Objective: To determine which non-narcotic analgesic, acetaminophen (Ofirmev (R)) or ketorolac (Toradol), provides better post-operative pain control when combined with an opioid patient-controlled analgesia (PCA) pump. Secondary objectives include comparisons of the rates of ileus, post-operative bleeding, transfusions, and length-of-hospitalization (LOH). Methods: A prospective, randomized trial of acetaminophen (A) 1-g intravenous (IV) every 6-h or ketorolac (K) 15-mg IV every 6-h from post-operative day 1-3 in addition to an opioid PCA for patients undergoing benign or malignant gynecologic laparotomy procedures was performed. Abstracted data included pain levels via visual analogue pain scales (VAS), amount of narcotic used, hepatic enzyme levels, hemoglobin, urine output, blood transfusions, time to return of flatus and LOH. Results: One-hundred patients were accrued and underwent 55 benign gynecologic laparotomies and 45 cancer-related laparotomies. VAS pain levels (3.3 K, 3.5 A) and morphine PCA use (79.1 oral morphine equivalents [OME] K vs. 84.5 A) were not different, however dilaudid PCA usage was less by K patients (84.4 OME K and 136.8 OME A, p < 0.001). There was a significant hemoglobin change between the two groups (2.6 g K vs. 2 g A, p = 0.015), however blood transfusions were equal (28% K, 22% A, p > 0.05). Return of flatus was 2.7-days for K vs. 3.4-days for A (p = 0.011) and LOH was not different (4.4-days K vs. 5.1-days A, p = 0.094). Conclusions: Both intravenous ketorolac and acetaminophen provide similar post-operative analgesia through VAS pain scales and total usage of morphine via PCA pumps. Use of ketorolac with dilaudid PCA was associated with less dependence on dilaudid and a quicker return of bowel function than acetaminophen, however length of stay and transfusion rates were not different. (C) 2019 Elsevier Inc. All rights reserved.

This prospective cohort study aimed to assess sentinel lymph node (SLN) mapping using isosulfan blue (ISB) compared with ISB plus indocyanine green (ICG) and near-infrared imaging (NIR) for patients with endometrial cancer.

Objectives. To compare the performance of sentinel lymph node (SLN) mapping with staging lymphadenectomy versus staging lymphadenectomy alone for the detection of metastasis and the use of adjuvant therapies in patients with endometrial cancer.Methods. All patients with apparent early-stage endometrial cancer (n = 780) who underwent robotic assisted hysterectomy with pelvic +/- aortic lymphadenectomy from July-2006 to June-2013 were compared [pelvic +/- aortic lymphadenectomy (n = 661) versus SLN-mapped cases with pelvic aortic lymphadenectomy (n = 119)]. Isosulfan-blue and indocyanine-green with near-infrared imaging were used for SLN mapping. Clinico-pathological data, FIGO stage, GOG risk category, and adjuvant therapies were compared.Results. Non-mapped and mapped cases were comparable with respect to BMI, histology, depth-of-invasion, and lympho-vascular space invasion. The mapped group had more pelvic lymph node (LN) harvested compared to non-mapped group (26.4 +/- 10.5 vs. 18.8 +/- 8.5, p < 0.001). Aortic LN yields were identical for both groups (9.0 +/- 5.6 vs. 9.0 +/- 6.0). The mapped group had more LN metastasis detected (30.3% vs. 14.7%, p < 0.001), more stage IIIC (30.2% vs. 14.5%, p < 0.001), more GOG high-risk cases (32.8% vs. 21.8%, p = 0.013), and received more chemotherapy + radiation (28.6% vs. 16.3%, p < 0.003). The SLN was the only metastasis in 18 (50%) mapped cases with positive nodes. The SLN false negative rate was 1/36 (2.8%). Micrometastases or isolated tumor cells were identified in 22/35 (62.9%) SLN metastases. Multivariate analysis demonstrated that SLN mapping imparted a significant effect on the detection of metastatic disease [adjusted OR = 3.29, p < 0.001].Conclusions. The performance of SLN mapping with staging lymphadenectomy increased the detection of lymph node metastasis and was associated with more use of adjuvant therapies. (C) 2016 Elsevier Inc. All rights reserved.

