Quality of life and long-term clinical outcome following robot-assisted radical trachelectomy.

Quality of Life and long-term clinical outcome following robot-assisted radical trachelectomy. OBJECTIVES: To evaluate quality of life (QoL) and long-term clinical outcome following robot-assisted radical trachelectomy (RRT). STUDY DESIGN: Prospectively retrieved clinical data were rereviewed on all women planned for a fertility sparing RRT for early stage cervical cancer at Skåne University Hospital, Sweden between 2007 and 2020. QoL was assessed using the validated questionnaires EORTC QLQ-C30, QLQ-CX24 and the Swedish LYMQOL. RESULTS: Data was analyzed from 49 women, 42 with a finalised RRT and seven with an aborted RRT due to nodal metastases (n = 3) or insufficient margins (n = 4). At a median follow-up time of 54 months one recurrence (2%) occurred (aborted RRT). According to QLQ-C30 the median global health status score was 75. The disease specific QLQ-C24 showed an impact on symptoms related to sexual function where sexual/vaginal functioning had a median score of 25 and 48% of patients reported worry that sex would cause physical pain. Despite this the functional items sexual activity and sexual enjoyment both had a median score of 66.7. Lymphoedema was reported in 45%, where 9% reported severe symptom with an impact on their QoL. No intraoperative complications and no postoperative complications ≥ Clavien Dindo grade III were observed. Twenty-two of 28 (79%) women who attempted to conceive were successful. A metronidazole/no intercourse regimen was applied between GW 15 + 0-21 + 6 in 26 of 28 pregnancies beyond first trimester resulting in a 92% term (≥GW 36 + 0) delivery rate. CONCLUSIONS: Although robot-assisted radical trachelectomy in this cohort was associated with a low recurrence rate, a high fertility rate and an exceptionally high term delivery rate, women's quality of life was affected postoperatively, particularly with regards to their sexual well-being and lymphatic side-effects.

Increased Institutional Surgical Experience in Robot-Assisted Radical Hysterectomy for Early Stage Cervical Cancer Reduces Recurrence Rate: Results from a Nationwide Study.

The aim of this study was to evaluate the impact of institutional surgical experience on recurrence following robotic radical hysterectomy (RRH) for early stage cervical cancer. All women in Sweden who underwent an RRH for stage IA2-IB1 cervical cancer at tertiary referral centers from its implementation in December 2005 until June 2017 were identified using a Swedish nationwide register and local hospital registers. Registry data were controlled by a chart review of all women. Recurrence rates and patterns of recurrence were compared between early and late (≤50 vs. >50 procedures) institutional series. Six hundred and thirty-five women were included. Regression analysis identified a lower risk of recurrence with increased experience but without a clear cut off level. Among the 489 women who did not receive adjuvant radio chemotherapy (RC-T), the rate of recurrence was 3.6% in the experienced cohort (>50 procedures) compared to 9.3% in the introductory cohort (p < 0.05). This was also seen in tumors < 2 cm regardless of RC-T (p < 0.05), whereas no difference in recurrence was seen when analyzing all women receiving RC-T. In conclusion, the rate of recurrence following RRH for early stage cervical cancer decreased with increased institutional surgical experience, in tumors < 2 cm and in women who did not receive adjuvant RC-T.

No survival difference between robotic and open radical hysterectomy for women with early-stage cervical cancer: results from a nationwide population-based cohort study.

PURPOSE: The aim of the study was to compare overall survival (OS) and disease-free survival (DFS) after open and robotic radical hysterectomy for early-stage cervical cancer. PATIENTS AND METHODS: This was a nationwide population-based cohort study on all women with cervical cancer stage IA1-IB of squamous, adenocarcinoma or adenosquamous histological subtypes, from January 2011 to December 2017, for whom radical hysterectomy was performed. The Swedish Quality Register of Gynaecologic Cancer was used for identification. To ensure quality and conformity of data and to disclose patients not yet registered, hospital registries were reviewed and validated. Cox and propensity score regression analysis and univariable and multivariable regression analysis were performed in regard to OS and DFS. RESULTS: There were 864 women (236 open and 628 robotic) included in the study. The 5-year OS was 92% and 94% and DFS was 84% and 88% for the open and robotic cohorts, respectively. The recurrence pattern was similar in both groups. Using propensity score analysis and matched cohorts of 232 women in each surgical group, no significant differences were seen in survival: 5-year OS of 92% in both groups (hazard ratio [HR], 1.00; 95% confidence interval [CI], 0.50-2.01) and DFS of 85% vs 84% in the open and robotic cohort, respectively (HR, 1.08; 95% CI, 0.66-1.78). In univariable and multivariable analysis with OS as the end-point, no significant factors were found, and in regard to DFS, tumour size (p < 0.001) and grade 3 (p = 0.02) were found as independent significant risk factors. CONCLUSION: In a complete nationwide population-based cohort, where radical hysterectomy for early-stage cervical cancer is highly centralised, neither long-term survival nor pattern of recurrence differed significantly between open and robotic surgery.

The effect of increased experience on complications in robotic hysterectomy for malignant and benign gynecological disease.

