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Robotic radical hysterectomy with pelvic lymphadenectomy: our early experience
C. Vasilescu, O. Sgarburã, St. Tudor, M. Popa, A. Turcanu, A. Florescu, V. Herlea, R. Anghel (Chirurgia, 104 (4): 393-397)

In the recent years, pelvic surgery has become a well individualized issue for robotic surgery experts all over the world (1,2,3). In 2009, a consensus statement was published to support the hypothesis that robotic surgery can overcome some limitations of laparoscopic surgery for prostate, rectal and uterine cancer (1). However, the use of minimally invasive surgery in gynecological oncology is still novel, with the first laparoscopic hysterectomy performed in 1989 by H. Reich (4), the first robotic hysterectomy performed in 2002 by C. Diaz-Arrastia (5) and the first robotic radical hysterectomy with lymphadenectomy performed in 2006 by Sert and Abeler(6). The latter techniques have produced an explosion of comparative studies, most of which were published in 2008 (7,8,9,10,11,12). These articles identify clear techical and medical benefits, offer scarce survival data, and sometimes complain about the lack of cost-effectiveness but mostly in non-US centers. Nevertheless, some authors (12,13) even praise the improved overall costs of this technology compared to the open approach meanwhile other authors (8) emphasize the superiority of lymphadenectomy and expect better survival results. Review articles and editorials range from highly optimistic, classifing the robotic gynecologic oncology as a new surgical paradigm, to a skeptical enthusiasm (14).
In this study we analyze the feasibility of robotic assisted lymphadenectomy in gynecological cancers in the initial experience of a recently devolopped robotic surgery program (15,16).

Material and Methods
It is a prospective study that started the 1st of March 2008 when the DaVinci S robotic system was acquired in Fundeni Clinical Institute, the Department of General Surgery and Liver Transplantation, and Carol Davila University of Medicine and Pharmacy. Since then, 250 cases of robotic surgery were performed out of which 29 cases addressed gynecological conditions. Out of this number, we performed 1 simple anexectomy, 9 simple total hysterectomies with bilateral anexectomies, 14 radical hysterectomies with pelvic lymphadenectomy, 4 tumour ablations with pelvic lympha-denectomy, 1 pelvic lymphadenectomy. We selected all radical hysterectomies with pelvic lymphadenectomy and completion hysterectomies or tumor ablation with pelvic lymphadenectomy summing up to 19 cases.
We assessed preoperative variables (age, tumour site, preoperative radiotherapy, comorbidities), perioperative variables (anesthesia time, skin-to-skin time, console time, intraoperative complication, technique), postoperative variables (early and late complications, hospital time, return to activity), survival and recurrence data.
All cases were recorded and analyzed with SPSS 15.0
software (SPSS Inc., Chicago, Illinois ). Average or median and standard deviation are provided for continuous variables, frequencies are provided for discrete and logistic data. Non-parametric tests were used to determine statistically significant differences. A p-value<0.05 was considered significant.

