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Background and Objectives: To compare the immediate operating room (OR), inpatient, and overall costs between three surgical modalities among women with endometrial cancer (EC) and Class III obesity or higher., Methods: A multicentre prospective observational study examined outcomes of women, with early stage EC, treated surgically. Resource use was collected for OR costs including OR time, equipment, and inpatient costs. Median OR, inpatient, and overall costs across surgical modalities were analyzed using an Independent-Samples Kruskal-Wallis Test among patients with BMI ≥ 40., Results: Out of 520 women, 103 had a BMI ≥ 40. Among women with BMI ≥ 40: median OR costs were $4197.02 for laparotomy, $5524.63 for non-robotic assisted laparoscopy, and $7225.16 for robotic-assisted laparoscopy (p < 0.001) and median inpatient costs were $5584.28 for laparotomy, $3042.07 for non-robotic assisted laparoscopy, and $1794.51 for robotic-assisted laparoscopy (p < 0.001). There were no statistically significant differences in the median overall costs: $10 291.50 for laparotomy, $8412.63 for non-robotic assisted laparoscopy, and $9002.48 for robotic-assisted laparoscopy (p = 0.185)., Conclusion: There was no difference in overall costs between the three surgical modalities in patient with BMI ≥ 40. Given the similar costs, any form of minimally invasive surgery should be promoted in this population., (© 2021 Wiley Periodicals LLC.)

Objective Data: Robotic assistance may facilitate completion of minimally invasive hysterectomy, which is the standard of care for the treatment of early-stage endometrial cancer, in patients for whom conventional laparoscopy is challenging. The aim of this systematic review was to assess conversion to laparotomy and perioperative complications after laparoscopic and robotic hysterectomy in patients with endometrial cancer and obesity (body mass index, ≥30 kg/m 2 )., Study: We systematically searched MEDLINE, EMBASE, and Evidence-Based Medicine Reviews (January 1, 2000, to July 18, 2018) for studies of patients with endometrial cancer and obesity (body mass index, ≥30 kg/m 2 ) who underwent primary hysterectomy., Study Appraisal and Synthesis Methods: We determined the pooled proportions of conversion, organ/vessel injury, venous thromboembolism, and blood transfusion. We assessed risk of bias with the Institute of Health Economics Quality Appraisal Checklist for single-arm studies, and Newcastle-Ottawa Quality Scale for double-arm studies., Results: We identified 51 observational studies that reported on 10,800 patients with endometrial cancer and obesity (study-level body mass index, 31.0-56.3 kg/m 2 ). The pooled proportions of conversion from laparoscopic and robotic hysterectomy were 6.5% (95% confidence interval, 4.3-9.9) and 5.5% (95% confidence interval, 3.3-9.1), respectively, among patients with a body mass index of ≥30 kg/m 2 , and 7.0% (95% confidence interval, 3.2-14.5) and 3.8% (95% confidence interval, 1.4-9.9) among patients with body mass index of ≥40 kg/m 2 . Inadequate exposure because of adhesions/visceral adiposity was the most common reason for conversion for both laparoscopic (32%) and robotic hysterectomy (61%); however, intolerance of the Trendelenburg position caused 31% of laparoscopic conversions and 6% of robotic hysterectomy conversions. The pooled proportions of organ/vessel injury (laparoscopic, 3.5% [95% confidence interval, 2.2-5.5]; robotic hysterectomy, 1.2% [95% confidence interval, 0.4-3.4]), venous thromboembolism (laparoscopic, 0.5% [95% confidence interval, 0.2-1.2]; robotic hysterectomy, 0.5% [95% confidence interval, 0.1-2.0]), and blood transfusion (laparoscopic, 2.8% [95% confidence interval, 1.5-5.1]; robotic hysterectomy, 2.1% [95% confidence interval, 1.6-3.8]) were low and not appreciably different between arms., Conclusion: Robotic and laparoscopic hysterectomy have similar rates perioperative complications in patients with endometrial cancer and obesity, but robotic hysterectomy may reduce conversions because of positional intolerance in patients with morbid obesity. Existing literature is limited by selection and confounding bias, and randomized trials are needed to inform practice standards in this population., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Objective: To compare laparotomy, laparoscopy, and robotic surgical approaches to lymphadenectomy for high-risk endometrial cancer staging., Methods: A retrospective cohort study enrolled patients who underwent surgery for pathologic high-risk endometrial carcinoma at the University Health Network, Toronto, Canada, between January 1, 2005 and December 31, 2013. The primary outcome, the median number of nodes retrieved, was compared based on surgical technique. The secondary outcome was the detection of metastatic nodes., Results: A total of 176 patients who underwent surgery for high-risk endometrial cancer were included, of whom 147 (83.5%) had pelvic and 78 (44.3%) had para-aortic lymphadenectomy. Laparotomy, laparoscopy, and robotic approaches were applied for 69 (39.2%), 44 (25.0%), and 63 (35.8%) patients, respectively. Minimally-invasive staging was associated with an increased proportion of patients undergoing pelvic lymphadenectomy compared with laparotomy (P=0.005). The median number of nodes removed in the pelvis and para-aortic regions did not differ between surgical approaches. The detection of metastatic nodes was also similar between the groups. Increased blood loss (P<0.001) and longer hospital admission (P<0.001) were observed with laparotomy procedures., Conclusion: All three techniques demonstrated adequate staging of high-risk endometrial carcinoma. Based on improved peri-operative outcomes, the use of minimally-invasive techniques is advocated where appropriate., (© 2016 International Federation of Gynecology and Obstetrics.)

