The IDEAL framework for surgical robotics: development, comparative evaluation and long-term monitoring.

The next generation of surgical robotics is poised to disrupt healthcare systems worldwide, requiring new frameworks for evaluation. However, evaluation during a surgical robot's development is challenging due to their complex evolving nature, potential for wider system disruption and integration with complementary technologies like artificial intelligence. Comparative clinical studies require attention to intervention context, learning curves and standardized outcomes. Long-term monitoring needs to transition toward collaborative, transparent and inclusive consortiums for real-world data collection. Here, the Idea, Development, Exploration, Assessment and Long-term monitoring (IDEAL) Robotics Colloquium proposes recommendations for evaluation during development, comparative study and clinical monitoring of surgical robots-providing practical recommendations for developers, clinicians, patients and healthcare systems. Multiple perspectives are considered, including economics, surgical training, human factors, ethics, patient perspectives and sustainability. Further work is needed on standardized metrics, health economic assessment models and global applicability of recommendations.

Role of Positron Emission Tomography/Computed Tomography in Preoperative Assessment of Carcinoma Endometrium-a Retrospective Analysis.

PET/CT has made significant inroads into routine oncological practice in recent times. In our study, we aim to determine its value in preoperative assessment of endometrial carcinoma. A retrospective study between January 2011 and March 2016 was conducted; we included all cases of carcinoma endometrium with a preoperative PET/CT scan. PET/CT images were analyzed and correlated with histological findings after surgical staging. A total of 46 cases were analyzed, mean age was 59.8 years, BMI 30.8 kg/m2, and most common histology endometrioid type (69.5%). We correlated PET/CT findings with histopathology as reference standard. PET/CT had a sensitivity of 40%, moderate specificity (75%) and accuracy (71.7%), good NPV (91.2%), but poor PPV (16.7%) for lymph node involvement. A total of 10 (21.7%) cases were detected to have distant metabolically active lesions on PET/CT, seven out of these were positive for malignancy. And 90% of them were either non-endometrioid type or grade two and higher. We found that SUV of primary tumor was significantly higher in patients with deep myometrial invasion (p = 0.018), and high-risk histological type of tumor (p = 0.022), though not statistically significant when lymph nodal involvement (p = 0.9), cervical involvement (p = 0.56), or histological grade (p = 0.84) were considered. Sensitivity and specificity of PET/CT in staging endometrial cancer is not high enough to reliably tailor lymphadenectomy. Although SUV of the primary tumor was significantly higher in patients with deep myometrial invasion and high-risk histological type, it's usefulness in classifying patients into predefined risk groups seems to be limited. However, it is useful in detecting distant metastasis especially in high-grade and non-endometrioid type of tumors. Thus, implementation of PET/CT as a surrogate for surgical staging of endometrial cancer remains enigmatic and is open to further research.

Findings and Outcomes in a Prevaccination Cohort of Women Younger Than 25 Years Attending a Tertiary Colposcopy Service.

OBJECTIVE: To describe clinical presentation and treatment in women younger than 25 years referred to the Royal Women's Hospital colposcopy clinic, before implementation of the National Human Papillomavirus Vaccination Program. METHODS: Retrospective cohort analysis of women younger than 25 years referred to a tertiary hospital colposcopy clinic between 1998 and 2007. Clinical presentation and correlation between cervical cytology, biopsy, and histology at treatment was examined. RESULTS: Approximately 14,635 colposcopies were undertaken in 4104 women (median age, 22 years); 3051 had abnormal referral cytology, of whom, 23.8% had high-grade disease on punch biopsy. High-grade disease was found in 15.1% of those with possible low-grade or low-grade cytology (293/1932), 42.4% of those with possible high-grade or high-grade cytology (474/1119). Sensitivity and specificity of colposcopy for high-grade disease (high-grade epithelial abnormality, adenocarcinoma in situ, cervical cancer up to 2 years follow-up) was 60.0% and 82.3%, respectively. Thirty-nine percent (n = 1180) with abnormal cytology had treatment, of which, 66.6% was ablative. Histological CIN3+ was found in 53.8% of those with a previous high-grade punch biopsy (126/234) at excisional treatment, and 23.0% of those with a previous low-grade punch biopsy (20/87) (relative risk, 2.3 [CI, 1.6-3.5]). Four cancers were detected (0.1% of the total cohort, 0.5% of those with a high-grade biopsy, and 1.7% of those with a high-grade biopsy who underwent excisional treatment.) CONCLUSIONS: Before vaccination, young women experienced a high real-time burden of high-grade disease and high rates of intervention. These baseline data contribute to monitoring of HPV vaccination and revised cervical screening strategies.

