specialties, single-incision robotic-assisted surgery manifests privileges in noninferior clinical outcomes an satisfactory cosmetic effect among strictly selected patients, and has the potential of a preferable surgical option for minimally invasive surgery.

Comparing surgical outcomes of da Vinci SP and da Vinci Xi for endometrial cancer surgical staging in a propensity score-matched study

The number of studies comparing robotic systems in endometrial cancer staging is limited. This retrospective study analyzed the medical records of 42 consecutive endometrial cancer patients, who underwent robotic staging using the da Vinci SP (SP) system, and 126 propensity score-matched patients who underwent staging using the da Vinci Xi (Xi) system. Median console and total operation times were longer in the SP group than those in the Xi group (125 vs. 77 min, p < 0.001; 225 vs. 154.5 min, p < 0.001, respectively). Notably, the median console time of the first 10 cases using SP was 184 min; it subsequently decreased to 99.5 min in the fourth 10 cases. SP had lesser postoperative hemoglobin (Hb) change (0.6 ± 0.7 g/dL vs. 1.8 ± 0.9 g/dL in Xi, p < 0.001) and lower median pain score at 6 h after surgery (2 vs. 3 in Xi, p = 0.046). Moreover, median postoperative hospital stay was shorter in the SP group (2 days) than that in the Xi group (6 days) (p < 0.001). Although SP was correlated with lower postoperative Hb change, shorter postoperative hospital stay, and lower pain score than those in Xi, it required longer operation times. Further prospective randomized studies are needed to validate the benefits of SP compared to other robotic platforms.

Surgical Outcomes Following Robotic Single-Site Versus Multiport Hysterectomy for Treatment of Endometrial Cancer: A Systematic Review and Meta-Analysis

Robotic single-site hysterectomy (RSSH) has emerged as a novel surgical approach for the treatment of endometrial cancer and atypical endometrial hyperplasia (AEH). Current research regarding the benefits of RSSH compared to robotic multiport hysterectomy (RMPH) for these indications has been inconclusive. Our team sought to compare surgical outcomes between these two approaches of robotic hysterectomy via systematic review and meta-analysis to ensure optimal surgical practices. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 Checklist guided our review. MEDLINE, Clinicaltrials.gov, and Cochrane Library were searched, yielding 59 results. Articles were filtered by title and abstract and then reviewed in full for inclusion and exclusion criteria. Inclusion criteria required that (1) studies compared outcomes for RSSH and RMPH, (2) hysterectomy was indicated for endometrial cancer or hyperplasia with atypia, and (3) studies were available in English. Excluded studies (1) compared single-site and multiport laparoscopic approaches, (2) compared robotic approaches to laparoscopic or abdominal (open) techniques, and (3) employed hysterectomy for benign conditions. Publication bias was assessed using the Egger Regression Correlation analysis. Four studies complied with the selection criteria, comprising 138 patients in the RSSH group and 259 in the RMPH group. Similar outcomes were noted across all measures, including conversion rate (relative risk [RR] = 1.84 and confidence interval [CI] = 0.99-3.43), blood loss (Cohen's d = 1.05 and Z = 18.62), operating time (Cohen's d = 0.29 and Z = 4.38), and length of hospital stay (Cohen's d = 1.06 and Z = 3.86). Publication bias was deemed minimal as indicated by Egger regression values of less than 0.05. These findings suggest that either a surgical approach or AEH with the proper standard of care can provide patients with endometrial cancer.