The study objective was to assess the effect of increased experience on complications in robotic hysterectomy for malignant and benign gynecological disease. This is a retrospective cohort study. It is a Canadian Task Force classification II-2 study conducted at the University Hospital, Sweden. The patients were 949 women planned for robotic hysterectomy for malignant (75 %) and benign (25 %) gynecological disease between October 2005 and December 2013. They were continuously evaluated for the rate of intraoperative and postoperative complications up to 1-year post-surgery, the latter according to Clavien-Dindo classification following the introduction of robotic surgery with special awareness of complications possibly related to robot-specific risk factors, the description of refinement of practice and assessment of the effect of these measures. The rate of intraoperative complications, the overall rate of complications and the rate of ≥grade 3 complications decreased from the first to the last time period (4.8 vs 2.6 %, p = 0.037, 34 vs 19 %, p = 0.003 and 13.5 vs 3.2 %, p = 0.0003, respectively). The rate of intraoperative complications and the rate of postoperative complications possibly related to robot-specific risk factors was reduced from the first to the last time period (3.8 vs 0.6 %, p = 0.028 and 7.7 vs 1.5 %, p = 0.003, respectively). In patients undergoing robotic hysterectomy for malignant and benign gynecological disease intraoperative and postoperative complications and complications possibly related to the robotic approach diminish with training, experience and refinement of practice.

A randomized trial comparing vaginal and laparoscopic hysterectomy vs robot-assisted hysterectomy.

STUDY OBJECTIVE: To investigate the hospital cost and short-term clinical outcome of traditional minimally invasive hysterectomy vs robot-assisted hysterectomy in women primarily not considered candidates for vaginal surgery. DESIGN: Randomized controlled trial (Canadian Task Force classification I). SETTING: University Hospital in Sweden. PATIENTS: One hundred twenty-two women with uterine size ≤ 16 gestational weeks scheduled to undergo minimally invasive hysterectomy because of benign disease. INTERVENTIONS: Robot-assisted hysterectomy or traditional vaginal or laparoscopic minimally invasive hysterectomy. MEASUREMENTS AND MAIN RESULTS: All women underwent surgery as randomized. There were no demographic differences between the 2 groups. Vaginal hysterectomy was possible in 41% in the traditional minimally invasive group, at a mean hospital cost of $4579 compared with $7059 for traditional laparoscopic hysterectomy. This was reflected in a mean hospital cost of $993 more per robotic-assisted hysterectomy than for traditional minimally invasive hysterectomy when the robot was a preexisting investment. This hospital cost increased by $1607 when including investments and cost of maintenance. A per-protocol subanalysis comparing laparoscopy and robotics demonstrated similar hospital cost when the robot was a preexisting investment ($7059 vs $7016). Robotic-assisted hysterectomy was associated with less blood loss and fewer postoperative complications. CONCLUSION: A similar hospital cost can be attained for laparoscopy and robotics when the robot is a preexisting investment. From the perspective of hospital costs, robotic-assisted hysterectomy is not advantageous for treating benign conditions when a vaginal approach is feasible in a high proportion of patients.

Hospital costs for robot-assisted laparoscopic radical hysterectomy and pelvic lymphadenectomy.

OBJECTIVE: To compare robot-assisted laparoscopy and laparotomy for radical hysterectomy and pelvic lymphadenectomy in terms of hospital costs. METHODS: Consecutive women undergoing radical hysterectomy and pelvic lymphadenectomy as a sole procedure between January 2001 and February 2012 were included. We compared OR times, hospital stay, procedure specific costs, blood transfusions and cost for readmissions and re-interventions until three months after surgery for 231 women operated who received either an open (n=51) or a robot-assisted laparoscopic radical hysterectomy (n=180). The hospital internal charges and purchase costs were used for estimation. The specific robotic cost was based on an investment depreciation time of seven years, with 400 operations performed annually, costs for maintenance, robotic instruments, robot-specific assistant's instruments and robot draping. RESULTS: The estimated mean costs for an open radical hysterectomy was $12,986, for the first 30 robotic radical hysterectomies was $18,382, and for the last 30 was $12,759, with a break even in cost after 90 robotic procedures. The specific robot costs ($3469) was, for the last robot cohort, compensated mainly by an average of 22 min shorter OR time and 4.9 days shorter hospital stay. CONCLUSION: Given 400 robot operations annually, and only after a substantial implementation period, it is feasible to perform robot-assisted radical hysterectomy at an equal hospital cost compared with open surgery.

Reproducibility and accuracy of robot-assisted laparoscopic fertility sparing radical trachelectomy.

