Robotic Versus Conventional Nipple-Sparing Mastectomy With Immediate Breast Reconstruction

Robotic nipple-sparing mastectomy: a comparative analysis with conventional and endoscopic techniques through a systematic review

Robotic nipple-sparing mastectomy (R-NSM) has emerged as an innovative approach in breast cancer surgery, offering improved aesthetic outcomes and patient satisfaction. However, its adoption remains controversial due to limited regulatory approval, higher costs, and the need for further comparative evidence. This systematic review aims to evaluate and compare conventional, endoscopic, and robotic NSM techniques to clarify their respective benefits, limitations, and outcomes. Following OSF registration (osf.io/6xt4s), a systematic review was conducted, identifying studies on nipple-sparing mastectomy (NSM) across multiple databases (January 2025). No language or data availability restrictions were applied. Study quality was assessed using the QualSyst criteria (range: 0.0-1.0). Twelve studies met inclusion criteria (ten observational, two clinical trials), with quality scores ranging from 0.75 to 0.95. R-NSM was associated with longer operative times (+ 25-60 min) and higher costs (+ $3,700-$5,000 per procedure). However, it demonstrated superior aesthetic outcomes, with concealed scars and higher patient satisfaction at 1-year follow-up (p = 0.03). Oncologic safety was comparable among NSM techniques, with no significant differences in recurrence, survival, or positive margin rates. While R-NSM initially resulted in prolonged hospital stays (+ 1.5-3 days), this effect diminished with surgical experience. In addition, R-NSM was linked to reduced intraoperative blood loss and a lower risk of severe postoperative complications, particularly nipple-areola complex necrosis. R-NSM offers promising benefits in selected patients, particularly regarding cosmetic outcomes and reduced complications. However, challenges remain, including high costs, longer surgical times, and the need for standardized protocols. Future research should focus on optimizing surgical techniques, refining patient selection, and conducting high-quality randomized controlled trials to establish its definitive role in breast cancer management.

Oncological, surgical, and cosmetic outcomes of endoscopic versus conventional nipple-sparing mastectomy: meta-analysis

BACKGROUND

Endoscopic nipple-sparing mastectomy has been developed to improve the cosmetic outcomes of conventional nipple-sparing mastectomy. This meta-analysis compares surgical, quality of life and oncological outcomes of endoscopic nipple-sparing mastectomy versus conventional nipple-sparing mastectomy.

METHODS

PubMed and Embase were systematically reviewed to identify literature relevant to endoscopic nipple-sparing mastectomy and conventional nipple-sparing mastectomy literature published through to August 2023. The risk of bias was assessed using the Newcastle-Ottawa Scale, and proportional and pairwise random-effects meta-analysis was performed. Surgical (operative time, duration of hospital stay, blood loss, necrosis, overall complications), quality of life (cosmesis, pain, nipple-areolar complex sensitivity) and oncological outcomes (margin positivity, recurrence, metastasis and breast cancer-specific mortality rate) were evaluated.

RESULTS

Of 1286 articles retrieved, 51 endoscopic nipple-sparing mastectomy studies and 12 conventional nipple-sparing mastectomy reviews were analysed; 10 non-randomized comparative studies (656 patients) were included in the pairwise analysis and 36 studies (comparative and single-group cohort studies; 2612 patients) in the proportional meta-analysis. Results showed no differences in oncological outcomes (mean follow-up of up to 52 months), comparable overall (OR = 0.49; P = 0.100) and necrotic complications (OR = 0.45; P = 0.150), and improved cosmetic satisfaction (OR = 1.88; P = 0.020). Comparing only single-incision endoscopic nipple-sparing mastectomy to conventional nipple-sparing mastectomy significantly reduced postoperative necrosis (OR = 0.19; P = 0.008). The proportional meta-analysis produced oncological and surgical outcome rates comparable to or lower than conventional nipple-sparing mastectomy rates. However, longer operative time (weighted mean difference = 43.08 min; P < 0.00001) and duration of hospital stay (weighted mean difference = 0.72 days; P = 0.0007) were observed.