The robotic single-port platform for gynecologic surgery: a systematic review of the literature and meta-analysis

Since the first robotic single-site hysterectomy was performed, the research focused on the use of robotic single-site surgery (RSSS) for all gynecological conditions. This review aims to examine the studies available in the literature on RSSS in gynecology both for benign and malignant indications. The systematic review was carried out in agreement with the preferred reporting items for systematic reviews and meta-analyses statement (PRISMA). All the articles were grouped into three sets based on the surgical indication (Group 1, 2, and 3 for benign, malignant, and mixed diseases, respectively). Two hundred and fifty total studies were analyzed, and 27 articles were included in the review. A total of 1065 patients were included in the analysis. Of these, 605 patients were included in group 1, 260 in group 2, and 200 in group 3. Ten (1.7%) patients with benign pathology, 16 (6.2%) patients with malignant disease, and 5 (2.5%) patients with both diseases developed major complications. Two (0.3%) patients in group 1, 3 (1.2%) patients in group 2 and 5 (2.5%) in group 3 were converted to a different type of surgery. No significant differences were found between groups for BMI (p = 0.235), operative time (p = 0.723), estimated blood loss (EBL) (p = 0.342), and hospital stay (p = 0.146). The complications and conversions incidence through pooled analysis showed a higher general conversion rate (p = 0.012) in group 3 (3.0%) and higher complications rate (p = 0.001) in group 2 (5.3%) compared to the other groups. RSSS seems to be a feasible and safe procedure for all gynecological surgical procedures. A long-term analysis would be necessary before considering the RSSS oncologically safe for patients with malignant disease.

Laparoendoscopic Single Site Hysterectomy: Literature Review and Procedure Description

Laparoendoscopic single site surgery (LESS) refers to a spectrum of surgical techniques that allow the performance of laparoscopic surgery through consolidation of all ports into one surgical incision. LESS has emerged as a potentially less invasive alternative to multiport laparoscopy and in the last year in gynecology; hence, this approach has been largely applied for selective indications to perform total hysterectomy. We performed a literature review on single site hysterectomy and described indications and technique, highlighting practical problems, pointers, limitations and recent technical development as robotic assistance.

Paucity of data evaluating patient centred outcomes following sentinel lymph node dissection in endometrial cancer: A systematic review

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SLND has potentially favourable patient-centred outcomes over systematic LND.

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High-quality evidence comparing SLND with other methods of staging is lacking.

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SLND was associated with shorter operating times and lower estimated blood loss.

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Intraoperative and postoperative complications were not conclusively different.

Sentinel lymph node dissection (SLND) is presently used by the majority of gynaecologic oncologists for surgical staging of endometrial cancer. SLND assimilated into routine surgical practice because it increases precision of surgical staging and may reduce morbidity compared to a full, systematic LND. Previous research focussed on the accuracy of SLND. Patient centred outcomes have never been conclusively demonstrated. The objective of this systematic review was to evaluate patient centred outcomes of SLND for endometrial cancer patients. Literature published in the last five years (January 2015 to April 2020) was retrieved from PubMed, EMBASE, and Cochrane library, across five domains: (1) perioperative outcomes; (2) adjuvant treatment; (3) patient-reported outcomes (PROs); (4) lymphedema, and (5) cost. Covidence software ascertained a standardised and monitored review process. We identified 21 eligible studies. Included studies were highly heterogeneous, with widely varying outcome measures and reporting. SLND was associated with shorter operating times and lower estimated blood loss compared to systematic LND, but intra-operative and post-operative complications were not conclusively different. There was either no impact, or a trend towards less adjuvant treatment used in patients with SLND compared to systematic LND. SLND had lower prevalence rates of lymphedema compared to systematic LND, although this was shown only in three retrospective studies. Costs of surgical staging were lowest for no node sampling, followed by SLND, then LND. PROs were unable to be compared because of a lack of studies. The quality of evidence on patient-centred outcomes associated with SLND for surgical staging of endometrial cancer is poor, particularly in PROs, lymphedema and cost. The available studies were vulnerable to bias and confounding.

Registration of Systematic Review: PROSPERO (CRD42020180339)

Evaluation of quality of life, body image and surgical outcomes of robotic total laparoscopic hysterectomy and sentinel lymph node mapping in low-risk endometrial cancer patients - A Robotic Gyne Club study

INTRODUCTION

The aims of the study were to evaluate quality of life, cosmetic results and surgical outcomes of robotic single-site and robotic multiport total laparoscopic hysterectomy with sentinel lymph node mapping in women treated for low-risk endometrial cancer.

