Minimally invasive surgery in gynecologic oncology l.jpg
This presentation is the property of its rightful owner.
Sponsored Links
1 / 37

Minimally Invasive Surgery in Gynecologic Oncology PowerPoint PPT Presentation


  • 267 Views
  • Uploaded on
  • Presentation posted in: General

Minimally Invasive Surgery in Gynecologic Oncology. Financial Disclosure “As it pertains to CME, I have no relevant financial relationships with any commercial interest to disclose.”. Minimally Invasive Surgery in Gynecologic Oncology. William M. Merritt, MD April 2010. Objectives.

Download Presentation

Minimally Invasive Surgery in Gynecologic Oncology

An Image/Link below is provided (as is) to download presentation

Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author.While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server.


- - - - - - - - - - - - - - - - - - - - - - - - - - E N D - - - - - - - - - - - - - - - - - - - - - - - - - -

Presentation Transcript


Minimally invasive surgery in gynecologic oncology l.jpg

Minimally Invasive Surgery in Gynecologic Oncology

Financial Disclosure

“As it pertains to CME, I have no relevant financial relationships with any commercial interest to disclose.”


Minimally invasive surgery in gynecologic oncology2 l.jpg

Minimally Invasive Surgery in Gynecologic Oncology

William M. Merritt, MD

April 2010


Objectives l.jpg

Objectives

  • Reviews types of gynecologic cancer and treatments

  • Minimally Invasive Surgery (MIS)

  • Role of MIS in Gynecologic Oncology (and Gynecology)

  • Patient benefits and risks with MIS


2009 estimates on female cancer l.jpg

2009 Estimates on Female Cancer

Thousands

© 2009, American Cancer Society, http://www.cancer.org


Ovarian cancer l.jpg

Ovarian Cancer

  • 21,550 estimated new cases in 2009

  • Lifetime risk: 1.7%

  • Average age: 59

  • Risk Factors: family history

  • Symptoms

    • Bloating

    • Weight gain

    • Abdominal discomfort

    • Early satiety (feeling full)

    • Nausea

  • Detection:

    • Pelvic exam

    • Imaging (Ultrasound, CT Scan)

    • Ca-125

    • OVA1 (recently FDA approved)


Endometrial uterine cancer l.jpg

Endometrial/ Uterine Cancer

  • Most common gynecologic cancer

    • 42,160 new cases in 2009

  • Risk Factors: obesity, unopposed estrogen, no pregnancies

  • Symptoms:

    • Abnormal uterine bleeding

    • Bleeding after menopause

  • Detection:

    • Pelvic exam

    • Endometrial biopsy

    • Pelvic ultrasound


Slide7 l.jpg

Gehrig et al, Gyn Onc 2010


Cervical cancer l.jpg

Cervical Cancer

  • 11,270 new cases in the 2009

  • Death rates decreasing due to early detection

  • Risk factors:

    • HPV infection

    • Cigarette smoking

    • Sexual activity at an early age (exposure)

  • Symptoms:

    • Abnormal vaginal bleeding

    • Vaginal discharge

  • Detection:

    • Pelvic Exam

    • Pap smear / HPV testing


Vulvar cancer l.jpg

Vulvar Cancer

  • Rare: 4% of all gynecologic cancers

  • Risk factors

    • HPV

    • Smoking

    • Skin disorders of the vulva

  • Symptoms

    • Itching (itch scratch cycle)

    • Vulvar mass / ulcer

    • Bleeding

  • Detection

    • Pelvic exam

    • Biopsy


Treatment l.jpg

Fallopian Tube

Uterus

Ovary

Myometrium

Myometrium

Endometrium

Endometrium

Cervix

Vagina

Fallopian Tube

Uterus

Ovary

Cervix

Vagina

Treatment

  • Ovarian cancer

    • Surgery + chemotherapy

  • Endometrial cancer

    • Surgery ± radiation (± chemotherapy)

  • Cervical cancer

    • Surgery OR radiation + chemotherapy

  • Vulvar cancer

    • Surgery ± radiation


Surgical options l.jpg

Surgical Options

  • Traditional: Laparotomy

Midline vertical

Transverse


Minimally invasive surgery mis l.jpg

Minimally Invasive Surgery (MIS)

  • An approach to surgery whereby operations are performed with specialized instruments designed to be inserted through small incisions or natural body openings

  • Types

    • Laparoscopic

    • Robotic


What can be done with mis l.jpg

What can be done with MIS

  • Hysterectomy

    • Supracervical

    • Total

  • Tubes and ovaries

  • Myomectomy

    • Removal of fibroids

  • Lymph node dissection

    • Pelvic

    • Aortic

  • Diagnostic (looking)


Mis what s so good about it l.jpg

MIS – What’s so good about it?

  • Less post-operative pain

  • Shorter hospital stay

  • Less blood loss

  • Quicker return to normal activities

  • Smaller incisions


Are there any drawbacks l.jpg

Are there any drawbacks?

  • Not all procedures are safe to do with MIS

  • Time

    • Learning curve

    • Some cases take longer compared to traditional approach

  • Cost


Role of mis in endometrial cancer l.jpg

Role of MIS in endometrial cancer

  • Feasibility

    • Is it possible?

    • Reproducible?

  • Comparison with standard approach

    • Better, worse, and equivalent?

