Endometrial Cancer SurgeryEndometrial Cancer SurgeryOpen vs Laparoscopic vs Robotic SurgeryOpen vs Laparoscopic vs Robotic Surgery
Advantages, Disadvantages, & ResultsAdvantages, Disadvantages, & Results
Ginger J. Gardner, MDGinger J. Gardner, MDAssociate Professor, Weill Cornell Medical CollegeAssociate Professor, Weill Cornell Medical College
Associate Member, Gynecology ServiceAssociate Member, Gynecology ServiceDirector, Survivorship ProgramDirector, Survivorship Program
Department of SurgeryDepartment of SurgeryMemorial Sloan-Kettering Cancer CenterMemorial Sloan-Kettering Cancer Center
• Trial DesignProspective Randomized Control Trial
2:1 Randomization Laparoscopy vs LaparoscopyClinical stage I-IIAAll histologic subtypesFull staging Required
Hysterectomy, BSO, Washings, Pelvic & Para-aortic nodal dissection
Conversion to Laparotomy if inaccessible by Laparoscopy
• Short Term Follow-up: Complications, LOS, QOL• Recurrence Rate and Overall Survival
GOG LAP-2GOG LAP-2
GOG LAP-2GOG LAP-2Perioperative OutcomesPerioperative Outcomes
Walker JL, et al. J Clin Oncol 2009;27:5331-5336
Laparotomy Laparoscopy P-value
N 920 1696
Median age (years)Median BMI (kg/m2)
63 (55-71)29 (24-34)
63 (55-72)28 (24-34)
Converted - 434 (25.8%)
Median operative time (min) 130 (102-167) 204 (160-252) <0.001
Complications Intraoperative – any Postoperative – any (grade≥2) Postoperative antibiotic use
69 (8%)191 (21%)211 (23%)
160 (10%)240 (14%)274 (16%)
0.1<0.001<0.001
Hospital stay Stay >2 days Median LOS (days)
245 (94%)4 (3-5)
867 (52%)3 (2-4)
2 (not converted)4 (converted)
<0.001
Medians reported with interquartile ranges
Walker JL, et al. J Clin Oncol 2009;27:5331-5336
Laparotomy Laparoscopy P-value
Pelvic lymph nodes Any obtained Median number
868 (99%)18 (12-24)
1585 (98%)17 (12-23)
0.18
Para-aortic lymph nodes Any obtained Median number
843 (97%)7 (4-11)
1482 (94%)7 (4-11)
0.002
Stage IIIC 84 (9%) 143 (9%) NS
Medians reported with interquartile ranges
GOG LAP-2GOG LAP-2Oncologic Surgical OutcomesOncologic Surgical Outcomes
Kornblith AB, et al. J Clin Oncol 2009;27:5337-5342.
GOG LAP-2GOG LAP-2Quality of LifeQuality of Life
GOG LAP-2GOG LAP-2Overall SurvivalOverall Survival
Walker, JL et al. J Clin Oncol 2012;30(7):695-700
OS89.8%89.8%
GOG LAP-2GOG LAP-2Types RecurrenceTypes Recurrence
Walker, JL et al. J Clin Oncol 2012;30(7):695-700
Incidence Port Site Metastasis 4/1696 (0.24%)Stage IV CarcinosarcomaStage IIIC grade 2 EndometrioidStage IIIA grade 2 EndometrioidStage IB grade 2 Endometrioid
No significant difference in types of recurrent disease (local vs distant) between laparoscopy and laparotomy cases
GOG LAP-2GOG LAP-2Recurrence by SubgroupRecurrence by Subgroup
Walker, JL et al. J Clin Oncol 2012;30(7):695-700
GOG LAP-2GOG LAP-2SummarySummary
Walker, JL et al. J Clin Oncol 2012;30(7):695-700
Laparoscopy for Endometrial Cancer Fewer post-operative complications Faster recovery Better quality of life Similar nodal counts Similar overall survival All histologic subtypes eligible Low (0.24%) rate of port mets, mostly occurs in already
advanced stage disease No differece in Overall Survival
BUT, 25% Conversion to Laparotomy
Dutch TrialDutch Trial
Mourits MJE, et al. Lancet Oncol 2010;11:763-771.
