Successful incorporation of robotic surgery into gynecologic oncology fellowship training

Background

The increasing role of robotic surgery in gynecologic oncology may impact fellowship training. The purpose of this study was to review the proportion of robotic procedures performed by fellows at the console, and compare operative times and lymph node yields to faculty surgeons.

Methods

A prospective database of women undergoing robotic gynecologic surgery has been maintained since 2008. Intra-operative datasheets completed include surgical times and primary surgeon at the console. Operative times were compared between faculty and fellows for simple hysterectomy (SH), bilateral salpingo-oophorectomy (BSO), pelvic (PLND) and paraaortic lymph node dissection (PALND) and vaginal cuff closure (VCC). Lymph nodes counts were also compared.

Results

Times were recorded for 239 SH, 43 BSOs, 105 right PLNDs, 104 left PLNDs, 34 PALND and 269 VCC. Comparing 2008 to 2011, procedures performed by the fellow significantly increased; SH 16% to 83% (p < 0.001), BSO 7% to 75% (p = 0.005), right PLND 4% to 44% (p < 0.001), left PLND 0% to 56% (p < 0.001), and VCC 59% to 82% (p = 0.024). Console times (min) were similar for SH (60 vs. 63, p = 0.73), BSO (48 vs. 43, p = 0.55), and VCC (20 vs. 22, p = 0.26). Faculty times (min) were shorter for PLND (right 26 vs. 30, p = 0.04, left 23 vs. 27, p = 0.02). Nodal counts were not significantly different (right 7 vs. 8, p = 0.17 or left 7 vs. 7, p = 0.87).

Conclusions

Robotic surgery can be successfully incorporated into gynecologic oncology fellowship training. With increased exposure to robotic surgery, fellows had similar operative times and lymph node yields as faculty surgeons.     

Radical hysterectomy: a comparison of surgical approaches after adoption of robotic surgery in gynecologic oncology

Objective

To compare intra-operative, postoperative and pathologic outcomes of three surgical approaches to radical hysterectomy and bilateral pelvic lymph node dissection over a three year time period during which all three approaches were used.

Methods

We reviewed all patients who underwent radical hysterectomy with pelvic lymph node dissection between 1/2007 and 11/2010. Comparison was made between robotic, laparoscopic and open procedures in regard to surgical times, complication rates, and pathologic findings.

Results

A total of 95 radical hysterectomy procedures were performed during the study period: 30 open (RAH), 31 laparoscopic (LRH) and 34 robotic (RRH). There were no differences in age, body mass index or other demographic factors between the groups. Operative time was significantly shorter in the RAH compared to LRH and RRH (265 vs 338 vs 328 min, p = 0.002). Estimated blood loss was significantly lower in LRH and RRH compared with RAH (100 vs 100 vs 350 mL, p < 0.001). Thirteen (24%) of RAH required blood transfusion. Conversion rates were higher in the LRH (16%) compared to RRH (3%) although not significant (p = 0.10). Median length of stay was significantly shorter in RRH (1 day) vs LRH or RAH (2 vs 4 days, p < 0.01). Pathologic findings were similar among all groups.

Conclusion

Minimally invasive surgery has made a significant impact on patients undergoing radical hysterectomy including decrease in blood loss and transfusion rates however; operative times were significantly longer compared to open radical hysterectomy. Our findings suggest that the robotic approach may have the added benefit of even shorter length of stay compared to traditional laparoscopy.     

Feasibility of same-day discharge after laparoscopic surgery in gynecologic oncology

Objective

The purpose of this study is to evaluate whether same-day discharge after laparoscopic gynecologic oncology surgery is feasible and determines factors associated with admission.

Methods

This retrospective cohort study included all patients consented for laparoscopy by two gynecologic oncologists at a tertiary care academic teaching hospital between January 2006 and June 2009. Procedures included those not typically discharged same-day, such as total laparoscopic simple or radical hysterectomies or radical trachelectomy +/− salpingo-oophorectomy +/− pelvic and para-aortic lymph node dissection +/− omentectomy. Those discharged same-day were compared to those admitted. Multivariate logistic regression analysis was done to determine factors associated with admission.

