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Objective: To compare perioperative and clinico-pathological outcomes of patients with early-stage cervical cancer who underwent robot-assisted radical hysterectomy (RRH) and open radical hysterectomy (ORH)., Methods: This retrospective multi-center study abstracted demographic, clinico-pathological and perioperative outcomes data from medical records of 491 cervical cancer patients treated with RRH (n = 259) ORH (n = 232) between 2005 and 2011 at two American and one Norwegian University Cancer Centres., Results: Mean estimated blood loss (EBL) and transfusion rates were less for RRH than for ORH (97 vs. 49 mL, p < 0.001, and 3% vs. 7%, p = 0.018, respectively). Mean length of hospital stay (LOS) was significantly shorter in RRH versus ORH (1.8 vs. 5.1 days, p < 0.001). Mean operative time was longer for RRH than ORH (220 vs. 156 min, p < 0.001). Although overall complications were similar (p = 0.49), intra-operative complications were less common in the RRH group than ORH (4% vs. 10%, p = 0.004). In multivariate regression analyses longer operative time, less EBL and intra-operative complications, shorter LOS, and more pre-operative cone were significantly associated with RRH versus ORH. Recurrence and death rates were not statistically different for the two groups at a mean follow-up time of 39 months (p = 1.00 and p = 0.48, respectively)., Conclusions: RRH had improved clinical outcomes compared to ORH in the treatment of early-stage cervical cancer in terms of EBL, intra-operative complications, transfusion rates, LOS, and pre-operative cone. Disease recurrence and survival were comparable for the two procedures., (Copyright © 2016 Elsevier Ltd. All rights reserved.)

Objective: Uterine manipulators are a useful adjunct for robotic-assisted radical hysterectomy (RARH), but some surgeons avoid their use for fear of altering pathology or interpretation of lymphovascular space involvement (LVSI). We retrospectively compared clinico-pathological data and tumor pathology from patients with cervical cancer operated by laparotomy vs. RARH., Methods: Charts from cervical cancer patients who underwent radical hysterectomy from January-1997 to June-2010 were reviewed for tumor histology, grade, FIGO stage, lymph node status, LVSI, depth of invasion, and tumor size. A ConMed V-Care® uterine manipulator was used in all robotic cases. H&E stained slides from 20 robotic and 24 open stage IB1 cases with LVSI reported in the original pathology were re-reviewed by a blinded pathologist for analysis of tissue artifacts and LVSI., Results: Two-hundred-thirty-six cases (185 open, 51 robotic) with stages IA2, IB1 and IB2 cervical cancer were reviewed. No significant differences in histology (squamous cell carcinoma, 65% vs. 51%; p=0.1), IB1 lesion size (≤2 cm, 62% vs. 61%, p>0.1), LVSI (34% vs. 39%, p>0.1), and depth of stromal invasion (p>0.1) was found between open and robotic groups. Histologic examination of all IB1 cervical carcinomas revealed a higher degree of surface disruption [45% (9/20) vs. 12.6% (3/24), p=0.038] and artifactual "parametrial carryover" [65% (13/20) vs. 29% (7/24), p=0.037] in robotic vs. open groups, respectively, but no significant differences in the rate of LVSI., Conclusion: RARH cases that utilized a uterine manipulator did not show any clinico-pathological differences in depth of invasion, LVSI, or parametrial involvement compared to open cases., (Copyright © 2012 Elsevier Inc. All rights reserved.)

Advanced laparoscopic procedures for hysterectomy and staging lymphadenectomy were not widely adopted for management of endometrial cancer despite nearly 20 years of improvements in laparoscopic technology. Many surgeons have recently embraced da Vinci robotic-assisted laparoscopy in preference to traditional laparoscopy because of its technological advantages of wristed instrumentation, high-definition 3-D optics, ergonomics and autonomy of camera control; the majority of women with endometrial cancer in the USA now undergo robotic-assisted surgery. The purpose of this article is to review the robotic surgical techniques for hysterectomy, pelvic and aortic lymphadenectomy procedures, and the current comparative literature discussing perioperative outcomes. Additionally, literature that discusses challenges managing obese patients and robotic surgical costs are reviewed. Future multi-institutional, prospective registration studies comparing perioperative outcomes, complications, pain, recovery time, cost and long-term clinical outcomes with open, laparoscopic and robotic procedures will be necessary to completely appreciate the impact of robotic-assisted technology., (© 2011 The Authors. Journal of Obstetrics and Gynaecology Research © 2011 Japan Society of Obstetrics and Gynecology.)