CONCLUSION

Endoscopic nipple-sparing mastectomy does not affect oncological outcomes in up to 52 months mean follow-up when compared with conventional nipple-sparing mastectomy and provides better cosmetic satisfaction, with a reduced risk of necrosis after single-incision endoscopic nipple-sparing mastectomy. As such, endoscopic nipple-sparing mastectomy may become a viable breast surgery option.

Comparative analysis of oncological and surgical outcomes of robotic versus conventional mastectomy for breast cancer

OBJECTIVE

This study aimed to compare the surgical and oncological outcomes of robotic mastectomy (RM) and conventional mastectomy (CM) for breast cancer.

METHODS

Our institutional registry of women with breast cancer who received RM between 2018 and 2023 and CM between 2016 and 2023 were reviewed. Propensity score matching of clinicopathological variables was used to match 123 RM patients with 123 CM patients. Surgical outcomes, reconstruction type, margin status, complications, recurrence-free survival (RFS), and overall survival (OS) were compared between the 2 groups. Complications with increasing RM experience were also examined.

RESULTS

More autologous flap reconstructions were used in RM (67 % vs. 39 %, p < 0.001), but more implant reconstructions were used in CM (61 % vs. 33 %, p < 0.001). The complication rate, especially breast skin necrosis, was lower in the RM group (10 % vs. 26 %, p = 0.002). Nipple-areolar complex necrosis in nipple-sparing mastectomy was similar between the groups (33 % vs. 27 %, p = 0.45). At a median follow-up of 30 months, RFS was comparable between the 2 groups, as was OS (median follow-up 36 months). More RM experience was associated with shorter operation time and lower surgical complication and margin positive rates.

CONCLUSION

The oncological outcomes of RM and CM are similar at a follow-up of about 3 years. RM is associated with a significantly lower rate of breast skin necrosis, and the advantage of RM exists with different types of breast reconstruction. Increasing RM experience leads to improved overall results.

Learning curve for robot-assisted nipple-sparing mastectomy: A single institution experience

BACKGROUND

Robot-assisted nipple sparing mastectomy (RANSM) is emerging because it offers hidden incisions and ergonomic movements. In this study, we report the learning curve and feasibility of RANSM.

METHODS

A retrospective study was conducted among women who underwent RANSM with immediate breast reconstruction from July 2019 to June 2022. All RANSM procedures were performed by a single surgeon. We divided all the cases into two phases: the early phase (cases 1 to 21) and the late phase (cases 22 to 46). The total operation time, breast operation time, docking time, and console time were analyzed, and the cumulative sum (CUSUM) method was used to evaluate the effects of case experience accumulation on the time required for RANSM. Postoperative complications were analyzed according to their Clavien-Dindo grade.

RESULTS

Overall, 42 women underwent 46 RANSM procedures. In the early and late phases, the mean console times were 78.1 min and 60.1 min (p = 0.011), respectively. In learning curve analysis, 21 RANSM procedures were required to reduce the breast operation time. Two cases of Clavien-Dindo grade III postoperative complications occurred (4.3 %). One case was an implant removal caused by infection, and the other was partial nipple ischemia; both occurred in the early phase, with none in the late phase.

CONCLUSIONS

The breast operation time improved after the 21st RANSM procedure, and only two cases had Clavien-Dindo grade III or higher postoperative complications. RANSM is thus technically feasible and acceptable, with a short learning curve.

Robotic nipple sparing mastectomy and immediate breast reconstruction: significant attempts with the latissimus dorsi muscle without island flap

BACKGROUND

This study presents preliminary results of robot-assisted nipple-sparing immediate breast reconstruction (R-NSMIBR) with gel implant combined with latissimus dorsi muscle flap without island flap and validation of the safety and utility of this novel surgical modality.

METHODS

Records pertinent to R-NSMIBR with gel implants combined with latissimus dorsi muscle flap surgery for breast reconstruction between September 2022 and May 2023 were examined. A total of 13 patients who underwent R-NSMIBR were analyzed, nine of which were performed without skin island.

RESULTS

We divided the patients with and without skin islands into two groups and recorded the operation time and bleeding respectively. The mean total operative time for R-NSMIBR was 436.5±56.88 minutes and 355.75±69.68 minutes. As experience in learning increased, time required to create the operating space and position the robotic arm decreased significantly. Not creating an island of skin also saves a great deal of surgical time. Average total blood loss was 37.5±6.45 mL and 26.25±7.5 mL. No cases of nipple-areolar complex necrosis or perioperative complications or no local recurrences were reported. There were no local recurrences or deaths that occurred during a mean follow-up period of 3±1 months.

