open radical hysterectomy has been the standard treatment for early stage cervical cancer for decades .
recent advances in laparoscopic instrumentation , however , have made it possible to safely perform radical hysterectomy laparoscopically .
the first total laparoscopic radical hysterectomy ( tlrh ) with pelvic and paraaortic lymphadenectomy was performed by nezhat et al in june of 1989 . since then , tlrh with pelvic or paraaortic lymph node dissection , or both , has gained acceptance as a feasible alternative to an open radical hysterectomy .
numerous authors have published their experience with tlrh , firmly establishing its safety and feasibility .
though no randomized trials have been performed , existing data suggest that the cure rate for laparoscopic radical hysterectomy is similar to that seen for the open procedure . despite the advantages of conventional laparoscopy over laparotomy ( shorter hospitalization , faster bowel function recovery , less postoperative pain , decreased overall cost ) , it is not without drawbacks .
first , the surgeon operates in an awkward and uncomfortable position at the operating table , using a flat , 2-dimensional image .
second , the majority of the instruments used are nonarticulating with an ergonomically inadequate handle design , which makes performance of fine movements exceedingly difficult .
third , though not clearly defined for laparoscopic radical hysterectomy , advanced laparoscopic surgery is associated with a significant learning curve , mostly due to the counterintuitive nature of the operation .
recently , computer enhanced technology ( robotics ) has been introduced into laparoscopic surgical practice .
the advantages offered by this new technology include a 3-dimensional magnified field , tremor filtration , and 5 or 6 degrees of instrument mobility inside the body , thus significantly reducing the ergonomic problems associated with the conventional laparoscopic approach .
there is convincing evidence that the intuitive nature of the robotic system provides an additional advantage in terms of the learning curve .
the initial development of the robotic system was intended for remote surgery as a telesurgical mentoring system that would allow an experienced surgeon to provide guidance during a procedure taking place in a different location .
the early robotic systems used for telementoring or telesurgery , however , had technical difficulties associated with signal latency and network instability . with advances in signal transmission technology ,
the earlier problems associated with remote communications are being resolved , expanding the role of robotics in telementoring and allowing inexperienced surgeons to adopt minimally invasive techniques safely while minimizing the risk of serious complications during their learning curve .
clinical applications for robotic systems have been evolving rapidly and are now used widely in various surgical fields .
comparative studies of robotically assisted and standard laparoscopic prostatectomies , colon resections , and nissen fundoplications show that the robotic technique is feasible , safe , and improves the surgeon 's dexterity and flexibility without compromising patient care . in this study
, we conducted a comparative analysis of our data from early cervical cancer patients who underwent tlrh versus those who had rrh with respect to intraoperative , pathologic , and postoperative outcomes .
this was a prospective nonrandomized analysis of all cases of rrh performed for cervical cancer at mount sinai medical center , new york .
the collected data were compared with a set of 30 cases of tlrh performed for cervical cancer at the same institution from august 2000 to june 2006 .
starting in 2006 , the robotic - assistance approach was offered to all patients for whom a laparoscopic approach was deemed appropriate .
selection criteria for tlrh and rrh were the same and included all women with newly diagnosed invasive cervical cancer stages ia1 to iia who desired a laparoscopic approach , after providing informed consent .
patients were not considered for the laparoscopic approach if they had metastatic disease beyond the uterus , a cervical lesion of more than 4 cm in size , a uterus size of more than 12 cm , inadequate bone marrow , or compromised renal and hepatic function , or if they were pregnant .
this was a prospective nonrandomized analysis of all cases of rrh performed for cervical cancer at mount sinai medical center , new york .
the collected data were compared with a set of 30 cases of tlrh performed for cervical cancer at the same institution from august 2000 to june 2006 .
starting in 2006 , the robotic - assistance approach was offered to all patients for whom a laparoscopic approach was deemed appropriate .
selection criteria for tlrh and rrh were the same and included all women with newly diagnosed invasive cervical cancer stages ia1 to iia who desired a laparoscopic approach , after providing informed consent .