MATERIAL AND METHODS

The study is a prospective, multicenter, case-control study conducted at Ospedale Santa Chiara in Trento and Novara and Pavia University Hospitals. Seventy-six consecutive patients with a biopsy-confirmed diagnosis of low-risk endometrial cancer or atypical endometrial hyperplasia who between January 2017 and January 2019 had undergone robotic total laparoscopic hysterectomy and sentinel lymph node mapping were included. Data on surgical outcomes, quality of life and cosmetic results were prospectively collected and analyzed based on the surgical approach with robotic single-site vs robotic multiport assistance. Patients' clinical characteristics, intra-operative parameters, sentinel lymph node mapping results and postoperative findings were prospectively recorded. Clinical follow up was performed 4 weeks and 6 and 12 months after surgery. Fifty-one patients underwent a robotic multiport procedure and 25 patients a robotic single-site surgery.

RESULTS

There was one significant difference between the two groups in terms of patient characteristics: mean body mass index (BMI) in the multiport group was 29 kg/m² vs 24.8 kg/m² in the single-site group (P value <.001). After univariate and multivariate analysis on intraoperative and postoperative findings, a shorter surgical time was observed in the single-site cohort than in the multiport group (148.7 vs 158.2 minutes, P value .0182). BMI also had a significant effect on surgical time (P = .022). No differences were seen in terms of sentinel lymph node detection: the bilateral detection rate was 96.1% for multiport (66.7% bilateral, 29.4% monolateral) and 96% for single-site (76% bilateral, 20% monolateral) procedures. No differences between the two approaches were identified with regard to postoperative complications, pain, cosmetic results or quality of life comparisons.

CONCLUSIONS

For the treatment of low-risk endometrial cancer and atypical endometrial hyperplasia with total hysterectomy and sentinel lymph node mapping, the robotic single-port approach is comparable to the multiport procedure in terms of intraoperative and postoperative findings, and has an advantage in terms of shorter surgical times. Further studies are required to identify possible differences in quality of life and cosmetic results.

Robotic laparoendoscopic single-site compared with robotic multi-port sacrocolpopexy for apical compartment prolapse

BACKGROUND

Sacrocolpopexy is a commonly performed procedure for repair of apical compartment prolapse. A Y-shaped mesh is attached to the prolapsed cervix or vagina and suspended to the anterior longitudinal ligament of the sacrum. In addition to conventional laparoscopic and multi-port robotic routes, the robotic laparoendoscopic single-site approach has emerged as a viable, feasible, and widely applicable minimally invasive approach to sacrocolpopexy.

OBJECTIVE

To compare robotic laparoendoscopic single-site with multi-port robotic sacrocolpopexy for women with either utero-vaginal or vaginal apical prolapse.

MATERIALS AND METHODS

In this single-center randomized controlled trial, 70 women at Pelvic Organ Prolapse Quantitative stages 2-4 were assigned randomly to undergo sacrocolpopexy by robotic laparoendoscopic single-site or multi-port robotic approaches from August 2017 to November 2018. Of 35 women randomized to each group, 32 underwent sacrocolpopexy. Operating time was the primary outcome of the trial. Secondary outcomes included intraoperative bleeding, length of hospitalization, pain during the first postoperative 24 hours (according to a 0-10 visual analogue scale), need for analgesics, and intraoperative and postoperative adverse events. At 6 weeks and 6 months after surgery, patients underwent a physical examination according to Pelvic Organ Prolapse Quantitative measurements, to assess the anatomical success of the surgery. The Pelvic Floor Distress Inventory-20 and Pelvic Organ Prolapse/Urinary Incontinence Sexual-12 questionnaires were administered prior to surgery and at 6-month follow-up. The Patient Scar Assessment Questionnaire and the Activity Assessment Scale were administered at 6 weeks and 6 months after the surgery. Exclusion criteria included contraindication to general anesthesia, a history of prior sacrocolpopexy, suspicious adnexal masses, suspicious thickened endometrium, and morbid obesity (body mass index of 40 kg/m² or more).