Laparotomy Laparoscopy P-value
N 94 185
Median age (years)Median BMI (kg/m2)
6329
6228
Converted - 20 (10.8%)
Median operative time (min)Median EBL (cc)Number days needing pain meds
71200
5
115100
3
<0.001<0.001<0.001
Complications Total major Total minor
14 (15%)11 (12%)
27 (15%)24 (13%)
NSNS
Hospital stay 5 2 <0.001
Resumption normal activities by 6 weeks postop
51 (62%) 129 (76%) 0.002
Laparoscopy were TLH; LND not done in any cases at allQOL better after LSC on 2 (two) SF-36 subscales
Bijen CB, et al. Gynecol Oncol 2011;121:76-82.
“TLH is cost effective compared to TAH…TLH should be recommended as a standard-of-care surgical procedure in early endometrial cancer.”
Dutch TrialCost effectiveness
LACE Trial*LACE Trial*
Janda M, et al. Lancet Oncol 2010;11:772-780.
Laparotomy Laparoscopy P-value
N 142 190
Mean age (years) 62.7 62.8
Mean operative time (min) 109 138 0.001
Complications Intraoperative Postoperative
8 (5.6%)33 (23.2%)
14 (7.4%)22 (11.6%)
NS0.004
Hospital stay >2 days 139 (97.9%) 72 (37.9%) <0.0001
*Australia, New Zealand, Hong KongLaparoscopy were TLH; All pelvic LND +/- PA LND
Janda M, et al. Lancet Oncol 2010;11:772-780.
LACE TrialQuality of life
Fram2002
Zorlu2005
Zullo2005
Tozzi2005
Dutch trial2010
LACE2010
GOG2009
Total # of cases 61 52 78 122 279 332 2616
OP time NO SAME NO - NO NO NO
EBL YES - YES YES YES - YES
LN counts SAME SAME SAME SAME - - SAME
LOS YES YES YES YES YES YES YES
Complications - - YES - SAME YES YES
QOL - - YES - YES YES YES
Cost-effective - - - - YES - -
Survival - - - SAME - - SAME
Summary of RCTsSummary of RCTsLaparoscopy is BetterLaparoscopy is Better
Natural Evolution of TechnologyNatural Evolution of Technology
Evolution of TechnologyEvolution of Technology
Konrad Zuse’s Z1 (1938)First binary computerMechanical calculator
UNIVAC I – UNIVersal Automatic Computer (1951)First commercial computer
U.S. Census BureauOriginal price: $159,000
Ultimate price: $1.5 million46 systems built and sold
IBM 701– (1953)First commercial IBM computer
$15,000/month rental feeOnly 19 systems built and sold
Evolution of TechnologyEvolution of Technology
Altair (1974)Scelbi (1974)
First personal computerKit that user had to put together, make it work,
and write software256 Byte RAM
$400
IBM 5100 – First IBM PC (1975)50 pounds
Programming language (APL or BASIC)64K storage version
$19,975
Robotic SurgeryRobotic Surgery
Robotic SurgeryRobotic Surgery
• Improved Visualization
• Increased Surgeon Control
• Instrument Functionality
• Computer Enhanced Surgery
Why Robotics?Why Robotics?A New Tool For LaparoscopyA New Tool For Laparoscopy
MSKCC RoboticsMSKCC RoboticsAll servicesAll services
1 0 10 0 110 0 16 0 160 5 15 0 20248
12 0
6216
106
16 0
142137 145
270
309321359
69
6
752
401 367
8737
886
568
423
14497
1223
478
358
116 119
1071
0
200
400
600
800
1000
1200
1400
GYN GU Thoracic Other Total
2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 *Jan-Sept
MSKCC Gynecology ServiceSurgical intraperitoneal cases
32% 26% P=0.002
698
945
101 106 137
10
100
200
300
400
500
600
700
800
900
1000
Uterine cancer
Benign CAH Cervical cancer
Adnexal cancer
Vulvar cancer
