Gynecologic oncologists were quick to recognize the advantages of robotic-assisted surgery in women with endometrial cancer. Initial studies praised ease of surgical technique, adequacy of surgical specimens for cancer staging, and reduction in patient hospital stay and time to recovery [8
]. One particular advantage of the robotic platform was surgical confidence in adequate lymphadenectomy (i.e., >4 lymph nodes retrieved from right and left pelvis and para-aortic node-bearing tissues) without undue risk of injury to pelvic organs and blood vessels ([8
Robotic surgery in endometrial cancer.
Consensus definitions of adequacy of cancer-staging surgery remain debatable. Endometrial cancer data have indicated that high tumor grade, deep myometrial invasion, involvement of the cervix, lymphovascular invasion, and presence of malignant lymph nodes, all contribute to adjuvant treatment recommendations [24
]. There has been no indication that robotic surgery limits these assessments (). An important retrospective study comparing robotic-assisted surgery and conventional surgery backs this claim [8
]. Of 275 women undergoing minimally-invasive total hysterectomy and pelvic and para-aortic lymphadenectomy, 102 underwent robotic-assisted and 173 underwent conventional laparoscopic cancer-staging surgeries. Surgery performed did not bias cancer grading or tumor type, number of lymph nodes retrieved from the pelvis or para-aortic tissues, or excised uterine weight. Intraoperative injury rates were similar (2.0% robotic versus 3.5% laparoscopic, P
= 0.71). There were also no substantial trends in prolonged hospital stay (1.9 days versus 2.3 days, P
= 0.09) or requirement of second surgery (e.g., small bowel perforation or repair of vaginal apex dehiscence, 1.9% versus 1.2%) after robotic or conventional surgery, respectively. Overall, robotic-assisted surgeries were deemed safe and comparable to laparoscopic surgeries. While these results are impressive, this study consisted of cases done by a single surgeon at a single academic practice dedicated to improving minimally-invasive surgical techniques, introducing substantial selection and performance bias. Over multiple studies, there has been a trend for more vaginal apex dehiscence in women undergoing robotic-assisted surgical procedures, with rates of 2.9% after robotic and 2.4% after conventional surgery [16
]. In addition, rates of procedure conversion from robot assisted to laparotomy have ranged between 4% and 15% [16
]. Dedicated multi-institutional study of robotic-assisted surgical approaches for endometrial cancer is needed so that over- or underestimates of appropriateness of cancer staging, surgical complications, and operative and patient recovery time are more relevant to practicing gynecologic oncologists.
Moreover, it is important for the gynecologic oncologist to recognize that surgery in the morbidly obese presents a unique surgical challenge. Not only are these patients more susceptible to postoperative complications such as poor wound healing, but their body mass often makes the surgical procedure technically more challenging whether the approach is laparoscopic or open. Many feel that the advantages of a robotic platform help overcome some of the barriers to operating on the morbidly obese with endometrial cancer. To date, few papers have addressed the use of robotic surgery specifically in the obese population. The limited data to date has shown that increased body mass index is not generally associated with greater complications in robotic staging for endometrial cancer [25
]. A randomized study conducted by the Gynecologic Oncology Group (LAP-2) comparing laparoscopy and laparotomy showed no substantial differences in oncologic assessment or outcome with laparoscopy, but there were increased odds of not successfully completing laparoscopy without conversion to laparotomy in the obese (odds ratio: 1.11, 95% confidence interval 1.09 to 1.13) [26
]. While it remains controversial to use robotic-assisted procedures in the obese, it has been shown that surgical intervention followed by adjuvant therapy successfully manages pelvis-confined endometrial cancer in the morbidly obese [27
]. Indeed, these studies indicate that the morbidly obese patient does not often have cancer limit life expectancy, but rather comorbidities resulting from obesity contribute to mortality. Robotic surgical techniques that limit confounding surgical morbidity in the obese may be of interest to the gynecologic oncologist. Further surgical development of robotic-assisted instrumentation for the obese is expected.