Robotic Surgery in Elderly and Very Elderly Gynecologic Cancer Patients

Study Objective

To investigate the feasibility, safety, and short-term outcomes of robotic surgery (RS) for gynecologic oncologic indications (cervical, endometrial, and ovarian cancer) in elderly patients, especially women age 65 to 74 years (elderly group [EG]) compared with women age ≥75 years (very elderly group [VEG]).

Evaluation of Positioning Devices for Optimization of Outcomes in Laparoscopic and Robotic-Assisted Gynecologic Surgery

In this review, we evaluate techniques, devices, and equipment for patient positioning and their effect on patient outcomes, such as cephalad slide and neuropathy, in laparoscopic and robotic-assisted gynecologic surgery. We conducted a systematic review by searching MEDLINE, Embase, and Cochrane Library for relevant articles published over a 15-year period. Study selection, data extraction, and quality assessment were performed by 2 reviewers independently. Seven articles, including 3 randomized controlled trials and 4 case series, were included in our analysis. Four studies evaluated cephalad patient slide. In 2 randomized controlled trials (n?=?103), the mean slide with various devices (i.e., memory foam, bean bag with shoulder braces, egg crate, and gel pad) ranged from 1.07 ± 1.93 cm to 4.5 ± 4.0 cm. The use of a bean bag with shoulder supports/braces was associated with minimal slide, with a median slide of 0 cm (range, 0–2 cm) in a retrospective series and with mean slide of 1.07 ± 1.93 cm in a randomized controlled trial (vs memory foam). No conclusive effect of body mass index on slide could be identified. Five studies evaluating the incidence of neuropathy found an overall incidence of 0.16% and no differences among slide-preventing devices. The minimal slide described across studies supports the conclusion that any of the currently used devices and techniques for safe patient positioning are within reason. The low overall incidence of neuropathy is also reassuring. Best evidence recommendations cannot be made for a specific device or technique; our findings suggest the importance of strict adherence to the basic tenets of safe patient positioning to minimize slide and prevent nerve injury.     

Systematic Review of Robotic Surgery in Gynecology: Robotic Techniques Compared With Laparoscopy and Laparotomy

The Society of Gynecologic Surgeons Systematic Review Group performed a systematic review of both randomized and observational studies to compare robotic vs nonrobotic surgical approaches (laparoscopic, abdominal, and vaginal) for treatment of both benign and malignant gynecologic indications to compare surgical and patient-centered outcomes, costs, and adverse events associated with the various surgical approaches. MEDLINE and the Cochrane Central Register of Controlled Trials were searched from inception to May 15, 2012, for English-language studies with terms related to robotic surgery and gynecology. Studies of any design that included at least 30 women who had undergone robotic-assisted laparoscopic gynecologic surgery were included for review. The literature yielded 1213 citations, of which 97 full-text articles were reviewed. Forty-four studies (30 comparative and 14 noncomparative) met eligibility criteria. Study data were extracted into structured electronic forms and reconciled by a second, independent reviewer. Our analysis revealed that, compared with open surgery, robotic surgery consistently confers shorter hospital stay. The proficiency plateau seems to be lower for robotic surgery than for conventional laparoscopy. Of the various gynecologic applications, there seems to be evidence that renders robotic techniques advantageous over traditional open surgery for management of endometrial cancer. However, insofar as superiority, conflicting data are obtained when comparing robotics vs laparoscopic techniques. Therefore, the specific method of minimally invasive surgery, whether conventional laparoscopy or robotic surgery, should be tailored to patient selection, surgeon ability, and equipment availability.     