CONCLUSIONS

All the patients expressed satisfaction with the aesthetic outcome following surgery. There were no significant differences between two groups. This surgical method shows promise for future promotion in the field.

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.

Six steps for a successful aesthetic free flap reconstruction after minimally invasive mastectomy: a retrospective case-control study

OBJECTIVE

Breast cancer treatment has evolved to the modern skin-sparing mastectomy and nipple-sparing mastectomy. To better perform these surgeries, minimally invasive techniques using the endoscope, or Da Vinci Robotic Surgery platform have been developed. The deep inferior epigastric perforator (DIEP) flap is the gold standard in breast reconstruction, but it is still not commonly performed after minimally invasive mastectomy due technical difficulty. Here the authors introduced six key steps to a successful aesthetic autologous free flap reconstruction in in minimally invasive mastectomies.

METHODS

There are six main steps to our technique: placement of mastectomy incision, precise flap design after angiography studies, trial of shaping, transcutaneous medial suture, footprint recreation and postoperative shaping with bra. Between November 2018 and July 2022, a total of 67 immediate breast reconstructions using free perforator flaps were performed in 63 patients after minimally invasive nipple-sparing mastectomy.

RESULTS

The results from the minimally invasive mastectomy group were compared with a group of conventional mastectomy patients ( n= 41) performed during the same period. There were no significant differences in flap exploration rates. One hundred percent of the flaps survived. In the minimally invasive group, the final scar was placed in the lateral region, where it would be hidden from the anterior view. Only 70.7% of the conventional mastectomy group could achieve a hidden lateral scar ( P <0.001). The aesthetic revision rates were similar between two groups.

CONCLUSION

With attention to the six steps above, autologous free flap reconstruction can be offered reliably in the setting of minimally invasive mastectomy.

Postoperative complications and surgical outcomes of robotic versus conventional nipple-sparing mastectomy in breast cancer: meta-analysis

BACKGROUND

Breast cancer is the most common cancer worldwide, with remarkable advances in early diagnosis, systemic treatments, and surgical techniques. Robotic nipple-sparing mastectomy has been trialled; however, the complication rates, surgical outcomes, and oncological safety of this approach remain obscure.

METHODS

A systematic search of the literature was conducted from conception until September 2022. Studies examining complications and operative variables where robotic nipple-sparing mastectomy was compared with conventional nipple-sparing mastectomy were included. Primary study outcomes were complications (Clavien-Dindo grade III complications, skin or nipple necrosis, seroma, haematoma, infection, implant loss, and wound dehiscence) and oncological safety (recurrence and positive margins). The secondary outcomes included operative variables, length of stay, cost-effectiveness, learning curve, and aesthetic outcome.

RESULTS

A total of seven studies of overall fair quality, involving 1674 patients, were included in the systematic review and meta-analysis. Grade 3 complications were reduced in robotic nipple-sparing mastectomy without statistical significance (OR 0.60 (95 per cent c.i. 0.35 to 1.05)). Nipple necrosis was significantly reduced in robotic nipple-sparing mastectomy (OR 0.54 (95 per cent c.i. 0.30 to 0.96); P = 0.03; I2 = 15 per cent). Operating time (mean difference +58.81 min (95 per cent c.i. +28.19 to +89.44 min); P = 0.0002) and length of stay (mean difference +1.23 days (95 per cent c.i. +0.64 to +1.81 days); P < 0.0001) were significantly increased in robotic nipple-sparing mastectomy, whereas the opposite was true for blood loss (mean difference -53.18 ml (95 per cent c.i. -71.78 to -34.58 ml); P < 0.0001).

CONCLUSION

Whilst still in its infancy, robotic breast surgery may become a viable option in breast surgery. Nonetheless, the oncological safety of this approach requires robust assessment.

