The RECOURSE Study: Long-term Oncologic Outcomes Associated With Robotically Assisted Minimally Invasive Procedures for Endometrial, Cervical, Colorectal, Lung, or Prostate Cancer: A Systematic Review and Meta-analysis.

OBJECTIVE: To assess long-term outcomes with robotic versus laparoscopic/thoracoscopic and open surgery for colorectal, urologic, endometrial, cervical, and thoracic cancers. BACKGROUND: Minimally invasive surgery provides perioperative benefits and similar oncological outcomes compared with open surgery. Recent robotic surgery data have questioned long-term benefits. METHODS: A systematic review and meta-analysis of cancer outcomes based on surgical approach was conducted based on Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines using Pubmed, Scopus, and Embase. Hazard ratios for recurrence, disease-free survival (DFS), and overall survival (OS) were extracted/estimated using a hierarchical decision tree and pooled in RevMan 5.4 using inverse-variance fixed-effect (heterogeneity nonsignificant) or random effect models. RESULTS: Of 31,204 references, 199 were included (7 randomized, 23 database, 15 prospective, 154 retrospective studies)-157,876 robotic, 68,007 laparoscopic/thoracoscopic, and 234,649 open cases. Cervical cancer: OS and DFS were similar between robotic and laparoscopic [1.01 (0.56, 1.80), P =0.98] or open [1.18 (0.99, 1.41), P =0.06] surgery; 2 papers reported less recurrence with open surgery [2.30 (1.32, 4.01), P =0.003]. Endometrial cancer: the only significant result favored robotic over open surgery [OS; 0.77 (0.71, 0.83), P <0.001]. Lobectomy: DFS favored robotic over thoracoscopic surgery [0.74 (0.59, 0.93), P =0.009]; OS favored robotic over open surgery [0.93 (0.87, 1.00), P =0.04]. Prostatectomy: recurrence was less with robotic versus laparoscopic surgery [0.77 (0.68, 0.87), P <0.0001]; OS favored robotic over open surgery [0.78 (0.72, 0.85), P <0.0001]. Low-anterior resection: OS significantly favored robotic over laparoscopic [0.76 (0.63, 0.91), P =0.004] and open surgery [0.83 (0.74, 0.93), P =0.001]. CONCLUSIONS: Long-term outcomes were similar for robotic versus laparoscopic/thoracoscopic and open surgery, with no safety signal or indication requiring further research (PROSPERO Reg#CRD42021240519).

Methodology to standardize heterogeneous statistical data presentations for combining time-to-event oncologic outcomes.

Survival analysis following oncological treatments require specific analysis techniques to account for data considerations, such as failure to observe the time of event, patient withdrawal, loss to follow-up, and differential follow up. These techniques can include Kaplan-Meier and Cox proportional hazard analyses. However, studies do not always report overall survival (OS), disease-free survival (DFS), or cancer recurrence using hazard ratios, making the synthesis of such oncologic outcomes difficult. We propose a hierarchical utilization of methods to extract or estimate the hazard ratio to standardize time-to-event outcomes so that study inclusion into meta-analyses can be maximized. We also provide proof-of concept results from a statistical analysis that compares OS, DFS, and cancer recurrence for robotic surgery to open and non-robotic minimally invasive surgery. In our example, use of the proposed methodology would allow for the increase in data inclusion from 108 hazard ratios reported to 240 hazard ratios reported or estimated, resulting in an increase of 122%. While there are publications summarizing the motivation for these analyses, and comprehensive papers describing strategies to obtain estimates from published time-dependent analyses, we are not aware of a manuscript that describes a prospective framework for an analysis of this scale focusing on the inclusion of a maximum number of publications reporting on long-term oncologic outcomes incorporating various presentations of statistical data.

Is robotic lobectomy cheaper? A micro-cost analysis.

