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Annals of Surgery Mar 2021Describe clinical outcomes (eg, postoperative complications, survival) after robotic surgery compared to open or laparoscopic surgery.
OBJECTIVE
Describe clinical outcomes (eg, postoperative complications, survival) after robotic surgery compared to open or laparoscopic surgery.
BACKGROUND
Robotic surgery utilization has increased over the years across a wide range of surgical procedures. However, evidence supporting improved clinical outcomes after robotic surgery is limited.
METHODS
We systematically searched MEDLINE, EMBASE, and the Cochrane Central Register of systematic reviews from inception to January 2019 for systematic reviews describing postoperative outcomes after robotic surgery. We qualitatively described patient outcomes of commonly performed robotic procedures: radical prostatectomy, hysterectomy, lobectomy, thymectomy, rectal resection, partial nephrectomy, distal gastrectomy, Roux-en-Y gastric bypass, hepatectomy, distal pancreatectomy, and cholecystectomy.
RESULTS
One hundred fifty-four systematic reviews included 336 studies and 18 randomized controlled trials reporting on patient outcomes after robotic compared to laparoscopic or open procedures. Data from the randomized controlled trials demonstrate that robotic-assisted radical prostatectomy offered fewer biochemical recurrence and improvement in quality of recovery and pain scores only up to 6 weeks postoperatively compared to open radical prostatectomy. When compared to laparoscopic prostatectomy, robotic surgery offered improved urinary and sexual functions. Robotic surgery for endometrial cancer had fewer conversion to open compared to laparoscopic. Otherwise, robotic surgery outcomes were similar to conventional surgical approaches for other procedures except for radical hysterectomy where minimally invasive approaches may result in patient harm compared to open approach.
CONCLUSION
Robotic surgery has been widely incorporated into practise despite limited supporting evidence. More rigorous research focused on patient-important benefits is needed before further expansion of robotic surgery.
Topics: Humans; Laparoscopy; Laparotomy; Postoperative Complications; Robotic Surgical Procedures; Survival Rate
PubMed: 32398482
DOI: 10.1097/SLA.0000000000003915 -
JAMA Oncology Jul 2020Minimally invasive techniques are increasingly common in cancer surgery. A recent randomized clinical trial has brought into question the safety of minimally invasive... (Meta-Analysis)
Meta-Analysis
IMPORTANCE
Minimally invasive techniques are increasingly common in cancer surgery. A recent randomized clinical trial has brought into question the safety of minimally invasive radical hysterectomy for cervical cancer.
OBJECTIVE
To quantify the risk of recurrence and death associated with minimally invasive vs open radical hysterectomy for early-stage cervical cancer reported in observational studies optimized to control for confounding.
DATA SOURCES
Ovid MEDLINE, Ovid Embase, PubMed, Scopus, and Web of Science (inception to March 26, 2020) performed in an academic medical setting.
STUDY SELECTION
In this systematic review and meta-analysis, observational studies were abstracted that used survival analyses to compare outcomes after minimally invasive (laparoscopic or robot-assisted) and open radical hysterectomy in patients with early-stage (International Federation of Gynecology and Obstetrics 2009 stage IA1-IIA) cervical cancer. Study quality was assessed with the Newcastle-Ottawa Scale and included studies with scores of at least 7 points that controlled for confounding by tumor size or stage.
DATA EXTRACTION AND SYNTHESIS
The Meta-analysis of Observational Studies in Epidemiology (MOOSE) checklist was used to abstract data independently by multiple observers. Random-effects models were used to pool associations and to analyze the association between surgical approach and oncologic outcomes.
MAIN OUTCOMES AND MEASURES
Risk of recurrence or death and risk of all-cause mortality.