Case DistributionCase Distribution5/15/07 – 10/2/125/15/07 – 10/2/12
N=1988
Robotics in Endometrial CancerRobotics in Endometrial CancerLiterature reviewLiterature review
Author Year SiteTime period
(months)Total
NConverted
N (%)OR time
(min)EBL (ml)
LOS(d)
Reynolds* 2005 US 20 4 0 257 50 2
Boggess* 2008 US 31 103 3 (2.9%) 191.2 74.5 1
Seamon** 2008 US 26 105 13 (12.4%) 242 99 1
Bell* 2008 US - 40 0 184 166 2.3
Veljovich** 2008 US 13 25 0 283 66.6 1.7
Lowe* 2009 US 70 405 27 (6.7%) 170.5 87.5 1.8
Holloway* 2009 US 21 100 4 (4%) 171 103 1.1
Hoekstra** 2009 US 13 32 1 (3%) 195 50 1
Peiretti** 2009 Italy 24 80 3 (3.7%) 170 50 2
Cardenas** 2010 US 20 102 1 (1%) 222 100 1
Jung* 2010 Korea 33 28 0 193.2 - 7.9
Gocmen* 2010 Turkey 14 10 0 234.6 95 2.8
Leitao** SGO2011 US 38 271 32 (12%) 217 50 1
TOTAL 13 - 70 1305 84 (6.4%) 170 - 283 50 - 166 1 – 7.9
Series with staging and not rad hysts or other*mean; **median
Robotics in Endometrial CancerRobotics in Endometrial CancerLaparoscopic vs RoboticLaparoscopic vs Robotic
Boggess* Seamon* Cardenas* Leitao**
LRSN=81
RBTN=103
P-valueLRSN=76
RBTN=105
P-value
LRSN=173
RBTN=102
P-valueLRS
N=278RBT
N=271P-
value
Conversion 4.9% 2.9% NS 26.3% 12.4% 0.02 5.2% 1% NS 12% 12% NS
Room time (min) 336 305 <0.001 253.5 301 <0.001
OP time (min) 213.4 191.2 <0.0001 287 242 <0.001 178 237 <0.0001 184.5 217 <0.001
EBL (ml) 145.8 74.5 <0.0001 200 88 <0.001 187 109 <0.0001 100 50 <0.001
PLN # 17.4 20.5 0.06 22 21 NS 16.1 13 0.005 16 14 NS
PAN # 6.3 12 <0.0001 11 10 NS 7.2 9 0.07 5 6 NS
Total LN # 23.1 32.9 <0.001 23 22 NS 22.5 21 NS
LOS (days) 1.2 1 0.001 2 1 <0.001 2.3 1.9 NS 2 1 <0.001
Complications 13.6% 5.8% 0.07 14% 13% NS 7.5% 9.8% NS 16% 11% NS
*mean; **medianLRS=standard laparoscopy; RBT=robotically-assisted laparoscopy
Robotics in Endometrial CancerRobotics in Endometrial CancerLaparoscopic vs RoboticLaparoscopic vs Robotic
Boggess* Seamon* Cardenas* Leitao**
LRSN=81
RBTN=103
P-valueLRSN=76
RBTN=105
P-value
LRSN=173
RBTN=102
P-valueLRS
N=278RBT
N=271P-
value
Conversion 4.9% 2.9% NS 26.3% 12.4% 0.02 5.2% 1% NS 12% 12% NS
Room time (min) 336 305 <0.001 253.5 301 <0.001
OP time (min) 213.4 191.2 <0.0001 287 242 <0.001 178 237 <0.0001 184.5 217 <0.001
EBL (ml) 145.8 74.5 <0.0001 200 88 <0.001 187 109 <0.0001 100 50 <0.001
PLN # 17.4 20.5 NS 22 21 NS 16.1 13 0.005 16 14 NS
PAN # 6.3 12 <0.0001 11 10 NS 7.2 9 NS 5 6 NS
Total LN # 23.1 32.9 <0.001 23 22 NS 22.5 21 NS
LOS (days) 1.2 1 0.001 2 1 <0.001 2.3 1.9 NS 2 1 <0.001
Complications 13.6% 5.8% NS 14% 13% NS 7.5% 9.8% NS 16% 11% NS
*mean; **medianLRS=standard laparoscopy; RBT=robotically-assisted laparoscopy
• Increased Rate of MIS Surgery for Endometrial Cancer Patients
• Decreased Post-Operative Pain
• Same Day Hysterectomy
• SLN Fluorescence
Advantages of Robotics Advantages of Robotics over Laparoscopy?over Laparoscopy?
Leitao MM…Gardner GJ. Gynecol Oncol 2012;125:394-399
RoboticsImpact on practice
P<0.001
24%
11%
16%9%
Leitao MM…Gardner GJ. Gynecol Oncol 2012;125:394-399
RoboticsImpact on practice
P<0.001
39%
19%
28%
18%
HysterectomyHysterectomyLess pain with robotic approach?Less pain with robotic approach?