Higher capital costs and operating room costs associated with Lobectomy via Robot Assisted Thoracic Surgery (RATS) have previously been suggested as the principal contributors to the elevated overall cost. This study uses a micro-costing approach to a previous analysis of clinical outcomes of RATS, Video-Assisted Thoracic Surgery (VATS) and Open Lobectomy to evaluate the most significant cost drivers for the higher cost of robot-assisted lobectomy. A micro-costing model was developed to reflect the pathway of patients from day of surgery through the first 30 days following lobectomy. Costs were provided for RATS, VATS and Open approaches. Sensitivity analysis was performed specifically in the area of staff costs. A threshold sensitivity analysis of the overall cost components was also performed. Total cost per case for the RATS approach was €13,321 for the VATS approach €11,567, and for the Open approach €12,582. The overall cost differences were driven primarily by the elevated consumable costs associated with RATS Lobectomy. Capital costs account for a relatively small proportion of the per-case cost difference. This study presents a detailed analysis of the cost drivers for lobectomy, modelled for the three primary surgical approaches. We believe this is a useful tool for surgeons, hospital management, and service commissioning agencies to accurately and comprehensively determine where cost savings can be applied in their programme to improve the cost-effectiveness of RATS lobectomy.

A systematic review of robotic versus open and video assisted thoracoscopic surgery (VATS) approaches for thymectomy.

BACKGROUND: Median sternotomy has been the most commonly used approach for thymectomy to date. Recent advances in video-assisted thoracoscopic surgery (VATS) and robotic access with CO2 insufflation techniques have allowed more minimally invasive approaches. However, prior reviews have not compared robotic to both open and VATS thymectomy. METHODS: A systematic review was conducted in accordance with the PRISMA guidelines using PubMed, Embase and Scopus databases. Original research articles comparing robotic to VATS or to open thymectomy for myasthenia gravis, anterior mediastinal masses, or thymomas were included. Meta-analyses were performed for mortality, operative time, blood loss, transfusions, length of stay, conversion to open, intraoperative and postoperative complication rates, and positive/negative margin rates. RESULTS: Robotic thymectomy is a valid alternative to the open approach; advantages include: reduced blood loss [weighted mean difference (WMD): -173.03, 95% confidence interval (95% CI): -305.90, -40.17, P=0.01], fewer postoperative complications (odds ratio: 0.37, 95% CI: 0.22, 0.60, P<0.00001), a shorter hospital stay (WMD: -2.78, 95% CI: -3.22, -2.33, P<0.00001), and a lower positive margin rate (relative difference: -0.04, 95% CI: -0.07, -0.01, P=0.01), with comparable operative times (WMD: 6.73, 95% CI: -21.20, 34.66, P=0.64). Robotic thymectomy was comparable with the VATS approach; both have the advantage of avoiding median sternotomy. CONCLUSIONS: While randomized controlled studies are required to make definitive conclusions, current data suggests that robotic thymectomy is superior to open surgery and comparable to a VATS approach. Long-term follow-up is required to further delineate oncological outcomes.

A systematic review and meta-analysis of robotic versus open and video-assisted thoracoscopic surgery approaches for lobectomy.

OBJECTIVES: A number of meta-analytical and database studies have sought to compare open, video-assisted thoracoscopic surgery (VATS) and robotic operative approaches to lobectomy, often with conflicting results. Our objective was to perform a comprehensive review of these meta-analytical and database studies published to date. METHODS: A systematic review was conducted in accordance with the preferred reporting items for systematic reviews and meta-analyses (PRISMA) guidelines using the PubMed and Scopus databases. Primary outcome was short-term mortality, and secondary outcomes were operative time, blood loss or transfusion rate, hospital stay, conversions, lymph node yield and complications. Meta-analyses of the primary and secondary outcomes were performed. RESULTS: Robotic lobectomy is a valid alternative to the VATS approach and is superior to the open approach with respect to complications [OR 0.67, 95% CI 0.58-0.76, P < 0.00001] and duration of hospital stay (WMD -1.4, 95% CI -1.96-0.85, P < 0.00001). It is inferior to both VATS and open with respect to operative duration (robotic vs. VATS; WMD 4.98, 95% CI 2.61-7.36, P < 0.001, robotic vs. open WMD 65.56, 95% CI 53.66-77.46, P < 0.00001). Robotic approach is superior with respect to 30-day mortality compared to VATS (OR 0.61, 95% CI 0.45-0.83, P = 0.001 and open approaches (OR 0.53, 95% CI 0.33-0.85, P = 0.008). CONCLUSIONS: This is the largest published systematic review and meta-analysis to date qualifying the robotic lobectomy as a reasonable alternative to VATS and open surgery. Short-term survival is superior in the robotic cohorts. No definitive conclusions on long-term outcomes can be drawn until a randomized controlled trial comparing approaches is conducted.

