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Financial Disclosure As it pertains to CME, I have no relevant financial relationships with any commercial interest to disclose. Minimally Invasive Surgery.

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Presentation on theme: "Financial Disclosure As it pertains to CME, I have no relevant financial relationships with any commercial interest to disclose. Minimally Invasive Surgery."— Presentation transcript:

1 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

2 William M. Merritt, MD April 2010

3 Objectives Reviews types of gynecologic cancer and treatments Reviews types of gynecologic cancer and treatments Minimally Invasive Surgery (MIS) Minimally Invasive Surgery (MIS) Role of MIS in Gynecologic Oncology (and Gynecology) Role of MIS in Gynecologic Oncology (and Gynecology) Patient benefits and risks with MIS Patient benefits and risks with MIS

4 2009 Estimates on Female Cancer Thousands © 2009, American Cancer Society,

5 Ovarian Cancer 21,550 estimated new cases in ,550 estimated new cases in 2009 Lifetime risk: 1.7% Lifetime risk: 1.7% Average age: 59 Average age: 59 Risk Factors: family history Risk Factors: family history Symptoms Symptoms –Bloating –Weight gain –Abdominal discomfort –Early satiety (feeling full) –Nausea Detection: Detection: –Pelvic exam –Imaging (Ultrasound, CT Scan) –Ca-125 –OVA1 (recently FDA approved)

6 Endometrial/ Uterine Cancer Most common gynecologic cancer Most common gynecologic cancer –42,160 new cases in 2009 Risk Factors: obesity, unopposed estrogen, no pregnancies Risk Factors: obesity, unopposed estrogen, no pregnancies Symptoms: Symptoms: –Abnormal uterine bleeding –Bleeding after menopause Detection: Detection: –Pelvic exam –Endometrial biopsy –Pelvic ultrasound

7 EndometrioidUPSC/Clear Cell Present in earlier stage Present with advanced stage Stage I73%Stage I54% Stage II11%Stage II8% Stage III13%Stage III22% Stage IV3%Stage IV16% 5-yr survival Stage I85-90%Stage I60% Stage II70%Stage II50% Stage III40-50%Stage III20% Stage IV15-20%Stage IV5-10% Gehrig et al, Gyn Onc 2010

8 Cervical Cancer 11,270 new cases in the ,270 new cases in the 2009 Death rates decreasing due to early detection Death rates decreasing due to early detection Risk factors: Risk factors: –HPV infection –Cigarette smoking –Sexual activity at an early age (exposure) Symptoms: Symptoms: –Abnormal vaginal bleeding –Vaginal discharge Detection: Detection: –Pelvic Exam –Pap smear / HPV testing

9 Vulvar Cancer Rare: 4% of all gynecologic cancers Rare: 4% of all gynecologic cancers Risk factors Risk factors –HPV –Smoking –Skin disorders of the vulva Symptoms Symptoms –Itching (itch scratch cycle) –Vulvar mass / ulcer –Bleeding Detection Detection –Pelvic exam –Biopsy

10 Treatment Ovarian cancer Ovarian cancer –Surgery + chemotherapy Endometrial cancer Endometrial cancer –Surgery ± radiation (± chemotherapy) Cervical cancer Cervical cancer –Surgery OR radiation + chemotherapy Vulvar cancer Vulvar cancer –Surgery ± radiation Vagina Uterus Endometrium Myometrium Ovary Fallopian Tube Cervix Vagina Uterus Endometrium Myometrium Ovary Fallopian Tube Cervix

11 Surgical Options Traditional: Laparotomy 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 An approach to surgery whereby operations are performed with specialized instruments designed to be inserted through small incisions or natural body openings Types Types –Laparoscopic –Robotic

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

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

15 Are there any drawbacks? Not all procedures are safe to do with MIS Not all procedures are safe to do with MIS Time Time –Learning curve –Some cases take longer compared to traditional approach Cost Cost

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

17 Laparoscopy

18 Laparoscopy vs Laparotomy – GOG LAP2 Study Population ( ) Study Population ( ) –L/S: 1,696 Open: 920 Conversion rate: 434 (25.8%) Conversion rate: 434 (25.8%) Surgical Staging Surgical Staging –Lymph node dissection 99% (open) vs. 98% (L/S) 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 Laparotomy (n=920) %Laparoscopy (n=1,248) %P OR time (min)130204<0.001 Hospital stay >2days <0.001 Complications -Vascular Post op fever Ileus/SBO Wound infection Transfusion Deaths8110<1 -Bladder/Bowel Walker et al, JCO 2009