Study group data
From March 2008 to April 2009, 250 patients underwent robotic surgery in the Department of Surgery and Liver Transplantation, Fundeni Clinical Institute. Out of these interventions, 29 operations addressed female genital conditions, 19 of them in females with malignant diseases. We included all patients with cervical or endometrial cancer with a limited local spread, requiring pelvic lympha-denectomy. We did not indicate robotic surgery in patients who had respiratory conditions associated with hyper- capnia, preventing the use of pneumoperitoneum. Previous pelvic surgery was a relative exclusion criteria, appliable only to patients with several lower abdominal interventions. Our final group consisted of 19 patients, aged between 40 and 78 years old, with an average age of 53.22 years (±10.03). Eleven patients were diagnosed with cervical cancer, out of which three had undergone a subtotal hysterectomy in another hospital in 1994, 1996 and 2002, respectively, for uterine leiomyoma. One patient had a recurrence after cervical cancer for which total hysterectomy with bilateral anexectomy but no lymphadenectomy had been performed in 2007. Seven patients were diagnosed with endometrial cancer. Nine out the eleven cervical cancer patients needed preoperative radiotherapy. In three patients the tumour was adherent to the urinary bladder. Average BMI was 25. 5 (±3.011), average BMI in endometrial cancer patients was 24.25 (±1.7). Ten patients had metrorrhagies and presented with anemia.
All patients had a complete history and physical examination including body mass index. Blood cell count and biochemistry were recorded for all patients. Magnetic resonance of the pelvis was performed in order to estimate local involvement in patients where other investigations suggested potentially locally advanced disease. Abdominal ultrasound examination and pulmonary X-Ray examination were used to assess distant metastases. Four patients presented with more than two comorbidities (hypertension and cardiac disease or hypertension and diabetes mellitus).
Operative technique
General anesthesia was used in every case. Perioperative antibiotics were administered. The patients were layed in a supine position with the legs wrapped in a compression device, placed in abduction. Foam padding was used to protect both arms and legs. The patients’ position on the operating table was secured using cloth tape in a circumferential fashion in two locations in order to prevent the patient from sliding while in steep Trendelenburg. One monitor was placed at each side of the operating table. The uterus was mobilized with a uterine manipulator (Karl Storz, Tuttlingen, Germany) but in cervical cancer patients the manipulator was not inserted into the cervix, only the cup was used for the mobilization of the uterus. The patient robotic cart was placed between the patient’s legs to allow ample access to the vagina. Standard draping of the operatory field as for conventional laparoscopic procedure was used. The trocars were inserted as shown in the figure (Fig. 1). The patient was placed in steep Trendelenburg position until the small bowel and sigmoid were displaced out of the pelvis. The robot was then docked. Commonly, the hook was placed on arm 1 (the right arm) and a bipolar forceps was placed on arm 2 (the left arm) until the closure of the vaginal cuff when a suturecut needle driver was placed on arm 1 and a large needle driver was placed on arm 2. The following laparos-copic instruments were used by the two assistant-surgeons: Liga Sure Atlas™ (Valleylab) device, two atraumatic graspers, the suction device. One assistant surgeon was placed on each side of the patient. One scrub nurse and one operating room nurse were also present.
The console surgeon started with the lymphadenectomy on the right side, then performed the lymphadenectomy on the left side, both with blunt dissection and monopolar coagulation from the common iliac artery to the inferior boundary of the circumflex iliac vein. He made an incision at the level of the pelvic brim to indentify the ureterus. The surgeon isolated and sealed the lomboovarian ligaments, then he transected the round ligament and continued with the ligation and transsection of the uterine artery close to the origine, with the participation of the assistants that handled the Liga Sure Atlas™ device. Then the surgeon dissected the vesicouterine fold. At this moment of the intervention, the cup of the uterine manipulator was highly efficient, providing the support for cutting the vagina. Posteriorly, the uterosacral ligaments were sealed and the transsection of the vagina was completed. The vaginal cuff was closed with two sutures of 2-0 Vicryl precut at 12 cm, a space for one drain was left between the sutures. After completing the procedure hemostasis and intact ureters were checked for, and the peritoneal cavity was thoroughly irrigated and lavaged. A suprapubic drain was placed transabdominally, a second drain was placed transvaginally.

Figure 1

Intraoperative and postoperative course
Three types of operative times were recorded: total anesthesia time that included the insertion of central venous catheters in four patients, skin-to-skin time, and console time. Docking of the robot and vaginal cuff closure were recorded separately. They are presented in table 1. The mean blood loss was 172.5 ml (±35 ml), with only one patient requiring blood transfusion. Mean number of lymph nodes was 22.23 (±4.1). In three cases the tumour was adherent to the urinary bladder and 2 parcelar cystectomies were performed. All three patients preserved the Foley urinary catheters for more than one week. One of the three patients needed the insertion of a Cook catheter for immediately postoperative uretero-hydronefrosis grade II. Postoperative complications included lymphorrhea but did not include vaginal cuff dehiscence or abcess.
Oral intake, including oral medication, were started the next day after the operation and the patients were discharged 3.5 (±1.2) days postoperatively. In the initial cases, we hospitalized the patients more than it was necessary in order to monitor all the consequences of a recently developped surgical technique.
Survival data is still of limited relevance since the follow-up interval ranges from 1 to 15 months. However, up to now, none of the patients in the studied group died. A life-table analysis will be performed when a minimum of 12 months follow up is reached for these patients.

