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Low incidence of port-site metastasis after robotic-assisted surgery for endometrial cancer staging
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Abstracts / Gynecologic Oncology 130 (2013) e1–e169
Cases included those presenting with pelvic mass, initial staging, or debulking after neoadjuvant chemotherapy. Patient characteristics and outcomes were compared using chi- squared or 2-tailed student’s t-tests. Results: Overall, 63 patients underwent a robotic approach and 26 patients underwent an abdominal approach. Patient characteristics were similar for age (59.8 vs. 55.7 years, P = 0.1371), uterine weight (81 vs. 114 g, P = 0.0508), and body mass index (27 vs. 28, P = 0.4805). The prior abdominal surgery rate was higher in the abdominal group (76% vs. 96%, P = 0.0257). Operative time was longer (139 vs. 95 min, P b 0.0001) and there was less blood loss (95 vs. 385 mL, P b 0.0001) for the robotic group. Hospital stay was shorter in the robotic group (2.3 vs. 6.2 days, P = 0.0009), and major complication rates were similar (16% vs. 23%, P = 0.4209). Lymph node dissection (13 vs. 11 nodes, P = 0.2310) and omentectomy (92% vs. 96%, P = 0.4840) were performed when indicated. The neoadjuvant chemotherapy rate was higher in the robotic group (52% vs. 15%, P = 0.0013). There was no residual disease in 68% of robotic and 50% of abdominal patients (P = 0.105) (Table). For the subgroup of stage II-IV patients, there was no residual disease in 24/43 (56%) of robotic vs. 8/20 (40%) of abdominal patients (P = 0.2425). Follow-up was longer for the abdominal group (15 vs. 24 months, P = 0.0096), although an equivalent percentage of patients had at least 1 year of follow-up (36/63 [57%] vs. 20/26 [77%], P = 0.0789). At 1 year, the survival (93% vs. 85%, P = 0.0888) and no evidence of disease (NED) (67% vs. 50%, P = 0.2211) rates were equivalent. These rates were also equivalent for stage II-IV patients at 1 year (survival: 92% vs. 88%, P = 0.6357 and NED: 68% vs. 56%, P = 0.4461). Conclusions: The use of a robotic approach in the management of epithelial ovarian cancer, including for patients treated with neoadjuvant chemotherapy, is feasible and effective. Debulking rates were similar to an abdominal approach and the 1-year data were encouraging, although further follow-up is needed. Table. Pathology and Survival.
373 Robotic surgery for the management of ovarian cancer T. Evans1, T. Randall2, I. Wilkinson-Ryan3. 1University of Pennsylvania Health Systems, Pennsylvania Hospital, Philadelphia, PA, 2University of Pennsylvania Medical Center, Philadelphia, PA, 3Washington University School of Medicine, St. Louis, MO. Objective: To determine the feasibility of the use of robotic surgery in the treatment of epithelial ovarian and fallopian tube cancer. Methods: Thirty patients with a preoperative diagnosis of epithelial ovarian/fallopian tube cancer who were scheduled to undergo robotic surgical management between 04/2011 and 08/2012 were reviewed. Major intraoperative and postoperative complications; operative characteristics, including operative time, blood loss, and additional procedures; transfusion rate; length of hospitalization; length of follow-up; patient demographics; and ability to optimally debulk and obtain periaortic and pelvic lymph nodes for staging were reviewed. Results: A total of 28 cases were included in the final analysis. Of the 30 procedures, 2 were aborted due to tumor burden and were not included in the final analysis. Two patients had a final surgical pathology of papillary serous adenocarcinoma of the endometrium. There were 19 debulking procedures and 9 staging procedures. There were no major intraoperative complications. No procedures were converted to laparotomy. There were 3 postoperative complications: atrial fibrillation on postoperative day 1 (1), small bowel obstruction requiring intravenous hydration and bowel rest with a nasogastric tube (1), and need for registered respiratory therapist on postoperative day 1 for somnolence on narcotics for pain control that resolved with administration of naloxone (1). The mean operative time was 227 minutes. The mean estimated blood loss was 74 mL, the mean hemoglobin change was 2.07 g/dL, and the mean hospital stay was 2 days. No gross residual or b1 cm residual tumor was seen in 94.7% of patients, 21.4% of patients had neoadjuvant chemotherapy, 64.3% of cases had stage III cancer, and 3.6% had stage IV disease. Conclusions: Robotic surgery may be feasible for the management of selected women with epithelial ovarian cancer. The presence of advanced-stage disease does not appear to be an absolute contraindication to minimally invasive surgery. Even in the setting of radical debulking surgery, minimally invasive surgery may decrease morbidity. doi:10.1016/j.ygyno.2013.04.432
374 Low incidence of port-site metastasis after robotic-assisted surgery for endometrial cancer staging D. Barraez1, T. McElrath2, D. Kredentser2, T. Morrissey2, P. Timmins2. 1 Berkshire OB/GYN Associates PC, Pittsfield, MA, 2Women’s Cancer Care Associates, Albany, NY.
