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Gynecologic Cancer
evidence supporting the use of robotic surgery for radical hospital stay. No cases were converted to open procedures, and no
hysterectomy, which allows for a full seven degrees of motion, patients recurred.
employs 3D vision, and reduces tremor through motion-dampening
controls. Drawbacks include cost (approximately $1.5 million for the Magrina et al.
12
have published the only account comparing RRH, TLRH,
da Vinci
®
robot [Sunnyvale, California]), loss of tactile feedback, large and ARH. They found mean operating times were 190, 220, and 167
bulky arms with long positioning times, and the requirement of a minutes, EBL was 133, 208, and 444cc, and mean length of stay was 1.7,
large, well-trained operating room staff. 2.4, and 3.6 days, respectively. There were no conversions to open
procedures in the laparoscopic or robotic groups, and there were no
Technique differences in intra-operative or long-term complications between all
Informed consent is obtained. All patients undergo pre-operative three groups. A multi-institutional trial
15
based at MD Anderson Cancer
bowel preparation and receive prophylactic antibiotics. After Center has recently opened for accrual in which patients with early-stage
placement in the lithotomy position with the arms out to the sides, a cervical cancer will be randomized to radical hysterectomy through
Foley catheter is inserted. A V-care
®
uterine manipulator (ConMed, laparotomy versus minimally invasive surgery (laparoscopy or robotics).
Utica, New York) is placed. Under direct visualization, a 12mm
bladeless trocar is placed 3cm above the umbilicus. A second Conclusion
12mm bladeless trocar is then placed above and 8cm to the left of the Total laparoscopic hysterectomy for early-stage cervical cancer has
first trocar, and is used by the assistant. The abdomen is then several advantages over abdominal hysterectomy: less blood loss, fewer
insufflated, and the patient is placed in steep Trendelenburg position. complications, improved cosmesis, and a shorter hospital stay. Therefore,
Three additional robotic trocars are then placed: one 15° below and it is both a safe and a feasible procedure. Robotic surgery may surpass
8cm to the left of the assistant trocar, another 8cm to the right of the both laparoscopy and laparotomy for radical hysterectomy, and we look
umbilical trocar, and a third 8cm to the right and 15° below the forward to the results of larger trials comparing these modalities. ■
second robotic trocar. The robot is then docked, as are the camera
and robotic arms. The steps for the RRH are subsequently the same as
Erin R King, MD, MPH, is a third-year Resident in the
described for the laparoscopic approach.
Department of Obstetrics and Gynecology at the University
of Virginia. She plans to pursue a fellowship in gynecological
Outcomes
oncology on completion of her training, and is conducting
ongoing research in the efficacy of advanced-line
Sert and Abeler
9
were the first to describe the robotic technique for
chemotherapeutic agents in recurrent epithelial ovarian
radical hysterectomy in cervical cancer. Since then, a number of cancer. Dr King is a junior member of the American College
investigators have published larger studies comparing robotic versus
of Obstetrics and Gynecology (ACOG).
abdominal and laparoscopic radical hysterectomy (see Table 2).
Pedro T Ramirez, MD, is an Associate Professor in the
Boggess et al.
10
examined 51 patients with early-stage cervical cancer
Department of Gynecologic Oncology at MD Anderson
who underwent RRH compared with 49 historic controls who Cancer Center. He is also Director of Minimally Invasive
underwent ARH. Patients who underwent RRH had a much lower EBL
Surgical Research and Education. He serves as Chair of the
Gynecologic Oncology Committee for the American
(96.5 versus 417cc; p<0.0001), and there was a higher lymph-node
Association of Gynecologic Laparoscopists (AAGL). He is also
yield (33.8 versus 23.3; p<0.0001). There were significantly fewer the principal investigator in the first phase III trial evaluating
complications in the RRH group, and hospital stay was only one day
laparotomy versus minimally invasive surgery for radical
hysterectomy in patients with early-stage cervical cancer. He
(versus 3.2 in the ARH group). Operative time was actually shorter in
is one of the leading surgeons in robotic surgery for women with gynecologic malignancies.
the RRH group (211 minutes versus 250 minutes). Recently, Nezhat et Dr Ramirez is also interested in the development of novel approaches for the treatment of
al.