patients were not considered for the laparoscopic approach if they had metastatic disease beyond the uterus , a cervical lesion of more than 4 cm in size , a uterus size of more than 12 cm , inadequate bone marrow , or compromised renal and hepatic function , or if they were pregnant .
clinical data for both the laparoscopic groups and the robotic groups were analyzed by a review of patients ' medical records and operation reports .
all patients were staged according to the international federation of gynecology and obstetrics ( figo ) criteria .
all patients had a computerized tomography ( ct ) scan of the abdomen and pelvis done preoperatively to evaluate lymph node status and potential extrapelvic and extraabdominal disease .
intraoperative and postoperative data including patient characteristics , operation details , histological data , and follow - up information were recorded .
duration of surgery was defined from the time of skin incision to the closure of the skin incision .
robotic docking time was recorded as the time to attach the robotic arms to the trocars and insertion of robotic instruments .
postoperative complications included those occurring during the same hospitalization or within 30 days following discharge .
perioperative workup and postoperative care were provided by a gynecologic oncology service run by a fellow .
all surgeries were performed by a gynecologic oncology fellow and a mentoring gynecologic oncology attending physician with experience in advanced laparoscopy .
the fellow at the beginning of his or her training participated as first assistant . as the fellow became more experienced and skilled , the fellow 's role transitioned to a primary surgeon with an attending surgeon or junior fellow acting as a first assistant under the attending physician 's supervision .
the da vinci robot is an integrated computer based system , consisting of 3 interactive robotic arms , a camera arm and a remote control console with 3-dimensional visual capabilities .
the motions of the surgeon at the console unit are replicated by the robotic arms placed within the patient . during robotic surgery , an assistant is available at the operating table .
the assistant performs robot - related tasks , including alignment and exchange of robotic instruments , operative maneuvers with conventional instruments such as organ manipulation , tissue countertraction , suction and irrigation , and any necessary alterations in the position of the intrauterine manipulator .
the presence of the scrubbed assistant is also crucial in the event that an emergency conversion to a laparotomy is required .
the technique of total laparoscopic hysterectomy and bilateral pelvic lymphadenectomy using harmonic shears has been previously described and served as the basis for the robotic procedure . after patients received appropriate preoperative counseling and gave their written informed consent , a standard outpatient mechanical bowel preparation was prescribed .
the procedure was performed with the patient under general endotracheal anesthesia in the dorsal lithotomy position with adjustable allen stirrups and lower extremity compression devices for deep venous thrombosis prophylaxis .
betadine solution was applied topically , and sterile drapes were placed in the usual sterile fashion .
a foley catheter was placed into the bladder before the procedure was started ; the catheter was drained by gravity for the duration of the surgery .
traditional diagnostic laparoscopy was performed first to assess for feasibility of the intended procedure , as well as to detect intraabdominal metastatic disease .
the procedure was terminated if metastatic disease was detected , and confirmed by frozen section evaluation , outside of the pelvis ( eg , in the omentum , bladder , liver , or bowel ) , in the uterine adnexa , or if the tumor extruded through the uterine wall into the peritoneal cavity .
if none of the above were found , the laparoscopic equipment was removed . a standard 12-mm trocar placed at the umbilicus
was used for camera placement , 2 working robotic arms were attached to 8-mm reusable trocars placed bilaterally , and ancillary 10-mm trocars were placed in the suprapubic region and the left or right upper quadrant .
the robotic ports were placed 1 cm to 2 cm below and 8 cm to 10 cm lateral to the intraumbilical trocar , so as to enable optimal movement of the robotic arm and to minimize the risk of collision ( figure 1 ) .
a 12-mm camera trocar is placed at the umbilicus , 2 working robotic arms are attached to 8-mm reusable trocars placed bilaterally , and additional ancillary 5-mm to 10-mm trocars are placed in the suprapubic region and the left upper quadrant . the camera port and each working robotic port are placed in a way that allows for optimal robot arm movement and minimizes risk of collisions .
the whole procedure is performed using the robotic monopolar electrosurgical scissors placed through the right port , and the fenestrated bipolar forceps placed through the left robotic port .
