How does robotic surgery affect gynecology patient care?

TL;DR

This review explores how robotic surgery impacts gynecology patient care by analyzing recent studies on patient needs and outcomes.

Contribution

The study provides a rapid synthesis of evidence on robotic surgery's effects on gynecological patient care needs.

Findings

Robotic surgery can address ongoing problems in gynecological patient care.

Findings are organized under themes like operative time, complications, and pain.

Most studies focused on endometrial cancer and hysterectomy procedures.

Abstract

The aim of this review is to map the current research on the needs of gynecological patients treated with robotic surgery. Systematic Rapid Review. Pubmed, Web of Science, Google Scholar. Search was limited from the years 2017–2021. The Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) statement was followed. Rapid review is a synthesis of information produced in a shorter time than systematic reviews, which allows clinical nurses to access evidence in the decision-making process. The methodological steps implemented were the following: (1) needs assessment and topic selection, (2) study development, (3) literature search, (4) screening and study selection, (5) data extraction, (6) risk-of-bias assessment and (7) knowledge synthesis. The search yielded 815 articles, 746 were excluded after screening the title and abstract, and 69 full-text syntheses were performed. Only 10 articles were included in the final analysis. This research evaluated the effects of robotic surgery on the patient under seven themes; operative time, length of stay, complications, estimated blood loss, pain, survivor, and conversion. Five studies were on endometrial cancer, one study on gynecologic cancer, two studies on hysterectomy, one study on patient safety, and one study on cervical cancer. The results show that robotic surgery can change the needs of patients by solving ongoing problems in gynecological patients. This requires a better understanding of robotic surgery procedures while facilitating nursing care over patient care.

Figures

Flowchart for the search and study selection process following the PRISMA guidelines [[27](#CR27)]

Full text

Introduction

Robotic surgery influences nursing care and have an impact on patients’ needs. The main role of nursing in the perioperative period is to ensure patient safety [1]. Robotic surgery is one of the latest surgical innovations in many countries worldwide [2] Robotic surgical systems are used in various procedures such as cardiothoracic surgery, urology, endocrine surgery, metabolic and bariatric surgery, head and neck surgery and all the intra-abdominal surgeries.

Using a computer-assisted platform, robotic surgery is a technologically more sophisticated extension of traditional laparoscopy [2]. Nurses working with robotic systems face a number of conceptual and technical challenges. Important behavioral markers namely eye contact and anticipatory movements are compromised in the operating theater. In addition, robotic surgery demands high technical competence and a more active role from the operating room nurse, whose responsibilities are to assist the surgeon, to pay attention to the rules of asepsis by distinguishing the sterile and non-sterile parts of the robot, to place the robot arms [3].

The trends of using robotic surgery by year are given in Table 1 [4, 5]. Robotic surgery has several advantages compared to the previous; ergonomically superior, tremor-control, camera stabilization, depth perception due to the 3D camera (less blood loss, reduced transfusions, reduced complications), and lower conversion rate to open surgery [2, 6]. Even so advantages of laparoscopic surgery over robotic surgery haptic feedback, cost-effective, and flexibility instrument configuration [6]. Da Vinci systems include EndoWrist instruments that provide greater feedback to the surgeon. Although these arms increase mobility through combinations of placement, tilt, yaw, roll, and grip, they provide limited tactile feedback [7, 8].Table 1. Trends of using robotic surgeryYearNameUsage areas1985PUMA 200 (first robot surgeon)Neurosurgical biopsies1988UROBOTUrologic1990“Master–slave system” identifiedRobotic based surgery1993Automated endoscopic system for optimal positioning (AESOP)Laparoscopic cholecystectomy, hernioplasty, fundoplication, colectomy1998ZEUS robotic surgical systemUrologic, gynecologic, heart surgeries2000Da Vinci ® FDA approvedAbdominal surgeries and commonly urologic, gynecological surgeries, including prostatectomy for cancer and hysterectomy for benign diseases

Despite the innovational advantages of robotic surgery that it can bring, there are studies that argue that there is no clinically significant difference between robotic surgery and other surgical methods [2, 9, 10]. Compared to other surgical methods, patients who underwent robotic-assisted surgery may need different patient care due to shorter operating times and shorter hospital stays [11]. Hence, this rapid review was conducted based on the different patient care results that robotic surgery brings. In this rapid review, the focus is on the needs of gynecology patients where robotic surgery is used the most and how it can affect nursing care.

Aim

The aim of this review is to map the current research on the needs of gynecological patients treated with robotic surgery.

