Robotic Gynaecological Cancer Surgery Outcomes: Four Cases

What are the outcomes of robotic gynaecological cancer surgery? Dr. Alka Dahiya, Senior Consultant, Gynaecological Surgical Oncology, BLK-Max Super Speciality Hospital, New Delhi, India, reports lower complication rates and shorter hospital stays with no loss of oncological quality across 251 robotic operations, 160 of them for cancer, and open surgery avoided in approximately 37 patients in a year of her own practice. Four of her cases show how.

The cases run from severe endometriosis to advanced ovarian cancer. Each shows a different reason for choosing the robot. The selection and containment rules behind robotic cancer surgery are set out in the companion article on patient selection and containment. For the platform and its limitations, see the complete guide to robotic surgery in gynaecologic oncology.

Case 1: robotic hysterectomy for severe endometriosis

The presentation. A woman in her early forties came to the outpatient clinic with chronic abnormal uterine bleeding, a haemoglobin of 6 g/dL (severe anaemia) and a CA-125 of 600 units. CA-125 is a blood marker raised in ovarian cancer but also in benign conditions, endometriosis among them, so a level this high needs careful evaluation before surgery. The work-up showed endometriosis of both the pelvis and the ovaries.

What surgery found. The pouch of Douglas, the space between the back of the uterus and the rectum, was obliterated. Both ovaries were stuck to the back of an enlarged uterus with adenomyosis (endometrial tissue growing into the muscle wall of the uterus), together with the rectosigmoid colon. This is the frozen, distorted anatomy in which Dr. Dahiya finds the robot's vision and precision particularly valuable.

The operation. She performed a robotic hysterectomy with removal of one ovary and tube (unilateral salpingo-oophorectomy) and removal of the opposite tube (salpingectomy). The dissection was carried down to the mesorectal fat around the rectum, all visible disease was removed from behind the uterus, and the final view showed a clean pouch of Douglas, a clean vaginal vault and no residual disease. Part of the left ovary was preserved.

The outcome. The patient did really well and was discharged on the fourth day. At one year there had been no recurrence of endometriosis.

Why the robot. Preserving ovarian tissue while clearing deep endometriosis from the rectum is exactly the combination of radicality and precision that, in Dr. Dahiya's experience, the 3D view and wristed instruments make achievable.

Case 2: robotic hysterectomy with sentinel node mapping for early endometrial cancer

The presentation. A woman in her mid-fifties had early-stage endometrial cancer.

Why the robot. Dr. Dahiya regards endometrial cancer as one field where robotics is genuinely useful, because so many of these patients are obese, hypertensive or diabetic and are difficult to operate on by the open or laparoscopic route.

The operation. A robotic hysterectomy with ICG-based sentinel lymph node dissection. Indocyanine green dye highlighted the sentinel nodes, the first nodes to which the cancer drains, and the uptake was clearly visible on the robotic camera. Only those nodes were removed; there was no need to empty the entire pelvic lymph node basin.

The outcome. At the time of the masterclass she had been on observation for six months after surgery.

Case 3: robotic interval cytoreduction for chemotherapy-resistant ovarian cancer

Dr. Dahiya called this one "a very special case".

The presentation. A woman in her sixties, who had had a hysterectomy in the past, developed low-grade serous carcinoma of the ovary. Because the disease load was high at the outset, she was given neoadjuvant chemotherapy (chemotherapy before surgery). The response was poor: the disease stayed stable rather than shrinking, and the ovarian mass was infiltrating the rectosigmoid colon, so she began to show signs of bowel obstruction.

The decision. She was older and obese, and her prognosis was guarded because the tumour had proved resistant to chemotherapy. The team offered her a minimally invasive operation: a robotic interval cytoreduction.

What the operation involved. Dr. Dahiya showed the procedure on video:

1. Assessment. Disease was present on both the left and right diaphragm and in the pelvis, with omental adhesions that were divided first.
2. Peritoneal stripping of the abdominal wall. The peritoneum, the lining of the abdominal cavity, was studded with tumour deposits. It was stripped completely from the left abdominal wall down to the pelvic brim until the muscle was exposed, then from the right wall, exposing the vessels, and finally from the anterior and lower abdominal wall towards the midline, where the urachus (the fibrous remnant running from the bladder to the navel) lies.
3. Mesentery and pelvis. Deposits on the bowel mesentery were addressed. The ureters were dissected away from the mass.
4. En bloc pelvic resection. The large ovarian mass, deeply lodged with dense adhesions and infiltrating the rectosigmoid, was lifted off the pelvic floor and removed in one piece together with the rectosigmoid colon, freed from the pelvic side wall muscle and the external iliac vessels, with the obturator nerve identified on the left. The peritoneum was stripped off the bladder and taken with the specimen. The mass came away, in her words, quite neatly, without much blood loss.
5. Diaphragmatic peritonectomy. The peritoneum was removed from the left dome of the diaphragm and then the right, without bleeding. The dissection continued under the liver, alongside the kidney and duodenum, to clear tumour deposits from the recess there, and the peritonectomy was completed.