20 What do the patients think? L/S (n=535) vs. open (n=267) L/S (n=535) vs. open (n=267) Quality of life (FACT-G) Quality of life (FACT-G) –Emotional –Physical –Social –Functional well-well being 6 weeks 6 weeks –L/S: better physical functioning and body image, less pain, earlier resumption of normal activities and return to work 6 months 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) MIS (L/S and robotic; n=66) vs open (n=115) OR time (min) OR time (min) –284 vs 203 P< EBL EBL –300 vs 100 mLP< Hospital stay Hospital stay –1 day vs 4 days P< Median narcotic use (24 hr post op) Median narcotic use (24 hr post op) –43 mg vs 10 mg (morphine equiv) P< Nausea – MIS patients required less rescue antiemetics 24hr pos op Nausea – MIS patients required less rescue antiemetics 24hr pos op Havrilesky et al, Gyn Onc 2009

22 Long term cancer benefit? L/S vs. Open (N) Follow up (months) Overall survival Disease free survival Cancer- related survival Tozzi et al 63 vs % vs 86%87% vs 92%25% (2/8) vs 40% (2/5) Zullo et al 40 vs % vs 84%80% vs 82%50% (4/8) vs 44% (4/7) Malzoni et al 81 vs ??? Tozzi et al, J Minim Invasive Gynecol 2005 Zullo et al, Am J Obstet Gynecol 2009 Malzoni et al, Gyn Onc 2009 No difference in survival recently reported for GOG LAP2 trial at 3-yr follow up

23 Cervical cancer No. ptsOR time (min) EBL (mL)Hosp. stay (d)MarginsComplications Spirtos et al. All L/S NRAll negative 3 cystotomies 1 ureterovaginal fistula Abu-Rustum et al. L/S vs. open 17 vs vs vs vs. 9.7NR No ureteral injuries or fistulas reported Frumovitz et al. L/S vs. open 35 vs vs vs vs. 5All negative - 18% vs. 53% infectious morbidities - No noninfectious reported Spirtos et al, AJOG 2002 Abu-Rustum et al, Gyn Onc 2003 Frumovitz et al, Obstet Gynec 2007 No difference in recurrence or survival reported NR = not reported

24 Robotic Surgery – What it isnt…

25 Robotic Surgery- What it is…

26 Robotic Surgery da Vinci robot system is the only robotic surgical system is use today da Vinci robot system is the only robotic surgical system is use today Benefits Benefits –Improved visual fields –Less dependence on surgical assistance –Surgeon comfort –Increased instrument mobility Drawbacks 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 surgeons 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) Open (n=138), L/S (n=81), & robotic (n=103) OR time: L/S (213 min) > robot (191) > open (147) OR time: L/S (213 min) > robot (191) > open (147) Robot Robot –Better lymph node count –Lower EBL 75 mL –Lower hospital stay (1 day) Complication rate: Robot (6%) vs. open (30%) Complication rate: Robot (6%) vs. open (30%) Conversion rate: L/S (5%) & robot (3%) Conversion rate: L/S (5%) & robot (3%) No long term follow up reported No long term follow up reported Boggess et al, AJOG 2009

32 Is robotic surgery better than laparoscopy? Robot assistedLaparoscopy OR time (min) EBL (mL) Hospital stay (days) Leitao et al, Gyn Onc Lowe et al, Gyn Onc Nevadunsky et al, Gyn Onc Mendivil et al, Gyn Onc 2009 No difference in survival at 40 months (n=141) 4

33 Robotics and cervical cancer No. patientsEBL (mL)OR time (min)Hosp. stay (min) Kim et al Fanning et al Sert et al Robot vs. L/S 7 vs. 771 vs vs vs. 8 Nezhat et al. Robot vs. L/S 13 vs vs vs vs. 3.8 Boggess et al Robot vs. LAP 51 vs vs vs 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

34 Fertility preservation? Laparotomy / vaginal approach Laparotomy / vaginal approach –Traditional approach OR time: 163 to 253 min OR time: 163 to 253 min –Recurrence rates: 2.7 to 7.3% –Pregnancy (delivery >37 weeks) 60% Robotic approach Robotic approach –4 studies (8 pts total) OR time – 172 to 373 min OR time – 172 to 373 min EBL (mL) – 62 to 200 EBL (mL) – 62 to 200 Hosp stay (d) – 1.5 to 3.5 Hosp stay (d) – 1.5 to 3.5 Complications: 2 (edema & neuropathy) Complications: 2 (edema & neuropathy) F/U: no recurrence in 105 d (Ramirez et al, Gyn Onc 2010) F/U: no recurrence in 105 d (Ramirez et al, Gyn Onc 2010) No pregnancies reported to date No pregnancies reported to date Dursun et al, EJSO 2007 Ramirez et al, Gyn Onc 2008 Ramirez et al, Gyn Onc 2010

35

36 Suturing During Hysterectomy

37 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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