Methods

Design

Rapid review is a synthesis of information produced in a shorter time than systematic reviews, which allows clinical nurses to access evidence in the decision-making process [12–14]. In line with the study design and aims, the quality appraisal of the studies was not performed while a selective process of data extraction was applied. The methodological steps implemented were the following: (1) needs assessment and topic selection, (2) study development, (3) literature search, (4) screening and study selection, (5) data extraction, (6) risk-of-bias assessment and (7) knowledge synthesis [15, 16].

Needs assessment, topic selection and study development

The rapid use of robotic surgery in the field of gynecology and how this changes patient needs and nursing care were deemed necessary by literature analysis [1, 6]. The needs we mention here arise from the changing results with robotic surgery. For example, does the change in surgery duration create new needs for patients or how is nursing care affected by this situation?

Screening and study selection

The following databases were utilized: Pubmed, Web of Science, and Google Scholar. Search was limited from the years 2017–2021. Data were collected using the following keywords; robotic surgery, patient need and robotic surgery nursing. The search yielded 815 articles, 746 were excluded after screening the title and abstract screened. 69 full-text syntheses were performed. Among 69 studies, 15 studies were included because they were related to gynecology. Of the 54 studies, 5 were excluded because they were head and jaw, 11 were urology, 21 were general surgery, 4 were thoracotomy, 8 were transoral, 2 were nephrectomy, and 3 were perioperative studies. Five of the 15 gynecology studies were excluded because the methods were different in specific patient groups. Only 10 articles were included in the final analysis (Table 2).Table 2. Characteristics of the articles (n = 10)Authors, name and countriesStudy desingnsStudy focusWhat type of desease/illness?Lindfors et al. [17], Sweden (2020)An observational cohort studyPatients n = 217Endometrial cancerPlanque et al. [18], France (2018)Retrospective StudyPatients n = 77Endometrial cancerGallotta et al. [19], Italy (2018)Retrospective Cohort StudyElderly and very elderly patients n = 204Gynecologic cancerHerrinton et al. [20], California (2019)Retrospective Cohort StudyPatients n = 7345Hysterectomy Benign conditionsBalafoutas et al. [21], Germany (2020)Retrospective AnalysisProcedures n = 110Patient safetySofer et al. [22], Israel (2020)Retrospective StudyObese women n =  138Endometrial cancerSilva e Silva et al. [23], Brazil (2018)Prospective Randomized StudyPatients n = 89Endometrial cancerSinha et al. [24], India (2019)Retrospective reviewPatients n = 165HysterectomyLiu et al. [25], Taiwan (2019)Retrospective StudyPatients n = 39Cervical cancerSoto et al. [26], Massachusetts (2017)Randomized Control TrialPatients n = 73Endometriosis

One researcher (SA) performed the literature search and two researchers (SA and KVJ) worked independently to evaluate study eligibility based on the title and abstract screening of each study that emerged. All articles considered to be eligible were then retrieved in full-text format. Two researchers (SA and KVJ) independently read the full text of all articles and evaluated their inclusion. The inclusion of any article was decided upon a joint agreement. The full process of study inclusion (from the database search to the inclusion phase) is explained in Fig. 1.Fig. 1. Flowchart for the search and study selection process following the PRISMA guidelines [27]

