Choosing the most appropriate minimally invasive approach to treat gynecologic cancers in the context of an enhanced recovery program: Insights from a comprehensive cancer center

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.

Comparison of Surgical Outcomes of Robotic versus Conventional Laparoscopic Hysterectomy of Large Uterus with Gynecologic Benign Disease

Hysterectomy is commonly performed for benign gynecological diseases. Minimally invasive surgical approaches offer several advantages. Unfortunately, few studies have compared the outcomes of different types of minimally invasive surgeries. Therefore, this study aimed to compare the surgical outcomes of robotic hysterectomy (RH) and conventional laparoscopic hysterectomy (CLH) in benign gynecologic diseases. We performed a retrospective cohort study at a single center between January 2014 and July 2022. A total of 397 patients (RH: 197 and CLH: 200) who underwent minimally invasive hysterectomy for benign diseases with uterine size exceeding 250 g were enrolled, and factors related to the surgical outcomes were compared. The median age was 46 (range, 35-74) years, and the median uterine weight was 400 (range, 250-2720) g. There were no significant differences between the two groups regarding age, body mass index, uterine weight, hospital stay, estimated blood loss, or operating time. Intraoperative and postoperative complication rates were not significantly different between the two groups. RH was not inferior to CLH in terms of perioperative and immediate postoperative outcomes in our study.

Influence of steep Trendelenburg position on postoperative complications: a systematic review and meta-analysis

Intraoperative physiologic changes related to the steep Trendelenburg position have been investigated with the widespread adoption of robot-assisted pelvic surgery (RAPS). However, the impact of the steep Trendelenburg position on postoperative complications remains unclear. We conducted a meta-analysis to compare RAPS to laparoscopic/open pelvic surgery with regards to the rates of venous thromboembolism (VTE), cardiac, and cerebrovascular complications. Meta-regression was performed to evaluate the influence of confounding risk factors. Ten randomized controlled trials (RCTs) and 47 non-randomized controlled studies (NRSs), with a total of 380,125 patients, were included. Although RAPS was associated with a decreased risk of VTE and cardiac complications compared to laparoscopic/open pelvic surgery in NRSs [risk ratio (RR), 0.59; 95% CI 0.51–0.72, p < 0.001 and RR 0.93; 95% CI 0.58–1.50, p = 0.78, respectively], these differences were not confirmed in RCTs (RR 0.92; 95% CI 0.52–1.62, p = 0.77 and RR 0.93; 95% CI 0.58–1.50, p = 0.78, respectively). In subgroup analyses of laparoscopic surgery, there was no significant difference in the risk of VTE and cardiac complications in both RCTs and NRSs. In the meta-regression, none of the risk factors were found to be associated with heterogeneity. Furthermore, no significant difference was observed in cerebrovascular complications between RAPS and laparoscopic/open pelvic surgery. Our meta-analysis suggests that the steep Trendelenburg position does not seem to affect postoperative complications and, therefore, can be considered safe with regard to the risk of VTE, cardiac, and cerebrovascular complications. However, proper individualized preventive measures should still be implemented during all surgeries including RAPS to warrant patient safety.

Surgical and Patient Outcomes of Robotic Versus Conventional Laparoscopic Hysterectomy: A Systematic Review

Hysterectomy is a commonly performed gynecologic surgery that can be associated with significant morbidity and mortality. However, the evolution of the surgical approach, from open to minimally invasive gynecologic surgery (MIGS), has substantially improved patient outcomes by reducing perioperative complications, pain, and length of hospitalization. The evident advantages and the approval of the da Vinci Surgical System by the Food and Drug Administration led to the exponential rise in the use of MIGS. In particular, robotic hysterectomy (RH) witnessed unparalleled popularity compared to other MIGS despite the lack of strong evidence demonstrating its superiority. Therefore, we conducted a systematic review of the literature to evaluate and compare various patient and surgical outcomes of RH with conventional laparoscopic hysterectomy (CLH), including operating time, estimated blood loss, length of hospitalization, overall complications, survival, and cost. Overall, the outcomes were comparable between RH and CLH except concerning cost. RH is significantly more expensive than CLH due to the higher costs of robotic equipment, including disposable instruments, equipment maintenance, and sterilization. Although RH demonstrated comparable outcomes and higher costs, its technical advantages such as improved ergonomics, three-dimensional view, a wider range of wristed mobility, mechanical lifting of robot's hand, and greater stability might benefit patient subsets (e.g., obesity, large uterine weights >750 g). Therefore, large and multicentered randomized control trials are imperative to determine the most effective surgical approach between RH and other MIGS for different patient subsets.