Objective: To summarize comparative studies describing clinical outcomes of robotic-assisted surgeries compared with traditional laparoscopic or laparotomy techniques for the treatment of endometrial cancer., Data Sources: Using search words "robotic hysterectomy" and "endometrial cancer," 22 citations were identified from Medline and PubMed (2005 to February 2010)., Methods of Study Selection: We selected English language studies reporting at least 25 robotic cases compared with laparoscopic or laparotomy cases that also addressed surgical technique, complications, and perioperative outcomes. Patients underwent total hysterectomy, bilateral salpingo-oophorectomy, and lymphadenectomy., Tabulation, Integration, and Results: Eight eligible comparative studies were identified that included 1,591 patients (robotic=589, laparoscopic=396, and laparotomy=606). Pooled means of the resected aortic lymph nodes for robotic hysterectomy and laparoscopy were 10.3 and 7.8 (P=.15), and robotic hysterectomy and laparotomy were 9.4 and 5.7 (P=.28). Pooled means of pelvic lymph nodes for robotic and laparoscopic hysterectomy were 18.5 and 17.8 (P=.95) and 18.0 compared with 14.5 (P=.11) for robotic hysterectomy compared with laparotomy. Estimated blood loss was reduced in robotic hysterectomy compared with laparotomy (P<.005) and laparoscopy (P=.001). Length of stay was shorter for both robotic and laparoscopic cases compared with laparotomy (P<.01). Operative time for robotic hysterectomy was similar to laparoscopic cases but was greater than laparotomy (P<.005). Conversion to laparotomy for laparoscopic hysterectomy was 9.9% compared with 4.9% for robotic cases (P=.06). Vascular, bowel, and bladder injuries; cuff dehiscence; and thromboembolic complications were similar for each surgical method. Transfusions for robotic hysterectomy compared with laparotomy was 1.7% and 7.2% (P=.06) and robotic hysterectomy compared were laparoscopy was 2.6% and 5.0% (P=.22)., Conclusion: Perioperative clinical outcomes for robotic and laparoscopic hysterectomy appear similar with the exception of less blood loss for robotic cases and longer operative times for robotic and laparoscopy cases.

Objectives: To provide an objective analysis of surgical performance of robotic-assisted laparoscopic hysterectomy (RALH) with lymphadenectomy for endometrial cancer during the learning phase of the procedure and to assess opportunities for improvement., Methods: From July 2006 to March 2008, 100 patients with endometrial cancer underwent RALH with lymphadenectomy using the da Vinci Robotic Surgical System. Data were analyzed for operative time (OT), estimated blood loss (EBL), length of stay (LOS), intra-operative complications, surgical-pathologic factors, and post-operative complications using an intent-to-treat analysis. A comparison of the data on a quartile (Q) basis was performed for the 100 RALH cases and separately for the 65 cases that had a complete pelvic-and-aortic lymphadenectomy (PAL)., Results: Age and body mass index (BMI) did not change significantly during the study. More grade 3 tumors were treated in the last 50 cases (22% vs. 10%, p<0.05). Stage III tumors were identified in 18.7% cases in Q2-4 and none in Q1 (p<0.05). The number of patients undergoing complete PAL and the number of aortic lymph nodes (LN) removed per case increased each quarter. There were 4 (4%) conversions to laparotomy. Delayed vaginal cuff healing decreased from 16% in Q1 to 0% in Q3-4. No case required blood transfusion. Comparing first 10 cases to the last 10 cases, the total LN counts increased from 15 to 21 nodes, the aortic LN counts increased from 4.7 to 8.0, and the OT decreased from 203 to 160 min. Intra-surgeon analysis revealed an improvement in the total LN yields from first 50 to second 50 cases for each surgeon., Conclusions: Operative times decreased and aortic dissections improved with increasing LN counts during the first 100 cases of RALH. Furthermore, patient safety and improvement in surgical performance was demonstrated.

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/m(2) (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.

Objective: To provide representative data analyses of surgical morbidity and clinical-pathologic factors for Types 2 and 3 abdominal radical hysterectomies (ARH) with pelvic+/-aortic node dissection performed in a private practice with a fellowship-training program., Methods: From 1997 to 2005, 329 cervical cancer patients underwent ARH with lymphadenectomy. Two hundred and one cases performed at our primary institution were analyzed for operative time, blood loss, intra-operative complications, surgical-pathologic data, recurrence of disease and adjuvant therapy., Results: We evaluated 201 surgical patients who underwent Type 2 (n=45) or Type 3 (n=156) ARH with node dissection. The FIGO stages were: IB1=64%, IB2=6.5%, IA=28.4%, and IIA=1%. Aortic node dissection was performed in 64% of Type 3 cases and none of Type 2 cases. Pfannenstiel incision was used in 80% (Type 2) and 76% (Type 3) cases. A suprapubic catheter was placed in 9% of Type 2 and 81% of Type 3 cases. Median age and weight were 47+/-13 years and 149+/-35 lb. Positive nodes were identified in 12% of Type 3 and 2.2% of Type 2 cases. No positive aortic nodes were found. For Types 2 and 3 ARH, median operative time was 80+/-19 vs. 99+/-23 min (p<0.001) and blood loss was 250+/-134 vs. 300+/-234 ml (p<0.001). The transfusion rate was 3%. Intra-operative complications included: 3 ureteral injuries and 1 colotomy. Tumor histology was 60% squamous, 37% adenocarcinoma, 1% adenosquamous, and 2% others., Conclusions: ARH with pelvic lymphadenectomy in modern practice is an efficient, safe procedure with low transfusion rate and shorter hospital stay than previously reported. Data will be useful as comparison when scrutinizing novel approaches to radical hysterectomy including robotic-assisted and laparoscopic techniques.