Role of Robotic Surgery in Obese Women with Endometrial Cancer

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1 Role of Robotic Surgery in Obese Women with Endometrial Cancer Anil Tailor Consultant Gynaecological Oncologist Royal Surrey County Hospital Guildford, Surrey, UK St Peters Hospital Chertsey, Surrey, UK

2 None Disclosures

3 Epidemiology Endometrial Cancer UK (2011) Denmark ( ) New cases (per year) Deaths (per year) Proportion of all cancers 5% 4.2% Incidence per Deaths per year survival 90% 94% 5 year survival 79% 83%

4 Obesity and Uterine Cancer 34% of uterine cancers in UK linked to overweight and obesity Relative risks compared to normal weight: Overweight (BMI 25-30): 1.32 Obese (BMI > 30): 2.54

5 Trend in obesity prevalence among adults Health Survey for England (3-year average) Adult (aged 16+) obesity: BMI 30kg/m 2 5 Patterns and trends in adult obesity

6 Trend in severe obesity among adults Health Survey for England (3-year average) Adult (aged 16+) severe obesity: BMI 40kg/m 2 6 Patterns and trends in adult obesity

7 Patterns and trends in adult obesity Obesity Map - England

8 Recent Trends Endometrial Cancer Incidence and Mortality

9 Surgery for Endometrial Cancer Standard treatment includes hysterectomy, removal of ovaries and peritoneal washings for cytology TAH BSO LAVH BSO or TLH BSO Robotic hysterectomy BSO Other controversial interventions Pelvic sampling or dissection Para-aortic sampling or dissection Role of adjuvant radiotherapy Role of adjuvant chemotherapy

10 Open Hysterectomy in Obese Women Intra-op difficulties: Deep pelvis Organs prolapsing into field of surgery Slippery tissues Post-op problems: Higher risk of wound complications (~ 30%) Higher risk of surgical site infections Higher risk of VTE

11 Minimal Access Surgery LAVH BSO TLH BSO Allows excision of adnexa through vaginal route Needs good vaginal access and uterine descent Vaginal access and uterine descent not critical Prolonged Trendelenburg position High intra-abdominal pressures Anaesthetic considerations Surgical fatigue Risk of conversion to laparotomy is dependent on BMI

12 Conversion Risk Laparoscopic hysterectomy is preferred over laparotomy in early endometrial cancer patients, except in very obese women. Bijen CBM et al

13 Minimal Access Surgery Robotic hysterectomy BSO Vaginal access and uterine descent not critical Prolonged Trendelenburg position LOW intra-abdominal pressures No surgical fatigue Decreased conversion rate to laparotomy

14 What is Robotic Surgery?

15 Robotic Surgery in Gynaecology Use of robotic surgery in gynaecology has overtaken urology in USA! More applications in gynaecology! Benign Almost all hysterectomies! Myomectomies Complex endometriosis surgery Prolapse surgery sacrocolpopexy Malignant Uterine cancers All except those with very big uterus Cervix cancer Pelvic and para-aortic lymphadenectomy

16 What is the penetration of robotic surgery? 2012 Figures Over 1400 da Vinci Robots installed worldwide US 1000 Europe 286 UK 23 In the USA 80% radical prostectomies 40% of malignant hysterectomies 55% of all hysterectomies in 2010 in USA

17 What are the potential benefits? Surgeon Related High definition 3D optics Better surgeon ergonomics Wristed instrumentation = better visualisation = less fatigue = more precision

18 What are the potential benefits? Surgeon Related Scaled movements No tremor Autonomy of camera control No assistant fatigue Consistently good image avoids time wastage Greater appreciation of surgical anatomy Reduced blood loss enhances vision Much shorter learning curve than for complex laparoscopic surgery Months rather than years

19 What are the potential benefits? Patient Related Reduced blood loss Less blood transfusion Less painful Faster recovery to normal activities Shorter hospital stay

20 What are the potential benefits? Patient Related Many more patients able to benefit from MAS Very poor uptake of advanced laparoscopic surgery by gynaecologists Only 15-30% of hysterectomies performed by laparoscopy

21 What are the potential disadvantages? Clashing of robotic arms Correct positioning of ports important Greater number of port sites than conventional laparoscopy

22 Guildford Data Robotic programme started in December robotic operations Largest gynaecological series in UK 3 surgeons (2 surgeons with 238 and 236 cases) 304 operations for endometrial cancers 140 with BMI > 30 (49 with BMI > 40) 3/140 converted to laparotomy (2.1%) 2/49 converted (4.1%) Length of stay: Mean = 1.8, Median = 1 night

23 Robotic surgery in the obese patient

24 What are the potential disadvantages? COST Purchase Consumables Service/running costs

25 Cost of Treating Endometrial Cancer US study Barnett JC et al Obstetrics & Gynecology: September Volume pp Cost Comparison Among Robotic, Laparoscopic, and Open Hysterectomy for Endometrial Cancer

26 Cost of Treating Endometrial Cancer Societal perspective model Inpatient hospital costs Robotic expenses Lost wages Caregiver costs Hospital perspective model Similar to above excluding: Lost wages and caregiver costs

27 Cost of Treating Endometrial Cancer Societal perspective model Inpatient hospital costs Robotic expenses Lost wages Caregiver costs Hospital perspective model Similar to above excluding: Lost wages and caregiver costs Laparotomy Laparoscopy Robot $12847 $10128 $11476 $7009 $6581 $8770 Robotic hysterectomy least expensive when robotic disposable equipment cost less than $1,046 per case (baseline cost $2,394)

28 Cost of Treating Endometrial Cancer UK study (Royal Marsden) Ind T et al International Journal of Medical Robotics and Computer Assisted Surgery March 2015 Introducing robotic surgery into an endometrial cancer service a prospective evaluation of clinical and economic outcomes in a UK institution

29 Cost of Treating Endometrial Cancer Compared the costs of treating endometrial cancer in 196 women before and after the introduction of a robotics programme. 130 pre and 66 post robot In depth study of: Ward costs High dependency Staffing Theatres Pharmacy Blood products Imaging Pathology Rehabilitation Capital depreciation included in analysis Costs reduced from to 10274

30 Conclusions Minimal access surgery should be the default approach for the treatment of endometrial cancers Robotic assistance has patient and surgeon related advantages in the obese cohort (conversion rates, surgeon fatigue) If an institution already possesses a robot for urological surgery, its use in gynaecological surgery for cancer may reduce costs.

31 Thank You