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. 2014 Dec 10;2014(12):CD011422.
doi: 10.1002/14651858.CD011422.

Robot-assisted surgery in gynaecology

Hongqian Liu  1 , Theresa A Lawrie, DongHao Lu, Huan Song, Lei Wang, Gang Shi
Affiliations

Robot-assisted surgery in gynaecology

Hongqian Liu et al. Cochrane Database Syst Rev. .

Update in

  • Robot-assisted surgery in gynaecology.
    Lawrie TA, Liu H, Lu D, Dowswell T, Song H, Wang L, Shi G. Lawrie TA, et al. Cochrane Database Syst Rev. 2019 Apr 15;4(4):CD011422. doi: 10.1002/14651858.CD011422.pub2. Cochrane Database Syst Rev. 2019. PMID: 30985921 Free PMC article.

Abstract

Background: This is an updated merged review of two originally separate Cochrane reviews: one on robot-assisted surgery (RAS) for benign gynaecological disease, the other on RAS for gynaecological cancer. RAS is a relatively new innovation in laparoscopic surgery that enables the surgeon to conduct the operation from a computer console, situated away from the surgical table. RAS is already widely used in the United States for hysterectomy and has been shown to be feasible for other gynaecological procedures. However, the clinical effectiveness and safety of RAS compared with conventional laparoscopic surgery (CLS) have not been clearly established and require independent review.

Objectives: To assess the effectiveness and safety of RAS in the treatment of women with benign and malignant gynaecological disease.

Search methods: For this update, we searched the Cochrane Central Register of Controlled Trials (CENTRAL) (2014, Issue 5) and the Cochrane Gynaecological Cancer Review Group Trials Register. We also searched MEDLINE and EMBASE databases, to complement the searches of the original malignant and benign disease reviews (conducted up to July 2010 and November 2011, respectively), from July 2010 to June 2014.

Selection criteria: Randomised controlled trials (RCTs) of RAS compared with CLS or open surgery in women requiring surgery for gynaecological disease.

Data collection and analysis: Two review authors independently assessed the studies for inclusion and risk of bias, and extracted study data and entered them into an Excel spreadsheet. We subgrouped data according to type of procedure and pooled data using random-effects methods in RevMan 5.3. We performed sensitivity analyses by excluding studies at high risk of bias.

Main results: We included six RCTs involving 517 women. Most were at low to moderate overall risk of bias; one was at high risk of bias. Four studies evaluated RAS for hysterectomy (371 women), and two studies evaluated RAS for sacrocolpopexy (146 women). All studies compared RAS with CLS, except for one study, which compared RAS with CLS or a vaginal surgical approach for hysterectomy. Confidence intervals for the risk of intraoperative and postoperative complications included benefits with either approach when they were analysed together (risk ratio (RR) 0.95, 95% confidence interval (CI) 0.46 to 1.99; participants = 513; studies = 6; I(2) = 74%) and separately (low-quality evidence). Moderate-quality evidence was found for the effects of RAS on intraoperative injury when compared with CLS (RR 1.23, 95% CI 0.44 to 3.46; participants = 415; studies = 5; I(2) = 0%), along with low-quality evidence for bleeding and infection complications.Mean total operating time was consistent across procedures and on average was about 42 minutes longer in the RAS arm compared with the CLS arm (95% CI 17 to 66 minutes; participants = 294; studies = 4; I(2) = 82%; moderate-quality evidence). Mean hospital stay for hysterectomy procedures was on average about seven hours shorter in the RAS arm than in the CLS arm (mean difference (MD) -0.30 days, 95% CI -0.54 to -0.06; participants = 217; studies = 2; I(2) = 0%; low-quality evidence). The estimated effect of conversion with RAS compared with CLS was imprecise (RR 1.28, 95% CI 0.40 to 4.12; participants = 337; studies = 4; I(2) = 0%; moderate-quality evidence). Limited data from two studies suggest that RAS for sacrocolpopexy may be associated with increased postoperative pain compared with CLS; this needs further investigation. We identified five ongoing trials-four of cancer surgery.

Authors' conclusions: We are uncertain as to whether RAS or CLS has lower intraoperative and postoperative complication rates because of the imprecision of the effect and inconsistency among studies when they are used for hysterectomy and sacrocolpopexy. Moderate-quality evidence suggests that these procedures take longer with RAS but may be associated with a shorter hospital stay following hysterectomy. We found limited evidence on the effectiveness and safety of RAS compared with CLS or open surgery for surgical procedures performed for gynaecological cancer; therefore its use should be limited to clinical trials. Ongoing trials are likely to have an important impact on evidence related to the use of RAS in gynaecology.