  • Risks/Benefits

    • Acute

    • Long term


Laparoscopy l.jpg

Laparoscopy


Laparoscopy vs laparotomy gog lap2 l.jpg

Laparoscopy vs Laparotomy – GOG LAP2

  • Study Population (1996-2005)

    • L/S: 1,696 Open: 920

      • Conversion rate: 434 (25.8%)

  • Surgical Staging

    • Lymph node dissection

      • 99% (open) vs. 98% (L/S)

        • Pelvic/aortic: 96% (open) vs. 92% (L/S)

        • Aortic: 97% vs. 94%

    • No difference in patients w/ advance surgical stage

Walker et al, JCO 2009


Slide19 l.jpg

Walker et al, JCO 2009


What do the patients think l.jpg

What do the patients think?

  • L/S (n=535) vs. open (n=267)

  • Quality of life (FACT-G)

    • Emotional

    • Physical

    • Social

    • Functional well-well being

  • 6 weeks

    • L/S: better physical functioning and body image, less pain, earlier resumption of normal activities and return to work

  • 6 months

    • L/S: better body image

Kornblith et al, Gyn Onc 2009.


Are there acute benefits l.jpg

Are there acute benefits?

  • MIS (L/S and robotic; n=66) vs open (n=115)

  • OR time (min)

    • 284 vs 203 P<0.0001

  • EBL

    • 300 vs 100 mLP<0.0001

  • Hospital stay

    • 1 day vs 4 days P<0.0001

  • Median narcotic use (24 hr post op)

    • 43 mg vs 10 mg (morphine equiv) P<0.0001

  • Nausea – MIS patients required less rescue antiemetics 24hr pos op

Havrilesky et al, Gyn Onc 2009


Long term cancer benefit l.jpg

Long term cancer benefit?

  • No difference in survival recently reported for GOG LAP2 trial at 3-yr follow up

Tozzi et al, J Minim Invasive Gynecol 2005

Zullo et al, Am J Obstet Gynecol 2009

Malzoni et al, Gyn Onc 2009


Cervical cancer23 l.jpg

Cervical cancer

NR = not reported

  • No difference in recurrence or survival reported

Spirtos et al, AJOG 2002

Abu-Rustum et al, Gyn Onc 2003

Frumovitz et al, Obstet Gynec 2007


Robotic surgery what it isn t l.jpg

Robotic Surgery – What it isn’t…


Robotic surgery what it is l.jpg

Robotic Surgery- What it is…


Robotic surgery l.jpg

Robotic Surgery

  • da Vinci robot system is the only robotic surgical system is use today

  • Benefits

    • Improved visual fields

    • Less dependence on surgical assistance

    • Surgeon comfort

    • Increased instrument mobility

  • Drawbacks

    • Cost

    • Loss of tactile feedback

    • Learning curve

    • Availability

    • Bulky machine

    • Trochar size


Set up l.jpg

Set-up


Set up28 l.jpg

Set-up


Set up29 l.jpg

Set-up


Robotic instruments l.jpg

Robotic Instruments

Instruments are controlled by the surgeon’s hands

High range of motion for robotic instruments allow for addressing complex surgical issues


Comparison of 3 methods open l s robotic l.jpg

Comparison of 3 methods:open, L/S, robotic

  • Open (n=138), L/S (n=81), & robotic (n=103)

  • OR time: L/S (213 min) > robot (191) > open (147)

  • Robot

    • Better lymph node count

    • Lower EBL 75 mL

    • Lower hospital stay (1 day)

  • Complication rate: Robot (6%) vs. open (30%)

  • Conversion rate: L/S (5%) & robot (3%)

  • No long term follow up reported

Boggess et al, AJOG 2009


Is robotic surgery better than laparoscopy l.jpg

Is robotic surgery better than laparoscopy?

  • No difference in survival at 40 months (n=141)4

  • 1. Leitao et al, Gyn Onc 2009

  • Lowe et al, Gyn Onc 2009

  • Nevadunsky et al, Gyn Onc 2009

  • Mendivil et al, Gyn Onc 2009


Robotics and cervical cancer l.jpg

Robotics and cervical cancer

Kim et al, Gyn Onc 2008

Fanning et al, AJOG 2008

Sert et al, Int J Med Robot 2007

Nezhat et al, JSLS 2008

Boggess et al, AJOG 2008


Fertility preservation l.jpg

Fertility preservation?

  • Laparotomy / vaginal approach

    • Traditional approach

      • OR time: 163 to 253 min

    • Recurrence rates: 2.7 to 7.3%

    • Pregnancy (delivery >37 weeks) 60%

  • Robotic approach

    • 4 studies (8 pts total)

      • OR time – 172 to 373 min

      • EBL (mL) – 62 to 200

      • Hosp stay (d) – 1.5 to 3.5

      • Complications: 2 (edema & neuropathy)

      • F/U: no recurrence in 105 d (Ramirez et al , Gyn Onc 2010)

      • No pregnancies reported to date

Dursun et al, EJSO 2007

Ramirez et al, Gyn Onc 2008

Ramirez et al, Gyn Onc 2010


Suturing during hysterectomy l.jpg

Suturing During Hysterectomy


Conclusions l.jpg

Conclusions

  • MIS surgery is a reasonable option in gynecologic cancer

    • Endometrial

    • Cervical

    • Ovary (early stage)

  • Laparotomy, laparoscopy and robotic surgery offer advantages for patients short term but are equivalent in patient survival

  • Robotic surgery offers surgeon advantages over laparoscopy


  • Login