robotİk onkolojİde gÜncel durum -...
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JİNEKOLOJİK ONKOLOJİDE ROBOTİK CERRAHİYE GÜNCEL YAKLAŞIM
Prof Dr Ahmet Göçmen
İstanbul Medeniyet Üniversitesi
Kadın Hast ve Doğum ABD İSTANBUL
JİNEKOLOJİK ONKOLOJİ DOĞU KARADENİZÇALIȘTAY VE SEMPOZYUMU2-3 MAYIS 2015 ÇORUM
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Histerektomi/SOMyomektomi DIEndometriosiz Sakroserviko-kolpopeksiOver cerrahisi Tubal cerrahi Abdominal serviko-istmik
serklaj Presakral nörektomi
Radikal Histerektomi Pelvik Lenfadenektomi Paraaortik Lenfadenektomi Endometrial kanser staging Erken evre over kanser
staging Radikal Trakelektomi Pelvik Exenterasyon İnguinofemoral LND
(Vulva Testis)
JİNEKOLOJİK ENDOSKOPİK CERRAHİ ( Laparoskopik/Robotik)
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Endoskopik cerrahi
1. Laparoskopi
Konvensiyonel/mikro laparoskopiLaparolift/İsobarik
2. Robotik
LESS (Laparoendoskopik single site surgery)OASIS (Orifice-assisted small incisionsurgery)
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Minimal invazifcerrahi
Daha az post-operatif ağrı
Kısa hastanede kalış
Daha az kan kaybı
Daha erken normal aktiviteye dönüş
Daha küçük insizyon
Görüntüleme yöntemlerinegöre daha güvenilir (MRI / CT scan)
Gereksiz eksploratiflaparotomiyi önler
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Endoskopik Onkolojik Cerrahide sorular Lapatomiye göre operatif onkolojik prensiplerde
fark
Kısa dönem sonuçlar
Uzun dönem sonuçlar
Komplikasyon/maliyet
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Konversiyon %27En sık seb kötü görüntü %15ozukluğu
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2009 results of LAP2 study :
Laparoscopically treated patients had ;
A superior QOL through the first 6 postoperative weeks.
Fewer complications
Less pain
Faster recovery
Reduced length of hospital stay
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Konversiyon %27En sık seb kötü görüntü %15ozukluğu
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Robotic Surgery Benefits
Improved visual fields Less dependence on surgical assistance Surgeon comfort Increased instrument mobility
Drawbacks
Cost Loss of tactile feedback Availability Bulky machine Trochar size
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da Vinci® Sistemin ilerlemesi
GelenekselLaparoskopi
da Vinci® Si™
• Tek Port Cerrahi• Çift Konsol Opsiyonu• Gelişmiş HD Vision (1080i)• Gelişmiş Ergonomi• Arttırılmış cerrah kontrolü• Küçülebilir yapı• Geliştirilmiş enstrumanlar
da Vinci® S™
• 3D HD Vision (720p) • Görüntü Girişi –
TilePro• Multi-quadrant akses• Kolay set-up• Operasyon spesifik
ve farklı enerji enstrumanları
da Vinci®•Lap kıstlamalarıortadan kaldırdı
• 4.Kol (2003)•Basit enstrumanlar
1999
2006
2009
2014
da Vinci Xi
Four quadrantaccess
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Endometrial Cancer (LT-LS)
Systematic review and Meta-analysis of randomised controlled trials
8 studies, 3666 patients,
Zullo F et al, 2012
Endometrial kanser evrelemesinde L/T vs L/S; İntraoperatif komplikasyon bakımından fark yok Post op komplikasyon oranı L/S grubunda daha az
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NO difference for intraoperative complicationsFewer postoperative complications in laparoscopy
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Endometrial CancerRobotic vs Laparoscopy vs Laparotomy
Prospective randomized trial yokEn geniş sistematik review8 comparative studies, 1591 hastaRobotik: 589, laparoskopik: 396,
laparotomi: 606Gaia G et al, 2010
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Recurrence & Survival Analysis
GOG LAP2 Prospective randomized trial Stage I - IIA 1696 laparoskopi vs 920 laparotomi Pelvik ve paraaortik LNDMedian follow-up 59.3 ay
Walker JL et al, 2012
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Estimated 5‐year overall survival :89.8% in the laparoscopy group 89.8% in the laparotomy groupA total of 350 deaths 224 of which resulted from disease
1 52 in the laparoscopy group 72 in the laparotomy group
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Endometrial Cancer PFS and OS For Robotic Surgery
Kilgore JE et al, 2013
Retrospective study,
499 cases
Median follow-up:
23 months.