Assessment of Robotic Console Skills (ARCS): construct validity of a novel global rating scale for technical skills in robotically assisted surgery.

BACKGROUND: Skill assessment during robotically assisted surgery remains challenging. While the popularity of the Global Evaluative Assessment of Robotics Skills (GEARS) has grown, its lack of discrimination between independent console skills limits its usefulness. The purpose of this study was to evaluate construct validity and interrater reliability of a novel assessment designed to overcome this limitation. METHODS: We created the Assessment of Robotic Console Skills (ARCS), a global rating scale with six console skill domains. Fifteen volunteers who were console surgeons for 0 ("novice"), 1-100 ("intermediate"), or >100 ("experienced") robotically assisted procedures performed three standardized tasks. Three blinded raters scored the task videos using ARCS, with a 5-point Likert scale for each skill domain. Scores were analyzed for evidence of construct validity and interrater reliability. RESULTS: Group demographics were indistinguishable except for the number of robotically assisted procedures performed (p = 0.001). The mean scores of experienced subjects exceeded those of novices in dexterity (3.8 > 1.4, p < 0.001), field of view (4.1 > 1.8, p < 0.001), instrument visualization (3.9 > 2.2, p < 0.001), manipulator workspace (3.6 > 1.9, p = 0.001), and force sensitivity (4.3 > 2.6, p < 0.001). The mean scores of intermediate subjects exceeded those of novices in dexterity (2.8 > 1.4, p = 0.002), field of view (2.8 > 1.8, p = 0.021), instrument visualization (3.2 > 2.2, p = 0.045), manipulator workspace (3.1 > 1.9, p = 0.004), and force sensitivity (3.7 > 2.6, p = 0.033). The mean scores of experienced subjects exceeded those of intermediates in dexterity (3.8 > 2.8, p = 0.003), field of view (4.1 > 2.8, p < 0.001), and instrument visualization (3.9 > 3.2, p = 0.044). Rater agreement in each domain demonstrated statistically significant concordance (p < 0.05). CONCLUSIONS: We present strong evidence for construct validity and interrater reliability of ARCS. Our study shows that learning curves for some console skills plateau faster than others. Therefore, ARCS may be more useful than GEARS to evaluate distinct console skills. Future studies will examine why some domains did not adequately differentiate between subjects and applications for intraoperative use.

Learning curve assessment of robot-assisted radical prostatectomy compared with open-surgery controls from the premier perspective database.

INTRODUCTION: The primary aims of this study were to assess the learning curve effect of robot-assisted radical prostatectomy (RARP) in a large administrative database consisting of multiple U.S. hospitals and surgeons, and to compare the results of RARP with open radical prostatectomy (ORP) from the same settings. MATERIALS AND METHODS: The patient population of study was from the Premier Perspective Database (Premier, Inc., Charlotte, NC) and consisted of 71,312 radical prostatectomies performed at more than 300 U.S. hospitals by up to 3739 surgeons by open or robotic techniques from 2004 to 2010. The key endpoints were surgery time, inpatient length of stay, and overall complications. We compared open versus robotic, results by year of procedures, results by case volume of specific surgeons, and results of open surgery in hospitals with and without a robotic system. RESULTS: The mean surgery time was longer for RARP (4.4 hours, standard deviation [SD] 1.7) compared with ORP (3.4 hours, SD 1.5) in the same hospitals (p<0.0001). Inpatient stay was shorter for RARP (2.2 days, SD 1.9) compared with ORP (3.2 days, SD 2.7) in the same hospitals (p<0.0001). The overall complications were less for RARP (10.6%) compared with ORP (15.8%) in the same hospitals, as were transfusion rates. ORP results in hospitals without a robot were not better than ORP with a robot, and pretreatment co-morbidity profiles were similar in all cohorts. Trending of results by year of procedure showed no differences in the three cohorts, but trending of RARP results by surgeon experience showed improvements in surgery time, hospital stay, conversion rates, and complication rates. CONCLUSIONS: During the initial 7 years of RARP development, outcomes showed decreased hospital stay, complications, and transfusion rates. Learning curve trends for RARP were evident for these endpoints when grouped by surgeon experience, but not by year of surgery.