Introduction: Robotic surgery is associated with a learning curve unique to each trainee. Knowledge about a trainee's baseline skill and learning curve would facilitate the development of a more individualized training curriculum. The aim of our study was to determine whether baseline laparoscopic skill is predictive of one's baseline robotic skill and short-term learning curve., Methods: Trainees from four different surgical specialties were included in the study. Each trainee participated in a 4-week, simulation-based robotic surgery basic skills training course. Precourse, baseline laparoscopic and robotic skills were assessed using validated test tasks; a basic peg transfer (PT) and an advanced intracorporeal suturing and knot tying (ISKT) task. Trainee robotic skill was assessed again 1 week postcourse. Each task performance was video recorded and scored by two blinded expert surgeons., Results: A total of 32 trainees were included; 14 urology, 7 gynecology, 8 thoracic Sx, 3 general Sx. Most (91%) were senior residents or clinical fellows and 50% had no prior robotic experience. There were no differences in baseline laparoscopic and robotic skill related to reported prior robotic experience. Between specialties, no differences were seen on baseline laparoscopic skill and only small differences were seen on baseline robotic skill. Both baseline Lap PT (p = 0.01) and Lap ISKT (p = 0.01) performances correlated with baseline robotic ISKT performance, but not robotic PT scores. Only baseline Lap ISKT performance correlated with postcourse robotic PT (p = 0.01) and ISKT (p < 0.01) performance. Baseline robotic ISKT scores, but not PT scores, correlated with postcourse robotic performance (p = 0.02 for PT, p < 0.01 for ISKT)., Conclusions: In this study, a trainee's baseline laparoscopic skill correlated with certain baseline robotic skills. Better baseline performance on an advanced, but not basic, laparoscopic and robotic skill task may correlate with a shorter learning curve for basic robotic skills. Further exploration of this finding may yield better training curricula.

Objective: To determine the rates of laparoscopy compared to laparotomy over time for the treatment of endometrial cancer in the province of Ontario, Canada, and to determine factors associated with having laparoscopic surgery., Methods: This was a population-based retrospective cohort study using healthcare administrative databases. Incident cases of endometrial cancer from April 2002-March 2011 were identified in the provincial cancer registry. Record linkages were made with other healthcare databases to determine type of hysterectomy (laparoscopic or abdominal±staging), year of diagnosis, comorbidities, location of residence, surgeon and hospital type., Results: 12,104 patients with endometrial cancer treated with hysterectomy were identified, of which 2116 had laparoscopic surgery (17.5%). Rates of laparoscopy increased over time from 6.5% in 2002 to 30.2% in 2011 (p<0.0001). The median length of hospital stay after abdominal hysterectomy was significantly longer (3 days vs 1 day, p<0.0001). Adjusting for age, comorbidity score, income quintile and type of hospital (community versus academic), the probability of admission or emergency room visit within 30 days of surgery was significantly higher in patients with abdominal surgery (OR 1.61) (95% CI 1.36-1.92) (p<0.0001). The odds of having laparoscopic surgery was higher with a gynecologic oncologist (OR 2.85, 95% CI 1.61-5.85) or a general gynecologist at an academic hospital (OR 2.07, 95% CI 1.09-3.95) compared to a general gynecologist at a community hospital., Conclusions: This population-based cohort study confirms the increased use over time of laparoscopic surgery to treat endometrial cancers in Ontario, and demonstrates the benefits of decreased hospital stay and decreased patient morbidity., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Total laparoscopic hysterectomy (LH) is a minimally invasive technique, which results in comparable morbidity and better cosmesis compared with total abdominal hysterectomy. The literature is discrepant as to whether it is associated with a higher incidence of positive peritoneal cytology compared with total abdominal hysterectomy and recently, associated artifacts, including vascular pseudoinvasion (VPI), have been described. A retrospective histopathologic review of 266 hysterectomy specimens from 2 centers was performed. The observers, blinded to the surgical technique, assessed for the presence of artifactual changes including disruption of the endometrial lining, nuclear crush artifact, VPI, endomyometrial cleft artifact with or without epithelial displacement, inflammatory debris within vessels, serosal carryover, and intratubal contaminants. In addition, the rates of positive peritoneal washings over a 5-year period, and the use of immunohistochemistry (IHC) to aid in cell typing over a 3-year period, were compared between hysterectomies in which a uterine manipulator (UM) device had and had not (nonmanipulated hysterectomies) been used. The hysterectomies were performed for malignant (n=160) and benign (n=102) uterine disease or for ovarian or cervical disease (n=4), and included total abdominal (n=108), vaginal (n=17), laparoscopy-assisted vaginal (n=24), laparoscopy converted to laparotomy (n=10), nonrobotic laparoscopic (n=51), and robot-assisted laparoscopic (n=56) hysterectomies. One hundred and two (38%) of these hysterectomies involved the use of a UM. Artifactual changes of disruption of the endometrial lining, endomyometrial clefts, intratubal contaminants, nuclear crush artifact, intravascular inflammatory debris, and VPI were significantly more common with LH and with the use of a UM, independent of whether the endometrial pathology was benign or malignant. IHC to aid in endometrial cancer subtyping was more likely to be used in manipulated hysterectomies (P=0.0166). Furthermore, peritoneal washings were significantly more likely to be positive in hysterectomies in which a UM had been used (P=0.0061). Histologic artifacts are significantly more common in LH and specifically in hysterectomies in which a UM is used. Such artifacts impair the pathologists' interpretation of cell type requiring an increased use of IHC, and displaced epithelial fragments present within vessels or artifactual clefts may result in the misinterpretation of prognostic and staging parameters. Furthermore, there is a significantly higher rate of positive peritoneal cytology in cases that are subjected to uterine manipulation, suggesting dissemination of malignant cells into the abdominal cavity. The clinical significance of this finding needs to be determined.

