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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.

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minimally invasive surgery in gynecologic oncology

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.”

objectives
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
2009 Estimates on Female Cancer

Thousands

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

ovarian cancer
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
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
cervical cancer
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
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

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
Surgical Options
  • Traditional: Laparotomy

Midline vertical

Transverse

minimally invasive surgery mis
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
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
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
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
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 vs laparotomy gog lap2
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

what do the patients think
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
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 mL P<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
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
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
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
robotic instruments
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
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
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
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
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

conclusions
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
ad