Description of the condition

Gynaecological cancer consists of vulval, vaginal, cervical, uterine, ovarian and fallopian cancers, and accounts for 10% to 15% of cancers in women with differing incidence and prognoses often dependent on geographical locations (Kehoe 2006). Cervical cancer is the second most common cancer in women, and approximately 80% of these cancers occur in developing countries (Boyle 2003). It is the most prevalent cancer in women living in sub‐Saharan Africa, Central and South America, and south‐east Asia. Ovarian cancer, the sixth most frequent cancer in women, contributes to the most frequent cause of death in gynaecological malignancies in the western world (Boyle 2003). The incidence differs worldwide, with the highest in Scandinavian countries (at over 20/100,000), and lowest in Japan (3/100,000) (Kehoe 2006). Cancer Research UK reported that the incidence of ovarian cancer over a woman's lifetime is one in 50 (Cancer Research UK 2009). According to the National Cancer Institute, uterine cancer is the most common type of gynaecologic cancer; in the United States, approximately 42,000 cases were diagnosed and 7780 women died from the disease in 2009 (American Cancer Society 2009).

Description of the intervention

New technologies such as a high intensity light source, flexible hand instruments and electrosurgical devices have led to modern day laparoscopy. Technological advances continue to grow rapidly in the area of minimally invasive gynaecologic surgery. Studies have clearly shown that laparoscopic surgery leads to faster recovery with shorter hospital stay, improved cosmesis, decreased blood loss, and reduced postoperative pain (Boike 1993; Lo 1999; Raju 1994; Yuen 1997). Robotic surgery is the latest innovation in the field of minimally invasive surgery. A robotic surgical system is not a "robot", because it does not perform a surgical procedure on its own and does not involve any artificial intelligence. Therefore, surgery with the "robot" is best described as "computer‐assisted laparoscopic surgery". Nevertheless, the terms, "robotic surgery", "robot‐assisted surgery" or "robot‐assisted laparoscopic surgery" have all been widely accepted.

One of the first applications of robotic‐assisted technology to gynaecologic surgery was a voice‐activated robotic arm known as Aesop (Computer Motion Inc., Goleta, CA). The primary role of Aesop was to operate the camera during laparoscopic surgery by voice. Mettler 1998 compared Aesop to a surgical assistant holding the laparoscope during gynaecologic surgery, and found that the operation time was faster with Aesop because it improved efficiency by allowing the two surgeons to use both hands for surgery.

Another predecessor to the current platform of surgical robots was Zeus (Computer Motion Inc., Goleta, CA). This system consists of three remotely controlled robotic arms that are attached to the surgical table and a workstation called a robotic console, which has all the instrument controls for operation, and three‐dimensional vision is obtained with the aid of special spectacles. The two operating arms with interchangeable "micro‐wrist" instruments are designed to mimic the movements of the human wrist. A third arm incorporates the Aesop, which provides the surgeon with magnified, rock‐steady visualisation of the internal operative field. This early robotic system represents a significant paradigm shift which allows the surgeon to step away from the operating table. Early studies reported Zeus' successful application to fallopian tube reanastomosis (procedures to reunite the fallopian tubes in order to reverse the effect of reproductive sterilisation and to regain fertility) with a pregnancy rate of 50% at one year (Falcone 2000).

There is currently only one robotic surgical platform commercially available, with FDA approval for performing gynaecologic procedures. This is the da Vinci surgical system (Intuitive Surgical Inc., Sunnyvale, CA, USA). It consists of three components. The first component is a surgeon‐operated console where the surgeon controls the robotic system remotely. A stereoscopic viewer as well as hand and foot controls are housed in this unit. The second component is the InSite Vision System (Intuitive Surgical Inc., Sunnyvale, CA), which provides a three‐dimensional stereoscopic imaging through a 12‐mm endoscope. The third component is a patient‐side cart with Endowrist instruments (Intuitive Surgical, Sunnyvale, CA) and three or four robotic arms. The robotic instruments have a wrist‐like mechanism that enables intra‐abdominal articulation, thereby providing seven degrees of freedom compared to the five degrees of freedom of traditional laparoscopy (Holloway 2009a; Oehler 2009).