dorsey smokevac suction irrigator pump , probe ( bard inc , murray hill , nj ) , grasping forceps and bipolar forceps as needed , as well as harmonic shears ( ethicon endo - surgery inc , blue ash , oh ) or a ligasure vessel sealing device ( valleylab , boulder , co ) .
adhesions were lysed first to restore normal anatomy , and the undersurfaces of the diaphragm , liver , gallbladder , stomach , omentum , and large and small bowel were examined visually , when possible .
the paraaortic lymph nodes were inspected , followed by the pelvic lymph nodes . proceeding with a radical hysterectomy
requires that 6 avascular pelvic spaces be developed and that the bladder and rectum be mobilized .
traditionally , we start out by dissecting the rectovaginal space . the uterus is sharply anteverted by using an intrauterine manipulator , and the peritoneum between the uterosacral ligaments is incised by using monopolar scissors ; the rectum can then be brought down gently away from the vagina .
a moistened sponge on a sponge - forceps is placed in the posterior vaginal fornix to facilitate visualization and development of this surgical plane ( figure 2 ) .
the posterior vaginal fornix is placed on tension ( marked by the arrow ) , and a moistened sponge on sponge - forceps is placed in the vagina to facilitate delineation of the tissue planes .
after round ligaments on either side of the uterus were desiccated and cut with the monopolar scissors , the anterior leaf of the broad ligament was opened bilaterally .
the bladder was gradually dissected away from the cervix and vagina with a moistened sponge on a sponge - forceps placed in the anterior vaginal fornix to facilitate development of the vesicovaginal space ( figure 3 ) .
the uterus ( b ) is pushed cephalad into the abdominal cavity to facilitate visualization .
the posterior leaf of the broad ligament was opened using monopolar scissors and forceps and the paravesical and pararectal spaces were developed using gentle blunt dissection . in cases
where ovarian preservation was indicated or desired , the uteroovarian ligament and the proximal portion of the fallopian tube were coagulated and divided .
if the adnexa were to be removed , the infundibulopelvic ligament was isolated , desiccated and divided using the bipolar forceps and scissors .
the paravesical space was developed by placing tension on the umbilical ligaments with sharp , blunt dissection performed with scissors , forceps , and suction irrigator .
the dissection was continued inferiorly to the iliac vessels , after which the obturator space was developed .
the structures surrounding the obturator space , including the obturator internus muscle and pubic bone , were examined visually and care was taken to avoid injury to the obturator nerve and vessels that traverse this area .
after development of the paravesical and pararectal spaces , the pelvic lymphadenectomy can be performed .
pelvic lymphadenectomy involves removal of the lymph node packets from the common iliac vessels and external iliac vessels down to the level of the deep circumflex iliac veins ( figure 4 ) .
the obturator nerve was identified , and the obturator fossa nodes and the hypogastric lymph nodes were completely removed and sent for pathological examination . at this point , the medial umbilical ligament was suspended with upward tension , and the origin of the uterine artery from the hypogastric artery was identified ( figure 5 ) .
the uterine artery was desiccated and divided at its origin with bipolar forceps and monopolar scissors as shown in figure 6 .
the uterine vessels were placed on medial tension , and the ureter was unroofed using the curved tip of the monopolar scissor out of the tunnel ( figure 7 ) , and then the surrounding tissues were coagulated and divided ( figure 8) .
the uterosacral ligaments , cardinal ligaments , and a portion of the paracolpos were then divided with the bipolar forceps and scissors , enabling complete mobilization of the uterus .
a circumferential incision was made into the vagina using monopolar scissors to ensure an adequate margin ( figure 9 ) .
the uterus was separated completely from the vagina and removed while attached to the uterine manipulator . in some cases ,
the specimen removal was done vaginally to allow for a superior visualization and delineation of the vaginal margins .
the vaginal cuff was closed with interrupted or running 0 vicryl suture tied intracorporeally or vaginally ( figure 10 ) .
lymph node packets ( f ) are removed from the left common external iliac artery ( a ) and vein ( b ) .
the left obturator nerve ( c ) , the left obliterated umbilical artery ( d ) , and the left ureter ( e ) are identified .