Objectives: A robotic surgery program was initiated in mid-2006 and perioperative outcomes data has been continuously collected and analyzed. The objective of this study was to perform a 6-year annual comparison of perioperative outcomes for patients with endometrial cancer (EC) who underwent robotic-assisted laparoscopic hysterectomy (RALH) and lymphadenectomy (LN).

Preoperative evaluation of patients presenting with ovarian masses is challenging, partly due to shortcomings with the commonly used marker, CA-125. Ovarian cancer is associated with systemic coagulation activation. Measurement of D-dimer, serum tissue factor (TF), and the coagulation process as a whole are considered candidates for improving discrimination between benign and malignant ovarian masses. We therefore sought to identify possible benefits by analyzing preoperative coagulation status in conjunction with CA-125 in patients with ovarian masses. Preoperative blood from 95 patients with ovarian masses (75 benign, 20 malignant) and 30 controls was analyzed, prospectively. Thromboelastography served for global hemostatic assessment. Plasma TF antigen and D-dimer were measured by ELISA and microparticle-associated TF activity by thrombin generation assay. TF+ microparticles were enumerated by flow cytometry. Time to clot formation by thromboelastography was similar between patients having either benign or malignant ovarian tumors. Clot formation rate, clot strength, and coagulation index were significantly increased in patients having malignant versus benign tumors, indicating that thromboelastography differentiated malignant from benign tumors. D-dimer alone differentiated malignant from benign ovarian tumors and also improved differentiation when combined with CA-125. Circulating TF antigen, activity, and TF+ microparticle numbers, however, failed to differentiate benign from malignant tumors. Significant coagulation activation occurs in women with ovarian malignancies. Plasma D-dimer may help discriminate between patients with benign and malignant tumors. Thromboelastography may also contribute meaningfully when combined with CA-125 in the preoperative evaluation of ovarian masses. Larger studies are needed to assess these possibilities.

Objectives. To evaluate recurrence-free survival (RFS) and overall survival (OS) for patients who underwent robotic-assisted laparoscopic hysterectomy (RALH) for uterine malignancies.Methods. Medical records from 372 patients with uterine malignancies who underwent RALH from 3/06 to 3/09 at two institutions were reviewed for dinico-pathologic data, adjuvant therapies, disease recurrence, and survival. Median follow-up for survival analysis was 31 +/- 14 months. Thirty (8.1%) patients were lost to follow-up before 12 months and censored from the recurrence analysis.Results. Mean age and BMI of 372 patients was 61.8 +/- 9.8 years and 32.2 +/- 8.4 kg/m(2) (range 19-70). Robotic procedures included RALH 16 (4.3%), RALH with pelvic lymphadenectomy (PL) 96 (25.8%), and RALH with pelvic-and-aortic lymphadenectomy (PAL) 252 (67.7%) cases. Histology included 319 (85.8%) endometrioid and 53 (12.6%) high-risk histologies. Mean pelvic and aortic lymph node counts were 16.8 +/- 8.7 and 8.4 +/- 4.5, respectively. Lymph node metastases were identified in 26 (7.3%) cases. Adjuvant therapies were prescribed for 108 (29.1%) of patients: 7.8% brachytherapy, 1.9% pelvic radiation + brachytherapy, 7.8% chemotherapy, 11.6% chemotherapy + radiation. Risk of recurrence for all patients was 8.3% and 17 (4.6%) patients died of disease. The estimated 3-year recurrence-free survival (RFS) for the entire study group was 89.3% and the estimated 5-year overall survival (OS) was 89.1%, compared to 92.5% and 93.4% for the endometrioid sub-set.Conclusions. Patients with endometrial cancer undergoing robotic hysterectomy with staging lymphade-nectomies during our 3-years of robotic experience had low-risk for recurrence and excellent disease-specific survival at a median follow-up time of 31 months. (c) 2012 Elsevier Inc. All rights reserved.