Results

Three hundred three patients were included. 6.9% were converted to laparotomy. One hundred forty-seven (48.5%) had same-day discharge (median stay 295 minutes). Among outpatients, 7 (4.8%) were readmitted within three weeks of surgery. Three patients (2%) could have avoided the ER or hospital admission had they been originally admitted postoperatively. No patients with same-day discharge had a major acute postoperative complication. Factors associated with admission include age (OR 1.76 for age 70 years vs 50 years, p = 0.001), surgeon (OR 6.91, p < 0.0001), conversion to laparotomy (p < 0.0001), radical hysterectomy (OR 3.43, p = 0.002), length of surgery (OR 2.94 for 4 hours vs 2 hours, p < 0.0001), and surgery start time after 1 PM (OR 3.77, p = 0.0001).

Conclusion

Same-day discharge for laparoscopic gynecologic oncology surgery is feasible, with low morbidity and few readmissions within three weeks of surgery. Successful same-day discharge can increase by refining patient selection and operating room scheduling.     

Feasibility of laparoscopic extraperitoneal surgical staging for locally advanced cervical carcinoma in a gynecologic oncology fellowship training program

STUDY OBJECTIVE: Feasibility of laparoscopic extraperitoneal surgical staging for locally advanced cervical carcinoma in a gynecologic oncology fellowship training program. DESIGN: Retrospective analysis (II-2) of all patients who underwent laparoscopic extraperitoneal surgical staging at Women and Children's Hospital for locally advanced cervical cancer between June 2002 and June 2005. SETTING: Gynecologic oncology fellowship training program at a University-County Hospital PATIENTS: Thirty-two patients with clinical stage IIB-IVA cervical carcinoma were identified. INTERVENTIONS: Laparoscopic extraperitoneal surgical staging for clinical stage IIB-IVA cervical cancer. MEASUREMENTS AND MAIN RESULTS: A total of 32 cases of laparoscopic extraperitoneal surgical staging for locally advanced cervical cancer performed by fellows-in-training were identified. Fellows were first assistant surgeon in 10 cases, and operating surgeon in 22 cases. Each fellow was mentored an average of 5 cases as first assistant surgeon. As operating surgeon, all 22 fellow cases (100%) were successfully performed without conversion to laparotomy. Fellow mean operative time was 163 minutes. Fellow mean aortic nodal count was 14. Fellow mean blood loss was 42 mL. The mean hospital stay was 1.6 days. Overall, 2 patients (6.2%) experienced a complication from the procedure. Over one half (53%) of the patients reported a prior abdominal surgery. No lymphedema has been reported in patients who underwent laparoscopic extraperitoneal surgical staging with a median follow-up of 10 months. Surgical comorbidities such as hypertension, diabetes, and obesity were common in the study group. A steep surgical learning curve for the fellows was demonstrated by comparing mean operative times to academic year. Aortic nodal metastasis was detected in 25% of cases, and 14% were occult. CONCLUSIONS: It is feasible to teach laparoscopic extraperitoneal surgical staging to fellows-in-training. Our data suggest that by the end of training, fellows can become proficient with the procedure and are capable of surgical outcomes and complication rates comparable to reported literature.     

妇科腹腔镜手术1560例临床分析

目的：探讨腹腔镜手术在妇科的临床应用价值。方法：1997～2002年对1560例腹腔镜手术者均采用全麻；异位妊娠术式为输卵管切除术、输卵管伞端取胚术及输卵管造口术；卵巢囊肿手术采用剔除术、剥除术及患侧附件切除术；子宫手术采用改良式CISH术、子宫次全切除术、子宫全切术及LAVH术；主要器械为单双极电凝及超声刀。结果：腹腔镜手术占同期妇科手术的45．28％，手术成功率99．55％，发生并发症7例(0．45％)。结论：适应证掌握得当。妇科大部分手术可在腹腔镜下完成。     

Prevention of venous thromboembolism in gynecologic oncology surgery

Gynecologic oncology patients are at a high-risk of postoperative venous thromboembolism and these events are a source of major morbidity and mortality. Given the availability of prophylaxis regimens, a structured comprehensive plan for prophylaxis is necessary to care for this population. There are many prophylaxis strategies and pharmacologic agents available to the practicing gynecologic oncologist. Current venous thromboembolism prophylaxis strategies include mechanical prophylaxis, preoperative pharmacologic prophylaxis, postoperative pharmacologic prophylaxis and extended duration pharmacologic prophylaxis that the patient continues at home after hospital discharge. In this review, we will summarize the available pharmacologic prophylaxis agents and discuss currently used prophylaxis strategies. When available, evidence from the gynecologic oncology patient population will be highlighted.     

