Transcript 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
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
Thousands
New Cases
Deaths
200
180
160
140
120
100
80
60
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© 2009, American Cancer Society, http://www.cancer.org
Ovarian Cancer
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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
–
–
–
–
Pelvic exam
Imaging (Ultrasound, CT Scan)
Ca-125
OVA1 (recently FDA approved)
Detection:
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
Endometrioid
UPSC/Clear Cell
Present in earlier
stage
Present with advanced
stage
Stage I
73%
Stage I
54%
Stage II
11%
Stage II
8%
Stage III
13%
Stage III
22%
Stage IV
3%
Stage IV
16%
5-yr survival
5-yr survival
Stage I
85-90%
Stage I
60%
Stage II
70%
Stage II
50%
Stage III
40-50%
Stage III
20%
Stage IV
15-20%
Stage IV
5-10%
Gehrig et al, Gyn Onc 2010
Cervical Cancer
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

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


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

Ovarian cancer
Fallopian Tube
– Surgery + chemotherapy

Endometrial cancer
Uterus
Myometrium
Ovary
Endometrium
– Surgery ± radiation (± chemotherapy)
Fallopian
Cervical
Tube
Vagina
cancer
Uterus radiation + chemotherapy
– Surgery OR

Vulvar cancer
Ovary
Myometrium
Endometrium
– Surgery ± radiation
Cervix
Vagina
Cervix
Surgical Options

Traditional: Laparotomy
Midline vertical
Transverse
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

Hysterectomy
– Supracervical
– Total
Tubes and ovaries
 Myomectomy

– Removal of fibroids

Lymph node dissection
– Pelvic
– Aortic

Diagnostic (looking)
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?
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

Feasibility
– Is it possible?
– Reproducible?

Comparison with standard approach
– Better, worse, and equivalent?

Risks/Benefits
– Acute
– Long term
Laparoscopy
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
Laparotomy %
(n=920)
Laparoscopy %
(n=1,248)
P
OR time (min)
130
204
<0.001
Hospital stay
>2days
845
94
867
52
-Vascular
29
4
75
5
-Post op fever
33
8
55
3
-Ileus/SBO
80
9
80
5
-Wound infection 33
4
53
3
-Transfusion
66
7
143
9
-Deaths
8
1
10
<1
-Bladder/Bowel
23
3
58
3
<0.001
Complications
Walker et al, JCO 2009
What do the patients think?
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L/S (n=535) vs. open (n=267)
Quality of life (FACT-G)
–
–
–
–
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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?


MIS (L/S and robotic; n=66) vs open (n=115)
OR time (min)
– 284 vs 203

EBL
– 300 vs 100 mL

P<0.0001
Hospital stay
– 1 day vs 4 days

P<0.0001
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/S vs. Open Follow up
(N)
(months)
Tozzi et al
Zullo et al
Malzoni et
al
63 vs 59
44
40 vs 38
79
81 vs 78
38.5
Overall
survival
Disease free
survival
Cancerrelated
survival
82% vs 86%
87% vs 92%
25% (2/8) vs
40% (2/5)
82% vs 84%
80% vs 82%
50% (4/8) vs
44% (4/7)
???
???
???
• 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 cancer
No. pts
OR time
(min)
EBL (mL)
Hosp. stay (d)
Margins
Complications
Spirtos et al.
All L/S
78
205
225
NR
All negative
3 cystotomies
1 ureterovaginal fistula
Abu-Rustum et al.
L/S vs. open
17 vs. 195
371 vs. 295
301 vs. 693
4.5 vs. 9.7
NR
No ureteral injuries or
fistulas reported
Frumovitz et al.
L/S vs. open
35 vs. 54
344 vs. 307
319 vs. 548
2 vs. 5
All negative
- 18% vs. 53%
infectious morbidities
- No noninfectious
reported
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…
Robotic Surgery- What it is…
Robotic Surgery
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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
–
–
–
–
–
–
Cost
Loss of tactile feedback
Learning curve
Availability
Bulky machine
Trochar size
Drawbacks
Set-up
Set-up
Set-up
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
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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?
OR time (min)
EBL (mL)
Hospital stay (days)
Robot assisted
Laparoscopy
2621
1692
1923
2061
50
97
49
100
1
1.6
1
2
1413
105
1
 No difference in survival at 40 months (n=141)4
1. Leitao et al, Gyn Onc 2009
2. Lowe et al, Gyn Onc 2009
3. Nevadunsky et al, Gyn Onc 2009
4. Mendivil et al, Gyn Onc 2009
Robotics and cervical cancer
No. patients
EBL (mL)
OR time (min) Hosp. stay
(min)
Kim et al
10
207
355
7.9
Fanning et al
20
300
390
1
Sert et al
Robot vs. L/S
7 vs. 7
71 vs. 160
241 vs. 3000
4 vs. 8
Nezhat et al.
Robot vs. L/S
13 vs. 30
157 vs. 200
323 vs. 318
2.7 vs. 3.8
Boggess et al
Robot vs. LAP
51 vs. 49
97 vs. 417
211 vs. 248
1 vs. 3.2
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?

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)
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
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
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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
No pregnancies reported to date
2010)
Dursun et al, EJSO 2007
Ramirez et al, Gyn Onc 2008
Ramirez et al, Gyn Onc 2010
Suturing During Hysterectomy
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
