Robot%chirurgie%in%de%Gynaecologische%Oncologie Verpleegkundigen%in%de%oncologie:%update 11%februari%2017%> Oostkamp Philippe'Van'Trappen,'MD'PhD'MRCOG(Gyn Onc) Head'Gynaecology/Oncology Bruges AZ'St.'Jan'Hospital'Bruges BELGIUM
Evolutie%gynaecologische%chirurgie 1898 1994 2003
ROBOTIC%SURGERY
Robot%console 3D%View Ergonomic positionsurgeon Telesurgery Endowristed instruments Controle%of%Camera%and all instruments
Plaatsen%trocars%+% docking%aan%robot
Plaatsen trocars + docking aan Robot
Robotic%Surgery%in Gynaecological%oncology! Welke%patienten:! Endometrium%carcinoom%(FIGO>stadium%I)! Cervix%carcinoom%(FIGO>stadium%IA2>IB1)! Ovarium%carcinoom%(FIGO>stadium%IA)
Robotic%Surgery%in Gynaecological%oncology! Welke%operaties:! Robot%hysterectomie%+/> pelviene%klieren! Robot%radicale%hysterectomie%(Wertheim>Meigs)! Robot%para>aortale%klierdissectie! Robot%radicale%cervixamputatie/trachelectomie%met%pelviene% klierdissectie
Robotic'Assisted'vs'Straight'Stick'(Laparoscopy)! No'haptic'feedback! Three'dimensions! More'degrees'of'freedom! No'tremor! Telesurgery! Telementoring! Easier! Quicker'to'learn!?cost!?'More'breakdown! Haptic'Feedback! Two'dimensions! Less'degrees'of'freedom! Max'tremor! No'telesurgery! No'telementoring! Less'easy! Slower'to'learn! Less'cost! Less'risk'of'op'breakdown
Robotic'Assisted'vs'Straight'Stick! Endometrial'cancer! Overweight! Cervix'Cancer! Complex'Surgery! Ovarian'Cancer! Complex'Surgery
Obesity 2009 11
Obesity 12
Endometrial Cancer 1985 13.5 14
Endometrial Cancer 1995 13.9 15
Endometrial Cancer 2001 16.5 16
Endometrial Cancer 2010 20.5 17
Endometrial Cancer 1995$% 13.9$/$100,000 x'2 2015$% 27.8$/$100,000$ 18
Risico%factoren%voor% endometrium%carcinoom
Laparoscopic vs Open Hysterectomy for Endometrial Cancer COMPLICATIONS Just RCTs 20
Laparoscopic Vs Open Surgery Endometrial Cancer Kalogiannidis et al Recurrence % Overall Survival % Disease-free survival % LH 8.7 93 91 AH 16 86 84 Zullo et al LH 20 82.5 NR AH 18.4 84.2 NR Nezhat et al LH 5.9 88.5 NR AH 7.8 85 NR Malzioni et al LH 8.6 93.2 91.4 AH 11.5 91.1 88.5 21
Laparoscopic Vs Open Surgery Endometrial Cancer Level%1%evidence Longer%operating%time Shorter%hospital%stay Less%blood%loss Less%post7operative%complications 22
National%statistics%for%endometrial%cancer Approaches to hysterectomy for endometrial ca 1998-2009 100 90 80 70 60 50 40 30 20 10 0 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 Open Vaginal Laparoscopic Unclassified Acknowledgment%to%Osama%Abughazza 23
Robotic Surgery Endometrial Cancer 24
Laparoscopic Vs Open Surgery Vs Robotic Endometrial Cancer Boggess$2008 Pats ORT$ (min) LOS$ (days) EBL$(ml) LN ALN PLN Conv$ (%) RH 103 191 1 75 32.9 12 20.5 2.9 5.8 LH 81 213 1.2 146 23.1 6.3 17.4 4.9 13.6 AH 138 146 4.4 266 14.9 3 11.5 29.7 Veljovich 2008 RH 25 283 1.7 66.6 17.5 1 20 LH 4 255 1.2 75 20.3 0 0 AH 131 139 5.3 198 13.1 29 Bell$2008 RH 40 184 2.3 166 17 0 7.5 LH 30 171 2 253 17.1 0 20 AH 40 109 4 316 14.9 27.5 DeNardis$2008 RH 56 177 1 105 19.8 6.5 13.3 13.3 AH 106 79 3.2 241 19 6.6 12.4 12.4 Comps$ (%) 25
