Prospective pilot study protocol evaluating the safety and feasibility of robot-assisted nipple-sparing mastectomy (RNSM)

Safety and Feasibility of Robotic Nipple-Sparing Mastectomy With Immediate Direct-to-Implant Reconstruction - Insights From the One of the Largest Centers in Asia

BACKGROUND

The use of robotic-assisted nipple-sparing mastectomy (R-NSM) with immediate direct-to-implant (DTI) reconstruction in treatment of breast cancer has been a controversial topic. The adoption of robotic surgery in breast cancer treatment has gained traction globally due to its minimally invasive nature, potential for improved cosmetic outcomes and better intraoperative visualization. This study provides insights on safety and feasibility robotic mastectomy at one of the largest centers in Asia.

METHODS

This retrospective study included patients who underwent robotic nipple-sparing mastectomy (R-NSM) with immediate direct-to-implant (DTI) reconstruction from April 2018 to September 2024. Our endpoints were mainly focused on perioperative outcomes, patient satisfaction, and oncologic outcomes.

RESULTS

A total of 266 procedures were included in our series, with 233 patients undergoing unilateral R-NSM with either DTI reconstruction or a tissue expander, and 33 patients underwent surgery on both breasts. Postoperative complications were recorded in 11 patients (4.14 %). The median follow-up of this study is 37.2 ± 23.3 months. Locoregional recurrence (LRR) was observed in 6 patients (2.5 %), with isolated skin recurrence being the most common. Distant metastasis was observed in 9 patients (3.86 %). The 3-year overall survival rate was 98.3 %.

CONCLUSION

Robotic NSM is a safe and feasible novel minimal invasive surgical approach for breast cancer surgery, providing both excellent cosmetic results and oncological outcomes that are noninferior to conventional or endoscopic approaches.

Postoperative outcomes of minimally invasive versus conventional nipple-sparing mastectomy with prosthesis breast reconstruction in breast cancer: a meta-analysis

Breast cancer is the most common malignant tumor worldwide, and mastectomy remains the primary strategy for treating early stage breast cancer. However, the complication rates, surgical variables, and oncologic safety of minimally invasive nipple-sparing mastectomy (MINSM) have not been fully addressed. We systematically searched PubMed, Web of Science, Embase, and the Cochrane Library for randomized-controlled trials (RCTs) and non-RCTs that compared MINSM with conventional nipple-sparing mastectomy (CNSM), both followed by Prosthesis Breast Reconstruction (PBR). The main outcomes observed included overall complications, (Grade III) complications, skin and nipple necrosis, wound dehiscence, infection, seroma, hematoma, implant loss, and oncologic safety (positive margins and recurrence). Secondary outcomes included operation time, blood loss, hospital stay, cost-effectiveness, and patient satisfaction. Binary and continuous variables were compared using odds ratios (OR) and mean differences (MD) with 95% confidence intervals (CI). A total of 10 studies involving 2,166 patients were included. There were no statistically significant differences between MINSM and CNSM in terms of skin necrosis, wound dehiscence, infection, seroma, hematoma, implant loss, or oncologic safety. However, MINSM significantly reduced overall complications (OR = 0. 74, 95% CI [0. 58, 0. 94], p = 0. 01) and (Grade III) complications (OR = 0. 47, 95% CI [0. 31, 0. 71], p = 0. 0003). Nipple necrosis events were also significantly reduced in the MINSM group (OR = 0. 49, 95% CI [0. 30, 0. 80], p = 0. 005). Patient satisfaction improved notably in the MINSM group. Additionally, compared with the CNSM group, the MINSM group had longer operating times (MD = 46. 88, 95% CI [19. 55, 74. 21], p = 0. 0008) and hospital stays (MD = 1. 39, 95% CI [0. 65, 2. 12], p < 0. 001), while intraoperative blood loss was significantly reduced (MD = -29. 05, 95% CI [-36. 20, -21. 90], p < 0. 001). Compared with CNSM, MINSM offers advantages in reducing complications and intraoperative blood loss, as well as improving aesthetic outcomes and patient satisfaction. Therefore, MINSM may become a viable option for breast surgery. Nevertheless, a long-term evaluation of the oncologic safety of this approach is necessary to ensure its efficacy and safety for patients.

