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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.”. Minimally Invasive Surgery in Gynecologic Oncology. William M. Merritt, MD April 2010. Objectives.

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Minimally Invasive Surgery in Gynecologic Oncology

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  1. 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.”

  2. Minimally Invasive Surgery in Gynecologic Oncology William M. Merritt, MD April 2010

  3. 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

  4. 2009 Estimates on Female Cancer Thousands © 2009, American Cancer Society, http://www.cancer.org

  5. 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)

  6. 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

  7. Gehrig et al, Gyn Onc 2010

  8. 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

  9. 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

  10. 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

  11. Surgical Options • Traditional: Laparotomy Midline vertical Transverse

  12. 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

  13. What can be done with MIS • Hysterectomy • Supracervical • Total • Tubes and ovaries • Myomectomy • Removal of fibroids • Lymph node dissection • Pelvic • Aortic • Diagnostic (looking)

  14. MIS – What’s so good about it? • Less post-operative pain • Shorter hospital stay • Less blood loss • Quicker return to normal activities • Smaller incisions

  15. 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

  16. Role of MIS in endometrial cancer • Feasibility • Is it possible? • Reproducible? • Comparison with standard approach • Better, worse, and equivalent? • Risks/Benefits • Acute • Long term

  17. Laparoscopy

  18. 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

  19. Walker et al, JCO 2009

  20. 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.

  21. 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

  22. 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

  23. 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

  24. Robotic Surgery – What it isn’t…

  25. Robotic Surgery- What it is…

  26. 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

  27. Set-up

  28. Set-up

  29. Set-up

  30. Robotic Instruments Instruments are controlled by the surgeon’s hands High range of motion for robotic instruments allow for addressing complex surgical issues

  31. 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

  32. 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

  33. 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

  34. 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

  35. Suturing During Hysterectomy

  36. 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

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