*Chi-squared contingency table. NED = no evidence of disease.
doi:10.1016/j.ygyno.2013.04.431
Objective: To evaluate the incidence and characteristics of patients with portsite metastasis following robotic-assisted surgery for gynecologic malignancies. Methods: This was a retrospective study of patients who underwent robotic-assisted total laparoscopic hysterectomy and surgical staging at a single institution. After institutional review board approval was obtained, patients with endometrial carcinoma undergoing robotic-assisted hysterectomy were identified through ICD-9-CM codes from November 2006 through November 2011. A review of medical records was performed, and data collected included diagnosis, histology, tumor extension, procedure, complications, and postsurgical intervention. At the time of procedure, hysterectomy specimens were retrieved vaginally and lymph nodes were placed in an EndoCatch bag and retrieved through the assistant port. All cases were discussed at tumor board and recommendations
Abstracts / Gynecologic Oncology 130 (2013) e1–e169
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Table. Characteristics of Patients With Port-Site Metastasis.
were made based on staging, pathology, and patients conditions. Portsite metastasis was differentiated between isolated and not isolated. All metastases were confirmed with biopsy and treated with chemotherapy and radiotherapy, as indicated. Results: A total of 452 patients with endometrial carcinoma were identified who had undergone robotic hysterectomy and node sampling. The incidence of port-site metastasis after robotic-assisted surgery for treatment of endometrial cancer was 0.8% in our patient population. The 4 patients with port-site metastasis are described in the Table. Two cases were reported as isolated metastasis and 2 as not isolated at the port-site. Peritoneal washing was positive in 1 patient (patient 3); lymph vascular space invasion was presented in patients 1, 2 and 3. No intraoperative complications were reported. Conclusions: The incidence of port-site metastasis is low after robotic-assisted surgery for treatment of endometrial cancer (0.8%). There is no clear risk factor for development of port-site metastasis or easily identifiable prevention.
robotics in 2006, proportional robotic volume grew an average 5 percentage points annually, accounting for 21% of fellows’ volume by 2009. After the introduction of robotics, open volume decreased 6.5 points annually (P = 0.02) (84% of fellows’ volume in 2006, 58% in 2009). After a brief contraction, proportional laparoscopic volume grew 2 points annually (P = 0.02), eclipsing pre-robotics proportions by 2009 (14% vs. 21%, 1999 vs. 2009) (Panel B). Procedurespecific volume trended similarly (Panel C). The proportional volume of robotic hysterectomies increased at the expense of open and vaginal hysterectomies, while proportional laparoscopic volume increased. Conclusions: Introduction of robotics has not compromised fellows’ exposure to laparoscopic cases. With the exception of urologic cases, advanced procedure volume was stable during the study period.
