Robotics in Gynecologic Surgery

Gynecologic surgery has been revolutionized in the past 30 years, especially because of laparoscopic surgery and, more recently, with the advent of robotic assisted surgery. It is well known that minimally invasive procedures lead to faster recovery, shorter hospital stay, reduced postoperative pain and decreased blood loss.¹

However, conventional laparoscopy presents several limitations that can be associated with the technique and/or with the surgeon. The limitations with the technique can be explained by the counterintuitive movements performed with long instruments through a fixed entry, in addition to a two-dimensional optics and unstable camera platform. Regarding the surgeon we can highlight motor tremors, fatigue during long procedures and ergonomy as the main issues.

The concept of robotic assisted surgery started in 1994, when FDA approved the AESOP™ platform, a robotic arm that controlled the camera by voice command. Five years later, in 1999, a new platform called ZEUS (Computer Motion Inc), first introduced the concept of what we now call robotic assisted surgery: a surgeon seated on a console controlling robotic arms attached to the patient through laparoscopic trocars.

The biggest step forward in the development of robotic surgery came with the advent of the da Vinci^® surgical platform (Intuitive Surgical Inc, Sunnyvale, CA) and its approval by the FDA in 2005. This platform consists of a surgeon console that allows control of the robotic arms with its articulated instruments (Endowrist), a three-dimensional vision system and the energy (monopolar or bipolar) connected to the instruments. Together these features, bring advantages in ergonomics and tremor reduction, and the movements performed by the robotic arms mimic open surgery, with better performance, for example, in suturing and knot tying.²

An increasing number of reports have been published in the current literature on robotic applications in the fields of general gynecology, urogynecology/pelvic reconstructive surgery, gynecologic oncology and reproductive endocrinology. This chapter discusses the benefits of robotic surgery for benign and malignant gynecologic conditions.

In recent years, it has been observed that the use of robotic surgery has increased significantly for some of the most common gynecologic procedures such as hysterectomies, myomectomies, adnexal surgery, sacrocolpopexies and endometriosis management. As a result, minimally invasive procedures are now more prevalent in gynecologic practice than ever before.

Hysterectomy

In 2003, more than 600,000 hysterectomies were performed in the United States and only 12% of the cases were laparoscopic.³ Between 2009 and 2010, 804,551 hysterectomies for benign conditions were performed, with 20.6% of the cases approached laparoscopically and 5.1% robotic assisted. Among minimally invasive procedures the use of robotic hysterectomy increased from 9.5% to 13.6% during the same length of time. Furthermore, the overall complication rates between the two techniques were similar, with lower incidence of blood transfusion in robotic cases, but with higher procedure costs.⁴

In a recent study, 95 patients were randomized to receive either conventional laparoscopic or robotic hysterectomy. There was no difference between the two groups in relation to age, body mass index (BMI) and uterus weight. The total operating time was shorter in the conventional laparoscopy group (75 vs. 106 minutes), but the complication rates, blood loss, length of time to return to work and analgesics use were similar in both groups. In the robotic group, an improved quality of life was observed during the first postoperative 6 weeks.⁵

Another randomized trial⁶ comparing robotic assisted hysterectomy and conventional laparoscopic hysterectomy showed a 77 minutes shorter operating time for laparoscopic patients but no difference regarding postoperative pain, complication rates, and length of time to return to work.

In summary, laparoscopic surgery, particularly when is robotic assisted, has contributed towards reducing the number of open hysterectomies with remarkable benefits to patients, particularly when quality of life is assessed.

Myomectomy

Laparoscopic removal of leiomyomas is challenging to the surgeon, since it requires special skills such as suturing and knotting, which usually require a long learning curve. Robotic assisted laparoscopy facilitates the removal of fibroids owing to intuitive movements and easier suturing and knotting, resulting in a shorter learning curve.

A retrospective study comparing open versus robotic assisted myomectomy showed reduced blood loss, complication rates and hospital stay, but with higher hospital charges in the robotic group.⁷

A larger retrospective study (n = 322) comparing abdominal, robotic and laparoscopic myomectomy revealed a longer operating time for robotic patients and no significant difference in complication rates between the three groups, but the minimally invasive procedures had less blood loss and shorter hospital stay compared with the open group. The authors concluded that robotic assisted myomectomy offers a minimally invasive alternative for the treatment of myomas.⁸

Sacrocolpopexy

Vaginal and uterovaginal prolapse are very common conditions and minimally invasive techniques have been used for surgical treatment. A controlled trial published in 2011 randomized 78 patients for laparoscopic or robotic sacrocolpopexy. Data retrieved showed longer operative time in the robotic group, also with higher postoperative pain between 3 and 5 weeks after surgery. Six weeks after surgery, pain was equivalent and both groups had significant improvement in vaginal support after 1 year of follow-up.⁹