Survival Impact of Secondary Cytoreductive Surgery for Recurrent Ovarian Cancer in an Asian Population.

OBJECTIVE: The aim of this study was to evaluate the role of secondary cytoreductive surgery in Asian patients with recurrent ovarian cancer and to assess prognostic variables on overall post-recurrence survival time. METHODS: We conducted a retrospective review of patients with recurrent ovarian cancer who underwent secondary cytoreduction at the Gynaecological Cancer Center at the KK Women's and Children's Hospital, Singapore, between 1999 and 2009. Eligible patients included those who had been firstly treated by primary cytoreductive surgery and followed by adjuvant chemotherapy and had a period of clinical remission of at least six months and subsequently underwent secondary cytoreductive surgery for recurrence. Univariate analysis was performed to evaluate various variables influencing the overall survival. RESULTS: Twenty-five patients met our eligibility criteria. The median age was 52 years (range=31-78 years). The median time from completion of primary treatment to recurrence was 25.1 months (range=6.4-83.4). Secondary cytoreduction was optimal in 20 of 25 patients (80%). The median follow-up duration was 38.9 months (range=17.8-72.4) and median overall survival time was 33.1 months (95% confidence interval, 15.3-undefined.). Ten (40.0%) patients required bowel resection, but no end colostomy was performed. One (4.0%) patient had wedge resection of the liver, one (4.0%) had a distal pancreatectomy, one (4.0%) had a unilateral nephrectomy, and one (4.0%) had adrenalectomy. There were no operative deaths. The overall survival of patients who responded to secondary cytoreductive surgery and adjuvant chemotherapy was significantly longer than those patients who did not respond to the treatment. Of those patients who responded to the surgical management, patients with clear cell carcinoma fared well compared to those with the endometrioid, mucinous adenocarcinoma, and papillary serous type (p<0.001). Complete secondary cytoreductive surgery appeared to have some relationship to overall survival but was not statistically significant. CONCLUSION: In carefully selected patients with recurrent ovarian cancer, optimal cytoreductive surgery is possible and in a subgroup of patients who respond to surgery and chemotherapy survival is significantly longer.

Endometriosis after surgical menopause mimicking pelvic malignancy: surgeons' predicament.

Prevalence of persistent endometriosis in women after menopause without any hormonal replacement therapy is very rare. This is a case of a woman with previous history of total hysterectomy and bilateral salpingo-oophorectomy for endometriosis who presented with hemoperitoneum, vaginal bleeding, pelvic mass, and pulmonary thromboembolism mimicking as rectovaginal septum carcinoma. This is the first case report with a unique mode of presentation wherein the patient presented with hemoperitoneum requiring emergency embolization of the vessel to stabilize the patient. She underwent en bloc resection of the tumor with high anterior resection of the rectum. Histopathology confirmed endometriosis.

Sertoli-Leydig cell tumor of the ovary: analysis of a single institution database.

