Guest Author: Dr Vrunda C. Karanjgaokar
MD, DGO, DNB, MNAMS, DFFP, CCT, FRCOG(Lon)

Introduction
Management of gynecologic cancer often involves surgery followed by radiation, chemotherapy, or a combination of both therapies. It is important for the gynecologic oncologist to consider technical aspects of surgery as it pertains to a patient’s goals for surgical intervention, planned extent of surgical removal of cancer-bearing organs and tissues, a patient’s postoperative speed of recovery, and how these relate to the timing and administration of future anticancer therapies. Techniques of minimally-invasive surgery, initially involving laparoscopy and more recently robot-assisted surgery, have emerged to address these considerations. Early on, gynecologic oncologists found that laparoscopic surgery was associated with less surgical morbidity :less pain, less scarring, less blood loss and shortened postoperative recovery,. Robotic surgery has expanded the potential cohort of women capable of undergoing minimally-invasive surgery, now including selectivelythe morbidly obese, those in poor health, and those having numerous comorbidities.

Technical Comparison with laparoscopic surgery
Robotic surgery differs substantially from laparoscopic surgery in important ways. Conventional laparoscopy utilizes a two-dimensional camera with images projected to monitors positioned in proximity to the surgeon within the operating room. Surgery is performed in which by the surgeon at the surgical bedside directly controlling the instruments. Commonly listed limitations to laparoscopy are difficulty in manipulating the instruments and collapsed two-dimensional optics rendering complex tasks associated with more radical pelvic surgery difficult. The nontraditional skills and unfamiliarity with two-dimensional optics needed for laparoscopy have led to infrequent use of a laparoscopic approach by gynecologic oncologists. As such, the number of patients benefitting from a minimally-invasive procedure to manage their gynecologic cancer is low. With the introduction of robotics, many of the frustrations and limitations of less experienced laparoscopic surgeons have been minimized due to the improvement in ergonomics inherent in the robotic surgery. Using a robotic platform to perform surgery allows the primary surgeon to control multiple surgical instruments in a “hands-off” manner. Moreover, the surgical instruments have greater range of motion than conventional laparoscopic instrumentation, allowing “wristed action” rotation of instruments and motion scaling. Improved optics allow three-dimensional view of the surgical field. These technical aspects of robotic surgery have advantages of speeding learning new surgical skills by the surgeon and translating and adapting their own surgical skills to the robotic surgery platform.

Robotic Surgery in Cervical Cancer
From available data in cervical cancer patients, robotic surgery appears to provide sufficient surgery to assess pathologic tumor size, tumor grade, deep cervix organ invasion, lymphovascular invasion, cancerous lymph node status, and cancer-free margins of resection without undue risk of intraoperative injury. Experiences with robotic surgery to perform radical hysterectomy in patients with early stage cervical cancer have demonstrated feasibility and safety of the technique. Blood loss secondary to cutting and extirpation of the uterus and cervix appears minimal when performing radical hysterectomy for cervical cancer.Operative times are longer than a conventional approach; however these do decrease with increasing familiarity and robotic skill. Robotic procedures are associated with fewer lymphocysts, lymphoceles, postoperative infections, and ileus This has contributed to a widespread adoption of robotic surgery in the management of women with early cervical cancer. Since improved cervical cancer screening has led to the earlier detection of organ-confined disease, it is likely that minimally-invasive robotic surgery will become more commonplace in the management of early-stage cervical cancer.As the basis of adjuvant radiation and chemotherapy recommendations are founded in surgicopathological parameters, gynecologic oncologists who perform robot-assisted radical hysterectomy for cervical cancer must ensure that their robotic surgery continues to provide this informative data.Clinical use of robotic surgery for management of more bulky (>4?cm) cervical cancer remains sparse. Initial case experience for early-stage cervical cancer is encouraging.

Endometrial Cancer
Gynecologic oncologists were quick to recognize the advantages of robotic-assisted surgery in women with endometrial cancer. Endometrial cancer data have indicated that high tumor grade, deep myometrial invasion, involvement of the cervix, lymphovascular invasion, and presence of malignant lymph nodes, all contribute to adjuvant treatment recommendations. There has been no indication that robotic surgery limits these assessments Initial studies praised ease of surgical technique, adequacy of surgical specimens for cancer staging, and reduction in patient hospital stay and time to recovery. One particular advantage of the robotic platform was surgical confidence in adequate lymphadenectomy (i.e., > 4 lymph nodes retrieved from right and left pelvis and para-aortic node-bearing tissues) without undue risk of injury to pelvic organs and blood vessels. Moreover, it is important to recognize that surgery in the morbidly obese presents a unique surgical challenge. Many feel that the advantages of a robotic platform help overcome some of the barriers to operating on the morbidly obese with endometrial cancer. Further surgical development of robotic-assisted instrumentation for the obese is expected.

Ovarian Cancer
Management of epithelial ovarian cancer is predicated upon optimal cytoreductive surgery, with less than 1?cm of residual disease. Recurrence and overall survival improves incrementally, with microscopic residual disease followed by a platinum-taxane combination intravenous chemotherapy. Most commonly ovarian cancer is identified at an advanced stage often requiring radical surgical procedures to achieve “optimal” status. While the improved ergonomics may aid in these type radical surgery, other limitations inherent in the robotic platform—namely the inability to simultaneously operate in the pelvis and abdomen—remain a significant disadvantage.Robotic surgery for ovarian cancer management remains relatively untested. In the limited experience to date, blood loss and postoperative complications of bowel injury and wound dehiscence are infrequent. Port site relapses have not been reported routinely among the early investigational studies. It must be emphasized that these patients must be highly selected and their results are not likely to apply to all patients with ovarian cancer. Patients with advanced disease requiring multiple complicated additional procedures, laparotomy remains the optimal surgical approach.

Robotic surgery costs: Robot-assisted gynecologic surgery costs more than conventional laparoscopic procedures.. And yet, “cost savings” are created by an offset of reduced hospitalization and resources, lower costs associated with management of resultant surgical morbidity, and earlier patient return to the activities.
The early results of minimally-invasive robotic surgery for select women with certain gynecologic cancers are encouraging. While it is important to investigate alternative means of surgery with high precision, it is important to exercise both enthusiasm and restraint while doing case selection. Moreover, cost analyses of robotic-assisted surgery versus other surgery are underway. In the end, randomized data over a longer period will be needed to better assess the oncologic outcome of robotic surgery for gynecologic malignancy.

 

 

Author – Dr Vrunda C. Karanjgaokar
Consultant Gynaecological Oncologist and Robotic Surgeon, Mumbai.
MMC 77822