Robotic Versus Conventional or Endoscopic-assisted Nipple-sparing Mastectomy and Immediate Prosthesis Breast Reconstruction in the Management of Breast Cancer: A Prospectively Designed Multicenter Trial Comparing Clinical Outcomes, Medical Cost, and Patient-reported Outcomes (RCENSM-P)

OBJECTIVE

To compare the clinical and patient-reported outcomes of minimal access and conventional nipple-sparing mastectomy (C-NSM). The secondary outcomes investigated included medical costs and oncological safety.

BACKGROUND

Minimal-access NSM has been increasingly applied in the treatment of patients with breast cancer. However, prospective multicenter trials comparing robotic-assisted NSM (R-NSM) versus C-NSM or endoscopic-assisted NSM (E-NSM) are lacking.

METHODS

A prospectively designed 3-arm multicenter, nonrandomized trial (NCT04037852) was conducted from October 1, 2019 to December 31, 2021, to compare R-NSM with C-NSM or E-NSM.

RESULTS

A total of 73 R-NSM, 74 C-NSM, and 84 E-NSM procedures were enrolled. The median wound length and operation time of C-NSM was (9 cm, 175 minutes), (4 cm, and 195 minutes) in R-NSM, and (4 cm and 222 minutes) in E-NSM. Complications were comparable among the groups. Better wound healing was observed in the minimal-access NSM group. The R-NSM procedure was 4000 and 2600 United States Dollars more expensive than C-NSM and E-NSM, respectively. Wound/scar and postoperative acute pain evaluation favored the use of minimal access NSM over C-NSM. Quality of life in terms of chronic breast/chest pain, mobility, and range of motion of the upper extremity showed no significant differences. The preliminary oncologic results showed no differences among the 3 groups.

CONCLUSIONS

R-NSM or E-NSM is a safe alternative if compared with C-NSM in terms of perioperative morbidities, especially with better wound healing. The advantage of minimal access groups was higher wound-related satisfaction. Higher costs remain one of the major limiting factors in the widespread adoption of R-NSM.

A systematic review of robotic breast surgery versus open surgery

Robotic-assisted breast surgery (RABS) is controversial. We systematically reviewed the evidence about RABS, comparing it to open conventional breast surgery (CBS). Following prospective registration (osf.io/97ewt), a search was performed in January 2023, without time or language restrictions, through bibliographic databases (PubMed, Web of Science, EMBASE, Scopus, Trip database and CDSR) and grey literature. Quality was assessed in duplicate using Qualsyst criteria (score range 0.0-1.0); reviewer agreement was 98%. The 16 selected studies (total patients: 334,804) had overall high quality (mean score 0.82; range 0.68-0.91). Nine of 16 (56.3%) were cohort studies, 2/16 (12.5%) RCTs, and 5/16 (31.3%) case-control studies. Taking p < 0.05 as the significance threshold, RABS versus CBS was better in aesthetic results and patient satisfaction (10/11 studies; 90%), was surgically costly (4/4 studies; 100%), time-consuming (9/13 studies; 69%), and less painful in the first 6-24 h (2/2 studies; 100%) and without statistically significant differences in complication rates (10/12 studies; 83%) or short-term oncological outcomes (10/10 studies; 100%). Surgical time could be dramatically reduced by training surgical teams, reaching no significant differences between approaches (p = 0.120). RABS was shown to be feasible and safe. The advantages of RABS and long-term outcomes need further research.

Robotics in Implant-Based and Autologous Breast Reconstruction

Autologous and implant-based breast reconstruction continues to evolve as new technology and mastectomy techniques become available. Robotic-assisted breast reconstruction represents a growing field within plastic surgery, with the potential to improve aesthetic and functional outcomes, as well as patient satisfaction. This article provides a review of indications, techniques, and outcome data supporting the use of robotic assistance in both implant-based and autologous breast reconstruction from surgeons around the world.

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.