RESULTS
Forty-nine studies were identified, of which 15 were included in the meta-analysis. Of 9499 patients who underwent radical hysterectomy, 49% (n = 4684) received minimally invasive surgery; of these, 57% (n = 2675) received robot-assisted laparoscopy. There were 530 recurrences and 451 deaths reported. The pooled hazard of recurrence or death was 71% higher among patients who underwent minimally invasive radical hysterectomy compared with those who underwent open surgery (hazard ratio [HR], 1.71; 95% CI, 1.36-2.15; P < .001), and the hazard of death was 56% higher (HR, 1.56; 95% CI, 1.16-2.11; P = .004). Heterogeneity of associations was low to moderate. No association was found between the prevalence of robot-assisted surgery and the magnitude of association between minimally invasive radical hysterectomy and hazard of recurrence or death (2.0% increase in the HR for each 10-percentage point increase in prevalence of robot-assisted surgery [95% CI, -3.4% to 7.7%]) or all-cause mortality (3.7% increase in the HR for each 10-percentage point increase in prevalence of robot-assisted surgery [95% CI, -4.5% to 12.6%]).
CONCLUSIONS AND RELEVANCE
This systematic review and meta-analysis of observational studies found that among patients undergoing radical hysterectomy for early-stage cervical cancer, minimally invasive radical hysterectomy was associated with an elevated risk of recurrence and death compared with open surgery.
Topics: Female; Humans; Hysterectomy; Minimally Invasive Surgical Procedures; Observational Studies as Topic; Survival Analysis; Uterine Cervical Neoplasms
PubMed: 32525511
DOI: 10.1001/jamaoncol.2020.1694 -
The Lancet. Oncology Aug 2022The trade-off between comparative effectiveness and reproductive morbidity of different treatment methods for cervical intraepithelial neoplasia (CIN) remains unclear.... (Meta-Analysis)
Meta-Analysis
Comparative effectiveness and risk of preterm birth of local treatments for cervical intraepithelial neoplasia and stage IA1 cervical cancer: a systematic review and network meta-analysis.
BACKGROUND
The trade-off between comparative effectiveness and reproductive morbidity of different treatment methods for cervical intraepithelial neoplasia (CIN) remains unclear. We aimed to determine the risks of treatment failure and preterm birth associated with various treatment techniques.
METHODS
In this systematic review and network meta-analysis, we searched MEDLINE, Embase, and the Cochrane Central Register of Controlled Trials database for randomised and non-randomised studies reporting on oncological or reproductive outcomes after CIN treatments from database inception until March 9, 2022, without language restrictions. We included studies of women with CIN, glandular intraepithelial neoplasia, or stage IA1 cervical cancer treated with excision (cold knife conisation [CKC], laser conisation, and large loop excision of the transformation zone [LLETZ]) or ablation (radical diathermy, laser ablation, cold coagulation, and cryotherapy). We excluded women treated with hysterectomy. The primary outcomes were any treatment failure (defined as any abnormal histology or cytology) and preterm birth (<37 weeks of gestation). The network for preterm birth also included women with untreated CIN (untreated colposcopy group). The main reference group was LLETZ for treatment failure and the untreated colposcopy group for preterm birth. For randomised controlled trials, we extracted group-level summary data, and for observational studies, we extracted relative treatment effect estimates adjusted for potential confounders, when available, and we did random-effects network meta-analyses to obtain odds ratios (ORs) with 95% CIs. We assessed within-study and across-study risk of bias using Cochrane tools. This systematic review is registered with PROSPERO, CRD42018115495 and CRD42018115508.
FINDINGS
7880 potential citations were identified for the outcome of treatment failure and 4107 for the outcome of preterm birth. After screening and removal of duplicates, the network for treatment failure included 19 240 participants across 71 studies (25 randomised) and the network for preterm birth included 68 817 participants across 29 studies (two randomised). Compared with LLETZ, risk of treatment failure was reduced for other excisional methods (laser conisation: OR 0·59 [95% CI 0·44-0·79] and CKC: 0·63 [0·50-0·81]) and increased for laser ablation (1·69 [1·27-2·24]) and cryotherapy (1·84 [1·33-2·56]). No differences were found for the comparison of cold coagulation versus LLETZ (1·09 [0·68-1·74]) but direct data were based on two small studies only. Compared with the untreated colposcopy group, risk of preterm birth was increased for all excisional techniques (CKC: 2·27 [1·70-3·02]; laser conisation: 1·77 [1·29-2·43]; and LLETZ: 1·37 [1·16-1·62]), whereas no differences were found for ablative methods (laser ablation: 1·05 [0·78-1·41]; cryotherapy: 1·01 [0·35-2·92]; and cold coagulation: 0·67 [0·02-29·15]). The evidence was based mostly on observational studies with their inherent risks of bias, and the credibility of many comparisons was low.