Objective: To determine which non-narcotic analgesic, acetaminophen or ketorolac, provides better postoperative pain control when combined with an opioid patient-controlled analgesic (PCA) pump, with attention to clinically important differences in ileus, narcotic requirement, length of hospitalization, and postoperative blood loss.

Objective: To analyze disease recurrence and survival for patients with early-stage cervical cancer who underwent abdominal radical hysterectomy (ARH) from 1997 to 2005, and to evaluate recurrence in relation to risk groups and use of adjuvant therapy.

To compare patient characteristics and operative outcomes among a cohort of women undergoing robotic-assisted laparoscopic hysterectomy (RALH) or abdominal hysterectomy (AH) for management of benign disease with complex pathology. This retrospective cohort study compared patients undergoing RALH between May 2006 and May 2009 to patients undergoing AH between July 2005 and May 2006. Demographic data, medical history, information on operative indications, findings, and complications were collected and analyzed. This study examined a population of women presenting to the Florida Hospital Gynecology Oncology (FHGO) Center for the management of non-malignant complex gynecologic pathology (e.g., leiomyomata, endometriosis, adenomyosis, benign ovarian masses). Women were eligible for inclusion under the following conditions: no pre- or post-operative evidence of malignancy, post-operative follow-up of ≥ 6 months, and medical record completion of ≥ 75%. As this study retrospectively examined the operative outcomes of robotic versus abdominal hysterectomy, there was no intervention. Compared to AH patients (n = 103), RALH patients (n = 245) were less likely to have significant co-morbidities (e.g., diabetes) and more likely to be of normal weight. RALH patients were less likely to have uterine weights of ≥500g or an adnexal or pelvic mass preoperatively. Although mean operative time was longer for RALH patients (99.8 versus 59.8 minutes), RALH resulted in reduced blood loss, reduced length of stay, and fewer wound infections postoperatively. After controlling for variables significantly associated with operative time (e.g., need for additional procedures including lysis of adhesions; BMI≥40 kg/m2), mean operative time remained longer for RALH patients (adjusted means, 102.9 mins versus 52.4 mins). Early case status (i.e., first 25 RALH cases for each surgeon) was also significantly associated with longer operative times for RALH patients. RALH is a safe and effective option for the management of patients with complex pathology, irrespective of uterine weight or patient BMI.

5117 Background: To determine outcomes of patients (pts) with stage IB-2 cervical carcinoma (CC) treated with concurrent chemoradiation (CRT) followed by extrafascial total abdominal hysterectomy (TAH) with common iliac and para-aortic lymphadenectomy (PAL). Methods: We reviewed 69 pts with stage IB-2 CC who were treated with CRT followed by TAH/PAL from 01/99 to 01/09. All pre-treatment CAT scans were negative for para-aortic (PA) lymphadenopathy. Brachytherapy was limited to 1,500-1,800 cGy. Results: Mean age was 46.7 ± 10.7 yr, BMI 29.5 ± 6 kg/m2, tumor size 5.4 ± 1.2 cm, operative time 62 ± 15 min, EBL 187 ± 103 mL, LOS 3.1 ± 1.0 days, and node counts 6.3 ± 2.9. Tumor histologies were: squamous=55, adenocarcinoma = 11, adenosquamous = 3. There were 6 (9%) radiation external beam and 23 (33%) brachytherapy protocol violations. All pts had a complete response to CRT prior to TAH. Complete pathologic responses were confirmed in 34 (49%) pts. At surgery, 11 (16%) pts had (+) PA nodes and 5/11 (45%) had pe...