the uterine artery ( a ) is identified and dissected from the point of its origin at the hypogastric artery ( b ) traversing over the ureter ( c ) .
the right uterine artery ( a ) is coagulated and divided at its origin by using bipolar forceps and monopolar scissors .
the right pararectal ( b ) and paravesical ( c ) spaces are fully developed ; and the right ureter ( d ) , right umbilical ( e ) , and right external iliac artery ( f ) are visible .
the paravesical space ( b ) and right obliterated umbilical artery ( c ) are identified .
the right ureter ( b ) , right obliterated umbilical ( c ) , and right external iliac arteries ( d ) are seen .
using monopolar scissors , a circumferential incision is made into the vagina assuring adequate margin . vaginal cuff closure with intracorporeal tying .
after removal of the specimen and closure of the vaginal cuff , the pelvic cavity was thoroughly evaluated .
both the pelvic and abdominal cavities were irrigated copiously with normal saline ( figure 11 ) .
once the surgeon had ensured hemostasis , indigo carmine was administered intravenously to assess ureteral and bladder integrity .
the rectum was then insufflated with air and evaluated intraabdominally under saline to rule out any bowel injuries .
the bladder was either distended with saline , or cystoscopy was performed to further ensure its integrity . upon completion of the procedure ,
the da vinci system was undocked , all of the instruments were removed , and the trocar sites were closed using a figure - of - eight 0 vicryl suture and 40 vicryl in a subcuticular fashion .
both ureters ( a and b ) have been dissected to the level of the bladder .
we routinely use subcutaneous heparin , low molecular weight heparin , or pneumatic compression devices until patients are fully ambulatory .
the patients were discharged home on the second or third postoperative day with a foley catheter in place .
comparative analysis was performed using statview software ( sas , north carolina ) . the outcomes from the laparoscopic radical and robotic - assisted groups
were compared using fisher 's exact test and the chi - squared test for categorical variables and 2 sample student t tests for continuous variables .
a total of forty seven patients met our inclusion criteria and had either tlrh or rrh with pelvic lymphadenectomy performed .
three of these 4 patients had only a portion of the entire procedure ( pelvic lymphadenectomy , bilateral ureterolysis or part of the parametrial dissection ) performed robotically with the majority of the procedure performed laparoscopically .
the remaining 13 cases comprised our rrh with bilateral pelvic lymphadenectomy cohort performed between april 2006 and january 2008 .
there were no differences in clinical tumor characteristics , such as stage , histology , and lympho - vascular space involvement between the two groups ( table 1 ) .
two patients in the rrh group underwent neoadjuvant chemotherapy , while only one patient in the tlrh group did so .
patient characteristics as shown in table 2 , mean operative time , estimated blood loss , and length of postoperative stay were similar between the 2 patient groups ( p > 0.05 ) .
the mean operative time for tlrh with pelvic lymphadenectomy leveled off at 318 minutes and did not significantly decrease over time .
mean operative time for rrh changed little over the study period as well ( figure 12 ) .
in contrast , the mean time for robotic docking was 12 minutes ( range 430 min ) , and decreased as the surgeon gained experience ( figure 13 ) .
clinical variables and outcomes three patients in the rrh group and 6 in the tlrh group underwent paraaortic lymphadenectomy before the hysterectomy due to paraaortic lymph node enlargement detected on preoperative imaging , or cervical lesions with a diameter greater than 2 cm .
seven patients in the tlrh group and one patient in the rrh group had ovarysparing procedures .
in addition , 2 patients in the tlrh group underwent umbilical hernia repair and one patient had a bartholin 's abscess excised .
the robotic group had 2 intraoperative incidental cystotomies , which occurred at the time of vaginal transection before specimen removal .
one of these patients had extensive endometriosis at the anterior vaginal margin , and the other had vaginal tumor extension with significantly fore - shortened anterior vaginal fornix . in the tlrh group , 2 patients underwent inadvertent cystotomies at the time of laparoscopic bladder dissection of the anterior vagina .
both patients had bilateral jj ureteral stents placed intraoperatively and had an otherwise uncomplicated recovery .
