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For Endrometrial Cancer

Bell MC, Torgerson J, Seshadri-Kreaden U, Suttle AW, Hunt S. Comparison of outcomes and cost for endometrial cancer staging via traditional laparotomy, standard laparoscopy and robotic techniques. Gynecologic Oncology2008 Nov;111(3):407-11.
Objectives: The study purpose was to compare hysterectomy and lymphadenectomy completed via robotic assistance, laparotomy, and laparoscopy for endometrial cancer staging with respect to operative and peri-operative outcomes, complications, adequacy of staging, and cost. Methods: One hundred and ten patients underwent hysterectomy with bilateral salpingo-oophorectomy, pelvic and para-aortic lymphadenectomy for endometrial cancer staging. All cases were performed by a single surgeon, at a single institution (40 robotic, 40 laparotomy, and 30 laparoscopic) and were retrospectively reviewed to compare demographics and peri-operative variables including, operative time, estimated blood loss, lymph node count, hospital stay, complications, and return to normal activity. Additionally, a cost comparison between all three modalities was performed. Results: Patients undergoing robotic assisted hysterectomy and staging experienced longer operative time than the laparotomy cohort with no difference in comparison to the laparoscopic cohort (184 min, 108.6 min, 171 min, p < 0.0001, p = 0.14). Estimated blood loss was significantly reduced for the robotic cohort in comparison to the laparotomy cohort and comparable to laparoscopic cohort (166 cc, 316 cc, 253 cc, p = 0.01, p = 0.25). The complication rate was lowest in the robotic cohort (7.5%) relative to the laparotomy (27.5%) and laparoscopic cohorts (20%) (p = 0.015, p = 0.03). Average return to normal activity for the robotic patients was significantly shorter than those undergoing laparotomy (24.1 days versus 52 days, p < 0.0001) and those undergoing laparoscopy (31.6 days, p = 0.005). Lymph node retrieval did not differ between the 3 groups (robotic 17 nodes, laparotomy 14 nodes, laparoscopic 17 nodes). The total average cost for hysterectomy with staging completed via laparotomy was $12,943.60, for standard laparoscopy $7569.80, and for robotic assistance $8212.00. The difference in cost between laparotomy and robotic cohorts was significant p = 0.0001 while there was no statistically significant difference in cost between laparoscopy and robotic cohorts p = 0.06. Conclusions: Robotic hysterectomy provides comparable node retrieval to laparotomy and laparoscopic procedures in the case of the experienced laparoscopic surgeon. While robotic hysterectomy takes longer to perform than hysterectomy completed via laparotomy, it is equivalent to laparoscopic hysterectomy and provides the patient with a more expeditious return to normal activity with reduced post-operative morbidity. Additionally, the average cost for hysterectomy and staging was highest for laparotomy, followed by robotic, and least for standard laparoscopy. © 2008 Elsevier Inc. All rights reserved.

Boggess JF, Gehrig PA, Cantrell L, Shafer A, Ridgway M, Skinner EN, Fowler WC. A comparative study of 3 surgical methods for hysterectomy with staging for endometrial cancer: robotic assistance, laparoscopy, laparotomy. American Journal of Obstetrics and Gynecology2008;199(4).
Objective: The purpose of this study was to compare outcomes in women who underwent endometrial cancer staging by different surgical techniques. Study Design: Three hundred twenty-two women underwent endometrial cancer staging: 138 by laparotomy (TAH); 81 by laparoscopy (TLH) and 103 by robotic technique (TRH). Results: The TRH cohort had a higher body mass index than the TLH cohort (P = .0008). Lymph node yield was highest for TRH (P < .0001); hospital stay (P < .0001) and estimated blood loss (P < .0001) were lowest for this cohort. Operative time was longest for TLH (213.4 minutes) followed by TRH (191.2 minutes) and TAH (146.5 minutes; P < .0001. Postoperative complication rates were lower for TRH, compared with TAH (5.9% vs 29.7%; P < .0001). Conversion rates for the robotic and laparoscopic groups were similar. Conclusion: TRH with staging is feasible and preferable over TAH and may be preferable over TLH in women with endometrial cancer. Further study is necessary to determine long-term oncologic outcomes. © 2008 Mosby, Inc. All rights reserved.