INTERPRETATION
More radical excisional techniques reduce the risk of treatment failure but increase the risk of subsequent preterm birth. Although there is uncertainty, ablative treatments probably do not increase risk of preterm birth, but are associated with higher failure rates than excisional techniques. Although we found LLETZ to have balanced effectiveness and reproductive morbidity, treatment choice should rely on a woman's age, size and location of lesion, and future family planning.
FUNDING
National Institute for Health and Care Research: Research for Patient Benefit.
Topics: Conization; Female; Humans; Infant, Newborn; Network Meta-Analysis; Premature Birth; Uterine Cervical Neoplasms; Uterine Cervical Dysplasia
PubMed: 35835138
DOI: 10.1016/S1470-2045(22)00334-5 -
European Journal of Obstetrics,... Oct 2023Following compelling evidence that open techniques may be related to better survival and disease free survival rates, many gynecologic oncologists in the US have turned... (Meta-Analysis)
Meta-Analysis Review
OBJECTIVE
Following compelling evidence that open techniques may be related to better survival and disease free survival rates, many gynecologic oncologists in the US have turned away from performing laparoscopic radical hysterectomy (LRH) and robotic radical hysterectomy (RRH) for the treatment of early-stage cervical cancer. While this may be warranted as a safety concern, there is little high-quality data on the head-to-head comparison of LRH and RRH and therefore little evidence to answer the question of where this decrease in patient survival is originating from. In our systematic review, we aimed to compare the complications and outcomes of LRH against those of RRH.
DATA SOURCES
We searched PubMed, Cochrane CENTRAL, Medline, ClinicalTrials.Gov, SCOPUS, and Web of Science from database inception until February 1st, 2022.
METHODS OF STUDY SELECTION
A total of 676 studies were identified and screened through a manual three-step process. Ultimately 33 studies were included in our final analysis. We included all studies that compared LRH and RRH and included at least one of our selected outcomes. We included retrospective cohorts, prospective cohorts, case-control, and randomized clinical trials.
TABULATION, INTEGRATION, AND RESULTS
Data was independently extracted manually by multiple observers and the analysis was performed using Review Manager Software. PRISMA guidelines were followed. We analyzed homogenous data using a fixed-effects model, while a random-effects model was used for heterogeneous outcomes. We found that following RRH, women had a decreased hospital stay (MD = 0.80[0.38,1.21],(P < 0.002). We found no differences in estimated blood loss (MD = 35.24[-0.40,70.89],(P = 0.05), blood transfusion rate ((OR = 1.32[0.86,2.02],(P = 0.20), rate of post-operative complications (OR = 0.84[0.60,1.17],(P = 0.30), the operative time (MD = 6.01[-4.64,16.66],(P = 0.27), number of resected lymph node (MD = -1.22[-3.28,0.84],(P = 0.25) intraoperative complications (OR = 0.78[0.51,1.19],(P = 0.25), five-year overall survival (OR = 1.37[0.51,3.69],(P = 0.53), lifetime disease free survival (OR = 0.89[0.59,1.32],(P = 0.55), intraoperative and postoperative mortality (within 30 days) (OR = 1.30[0.66,2.54],(P = 0.44), and recurrence (OR = 1.14[0.79,1.64],(P = 0.50).
CONCLUSIONS
RRH seems to result in the patient leaving the hospital sooner after surgery. We were unable to find any differences in our ten other outcomes related to complications or efficacy. These findings suggest that the decreased survival seen in minimally invasive RH in previous studies could be due to factors inherent to both LRH and RRH.
PROSPERO PROSPECTIVE REGISTRATION NUMBER
CRD42022273727.
