[Da vinci robotic surgery in gynaecological oncology: a critical interim appraisal]

Abstract

Objective: Benefit evaluation of robot-assisted surgery in gynecological oncology. The parameters observed were feasibility, safety, overal surgery length and economic aspects.

Design: Prospective study analysing our experience in 10 patients operated due to gynaecological malignancy, adnexal tumors or planned for the procedure used as a part of extensive oncological surgery.

Settings: Department of Gynecology and Minimally Invasive Surgery Na Homolce Hospital, Prague.

Methods: The surgeries were performed with Da Vinci robotic system (Intuitive Surgical, inc., USA) including surgeon's console with stereoscopic viewer with hand and foot controls. The second component of the system was In Site vision system with 3D 12 mm endoscope. The third part comprised of 3 telerobotic arms with Endowrist instruments. From 2/2006 to 9/2006 10 patients were operated upon. 2 patients with early invasive cervical cancer, 2 patients with cervical cancer in situ (CIS), 3 patients with complex ovarian tumors, 2 patients with symptomatic atypical endometrial glandular hyperplasia and 1 patient underwent necessary gynecological surgery as a part of oncological treatment of breast cancer. The range of surgery included Total robotic hysterectomy, Robot-assisted vaginal hysterectomy with adnexectomy and frozen section, Robot-assisted radical vaginal trachelectomy with pelvic lymphadenectomy and unilateral adnexectomy with frozen section. The average age of patients was 52 years (range 32-58 years). 30% of patients had a previous laparotomy in their history.

Results: All procedures were finished with robot-assisted system. In 2 patients a temporary conversion to laparoscopy was made. In 3 patients a technical fault of the robotic system was noticed. This was corrected during the surgery. The overal surgery time was significantly longer (29 hours for robot-assisted versus 12 hours for laparoscopy). This represented operation time increase of 59% in comparison to identical laparoscopic procedures in our department in 2006. This was caused by lengthy assembly and disassembly time of the robotic system. No patients experienced any peroperative or postoperative comlications. The costs in our setting were approximately 10 times higher in comparison to laparoscopy.

Conclusion: Our preliminary experience shows that Robot-assisted surgery is comparable to the standard laparoscopic procedure in terms of feasibility and outcome, but costs are considerably higher owing to longer operating time and the use of more expensive instruments. A major limitation is the lack of a large operation field. The enormous costs and the lack of appropriate instruments can be a major problem in the further expansion of robotic surgery. The use of robotic system in gynecologic oncologic surgery and in abdominal surgery in general offers, at this stage, no relevant benefit and thus is not justified. Clinical data demonstrating improved outcomes are so far lacking for robotic surgical application within the abdomen.