DeNardis SA, Holloway RW, Bigsby Iv GE, Pikaart DP, Ahmad S, Finkler NJ. Robotically assisted laparoscopic hysterectomy versus total abdominal hysterectomy and lymphadenectomy for endometrial cancer. Gynecologic Oncology 2008 Dec;111(3):412-7. Epub 2008 Oct 1.
Objective: To compare surgical morbidity and clinical-pathologic factors for patients with endometrial cancer (EC) undergoing robotic-assisted laparoscopic hysterectomy (RALH) versus total abdominal hysterectomy (TAH) with aortic and/or pelvic lymphadenectomy (LA). Methods: During the first 14 months of a robotics surgical program, 56 patients with EC were scheduled to undergo RALH with LA. Cases were analyzed for operative (op) time, estimated blood loss (EBL), transfusion, intra- and post-op complications, surgical-pathologic data, patient demographics and length of stay (LOS). Data was compared to 106 serially treated patients with EC who underwent TAH with LA immediately prior to initiation of our robotics program. Results: Three robotic cases (5.4%) were converted to TAH secondary to intra-op factors. FIGO stages for RALH vs. TAH were: stage I (82 vs. 69%), stage II (7 vs. 7.5%) and stage III (11 vs. 21.5%). Patients' mean age was 59 ± 10 vs. 63 ± 11 years (p = 0.05) and body mass index (BMI) was 29 ± 6.5 vs. 34 ± 9 kg/m2 (p = 0.0001) for the robotic and open groups, respectively. Severe medical co-morbidities affected 5.4% of robotic patients compared to 8.5% of open cases (p > 0.05). Comparing RALH and TAH, mean op time was 177 ± 55 vs.79 ± 17 min (p = 0.0001), EBL was 105 ± 77 vs. 241 ± 115 ml (p < 0.0001), transfusion was 0 vs. 8.5% (p = 0.005), and LOS was 1.0 ± 0.5 vs. 3.2 ± 1.0 days (p < 0.0001). Robotic patients incurred a 3.6% major peri-operative complication rate while women undergoing open procedures had an incidence of 20.8% (p = 0.007). Total lymph node count was 19 ± 13 nodes for robotic cases vs. 18 ± 10 nodes obtained from open hysterectomy patients. Conclusions: Patients with EC who underwent RALH with LA during the first year of our robotics program were younger, thinner and had less cardio-pulmonary illness than patients previously treated with TAH and LA. LOS, EBL and peri-op complication rates were significantly lower for the robotic cohort. © 2008 Elsevier Inc. All rights reserved.

Seamon. Minimally invasive comprehensive surgical staging for endometrial cancer: Robotics or laparoscopy? Gynecologic Oncology 2009 Apr;113(1):36-41. Epub 2009 Jan 24.
Objective: To compare outcomes between robotic versus laparoscopic hysterectomy and lymphadenectomy in patients with endometrial cancer. Methods: A cohort study was performed by prospectively identifying all patients with clinical stage I or occult stage II endometrial cancer who underwent robotic hysterectomy and lymphadenectomy from 2006-2008 and retrospectively comparing data using the same surgeons' laparoscopic hysterectomy and lymphadenectomy cases from 1998-2005, prior to our robotic experience. Patient demographics, operative times, complications, conversion rates, pathologic results, and length of stay were analyzed. Results: 181 patients (105 robotic and 76 laparoscopic) met inclusion criteria. There was no significant difference between the two groups in median age, uterine weight, bilateral pelvic or aortic lymph node counts, or complication rates in patients whose surgeries were completed minimally invasively. Despite a higher BMI (34 vs. 29, P < 0.001), the estimated blood loss (100 vs. 250 mL, P < 0.001), transfusion rate (3% vs. 18%, RR 0.18, 95%CI 0.05-0.64, P = 0.002), laparotomy conversion rate (12% vs. 26%, RR 0.47, 95%CI 0.25-0.89, P = 0.017), and length of stay (median: 1 vs. 2 nights, P < 0.001) were lower in the robotic patients compared to the laparoscopic cohort. The odds ratio of conversion to laparotomy based on BMI for robotics compared to laparoscopy is 0.20 (95% CI 0.08-0.56, P = 0.002). The mean skin to skin time (242 vs. 287 min, P < 0.001) and total room time (305 vs. 336 min, P < 0.001) was shorter for the robotic cohort. Conclusion: Robotic hysterectomy and lymphadenectomy for endometrial carcinoma can be accomplished in heavier patients and results in shorter operating times and hospital length of stay, a lower transfusion rate, and less frequent conversion to laparotomy when compared to laparoscopic hysterectomy and lymphadenectomy. © 2008 Elsevier Inc. All rights reserved.

Veljovich DS, Paley PJ, Drescher CW, Everett EN, Shah C, Peters WA, 3rd. Robotic surgery in gynecologic oncology: program initiation and outcomes after the first year with comparison with laparotomy for endometrial cancer staging. Am J Obstet Gynecol2008 Jun;198(6):679 e1-9; discussion  e9-10.
OBJECTIVE: The objective of the study was to evaluate outcomes during the first year of a robotic surgery program in gynecologic oncology. STUDY DESIGN: We studied the initiation of a robotic surgery program with prospective data collection, including intraoperative times, estimated blood loss (EBL), length of stay (LOS), lymph node yields, and complications. Patients were compared with historical and contemporary open staging surgery for endometrial cancer. RESULTS: One hundred eighteen patients underwent robotic surgery (mean age 52.5 years, body mass index of 26.3 kg/m(2), hospital stay of 32.4 hours), with 8 major and 13 minor complications. Compared with open endometrial staging (n = 131), the robotic procedure (n = 25) was longer (283 vs 139 minutes, P < .0001), had less blood loss (66.6 vs 197.6 mL, P < .0001), and had shorter length of stay (40.3 vs 127 hours, P < .0001) with comparable node yields (17.5 vs 13.1, P = .1109). CONCLUSION: Robotic surgery is feasible in gynecologic oncology and facilitated a dramatic expansion in our minimally invasive surgical practice. Despite longer operative times, EBL and LOS are reduced and lymph node yields are comparable.