Data analysis

Data were analyzed using Braun and Clarke’s thematic analysis method [28]. Theme topics were found by two independent researchers (SA, KVJ) using the thematic analysis method (Table 3). These themes; operative time, length of stay, complications, estimated blood loss, pain, survivors and conversion.Table 3. Data extraction table (n = 10)Author and yearOperative timeLength of stay hospitalComplicationsEstimated blood lossPainSurvivorConversionA. Lindfors et al. [17], (2020) Robotic or open surgery in obese women with endometrial cancerRobotic surgery shorter operation timeRobotic surgery shorter postoperative stay (P < 0.001)Obese patients in terms of a reduced complication rate. there was a significant reduction in complications in the robotic groupRobotic surgery reduction in estimated blood loss–Robotic surgery not found a significant independent factor for survival. (P = 0.024)–H. Planque et al. [18], Comparison of robotic surgery in obese and non-obese patients endometrial cancerThere was no difference for the total operative time (P = 0.50)The median hospital stay was 3 days (P = 0.92)There was no statistical difference for postoperative complications (P = 1)–––One patient (not obese) had a laparoconversionGallotta et al. [19], Robotic Surgery in Elderly and Very Elderly Gynecologic Cancer PatientsThe Elderly and Very elderly were comparable in terms of operative time. (P = 0.311)The median length of hospital stay was 2 days in each group. (P = 0.172)A total of 11 patients (5.6%) had early postoperative complicationsThe Elderly and Very elderly were comparable in terms of blood loss. (P = 0.919)––A total of 7 (3.4%) conversions to open surgery were registered (P = 1.00)Herrinton et al. [20],The average operative time was reduced (P < 0.0001)mean length of stay was similar for the robotic and conventional groupAmong noncomplex cases, robotic surgery was associated with complications of the urinary tract (P = 0.04). No other significant differences in risk of complications between conventional and robotic casesRobotic surgery reduction in estimated blood loss–––Balafoutas et al. [21],––Ninety (81.8%) procedures were completed without any problemsNo blood transfusion was needed––No need for conversion to laparotomy was observedSofer et al. [22],Robotic surgery was longer operating theater time (P < 0.001)Robotic surgery was associated with shorter hospital stays (P < 0.0001)Robotic surgery fewer postoperative complications (P = 0.0008)––5-year survival was higher in the robotic surgery group. Quality of life measures were better after robotic surgery–Silva e Silva A et al. [23],In our study, robotic surgery was more time consuming than traditional laparoscopic surgeryThe median hospital stay was was similar in both groupsEight major complications were registered in each groupEstimated blood loss was higher in the robotic surgery group, but not significant (P = 0.64)One patient in the robotic surgery group was converted to laparotomySinha R et al. [24], Comparison of Robotic and Laparoscopic Hysterectomy for the Large UterusRobotic surgery took longer operating time (P = 0.006)Postoperative stay was similar in both groups (1.4 days)Robotic surgery had less drop in Hb (P < 0.001)Requirement of intravenous analgesia was significantly lower in the Robotic surgery group (P < 0.001)Open conversion rate was 4.3% (RH) and 10.9% (LH) but not significantLiu et al. [25], Comparative Analysis between the Robotic and Abdominal ApproachesRobotic surgery shorter operation time P < 0.001Hospital stay (days) reduced robotic surgery P < 0.001had in 2 patients in robotic surgery intraoperative period P = 0.49 had in 3 patients in robotic surgery postoperative complications P = 0.814Robotic surgery reduction in estimated blood loss P < 0.001Postoperative pain score (VAS) and 24-h postoperative pain score (VAS) less in robotic surgery P < 0.001–No conversion to laparotomy was needed in the robotic surgery groupSoto et al. [26], Laparoscopy vs. Robotic Surgery for Endometriosis (LAROSE): a multicenter, randomized, controlled trialThere were no statistical differences in operative time–There were no differences in postoperative complicationsThere were no statistical differences in blood loss––There were no differences in rates of conversion to laparotomy in the two arms

Risk-of-bias assessment and knowledge synthesis

Several strategies were used to avoid bias: (a) the review team shared each step of the study inclusion and exclusion process; (b) the three main databases and reference lists of the included studies were carefully reviewed; (c) data extraction was performed by two reviewers; and (d) articles in English are included.

Thematic analysis was conducted by systematically coding and categorizing the textual information obtained from the included articles of how robotic surgical treatment will change patient outcomes.

Results

Table 3 presents the characteristics of the included ten studies. Papers were published within the year 2017–2021 involving gynecologic participants. Five studies were on endometrial cancer, one study on gynecologic cancer, two studies on hysterectomy, one study on patient safety, one study on cervical cancer. The country of origins were from Sweden, France, Italy, California, Germany, Israel, India, Taiwan, Brazil, and Massachusetts.

Reported content of robotic surgeries

Operative time = In 3 studies, it was stated that robotic surgery shortened the operation time, in 3 studies it did not affect the operation time, and in 3 studies it extended the operation time.

Length of stay = It was seen that robotic surgery did not affect the length of stay in hospital in 5 studies and robotic surgery treatment in 3 studies significantly reduced the length of stay in hospital.

Complications = In the studies, it was determined that postoperative and intraoperative complications can be seen in robotic surgery, that complications decreased in some studies, and that it was not significant between the groups in some comparative studies.

Estimated Blood Loss = Most of the studies show that the estimated blood loss is reduced in the treatment of robotic surgery.

Pain = In two studies, it was stated that robotic surgery treatment significantly reduced pain.

Survior = Studies have shown no significant outcome of robotic surgery on survival. Only the results of two studies were looked at.

Conversion = It was stated in studies that there was a transition from robotic surgery to open surgery.

Discussion

How the results might affect nursing care and patient needs were interpreted in line with the literature. Changes in the themes found may require new changing needs. Shorter stay for patients, shorter or longer operation time, less pain etc. The effects of robotic surgery on the patient were evaluated under seven themes.