OBJECTIVE:Although intra-operative and immediate postoperative complications of robotic surgery are relatively low, little is known about long-term morbidity. We set out to assess both short- and long-term morbidities after robotic surgery for endometrial cancer staging.METHODS:All patients who underwent robotic staging for EMCA between 2006 and 2009 from two institutions were identified. Patient charts were retrospectively reviewed for surgical complications and postoperative morbidities.RESULTS:Five hundred three patients were identified. No differences in complication rates were found between 2006-2007 and 2008-2009, even though the median BMI increased from 29.9 (range 19-52) to 32 (range 17-70) (p=0.03). 6.4% of cases were converted to laparotomy. Median length of stay was one day (range 1-46). No cystotomies, two enterotomies, one ureteric injury, and five vessel injuries occurred (1.6% intra-operative complications). Thirty-eight (7.6%) patients developed major postoperative complications, 11 (2.2%) had wound infections, and 15 (3%) required a transfusion in the 30-day peri-operative period. The total venous thromboembolism (VTE) rate for robotic cases was 1.7%. Partial cuff dehiscence managed conservatively occurred in 5 (1%) and complete dehiscence requiring closure in 7 (1.4%) patients; Sixty-three (13.4%) patients who had robotic staging developed lymphedema, with 40 (8%) requiring physical therapy.CONCLUSIONS:This study provides one of the largest cohorts of patients with robotic-assisted hysterectomy and lymphadenectomy (in 92.6%) with an assessment of morbidity. Our data demonstrates that robotic surgical staging can be safely performed with a low risk of short-term complications and lymphedema is the most frequent long-term morbidity.

We analyzed peri-operative outcomes of 80 patients who underwent robotic-assisted laparoscopic surgery and were diagnosed with stage IV endometriosis (revised American Society for Reproductive Medicine) between January 2007 and December 2010 at a tertiary gynecologic oncology referral center with a fellowship training program. Eligible women had a combination of one or more factors: pelvic mass, sub-acute or chronic pelvic pain, dysmenorrhea, dyspareunia, elevated serum CA-125, diagnosed with stage IV endometriosis at surgery with robotic-assisted gynecologic procedures using the da Vinci(®) Surgical System. The mean age was 43.7 ± 7.0 years, body mass index 27.5 ± 7.4 kg/m(2), and 23 (28.9%) patients had prior endometriosis surgery. Presenting symptoms included: chronic pelvic pain (48.8%), dysmenorrhea (40.3%), and dyspareunia (33.8%). Sixty-nine (86%) patients had pelvic masses (43 unilateral and 26 bilateral). Thirty-seven (46.3%) had elevated CA-125 levels (mean 97.9 ± 71.6 U/ml). Forty-eight (60%) underwent robotic-assisted laparoscopic hysterectomy (RALH)/bilateral salpingo-oophorectomy (BSO), 9 (11.3%) RALH/unilateral salpingo-oophorectomy (USO), 5 (6.3%) modified radical hysterectomy, and 10 (13%) USO or BSO only. Four (5%) had ovarian cystectomies with excision of endometriotic implants. Three (3.8%) underwent appendectomy and no patient required bowel resection. Four (5%) patients required conversion to laparotomy during the first 15 cases of this series [dense adhesions (3) and ureteral injury (1)]. Mean operative time was 115 ± 46 min, blood loss 88 ± 67 ml, and length of stay 1.0 ± 0.4 days. There were four (5%) complications (ureteral injury, cuff abscess, cuff hematoma, re-admission for nausea and vomiting secondary to narcotics) and no transfusions. One (1.3%) patient underwent a second surgery for pain (dyspareunia). Robotic-assisted surgery for stage IV endometriosis resulted in excellent pain relief, with few laparotomy conversions or complications during a robotic learning-curve experience.