doi:10.1016/j.ygyno.2013.04.433 *Reflects combined proportional volume of clinical and research fellows
375 Trends in surgical training among gynecologic oncology fellows before and after the introduction of robotic surgery J. Knight1, A. Talati2, S. Rao1, P. Escobar1. 1The Cleveland Clinic Foundation, Cleveland, OH, 2Case Western Reserve University School of Medicine, Cleveland, OH. Objective: To describe trends in gynecologic oncology surgical training at 1 institution and assess the impact of robotic surgery on fellows’ open, laparoscopic, and robotic case mix. Methods: Fellows’ case logs were retrieved and reviewed with institutional review board approval. Total case volume was calculated using clinical and research fellows’ logs. Cases performed by clinical fellows during each year were divided by the number of clinical fellows each year to determine case volume per clinical fellow year (CFY). Cases were grouped by approach and indication, allowing tabulation of proportional case volumes. Significance of proportional variance over time was tested with linear-by-linear chi square. Trends were described by the best fit line with |r| N0.45 and P b0.05. Results: Between 1999 and 2010, 15 fellows completed 22 CFYs of training. A total of 5,202 surgical episodes resulting in 13,804 distinct procedures were logged, corresponding to 237 episodes and 661 distinct procedures per CFY. The mix of benign and oncologic cases was stable, averaging 42% and 58% annually (standard deviation [SD] = 3.6, P = 0.67). Among oncology cases, endometrial, ovarian, and cervix cancers were the most common indications (45%, 31%, and 11% of fellows’ case mix [SD = 4.6, 4.9, and 2.6]), without significant variability (P = 0.71). Advanced surgical volume (Panel A) was stable except for urologic cases, declining an average 5% annually, (P = 0.02). Adnexal mass, preinvasive disease, and risk-reducing surgery were the most prevalent indications for benign surgery (40%, 27%, and 9%). Surgery for risk reduction and adnexal mass grew 14% and 3% annually per CFY (P = 0.02 and 0.02). Upon introduction of
. Table 1.
doi:10.1016/j.ygyno.2013.04.434
Abstracts / Gynecologic Oncology 130 (2013) e1–e169
Cases included those presenting with pelvic mass, initial staging, or debulking after neoadjuvant chemotherapy. Patient characteristics and outcomes were compared using chi- squared or 2-tailed student’s t-tests. Results: Overall, 63 patients underwent a robotic approach and 26 patients underwent an abdominal approach. Patient characteristics were similar for age (59.8 vs. 55.7 years, P = 0.1371), uterine weight (81 vs. 114 g, P = 0.0508), and body mass index (27 vs. 28, P = 0.4805). The prior abdominal surgery rate was higher in the abdominal group (76% vs. 96%, P = 0.0257). Operative time was longer (139 vs. 95 min, P b 0.0001) and there was less blood loss (95 vs. 385 mL, P b 0.0001) for the robotic group. Hospital stay was shorter in the robotic group (2.3 vs. 6.2 days, P = 0.0009), and major complication rates were similar (16% vs. 23%, P = 0.4209). Lymph node dissection (13 vs. 11 nodes, P = 0.2310) and omentectomy (92% vs. 96%, P = 0.4840) were performed when indicated. The neoadjuvant chemotherapy rate was higher in the robotic group (52% vs. 15%, P = 0.0013). There was no residual disease in 68% of robotic and 50% of abdominal patients (P = 0.105) (Table). For the subgroup of stage II-IV patients, there was no residual disease in 24/43 (56%) of robotic vs. 8/20 (40%) of abdominal patients (P = 0.2425). Follow-up was longer for the abdominal group (15 vs. 24 months, P = 0.0096), although an equivalent percentage of patients had at least 1 year of follow-up (36/63 [57%] vs. 20/26 [77%], P = 0.0789). At 1 year, the survival (93% vs. 85%, P = 0.0888) and no evidence of disease (NED) (67% vs. 50%, P = 0.2211) rates were equivalent. These rates were also equivalent for stage II-IV patients at 1 year (survival: 92% vs. 88%, P = 0.6357 and NED: 68% vs. 56%, P = 0.4461). Conclusions: The use of a robotic approach in the management of epithelial ovarian cancer, including for patients treated with neoadjuvant chemotherapy, is feasible and effective. Debulking rates were similar to an abdominal approach and the 1-year data were encouraging, although further follow-up is needed. Table. Pathology and Survival.