Topics: Female; Humans; Robotic Surgical Procedures; Prospective Studies; Retrospective Studies; Uterine Cervical Neoplasms; Hysterectomy; Laparoscopy
PubMed: 37690282
DOI: 10.1016/j.ejogrb.2023.09.002 -
European Journal of Surgical Oncology :... Apr 2024This systematic review (SR) and meta-analysis aims to compare the surgery-related results and oncological outcomes between SH and RH in patients with early-stage... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
This systematic review (SR) and meta-analysis aims to compare the surgery-related results and oncological outcomes between SH and RH in patients with early-stage cervical cancer.
METHOD
We systematically searched databases including PubMed, Embase and Cochrane to collect studies that compared oncological and surgery-related outcomes between SH and RH groups in patients with stage IA2 and IB1 cervical cancer. A random-effect model calculated the weighted average difference of each primary outcome via Review Manager V.5.4.
RESULT
Seven studies comprising 6977 patients were included into our study. For oncological outcomes, we found no statistical difference in recurrence rate [OR = 0.88; 95% CI (0.50, 1.57); P = 0.68] and Overall Survival (OS) [OR = 1.23; 95% CI (0.69, 2.19), P = 0.48]. No difference was detected in the prevalence of positive LVSI and lymph nodes metastasis between the two groups. Concerning surgery-related outcomes, the comprehensive effects revealed that the bladder injury [OR = 0.28; 95% CI (0.08, 0.94), P = 0.04] and bladder disfunction [OR = 0.10; 95% CI (0.02, 0.53), P = 0.007] of the RH group were higher compared to the SH group.
CONCLUSION
This meta-analysis suggested there are no significant differences in terms of both recurrence rate and overall survival among patients with stage IA2-IB1 cervical cancer undergoing SH or RH, while the SH group has better surgery-related outcomes. These data confirm the need to narrow the indication for RH in early-stage cervical cancer.
Topics: Female; Humans; Disease-Free Survival; Uterine Cervical Neoplasms; Neoplasm Staging; Hysterectomy; Neoplasm Recurrence, Local; Retrospective Studies
PubMed: 38471373
DOI: 10.1016/j.ejso.2024.108252 -
Journal of Robotic Surgery Jun 2023The use of robotic surgery has increased exponentially in the United States. Despite this uptick in popularity, no standardized training pathway exists for surgical... (Review)
Review
The use of robotic surgery has increased exponentially in the United States. Despite this uptick in popularity, no standardized training pathway exists for surgical residents or practicing surgeons trying to cross-train onto the platform. We set out to perform a systematic review of existing literature to better describe and analyze existing robotic surgical training curricula amongst academic surgery programs. A systematic electronic search of the PubMed, Cochrane, and EBSCO databases was performed for articles describing simulation in robotic surgery from January 2010 to May 2022. Medical Subject Heading (MeSH) terms and keywords used to conduct this search were "Robotic," "Surgery," "Robotic Surgery," "Training," "Curriculum," "Education," and "Residency Program." A total of 110 articles were identified for the systematic review. After screening the titles and abstracts, a total of 36 full-text original articles were included in this systematic review. Of these, 24 involved robotic surgery curricula designed to teach general robotic skills, whereas the remaining 12 were for teaching procedure specific skills. Of the 24 studies involving general robotic skills, 13 included didactics as a part of the curriculum, 23 utilized virtual reality trainers, 3 used inanimate tissue, and 1 used live animal models. Of the 12 papers reviewed regarding procedure specific curricula, seven involved urologic procedures (radical prostatectomy and nephrectomy), two involved general surgical procedures (colectomy and Roux-en-Y gastric bypass surgery), two involved obstetrics and gynecology procedures (hysterectomy with myomectomy and sacrocolpopexy, hysterectomy with pelvic lymphadenectomy) and one involved a cardiothoracic surgery procedure (robotic internal thoracic artery harvest). With the rapid implementation of robotic surgery, training programs have been tasked with the responsibility of ensuring their trainees are adequately proficient in the platform prior to graduation. However, due to the lack of uniformity between surgical training programs, when it comes to robotic surgical experience, a strong need persists for a standardized national robotics training curriculum.