To review peri-operative outcomes of patients with adnexal malignancies who underwent robotic-assisted laparoscopic surgical (RALS) staging procedures. Retrospective analyses of 59 patients with a malignant "adnexal mass" diagnosed at robotic surgery or incompletely staged ovarian cancer undergoing robotic staging. A tertiary gynecologic oncology referral center with a fellowship training program. All cases with a pre-operative diagnosis of "adnexal mass" subsequently proven to be malignant or cases of "unstaged ovarian cancer" undergoing robotic staging identified in a robotic surgery database (10/06 to 01/11). RALS utilizing da Vinci® Surgical System. Abstracted data included demographics, peri-operative outcomes, and complications for 59 cases (36 primary surgery, 23 staging surgery with prior diagnosis). Mean age was 50 ± 16 years (range 19-89), BMI 28 ± 6 kg/m2. Pre-op CA-125 for primary cases was 48 ± 39 U/mL, and tumor size 6 ± 3 cm (range 1-11). Pathology for staged malignancies were: 22 epithelial ovarian cancer, 20 low-malignant-potential (LMP), 9 granulosa cell, 7 fallopian tube, and 1 germ cell. All patients had washings, peritoneal biopsies, and omentectomy. 46 patients had lymphadenectomy (45 pelvic, 26 pelvic+aortic, 16 unilateral). Mean pelvic node counts were 11 ± 7 (range 2-33) and aortic node counts were 8 ± 6 (range 1-22). Robotic surgery upstaged only 1 (5%) of LMP and 9 (15.3%) of non-LMP cases (IIC = 5, IIIB = 1, and IIIC = 4). Mean operative time was 147 ± 46 min and estimated blood loss 81 ± 82 mL. Mean hospital length-of-stay was 1.0 ± 0.2 days (range 0.5-5.0). There were two laparotomy conversions, one transfusion, 3 (5.1%) major post-operative complications (transverse colo-vaginal fistula, PTE post-op day-18, and laparotomy wound infection) and five cases of transient anterior thigh paresthesias. Consistent with reports of RALS for cervical and endometrial cancers, surgical staging of apparent early-stage ovarian cancer was associated with low morbidity, few laparotomy conversions, and a 23% upstaging in non-LMP cases.

Objective: The purpose of this study was to evaluate progression-free and overall survival for patients who underwent robot-assisted laparoscopic staging (RALS) for uterine malignancy, with analysis of adjuvant therapies.