Objectives Minimally invasive radical hysterectomy is associated with decreased survival in patients with early cervical cancer. The objective of this study was to determine whether the use of an intra-uterine manipulator at the time of laparoscopic or robotic radical hysterectomy is associated with inferior oncologic outcomes. Methods A retrospective cohort study was carried out of all patients with cervical cancer (squamous cell carcinoma, adenocarcinoma or adenosquamous carcinoma) International Federation of Gynecology and Obstetrics 2009 stages IA1 (with positive lymphovascular space invasion) to IIA who underwent minimally invasive radical hysterectomy at two academic centers between January 2007 and December 2017. Treatment, tumor characteristics, and survival data were retrieved from hospital records. Results A total of 224 patients were identified at the two centers; 115 had surgery with the use of an intra-uterine manipulator while 109 did not; 53 were robotic and 171 were laparoscopic. Median age was 44 years (range 38--54) and median body mass index was 25.8 kg/m2 (range 16.6--51.5). Patients in whom an intra-uterine manipulator was not used at the time of minimally invasive radical hysterectomy were more likely to have residual disease at hysterectomy (p<0.001), positive lymphovascular space invasion (p=0.02), positive margins (p=0.008), and positive lymph node metastasis (p=0.003). Recurrencefree survival at 5 years was 80% in the no intra-uterine manipulator group and 94% in the intra-uterine manipulator group. After controlling for the presence of residual cancer at hysterectomy, tumor size and high-risk pathologic criteria (positive margins, parametria or lymph nodes), the use of an intra-uterine manipulator was no longer significantly associated with worse recurrence-free survival (HR 0.4, 95% CI 0.2 to 1.0, p=0.05). The only factor which was consistently associated with recurrencefree survival was tumor size (HR 2.1, 95% CI 1.5 to 3.0, for every 10 mm increase, p<0.001). Conclusion After controlling for adverse pathological factors, the use of an intra-uterine manipulator in patients with early cervical cancer who underwent minimally invasive radical hysterectomy was not an independent factor associated with rate of recurrence. [ABSTRACT FROM AUTHOR]

Objective To assess the impact of adjuvant chemotherapy on survival in patients with surgical stage I ovarian clear cell carcinoma (OCCC). Methods Data collection and analysis of surgical stage I OCCC patients treated at two tertiary cancer centers was performed. Descriptive statistics, univariate and multivariable analyses and Kaplan-Meier survival probability estimates were completed. Results Sixty stage I OCCC patients who underwent comprehensive surgical staging were identified. 29 patients received adjuvant chemotherapy and 31 did not. Median follow-up was 4.96 (0.4–16.4) years. The 5-year disease specific survival (DSS) was 84.2%: 95% for stage IA and 76% for stage IB + IC (p = 0.16). There were 11 disease specific deaths: 7 in the no adjuvant chemotherapy group (NACG) and 4 in the adjuvant chemotherapy group (ACG). 5-year DSS was 84.2%: 74% in NACG and 93% in ACG, (p = 0.13). Seventeen patients recurred: 11 in NACG and 6 in ACG (p = 0.2). None of the 21 patients with stage I known negative cytology recurred. 5-year PFS was 74%: 58% in NACG and 86% in ACG (p = 0.035). On univariate analysis, no-adjuvant chemotherapy and positive cytology were poor prognostic factors for PFS: HR = 2.36, p = 0.04 and HR = 3.1, p = 0.027, respectively. After adjusting for positive cytology, no-adjuvant chemotherapy was still found to significantly correlate with a worse PFS (HR = 4, p = 0.01). Conclusion Our data supports the use of adjuvant chemotherapy for surgical stage I OCCC. As no patients in our cohort with surgical stage I known negative cytology recurred, more research on the benefit of adjuvant chemotherapy in this group is warranted. [ABSTRACT FROM AUTHOR]