Combined modality management of advanced cervical cancer including novel sensitizers.

The management of advanced cervical cancer has evolved with time. Combined modality treatments for cervical cancer have been shown to improve clinical outcomes for these patients. The role of surgery is reviewed in this article for specific situations such as the treatment of bulky lymph nodes and even in the metastatic setting. External beam radiotherapy and brachytherapy techniques have improved which has decreased patient toxicity. Systemic therapy such as chemotherapy, immunotherapy, and novel sensitizing agents have been extensively studied and have shown promising results. The combination of these three different modalities of treatment can be tailored to each specific patient to achieve the best outcomes. We review the recent advances and various international guidelines for the management of cervical cancer in this article.

Gynaecologic robot-assisted cancer and endoscopic surgery (GRACES) in a tertiary referral centre.

INTRODUCTION: Robotic-assisted gynaecologic surgery is gaining popularity and it offers the advantages of laparoscopic surgery whilst overcoming the limitations of operative dexterity. We describe our experience with the fi rst 40 cases operated under the GRACES (Gynaecologic Robot- Assisted Cancer and Endoscopic Surgery) programme at the Department of Obstetrics & Gynecology, National University Hospital, Singapore. MATERIALS AND METHODS: A review was performed for the fi rst 40 women who had undergone robotic surgery, analysing patient characteristics, surgical timings and surgery-related complications. All cases were performed utilising the da Vinci® surgical system (Intuitive Surgical, Sunnyvale, CA) with 3 arms and 4 ports. Standardised instrumentation and similar cuff closure techniques were used. RESULTS: Seventeen (56%) were for endometrial cancer and the rest, for benign gynaecological disease. The mean age of the patients was 52.3 years. The average docking time was 11 minutes (SD 0.08). The docking and operative times were analysed in tertiles. Data for patients with endometrial cancer and benign cases were analysed separately. There were 3 cases of complications- cuff dehiscence, bleeding from vaginal cuff and tumour recurrence at vaginal vault. CONCLUSION: Our caseload has enabled us to replicate the learning curve reported by other centres. We advocate the use of a standard instrument set for the fi rst 20 cases. We propose the following sequence for successful introduction of robot-assisted gynaecologic surgery - basic systems training, followed shortly with a clinical case, and progressive development of clinical competence through a proctoring programme.