Study ObjectiveTo perform a 4-year annual comparison of peri-operative outcomes for patients with endometrial cancer (EC) treated with robotic-assisted laparoscopic hysterectomy (RALH) and lymphadenectomy.DesignIRB-approved retrospective analyses of clinical-pathologic factors and surgical outcomes data from 391 patients with EC who underwent successful RALH with lymphadenectomy from 07/2006 to 06/2010.SettingA tertiary gynecologic oncology referral center with a fellowship training program.PatientsAnnual comparison of all EC cases (n=391) treated with RALH/lymphadenectomy at a single institution.InterventionRALH/lymphadenectomy utilizing da Vinci® Surgical System.Measurements and Main ResultsAbstracted data included demographics, clinical-pathologic and peri-operative outcomes, and complications for 391 EC cases. 222(56.8%) of RALH cases had complete pelvic/aortic lymphadenectomy (PAL) and 169 had only pelvic lymphadenectomy (PL). 42, 79, 108, and 162 RALH cases were performed in years 1, 2, 3, and 4, respectively. Between year 1 vs. 4, mean age increased (57.4±10.7 vs. 63.8±10.6; p<0.01), but hospital length-of-stay and estimated blood loss did not change significantly (1.0±0.4 vs. 1.4±1.8 days, and 94±59 vs. 79±59 mL). Mean BMI increased (28.2±7.1 vs. 31.7±7.4 kg/m2, p<0.01). Operative time (OT) decreased (173±56 vs. 148±34 min, p<0.001), total lymph node (LN) counts increased (16.9±11.8 vs. 24.2±10.9, p<0.001) and aortic LN increased (6.6±5.0 vs. 11.0±6.7, p<0.001) by years 1 vs. 4. For PAL cases only, OT was 185, 181, 185, and 165 min, and node counts were 21, 25, 27, 29 for years 1-4, respectively. 58.3% of RALH cases were grade 1 and LN metastasis were identified in 8.2% cases. Surgical Stage II to IV disease was present in 90(23%) of RALH cases. There were 30(7.7%) complications and only 2(0.5%) transfusions.ConclusionThis 4-year comparative analysis of RALH cases for EC reveals a significant reduction in OT, despite an increase in BMI, age, and lymph node retrieval. A reduction in OT for PAL cases was recognized in the year-4. Study ObjectiveTo perform a 4-year annual comparison of peri-operative outcomes for patients with endometrial cancer (EC) treated with robotic-assisted laparoscopic hysterectomy (RALH) and lymphadenectomy. To perform a 4-year annual comparison of peri-operative outcomes for patients with endometrial cancer (EC) treated with robotic-assisted laparoscopic hysterectomy (RALH) and lymphadenectomy. DesignIRB-approved retrospective analyses of clinical-pathologic factors and surgical outcomes data from 391 patients with EC who underwent successful RALH with lymphadenectomy from 07/2006 to 06/2010. IRB-approved retrospective analyses of clinical-pathologic factors and surgical outcomes data from 391 patients with EC who underwent successful RALH with lymphadenectomy from 07/2006 to 06/2010. SettingA tertiary gynecologic oncology referral center with a fellowship training program. A tertiary gynecologic oncology referral center with a fellowship training program. PatientsAnnual comparison of all EC cases (n=391) treated with RALH/lymphadenectomy at a single institution. Annual comparison of all EC cases (n=391) treated with RALH/lymphadenectomy at a single institution. InterventionRALH/lymphadenectomy utilizing da Vinci® Surgical System. RALH/lymphadenectomy utilizing da Vinci® Surgical System. Measurements and Main ResultsAbstracted data included demographics, clinical-pathologic and peri-operative outcomes, and complications for 391 EC cases. 222(56.8%) of RALH cases had complete pelvic/aortic lymphadenectomy (PAL) and 169 had only pelvic lymphadenectomy (PL). 42, 79, 108, and 162 RALH cases were performed in years 1, 2, 3, and 4, respectively. Between year 1 vs. 4, mean age increased (57.4±10.7 vs. 63.8±10.6; p<0.01), but hospital length-of-stay and estimated blood loss did not change significantly (1.0±0.4 vs. 1.4±1.8 days, and 94±59 vs. 79±59 mL). Mean BMI increased (28.2±7.1 vs. 31.7±7.4 kg/m2, p<0.01). Operative time (OT) decreased (173±56 vs. 148±34 min, p<0.001), total lymph node (LN) counts increased (16.9±11.8 vs. 24.2±10.9, p<0.001) and aortic LN increased (6.6±5.0 vs. 11.0±6.7, p<0.001) by years 1 vs. 4. For PAL cases only, OT was 185, 181, 185, and 165 min, and node counts were 21, 25, 27, 29 for years 1-4, respectively. 58.3% of RALH cases were grade 1 and LN metastasis were identified in 8.2% cases. Surgical Stage II to IV disease was present in 90(23%) of RALH cases. There were 30(7.7%) complications and only 2(0.5%) transfusions. Abstracted data included demographics, clinical-pathologic and peri-operative outcomes, and complications for 391 EC cases. 222(56.8%) of RALH cases had complete pelvic/aortic lymphadenectomy (PAL) and 169 had only pelvic lymphadenectomy (PL). 42, 79, 108, and 162 RALH cases were performed in years 1, 2, 3, and 4, respectively. Between year 1 vs. 4, mean age increased (57.4±10.7 vs. 63.8±10.6; p<0.01), but hospital length-of-stay and estimated blood loss did not change significantly (1.0±0.4 vs. 1.4±1.8 days, and 94±59 vs. 79±59 mL). Mean BMI increased (28.2±7.1 vs. 31.7±7.4 kg/m2, p<0.01). Operative time (OT) decreased (173±56 vs. 148±34 min, p<0.001), total lymph node (LN) counts increased (16.9±11.8 vs. 24.2±10.9, p<0.001) and aortic LN increased (6.6±5.0 vs. 11.0±6.7, p<0.001) by years 1 vs. 4. For PAL cases only, OT was 185, 181, 185, and 165 min, and node counts were 21, 25, 27, 29 for years 1-4, respectively. 58.3% of RALH cases were grade 1 and LN metastasis were identified in 8.2% cases. Surgical Stage II to IV disease was present in 90(23%) of RALH cases. There were 30(7.7%) complications and only 2(0.5%) transfusions. ConclusionThis 4-year comparative analysis of RALH cases for EC reveals a significant reduction in OT, despite an increase in BMI, age, and lymph node retrieval. A reduction in OT for PAL cases was recognized in the year-4. This 4-year comparative analysis of RALH cases for EC reveals a significant reduction in OT, despite an increase in BMI, age, and lymph node retrieval. A reduction in OT for PAL cases was recognized in the year-4.

