Page 25 - Journal of Laparoscopic Surgery

WJOLS

Advances in Minimal Access Surgery in the Surgical Staging of Carcinoma Endometrium

laparotomy group. Operating time was significantly more for p < 0.0001). Conversion rates for the robotic and laparoscopic
the robotic group. (283 minutes vs 139 minites, p < 0.001). 21 groups were similar.
Akhila Subrahmanian et al have also compared robotic They concluded that TRH with staging is feasible and
surgery and laparotomy in a retrospective cohort study and preferable over TAH and may be preferable over TLH in women
has concluded that robotic management of obese women with with endometrial cancer. Further study is necessary to determine
endometrial cancer yields acceptable staging results and long-term oncologic outcomes. 25
improved surgical outcomes. Although operating time is longer,
hospital time is shorter. Robotic surgery may be an ideal Long-term Oncologic Outcome
approach for these patients. 22 One of the most important concerns when any new modality of
From University of Pennsylvania, Joel cardinas et al have treatment is introduced in oncology is its long-term outcome.
conducted a retrospective chart review of cases of women There are now several reassuring reports on the long-term
undergoing minimally invasive total hysterectomy and pelvic outcome of minimal access surgery in the staging of carcinoma
and para-aortic lymphadenectomy by a robotic-assisted endometrium especially laparoscopic approach as it is now more
approach or traditional laparoscopic approach. A total of than a decade older than robotics.
275 cases were identified—102 patients with robotic-assisted Nezhat et al have done a retrospective cohort study to assess
staging and 173 patients with traditional laparoscopic staging. the effect of laparoscopic surgery on the survival of women in
There was no significant difference in the rate of major early stage endometrial carcinoma from Jan 1993 to June 2003.
complications between groups (p = 0.13). The mean operative A total of 67 women were treated by laparoscopy and 127 by
time was longer in cases of robotic-assisted staging (237 minutes laparotomy. Two and 5-year recurrence-free survival were 93
vs 178 minutes, p < 0.0001); however, blood loss was significantly and 91.7% respectively. Overall 5-year survival rate was 100
lower (109 vs 187 ml, p < 0.0001). The mean number of lymph and 97% respectively. They concluded that laparoscopic
nodes retrieved were similar between groups (p = 0.32). There surgery resulted in similar survival rates as laparotomy. 26
were no significant differences in the time to discharge, re- Another long-term data on this issue is published in 2009.
admission or reoperation rates between the two groups. 23 Randomized control trial comparing laparoscopy (n = 40) and
Seamon et al have done a prospective cohort study of laparotomy (n = 38) with a follow-up period of 78 months. The
surgically staged carcinoma endometrium. A total of 105 patients cumulative recurrence rates were 8/40 and 7/38 respectively
underwent robotic staging from 2006 to 2008. Patients (n = 76), (p = 0.860). Death reported were 7/40 and 6/38 (p = 0.839), overall
who underwent laparoscopic staging by the same surgeon from survival and disease-free survival were comparable (p = 0.535
1998 to 2005, were taken as the other cohort. Mean BMI was 34 and p = 0.515 respectively). 27
in the robotic group, whereas mean BMI was 29 in the Ghezzi et al report another comparative study supporting
laparoscopy group. The estimated blood loss, transfusion rate, the same observations. A total of 117 patients of laparoscopy
laparotomy conversion rate and length of stay were lower in cohort were compared with 122 patients of laparotomy cohort
the robotic cohort. The odds ratio for conversion to laparotomy with a median follow-up period of 52 months and 80 months
based on BMI for robotics to laparoscopy is 0.2% (95% CI respectively. Three-year recurrence-free survival and overall
0.08-0.56, p = 0.002). Mean skin to skin time was 242 minutes in survival were comparable. Multivariate analysis showed that
robotic cohort, whereas it is 287 minutes in laparoscopic cohort, advanced surgical stage, unfavorable histology and patient
(p < 0.001). They concluded that robotic hysterectomy and age > 65 years significantly affect survival, regardless of the
lymphadenectomy can be achieved in heavier patients surgical approach used. 28
successfully. 24 Due to the recent incorporation of robotics in staging long-
John FA Boggess et al have done a comparative study of term survival data are not available. Prospective randomized
three surgical methods for hysterectomy with staging for trials are awaited.
endometrial cancer: Robotic assistance, laparoscopy,
laparotomy. Quality of Life
A total of 322 women underwent endometrial cancer staging: The first 802 eligible patients (laparoscopy, n = 535, laparotomy,
138 by laparotomy (TAH); 81 by laparoscopy (TLH) and 103 by n = 267) participated in the QoL study in a gynecologic
robotic technique (TRH). oncology group (GOG) randomized trial of laparoscopy versus
The TRH cohort had a higher body mass index than the laparotomy (GOG 2222). Patients completed QoL assessments
TLH cohort (p = 0.0008). Lymph node yield was highest for at baseline; at 1, 3 and 6 weeks; and at 6 months postsurgery.
TRH (p < 0.0001); hospital stay (p < 0.0001) and estimated blood Laparoscopy patients reported significantly higher functional
loss (p < 0.0001) were lowest for this cohort. Operative time was assessment of cancer therapy-general (FACT-G) scores
longest for TLH (213.4 minutes) followed by TRH (191.2 minutes) (p < 0.001), better physical functioning (p < 0.006), better body
and TAH (146.5 minutes; p < 0.0001. Postoperative complication image (BI; p < 0.001), less pain (p < 0.001) and its interference
rates were lower for TRH, compared with TAH (5.9 vs 29.7%; with QoL (p < 0.001), and an earlier resumption of normal activities

World Journal of Laparoscopic Surgery, September-December 2011;4(3):149-155 151