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

2. Robotics in gynecologic oncology
Radical hysterectomy
Sentinel procedure with fluorescence imaging
Radical trachelectomy
Hysterectomy (especially in obese patients)
Pelvic and/or para-aortic lymphadenectomy as staging procedure
Parametrectomy
Exenteration …

3. Robotics in gynecologic oncology
Radical hysterectomy
Sentinel procedure with fluorescence imaging
Radical trachelectomy
Hysterectomy (especially in obese patients)
Pelvic and/or para-aortic lymphadenectomy as staging procedure
Parametrectomy
Exenteration …

4. Advantages for Surgeons Technological Comparison With Laparoscopy
Features
Laparascopy
Robotics
Instruments
Rigid
Articulated - 360°
Movement
Direct
Downscaled
Pressure below 8 mm Hg
Difficult
Easy
Hand instruments
Opposite
Follows hand
Haptics
(No)
Tremor
Yes No
Image
2-3D
3-D
Surgeon
Standing
Sitting
Arm fatigue
Learning curve
Longer & steep
Faster & Easier
Control of 3 arms + camera

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. Pelvic plexus Hypogastric nerve Pelvic splanchnic nerves
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 Performance Evidence-Based Medicine : Level of Evidence
Level I
Adequately powered, high quality randomized trial, or meta-analysis of randomised trials showing statistically consistent results
Level II
Randomised trials inadequately powered, possibly biased, or showing statistically inconsistent results
Level III
Non-randomised studies with concurrent controls
Level IV
Non-randomised studies with historical controls (ie, typical single-arm phase II studies)
Level V
Expert committee review, case reports, retrospective studies
then comes the methodology
And we have to look forthe best level of evidence
Tannock IF, et al. Eur J Cancer Supplements. 2003;1(5):

8. FIRST REPORT : Childers JM, et al. Obstet Gynecol. 1994;83(4):597-600.
Take into account the time it took to obtain level I evidence for laparoscopy early stage endometrial cancers,
FIRST REPORT : Childers JM, et al. Obstet Gynecol. 1994;83(4):

9. Many RCT have been pulblished last year

10. Robotic RH compared with open RH:
Meta-Analysis Comparing Robotic Wertheim (RH) With Open Wertheim O’Neill Arch Gynecol 2013
Robotic RH compared with open RH:
Significantly different:
Reduced blood loss
Reduction for transfusion
Shorter hospital stay
Fewer complications (P = .06)
Longer operation duration, but no longer significant after excluding 1 outlier (Schreuder < 30 patients)
O’Neil M, et al. Arch Gynecol Obstet. 2013;287(5):

11. Robotic HT+Ln compared with open HT+Ln:
Meta-Analysis Comparing Robotic HT+Ln With Open HT+Ln O’Neill Arch Gynecol 2013
Robotic HT+Ln compared with open HT+Ln:
Significantly different:
Reduced blood loss
Reduction for transfusion
Shorter hospital stay
Fewer complications
But, longer operation duration
O’Neil M, et al. Arch Gynecol Obstet. 2013;287(5):

12. Robotic vs Laparoscopic Wertheim Reza Br J Surg 2013
Robotic RH compared with laparoscopic RH:
Significantly different:
Reduced blood loss
Tendency but not significantly different (numbers very low for laparoscopy):
Duration of hospitalization
Need for conversion
LN number
Duration of operation
Reza M, et al. Br J Surgery. 2010;97(12):

13. Robotic HT+LN compared with Laparoscopic HT + LN:
Meta-Analysis Comparing Robotic HT+ LN With Laparoscopic HT +LN O’Neill Arch Gynecol 2013
Robotic HT+LN compared with Laparoscopic HT + LN:
Significantly different:
Reduced blood loss
Shorter hospital stay
Fewer complications
Fewer conversions
O’Neil M, et al. Arch Gynecol Obstet. 2013;287(5):

15. 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.

16. Further Criticial Evaluation of Robotic RH
Learning curve
Bladder function after nerve-sparing RRH
Do robotics reduce the possibility for training fellows?
Costs and RRH
Oncologic follow-up

17. Further Criticial Evaluation of Robotic RH
Learning curve
Bladder function after nerve-sparing RRH
Do robotics reduce the possibility for training fellows?
Costs and RRH
Oncologic follow-up

18. Robotic RH and Cost in Europe Reynisson (Sweden) Gynecol Oncol 2013 n = 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. Gynecol Oncol. 2013;130(1):95-99.

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

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

21. Robotic RH and Cost
Cost of new technologies are always relatively high and drop as the market grows and industry competition drives down costs of equipment

22. Oncologic Follow-Up After Robotic Radical Hysterectomy
Few data exist, but recently some interesting data were presented:

23. Oncologic Follow-Up After Robotic Radical Hysterectomy Jackson et al (North Carolina) ASCO 2013
121 robotic RH compared with 97 open RH ( )
80% Stage Ib1
No differences in age, stage, short-term and long-term complications and comorbidities
Median follow-up 25 months
PFS significantly better with robotic RH compared with open RH (HR: 3,12, CI: )
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.

24. Oncologic Follow-Up After Robotic Radical Hysterectomy Vergote et al (Belgium) SERGS 2013
102 Robotic RH
9% Ia, 66% Stage Ib1, 4% Ib2, 22% II
17 patients after neoadjuvant chemotherapy (Ib2-IIb)
Median follow-up 24 months
Recurrences: 14%, 10 recurrences in the pelvis, 5 with distant metastases, no port site metastases
3 deaths due to cancer
Vergote I. Presented at: Society of European Robotic Gynaecological Surgery (SERGS) Meeting; June 2013: London, United Kingdom.

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

26. European Institute of Oncology, Milan: Oncologic Results
ARH RRH
Primary Recurrences (2.7%) (7.1%)
Pelvis (67%) (71%)
Pelvis+abdomen
Distance
Port site *
DOD
*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).

27. 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

28. Robot-assisted surgery is still in its infancy!
Advanced Instrumentation
Surgeon Training
Fusion of MR and Robotic image
Double teaching console
Not only does the Si offer superior vision, precision and control, but we view it as the ultimate surgical cockpit where surgeons have access to all their tools from the surgeon console. And today we’re going to discuss 4 of our new platform technologies for the Si. Advanced instruments, surgeon training, advanced imaging and single-access surgery.
Advanced Imaging
Single Access Surgery

30. Comparison of laparoscopy with robotic surgery
Annual SERGS Meeting
on Robotic Gynaecological Surgery
22.– · 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 Leuven / Belgium