Study ObjectiveTo describe feasibility and surgical outcomes of robotic-assisted extra-fascial hysterectomy with bilateral salpingo-oophorectomy (BSO) with common and para-aortic lymphadenectomy (PAL) following whole pelvic radiation therapy (WPRT) with concurrent chemotherapy for the treatment of IB-2 cervical carcinoma.DesignA retrospective review of nine patients undergoing robotic-assisted laparoscopic hysterectomy (RALH) with BSO following WPRT between June 2008 and February 2011.SettingA single tertiary gynecologic oncology referral center with fellowship training program.PatientsNine patients with clinical stage IB-2 cervical carcinoma.InterventionAll patients had pre-treatment PET or CT scans without extra-pelvic disease. Patients underwent 4500-5040 cGy of WPRT with concurrent platinum-based chemotherapy followed by HDR brachytherapy in three fractions, delivering 1500 cGy. RALH and BSO with PAL was completed 6-8 weeks after radiation.Measurements and Main ResultsThe mean tumor size was 5.7 ± 1.1 cm. The mean age was 45.8 ± 7.2 years, BMI 24.2 ± 4.4 kg/m2. The mean operative time was 119 ± 34 min, estimated blood loss was 69 ± 30 mL. The mean lymph node yield was 8.2 ± 3.0. All patients were discharged on post-operative day-1. There was no vaginal cuff dehiscence. Two patients developed cuff granulation tissue which resolved. There have been no major complications including gastrointestinal and genitourinary fistula. In this short follow-up, we have seen normal sexual function with no vaginal stenosis.ConclusionThe NCCN treatment guideline of pre-operative WPRT and concurrent chemotherapy with brachytherapy followed by extra-fascial hysterectomy for IB-2 cervical carcinoma is feasible with robotic surgery. Surgery 6-8 weeks after radiation appears safe without surgical morbidity. Study ObjectiveTo describe feasibility and surgical outcomes of robotic-assisted extra-fascial hysterectomy with bilateral salpingo-oophorectomy (BSO) with common and para-aortic lymphadenectomy (PAL) following whole pelvic radiation therapy (WPRT) with concurrent chemotherapy for the treatment of IB-2 cervical carcinoma. To describe feasibility and surgical outcomes of robotic-assisted extra-fascial hysterectomy with bilateral salpingo-oophorectomy (BSO) with common and para-aortic lymphadenectomy (PAL) following whole pelvic radiation therapy (WPRT) with concurrent chemotherapy for the treatment of IB-2 cervical carcinoma. DesignA retrospective review of nine patients undergoing robotic-assisted laparoscopic hysterectomy (RALH) with BSO following WPRT between June 2008 and February 2011. A retrospective review of nine patients undergoing robotic-assisted laparoscopic hysterectomy (RALH) with BSO following WPRT between June 2008 and February 2011. SettingA single tertiary gynecologic oncology referral center with fellowship training program. A single tertiary gynecologic oncology referral center with fellowship training program. PatientsNine patients with clinical stage IB-2 cervical carcinoma. Nine patients with clinical stage IB-2 cervical carcinoma. InterventionAll patients had pre-treatment PET or CT scans without extra-pelvic disease. Patients underwent 4500-5040 cGy of WPRT with concurrent platinum-based chemotherapy followed by HDR brachytherapy in three fractions, delivering 1500 cGy. RALH and BSO with PAL was completed 6-8 weeks after radiation. All patients had pre-treatment PET or CT scans without extra-pelvic disease. Patients underwent 4500-5040 cGy of WPRT with concurrent platinum-based chemotherapy followed by HDR brachytherapy in three fractions, delivering 1500 cGy. RALH and BSO with PAL was completed 6-8 weeks after radiation. Measurements and Main ResultsThe mean tumor size was 5.7 ± 1.1 cm. The mean age was 45.8 ± 7.2 years, BMI 24.2 ± 4.4 kg/m2. The mean operative time was 119 ± 34 min, estimated blood loss was 69 ± 30 mL. The mean lymph node yield was 8.2 ± 3.0. All patients were discharged on post-operative day-1. There was no vaginal cuff dehiscence. Two patients developed cuff granulation tissue which resolved. There have been no major complications including gastrointestinal and genitourinary fistula. In this short follow-up, we have seen normal sexual function with no vaginal stenosis. The mean tumor size was 5.7 ± 1.1 cm. The mean age was 45.8 ± 7.2 years, BMI 24.2 ± 4.4 kg/m2. The mean operative time was 119 ± 34 min, estimated blood loss was 69 ± 30 mL. The mean lymph node yield was 8.2 ± 3.0. All patients were discharged on post-operative day-1. There was no vaginal cuff dehiscence. Two patients developed cuff granulation tissue which resolved. There have been no major complications including gastrointestinal and genitourinary fistula. In this short follow-up, we have seen normal sexual function with no vaginal stenosis. ConclusionThe NCCN treatment guideline of pre-operative WPRT and concurrent chemotherapy with brachytherapy followed by extra-fascial hysterectomy for IB-2 cervical carcinoma is feasible with robotic surgery. Surgery 6-8 weeks after radiation appears safe without surgical morbidity. The NCCN treatment guideline of pre-operative WPRT and concurrent chemotherapy with brachytherapy followed by extra-fascial hysterectomy for IB-2 cervical carcinoma is feasible with robotic surgery. Surgery 6-8 weeks after radiation appears safe without surgical morbidity.