11
compared 30 patients who underwent TLRH with 13 who
young women with gynecologic malignancies who wish to preserve their fertility.
underwent RRH, and found no difference in operative times, EBL, or
1. Canis M, Mage G, Wattiez A, et al., Does endoscopic surgery 6. Ramirez P, Slomovitz BM, Soliman PT, et al., Total hysterectomy cases. The future is now?, Int J Med Robot, 2007;
have a role in radical surgery of cancer of the cervix uteri?, laparoscopic radical hysterectomy and lymphadenectomy: 3:224–8.
J Gynecol Obstet Biol Reprod (Paris), 1990;19:921. the M. D. Anderson Cancer Center experience, Gynecol Oncol, 11. Nezhat FR, Datta MS, Liu C, et al., Robotic radical
2. Nezhat CR, Burrell MO, Nezhat FR, et al., Laparoscopic 2006;102:252–5. hysterectomy versus total laparoscopic radical
radical hysterectomy with paraaortic and pelvic node 7. Pomel C, Atallah D, Le Bouedec G, et al., Laparoscopic hysterectomy with pelvic lymphadenectomy for treatment
dissection, Am J Obstet Gynecol, 1992;166:864–5. radical hysterectomy for invasive cervical cancer: 8-year of early cervical cancer, JSLS, 2008;11:227–37.
3. Frumovitz M, does Reis R, Sun CC, et al., Comparison of experience of a pilot study, Gynecol Oncol, 2003;91:534–9. 12. Magrina JF, Goodrich MA, Weaver AL, et al., Modified radical
total laparoscopic and abdominal radical hysterectomy for 8. Abu-Rustum NR, Gemignani ML, Moore K, et al., Total hysterectomy: morbidity and mortality, Gynecol Oncol, 1995;
patients with early-stage cervical cancer, Obstet Gynecol, laparoscopic radical hysterectomy with pelvic 59:277–82.
2007;110:96–102. lymphadenectomy using the argon-beam coagulator: pilot 13. Kim YT, Kim SW, Hyung WJ, et al., Robotic radical
4. Spirtos NM, Eisenkop SM, Schlaerth JB, et al., Laparoscopic data and comparison to laparotomy, Gynecol Oncol, 2003;91: hysterectomy with pelvic lymphadenectomy for cervical
radical hysterectomy (type III) with aortic and pelvic 402–9. carcinoma: a pilot study, Gynecol Oncol, 2008;108:312–16.
lymphadenectomy in patients with stage I cervical cancer: 9. Li G, Yan X, Shang H, et al., A comparison of laparoscopic 14. Fanning J, Fenton B, Purohit M, Robotic radical
Surgical morbidity and intermediate follow-up, Am J Obstet radical hysterectomy and pelvic lymphadenectomy and hysterectomy, Am J Obstet Gynecol, 2008;198:649e1–e4.
Gynecol, 2002;187:340–48. laparotomy in the treatment of Ib-IIa cervical cancer, Gynecol 15. Obermair A, Gebski V, Frumovitz M, et al., A phase III
5. Chen Y, Xu H, Li Y, et al., The outsome of laparoscopic radical Oncol, 2007;105:176–80. randomized controlled trial comparing laparoscopic or
hysterectomy and lymphadenectomy for cervical cancer: A 10. Sert BM, Abeler VM, Robotic-assisted laparoscopic radical robotic radical hysterectomy with abdominal radical
prospective analysis of 295 patients, Ann Surg Oncol, 2008; hysterectomy in early-stage cervical carcinoma patients, hysterectomy in patients with early stage cervical cancer,
15:2847–55. comparing results with total laparoscopic radical J Min Inv Gyn, 2008;15:584–8.
92 US ONCOLOGY
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