373 Robotic surgery for the management of ovarian cancer T. Evans1, T. Randall2, I. Wilkinson-Ryan3. 1University of Pennsylvania Health Systems, Pennsylvania Hospital, Philadelphia, PA, 2University of Pennsylvania Medical Center, Philadelphia, PA, 3Washington University School of Medicine, St. Louis, MO. Objective: To determine the feasibility of the use of robotic surgery in the treatment of epithelial ovarian and fallopian tube cancer. Methods: Thirty patients with a preoperative diagnosis of epithelial ovarian/fallopian tube cancer who were scheduled to undergo robotic surgical management between 04/2011 and 08/2012 were reviewed. Major intraoperative and postoperative complications; operative characteristics, including operative time, blood loss, and additional procedures; transfusion rate; length of hospitalization; length of follow-up; patient demographics; and ability to optimally debulk and obtain periaortic and pelvic lymph nodes for staging were reviewed. Results: A total of 28 cases were included in the final analysis. Of the 30 procedures, 2 were aborted due to tumor burden and were not included in the final analysis. Two patients had a final surgical pathology of papillary serous adenocarcinoma of the endometrium. There were 19 debulking procedures and 9 staging procedures. There were no major intraoperative complications. No procedures were converted to laparotomy. There were 3 postoperative complications: atrial fibrillation on postoperative day 1 (1), small bowel obstruction requiring intravenous hydration and bowel rest with a nasogastric tube (1), and need for registered respiratory therapist on postoperative day 1 for somnolence on narcotics for pain control that resolved with administration of naloxone (1). The mean operative time was 227 minutes. The mean estimated blood loss was 74 mL, the mean hemoglobin change was 2.07 g/dL, and the mean hospital stay was 2 days. No gross residual or b1 cm residual tumor was seen in 94.7% of patients, 21.4% of patients had neoadjuvant chemotherapy, 64.3% of cases had stage III cancer, and 3.6% had stage IV disease. Conclusions: Robotic surgery may be feasible for the management of selected women with epithelial ovarian cancer. The presence of advanced-stage disease does not appear to be an absolute contraindication to minimally invasive surgery. Even in the setting of radical debulking surgery, minimally invasive surgery may decrease morbidity. doi:10.1016/j.ygyno.2013.04.432
374 Low incidence of port-site metastasis after robotic-assisted surgery for endometrial cancer staging D. Barraez1, T. McElrath2, D. Kredentser2, T. Morrissey2, P. Timmins2. 1 Berkshire OB/GYN Associates PC, Pittsfield, MA, 2Women’s Cancer Care Associates, Albany, NY.
*Chi-squared contingency table. NED = no evidence of disease.
doi:10.1016/j.ygyno.2013.04.431
Objective: To evaluate the incidence and characteristics of patients with portsite metastasis following robotic-assisted surgery for gynecologic malignancies. Methods: This was a retrospective study of patients who underwent robotic-assisted total laparoscopic hysterectomy and surgical staging at a single institution. After institutional review board approval was obtained, patients with endometrial carcinoma undergoing robotic-assisted hysterectomy were identified through ICD-9-CM codes from November 2006 through November 2011. A review of medical records was performed, and data collected included diagnosis, histology, tumor extension, procedure, complications, and postsurgical intervention. At the time of procedure, hysterectomy specimens were retrieved vaginally and lymph nodes were placed in an EndoCatch bag and retrieved through the assistant port. All cases were discussed at tumor board and recommendations
Abstracts / Gynecologic Oncology 130 (2013) e1–e169
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Table. Characteristics of Patients With Port-Site Metastasis.
