Who Is Suitable for Robotic Gynaecological Cancer Surgery

Whether a patient is suitable for robotic gynaecological cancer surgery comes down to one test: will the robot deliver the same oncological result as the best alternative? For Dr. Alka Dahiya, Senior Consultant, Gynaecological Surgical Oncology, BLK-Max Super Speciality Hospital, New Delhi, India, that means small, early tumours, no uterine manipulators, no tumour spillage, frozen section when the diagnosis is uncertain and early conversion to open surgery.

The platform changes; these rules do not. This article sets out how she applies those rules to cervical, endometrial and ovarian disease. For the platform itself, its advantages and its limitations, start with the complete guide to robotic surgery in gynaecologic oncology.

Who is suitable for robotic gynaecological cancer surgery

A patient is suitable only when the robotic operation can match the best alternative on three outcomes, which Dr. Dahiya treats as non-negotiable whatever the approach: the recurrence rate, clear oncological margins and an adequate lymph node yield. She returns to the point repeatedly, warning that an inadvertent injury, an inadvertent spillage or a wrong decision in cervical cancer or an ovarian mass can land both the patient and the surgeon in trouble.

Which gynaecological cancers can be operated on robotically

At her centre, robotic surgery is used for:

• Pre-invasive lesions of the cervix, the precancerous changes that precede invasive cervical cancer.
• Cervical cancer, in its earliest stages and under strict criteria (below).
• Endometrial cancer, cancer of the lining of the uterus, especially in its early stages.
• Small ovarian masses and benign ovarian masses.
• Interval cytoreductive surgery for ovarian cancer, the removal of all visible tumour after a first course of chemotherapy has been given.
• Exenteration procedures for central recurrences of cervical cancer. Pelvic exenteration is the removal of the pelvic organs involved by a cancer that has returned in the centre of the pelvis.

Robotic radical hysterectomy for early cervical cancer: the criteria

Radical hysterectomy removes the uterus and cervix together with the parametrium (the tissue that anchors the cervix to the pelvic side walls) and a cuff of the upper vagina. It is where Dr. Dahiya is most cautious. Her protocol for choosing a patient has four parts:

1. The tumour must be small: less than 2 centimetres, and preferably after conisation, the excision of a cone of tissue from the cervix for diagnosis.
2. No uterine manipulator.
3. Vaginal closure: the vagina is closed below the tumour before it is opened, so that the cervical tumour is never exposed to the abdominal cavity.
4. No compromise on radicality: the operation must remove as much tissue as the open operation would.

In practice she goes further. She restricts robotic surgery for cervical cancer to very early, micro-invasive disease, stage IA, in which the invasion is visible only under the microscope. Several studies from India and abroad, she noted, have reported better outcomes from robotic than from laparoscopic radical hysterectomy, but randomised controlled trials have yet to report.

Is minimally invasive radical hysterectomy safe for cervical cancer?

Only in carefully selected low-risk tumours, and that restraint matches the wider evidence. The LACC randomised trial, published in 2018, found lower disease-free and overall survival after minimally invasive than after open radical hysterectomy for early cervical cancer, and international guidelines name open surgery as the standard approach for radical hysterectomy. Dr. Dahiya's criteria define exactly that low-risk territory.

For screening, vaccination and the earlier end of the cervical cancer pathway, see Dr. Punyashree R M's article on cervical cancer screening and the HPV vaccine.

Robotic surgery for endometrial cancer and ICG sentinel node mapping

Endometrial cancer is, in Dr. Dahiya's view, one field where robotics is especially useful. Most women with hormone-dependent, endometrioid endometrial cancer are obese and have hypertension or diabetes, a combination long described as the corpus cancer syndrome. In these patients, she notes, both open and laparoscopic surgery can be really challenging and are sometimes associated with morbidity. Minimally invasive hysterectomy is the standard approach for early endometrial cancer: it carries fewer wound complications and a shorter hospital stay than open surgery, with equivalent survival.

The robot also makes sentinel lymph node mapping practical during the hysterectomy. A sentinel lymph node is the first node to which a cancer drains. Indocyanine green (ICG), a dye injected into the cervix, travels through the lymphatic channels and makes the sentinel nodes glow under near-infrared light on the robotic camera. The surgeon removes only those nodes, rather than emptying the entire pelvic lymph node basin in a full lymphadenectomy. In one of her cases, the sentinel node uptake was clearly visible and only those nodes were removed; there was no need to clear the pelvic basin. Removing fewer nodes lowers the risk of lymphoedema, the chronic limb swelling that can follow a full lymph node dissection, and sentinel node mapping is an accepted staging approach in major guidelines for cancer apparently confined to the uterus.