RESULTS

The mean age of the patients was 58.4 years. More than half of the patients (54%) had stage III prolapse. Mean total operative times were 181.3 ± 32.6 and 157.5 ± 42 minutes for robotic laparoendoscopic single-site and multi-port robotic sacrocolpopexy, respectively; the difference was 23.8 minutes (95% confidence interval, 4.2-43.4, P = .018). The mean differences in duration between the procedures were as follows: 29.8 minutes, 95% confidence interval, 9.2-50.4, P = .005 for anesthesia time; 33.1 minutes, 95% confidence interval, 16.5-49.7, P < .0001 for console time; 8.6 minutes, 95% confidence interval, 1.1-16.3, P = .025 for supracervical hysterectomy time; 8.3 minutes, 95% confidence interval, 1.8-14.8, P = 0.03 for mesh suturing and fixation to the promontory; and 4.7 minutes, 95% confidence interval, 1.5-7.7, P = .004 for peritoneum suturing. Statistically significant differences were not observed between the groups in regard to estimated blood loss, intraoperative complications, and demand for analgesics during hospital stay. Quality-of-life parameters were similar. Patients' assessments of their scars were more favorable in the robotic laparoendoscopic single-site group.

CONCLUSION

For sacrocolpopexy, the operative time was longer for the robotic laparoendoscopic single-site than for the multi-port robotic approach. Both approaches are feasible, and short-term outcomes, quality-of-life parameters, and anatomic repair are comparable. Our results are generalizable only to the specific robotic platforms used in the study.

Robotic Surgery in Gynecology

The robotic-assisted laparoscopic surgical approach has improved complex gynecologic surgeries. It has the advantages of excellent visualization through the high-resolution 3-dimensional view, a wrist-like motion of the robotic arms and improved ergonomics. Similar to conventional laparoscopic surgeries, it is associated with a decrease in long-term surgical morbidity, early recovery and return to work, and improved esthetics. We discuss preoperative planning, surgical techniques, and some of the latest clinical results of robotic-assisted laparoscopic gynecologic surgery.

Robotic Single-Port Platform in General, Urologic, and Gynecologic Surgeries: A Systematic Review of the Literature and Meta-analysis

BACKGROUND

Robotic platforms have recently acquired progressive importance in different surgical fields, such as urology, gynecology, and general surgery. Through the years, new surgical robots have become available as single-port robotic platform. The study is aimed to value the single-port robotic platform characteristics in different surgical specialties.

METHODS

The terms "LESS" OR "single port" OR "single site" AND "robot" OR "robotic" were systematically used to search the PubMed and Scopus databases. A total of 57 studies were considered eligible for the present review. The articles included were divided according to the surgical field in which the study was conducted: General surgery (29 articles), Gynecology (18 articles), Urology (10 articles).

RESULTS

Most part of the articles showed the feasibility of robotic single-port surgical procedures and described advantages in terms of cosmetic, hospital stay, and in some series even cost reduction. A meta-analysis was conducted, showing a significant increment of complications using RSP if compared with SLPS and a trend (P = 0.008) when RSP was compared with LESS. The comparison of different techniques in terms of conversion to laparotomy did not show any significant difference.

CONCLUSION

Robotic single port potentially furnishes an important surgical and post-operatory improvement; however, some limits still prolong the surgical time and complication rate.