were made based on staging, pathology, and patients conditions. Portsite metastasis was differentiated between isolated and not isolated. All metastases were confirmed with biopsy and treated with chemotherapy and radiotherapy, as indicated. Results: A total of 452 patients with endometrial carcinoma were identified who had undergone robotic hysterectomy and node sampling. The incidence of port-site metastasis after robotic-assisted surgery for treatment of endometrial cancer was 0.8% in our patient population. The 4 patients with port-site metastasis are described in the Table. Two cases were reported as isolated metastasis and 2 as not isolated at the port-site. Peritoneal washing was positive in 1 patient (patient 3); lymph vascular space invasion was presented in patients 1, 2 and 3. No intraoperative complications were reported. Conclusions: The incidence of port-site metastasis is low after robotic-assisted surgery for treatment of endometrial cancer (0.8%). There is no clear risk factor for development of port-site metastasis or easily identifiable prevention.
robotics in 2006, proportional robotic volume grew an average 5 percentage points annually, accounting for 21% of fellows’ volume by 2009. After the introduction of robotics, open volume decreased 6.5 points annually (P = 0.02) (84% of fellows’ volume in 2006, 58% in 2009). After a brief contraction, proportional laparoscopic volume grew 2 points annually (P = 0.02), eclipsing pre-robotics proportions by 2009 (14% vs. 21%, 1999 vs. 2009) (Panel B). Procedurespecific volume trended similarly (Panel C). The proportional volume of robotic hysterectomies increased at the expense of open and vaginal hysterectomies, while proportional laparoscopic volume increased. Conclusions: Introduction of robotics has not compromised fellows’ exposure to laparoscopic cases. With the exception of urologic cases, advanced procedure volume was stable during the study period.
doi:10.1016/j.ygyno.2013.04.433 *Reflects combined proportional volume of clinical and research fellows
375 Trends in surgical training among gynecologic oncology fellows before and after the introduction of robotic surgery J. Knight1, A. Talati2, S. Rao1, P. Escobar1. 1The Cleveland Clinic Foundation, Cleveland, OH, 2Case Western Reserve University School of Medicine, Cleveland, OH. Objective: To describe trends in gynecologic oncology surgical training at 1 institution and assess the impact of robotic surgery on fellows’ open, laparoscopic, and robotic case mix. Methods: Fellows’ case logs were retrieved and reviewed with institutional review board approval. Total case volume was calculated using clinical and research fellows’ logs. Cases performed by clinical fellows during each year were divided by the number of clinical fellows each year to determine case volume per clinical fellow year (CFY). Cases were grouped by approach and indication, allowing tabulation of proportional case volumes. Significance of proportional variance over time was tested with linear-by-linear chi square. Trends were described by the best fit line with |r| N0.45 and P b0.05. Results: Between 1999 and 2010, 15 fellows completed 22 CFYs of training. A total of 5,202 surgical episodes resulting in 13,804 distinct procedures were logged, corresponding to 237 episodes and 661 distinct procedures per CFY. The mix of benign and oncologic cases was stable, averaging 42% and 58% annually (standard deviation [SD] = 3.6, P = 0.67). Among oncology cases, endometrial, ovarian, and cervix cancers were the most common indications (45%, 31%, and 11% of fellows’ case mix [SD = 4.6, 4.9, and 2.6]), without significant variability (P = 0.71). Advanced surgical volume (Panel A) was stable except for urologic cases, declining an average 5% annually, (P = 0.02). Adnexal mass, preinvasive disease, and risk-reducing surgery were the most prevalent indications for benign surgery (40%, 27%, and 9%). Surgery for risk reduction and adnexal mass grew 14% and 3% annually per CFY (P = 0.02 and 0.02). Upon introduction of
. Table 1.
doi:10.1016/j.ygyno.2013.04.434