Operative time

The operative time of robotic surgery was evaluated in the articles. There are different results that show the operating time of robotic surgery to be shorter [17, 20, 25] and longer [22–24] than other methods. While there are studies showing that the duration of robotic surgery is longer in endometrial cancer surgeries [22, 23] one study [17] has shown it to be shorter. When the robotic surgery operative time was compared in hysterectomy and abdominal approaches, it was observed that there were different results [20, 24, 25]. No significant difference was found in studies comparing the duration of robotic surgery in obese and elderly patients [18, 19]. It has been stated that the surgeon’s experience and the training of the operating room staff will contribute to shortening the operating time [7, 29, 30]. In terms of nursing care, job descriptions in robotic surgery can be made and situations that prolong the operation time can be determined.

Length of stay

Studies have shown that robotic surgery does not prolong hospital stay. However, in five studies out of ten no effect of robotic surgery on length of stay was observed, while in three studies it was observed that it shortened the length of stay [17, 22, 25].

Complications, estimated blood loss, pain

While there are results showing a decrease in complications in studies, there are also results that do not find a significant difference. It cannot be said that robotic surgery treatment completely reduces complications after gynecological surgery. Compared to laparoscopic surgery, robotic surgery has been shown to reduce estimated blood loss. Only one study showed greater blood loss in robotic surgery. In two studies comparing robotic surgery and laparoscopic surgery, pain was found to be significantly reduced in patients after robotic surgery. Reducing pain after surgery will also reduce patients’ need for painkillers. This may facilitate nursing care.

Survivor, conversion

The effect of robotic surgery on survival was examined in two studies. In one study, robotic surgery was not found to be significant in survival, while in another it was found to be more effective in five-year survival. Conversion was evaluated in six studies. Conversion was not required in two of the studies [21, 25]. In a study comparing robotic surgery and laparoscopic treatments, the conversion rate of robotic surgery to open surgery was found to be lower than laparoscopy [24]. Transitions from robotic surgery to laparotomy were observed in two studies [18, 23]. In a study evaluating the treatment of elderly and very elderly patients with robotic surgery, a total of seven patients were converted to open surgery [19]. Conversion is a new definition developed by minimally invasive surgery for nurses. The transformation from robotic surgery to laparotomy or open surgery is a new role for nursing.

Effectiveness of robotic surgery for gynecological patients

RAS (robot-assisted surgery) is a system in which robots are used in a minimally invasive surgery method. It functions under the guidance of robot surgeons [31]. It is argued that with an experienced and trained team, the effectiveness of robotic surgery will increase and eliminate complexity in difficult parts of the body [29, 31]. There are studies showing that robot-assisted surgery is safe and effective in gynecological patients [29, 32, 33]. According to the patient results in our review, it appears that robotic surgery can also be used in gynecological patients. However, when we compare the results with laparoscopic surgery, we cannot always say that robotic surgery is superior. This may vary depending on the type of surgery and patient characteristics (age, obesity).

Nursing care needs for gynecologic patients who underwent robotic surgery

The surgical center is a risky area of the hospital where critical decisions are made, where emergency or elective surgical diagnoses and treatments are made. Patient safety and comfort are considered the primary areas in robotic surgery. Organizing the perioperative period and continuity of care is the responsibility of the nurse. Robotic surgery has increased with technological advances, does not change the reality of care, which is the basic duty of the nurse. However, these practices may add different roles to nurses. In addition, nurses also play a role in robot management [1, 34].

The themes of our research, operation time, conversion and estimated blood loss, are the results that affect the intraoperative period. In our rapid review there are studies showing that robotic surgery prolongs the operation time and concluding that conversion to laparoscopy or open surgery has occurred. We conclude that the estimated blood loss is reduced more with robotic surgery. We believe that there is a need for nursing research intraoperative gynecological patients using robotic surgery.

Prolonged hospital stay, complications and pain are undesirable situations in the postoperative period. The solution of robotic surgery in these areas can increase the quality of nursing care and patient satisfaction.

Limitations

Rapid reviews are syntheses in which systematic reviews are simplified. However, it has been stated that it is useful for nurses in clinical practice [12]. Although the search, screening and abstraction stages were not carried out as meticulously as a systematic review, this study provides up-to-date information to nurses on the subject.

A further limitation was introduced by simplifying the search and screening steps, creating the risk of missing some relevant evidence. However, the initial decision-making process of the study and the inclusion of the articles were decided by two researchers in a face-to-face meeting. Additionally, the researchers’ expertise in the fields of nursing, surgical nursing, and gynecology nursing was effective in reducing the risk of bias.

Conclusion

The results show that robotic surgery can change the needs of patients by solving ongoing problems in gynecological patients. This requires a better understanding of robotic surgery procedures while facilitating nursing care over patient care.