Laparoscopic Vs Open Surgery Vs Robotic Endometrial Cancer Gaia$2010 Pats ORT$ (min) LOS$ (days) EBL$(ml) LN ALN PLN Conv$ (%) RH 424 219 1.4 92 28.8 10.3 18.5 4.9 LH 396 209 1.9 182 25.6 7.8 17.8 9.9 RH 333 207 1.2 101 27.4 9.4 18 AH 606 130 3.9 291 20.2 5.7 14.5 Seamon$2009 RH 105 242 1 88 31 10 21 12.4 LH 76 287 2 200 33 11 22 26.3 RH 109 228 1 109 27 8.5 18.5 15.6 AH 191 143 3 394 25.9 7.2 18.7 Coronado$2012 RH 71 189 3.5 99 2.8 21.2 LH 84 218 4.6 190 8.1 28.5 AH 192 157 8.1 231 34.9 Comps$ (%) 26
COSTS'??? Robotic%Surgery%For%Endometrial%Cancer 27
Costs Before & After Pre-Robot Median (Range) Post-Robot Median (Range) All Cases Median (Range) Comparison Mann-Whitney P (Med. Dif.: 95%CI) Ward/Clinic Costs ( ) 3,391 (641 14,303) 1,585 (380 4,410) 2,631 (380 14,303) P < 0.0001 (1,528: 1,070 2,021) Medical Staffing Costs ( ) 2,153 (143 7,936) 2,322 (73 5,811) 2,182 (73 7,936) NS (11: -304 to 349) Theatre Costs ( ) 2,325 (917 5,264) 2,476 (599 4,722) 2,355 (599 5,264) NS (118: -45 to 279) Drugs / Pharmacy Costs ( ) 150 (16 5,178) 139 (7 579) 147 (7 5,178) NS (18: -12 to 49) Blood Products Costs ( ) 0 (0 490) 0 (0 588) 0 (0 588) NS (0: 0 to 0) Imaging Costs ( ) 54 (0 893) 133 (0 602) 71 (0 893) NS (0: 0 to 55) Pathology Costs ( ) 614 (35 1,804) 585 (35 1,134) 605 (35 1,804) NS (41: -23 to 105) Rehab Therapy Costs ( ) 198 (0 3,582) 0 (0 8,174) 153 (0 8,714) P < 0.0001 (84: 41 to 158) High Dependency Care Costs ( ) 2,830 (0 9,639) 2,560 (0 5,222) 2,830 (0 9,639) NS (270: -128 to 270) Total Cost ( ) 11,463 (3,062 34,276) 10,048 (4,192 17,306) 11,115 (3,062 34,276) P = 0021 (1,707: 638 to 2,745) Cost Including Depreciation ( ) 11,476 (3,088 34,276) 10,274 (4,402 17,306) 11,124 (3,088 34,276) P = 0.0065 (1,470: 441 to 2,478)!
29 Laparoscopic Vs Open Surgery Vs Robotic Endometrial Cancer Lau et al 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 2005 2006 2007 2008 2009 2010 2011 l-tomy Robotics l- scopy Acknowledgement Slide provided by Walter Gotlieb, Canada.
30 Laparoscopic Vs Open Surgery Vs Robotic Endometrial Cancer Lau et al Apr$2003% Nov$2007 L%tomy+L%scopy (n=160) Dec$2007$ May$2010 Robotic (n=143) pivalue BMI$(mean) Obese%(30)39.9) Morbidly%Obese%(>40) Age$(mean) <56 56I65 66I75 >75 27.6 31.9% 8.8% 65.3 20 36 23 22 29.8 33.6% 16% 65.7 18 36 21 25 0.005 Complications$> gr2 41.9% 13.3% <0.0001 0.9 Wound$complications 15.6% 3.5% <0.0001 Acknowledgement Slide provided by Walter Gotlieb, Canada.
31 Laparoscopic Vs Open Surgery Vs Robotic Endometrial Cancer Lau et al Apr$2003% Nov$2007 L%tomy+L%scopy Mean$(P25%P75) (n=160) Dec$2007$ May$2010 Robotic Mean$(P25%P75) (n=143) pivalue Time$(skin$to$skin,$min.) 207(159I 244) 241'(205I272) <0.0001 EBL$(ml) 266''(100I300) 73'(20I100) <0.0001 Hospital$stay$(days) 5'(4I6) 1'(1I2) <0.0001 Overall$Cost$per$surgery Including$amortization 10368 (8236%12500) 8370$ (7090%9651) 0.0002 Acknowledgement Slide provided by Walter Gotlieb, Canada.