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Cost Analysis
Direkt cost : Robotik sistem 1.5 - 3 millyon $
İndirekt cost:
( Hekim ücreti, robotik sarflar, operasyon odası ücreti,lLaboratuvar-radyoloji ve ilaç ücretleri, komplikasyonlara ait ücretler, iş gücü kaybına bağlı ücret, robotik bakım ücreti)
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Cost Analysis
Barnett JC et all, 2010
3 decision models to compare the cost associated with robotic, laparoscopic, and open hysterectomy for the treatment of endometrial cancer.
1) Societal perspective model: inpatient hospital costs, robotic expenses, lost wages and caregiver costs
2) Hospital perspective and robot cost model: İdentical to model 1 but excluded lost wages and caregiver costs.
3) Hospital perspective without robot cost model: Identical to model 2 except that it excludes initial cost of robot.
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Cost Analysis
Model 1: Laparoscopy $10.128
Robotic $11.476
Open $12.847
Model 2: Laparoscopy $6581
Open $7009
Robotic $8770
Model 3: Laparoscopy is
the least expensive
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Monopolar makas 5000$/10 kul
Bipolar Maryland Forceps
4000$ / 10 kul
Bipolar Fenestrated forceps
4000$/ 10 kul
Prograsper 3500 / 10 kul
Sütür kesici iğne tutucu
3800/ 10 kul
Rob enst kolu drape 75 $/ kul (x3)
Rob kamera kolu drape
50$/ kul
Rob kamera headdrape
40$/ kul
Robotik enstruman/kul
3-4 kol drape240-315 $
2 robotik enstruman1 makas+1 Bipolar
500 400 240
11403 robotik enstruman1 makas +1 Bipol + 1 sutur cut portegu
500+400+380+320+=1600$
4 robotik enstrumanmakas+bipolar+ prograsp +iğne tutucu
500 400 380 350 320
19505 robotik enstrumanMakas+bipolar+ prograsp+ iğne t(2)
1000$ 1400$
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Endoskopik cerrahiye bağlı endişeler
1. Uterin manipulatör-tümör yayılımı
2. Port site rekürrens
3. Cuff evisserasyonu
4. Port site herni
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RUMI®
HOHL Uterine Manipulator CLERMONT-FERRAND
KONINCKX
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Four RCTs compared robot-assisted surgery forbenign gynecologic disease with laparoscopy, andnone showed any benefit from using the roboticapproach.
These and other studies show that robot-assistedgynecologic surgery can be performed safely incenters with experienced surgeons and that thisminimally invasive approach could be consideredfor procedures that might otherwise requirelaparotomy.
Sarlos D Obstet Gynecol 2012
Paraiso MF Am J Obstet Gynecol 2013 Anger JT Obstet Gynecol 2014
Benign
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Gynecologic MalignanciesEndometrial cancer
Although randomized prospective trialscurrently do not exist for the roboticassisted surgical management ofendometrial cancer, there are 13retrospective trials comparing robot-assisted hysterectomy with eitherconventional laparoscopic or abdominalhysterectomy.
Hastanede kalma süresi ve kankaybı robotik grupta daha azLenf nodu sayısı bakımındanfark yok
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Robot-assisted surgery is increasingly used fortreatment of , but outcome data are limitedto retrospective reviews.One study that compared robot assistedhysterectomy with laparoscopic radicalhysterectomy found no advantages to therobotic approach.
Additional studies are necessary to helpvalidate whether robot-assisted andlaparoscopic radical hysterectomy havesimilar outcomes.
Cervical cancer
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