Health-Related Quality of Life Following Robotic Surgery: A Pilot Study

ObjectivesTo determine the relationship between BMI, age, and the physical, functional, and psychosocial areas of health-related quality of life (HRQoL) and patient satisfaction in women with endometrial cancer undergoing robotic-assisted surgery.MethodsDuring the first two years of the robotic surgery program, we prospectively collected data concerning patient demographics and surgical outcomes. At the first postoperative visit (21 to 28 days after surgery), all participants completed a HRQoL questionnaire. We examined the association between BMI and age, as well as the different areas of HRQoL, using chi-square and ANOVA.ResultsOf 109 participants, 41 were 70 years of age or older, and 51 had a BMI of 30 kg/m² or more. Following surgery, the mean (± SD) duration of hospital stay was 1.9 ± 1.5 days, and reported pain level was highest on the second postoperative day, with a mean score of 3.4 ± 2.1 on a seven-point scale. Moreover, two thirds of women reported no pain by the first postoperative visit, and only 18.2% of women aged 70 years or older used any narcotic for pain control. These results indicated that there was little influence of the surgery on HRQoL, and women resumed typical activities within an average of 11 days after surgery. Lastly, participants’ average rating of satisfaction was 6.7 on a seven-point scale.ConclusionThis pilot study has demonstrated the advantages for HRQoL of robotic-assisted surgery in the management of endometrial cancer. Women with endometrial cancer benefited from use of robotic surgery regardless of age or BMI.     

Robotic,Laparoscopic, or Open Hysterectomy: Surgical Outcomes by Approach in Endometrial Cancer

Study Objectives

To compare patient outcomes by surgical approach in the management of endometrial cancer (EC) in Washington State from 2008 to 2013.

Quality of life and survival in advanced cervical cancer: a Gynecologic Oncology Group study

Purpose

To determine associations between pretreatment health-related quality of life subscales with progression-free (PFS) and overall survival (OS) in advanced and recurrent cervical cancer.

Patients and Methods

Patients included those participating in Gynecologic Oncology Group advanced or recurrent cervical cancer phase III treatment trials who completed the Functional Assessment of Cancer Therapy for patients with cervical cancer (FACT-Cx) and a single-item pain scale at study entry. The FACT-Cx includes five domains: physical (PWB), emotional (EWB), social (SWB), functional well being (FWB), and cervix cancer subscale (CCS). A high quality of life (QoL) score reflects better QoL. After stratifying by protocol and adjusting for patient and disease characteristics, a Cox proportional hazards model was fitted for each subscale as a continuous variable. If statistically significant, (p < 0.05), an analysis on mean item scores (MIS) was performed.

Results

Nine-hundred-ninety-one patients were enrolled from 1997 to 2007. The majority (87%) had recurrent disease. After adjustment for covariates and predictors, only the PWB domain (better physical QoL) was associated with improved OS [HR 0.96 95% CI 0.95-0.98; p < 0.001]. When classifying patients based on the MIS of each subscale, the patients with the lowest risk of death were likely to report less compromised QoL (MIS > 3) for PWB [HR 0.44 (0.33-0.58) P < 0.001], FWB [0.49 (0.38-0.62) P < 0.001], and CCS [0.48 (0.38-0.61) P < 0.001].

Conclusion

The pretreatment patient-reported PWB as measured by the PWB subscale of the FACT-Cx, is significantly associated with survival in advanced cervical cancer trials, even after controlling for known prognostic factors.     

Long-Term Outcomes on Quality of Life in Women Submitted to Laparoscopic Treatment for Bowel Endometriosis