Summary for Robotic! Less complications! Shorter hospital stay! Longer time in theatre! Cheaper
Robotic%surgery%with%staging%for%endometrial%cancer:% multi>institutional%experience Lowe et al, Obstet Gynecol 2009 n patients Oper.'time Blood'loss n'lns Hosp.'stay Intraoper.' compl Postoper.' compl. 405 170.5'min 87.5'ml 15.5 1.8'days 3.5% 14.6%
Robotic%hysterectomy%+%LND%versus%Laparoscopic% hysterectomy%+%lnd: case>matched%controlled%study%on% surgical%outcome Lim et al, Gynecol Oncol 2011 Robot N%=%122 Laparoscopy N%=%122 Oper.%Time 147.2%min LN N%=%19.2 Blood%loss 81.1%ml Hosp. 1.5%days Oper.%Time 186.8%min LN N%=%24.7 Blood%loss 207.4%ml Hosp. 3.2%days
Robotic hysterectomy +%LND%versus%Laparoscopic hysterectomy +%LND: surgical outcomes at%a% minimally invasive surgical center Cardenas et al, Gynecol Oncol 2010 Robot N=%102 Laparoscopy N%=%173 Oper.%Time 237%min Oper.%Time 178%min Blood%loss 109%ml Blood%loss 187%ml n LNs and complications equal
Robotic surgeryfor patients with low%andhigh%bmi%in%a German Gynecological Cancer%Center Kannisto et)al,)archgynecol Obstet,)2014)July Retrospective study N=116%patients Operations:%Robot%(radical)%hysterectomy,%Adnexectomy,%LN%dissection,%etc Complications overall:%15/116%(12.9%) Perioperative complications:%normal BMI'='high'BMI > vascular injury (2) > intestinal injury (2) > not well%exposedparaaortic field%(1) > bladder%injury (1) Late%complications:%vaginaldehiscence (2),%vaginalhemorrhage (1),%cuff hematoma (4), Lymphocyst (1),%urinary tract injuries,%ureter%(2)%
Robot%versus%Laparoscopicnerve>sparing%radical hysterectomy for early>stage%cervical cancer Chong et)al,)int)j)gynecol Cancer,)2013)July 50)Robot Robot N%=%50 Oper.%Time 230.1%min Laparoscopy N%=%50 Oper.%Time 211.2%min LN N%=%25 LN N%=%23.1 Blood%loss 54.9%ml Normal%res.% urine 9.6%days Blood%loss 201.9%ml Normal%res.% urine. 11%days P<0.001
Robot%versus%Laparoscopicnerve>sparing%radical hysterectomy for early>stage%cervical cancer Chong et)al,)int)j)gynecol Cancer,)2013)July Complication rate!!: > ROBOT:%0% > LAPAROSCOPIC:%8%
Robotic vs Laparoscopic Surgery Endometrial Cancer Operative$Time 39
Robotic vs Laparoscopic Surgery Endometrial Cancer Days$Stay 40
Robotic vs Laparoscopic Surgery Endometrial Cancer EBL 41
Robotic vs Laparoscopic Surgery Endometrial Cancer Complications 42
Robotic vs Laparoscopic Surgery Endometrial Cancer Conversions 43
ROBOTIC PROCEDURES IN GYNAECOLOGY/ONCOLOGY in AZ St. Jan BRUGES CONSOLE OPERATIVE TIMES (average): -Robot Hysterectomy (large/myomatous uteri): 60 min -Robot Hysterectomy (endometrial cancer): 45min -Robot Hysterectomy + Pelvic Lymph Node Dissection (endometrial cancer): 90min -Robot Radical Hysterectomy + Pelvic Lymph Node Dissection: 150min -Robot Pelvic and Para-aortic Lymph Node Dissection: 60-90min
Vessel Sealer for lateralising ureter
Vessel Sealer for dissecting Para>Vesical and%para>rectal space in% Robot%Radical Hysterectomy ParaQVesical Space BLADDER UTERUS LEFT OVARY
Vessel Sealer for opening%space between bladder%and cervix/vagina Left uterine'artery Left ureter
Vessel Sealer for opening%para> rectal space Identification of% splanchnic (Hypogastric)% nerves in%meso> ureter%during Radical Hyterectomy. Splanchnicnerves in%meso>ureter
Vessel Sealer for Pelvic Lymph Node%Dissection (iliac vessels) LYMPH%NODE%TISSUE Right%External Iliac Artery/Vene
Vessel Sealer for dissecting lymph node%tissue% (obturator fossa)
Vessel Sealer for lymph node%dissection at Para>aortic region (here left side) Lymph node'tissue Left Coimmon Iliac Artery Aorta
Left Para>aortic region
Left Ureter' Inferior Mesenteric Artery Left'ParaQaortic'Region' after'removal'ln Aorta
Right'Ureter Aorta Vena'Cava Lymph nodes
Right%Common%Iliac Artery AortaQVena'CavaQUreter'Right
Radical Hysterectomy (end%of% procedure) BLADDER Ureters
BLADDER PUBIC%BONE after PLND%and Radical Hysterectomy Obliterated Hypogastric Artery VAGINA open Vaginal swab OBTURATOR' NERVE EXT'ILIAC' VESSELS RIGHT'URETER
BLADDER PUBIC'BONE Obliterated Hypogastric Artery VAGINA closed OBTURATOR NERVE EXT'ILIAC' VESSELS RIGHT%URETER
Fibrin/collagen patch%on%iliac vessels after lymph node% dissection
4>arm%da%Vinci%Xi Single%arm da%vinci%sp