Robotic single site radical hysterectomy plus pelvic lymphadenectomy in gynecological cancers

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.

Urological Complications in Radical Surgery for Cervical Cancer: A Comparative Meta-Analysis before and after LACC Trial

BACKGROUND

After the LACC trial publication in 2018, the minimally invasive approach (MIS) has severely decreased in favor of open surgery: MIS radical hysterectomy was associated with worse oncological outcomes than open surgery, but urological complications were never extensively explored in pre- versus post-LACC eras, even if they had a great impact on post-operative QoL. The purpose of this meta-analysis is to compare functional and organic urological complication rates before and after LACC trial.

METHODS

An independent search of the literature was conducted 4 years before and after the LACC trial and 50 studies were included.

RESULTS

The overall rate of urologic complications was higher in pre-LACC studies while no differences were found for organic urological complications. Conversely, the overall risk of dysfunctional urological complications showed a higher rate in the pre-LACC era. This is probably related to a sudden shift to open surgery, with potential lower thermal damage to the urinary tract autonomic nervous fibers.

CONCLUSIONS

This meta-analysis showed that the incidence of urological complications in radical cervical cancer surgery was higher before the LACC trial, potentially due to the shift to open surgery. Nevertheless, further studies are needed to shed light on the connection between minimally invasive surgery and urological damage.

Robot-Assisted Surgery in the Treatment of Gynecological Carcinoma and Malignancies: Introduction to the da Vinci Robotic Surgery System

Robotic surgery is a surgical intervention that was developed from traditional manual surgeries because of the intrusive procedures it uses. It is now accomplished in hospitals worldwide, and comprehensive programs for the application of technology in the management of gynecological cancer are being developed. Robotic surgery should be straightforwardly compared with manual and traditional laparoscopy to see if the higher indirect costs are justified by some improvements in patient studies. This paper aims to evaluate the procedure of robotic surgery and its implementation in gynecological cancer to verify its safeness, practicability, and effectiveness. A higher chance of infections is usually in classical surgery, particularly in comparison to laparoscopic or robotic surgery. Surgical and hospital stay are much less with any of these new technologies than the aforementioned; however, the drawbacks are the scarcity of robot systems, their high price, and the realization that it is only appropriate in learning institutions with infrastructure and highly skilled surgeons. In conclusion, tissue engineering constitutes a significant discovery and approach for treating gynecological cancer with improved methods than some other types of traditional surgery, and it will likely become dominant technology shortly.

Pain nursing for gynecologic cancer patients

Gynecological malignancy remains a prevalent cause of mortality among women. Chronic cancer pain, as a severe complication of malignancy and its therapies, accounts for a substantial burden of physical and psychological distress in affected patients. Accordingly, early identification, assessment, and standardized management of such pain are crucial in the prevention or delay of its progression. In the present review, we provide a comprehensive overview of the pathological factors that contribute to pain in patients with gynecological malignancy while highlighting the underlying mechanisms of pain in this population. In addition, we summarize several treatment modalities targeting pain management in gynecologic cancer patients, including surgery, radiotherapy, and chemotherapy. These interventions are crucial for tumor elimination and patient survival. Chronic cancer pain exerts a significant impact on wellbeing and quality of life for patients with gynecologic cancer. Therefore, our review emphasizes the importance of addressing this pain and its psychological sequelae and advocates for a multidisciplinary approach that encompasses nursing and psychological support. In summary, this review offers valuable insights into the pathological factors underlying pain, reviews pain management modalities, and stresses the critical role of early intervention and comprehensive care in enhancing the quality of life of these patients.

Robotic Single-Site Radical Hysterectomy for Early Cervical Cancer: A Single Center Experience of 5 Years

BACKGROUND

The mainstay of treatment for early-stage cervical cancer is surgery; we present a 5-year experience of robotic single-site radical hysterectomy (RSRH) focused on surgical and oncologic outcomes.

METHODS

This retrospective study included 44 cases of RSRH performed in patients with early-stage cervical cancer.

RESULTS

The median follow-up period for the 44 patients was 34 months. The mean total operation time was 156.07 ± 31.77 min, while mean console time was 95.81 ± 24.95 min. Two cases had complications, which required surgical management, while four cases (9.1%) exhibited recurrence. The disease-free survival rate at 5 years was 90.9%. The sub-division analysis showed that Stage Ia2 and stage Ib1 patient sub-group showed better DFS than that of the stage Ib2 patient sub-group. The learning curve analysis showed that the CUSUM-T initially peaks at the sixth case then gradually decreases before rising and peaking at the 24th case. After 24th case, the CUSUM-T gradually decreases and reaches zero.

CONCLUSION

The surgical outcomes of RSRH for early-stage cervical cancer treatment were safe and acceptable. However, RSRH could be considered carefully only in well-selected patient groups. Large-scale prospective studies are necessary in the future to validate the results.