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Conflict of interest statement

The review authors have reported no known conflicts of interest.

Figures

Figure 1
Figure 1
Study flow diagram for updated searches (30 June 2014).
Figure 2
Figure 2
Risk of bias summary: review authors' judgements about each risk of bias item for each included study.
Figure 3
Figure 3
Intraoperative and postoperative complications, with Martinez‐Maestro 2014 included.
Figure 4
Figure 4
Total operating time, with Martinez‐Maestro 2014 included.
Analysis 1.1
Analysis 1.1
Comparison 1 Robot‐assisted surgery versus conventional laparoscopic surgery, Outcome 1 Intraoperative and postoperative complications.
Analysis 1.2
Analysis 1.2
Comparison 1 Robot‐assisted surgery versus conventional laparoscopic surgery, Outcome 2 Intraoperative complications.
Analysis 1.3
Analysis 1.3
Comparison 1 Robot‐assisted surgery versus conventional laparoscopic surgery, Outcome 3 Sensitivity analysis: intraoperative complications.
Analysis 1.4
Analysis 1.4
Comparison 1 Robot‐assisted surgery versus conventional laparoscopic surgery, Outcome 4 Complications: intraoperative injury.
Analysis 1.5
Analysis 1.5
Comparison 1 Robot‐assisted surgery versus conventional laparoscopic surgery, Outcome 5 Postoperative complications.
Analysis 1.6
Analysis 1.6
Comparison 1 Robot‐assisted surgery versus conventional laparoscopic surgery, Outcome 6 Sensitivity analysis: postoperative complications.
Analysis 1.7
Analysis 1.7
Comparison 1 Robot‐assisted surgery versus conventional laparoscopic surgery, Outcome 7 Complications: bleeding.
Analysis 1.8
Analysis 1.8
Comparison 1 Robot‐assisted surgery versus conventional laparoscopic surgery, Outcome 8 Complications: infection.
Analysis 1.9
Analysis 1.9
Comparison 1 Robot‐assisted surgery versus conventional laparoscopic surgery, Outcome 9 Total operating time.
Analysis 1.10
Analysis 1.10
Comparison 1 Robot‐assisted surgery versus conventional laparoscopic surgery, Outcome 10 Operating room time [min].
Analysis 1.11
Analysis 1.11
Comparison 1 Robot‐assisted surgery versus conventional laparoscopic surgery, Outcome 11 Overall hospital stay.
Analysis 1.12
Analysis 1.12
Comparison 1 Robot‐assisted surgery versus conventional laparoscopic surgery, Outcome 12 Conversion to another approach.
Analysis 1.13
Analysis 1.13
Comparison 1 Robot‐assisted surgery versus conventional laparoscopic surgery, Outcome 13 Blood transfusions.
Analysis 1.14
Analysis 1.14
Comparison 1 Robot‐assisted surgery versus conventional laparoscopic surgery, Outcome 14 Estimated blood loss.
Analysis 1.15
Analysis 1.15
Comparison 1 Robot‐assisted surgery versus conventional laparoscopic surgery, Outcome 15 Pain at 1 to 2 weeks.
Analysis 1.16
Analysis 1.16
Comparison 1 Robot‐assisted surgery versus conventional laparoscopic surgery, Outcome 16 Quality of life (6 weeks).
Analysis 1.17
Analysis 1.17
Comparison 1 Robot‐assisted surgery versus conventional laparoscopic surgery, Outcome 17 Quality of life (6 months).
Analysis 1.18
Analysis 1.18
Comparison 1 Robot‐assisted surgery versus conventional laparoscopic surgery, Outcome 18 Reintervention.
Analysis 1.19
Analysis 1.19
Comparison 1 Robot‐assisted surgery versus conventional laparoscopic surgery, Outcome 19 Readmission.
Analysis 1.20
Analysis 1.20
Comparison 1 Robot‐assisted surgery versus conventional laparoscopic surgery, Outcome 20 Overall cost.
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References

References to studies included in this review

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    1. Green JL, Deimling T, Tam T, Davies MF, Harkins GJ. A randomized controlled trial comparing conventional laparoscopic hysterectomy with robot‐assisted laparoscopic hysterectomy in a teaching institution. Journal of Minimally Invasive Gynecology Conference: 42nd Global Congress of Minimally Invasive Gynecology, AAGL 2013 Washington, DC United States. Conference Start: 20131110 Conference End: 20131114. Conference Publication:(var.pagings). 2013:S4.
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    1. Lonnerfors C, Reynisson P, Persson J. A randomized trial comparing vaginal‐ and laparoscopic hysterectomy to robot‐assisted hysterectomy. Journal of Minimally Invasive Gynecology 2014;Jul 18:doi: 10.1016/j.jmig.2014.07.010. [Epub ahead of print]. - PubMed
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References to studies excluded from this review