Study ObjectiveTo evaluate the long-term effects of laparoscopic surgery on quality of life in women with bowel endometriosis.DesignObservational prospective cohort study (Canadian Task Force classification II).SettingCentral Hospital of Santa Casa, Sao Paulo, Brazil.PatientsForty-five patients answered a short-form, 36-item, quality-of-life questionnaire (SF-36) at 3 different times.InterventionsBetween June 2007 and September 2008, patients underwent laparoscopic surgery to treat deep infiltrative endometriosis, with colorectal resection.Measurements and Main ResultsForty-five patients with bowel endometriosis were followed up from 2007 to 2012. Before surgery, all patients exhibited signs suggestive of bowel endometriosis at magnetic resonance imaging and transrectal ultrasound. The patients underwent laparoscopic surgery for resection of the endometriosis lesions, including colorectal resection. The patients completed the questionnaire before surgery (T0), at 12 (T12) and 48 (T48) months after surgery. The 8 items of the SF-36 questionnaire at the different time points of application were compared. For each domain attribute, a score of 0 to 100 was assigned, where 0 signified the worst quality of life, and 100 the best. Statistical analysis was performed using analysis of variance. If differences were detected, multiple comparisons were performed using the Tukey test. Analysis of each domain revealed improved quality of life when comparing the period before surgery with 12 and 48 months after surgery. There was a significant increase (p < .001) in the scores in all of the SF-36 domains when comparing T0 vs T12 and T0 vs T48, with higher average scores at T48 corresponding to the domains of physical functioning, role physical, and social functioning (scores of 85.56, 75.69, and 73.61, respectively).ConclusionLaparoscopic treatment of bowel endometriosis improved the long-term quality of life of patients.     

A Comparison of Quality Outcome Measures in Patients Having a Hysterectomy for Benign Disease: Robotic vs. Non-robotic Approaches

Study ObjectiveTo measure procedure-related hospital readmissions within 30 days after discharge for patients who have a hysterectomy for benign disease. Secondary outcome quality measures evaluated were cost, estimated blood loss, length of stay and sum of costs associated with readmissions.DesignRetrospective cohort study (Canadian Task Force classification II-2).SettingAcademic community hospital.PatientsPatients who underwent hysterectomy to treat benign disease from January 2008 to December 2012.InterventionsPatients were grouped according to route of hysterectomy: robotic-assisted laparoscopic hysterectomy (robotic), laparoscopic hysterectomy (laparoscopic), abdominal hysterectomy (open via laparotomy), and vaginal hysterectomy (vaginal).Measurements and Main ResultsInclusion criteria were met by 2554 patients: 601 in the robotic group, 427 in the laparoscopic group, 1194 in the abdominal group, and 332 in the vaginal group. Readmission rates in the robotic cohort were significantly less (p<.05) than in non-robotic cohorts: Robotic (1%), laparoscopic (2.5%), open (3.5%), vaginal (2.4%). Estimated blood loss, length of stay, and sum of readmission costs were also significantly less in the robotic cohort (p<.05) compared with the other 3 cohorts.ConclusionPatients who undergo robotic-assisted laparoscopic hysterectomy have a significantly lower chance of readmission <30 days after surgery compared with those who undergo laparoscopic, abdominal (open) hysterectomy, and vaginal approaches. Patients in the robotics cohort also experienced a shorter length of stay, less estimated blood loss, and a cost savings associated with readmissions when compared to non-robotic approaches. Prospective registries describing quality outcomes, total sum of costs including 30 days follow-up, as well as patient-related quality of life benefits are recommended to confirm these findings and determine which surgical route offers the highest patient and societal value.     

Robotic Radical Hysterectomy for Cervical Cancer: A Population-Based Study of Adoption and Immediate Postoperative Outcomes in the United States

Study Objective

To compare the use of robotic radical hysterectomy (RRH) and abdominal radical hysterectomy (ARH) in the United States, with secondary outcomes of perioperative complications, hospital length of stay (LOS), immediate postoperative mortality, cost and a subanalysis compared with laparoscopic radical hysterectomy (LRH).

Improving the Rate of Same-day Discharge in Gynecologic Oncology Patients with Endometrial Cancer undergoing Minimally Invasive Robotic Surgery: A Quality Improvement Initiative