Topics: Humans; Animals; Female; Pregnancy; Male; Robotic Surgical Procedures; Curriculum; Robotics; Colectomy; Computer Simulation
PubMed: 36413255
DOI: 10.1007/s11701-022-01500-y -
Journal of Minimally Invasive Gynecology Mar 2021To compare recurrence rate, progression-free survival (PFS), and overall survival for early-stage cervical cancer after minimally invasive (MIS) vs abdominal radical... (Meta-Analysis)
Meta-Analysis
OBJECTIVE
To compare recurrence rate, progression-free survival (PFS), and overall survival for early-stage cervical cancer after minimally invasive (MIS) vs abdominal radical hysterectomy.
DATA SOURCES
MEDLINE, Embase, Cochrane Central Register of Controlled Trials, and Cochrane Library databases.
METHODS OF STUDY SELECTION
We identified studies from 1990 to 2020 that included women with stage I or higher cervical cancer treated with primary radical hysterectomy and compared recurrence and/or PFS and overall survival with MIS vs abdominal radical hysterectomy. (The review protocol was registered with the International Prospective Register of Systematic Reviews: CRD4202173600).
TABULATION, INTEGRATION, AND RESULTS
We performed random-effects meta-analyses overall and by length of follow-up. Fifty articles on 40 cohort studies and 1 randomized controlled trial that included 22 593 women with cervical cancer met the inclusion criteria. Twenty percent of the studies had <36 months of follow-up, and 24% had more than 60 months of follow-up. The odds of PFS were worse for women undergoing MIS radical hysterectomy (odds ratio 1.54; 95% CI [confidence interval], 1.24-1.94; 14 studies). When limited to studies with longer follow-up, the odds of PFS were progressively worse with MIS radical hysterectomy (HR [hazard ratio] 1.48 for >36 months; 95% CI, 1.21-1.82; 10 studies; HR 1.69 for >48 months; 95% CI, 1.26-2.27; 5 studies; and HR 2.020 for >60 months; 95% CI, 1.36-3.001; 3 studies). For overall survival, the odds were not significantly different for MIS vs abdominal hysterectomy (odds ratio 0.94; 95% CI, 0.66-1.35; 14 studies) (HR 0.99 for >36 months; 95% CI, 0.66-1.48; 9 studies; HR 1.05 for >48 months; 95% CI, 0.57-1.94; 4 studies; and HR 1.35 for >60 months; 95% CI, 0.73-2.51; 3 studies).
CONCLUSION
In our meta-analysis of 50 studies, MIS radical hysterectomy was associated with worse PFS than open radical hysterectomy for early-stage cervical cancer. The emergence of this finding with longer follow-up highlights the importance of long-term, high-quality studies to guide cancer and surgical treatments.
Topics: Adenocarcinoma; Adult; Carcinoma, Squamous Cell; Cohort Studies; Female; Humans; Hysterectomy; Middle Aged; Minimally Invasive Surgical Procedures; Neoplasm Recurrence, Local; Neoplasm Staging; Progression-Free Survival; Randomized Controlled Trials as Topic; Survival Analysis; Uterine Cervical Neoplasms
PubMed: 33359291
DOI: 10.1016/j.jmig.2020.12.023 -
International Journal of Gynaecology... Jan 2023To evaluate the efficacy and safety of five different approaches to cervical cancer surgery. (Meta-Analysis)
Meta-Analysis Review
OBJECTIVE
To evaluate the efficacy and safety of five different approaches to cervical cancer surgery.
METHODS
We conducted a systematic search for comparative studies on different radical hysterectomy types for cervical cancer in PubMed, Embase, the Cochrane Library, and Web of Science databases. All included observational studies used survival analyses to compare clinical outcomes of patients undergoing different radical hysterectomy types. All studies were assessed by the Newcastle-Ottawa Scale with scores of at least seven points. We extracted the relevant data and conducted a network meta-analysis to compare clinical outcomes among five surgical approaches.
RESULTS
Thirty studies (n = 11 353) were included. Robotic surgery had the lowest blood loss volume and hospitalization duration; open surgery had the shortest operative time. Vaginal assisted laparoscopic surgery was associated with the highest number of resected lymph nodes and lowest rate of perioperative complications. Survival outcomes and tumor recurrence outcomes were similar among the approaches.
CONCLUSION
The current approaches to cervical cancer surgery have comparable efficacies.
