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Robot-geassisteerde chirurgie in de gynaecologische oncologie (Pro)

Robot-geassisteerde chirurgie in de gynaecologische oncologie (Pro). Ignace Vergote MD, PhD, FSPS, FACS University Hospital Leuven, Belgium. Robotics in gynecologic oncology. Radical hysterectomy Sentinel procedure with fluorescence imaging Radical trachelectomy

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Robot-geassisteerde chirurgie in de gynaecologische oncologie (Pro)

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  1. Robot-geassisteerde chirurgie in de gynaecologische oncologie (Pro) Ignace Vergote MD, PhD, FSPS, FACS UniversityHospital Leuven, Belgium

  2. Robotics in gynecologic oncology • Radicalhysterectomy • Sentinel procedure withfluorescence imaging • Radicaltrachelectomy • Hysterectomy (especially in obesepatients) • Pelvic and/or para-aortic lymphadenectomy as staging procedure • Parametrectomy • Exenteration • …

  3. Robotics in gynecologic oncology • Radicalhysterectomy • Sentinel procedure withfluorescence imaging • Radicaltrachelectomy • Hysterectomy (especially in obesepatients) • Pelvic and/or para-aortic lymphadenectomy as staging procedure • Parametrectomy • Exenteration • …

  4. Advantages for SurgeonsTechnological Comparison WithLaparoscopy

  5. Robotic Surgery in Gynecologic Oncology Robotics is not for every procedure, but will find a home in the female pelvis Image is courtesy of A. Maggioni

  6. Courtesy of N. Sakuragi Line for incision Cut end of cardinal ligament Pelvic plexus Rectum Hypogastric nerve Pelvic splanchnic nerves Nerve-sparing radical hysterectomy is probably the best indication for robotic surgery in gynecologic oncology.

  7. To Evaluate PerformanceEvidence-Based Medicine : Level of Evidence Tannock IF, et al. Eur J Cancer Supplements. 2003;1(5):93-101.

  8. Takeintoaccount the timeittook to obtainlevel I evidence for laparoscopyearly stage endometrial cancers, FIRST REPORT : Childers JM, et al. ObstetGynecol. 1994;83(4):597-600.

  9. Meta-Analysis Comparing Robotic Wertheim (RH) With Open WertheimO’Neill Arch Gynecol 2013 • Robotic RH comparedwith open RH: • Significantlydifferent: • Reducedbloodloss • Reduction for transfusion • Shorterhospitalstay • Fewer complications (P = .06) • Longer operation duration, but no longer significantafterexcluding 1 outlier (Schreuder < 30 patients) O’Neil M, et al. ArchGynecolObstet. 2013;287(5):907-918.

  10. Meta-Analysis Comparing Robotic HT+Ln With Open HT+LnO’Neill Arch Gynecol 2013 • Robotic HT+Lncomparedwith open HT+Ln: • Significantlydifferent: • Reducedbloodloss • Reduction for transfusion • Shorterhospitalstay • Fewer complications • But, longer operation duration O’Neil M, et al. ArchGynecolObstet. 2013;287(5):907-918.

  11. Robotic vs Laparoscopic WertheimReza Br J Surg 2013 • Robotic RH comparedwithlaparoscopic RH: • Significantlydifferent: • Reducedbloodloss • Tendency but not significantlydifferent (numbersverylow for laparoscopy): • Duration of hospitalization • Need for conversion • LN number • Duration of operation Reza M, et al. Br J Surgery. 2010;97(12):1772-1783.

  12. Meta-Analysis Comparing Robotic HT+ LN With Laparoscopic HT +LNO’Neill Arch Gynecol 2013 • Robotic HT+LN comparedwithLaparoscopic HT + LN: • Significantlydifferent: • Reducedbloodloss • Shorterhospitalstay • Fewer complications • Fewer conversions O’Neil M, et al. ArchGynecolObstet. 2013;287(5):907-918.

  13. Robotic staging of endometrial cancer – obesity • Seamon (2009): BMI > 30 (mean 40) n =109: • Conversion rate 15% (Walker JCO 2009, LAP2 GOG study – unselected patients with endometrial cancer: 26% laparoscopy converted to -tomy) • Compared with -tomy: • Similar ln count (median: 25) • Hospital stay, transfusion rate, wound complications less with robotics compared with matched controls operated with- tomy. • Gehrig (2008) : similar population (n = 49) • Similar experience as Seamon.