outpatient cystoscopy , cystogram , and stent removal was performed on both patients 10 days later with no long - term sequela .
postoperative complications in the rrh group included one case of postoperative ileus , prolonged urinary retention , vaginal lymph drainage , and c. difficile colitis .
the tlrh group had complications including two cases of deep vein thrombosis pulmonary embolism and c. difficile colitis and cases of ileus , and prolonged urinary retention ( table 3 ) .
the mean yield of the pelvic lymph nodes was 24.7 in the rrh group and 31 in the tlrh group ( table 2 ) .
there were no recurrences in either group with a mean follow - up time of 12 months in the rrh group and 29 months in the tlrh group .
we did not note a significant difference between rrh and tlrh with respect to operative time , operative blood loss , length of hospital stay , or complication profile .
the only intraoperative complication observed in both groups was cystotomy . along with ureteral injury , these are the most common reported intraoperative complications associated with laparoscopic radical hysterectomy .
bladder injuries in the tlrh group were neither related to radical parametrial resection nor to lymph node dissection . similarly , in the rrh group , cystotomies were not related to the use of the robot system and took place at the time of the vaginal specimen removal .
none of the patients had a recurrence with a mean follow - up of 12 months in the robotic group and 29 months in the laparoscopic group .
several recent publications strongly demonstrated that computer - assisted surgical approaches are becoming increasingly feasible .
in fact , our evidence , as well as the evidence of others , supports robotic surgery as a more attractive option , both for the surgeon and the patient .
however , questions remain , including whether the robot provides any additional benefits to a surgeon who is an experienced laparoscopist and comfortable performing the most advanced gynecologic procedures using traditional laparoscopy , whether there is an advantage for an inexperienced laparoscopic surgeon to use robotic technology compared with traditional laparoscopic instrumentation , and what the learning curve is with either approach .
several gynecologic surgeons have reported their experiences performing tubal reanastomosis , salpingo - oophorectomy , and hysterectomy using an earlier robotic system .
most recently , nezhat and colleagues and koh and colleagues reported their experiences performing various advanced gynecologic procedures using the current generation of the da vinci system .
the largest experience using robotic systems for the surgical treatment of gynecologic cancers was reported by j. magrina of the mayo clinic ( scottsdale , az ) .
it comprised 142 patients treated surgically with the da vinci robotic system for various primary and recurrent gynecologic malignancies .
the mean operating time was 218 minutes , estimated blood loss was 176 ml , and the hospitalization time was 1.9 days .
the authors concluded that robotic surgery is preferable to conventional laparoscopy for gynecologic oncology procedures because it provides improved dexterity , 3-dimensional viewing , surgical precision with tremor filtration , a comfortable fatigue - reducing console , and greater motion freedom allowed by the robotic instruments , which significantly reduced ergonomic problems associated with conventional laparoscopic equipment .
the author performed 13 rrh procedures that were compared with 48 historic abdominal radical hysterectomies .
lymph node yield was significantly higher in the robotic group ( 33 vs. 22 ) , and operative time was similar between the groups .
blood loss as well as transfusion requirements in the robotic group were significantly less than that in the abdominal group .
all patients who underwent robotic rrh were discharged the day after surgery with significantly lower pain medication requirements than patients who underwent an open procedure .
the gynecologic oncology community has been appropriately cautious in accepting laparoscopic procedures , including tlrh , as a standard of care due to a lack of oncological outcome data .
data on specimen size , margin adequacy , and parametria appear to be equivalent . with the follow - up data in some of the studies approaching or exceeding 5 years ,
does the recurrence rate in the laparoscopically managed patients exceed that of the patients who underwent an open procedure . as was the case with laparoscopy 10 years ago
abdominal radical hysterectomy continues to be the most common surgical approach in treatment of an early stage carcinoma of the cervix .
the role of laparoscopy in this setting is to offer all of the benefits of a minimally invasive approach , namely faster recovery , decreased blood loss and transfusion rates , and decreased postoperative pain , while maintaining the excellent oncological outcomes of an open approach . while all gynecologic surgeons taking care of patients with early cervical cancer
are trained to perform abdominal radical hysterectomy , only a few are comfortable performing the procedure laparoscopically .