Outcomes of robotic nipple-sparing mastectomy versus conventional nipple-sparing mastectomy in women with breast cancer: a systematic review and meta-analysis

The promising results of the robotic approach for multiple cancer operations has led to interest in the potential of robotic nipple-sparing mastectomy (R-NSM); however, further studies are required to compare the benefits and complications of this approach with those of conventional open nipple-sparing mastectomy (C-NSM). We performed a meta-analysis to compare surgical complications of R-NSM versus C-NSM. We performed a review of literature through June 2022 in PubMed, Scopus, and EMBASE. We included randomized controlled trials (RCTs), cohorts, case-control studies, and case series with > 50 patients comparing the two techniques. Separate meta-analyses were conducted according to study design. From 80 publications, we identified six studies. The sample size ranged from 63 to 311 mastectomies from 63 to 275 patients. The tumor size and disease stage were similar between groups. The positive margin rate was 0-4.6% in the R-NSM arm and 0-2.9% in the C-NSM arm. Four studies reported early recurrence data, which were similar between groups (R-NSM: 0%, C-NSM: 0-8%). The R-NSM group had a lower rate of overall complications compared to the C-NSM group in cohorts/RCTs (RR = 0.68, 95%CI 0.49-0.96). In case-control studies, rate of necrosis was lower with R-NSM. Operative time was significantly longer in the R-NSM group in cohort/RCTs. In early experience with R-NSM, R-NSM had a lower overall complication rate compared to C-NSM in cohorts/RCTs. While these data are promising, our results show variability and heterogeneity limiting definitive conclusions. Additional trials are needed to guide the role of R-NSM and its oncologic outcomes.

The Expanding Utility of Robotic-Assisted Flap Harvest in Autologous Breast Reconstruction: A Systematic Review

The expansion of robotic surgery has led to developments in robotic-assisted breast reconstruction techniques. Specifically, robotic flap harvest is being evaluated to help maximize operative reliability and reduce donor site morbidity without compromising flap success. Many publications are feasibility studies or technical descriptions; few cohort analyses exist. This systematic review aims to characterize trends in robotic autologous breast reconstruction and provide a summative analysis of their results. A systematic review was conducted using PubMed, Medline, Scopus, and Web of Science to evaluate robot use in breast reconstruction. Studies dated from 2006 to 2022 were identified and analyzed using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Full-text, peer-reviewed, English-language, and human subject studies were included. Non-breast reconstruction articles, commentary, expert opinion, editor's letter, and duplicate studies were excluded. A total of 17 full-text articles were analyzed. The two robotic breast procedures identified were the deep inferior epigastric perforator (DIEP) and the latissimus dorsi (LD) flap. Results showed comparable complication rates and increased operative times compared to NSQIP data on their corresponding open techniques. Additional findings reported in studies included patient reported outcomes, incision lengths, and downward trends in operative time with consecutive procedures. The available data in the literature confirms that robotic surgery is a promising alternative to traditional open methods of breast reconstruction following mastectomy.

Use of Magnetic Resonance Imaging for Evaluating Residual Breast Tissue After Robotic-Assisted Nipple-Sparing Mastectomy in Women With Early Breast Cancer

OBJECTIVE

Prospective studies on postoperative residual breast tissue (RBT) after robotic-assisted nipple-sparing mastectomy (R-NSM) for breast cancer are limited. RBT presents an unknown risk of local recurrence or the development of new cancer after curative or risk-reducing mastectomies. This study investigated the technical feasibility of using magnetic resonance imaging (MRI) to evaluate RBT after R-NSM in women with breast cancer.

MATERIALS AND METHODS

In this prospective pilot study, 105 patients, who underwent R-NSM for breast cancer at Changhua Christian Hospital between March 2017 and May 2022, were subjected to postoperative breast MRI to evaluate the presence and location of RBT. The postoperative MRI scans of 43 patients (age, 47.8 ± 8.5 years), with existing preoperative MRI scans, were evaluated for the presence and location of RBT. In total, 54 R-NSM procedures were performed. In parallel, we reviewed the literature on RBT after nipple-sparing mastectomy, considering its prevalence.

RESULTS

RBT was detected in 7 (13.0%) of the 54 mastectomies (6 of the 48 therapeutic mastectomies and 1 of the 6 prophylactic mastectomies). The most common location for RBT was behind the nipple-areolar complex (5 of 7 [71.4%]). Another RBT was found in the upper inner quadrant (2 of 7 [28.6%]). Among the six patients who underwent RBT after therapeutic mastectomies, one patient developed a local recurrence of the skin flap. The other five patients with RBT after therapeutic mastectomies remained disease-free.

CONCLUSION

R-NSM, a surgical innovation, does not seem to increase the prevalence of RBT, and breast MRI showed feasibility as a noninvasive imaging tool for evaluating the presence and location of RBT.