Computer vision for total laparoscopic hysterectomy

INTRODUCTION

Laparoscopic surgery is widely performed in various surgical fields, but this technique requires time for surgeons to master. However, at the same time, there are many advantages in visualizing the operative field through a camera. In other words, we can visualize what we cannot see with our own eyes by using augmented reality and computer vision. Therefore, we investigated the possibilities and usefulness of computer vision in total laparoscopic hysterectomy.

METHODS

This study was approved by the Mitsui Memorial Hospital ethics committee. Patients who underwent total laparoscopic hysterectomy at Mitsui Memorial Hospital from January 2015 to December 2015 were enrolled. We evaluated 19 cases in which total laparoscopic hysterectomy was performed by the same operator and assistant. We used the Open Source Computer Vision Library for computer vision analysis. The development platform used in this study was a computer operating on Mac OS X 10.11.3.

RESULTS

We created panoramic images by matching features with the AKAZE algorithm. Noise reduction methods improved haziness caused by using energy devices. By abstracting the color of the suture string, we succeeded in abstracting the suture string from movies. We could not achieve satisfactory results in detecting ureters, and we expect that creative ideas for ureter detection may arise from collaborations between surgeons and medical engineers.

CONCLUSIONS

Although this was a preliminary study, the results suggest the utility of computer vision in assisting laparoscopic surgery.

Review of strategies and factors to maximize cost-effectiveness of robotic hysterectomies and myomectomies in benign gynecological disease

Common benign gynecologic procedures include hysterectomies and myomectomies, with hysterectomy being the most common gynecologic procedure in the United States [1]. While historically performed via laparotomy, the field of gynecologic surgery was revolutionized with the advent of laparoscopic techniques, with the most recent advancement being the introduction of robotic-assisted surgery in 2005. Robotic surgery has all the benefits of laparoscopic surgery such as decreased blood loss, quicker return to activities, and shorter length of hospital stay. Additional robotic-specific advantages include but are not limited to improved ergonomics, 3D visualization, and intuitive surgical movements. Despite these advantages, one of the most commonly cited drawbacks of robotic surgery is the associated cost. While the initial cost to purchase the robotic console and its associated maintenance costs are relatively high, robotic surgery can be cost-effective when utilized correctly.This article reviews application strategies and factors that can offset traditional costs and maximize the benefits of robotic surgery.

Extent of lymphadenectomy and postoperative major complications among women with endometrial cancer treated with minimally invasive surgery

BACKGROUND

In patients with endometrial cancer, sentinel lymphadenectomy is used to accurately prognosticate extent of disease, and has been proposed as a method to decrease the incidence of medical and surgical complications associated with more extensive lymphadenectomy. It is unknown whether patients who undergo traditional lymphadenectomy experience major postoperative complications at the same rates as those who undergo sentinel lymphadenectomy or those who do not undergo lymphadenectomy.

OBJECTIVE

The aim of this study was to compare the incidence of major postoperative complications among endometrial cancer patients undergoing total laparoscopic hysterectomy with traditional lymphadenectomy vs sentinel or no lymphadenectomy.

MATERIALS AND METHODS

Patients with endometrial cancer who underwent total laparoscopic hysterectomy recorded in the National Surgical Quality Improvement Program (NSQIP) database between 2015 and 2016 were identified using Current Procedural Terminology (CPT) and International Classification of Diseases (ICD) codes. Primary exposure was extent of lymphadenectomy. The primary outcome was major postoperative complications as defined by the Clavien-Dindo scale. Associations were examined with bivariable tests and multivariable logistic regression.