Study Objective/Setting/PatientsSame-day discharge (SDD) in patients with endometrial cancer undergoing minimally invasive surgery (MIS) is safe and feasible, with multiple patient and healthcare system benefits. Despite this, our local rate of SDD was only 29.4%. Several studies have suggested methods to improve rates of SDD but few have evaluated the application of such methods. The objectives of our quality improvement (QI) initiative were 2-fold: (1) to increase the rate of SDD in eligible patients with endometrial cancer undergoing MIS to 70% and (2) to evaluate the implementation of methods to improve rates of SDD.Design/Interventions/MeasurementsAt our center, QI diagnostics were conducted, and root causes were identified. Four interventions were introduced: (1) setting SDD as the default discharge plan, (2) ensuring that a physician order for discharge was on the chart, (3) removing the Foley catheter in the operating room, and (4) introducing pre- and postoperative patient education documents. A time-series design was used; rate of SDD was tracked using baseline data and continuous post-intervention monitoring. Process measures (for each intervention) and balancing measures were defined and tracked.Main ResultsAt the conclusion of our QI initiative, the average rate of SDD was 78.3%—exceeding our aim of 70%. This was achieved without compromising patient satisfaction (98.2%) or significantly impacting rates of readmission or presentations to the emergency department.ConclusionsOur initiative demonstrated the application of simple interventions that resulted in a substantial increase in our rate of SDD in the population of interest, without causing negative impacts on the defined balancing measures. These interventions were nonspecific to gynecologic oncology and could easily be applied across other surgical disciplines.     

Quality of life in long-term survivors of ovarian germ cell tumors: a Gynecologic Oncology Group study

PURPOSE: This report describes the strength and significance of the association between antecedent and mediating variables across four categories of quality of life (QOL) outcomes in 132 disease free women with ovarian germ cell survivors. METHODS: Survivors (n=132) participated in a mailed questionnaire and computer-assisted telephone survey. Participants in four prospective GOG protocols were contacted their treating physician for verbal consent to be approached by investigators at the Indiana University Cancer Center about a quality of life study. Similar patients treated at the MD Anderson Cancer Center were also included. If women verbally consented after being contacted by investigators at Indiana University, an informed consent and questionnaire packet was sent via mail. After return of the written informed consent and background questionnaire, a trained research assistant scheduled a computer-assisted interview to complete data collection. RESULTS: Median follow-up from diagnosis was 10.2 years. Mediating variables of self-efficacy or social support played a significant role (p=0.05 to p=0.001) in all four QOL categories: physical functioning, psychological functioning, sexual functioning, and spiritual functioning. Being a younger age at diagnosis and married were positively related to sexual functioning (p=0.05). Menstrual and gynecological symptoms were inversely related. IMPLICATIONS: Results indicate that clinicians may want to be especially sensitive to identifying a survivor's social support and confidence (self efficacy) in handling issues evolving from treatment since these skills may be related to overall quality of life outcomes.     

Evaluation of the American College of Surgeons National Surgical Quality Improvement Program Surgical Risk Calculator in Gynecologic Oncology Patients Undergoing Minimally Invasive Surgery

Study Objective

To evaluate the ability of the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) surgical risk calculator to predict discharge to postacute care and perioperative complications in gynecologic oncology patients undergoing minimally invasive surgery (MIS).

机器人手术在妇科恶性肿瘤手术治疗中的应用

机器人技术的出现使外科微创手术进入新的发展阶段。在妇科恶性肿瘤手术治疗中机器人也逐步得到应用,其主要应用于宫颈癌的广泛性全子宫切除和盆腔淋巴清扫术,此外机器人根治性宫颈切除术、晚期宫颈癌分期手术及复发性宫颈癌的盆腔脏器切除术也有相关报道;子宫内膜癌和卵巢癌的机器人分期手术也日趋增多。目前,机器人手术多是回顾性病例报告,缺乏随机对照、大样本比较性研究,其适应证和手术效果还需要大量临床探索,以作出全面的评价。     

机器人手术在妇科恶性肿瘤手术治疗中的应用

机器人技术的出现使外科微创手术进入新的发展阶段.在妇科恶性肿瘤手术治疗中机器人也逐步得到应用,其主要应用于宫颈癌的广泛性全子宫切除和盆腔淋巴清扫术,此外机器人根治性宫颈切除术、晚期宫颈癌分期手术及复发性宫颈癌的盆腔脏器切除术也有相关报道;子宫内膜癌和卵巢癌的机器人分期手术也日趋增多.目前,机器人手术多是回顾性病例报告,...