Conclusions and Discussion
Throughout the years, it has been proved that laparoscopy can be safely and adequately used in the treatment of endometrial and cervical cancers (17). The surgical management, usually done by laparotomy because of tissue retraction and fibrosis after chemoradiation, was then done by laparoscopy and now by robotic surgery with comparable histological results. Nevertheless, surgeons willing to perform laparoscopy encountered some disadvantages (18-21): counterintuitive hand movements, two-dimensional visualization, and limited degrees of instrument motion within the body as well as ergonomic difficulty and tremor amplification. All these are overcome by the DaVinci surgical robotic systems (15). Our experience in the laparoscopic approach of female genital cancers is still limited because we started these operations in January 2008 and published our technique after the initial case (22). Shortly after, the robotic system was acquired in our center and, due to its well known advantages, it became our prefered approach in pelvic pathology.
Most of the patients referred to our center for locally limited gynecological cancers were fitted for minimal invasive surgery. The console surgeon was experienced in laparoscopy, including colorectal surgery, and trained in robotic surgery, the assistant surgeons were trainees experienced in laparoscopy and trained as side-assistants in robotic surgery. Their role was important since, due to the lack availability of hemostatic instrument for the robotic arms except for monopolar, bipolar and ultrasonic coagulation, Liga Sure Atlas™ device and clips are applied by the patient side-assistants.
The major advantage of this system over laparoscopy stands out during the lymphadenectomy. The 7 degrees of freedom of the Endo Wrist® instruments allow the thorough prelevation of the nodes in the proximity of large vessels. Some authors (8) report the prelevation of statistically significant more lymph nodes in robotic surgery than in laparoscopic or open surgery (31.8 vs 25.9 vs 27.7, p<0.001). Other authors report the prelevation of 17.5 nodes (9), 18 nodes (23), 25.9 nodes (24) which compares favourable to our average of 22.23 nodes (17-25). Most authors state that the learning curve rises up to 20 cases (25) which implies that lymphodissection becomes even more accurate at the end of the curve.
Recent studies attempt a turmoil in the oncologic principles of radical hysterectomy with pelvic lymphadenectomy by suggesting surgeons to follow embriological landmarks (26,27). Whether or not these principles are valid remains to be demonstrated.
One of our most frequent concerns is related to the indications of robotic surgery. Most of the authors recommend the use of minimal surgery in cervical cancer stages IA2-IB2, until a maximum of IIA (8,9) and endometrial cancers stages IA-IIIC. It is well known that in the vast majority of cases, our patients refer with more advanced stages of the disease and they generally come to our department after previous radiotherapy. Our experience proved that robotic surgery is feasible in cervical cancer stages IIA-IIB.
The cost of the DaVinci surgical system is a limiting factor for the development of robotic surgery. Despite the initial cost of this technology that includes the investment and the 10% per year for maintenance, economic use of instruments can reduce the cost of procedures. The intraoperative costs of these operations may be higher but indirect costs should also be taken into account. Therefore, shorter hospital stay and earlier return to activity are not neglactible factors. Furthermore, it is important to realize that the costs of hospital beds vary between hospitals, especially between community hospitals and academic medical centers. This explains why studies show that a robotic program can be most competitive in a high-cost hospital combined with a high volume of cases (2,28). Cost-effective studies were conducted mostly in the field of robotic prostatectomies. One of the authors (29,30) estimated that nearly 80 robotic prostatectomies per year were necessary for a hospital to pay the robot. Given these data, it is most probable that an academic high-volume center where robotic procedures address pelvic, hepatic, splenic, pancreatic and eso-gastric pathology would recover its investment.
In conclusion, we believe that robotic pelvic lympha-denectomy in gynecological cancers is a rapid, feasible, and secure method that should be used whenever available. However further prospective studies and late follow-up results are needed in order to conclude over its oncological impact and to fully assess the value of this new technology.

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