OBJECTIVE: To assess the accuracy and reproducibility of robot-assisted laparoscopic abdominal fertility sparing radical trachelectomy in women with early stage cervical cancer. METHODS: Relevant prospective clinical data from 13 consecutive women planned for robotic radical trachelectomy between 2007 and 2012 were compared with retrospective data from 12 consecutive women planned for vaginal radical trachelectomy between 2000 and 2007. The first follow up on all women included a similar vaginal ultrasonographic measurement of the remaining cervical length and the position of the cerclage, enabling a direct comparison. Peri- and postoperative clinical data were evaluated. RESULTS: The remaining cervical length was equal between the robotic and vaginal procedures (mean 11 mm, range 8-13 mm; mean 11 mm, range 5-19 mm respectively, p=0.92). The distance from the cerclage to the inner cervical os was significantly shorter and less variable in the robot group (robot mean 2mm, range of 1-4mm, vaginal mean 4mm, range 2-7 mm, p=0.003). Rejection of the cerclage (n=3) and/or cervical stenosis (n=3) was diagnosed in four women, all of whom in the vaginal group, between one and 13 months after surgery. CONCLUSIONS: Robotic trachelectomy is equally reproducible and accurate as the vaginal trachelectomy in terms of the remaining cervical length and results in a significantly more precise placement of the cerclage.

Tensile strength of surgical knots performed with the da Vinci surgical robot.

The objective of this study was to estimate the tensile strength of surgical knots made using the da Vinci robot. Four different types of flat square knots (strand-to-strand 4 throw, strand-to-strand 6 throw, loop-to-strand 4 throw, and loop-to-strand 6 throw) were made using the da Vinci-S system by 4 different surgeons, all experienced with the system. For the knots, we used braided polyglactin 910 (Vicryl 2-0). Hand-tied, flat, square, 4-throw strand-to-strand knots were used as reference. The tensile strength was measured for all knots using the Instron 5566 system calibrated to an accuracy of + or - .5% at 4 to 10 newtons (N) and + or - .4% at greater than 10 N. Compared with reference knots, only 1 of 4 surgeons could make knots as equally strong with the robot. For all surgeons, strand-to-strand knots had a significantly higher tensile strength than loop-to-strand knots when made with the robot. Adding 2 throws to the knot did not increase the knots strength in the robot. It is possible to make equally strong surgical knots with the da Vinci robot as by hand; however, despite previous experience with the robot, only 1 of 4 surgeons managed to do so. Adding 2 throws to R4SS and R4LS knots did not increase the tensile strength significantly for any of the 4 surgeons. It is important to train and tie knots using the da Vinci system with the same care as by hand and to be aware of possible differences in knot-tying technique with the robot and manually. With the robot, strand-to-strand knots were stronger than loop-to-strand knots, and should be preferred.

Histopathology indicates lymphatic spread of a pelvic retroperitoneal ectopic pregnancy removed by robot-assisted laparoscopy with temporary occlusion of the blood supply.

Retroperitoneal ectopic pregnancies are extremely rare and a diagnostic and therapeutic challenge as an early diagnosis is difficult and all treatments entail a risk for severe bleeding. We present a case of a live completely retroperitoneal ectopic pregnancy in the right obturator fossa. Following 3D color Doppler vaginal ultrasonography to evaluate the relation to larger blood vessels the pregnancy was completely removed by robot-assisted laparoscopic surgery. The hypogastric artery was temporarily occluded by removable vessel clips. Time for surgery was 126 minutes, no bleeding occurred. The postoperative course was uneventful and s-betahCG normalized in five weeks. Histopathology of the intact specimen showed trophoblast surrounded by lymphatic tissue. We believe robot-assisted laparoscopic surgery is a feasible and safe technique for surgery of retroperitoneal ectopic pregnancies with similar or other locations allowing occlusion of the main supplying artery. Lymphatic spread may explain retroperitoneal ectopic pregnancies.

Robot assisted laparoscopic radical hysterectomy and pelvic lymphadenectomy with short and long term morbidity data.

OBJECTIVE: To evaluate feasibility and morbidity of robot assisted laparoscopic radical hysterectomy. METHODS: From December 2005 to September 2008 robot assisted laparoscopic radical hysterectomy and pelvic lymphadenectomy was performed on 80 women. Using a prospective protocol, and an active investigation policy for defined adverse events, perioperative, short and long term data were obtained. RESULTS: Time for surgery (skin to skin) reached 176 and 132 min after 9 and 34 procedures respectively. All tumours were radically removed. Median number of retrieved lymph nodes was 26 (range 15-55). All women had an early follow up (1-3 months) and 43 of eligible 46 women (93%) had a long term follow up (> or =12 months). In 33 of 80 women (41%) the peri/postoperative period was uneventful. The remainder had one or more mainly mild adverse events, most commonly from the vaginal cuff (n=17, 21%) or the lymphatic system (n=16, 20%). The proportion of uneventful cases increased significantly over time. Five women were resutured for dehiscence of the vaginal cuff, two women were reoperated for trocar site hernias and one woman had a ureter stricture that resolved following stent treatment. Eight women (14%) needed 60 days or more to resume spontaneous voiding. One 72-year old woman with disseminated endometrial cancer on autopsy died of pulmonary embolism 31 days after surgery. CONCLUSIONS: Robot assisted laparoscopic radical hysterectomy is a feasible alternative to conventional laparoscopy and open surgery. Effort should be made to ensure proper closure of the vaginal cuff, trocar sites and to develop nerve sparing techniques.