AIM: To evaluate the clinicopathological features, management, survival and prognostic factors of patients with Sertoli-Leydig cell tumors of the ovary (SLCT) managed at a single institution. MATERIAL AND METHODS: The clinical records of patients with Sertoli-Leydig cell tumors of the ovary managed at the KK Women's and Children's Hospital, Singapore, between October 1998 and December 2008 were reviewed. Data of pathological features, treatment given and progress on follow-up was studied. RESULTS: Sertoli-Leydig cell tumor of the ovary accounted for 1.3% of malignant ovarian neoplasms. The median age of the patient was 30 years. The most common mode of presentation was with hormonal-related symptoms (80%) in the form of secondary amenorrhea, irregular menses and features of virilization. Thirteen of the 15 patients underwent surgical staging and all were found to have stage-I disease at the time of diagnosis. Ten patients with intermediate and poorly differentiated tumors received adjuvant bleomycin, etoposide and cisplatin (BEP) chemotherapy. Recurrent disease was detected in two patients (13.3%) during a median follow-up of 63 months, both of whom had poorly differentiated type of tumor. Both these patients underwent optimal debulking surgery followed by postoperative chemotherapy (BEP regimen). There were no disease -elated deaths and all patients were under complete remission at the last follow-up. CONCLUSION: As most Sertoli-Leydig cell tumors of the ovary are seen in young women and detected while still in the early stages, a favorable outcome can be achieved by conservative surgery. Patients with moderate and poorly differentiated types of tumors benefit from adjuvant chemotherapy. Recurrences tend to occur early and are commonly seen in patients with poorly differentiated tumors.

Autofluorescence of normal, benign, and malignant ovarian tissues: a pilot study.

OBJECTIVE: The objective of this study is to evaluate the efficacy of laser-induced fluorescence (LIF) data obtained at 325-nm pulsed laser excitation for the discrimination of normal, benign, and malignant ovarian tissues. BACKGROUND DATA: Several studies have reported that the autofluorescence technique has a high specificity and sensitivity for discrimination between diseased and non-diseased tissues of various cancers, and also has the advantages of being non-invasive and producing a real-time diagnosis. When using this technique on ovarian tissues in most of the previously reported studies, multivariate statistical tools were used and classification analyses were carried out. MATERIALS AND METHODS: Autofluorescence spectra of normal, benign, and malignant ovarian tissues were recorded with 325-nm pulsed laser excitation in the spectral region from 350-600 nm in vitro. The spectral analysis for discrimination between the different types of tissues was carried out using principal component analysis (PCA)-based non-parametric k-nearest neighbor (k-NN) analysis. RESULTS: A total of 97 (34 normal, 33 benign, and 30 malignant) spectra were obtained from 22 subjects with normal, benign, and malignant tissues. The discrimination analysis of data using a PCA-based k-NN algorithm showed very good discrimination. The performance of the analysis was evaluated by calculating statistical parameters, specificity, sensitivity, and accuracy and were found to be 100%, 90.90%, and 94.2%, respectively. CONCLUSION: The results show that the discrimination of normal, benign, and malignant ovarian conditions can be achieved quite successfully using LIF.

Pregnancy associated breast cancer--the obstetrician's role.

Breast cancer is the most common cancer in many geographic areas, the most frequent cause of cancer deaths in women, and is also the cancer most likely to be seen during pregnancy and lactation. Delay in diagnosis appears to be the primary reason for the generally worse prognosis overall for all patients with breast cancer diagnosed during pregnancy and lactation. In this context, the patient's family physician or obstetrician who performs the routine antenatal examinations can play an important role by performing a vital breast examination which might bring to light and prompt timely investigation of otherwise asymptomatic breast masses.

Diagnosis of ovarian cancer by Raman spectroscopy: a pilot study.

OBJECTIVE: To assess the efficacy of conventional Raman spectroscopy in combination with discriminating parameters, Mahalanobis distance, spectral residuals, and "limit test" methodology in differentiation of normal and malignant ovarian tissues. BACKGROUND DATA: Ovarian cancer is the second most common cancer among women and the leading cause of death among gynecologic malignancies. Initial laparotomy and subsequent frozen section analysis can influence the surgical management of ovarian cancers. Although frozen section pathology is sensitive and specific enough, interpretation is often subjective, time consuming, and requires highly skilled personnel. Raman spectroscopy is sensitive to biochemical variations in the samples, rapid, more objective, and amenable to multivariate statistical tools. It can therefore be an ideal tool for discrimination between normal and malignant ovarian tissues. METHODS: 72 Spectra from eight normal and seven malignant ovarian tissues were recorded by conventional near-infrared (NIR) Raman spectroscopy (excitation wavelength of 785 nm). Spectral data were analyzed by principal components analysis (PCA) and other discriminating parameters such as Mahalanobis distance, spectral residuals, and a multiparametric limit test approach. RESULTS: A mean malignant spectrum exhibits a broader amide I band, a stronger amide III band, a minor blue shift in the delta CH2 band, and a hump around 1480 cm(-1) compared to a normal spectrum. The normal spectra show relatively stronger peaks around the 855 and 940 cm(-1) region. Scores of factor 1 as well as Mahalanobis distance and spectral residuals gave good classification among the tissue types. The limit test approach provided unambiguous and objective discrimination. CONCLUSION: The findings of this study demonstrate the efficacy of conventional Raman spectroscopy and our statistical methodologies in discrimination of normal from malignant ovarian tissues. Prospectively, by evaluating the models and developing suitable fiberoptic probes, this technique could be useful in diagnosis during initial laparotomy.