Bibliometric analysis of robotic surgery research in breast cancer conducted between 2008 and 2022

BACKGROUND

To carry out a bibliometric analysis of robotic surgery research in the field of breast cancer conducted between 2008 and 2022 and to evaluate the status and trends in the field.

METHODS

A systematic search was undertaken in the Web of Science (WoS) for published articles related to surgical robots and breast cancer. R and VOSviewer software were used to carry out a quantitative analysis to explore the trend of annual publication volume and the cooperative relationship between countries, institutions, authors, and keywords.

RESULTS

A total of 177 publications were retrieved, 79.66% of which were published from 2016 to 2022, and most were conducted in the United States (US), China, and South Korea. Articles from the US had the most frequent international cooperation. A tally of institutional publications showed that Yonsei University (YONSEI UNIV; Korea) had produced the most publications. The author with the most published papers was Lee of YONSEI UNIV. The most accepted journal was the Asian Journal of Surgery. Keyword co-occurrence analysis showed that current research hotspots were mainly focused on nipple-conserving mastectomy and breast reconstruction, and breast-conserving and nipple-conserving mastectomy may be future research hotspots.

CONCLUSIONS

The annual incidence of robotic surgery and breast cancer is gradually increasing. The predominant countries conducting research in this field include the US, China, and South Korea, and the institutions are mainly distributed in universities and hospitals. Nipple-conserving mastectomy and breast reconstruction may be the current research hotspots, and breast-conserving mastectomy and minimally invasive surgery may represent hot research areas in the future. These findings may help scholars who are committed to the application of surgical robots to breast cancer to better understand the current research status and trends.

Mastectomy with Reconstruction Including Robotic Endoscopic Surgery (MARRES): a prospective cohort study of the Korea Robot-Endoscopy Minimal Access Breast Surgery Study Group (KoREa-BSG) and Korean Breast Cancer Study Group (KBCSG)

BACKGROUND

Robotic nipple-sparing mastectomy (RNSM) has emerged as a new treatment option for breast cancer and risk-reducing mastectomy (RRM) for women who have a high risk of pathogenic variants. Even though several studies have reported that RNSM is a feasible procedure, some argue that it should only be performed by specialized surgeons, and data on oncologic outcomes and patient-reported outcomes (PROs) are limited. Recently, the United States Food and Drug Administration and several surgeons warned that robotic breast surgery should be performed only by specialized surgeons and recommended that the benefits, risks, and alternatives of all available treatment options be discussed with patients so they can make informed treatment decisions. The Korea Robot-Endoscopy Minimal Access Breast Surgery Study Group (KoREa-BSG) has been established to evaluate, standardize, and teach this state-of-the-art procedure. We have designed a multicenter prospective cohort study entitled Mastectomy with Reconstruction Including Robot Endoscopic Surgery (MARRES) to report surgical, PRO, and oncologic outcomes.

METHODS

MARRES is a multi-institution cohort study prospectively collecting data from patients undergoing mastectomy and reconstruction. The patient inclusion criteria are adult women older than 19 with breast cancer or a high risk of breast cancer (patients with BRCA1/2, TP53, PALB2 mutations, etc.), who have scheduled therapeutic or RRM and want immediate reconstruction. Surgical outcomes, including pre- and postoperative photos, oncologic outcomes, cost-effectiveness, and PRO, are collected. The primary endpoints are postoperative complication rates within 30 postoperative days and the Clavien-Dindo grade of postoperative complications within 180 postoperative days. The secondary endpoints are 5-year postoperative recurrence-free survival and cancer incidence rate (for those who underwent RRM), patient satisfaction with reconstruction expectations preoperative (baseline) and results within 6 to 12 postoperative months, surgeon satisfaction with postoperative results in 6 postoperative months, and cost-effectiveness of the definitive surgery. Patient recruitment will be completed in April 2025, and the target number of enrolled patients is 2000.

DISCUSSION

This study will provide evidence about the surgical outcomes, oncologic outcomes, and patient satisfaction with RNSM and endoscopic nipple-sparing mastectomy (NSM), compared with conventional NSM.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier NCT04585074. Registered April 8, 2020.

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.