Robotic surgery has significant technical advantages compared to conventional laparoscopy (a type of minimally invasive surgery in which a small incision is made in the abdominal wall through which an instrument called a laparoscope is inserted to allow structures within the abdomen and pelvis to be seen), including the availability of three‐dimensional vision, instrument freedom, greater precision, easier suturing and knot tying, and a shorter learning process (Cho 2009). The only technical disadvantage of the robotic surgical system when compared to laparotomy (an operation to open the abdomen) is the lack of tactile perception, although the importance of tactile perception in most gynaecological procedures is currently unknown (Moy 2010). Another major downside of robotic surgery is cost, which is difficult to evaluate in a new technology. Furthermore, the expenses for disposable and limited‐use robotic instruments add significantly to these costs.

How the intervention might work

Robotic assisted surgery has been reported in endometrial cancer and cervical cancer. At present, no publication has been found with robotic assisted surgery in ovarian cancer.

Standard treatment for endometrial cancer involves hysterectomy with bilateral salpingo‐oophorectomy (resection of bilateral fallopian tubes and ovaries).The role of routine pelvic and para‐aortic lymphadenectomy (surgical removal of a lymph node or nodes) remains controversial. For many institutions, robotic surgery has become an alternative for patients with endometrial cancer, which includes hysterectomy and lymphadenectomy. An increasing number of studies describe excellent results in robotic‐assisted hysterectomy with lymphadenectomy for endometrial cancer (Bell 2008; Cardenas‐Goicoechea 2010; DeNardis 2008; Field 2007; Gehrig 2008; Holloway 2009b; Lambaudie 2008; Reynolds 2005; Seamon 2009; Shafer 2008; Veljovich 2008; ), including good lymph node yield, low blood loss, reasonable operative time, with short hospital stays. Gehrig 2008 reported 49 obese women undergoing robotic endometrial cancer staging and found that robotic surgery was more favourable in obese women compared with conventional laparoscopy.

Radical hysterectomy with lymphadenectomy is the standard surgical treatment for stage 1A2‐1B uterine cervical cancer. Magrina 2008 compared robotic radical hysterectomy, laparoscopic radical hysterectomy and laparotomy for radical hysterectomy. The patients who underwent robotic surgery had significantly less blood loss and a shorter hospital stay than the other two groups. Complications in this series of patients were minor. Smaller studies describing the use of robotic surgery in radical hysterectomy showed similar success (Boggess 2008; Fanning 2008; Kim 2008; Lowe 2009; Maggioni 2009; Nezhat 2008;; Persson 2009). Recently, a proposal for a randomised controlled trial (RCT) has been published to compare robotic/laparoscopic radical hysterectomy with laparotomy in cervical cancer. The proposal plan is to enrol 740 patients in total (Obermair 2008). Various radical trachelectomy (surgical removal of the cervix, the lower portion of the uterus that protrudes into the vagina) results suggest that fertility‐sparing treatment is a viable option in early stage cervical cancer (Diaz 2008; Plante 2008). Persson 2008 recently described two cases of robotic radical trachelectomy. Together with the report by Geisler 2008, the findings suggest that the robot offers excellent visualisation of the vasculature and parametrial tissues (the connective tissue and fat adjacent to the uterus) which must be isolated during the procedure, while still offering a minimally invasive technique that is likely to preserve fertility and lead to fast recovery. These case reports suggest that this technique may provide a good option for women seeking to preserve fertility. Surgical options for assessing para‐aortic node status include extraperitoneal (taking place outside the peritoneal cavity) or transperitoneal (passing or performed through the peritoneum) techniques. Vergote 2008 reported on a series of five patients assessed through a retroperitoneal (situated behind the peritoneum) robotic technique. The reported results are excellent with brief hospital stays and minimal blood loss. All the procedures were completed with less than one hour console time. The authors conclude that robotic retroperitoneal para‐aortic sampling is a feasible procedure that warrants further evaluation.

Lenihan 2008 indicated that 50 cases are required to reach an acceptable level of proficiency and stable operative times for benign gynaecological robotic assisted surgery. Currently however it is still generally accepted that we are on a learning curve for the procedure.

Why it is important to do this review

The mounting evidence demonstrates the feasibility and safety of robotic surgery in gynaecology. Although the experience with robotics in gynaecology is limited, the potential is significant. However, it is still unknown which gynaecological procedures are going to benefit most from robotics. Robotic technology seems to have advantages to conventional laparoscopy and open procedures for the surgical treatment of gynaecological malignancies. Therefore, this systematic review aims to fully assess the beneficial and harmful effects of robotic assisted surgery for gynaecological cancers.