For the diagnostic side of endometrial cancer, including the endometrial thickness thresholds that trigger investigation, see Dr. Punyashree R M's article on endometrial cancer.

Robotic surgery for ovarian masses: containment comes first

Ovarian masses are where Dr. Dahiya urges the greatest care, because the diagnosis is often uncertain until the mass is out and because rupture can spread tumour cells through the abdomen. Her rules are:

• Make liberal use of specimen retrieval bags (endobags), so that the mass is removed inside a sealed bag.
• Avoid spillage as much as possible.
• For large benign masses, use controlled aspiration with a purse-string suture: the cyst is drained through a needle held inside a stitch tightened around it, so that fluid does not leak.
• In malignant cases, ensure the right operation with complete cytoreduction, leaving no visible disease behind.

The evidence behind the containment rules

Her own study of 80 patients operated on for adnexal masses (masses of the ovary or fallopian tube) shows why. Eleven per cent of the masses were malignant and the rest were benign or borderline. Three factors decided recurrence:

1. Residual disease left behind at surgery.
2. Intraoperative spill of the cyst contents.
3. Cyst size greater than 8 centimetres.

Two of the three are within the surgeon's control, which is why containment and completeness carry so much weight in her practice. For the symptoms that bring these masses to attention, see Dr. Punyashree R M's article on early ovarian cancer symptoms.

Interval cytoreduction after chemotherapy

When advanced ovarian cancer is treated first with neoadjuvant chemotherapy (chemotherapy given before surgery to shrink the disease), the operation that follows is called interval cytoreductive surgery. Dr. Dahiya performs selected interval cytoreductions robotically. In one such case, described in the cases and outcomes article, the robot was used to strip the diseased peritoneum from the abdominal wall and both domes of the diaphragm and to remove the tumour en bloc with the rectosigmoid colon.

Intraoperative principles of minimally invasive cancer surgery

Dr. Dahiya's central point is that the principles of cancer surgery are the same whether the operation is done with a robot or a laparoscope:

1. Avoid spillage.
2. Aspirate large benign masses in a controlled way, with a purse-string suture.
3. Protect the port sites, so that tumour cells are not implanted in the wound as the specimen passes through it.
4. Convert early. If a diagnostic laparoscopy or diagnostic robotic look shows that the operation cannot be completed safely by the minimally invasive route, convert, and keep a low threshold for doing so.
5. Have frozen section available whenever the diagnosis is not certain beforehand. A frozen section is a rapid examination of tissue by a pathologist during the operation, which tells the surgeon within minutes whether a mass is benign, borderline or malignant, and so which operation to complete.
6. Preserve organs in younger patients. Keeping an ovary or the uterus where it is oncologically safe matters greatly to a young woman's hormonal health and fertility.

Positioning, and why manipulators stay out of cancer cases

Robotic gynaecological surgery needs a steeper head-down tilt than laparoscopy. Dr. Dahiya places the patient in a low lithotomy position, legs abducted and moderately flexed, and then in the Trendelenburg position, in which the table is tilted so that the head is lower than the pelvis and the bowel falls away from the operating field. Because the robotic Trendelenburg is quite extreme compared with laparoscopy, she always applies good shoulder braces and chest support to stop the patient from sliding.

In benign cases she uses vaginal and uterine manipulators, instruments placed through the vagina to move the uterus and present the operating field. In cancer cases she avoids them, because of the fear of tumour spread that many past studies have raised. The rule appears twice in her protocol: once in general positioning, and again as a named criterion for robotic radical hysterectomy.

The patient selection checklist in one place

Dr. Dahiya's closing summary condensed the approach into a short list:

• Careful patient selection, which, in her words, cannot be emphasised enough.
• Containment protocols: avoid spillage at all costs, use specimen bags liberally and protect the specimen.
• Convert early if any contamination is suspected, because outcomes cannot be compromised.
• Surgical mastery is essential.

Dr. Dahiya's answers to the doctors who attended, on training, fellowships and cost, are in the Live Discussion from this masterclass. Indicative costs for the operation discussed above are on the radical hysterectomy cost page, and related care sits within the site's oncology specialty.