Mastectomy and Immediate Breast Reconstruction with Pre-Pectoral or Sub-Pectoral Implant: Assessing Clinical Practice, Post-Surgical Outcomes, Patient's Satisfaction and Cost

Immediate breast reconstruction (IBR) rates increase during last years and implant-based reconstruction was the most commonly performed procedure. We examined data collected over 25 months to assess complication rate, duration of surgery, patient's satisfaction and cost, according to pre-pectoral or sub-pectoral implant-IBR. All patients who received an implant-IBR, from January 2020 to January 2022, were included. Results were compared between pre-pectoral and sub-pectoral implant-IBR in univariate and multivariate analysis. We performed 316 implant-IBR, 218 sub-pectoral and 98 (31%) pre-pectoral. Pre-pectoral implant-IBR was significantly associated with the year (2021: OR=12.08 and 2022: OR=76.6), the surgeons and type of mastectomy (SSM vs NSM: OR=0.377). Complications and complications Grade 2-3 rates were 12.9% and 10.1% for sub-pectoral implant-IBR respectively, without significant difference with pre-pectoral implant-IBR: 17.3% and 13.2%. Complications Grade 2-3 were significantly associated with age <50-years (OR=2.27), ASA-2 status (OR=3.63) and cup-size >C (OR=3.08), without difference between pre and sub-pectoral implant-IBR. Durations of surgery were significantly associated with cup-size C and >C (OR=1.72 and 2.80), with sentinel lymph-node biopsy and axillary dissection (OR=3.66 and 9.59) and with sub-pectoral implant-IBR (OR=2.088). Median hospitalization stay was 1 day, without difference between pre and sub-pectoral implant-IBR. Cost of surgery was significantly associated with cup-size > C (OR=2.216) and pre-pectoral implant-IBR (OR=8.02). Bad-medium satisfaction and IBR-failure were significantly associated with local recurrence (OR=8.820), post-mastectomy radiotherapy (OR=1.904) and sub-pectoral implant-IBR (OR=2.098).

Conclusion

Complications were not different between pre and sub-pectoral implant-IBR. Pre-pectoral implant-IBR seems a reliable and faster technique with better patient satisfaction but with higher cost.

Breakthrough in breast reconstruction in the context of COVID-19: safety and efficiency of endoscopic breast reconstruction at a day surgery center

Background

In recently years, breast endoscopic reconstruction surgery is becoming increasingly popular. And we have explored a series of endoscopic breast reconstruction procedures and applied it to our day surgery under the epidemic control of the novel coronavirus.

Methods

The present study was a retrospective analysis. Patients who underwent unilateral breast endoscopic reconstruction surgery in the West China Hospital from April 2017 to February 2021 were included in the study. Patients were divided into the following three groups: ward exploration period (WEP), ward maturation period (WMP), and day surgery period (DSP), respectively. We compared the results of postoperative complications, hospitalization costs, operation time, and BREAST-Q (a patient-reported outcome instrument measuring health-related quality-of-life and patient satisfaction in breast surgery) scale scores among the three groups of patients.

Results

A total of 66 patients were included (WEP n=30, WMP n=14, DSP n=22). Four people refused to complete the BREAST-Q scale, and five patients missed complication record sheets. Patients in the DSP and WMP groups had slightly higher postoperative satisfaction with their breasts than WEP, but there was no statistically significant difference (3 months postoperatively: WEP vs. WMP =0.515, WEP vs. DSP =0.418, WMP vs. DSP =0.982). On the postoperative BREAST-Q scale scores of psychosocial, sexual life and chest well-being, patients with DSP scored slightly higher than those with WEP versus WMP, but there was no statistically significant difference. The incidence of postoperative complications was generally higher in the WEP group than in the WMP and DSP groups, but there was no statistically significant incidence of either major or minor complications (P=1.000). With the use of prostheses and mesh, patients in the DSP group had lower hospitalization costs than other two groups. In terms of operative time, patients in the WMP and DSP groups had shorter operative times compared with the WEP group, and the results were statistically significant (WEP vs. WMP =0.000, WEP vs. DSP =0.000, WMP vs. DSP =0.243).

Conclusions

We believe that performing our newly developed endoscopic breast reconstructive surgery at a day surgery center is safe and reliable.