Objectives. To provide an objective analysis of surgical performance of robotic-assisted laparoscopic hysterectomy (RALH) with lymphadenectomy for endometrial cancer during the learning phase of the procedure and to assess Opportunities for improvement.Methods. From July 2006 to March 2008, 100 patients with endometrial cancer underwent RALH with lymphadenectomy using the da Vinci (R) Robotic Surgical System. Data were analyzed for operative time (OT), estimated blood loss (EBL), length of stay (LOS), intra-operative complications, surgical-pathologic factors, and post-operative complications using an intent-to-treat analysis. A comparison of the data on a quartile (Q) basis was performed For the 100 RALH cases and separately for the 65 cases that had a complete pelvic-and-aortic lymphadenectomy (PAL).Results. Age and body mass index (BMI) did not change significantly during the study. More grade 3 turners were treated in the last 50 cases (22% vs. 10%, p<0.05). Stage HI turners were identified in 18.7% cases in Q2-4 and none in Q1 (p<0.05). The number of patients undergoing complete PAL and the number of aortic lymph nodes (LN) removed per case increased each quarter. There were 4 (4%) conversions to laparotomy. Delayed vaginal cuff healing decreased from 16% in Q1 to 0% in Q3-4. No case required blood transfusion, Comparing first 10 cases to the last 10 cases, the total LN Counts increased from 15 to 21 nodes, the aortic LN Counts increased from 4.7 to 8.0, and the OT decreased from 203 to 160 min. Intra-surgeon analysis revealed an improvement in the total LN yields from first 50 to second 50 cases for each surgeon.Conclusions. Operative times decreased and aortic dissections improved with increasing LN counts during the first 100 cases of RALH Furthermore, patient safety and improvement in Surgical performance was demonstrated. (C) 2009 Elsevier Inc. All rights reserved.