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 Wertheim Laparoscopy Robot Telesurgery 1898 1994 2003

ROBOTIC SURGERY

Robot console 3D View Ergonomic position surgeon 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

Obesity 2009

Obesity

Endometrial Cancer 1985 13.5

Endometrial Cancer 1995 13.9

Endometrial Cancer 2001 16.5

Endometrial Cancer 2010 20.5

Endometrial Cancer 1995 - 13.9 / 100,000 2015 - 27.8 / 100,000 x 2

Risico factoren voor endometrium carcinoom

Laparoscopic vs Open Hysterectomy for Endometrial Cancer COMPLICATIONS Just RCTs

Laparoscopic Vs Open Surgery Endometrial Cancer Recurrence % Overall Survival % Disease-free survival % Kalogiannidis et al LH 8.7 93 91 AH 16 86 84 Zullo et al 20 82.5 NR 18.4 84.2 Nezhat et al 5.9 88.5 7.8 85 Malzioni et al 8.6 93.2 91.4 11.5 91.1

Laparoscopic Vs Open Surgery Endometrial Cancer Level 1 evidence Longer operating time Shorter hospital stay Less blood loss Less post-operative complications

National statistics for endometrial cancer Acknowledgment to Osama Abughazza

Robotic Surgery Endometrial Cancer

Laparoscopic Vs Open Surgery Vs Robotic Endometrial Cancer Pats ORT (min) LOS (days) EBL (ml) LN ALN PLN Conv (%) Comps (%) Boggess 2008 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 4.4 266 14.9 3 11.5 29.7 Veljovich 2008 25 283 1.7 66.6 17.5 20 4 255 20.3 131 139 5.3 198 13.1 29 Bell 2008 40 184 2.3 166 17 7.5 30 171 2 253 17.1 109 316 27.5 DeNardis 2008 56 177 105 19.8 6.5 13.3 106 79 3.2 241 19 6.6 12.4

Laparoscopic Vs Open Surgery Vs Robotic Endometrial Cancer Pats ORT (min) LOS (days) EBL (ml) LN ALN PLN Conv (%) Comps (%) Gaia 2010 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 9.9 333 207 1.2 101 27.4 9.4 18 AH 606 130 3.9 291 20.2 5.7 14.5 Seamon 2009 105 242 1 88 31 10 21 12.4 76 287 2 200 33 11 22 26.3 109 228 27 8.5 15.6 191 143 3 394 25.9 7.2 18.7 Coronado 2012 71 189 3.5 99 2.8 21.2 84 218 4.6 190 8.1 28.5 192 157 231 34.9

Robotic Surgery For Endometrial Cancer COSTS ??? Robotic Surgery For Endometrial Cancer

Costs Before & After

Laparoscopic Vs Open Surgery Vs Robotic Endometrial Cancer – Lau et al Acknowledgement – Slide provided by Walter Gotlieb, Canada.

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) p-value BMI (mean) Obese (30-39.9) Morbidly Obese (>40) 27.6 31.9% 8.8% 29.8 33.6% 16% 0.005 Age (mean) <56 56-65 66-75 >75 65.3 20 36 23 22 65.7 18 21 25 0.9 Complications > gr2 41.9% 13.3% <0.0001 Wound complications 15.6% 3.5% Acknowledgement – Slide provided by Walter Gotlieb, Canada.

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 (n=143) p-value Time (skin to skin, min.) 207(159- 244) 241 (205-272) <0.0001 EBL (ml) 266 (100-300) 73 (20-100) Hospital stay (days) 5 (4-6) 1 (1-2) 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 Robot N = 122 Oper. Time 147.2 min LN N = 19.2 Blood loss 81.1 ml Hosp. 1.5 days Laparoscopy 186.8 min N = 24.7 207.4 ml 3.2 days Lim et al, Gynecol Oncol 2011

Robotic hysterectomy + LND versus Laparoscopic hysterectomy + LND: surgical outcomes at a minimally invasive surgical center Cardenas et al, Gynecol Oncol 2010 Robot N= 102 Oper. Time 237 min Blood loss 109 ml Laparoscopy N = 173 178 min 187 ml n LNs and complications equal

Robotic surgery for patients with low and high BMI in a German Gynecological Cancer Center Kannisto et al, Arch Gynecol 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 exposed paraaortic field (1) - bladder injury (1) Late complications: vaginal dehiscence (2), vaginal hemorrhage (1), cuff hematoma (4), Lymphocyst (1), urinary tract injuries, ureter (2)

50 Robot Robot versus Laparoscopic nerve-sparing radical hysterectomy for early-stage cervical cancer Chong et al, Int J Gynecol Cancer, 2013 July Robot N = 50 Oper. Time 230.1 min LN N = 25 Blood loss 54.9 ml Normal res. urine 9.6 days Laparoscopy 211.2 min N = 23.1 201.9 ml Normal res. urine. 11 days 50 Robot P<0.001

Robot versus Laparoscopic nerve-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

Robotic vs Laparoscopic Surgery Endometrial Cancer Days Stay

Robotic vs Laparoscopic Surgery Endometrial Cancer EBL

Robotic vs Laparoscopic Surgery Endometrial Cancer Complications

Robotic vs Laparoscopic Surgery Endometrial Cancer Conversions

GYNAECOLOGY/ONCOLOGY in AZ St. Jan BRUGES 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

BLADDER Vessel Sealer for dissecting Para-Vesical and Para-Rectal space in Robot Radical Hysterectomy Para-Vesical Space UTERUS LEFT OVARY

Vessel Sealer for opening space between bladder and cervix/vagina Left uterine artery Vessel Sealer for opening space between bladder and cervix/vagina Left ureter

Vessel Sealer for opening para-rectal space Identification of splanchnic (Hypogastric) nerves in meso-ureter during Radical Hyterectomy. Splanchnic nerves 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)

Aorta Lymph node tissue Left Coimmon Iliac Artery Vessel Sealer for lymph node dissection at Para-aortic region (here left side)

Left Para-aortic region

Aorta Left Ureter Inferior Mesenteric Artery Left Para-aortic Region after removal LN

Aorta Vena Cava Right Ureter Lymph nodes

Aorta-Vena Cava-Ureter Right Right Common Iliac Artery Aorta-Vena Cava-Ureter Right

Radical Hysterectomy (end of procedure) BLADDER Ureters

after PLND and Radical Hysterectomy BLADDER PUBIC BONE after PLND and Radical Hysterectomy Obliterated Hypogastric Artery Vaginal swab OBTURATOR NERVE VAGINA open EXT ILIAC VESSELS RIGHT URETER

VAGINA closed RIGHT URETER PUBIC BONE BLADDER Obliterated Hypogastric Artery OBTURATOR NERVE VAGINA closed 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