Topics: Female; Humans; Uterine Cervical Neoplasms; Network Meta-Analysis; Neoplasm Recurrence, Local; Hysterectomy; Robotic Surgical Procedures; Laparoscopy; Neoplasm Staging
PubMed: 35373333
DOI: 10.1002/ijgo.14209 -
International Journal of Gynecological... Nov 2023The objective of this systematic review was to evaluate the effect of different types of neoadjuvant chemotherapy regimens, in terms of optimal pathological response and...
OBJECTIVE
The objective of this systematic review was to evaluate the effect of different types of neoadjuvant chemotherapy regimens, in terms of optimal pathological response and oncological outcomes, in patients with locally advanced cervical cancer.
METHODS
A systematic search of the literature was performed. MEDLINE through PubMed and Embase databases were searched from inception to June 2023. The study was registered in PROSPERO (ID number CRD42023389806). All women with a pathological diagnosis of locally advanced cervical cancer (International Federation of Gynecology and Obstetrics (FIGO) 2009 classification stages IB2-IVA), any age or histology, who underwent intravenous neoadjuvant chemotherapy before radical surgery, and articles only in English language, were included. We conducted a meta-analysis for optimal pathological response after surgery and survival outcomes. The risk of bias was assessed using the Newcastle-Ottawa scale and the Risk of Bias 2 (RoB) tools. The review methods and results were reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.
RESULTS
25 studies with a total number of 1984 patients fulfilled the eligibility criteria of our review and were included for data extraction and efficacy analysis. When compared with a two-drug regimen, the three-drug combination including cisplatin, paclitaxel, and ifosfamide or anthracyclines showed superior efficacy in terms of optimal pathological response with an odds ratio of 0.38 (95% CI 0.24 to 0.61, p<0.0001), with no difference in disease-free survival (hazard ratio (HR) 0.72, 95% CI 0.50 to 1.03, I=0%, p=0.07) and higher overall survival (HR 0.63, 95% CI 0.41 to 0.97, I=0%, p=0.03).
CONCLUSIONS
The three-drug combination of cisplatin, paclitaxel, and ifosfamide or anthracyclines showed a higher rate of complete or optimal partial response, with the triple regimens having an advantage over the platinum-based schedules in terms of overall survival. Neoadjuvant chemotherapy followed by radical surgery should not be considered a standard of care in locally advanced cervical cancer.
PubMed: 38011989
DOI: 10.1136/ijgc-2023-004863 -
Gynecologic and Obstetric Investigation 2022The aim of the study was to explore the effects of low-frequency electrical stimulation (LFES) in preventing urinary retention after radical hysterectomy (RH) in women... (Meta-Analysis)
Meta-Analysis
INTRODUCTION
The aim of the study was to explore the effects of low-frequency electrical stimulation (LFES) in preventing urinary retention after radical hysterectomy (RH) in women with cervical cancer.
METHODS
Seven electronic bibliographic databases were searched from inception to December 25, 2021. The mean difference (MD) or risk ratio (RR) with its corresponding 95% CI was selected as effect size. The meta-analysis of all data was conducted using RevMan 5.4 and the evidence was summarized according to GRADE (the grading of recommendation, assessment, development, and evaluation).
RESULTS
Twelve randomized control trials consisting of 1,033 women with cervical cancer who had undergone RH were included. Compared with women in the control group, women receiving LFES had improved therapeutic effect (RR = 0.22, 95% CI: 0.16-0.29) and reduced residual urine volume (MD = -32.27, 95% CI: -34.10 to -30.43) and catheter retention time (MD = -4.46, 95% CI: -5.17 to -3.76) following treatment. Muscle strength scores of pelvic floor type I and type II muscle fibers in the LFES group were also higher than in the control group (MD = 1.07, 95% CI: 0.91-1.24).
CONCLUSION
LFES may be an effective auxiliary treatment for women with cervical cancer after hysterectomy, which can help reduce the duration of indwelling urethral catheter and residual urine volume.
Topics: Female; Humans; Uterine Cervical Neoplasms; Hysterectomy; Pelvic Floor; Urinary Bladder; Electric Stimulation
PubMed: 36244342
DOI: 10.1159/000527148