Ten-year experience with laparoscopy on a gynecologic oncology service: analysis of risk factors for complications and conversion to laparotomy

OBJECTIVE: The purpose of this study was to analyze our initial 10-year experience with laparoscopy and to determine risk factors for complications and conversions to laparotomy for technical difficulty. STUDY DESIGN: We reviewed the charts of all laparoscopic procedures from January 1991 through December 2000 and divided the procedures into 4 levels on the basis of the degree of difficulty: level I, diagnostic; level II, procedures on the uterus and/or adnexa; level III, second look operations for malignancy; and level IV, lymphadenectomies/other complex procedures. Complications were graded from 1 (mild) to 5 (death). Standard univariate and multivariate analyses were performed. RESULTS: We identified 1451 evaluable procedures. The number of complications was as follows: grades 1 to 5, 129 complications (9%); grades 3 to 5, 36 complications (2.5%). On multivariate analysis, older age ( P = .03), previous radiation ( P = .03), and malignancy ( P = .006) were associated with an increased risk of complications grades 3 to 5. Complication rates for grades 3 to 5 for patients with malignancy versus benign disease was 4% versus 1%, respectively. Technical difficulty led to conversion to laparotomy in 105 cases (7%). Previous abdominal surgery ( P < .001) significantly increased the rate of conversion to laparotomy; more complex, higher procedure levels were associated with a significant decrease in conversions ( P = .005). CONCLUSION: Both simple and complex laparoscopic procedures can be performed by a gynecologic oncology service with a low rate of complications and conversions to laparotomy. Older age, malignancy, previous radiation therapy, and previous abdominal surgery were identified as significant risk factors for complications and/or conversion and should be taken into account in patient selection, preoperative counseling, and surgical planning.     

Single port transumbilical laparoscopic surgery for adnexal lesions: a single center experience in Korea

Objectives

The purpose of this study was to demonstrate the feasibility of single port transumbilical laparoscopic surgery (SPLS) for the treatment of adnexal lesions.

Methods

We have performed SPLS to treat adnexal lesions using a single three-channel port system with a wound retractor and surgical glove since October 2008. All patients who underwent SPLS for adnexal lesions between October 2008 and September 2009 were included in the study. We retrospectively reviewed their medical records and analyzed demographic data and surgical outcomes including age, medico-surgical illness, surgical indications, operative times and pathologic results.

Results

Eighty-six patients underwent SPLS for adnexal lesions. The median age of the patients was 31 years (range 14-78 years), the median body mass index was 21.0 kg/m² (range 16.7-32.2 kg/m²), and the median operation time was 64.5 min (range 21-176 min). The median blood loss was 10 ml (range 10-300 ml). The median length of postoperative hospital stay was 2 days (range 1-7 days). Endometriosis was the most frequently diagnosed etiology (34.9%). Other laparoscopic approaches were employed in two cases (2.3%). There were four cases (4.7%) with complications: three with pelvic infections and one with postoperative hemorrhage.

Conclusions

SPLS is a feasible approach for the treatment of adnexal lesions.     

A phase II trial of a surgical protocol to decrease the incidence of wound complications in obese gynecologic oncology patients

Objectives

Obese women have a high incidence of wound separation after gynecologic surgery. We explored the effect of a prospective care pathway on the incidence of wound complications.

Methods

Women with a body mass index (BMI) ≥ 30 kg/m² undergoing a gynecologic procedure by a gynecologic oncologist via a vertical abdominal incision were eligible. The surgical protocol required: skin and subcutaneous tissues to be incised using a scalpel or cutting electrocautery, fascial closure using #1 polydioxanone suture, placement of a 7 mm Jackson-Pratt drain below Camper's fascia, closure of Camper's fascia with 3-0 plain catgut suture and skin closure with staples.Wound complication was defined as the presence of either a wound infection or any separation. Demographic and perioperative data were analyzed using contingency tables. Univariable and multivariable regression models were used to identify predictors of wound complications. Patients were compared using a multivariable model to a historical group of obese patients to assess the efficacy of the care pathway.