    1. Advincula AP, Xiao Xu, Goudeau S, Ransom SB. Robot‐assisted laparoscopic myomectomy versus abdominal myomectomy: a comparison of short‐term surgical outcomes and immediate costs. Journal of Minimally Invasive Gynecology 2007;14(6):698‐705. - PubMed
    1. Bell MC, Torgerson J, Seshadri‐Kreaden U, Suttle AW, Hunt S. Comparison of outcomes and cost for endometrial cancer staging via traditional laparotomy, standard laparoscopy and robotic techniques. Gynecologic Oncology 2008;111(3):407‐11. - PubMed
    1. Boggess JF, Gehrig PA, Cantrell L, Shafer A, Ridgway M, Skinner EN, et al. A case‐control study of robot‐assisted type III radical hysterectomy with pelvic lymph node dissection compared with open radical hysterectomy. American Journal of Obstetrics and Gynecology 2008;199(4):357.e1‐7. - PubMed
    1. Boggess JF, Gehrig PA, Cantrell L, Shafer A, Ridgway M, Skinner EN, et al. A comparative study of 3 surgical methods for hysterectomy with staging for endometrial cancer: robotic assistance, laparoscopy, laparotomy. American Journal of Obstetrics and Gynecology 2008;199(4):360.e1‐9. - PubMed
    1. Campos LS, Limberger LF, Stein AT, Kalil AN. Postoperative pain and perioperative outcomes after laparoscopic radical hysterectomy and abdominal radical hysterectomy in patients with early cervical cancer: a randomised controlled trial. Trials 2013;14:293. - PMC - PubMed

References to ongoing studies

    1. Kjölhede P. RCT comparing robot assisted laparoscopic hysterectomy to abdominal hysterectomy in endometrial cancer [NCT01526655]. Clinicaltrials.gov2012.
    1. Soto E. Laparoscopy vs. robotic surgery for endometriosis (LAROSE): a prospective randomized controlled trial [NCT01556204]. Clinicaltrials.gov2012. - PubMed
    1. Narducci F. Perioperative morbidity in gyneco‐oncology according to the procedure: coelioscopy vs robot‐assisted coelioscopy [NCT01247779]. Clinicaltrials.gov2010.
    1. Obermair A, Gebski V, Frumovitz M, Soliman PT, Schmeler KM, Levenback C. A phase III randomized clinical trial comparing laparoscopic or robotic radical hysterectomy with abdominal radical hysterectomy in patients with early stage cervical cancer [NCT00614211]. Journal of Minimally Invasive Gynecology 2008;15(5):584‐8. - PubMed
    1. Falconer H. Robotic versus abdominal surgery for endometrial cancer (RASHEC) [NCT01847703]. Clinicaltrials.gov2013.

Additional references

    1. Advincula AP, Song A, Burke W, Reynolds RK. Preliminary experience with robot‐assisted laparoscopic myomectomy. The Journal of the American Association of Gynecologic Laparoscopists 2004;11:511‐8. - PubMed
    1. Bell MC, Torgerson JL, Kreaden U. The first 100 da Vinci hysterectomies:an analysis of the learning curve for a single surgeon. S D Med 2009;62(91):93‐5. - PubMed
    1. Cadiere GB, Himpens J, Germay O, Izizaw R, Degueldre M, Vandromme J, et al. Feasibility of robotic laparoscopic surgery: 146 cases. World Journal of Surgery 2001;25:1467‐77. - PubMed
    1. Cela V, Freschi L, Simi G, Tana R, Russo N, Artini PG, et al. Fertility and endocrine outcome after robot‐assisted laparoscopic myomectomy (RALM). Gynecological Endocrinology 2013;29(1):79‐82. - PubMed
    1. Cho JE, Nezhat FR. Robotics and gynecologic oncology: review of the literature. Journal of Minimally Invasive Gynecology 2009;16(6):669‐81. - PubMed

References to other published versions of this review

    1. Liu H, Lu D, Wang L, Shi G, Song H, Clarke J. Robotic surgery for benign gynaecological disease. Cochrane Database of Systematic Reviews 2012, Issue 2. [DOI: 10.1002/14651858.CD008978.pub2] - DOI - PubMed
    1. Lu D, Liu Z, Shi G, Liu D, Zhou X. Robotic assisted surgery for gynaecological cancer. Cochrane Database of Systematic Reviews 2012, Issue 1. [DOI: 10.1002/14651858.CD008640.pub2] - DOI - PubMed

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