Variable ROBOT TLH P-value
N 26 44
Mean age (years) 44.9 42.2 NS
Mean BMI (kg/m2) 30.3 30.5 NS
Mean room time (min) 185 161.7 0.01
Mean OP time (min) 142.2 122.1 0.03
Mean ut weight (g) 212 170.4 NS
Mean EBL (ml) 113.5 98.8 NS
Mean Hgb drop 1.87 1.81 NS
Mean narcotic use (units) 1.2 5 0.002
Mean LOS (days) 1 1.4 0.01
Shashoua, et al. JSLS 2009
Robotics in Endometrial CancerRobotics in Endometrial CancerPostoperative painPostoperative pain
Variable ROBOT LRS P-value
Non-converted cases 239 244 -
IV PCA used 206 (86%) 217 (90%) 0.2
Procedure LAVH TLH Other
0202 (88%)
4 (2%)
189 (87%)28 (13%)
0
<0.001
Basal rate used 3 (2%) 21 (10%) 0.001
Time with PCA (hrs) Median (range) 14.9 (0-51) 16.8 (7-180) <0.001
Total fentanyl dose (ucg) Median (range) 242.5 (0-2705) 367.5 (0-2625) <0.001
Hourly total fentanyl dose (ucg) Median (range)
16.7 (0-122.5) 22.7 (0-132.4) 0.01
Leitao, Gardner, et al. SGO 2011
Robotic approach independently associated with less pain medication use when controlling for PCA medication used, use of basal rate, and time on PCA (P=0.04)
7/27/10 – 9/8/11
Median (range) or N (%)
Total 106
Median age (yrs)Median BMI (kg/m2)Median ASA classPreop diagnosis Endometrial cancer Ovarian cancer Cervical cancer Non-gyn cancer or benignPrior laparoscopy and/or laparotomy
52 (31 - 77)26.8 (18.5 – 56.8)
2 (1 – 3)
42 (40)4 (4)3 (3)
57 (54)53 (50%)
Same day hysterectomySame day hysterectomyOverall baseline cohort characteristicsOverall baseline cohort characteristics
Leitao Jr MM, et al. SGO 2012
7/27/10 – 9/8/11
Median (range) or N (%)
Median uterine weight (g)Median EBL (ml)Procedures* Simple ComplexMedian room time (min)Median operative time (min)Median time case ended (hr:min)Median intraop crystalloid used (ml)Intraop ketorolac usedTrocar site marcaine used
98 (37 – 874)50 (5 – 300)
55 (52)51 (48)
197 (134 – 351)153 (79 – 289)
13:20 (10:06 – 22:03)1800 (600 – 3000)
75 (71)45 (43)
Same day hysterectomySame day hysterectomyOverall surgicopathologic characteristicsOverall surgicopathologic characteristics
Leitao Jr MM, et al. SGO 2012
*Simple procedure defined as total laparoscopic hysterectomy +/- BSO; complex procedure defined as TLH +/- BSO and any of the additional: SLN mapping, pelvic and/or aortic LND, appendectomy, omentectomy
7/27/10 – 9/8/11
Median (range) or N (%)
Median time to discharge* Minutes HoursMedian distance from hospital (miles)Destination postop NY NJ PA CTStayed overnightMedical reason for staying overnight**
345 (146 – 1827)5.75 (2.4 – 3-.5)30.5 (0.2 – 149)
77 (73)24 (23)
3 (3)2 (2)
28 (26)13/28 (46)
Same day hysterectomySame day hysterectomyOverall discharge outcomesOverall discharge outcomes
Leitao Jr MM, et al. SGO 2012
*From end of case to discharge** Medical reasons: pain, nausea, fever, urinary retention, sinus arrhythmia, intraop complication, minilap, vasovagal (pre/postop); Non-medical reasons: patient desire, weather, late case, long commute
7/27/10 – 9/8/11
Median (range) or N (%)
UCC postop visit UCC ≤ 48 hrs UCC 48 hrs to ≤ 7 days UCC 7 to 30 daysReadmitted to inpatientReasons for readmission Pelvic hematoma Retained foreign body Non-trocar ventral hernia (incarcerated) Abd wall hematoma, anemia, transfused
8 (7.5)1 (1)3 (3)4 (4)
4 (3.8)
1111
Same day hysterectomySame day hysterectomyOverall post-discharge outcomesOverall post-discharge outcomes
Leitao Jr MM, et al. SGO 2012
7/27/10 – 10/2/12
N
Total 196
Indications Uterine cancer Ovarian cancer Cervical cancer Non-gyn cancer indications
81 (40%)8 (4%)5 (2%)
102 (55%)
Procedures TLH +/-BSO TLH +/-BSO +SLN TLH +/-BSO +PLND TLH +/-BSO +PLPALND TLH +/-BSO +PLPALND +SLN TLH +/-BSO +PLPALND +oment TLH +/-BSO +PLPALND +oment +appy TLH +/-BSO +oment TLH +/-BSO +PALND TLH +/-BSO +PALND +oment +SLN PLPALND PALND PLPALND +omentect +Ipport Trachelectomy (simple) + BSO Debulking
102 (53%)58 (29%)
4 (2%)9 (6%)4 (1%)2 (2%)1 (1%)4 (2%)1 (1%)2 (1%)2 (1%)1 (1%)2 (1%)3 (2%)1 (1%)
Robotics at MSKCCRobotics at MSKCCSame day dischargeSame day discharge
7/27/10 –10/2/12
N
Total 196
