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

https://doi.org/10.1016/j.ygyno.2009.01.022Get rights and content

Abstract

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 (≥ 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.

Introduction

The adoption of laparoscopic surgery has provided the advantages of minimally invasive surgery also for women with gynecological malignancies. Several studies have demonstrated that laparoscopic surgery is safe for this group of women [1], [2], [3], [4]. However, the complexity of the procedures has limited laparoscopic surgery to centres with large volumes of cancer. In many parts of the world, the incidence of cervical cancer, the main indication for radical hysterectomy and pelvic lymph node dissection, has diminished and even larger centres may have a too low case load to maintain and develop good laparoscopic skill.

The da Vinci system (da Vinci® Surgical System, Intuitive Surgical Inc, CA, USA) was approved for gynecological applications in April 2005 by the Food and Drug Administration of the United States. The system provides instruments with a wrist function at the tip, movement downgrading, tremor elimination, a stable 3-dimension view of the operative field and an ergonomic working position. These features may help the surgeon overcome some of the limitations associated with traditional laparoscopic surgery.

The use of robot-assistance for radical hysterectomies is still in its infancy. A few reports describing the technique are published [5], [6], [7], [8], [9], [10]. Magrina et al. report shorter operative time for robot assisted laparoscopy compared with traditional laparoscopy and shorter hospital stay and less blood loss compared with open surgery [9]. Boggess et al. report shorter operative time, less blood loss and shorter hospital stay in favour of the robot assisted approach when comparing with open surgery [10].

Lund University Hospital is a tertiary referral centre for gynecological oncologic surgery with an expected annual case load of 40 radical hysterectomies. Included surgeons had a minimum of five years experience with advanced conventional laparoscopic procedures, e.g. pelvic lymphadenectomies with less case load for surgeon C. Four laparoscopic radical hysterectomies have been performed.

Robot assisted surgery was introduced in October 2005 following a training programme for surgeons and operating room teams. From the start, detailed protocols for prospective retrieval of perioperative and follow up data were used. All data were consecutively entered to a computerized quality registry instituted for all robot assisted gynecological procedures on demand of, and approved by, the hospital administration. For the present study, we retrieved the data from women planned for robot assisted laparoscopic radical hysterectomy and pelvic lymphadenectomy with the aim of assessing feasibility, short and long term morbidity of the procedure. The study was approved by the regional Institutional Review Board.

Section snippets

Subject and method

From December 2005 to September 2008, 110 consecutive women with early stage cervical cancer or stage 2 endometrial cancer were considered for a modified Piver II–III robot assisted laparoscopic radical hysterectomy and pelvic lymphadenectomy. We excluded women with a compromising cardiovascular/respiratory comorbidity (n = 5), a uterine size not allowing vaginal retrieval (n = 4) and known intraabdominal adhesions or multiple midline incision (n = 6). Five women had open surgery due to limited

Results

During surgery, metastatic sentinel lymph nodes were identified in six women and the radical hysterectomy was aborted. Four women were converted to open surgery, one due to an irreversible robot system error, two for anesthesiological reasons and one due to intraabdominal metastases.

Thus, 80 women, 64 with cervical cancer (stage 1A1 n = 4, stage 1A2 n = 10, stage 1B1 n = 44, and stage 2A n = 6) and 16 with stage 2 endometrial cancer, underwent the complete procedure. The four women staged as 1A1

Discussion

This study indicates that the da Vinci robot is useful for implementing laparoscopic radical hysterectomy in a centre with limited experience of this procedure by traditional laparoscopy and with a restricted case load of cervical cancers. Time for surgery decreased rapidly and short term complications diminished significantly over time. The operating time was comparable with times reported for conventional laparoscopic radical hysterectomies by larger institutions [11], [12], [13].

Times for

Conflict of interest statement

Jan Persson is a proctor for surgery with the Da Vinci Robot.

The remaining authors all declare that there are no conflicts of interest.

References (15)

There are more references available in the full text version of this article.

Cited by (0)

View full text