Adnexal Surgery

A retrospective study involving 174 patients, compared robotic-assisted with laparoscopic adnexectomy. The robotic operating time was 12 minutes longer but there were no differences relative to mean blood loss, hospital stay and complication rates.¹⁰

Endometriosis

The laparoscopic approach for the diagnosis and surgical removal of endometriosis has become optimal as compared with laparotomy. One prospective randomized trial is under way comparing robotic versus laparoscopic surgery for endometriosis (LAROSE trial – NCT01556204). To date, there are two prospective studies comparing robotic with a laparoscopic approach. Both studies showed no differences relative to operating time, blood loss, hospital stay, and complication rates.¹¹

Robotic surgery has become popular and is preferred by most gynecologic oncologists for the surgical treatment of patients with gynecologic malignancies including cervical, endometrial and ovarian cancer with limited metastatic disease. Procedures for which robotics have become a preferable approach include pelvic and aortic lymphadenectomy, radical hysterectomy, radical trachelectomy, resection of diaphragm and liver metastases, pelvic recurrences, and isolated recurrences of ovarian cancer.

Endometrial Cancer

Endometrial cancer is the most common malignancy of the female genital tract in North America.¹² The American Cancer Society estimated that there were 49,560 new cases in 2013 with 8190 deaths.¹³ Because most of these patients are obese and have comorbidities, a minimally invasive approach is preferable.

Several studies, including our experience, have shown a reduction in blood loss, complications, hospital stay, and recovery time without compromising recurrence and survival outcomes in patients with endometrial cancer treated by laparoscopy as compared with laparotomy.^{14, 15, 16} Robotics have been shown to provide similar or improved benefits as compared with laparoscopy.¹⁵

In a prospective study comparing robotic (n = 105) and laparoscopic (n = 76) approaches for endometrial cancer, the robotic group had shorter hospital stay and less blood loss. The operative time was longer and the complication and number of lymph nodes were similar.¹⁷

A recent retrospective study compared women that underwent hysterectomy with pelvic and para-aortic lymphadenectomy by robotic (n = 187) or laparoscopic (n = 245) approaches at two academic institutions. They found similar rates of intraoperative complications (1.6% vs. 2.9%, p = 0.525), but urinary injuries were higher in the laparoscopic group (2.9% vs. 0.0%, p = 0.020). They also noted that patients in the robotic group had a shorter hospital stay (1.96 vs. 2.45 days, p = 0.016), but a mean operating time 57 minutes longer than the laparoscopic group (218 vs. 161 minutes, p = 0.0001). There were no significant differences in blood transfusion rates and number of lymph nodes retrieved.¹⁸

The same authors published another retrospective study comparing survival of women with endometrial cancer managed by robotic (n = 183) or laparoscopic (n = 232) surgery over a period of 7 years. With a median follow-up of 38 months for robotic and 58 months for laparoscopic group, there were no significant differences in survival (3-year overall survival 93.3% and 93.6%), disease-free survival (3-year DFS 83.3% and 88.4%), or tumor recurrence (14.8% and 12.1%) between both groups, respectively.¹⁹

We reported the results of endometrial cancer comparing the laparoscopic, robotic, vaginal/laparoscopic and open approaches. The robotics and laparoscopy groups had similar perioperative outcomes but the conversion rate was lower in the robotic group (3% vs. 10%), making it a more favorable approach. The longest operating time was for the group undergoing a vaginal hysterectomy and laparoscopic lymphadenectomy when indicated. Laparotomy patients had the highest blood loss and the longest hospital stay.²⁰

Cervical Cancer

For many decades, women with early cervical cancer have been managed by abdominal radical hysterectomies with excellent cure rates. The laparoscopic approach for radical hysterectomy²¹ did not become widespread owing to the limitations of the technology in spite of studies showing decreased blood loss, equivalent number of retrieved lymph nodes, shorter recovery time, shorter hospitalization, improved cosmesis, faster return of bowel function, and improved quality of life.^{22, 23, 24, 25}

Marchal et al.²⁶ reported on 30 cases of robotic assisted surgery, seven of which were type II radical hysterectomies for stage I cervical cancer. Two other studies compared outcomes between robotic radical hysterectomy and laparotomy with similar advantages to laparoscopy, including a median length of stay of 1 day in the robotic cohort compared with 3 or more days in the open surgery cohort.^{27, 28}               