Stayed overnightReasons Long commute Patient “wanted” Weather Late case Pain Nausea/HA Nausea/fever Emesis on emergence Urinary retention Abnormal EKG Intraop vaginal laceration Intraop cystotomy Pre- and/or postop vasovagal episodes Minilap to remove specimen Postop hypoxemia
42 (22%)
2101544114131221
Readmitted – totalReadmitted – went homeReadmitted – stayed o/n Pelvic hematoma Retained foreign object (driver cover) Abd wall hematoma Ventral (non-trocar) hernia
4/196 (2.1%)2/154 (1.3%)2/42 (4.8%)
1111
Robotics at MSKCCRobotics at MSKCCSame day hysterectomySame day hysterectomy
1. Provide a more accurate identification of tumor drainage
2. May avoid total lymphadenectomy
3. Decrease the risk of leg lymphedema, symptomatic lymphocysts, nerve injury, vascular injury and VTE
4. Provide for pathologic ultra staging analysis
5. Potential application in fertility-sparing surgery
Sentinel Lymph Node (SLN) Mapping in Endometrial Cancer
Robotic Fluorescence for Robotic Fluorescence for Sentinel Node MappingSentinel Node Mapping
CharacteristicLSC/RBT*Blue dye
RBT **ICG
P-value
NSuccessful SLN mapping – by patientBilateral pelvic mapping
270224 (83%)133 (49%)
125123 (98%)105 (84%)
<0.0005<0.0005
SLN mappingSLN mappingMSK experienceMSK experience
Disadvantages of Robotics?
• Learning Curve of New Technology
• Docking Time
• Cost
RoboticsRoboticsConversion ratesConversion rates
5/15/07-12/31/11 18.8% 15.8% 9.1% 7.4%
0
100
200
300
400
500
600
700
2007 2008 2009 2010 2011
5.7%
ResultsRobotic learning curve
COMPLETED Uterine cancer cases (310 RBT/263 LSC) - 5/07 - 12/31/10 (44 months)Median total room time
Leitao MM…Gardner GJ. Gynecol Oncol 2012;125:394-399
N 111 80 51 36 20 20 20 9
Median time (min) 350 310 267 266 232 247 211 241
Range 186-613 194-548 189-445 197-377 142-400 177-353 169-315 205-335
P<0.001
LRS = 250 min
ResultsRobotic learning curve
COMPLETED Uterine cancer cases (310 RBT/263 LSC) - 5/07 - 12/31/10 (44 months)Median operative time
Leitao MM…Gardner GJ. Gynecol Oncol 2012;125:394-399
P<0.001
LRS = 184 min
N 111 80 51 36 20 20 20 9
Median time (min) 267 227 193 176 164 152 145 163
Range 131-533 126-476 124-348 115-266 120-307 99-272 96-224 122-215
5/1/07 – 12/31/10 LSC RBT P-value
Hysterectomy only* N Total room time (min) Total skin-skin time (min)
24222 (135-380)152 (80-308)
32225.5 (142-512)
147 (99-440)0.40.9
SLN algorithm** N Total room time (min) Total skin-skin time (min)
120205.5 (128-415)
147 (85-322)
117254 (169-465)172 (96-334)
<0.001<0.001
PLPALND N Total room time (min) Total skin-skin time (min)
119300 (203-532)231 (128-445)
71312 (214-548)228 (157-476)
0.020.4
Times are reported as medians (ranges) for completed uterine cancer cases*Few hyst only cases – these data represent all RBT case and do not exclude first 20**Variable extent of selective LND and SLN introduced in RBT in mid 2009
Learning curveLearning curveTimes after first 20 robot casesTimes after first 20 robot cases
Leitao MM…Gardner GJ. Gynecol Oncol 2012;125:394-399
Robotics Learning CurveRobotics Learning CurveMedian docking time (min)Median docking time (min)
Robotics Costs
• Current cost analyses are based modeling and do not provide direct cost comparisons
• The greatest contribution to cost is the OR time • OR time is always longer when first learning
something new• Analyses compare early learning of robotics to
≥10-20 years of laparoscopic experience of often low volume robotic surgeons
• Higher volume more experienced centers result in lower costs
Robotics Points to consider about cost comparison
• Assess after robotic learning curve achieved • Compare costs of care of patients before and after
robotics introduced efficiently into practice (not just LRS vs RBT) – OR times equalize after learning curve– OR times better than LRS for many surgeons– More cases are done minimally invasive leading to all the
proven benefits of MIS being realized in greater number of patients
– Shorter LOS results in greater free inpatient beds to bring in more surgical volume
• Forget RBT vs OPEN comparisons – irrelevant• Costs decrease for technology over time and with
increasing competition• What are costs of drugs we use to improve PFS/OS
only by 2-4 months?