RESULTS

A total of 3282 women with endometrial cancer who underwent total laparoscopic hysterectomy were identified; of these, 2049 (62.4%) did not undergo lymphadenectomy, 1089 (33.2%) underwent traditional lymphadenectomy, and 144 (4.4%) underwent sentinel lymphadenectomy. Traditional lymphadenectomy had the highest rate of major complications (3.6%) compared with sentinel lymphadenectomy (2.0%) and no lymphadenectomy (2.0%) (P = .03). Patients who underwent traditional lymphadenectomy also had the longest operating room times and procedures that were most surgically complex (171 minutes, 30.6 relative value units [RVU]) compared with patients who underwent sentinel lymphadenectomy (166 minutes, 24.9 RVU) or no lymphadenectomy (141 minutes, 15.0 RVU) (all P < .001). Patients who underwent traditional lymphadenectomy had nearly twice the odds of a major complication (adjusted odds ratio [aOR], 1.8; 95% confidence interval [CI], 1.2-2.9) and need for readmission (aOR, 2.2; 95% CI, 1.5-3.4) compared to those who underwent sentinel or no lymphadenectomy. The incidence of readmission after traditional lymphadenectomy was higher (4.6%) than after sentinel lymphadenectomy (1.4%) and no lymphadenectomy (2.2%) (P < 0.001).

CONCLUSION

Sentinel lymphadenectomy among patients undergoing total laparoscopic hysterectomy for endometrial cancer was associated with a decreased incidence of major postoperative complications and need for readmission when compared with traditional lymphadenectomy.

Robotic laparoendoscopic single-site surgery in gynecology: A systematic review

Robotic laparoendoscopic single-site (R-LESS) seems to be the next route in advancing minimal invasive surgery, with the potential for better cosmetic results and reduced patient morbidity compared with multi-port surgery. This review describes the history and development of (R-LESS) gynecologic surgery and outlines the latest advancements in the realm of gynecology. The review was conducted according to the PRISMA guidelines. Pubmed and ClinicalTrials.gov (www.clinicaltrials.gov) were the main search engines utilized for retrieval of study data (1990 - present). The following subject headings and keywords were searched: "robotic laparoscopic single incision", "robotic laparoendoscopic single site", "single incision robotic surgery" and "single-port robotic surgery". All original research articles including randomized, non-randomized controlled trials, cohort studies, patient series, and case reports were included. The search produced a total of 1127 results. After duplicate removal, 452 remained, and each title and abstract was reviewed by 2 reviewers. Subsequently, 56 full texts were selected for full review and an additional 20 excluded, leaving 36 studies that were included in the final review. Based on the data gathered we reached the conclusion that R-LESS surgery is feasible, safe and has equivalent surgical outcomes as conventional LESS surgery; in addition to shorter recovery times, less postoperative pain and better cosmetic outcomes than robotic multi-port surgery. To conclude, R-LESS is a feasible approach with low complication rates, minimal blood loss and postsurgical pain, fast recovery, and virtually scar-free results. However, the lack of large comparative prospective randomized controlled studies prevents drawing absolute conclusions.

Feasibility of sentinel lymph node fluorescence detection during robotic laparoendoscopic single-site surgery in early endometrial cancer: a prospective case series

Background

In the last few decades, the introduction of technologies such as single-site surgery, robotics, and sentinel lymph node detection has reduced invasiveness in the treatment and staging of endometrial cancer patients. The goal of the present prospective cohort study is to evaluate the feasibility of lymph node fluorescence detection with robotic single-site approach in low-risk endometrial cancer.

Results

Fifteen non consecutive low-risk endometrial atypical hyperplasia (EAH) patients underwent sentinel lymph node (SLN) biopsy and total hysterectomy utilizing the Da Vinci Si Single-Site Surgical. System and Firefly 3D imaging. Indications for surgery included eight (53.3%) IA FIGO stage G1 EC, three (20%) IA FIGO stage G2 EC, and four (26.6%) EAH. Mean operative time was 155 min (range 112–175). One vaginal laceration was the only perioperative complication encountered, and all patients were discharged within 48 h of surgery.

SLN was detected in 86.6% of cases; 1/29 (3.4%) SLN results were positive for isolated tumor cells (ITCs) at immunohistochemical analysis.

Conclusions

The present study demonstrates the feasibility and applicability of robotic single-site approach with SLN fluorescence detection for the staging of low-risk endometrial cancer.