Comparison of Multi- and Single-Site Robotic Myomectomy Using the Da Vinci® SP Surgical System: A Propensity Score Matching Analysis

Objective: This study aimed to compare the surgical outcomes between robotic multi-site myomectomy (RMSM) and robotic single-site myomectomy (RSSM), using the da Vinci® SP surgical system and perform propensity score matching analysis to ensure inter-group comparability. Methods: This retrospective study included 105 patients who underwent either three-incision RMSM or RSSM using the da Vinci® SP surgical system. We retrospectively reviewed and compared surgical outcomes using 1:1 propensity score matching. Results: After 1:1 propensity score matching, there were no differences in the total operation time and estimated blood loss between the groups. The docking time (p < 0.0001) and duration of hospital stay (p = 0.0001) were significantly shorter in the RSSM group than in the RMSM group. Conclusions: The surgical outcomes of RSSM were comparable to those of RMSM. Moreover, compared to RMSM, RSSM using the da Vinci® SP surgical system has shorter docking and morcellation times, and duration of hospital stay.

Percutaneous-assisted laparoscopy for ovarian tissue cryopreservation: a single-center experience

PURPOSE

To compare surgical and post-operative outcomes of patients submitted to traditional laparoscopy and percutaneous-assisted laparoscopy for ovarian tissue explant for cryopreservation.

METHODS

This is a single-center retrospective comparative study conducted in IRCCS "Regina Elena" National Cancer Institute of Rome. Patients submitted to laparoscopic excision of ovarian tissue, before starting chemotherapy were enrolled. We compared the classic laparoscopic approach vs percutaneous-assisted laparoscopy, using the Percuvance grasping forceps.

RESULTS

Fifty-nine young oncologic women were enrolled; 38 underwent a conventional laparoscopy (LAP), 21 received a percutaneous laparoscopy (PERC). The baseline characteristics were similar in both groups, furthermore no differences were found in terms of peri-operative complications, median estimated blood loss (p = 0.4), operative time (p = 0.2), recovery times (p = 0.1), median time to chemotherapy (p = 0.7), median area of collected samples (p = 0.9). The postoperative pain evaluated by VAS-score, was significantly lower in the PERC group vs LAP group, both the day of surgery (range 0-4 vs 0-2; p = 0.02) and after 1 (range 0-3 vs 0-2; p = 0.002) and 2 days (range 0-3 vs 0-1; p = 0.0001). Moreover, better aesthetic results were detected in the PERC group, 2 months after surgery (median 9 vs 10, range 7-10 vs 9-10; p = 0.0001).

CONCLUSIONS

Percutaneous-assisted laparoscopy has proven to be an effective and safe procedure for the excision of ovarian tissue for cryopreservation, in young oncologic patients that want to preserve their fertility. The percutaneous procedure appears superior to conventional laparoscopy in terms of aesthetic outcomes and post-operative pain reduction.

CLINICAL TRIAL ID

NCT05134090, 24^th Nov 2021, retrospectively registered.

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.

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 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.

Comparative analysis of genitourinary function after type C1 robotic nerve-sparing radical hysterectomy versus type C2 robotic radical hysterectomy

BACKGROUND

To compare the return of bladder function and genitourinary complications after type C1 robotic nerve-sparing radical hysterectomy (C1-RRH) to type C2 robotic radical hysterectomy (C2-RRH) in gynecologic cancers.

METHODS

A retrospective analysis between C1-RRH (n = 42) and C2-RRH (n = 43) was performed. Operative outcomes and perioperative genitourinary complications between the two groups were analyzed.

RESULTS

The C1-RRH group had shorter hospitalization (0.7 vs. 1.7 days, p < 0.001) and shorter DUC (1 vs. 28 days, p < 0.001). About 76% of C1-RRH group required a catheter for less than 1 week while 84% of the C2-RRH group did for more than 1 week (54% for 1-6 weeks; 30% > 6 weeks). In spite of the short stay after surgery (95% of C1-RRH ≤ 1 day), only two patients (4.8%) in C1-RRH group were admitted again because of urinary tract infection. C1-RRH was only independent predictor for early bladder function return within 1 week after surgery.

CONCLUSION

The C1-RRH showed early bladder function return and feasible outcomes in spite of early discharge. It can be considered as the first surgical option in gynecologic cancer patients who need RH to preserve their bladder function.

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.

Robotic lower pelvic port placement for optimal upper paraaortic lymph node dissection

Objective

Upper paraaortic lymph node dissection (UPALD) to the infrarenal level is one of the most challenging robotic procedures. Because robotic system has the limitation in robotic arm mobility. This surgical video introduces a novel robotic approach, lower pelvic port placement (LP3), to perform optimally and simultaneously both UPALD and pelvic procedures in gynecologic cancer patients using da Vinci Xi system.

Methods

The patient presented with high-grade endometrial cancer. She underwent robotic surgical staging operation. For the setup of the LP3, a line was drown between both anterior superior iliac spines. At 3 cm below this line, another line was drown and four robotic ports were placed on this line.

Results

After paraaortic lymph node dissection (PALD) was completed, the boom of robotic system was rotated 180° to retarget for the pelvic lateral displacement. Robotic ports were placed and docked again. The operation was completed robotically without any complication.

Conclusion

The LP3 was feasible for performing simultaneously optimal PALD as well as procedures in pelvic cavity in gynecologic cancer patients. The advantage of LP3 technique is the robotic port placement that affords for multi-quadrant surgery, abdominal and pelvic dissection. The LP3 is facilitated by utilizing advanced technology of Xi system, including the patient clearance function, the rotating boom, and ‘port hopping’ that allows using every ports for a camera. The LP3 will enable surgeons to extend the surgical indication of robotic surgical system in the gynecologic oncologic field.