Jonsdottir GM, et al. Obstet Gynecol 2011;117:1142-1149
CostsImpact of increasing MIS approach
Jonsdottir GM, et al. Obstet Gynecol 2011;117:1142-1149
CostsImpact of increasing MIS approach
Jonsdottir GM, et al. Obstet Gynecol 2011;117:1142-1149
CostsImpact of increasing MIS approach
Indirect societal cost estimates for 2009
Abdominal Vaginal LSCRBT
$17,671-$18,065$15,631-$16,419$14,826-$15,483$13,501-$14,158
Wright JD, et al. J Clin Oncol 2012;30:783-791
CostsPopulation-based analysis of RBT vs LRS
• PERSPECTIVE DATABASE• Voluntary, fee-supported database• Samples >500 acute care hospitals • Submit data on inpatient admissions• Represents approximately 15% of nationwide
hospitalizations
Wright JD, et al. J Clin Oncol 2012;30:783-791
CostsPopulation-based analysis of RBT vs LRS
Wright JD, et al. J Clin Oncol 2012;30:783-791
CostsPopulation-based analysis of RBT vs LRS
A different “PERSPECTIVE”A review of inexperienced MIS/RBT surgeons
Wright JD, et al. J Clin Oncol 2012;30:783-791
A different “PERSPECTIVE”More complex cases done with RBT?
Wright JD, et al. J Clin Oncol 2012;30:783-791
A different “PERSPECTIVE”Effect of surgeons on early learning curve on
cost?
Wright JD, et al. J Clin Oncol 2012;30:783-791
<9 cases per year >14 cases per year
45% decrease in cost!!
Cancer RegimensPFS
(mos)OS
(mos)Δ
(mos)Costs
(approx.)
Colon(N=923)
Lung(N=731)
Lung maintain(N=889)
Melanoma(N=502)
Ovary (recur)(N=484)
Breast - early(pooled)
IFL + bevIFL
ErlotinibBSC
ErlotinibPlacebo
Dacarbazine + IpilimumabDacarbazine + placebo
Gem/carbo + bevGem/Carbo + placebo
TrastuzumabNon-trastuzumab
10.66.2
12.48.4
20.315.6
6.74.7
12.3 wks11.1 wks
11.29.1
33.3*35.2*
mortality6%
8.5%
+4.7
+3.0
+1.2 wks
+2.1
+4.0 (pfs)-1.9 (os)*
$5000/doseq3wks
$3300/monthqd dosing
$30,000/doseX4
$5000/doseq3wks
$2600/doseq3wk x 17
““AdvancesAdvances”” in cancer in cancer Targeted therapy costsTargeted therapy costs
Conclusions • Prospective controlled trials suggest that Minimally
Invasive Surgical approach is superior for endometrial cancer when feasible: decreased rate of complications, hospital length of stay, equivalent nodal counts and oncologic outcomes
• Retrospective studies demonstrate equivalent excellent outcome for Robotics vs. Standard Laparoscopy
• Benefits of Robotics include increased case eligibility for MIS, increased instrument functionality, less pain, same day surgery, SLN flourescence
• Potential disadvantages: Learning Curve, Docking, Cost
THANK YOU!THANK YOU!
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