At the Mayo Clinic in Arizona, we compared the three different surgical approaches to radical hysterectomy (robotic n = 27, laparoscopic n = 31 and laparotomy n = 35), and published the results in 2008. The mean operative time was significantly longer for the laparoscopic group (220.4 minutes) compared with the robotic (189.9 minutes) and laparotomy (166.8 minutes) groups (p <0.001). The mean blood loss (443 ml, 133 ml, 208 ml, respectively) and mean length of hospital stay (3.6 days, 1.7 days, 2.4 days, respectively) were significantly higher for the laparotomy group compared with robotic and laparoscopy groups. There was no statistically significant difference in the number of retrieved lymph nodes or postoperative complications among the three groups. At a mean follow-up of 31.1 months (range 10–50 months), none of the patients in the robotic group experienced recurrence.²⁹

To date, there are no published randomized trials on robotic assisted radical hysterectomy. There is one randomized clinical trial under way comparing laparoscopic or robotic assisted radical hysterectomy with abdominal radical hysterectomy in patients with early-stage cervical cancer (NCT00614211).³⁰ The safety of robotic assisted surgery in cervical cancer regarding recurrence, long-term survival, and oncological outcomes remains to be determined in future randomized trials.

Radical trachelectomy with pelvic lymphadenectomy is a safe alternative for women with early-stage cervical cancer who wish to preserve fertility.^{31, 32} A recent review of the literature indicates that pregnancies are clearly possible after radical trachelectomy for early-stage cervical cancer, and the majority of women will conceive spontaneously. However, there is a higher incidence of preterm deliveries, miscarriages and chorioamnionitis.³³ 

Persson et al.³⁴ reported on two patients with stage IB1 adenocarcinoma of the cervix. Operative times were 387 and 358 minutes, respectively, and the authors justified the prolonged duration owing to the 'experience factor' and the time consumed waiting for frozen section analysis. No perioperative complications were observed. Their conclusion was that robotic assisted radical trachelectomy is a safe and feasible alternative to a combined laparoscopic and vaginal approach.

A retrospective review was published in 2010, including four patients with stage IA cervical cancer who underwent robotic radical trachelectomy and bilateral lymphadenectomy. The median operative time was 339.5 minutes (range 245–416 minutes) and the median blood loss was 62.5 ml (range 50–75 ml), without intraoperative complications. At a median follow-up of 105 days (range 82–218 days) no recurrences were observed. Their conclusion was that this procedure is safe and feasible and should be considered for patients desiring fertility sparing surgery.³⁵

In 2012, a retrospective study comparing open (n = 25) with robotic radical trachelectomy (n = 12) for patients with stages IA and IB demonstrated the robotic group was associated with less blood loss (62.5 ml vs. 300 ml, p = 0.0001) and decreased length of postoperative stay (1 vs. 4 days, p <0.001), with no difference in operative time or histopathologic outcomes as compared with the open group. Out of 11 (36%) patients attempting pregnancy, three achieved pregnancy. At a median follow-up of 17.0 months (range 0.30–64.9 months), there were no recurrences.³⁶

In summary, robotic radical trachelectomy and bilateral pelvic lymphadenectomy appear feasible and safe for patients with early cervical cancer desiring fertility-sparing surgery. Multicenter prospective randomized studies would be preferable to define the most favorable management for these patients.

Ovarian Cancer

The incidence of ovarian cancer increases with age and is most prevalent in the eighth decade of life. The median age at diagnosis is 63 years, and more than 70% of patients present with advanced disease.³⁷

There are only a few studies reporting on the use of robotics for ovarian cancer. In a retrospective analysis comparing patients with ovarian cancer (stages II–IV) that underwent robotic or laparotomic staging, there was no difference in relation to complication rates and survival; however, robotic surgery was associated with less blood loss and reduced hospital stay.³⁸

In our experience, at the Mayo Clinic in Arizona, comparing laparoscopic, robotic and open debulking surgery for ovarian cancer, the laparotomy group experienced increased blood loss, longer hospital stay and increased complications. The laparoscopy and robotic groups had similar perioperative outcomes. There was no difference relative to complete debulking, survival or disease-free survival among the three groups.³⁹

In another comparison study from Mayo Clinic in Arizona, patients with recurrent ovarian cancer operated by laparoscopy and robotics had improved perioperative outcomes as compared to the laparotomy group.⁴⁰

In summary, robotic surgical staging is safe and feasible for patients with ovarian cancer. Robotic debulking surgery is appropriate for patients with primary early metastatic ovarian cancer or with isolated recurrences. Neoadjuvant chemotherapy increases the likelihood of performing a minimally invasive approach in patients with disseminated ovarian cancer. To date, there is no randomized trial indicating the routine use of laparoscopic surgery for ovarian cancer.

Robotic surgery is safe and feasible for patients with benign and malignant gynecological conditions. Perioperative outcomes demonstrate that it is preferable to laparotomy, and similar to laparoscopy. There are some improved perioperative outcomes using robotics for patients with endometrial and cervical malignancies.  The increased costs associated with robotic surgery are the major limitation preventing general use.