FTIR and Raman microspectroscopy of normal, benign, and malignant formalin-fixed ovarian tissues.

Ovarian cancer is the sixth most common cancer among women worldwide, and mortality rates from this cancer are higher than for other gynecological cancers. This is attributed to a lack of reliable screening methods and the inadequacy of treatment modalities for the advanced stages of the disease. FTIR and Raman spectroscopic studies of formalin-fixed normal, benign, and malignant ovarian tissues have been undertaken in order to investigate and attempt to understand the underlying biochemical changes associated with the disease, and to explore the feasibility of discriminating between these different tissue types. Raman spectra of normal tissues indicate the dominance of proteins and lower contents of DNA and lipids compared to malignant tissues. Among the pathological tissues studied, spectra from benign tissues seem to contain more proteins and less DNA and lipids compared to malignant tissue spectra. FTIR studies corroborate these findings. FTIR and Raman spectra of both normal and benign tissues showed more similarities than those of malignant tissues. Cluster analysis of first-derivative Raman spectra in the 700-1700 cm(-1) range gave two clear groups, one corresponding to malignant and the other to normal+benign tissues. At a lower heterogeneity level, the normal+benign cluster gave three nonoverlapping subclusters, one corresponding to normal and two for benign tissues. Cluster analysis of second-derivative FTIR spectra in the combined spectral regions of 1540-1680 and 1720-1780 cm(-1) resulted into two clear clusters corresponding to malignant and normal+benign tissues. The cluster corresponding to normal+benign tissues produced nonoverlapping subclusters for normal and benign tissues at a lower heterogeneity level. The findings of this study demonstrate the feasibility of Raman and FTIR microspectroscopic discrimination of formalin-fixed normal, benign, and malignant ovarian tissues.

Evaluation of the suitability of ex vivo handled ovarian tissues for optical diagnosis by Raman microspectroscopy.

A pilot Raman microspectroscopy study of formalin-fixed, paraffin-embedded, and deparaffinized sections from the same ovarian normal and malignant tissues was carried out. This approach was considered in order to evaluate the suitability of these ex vivo tissue handling procedures in discrimination as well as biochemical characterization. The spectra of formalin-fixed normal and malignant tissues exhibited no contamination due to formalin, which is indicated by the absence of strong formalin peaks; spectral features also show significant differences for normal and malignant tissues. The differences between spectral profiles of deparaffinized normal and malignant tissues are subtle and spectra show few residual sharp peaks of paraffin. Complete dominance of paraffin swamping signals from tissues was observed in the spectra of paraffin-embedded tissues. Principal components analysis (PCA), which was employed for discrimination of tissue type, provided good discrimination for formalin-fixed and paraffin-embedded tissue spectra. PCA of deparaffinized tissues resulted in a poor classification with significant overlap among the clusters. Thus, this study indicates that formalin fixation is the most suitable among the three procedures employed in the study. Significant differences between spectral profiles of normal and malignant formalin-fixed tissues can not only be exploited for discrimination but can also provide information on biochemical characteristics of the tissues. Deparaffinized tissues provide poor discrimination and information on tissue biochemistry is lost. Paraffin-embedded tissues may provide good discrimination, but predominance of paraffin in the spectra could jeopardize biochemical characterization. Prospectively, as a result of the better availability of paraffin-embedded tissues and problems associated with frozen sectioning of formalin-fixed tissues, the results of this study using paraffin-embedded tissues are very encouraging.