tlrh is one of the most challenging laparoscopic procedures in gynecologic oncology , requiring significant technical expertise and experience . because this is a relatively new technique , the number of cases required to obtain proficiency is not known . as
more centers perform these procedures , report their experiences , and the technique itself is developed , standardized , and taught systematically , we will better understand the learning curve required for both tlrh and rrh .
the available urological data suggest that the intuitive nature of the robotic approach may provide a significant advantage in terms of its learning curve especially to surgeons with little or no advanced laparoscopic experience .
ahlering and colleagues reported the initial experience of performing robotic - assisted radical prostatectomy by an experienced abdominal surgeon without any laparoscopic experience .
it required only 12 cases to achieve proficiency in performing radical prostatectomy with robotic assistance .
robotic - assisted prostatectomy outcomes were comparable to those achieved by a skilled laparoscopic surgeon after 100 cases of laparoscopic radical prostatectomies .
as the number of early cervical cancer cases is decreasing , fast acquisition of advanced endoscopic skills is paramount .
therefore , the robotic interface , which allows for significant shortening of the learning curve , may make a minimally invasive approach possible even in centers with very few cases of early cervical cancer .
the robotic systems have their own drawbacks ; most commonly mentioned are the absence of tensile feedback , the complexity of the system , the size of the system , and the cost .
robotic technology is developing rapidly , and new instruments , smaller arms , the addition of a fourth arm and tactile feedback are already becoming available .
currently , operations performed with a robot are expensive , but the widespread use of this technology , combined with the shorter hospital stay , hopefully , will lead to an overall , and substantial , decrease in cost .
though robotic technology has revolutionized urologists ' treatment of prostate cancer , its use in the treatment of cervical cancer by gynecologic oncologists is still in development .
we have found that the substantial magnification , dexterity , and flexibility offered by the robotic system significantly simplify the most difficult stages of radical hysterectomy and pelvic lymphadenectomy , which would enable a greater number of surgeons to perform this procedure laparoscopically . as we continue to develop new surgical techniques
, we can not compromise the patient 's safety or oncological outcome , so we should subject these newer approaches to thorough evaluation before they become the standard .
 background and objectives : to compare intraoperative , pathologic and postoperative outcomes of robotic radical hysterectomy ( rrh ) to total laparoscopic radical hysterectomy ( tlrh ) in patients with early stage cervical carcinoma.methods:we prospectively analyzed cases of tlrh or rrh with pelvic lymphadenectomy performed for treatment of early cervical cancer between 2000 and 2008.results:thirty patients underwent tlrh and pelvic lymph - adenectomy for cervical cancer from august 2000 to june 2006 . 
 thirteen patients underwent rrh and pelvic lymph - adenectomy for cervical cancer from april 2006 to january 2008 . 
 there were no differences between groups for age , tumor histology , stage , lymphovascular space involvement or nodal status . 
 no statistical differences were observed regarding operative time ( 323 vs 318 min ) , estimated blood loss ( 157 vs 200 ml ) , or hospital stay ( 2.7 vs 3.8 days ) . 
 mean pelvic lymph node count was similar in the two groups ( 25 vs 31 ) . 
 none of the robotic or laparoscopic procedures required conversion to laparotomy . the differences in major operative and postoperative complications between the two groups were not significant . 
 all patients in both groups are alive and free of disease at the time of last follow up.conclusion:based on our experience , robotic radical hysterectomy appears to be equivalent to total laparoscopic radical hysterectomy with respect to operative time , blood loss , hospital stay , and oncological outcome . 
 we feel the intuitive nature of the robotic approach , magnification , dexterity , and flexibility combined with significant reduction in surgeon 's fatigue offered by the robotic system will allow more surgeons to use a minimally invasive approach to radical hysterectomy . 
INTRODUCTION
MATERIALS AND METHODS
Study Design
Patient Population
Data Collection
Surgeons
Robotic Laparoscopic Radical Hysterectomy Surgical Technique
Postoperative Care
Statistical Analysis
RESULTS
DISCUSSION
CONCLUSION