A novel technique of reverse-sequence endoscopic nipple-sparing mastectomy with direct-to-implant breast reconstruction: medium-term oncological safety outcomes and feasibility of 24-h discharge for breast cancer patients

BACKGROUND

Due to the short operation time and no need for special instruments, reverse-sequence endoscopic nipple-sparing mastectomy (R-E-NSM) with direct-to-implant breast reconstruction (DIBR) has been rapidly becoming popular in the last three years. However, there has yet to be an evaluation of its oncologic safety or the feasibility of discharging patients within 24 h.

MATERIALS AND METHODS

In this single-centre retrospective cohort study, individuals diagnosed with stage 0-III breast cancer between May 2020 and April 2022 who underwent traditional open mastectomy or R-E-NSM with DIBR were included. Follow-up started on the date of surgery and ended in December 2023. Data, including demographics, tumour characteristics, medium-term oncological outcomes, and postoperative complications, were collected and analyzed. Propensity score matching (PSM) was performed to minimize selection bias.

RESULTS

This study included 1679 patients [median (IQR) age, 50 [44-57) years]. Of these, 344 patients underwent R-E-NSM with DIBR (RE-R group), and 1335 patients underwent traditional open mastectomy (TOM group). The median [IQR] follow-up time was 30 [24-36] months [29 (23-33) months in the RE-R group and 30([24-36) months in the TOM group]. Regarding before or after PSM, the P value of local recurrence-free survival (LRFS, 0.910 and 0.450), regional recurrence-free survival (RRFS, 0.780 and 0.620), distant metastasis-free survival (DMFS, 0.061 and 0.130), overall survival (OS, 0.260 and 0.620), disease-free survival (DFS, 0.120 and 0.330) were not significantly different between the RE-R group and the TOM group. The 3y-LRFS and 3y-DFS rates were 99.0% and 97.1% for the RE-R group and 99.5% and 95.3% for the TOM group, respectively. The rates of any complications and major complications were not significantly different between the RE-R patients who were discharged within 24 h and the RE-R patients who were not discharged within 24 h ( P =0.290, P =0.665, respectively) or the TOM patients who were discharged within 24 h ( P  =0.133, P =0.136, respectively).

CONCLUSIONS

R-E-NSM with DIBR is an innovative oncologic surgical procedure that not only improves cosmetic outcomes but also ensures reliable oncologic safety and fewer complications, enabling patients to be safely discharged within 24 h. A long-term prospective multicenter assessment will be supporting.

Robotic-Assisted Nipple Sparing Mastectomy

Minimally invasive approaches to breast surgery have evolved from endoscopic techniques to recent developments in robotic-assisted mastectomies. Initial studies on robotic-assisted nipple-sparing mastectomy (RNSM) have shown improved patient satisfaction and aesthetic outcomes with similar complication rates and oncological outcomes in selected patients. This chapter reviews techniques used and available data on complications and clinical outcomes for RNSM. Currently, RNSM is an investigational technique in the United States and should be performed in clinical trials with U.S. Food & Drug Administration approval to rigorously evaluate the safety and effectiveness of this approach.

Robot-assisted Nipple Sparing Mastectomy: Recent Advancements and Ongoing Controversies

Purpose of review

The purpose of this review is to summarize the recent technical advancements in RNSM, describe the ongoing teaching programs, and discuss the ongoing controversies.

Recent findings

Robot-assisted nipple sparing mastectomy (RNSM) is the newest addition to the armamentarium of surgical techniques for patients who require a mastectomy. The potential benefits of using the da Vinci® Robotic Surgical System (Intuitive Surgical, Sunnyvale, CA) are the small 3D camera and lighting offering superior visualization, the Endowrist robotic instruments offering greater range of motion, and surgeon being at a seated position at the console rendering a more ergonomic operating position.

Summary

RNSM can potentially help overcome the technical difficulties of performing a conventional NSM. Further studies are needed to elucidate the oncologic safety and cost-effectiveness of RNSM.