The outcome. After surgery she went on to second-line chemotherapy and had been disease-free for eight months at the time of the session.

Why it matters. Upper-abdominal and diaphragmatic surgery of this extent has traditionally required a long midline incision. The case shows how far the robotic approach can reach in an older, obese patient for whom a large open operation was a heavy burden.

Case 4: robotic modified radical hysterectomy for early cervical cancer

The presentation. A woman in her early forties had bleeding from the cervix. Her Pap smear showed a high-grade squamous intraepithelial lesion (HSIL), a high-grade precancerous change. A LEEP (loop electrosurgical excision procedure, which removes the abnormal area of the cervix with a heated wire loop) revealed early-stage cervical cancer. The metastatic work-up was negative.

The operation. A robotic modified radical hysterectomy with pelvic lymph node dissection. To achieve a good vaginal margin and parametrial clearance, the bladder was fully mobilised so that at least 1.5 centimetres of healthy vaginal cuff could be taken, and the parametrium was cleared on each side.

The pathology. The final stage was IA1 squamous cell carcinoma, the earliest stage of invasive cervical cancer. The specimen showed good vaginal margins all round and a well-cleared parametrium.

The outcome. The Peters and Sedlis criteria were all negative. These are the two standard pathology rule sets for deciding whether radiotherapy is needed after radical hysterectomy: the Peters criteria (positive lymph nodes, positive margins or parametrial involvement) define high risk, and the Sedlis criteria (combinations of lymphovascular space invasion, depth of stromal invasion and tumour size) define intermediate risk. With both negative, the patient needed no adjuvant treatment. She had been disease-free for ten months.

Why it matters. The case sits inside Dr. Dahiya's strict rule for cervical cancer: she restricts robotic surgery to very early, micro-invasive stage IA disease. Why the wider evidence confines minimally invasive radical hysterectomy to low-risk tumours is explained in the article on patient selection.

Robotic gynaecological cancer surgery outcomes: the 251-patient series

Dr. Dahiya presented a study her team conducted at their corporate hospitals: 251 patients who underwent robotic surgery for any gynaecological or gynae-oncological indication. One hundred and sixty had malignant disease; the remaining 91 had benign conditions. The series showed:

• a lower complication rate;
• a shorter hospital stay;
• no compromise on oncological outcomes: recurrence, cancer-free margins and lymph node yield.

The conclusion she drew is that a number of gynaecological operations can be performed robotically with minimal morbidity and uncompromised surgical outcomes, provided four conditions hold: careful patient selection, good surgical expertise, prospective research and patient affordability.

Complications and hospital stay: an audit of one surgeon's practice

With Intuitive, the company behind the da Vinci system, Dr. Dahiya ran a study to quantify how robotics had changed her own practice towards minimally invasive surgery in gynaecology and gynaecologic oncology.

Measures compared with laparoscopic and open surgery: length of hospital stay, pain score, readmission and re-operation rates, and pelvic lymph node dissection. On each, robotics was either superior or at least equal; for clearance and pelvic lymph node dissection, it was equal to open surgery.

Complications tracked: vault infection, dyspareunia (pain during intercourse), vault granulation tissue, lymphoedema and positive surgical margins. On all of these robotics performed very well, especially when performed with good expertise, with no compromise on radicality or lymph node yield.

The annual impact on her patients:

• open surgery avoided in approximately 37 patients;
• complications avoided in 9;
• a much lower rate of vault infection;
• fewer women reporting pain during intercourse or vaginal pain after hysterectomy;
• better overall pain scores and a shorter hospital stay.

What the cases and outcomes data add up to

The four cases share a pattern. In each, the robot was chosen for a specific reason: frozen anatomy in endometriosis, obesity and sentinel node mapping in endometrial cancer, the extent of disease in an older, obese patient with chemotherapy-resistant ovarian cancer, and a strictly early tumour in cervical cancer. Dr. Dahiya's own summary is that these are patients who benefited from the approach, and that she continues to build it into her practice on an evidence-based footing.

The questions doctors asked her after these cases, on training, fellowships and cost, are answered in the Live Discussion from this masterclass. Indicative costs for related operations are on the radical hysterectomy and ovarian cystectomy cost pages.