Robotic Surgery for Gynecologic Cancer

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Presented by: Amer Karam, MD
Associate Clinical Professor, Associate Director Division of Gynecologic Oncology, Stanford Hospital and Clinics
January 30, 2014

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This robot saves lives. But it owes everything to the skill of its operator—a human being. Together, they are one of the best teams a woman could ask for if she needs surgery to get rid of cancer in her reproductive system.

The robot is a device known as the da Vinci Surgical System, which has propelled robotic surgery to become a leading treatment for gynecologic cancer, according to Amer Karam, MD. Gynecologic cancer includes malignancies of the uterus, cervix, ovaries and other reproductive organs and tissues, which are diagnosed in about  80,000 women in the United States each year.

Robotic surgery is a term that can be misleading, because the robot never operates alone, said Karam, director of the robotic surgery program in gynecologic oncology at Stanford Hospital & Clinics.

“The instruments are controlled by the surgeon at all times,” said Karam, who is also associate clinical professor of gynecologic oncology at Stanford University School of Medicine. “They only move if the surgeons move the instruments.”

Robotic tools began to be used for gynecologic surgery about 10 years ago. It has become a widespread method for treating gynecologic cancer because of its precision in targeting and removing cancer tissue, Karam told the audience at a Jan. 30 lecture sponsored by the Stanford Health Library and the Stanford Gynecologic Cancer Center. Removing every last bit of malignant tissue is the best way to eliminate and cure gynecologic cancer.

The traditional method for doing surgery to remove gynecologic cancer is the radical hysterectomy. That means removing a woman’s reproductive system—the uterus, fallopian tubes, ovaries and cervix. Decades ago, this always required a large incision in the abdomen, like the cut made for a Caesarean section birth. That meant either a long vertical incision from the pubic area to the belly button, or the horizontal “bikini cut” above the pubic area. At that time, the large incision was necessary for surgeons to see the reproductive systems inside the abdomen.

About 25 years ago, surgeons developed methods for hysterectomy that used much smaller incisions, called “minimally invasive surgery.”  Smaller incisions caused less bleeding, fewer complications, fewer scars, less pain and a shorter hospital stay. “These incisions were a lot easier to hide, and to heal from,” Karam said.

Doing surgery with smaller incisions was made possible with laparoscopy—inserting a miniature camera to see inside the abdomen. Surgeons make “keyhole” incisions, inflate the interior abdomen with gas to improve visibility, and insert the camera. Even with these improvements, there are drawbacks to laparoscopy, Karam said.

The instruments for laparoscopy are rigid metal and not as nimble as a surgeon’s fingers. “These instruments were a lot harder to move around than my hands,” Karam said. Also, the miniature camera uses a screen that shows only a two-dimensional view of the target tissues in the abdomen. “That’s a very big limitation for surgeons who operate in a 3D world,” Karam said.

Now robotic surgery has come along, combining small incisions with better instruments and improved imaging of the interior abdomen.  Hysterectomy is typically done with three to five incisions that are each about one-quarter of an inch long.  The tools are flexible enough to let surgeons “use the full capacity of our very dexterous fingers,” Karam said.

The robotic system also magnifies the images of the body tissues targeted in surgery. “You’re now able to cut things out more precisely,” Karam said. “You’re immersed in a 3D environment. It’s typically a high-definition image. You actually see details of what you’re working with,” Karam said.

That’s a valuable advantage when a woman’s survival depends on finding and removing all the cancer tissues in her abdomen. Other benefits of the robotic surgery include a shorter hospital stay of only one night—compared with three or four nights with traditional surgery–and faster healing of the small incisions.

Robotic surgery is still evolving to include innovations that further improve the surgeon’s ability to treat cancer, Karam said. Better imaging with higher magnification and high definition vision has become available. A technology called fluorescence imaging also combines infrared light with dyes for the body tissue so that they “glow in the dark,” Karam said.

“All of a sudden you can see these structures you couldn’t see before with the naked eye,” he said. That helps especially when the surgeon is tracking down lymph nodes that are hidden from view but may still harbor some cancer.

Robotic surgery can be used for all of the most common kinds of gynecologic surgeries for cancer as well as some noncancerous conditions that require hysterectomies, Karam said.

The most common gynecologic cancers are those that arise in the uterus, the cervix, and the ovaries, Karam said. The first symptoms can be abnormal menstrual bleeding or postmenopausal bleeding, pelvic pain, pain during intercourse or changes in bowel movements or urination.

Surgery is often the first step in treatment to survive. Once the cancer spreads to other parts of the body, chemotherapy or radiation may be needed. Karam described the risk factors and treatment options that women face for each of these cancers:

  • Uterine cancer is the most common gynecologic cancer in the United States, striking about 50,000 women each year. Risk factors for this cancer include age over 50, being overweight, having diabetes or high blood pressure or a history of taking hormone replacement therapy (especially estrogen without progesterone). Uterine cancer is usually diagnosed when it is still confined to the uterus, Karam said. This means it can often be cured, mainly by surgery to remove all cancerous tissue.
  • Ovarian cancer is the second most common gynecologic cancer in the United States, and it is the deadliest and hardest to treat, Karam said. One of the most important risk factors for this disease is family history of ovarian or breast cancer. A history of endometriosis can also increase the risk for ovarian cancer. Symptoms of ovarian cancer often aren’t noticed until the cancer has spread beyond the ovaries and fallopian tubes, Karam said. Treatment usually includes surgery to remove the malignancy plus chemotherapy.
  • Cervical cancer, the third most common gynecologic cancer in the United States, strikes about 12,000 U.S. women each year and is usually curable. Risk factors include infection with the human papillomavirus (HPV) and smoking. Cervical cancer is mostly preventable because it can be caught in a precancerous state with a Pap smear test, Karam said. A vaccine can also be used to treat or prevent infection with HPV. Early diagnosis of cervical cancer enables surgery to cure it. If the malignancy has not spread, in younger women who still hope to have children, the upper end of the uterus can be preserved so they can still bear children.

Some surgeons are also pushing the envelope in robotic surgery to operate with only a single incision made through the belly button for a hysterectomy. “It’s virtually scarless,” Karam said. This single-site surgery is done now at Stanford, although so far Karam uses it only for noncancer hysterectomies.

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About Dr. Karam

Stanford Gynecologic Cancer Program