Results

105 women were enrolled with a median BMI of 38.1. Overall, 39 (37%) had a wound complication. Women with a BMI of 30–39.9 kg/m² had a significantly lower risk of wound complication as compared to those with a BMI > 40 kg/m² (23% vs 59%, p < 0.001). After controlling for factors associated with wound complications the prospective care pathway was associated with a significantly decreased wound complication rate in women with BMI < 40 kg/m² (OR 0.40, 95% C.I.: 0.18–0.89).

Conclusion

This surgical protocol leads to a decreased rate of wound complications among women with a BMI of 30–39.9 kg/m².     

Clinical outcome and complications of laparoscopic surgery compared with traditional surgery in women with endometrial cancer

Introduction The purpose of this study was to evaluate the feasibility, clinical outcome and complications of laparoscopic surgery in women with endometrial cancer and to compare surgical outcome and postoperative early and late complications with results of traditional laparotomy. Methods Forty women with endometrial cancer underwent laparoscopic hysterectomy, bilateral salpingo-oophorectomy and pelvic lymphadenectomy. Each patient operated by laparoscopy was matched by age, preoperative clinical stage and histology of the endometrial cancer with a patient treated by the same operation but using traditional laparotomy. Half of these patients underwent total pelvic lymphadenectomy and half had pelvic lymph node sampling. The groups were compared in clinical characteristics, surgical outcomes, recoveries and early and late postoperative complications. Results The patients in the laparoscopy group had less blood loss, more lymph nodes removed, shorter hospital stay but longer operation time than those treated by laparotomy. Only one (2.5%) laparoscopy was converted to laparotomy due to pelvic adhesions. There were no intraoperative complications in either group. Postoperative complications were more common (55.0%) in the laparotomy than in the laparoscopy group (37.5%). Only one major complication (2.5%) occurred among patients undergoing laparoscopy as compared with three (7.5%) major complications in the laparotomy group. Superficial wound infection was the most common (20%) infection in laparotomy patients while vaginal cuff cellulitis occurred in 10% of laparoscopy patients. Late (>42 days) postoperative complications were almost equally frequent (20.0 and 22.5%) in both groups. Lower extremity lymph edema or pelvic lymph cyst was found in 12.5% of all cases. As a result of surgical staging the disease of 6 women (15%) in both groups was upgraded. Conclusions Laparoscopic surgery is a viable alternative to traditional surgery in the management of endometrial cancer. The surgical outcome is similar in both cases. In laparoscopic procedures the operation time is longer but the postoperative recovery time shorter than in laparotomy. Severe complications were limited in both groups, while wound infections can be avoided using laparoscopy.     

Outpatient rapid 4-step desensitization for gynecologic oncology patients with mild to low-risk,moderate hypersensitivity reactions to carboplatin/cisplatin

Objective

The primary objective of this study is to assess the efficacy and safety of an outpatient, 4-step, one-solution desensitization protocol in gynecologic oncology patients with history of mild to low-risk, moderate hypersensitivity reactions (HSRs) to platinums (carboplatin and cisplatin).

Methods

This was a single institutional retrospective review. Gynecologic oncology patients with a documented history of mild or low-risk, moderate immediate HSRs to carboplatin/cisplatin and continued treatment with 4-step, one-solution desensitization protocols in the outpatient infusion center were included. Patients with delayed HSRs or immediate high-risk, moderate or severe HSRs were excluded. The primary end point was the rate of successful administrations of each course of platinums.

Results

From January 2011 to June 2013, eighteen eligible patients were evaluated for outpatient 4-step, one-solution desensitization. Thirteen patients had a history of HSRs to carboplatin and 5 with HSRs to cisplatin. All of 18 patients successfully completed 94 (98.9%) of 95 desensitization courses in the outpatient infusion center. Eight of 8 (100%) patients with initial mild HSRs completed 29/29 (100%) desensitization courses, and 9 of 10 (90%) of patients with initial moderate HSRs completed 65/66 (94%) desensitization courses. In total, 65/95 (68%) desensitizations resulted in no breakthrough reactions, and mild, moderate and severe breakthrough reactions were seen in 19%, 12% and 1% desensitizations, respectively. No patients were hospitalized during desensitization.

Conclusions

The outpatient rapid, 4-step, one-solution desensitization protocol was effective and appeared safe among gynecologic oncology patients who experienced mild to low-risk, moderate HSRs to carboplatin/cisplatin.