  14. Further Criticial Evaluation of Robotic RH • Learning curve • Bladder function after nerve-sparing RRH • Do roboticsreduce the possibilityfor training fellows? • Costs and RRH • Oncologic follow-up

  15. Further Criticial Evaluation of Robotic RH • Learning curve • Bladder function after nerve-sparing RRH • Do roboticsreduce the possibilityfor training fellows? • Costs and RRH • Oncologic follow-up

  16. Robotic RH and Cost in EuropeReynisson (Sweden) Gynecol Oncol 2013n = 180, one center - Lund • First 30 cases: • Open $12,986 vs $18,382 for robotic • Last 30 cases: • Robotic: $12,759, with a break-even compared with open RH after 90 cases • The reduction of costs for robotic was mainly induced by shorter OR time and hospital stay with more experience Reynisson P, et al. GynecolOncol. 2013;130(1):95-99.

  17. Learning Curve With Robotic RH: Operation TimeReynisson Gynecol Oncol 2013 Reynisson P, et al. GynecolOncol. 2013;130(1):95-99.

  18. Evolution of Hospital Stay With Robotic RHReynisson Gynecol Oncol 2013 Reynisson P, et al. GynecolOncol. 2013;130(1):95-99.

  19. Robotic RH and Cost • Cost of new technologies are always relatively high and drop as the marketgrows and industry competition drives down costs of equipment

  20. Oncologic Follow-Up After Robotic Radical Hysterectomy Few data exist, but recentlysomeinteresting data werepresented:

  21. Oncologic Follow-Up After Robotic Radical HysterectomyJackson et al (North Carolina) ASCO 2013 • 121 robotic RH compared with 97 open RH (2005-2012) • 80% Stage Ib1 • No differences in age, stage, short-term and long-term complications and comorbidities • Median follow-up 25 months • PFS significantlybetterwithrobotic RH comparedwith open RH (HR: 3,12, CI: 0.01-0.98) • 3 deaths in the robotic group and 10 with open RH (OS, NS) Jackson AL, et al. J Clin Oncol. 2013;31(Suppl): Abstract 5607.

  22. Oncologic Follow-Up After Robotic Radical HysterectomyVergote et al (Belgium) SERGS 2013 • 102 RoboticRH • 9% Ia, 66% Stage Ib1, 4% Ib2, 22% II • 17 patientsafterneoadjuvantchemotherapy (Ib2-IIb) • Median follow-up 24 months • Recurrences: 14%, 10 recurrences in the pelvis, 5 withdistant metastases, no port site metastases • 3 deathsdueto cancer Vergote I. Presentedat: Society of EuropeanRoboticGynaecologicalSurgery (SERGS) Meeting; 13-15 June 2013: London, United Kingdom.

  23. European Institute on Oncology, Milano: Oncological Results ARH RRH Primary recurrences 3 (2.7%) 7 (7.1%) Time of rec.(median) 15 mts 12 mts Size of tumor < 2cm 3 > 2cm 3 4 Maggioni A, et al. Int J Gynecol Cancer. 2012;22(8): Abstract. (Presented at Vancouver IGCS 2012).

  24. European Institute of Oncology, Milan: Oncologic Results ARH RRH Primary Recurrences 3 (2.7%) 7 (7.1%) Pelvis 2 (67%) 5 (71%) Pelvis+abdomen 2 Distance 1 Port site 3* DOD 0 1 *3 port site in a patient after adjuvant RT = median 18 mth ( 2 sq -1 adenocarc) Maggioni A, et al. Int J Gynecol Cancer. 2012;22(8): Abstract. (Presented at Vancouver IGCS 2012).

  25. Robotic Radical Hysterectomy Leuven Technique • Preparation of the vagina cuff vaginally • Frozen section of the vaginal margin at the start of the operation • The vaginal cuff is closed to avoid disemmination and the traction stitches are used to remove the uterus

  26. Robot-assisted surgery is still in its infancy! Surgeon Training Advanced Instrumentation Fusion of MR and Robotic image Double teaching console Advanced Imaging Single Access Surgery

  27. Comparison of laparoscopy with robotic surgery 6th Annual SERGS Meeting on Robotic Gynaecological Surgery 22.–24.05.2014 · Essen / Germany Congress Center Essen Congress President: Professor Dr. Rainer Kimmig University Clinic Essen (UKE) – Dpt. Gynecology and Obstetrics Hufelandstr. 55 45147 Essen / Germany President SERGS: Professor Dr. Ignace Vergote University Clinic Leuven (UZL) –Dpt. Gynecology and Obstetrics Herestraat 493000 Leuven / Belgium www.sergs2014.org

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