Appendix 1: Literature Search Strategies

APPENDICES

Appendix 1: Literature Search Strategies

Search date: Jun 24, 2014

Databases searched: Ovid MEDLINE, Ovid MEDLINE In-Process, Embase, All EBM Databases (see below)

Limits: 2009-current; English

Database: EBM Reviews - Cochrane Database of Systematic Reviews <2005 to May 2014>, EBM Reviews - ACP Journal Club <1991 to May 2014>, EBM Reviews - Database of Abstracts of Reviews of Effects <2nd Quarter 2014>, EBM Reviews - Cochrane Central Register of Controlled Trials <May 2014>, EBM Reviews - Cochrane Methodology Register <3rd Quarter 2012>, EBM Reviews - Health Technology Assessment <2nd Quarter 2014>, EBM Reviews - NHS Economic Evaluation Database <2nd Quarter 2014>, Embase <1980 to 2014 Week 25>, Ovid MEDLINE(R) <1946 to June Week 2 2014>, Ovid MEDLINE(R) In-Process & Other Non-Indexed Citations <June 23, 2014>

Search Strategy:

# / Searches / Results
1 / exp Hysterectomy/ / 72621
2 / (hysterectom* or colpohysterectom* or LAVH or TLH).ti,ab. / 64527
3 / or/1-2 / 93626
4 / Surgery, Computer-Assisted/ use mesz,acp,cctr,coch,clcmr,dare,clhta,cleed / 10179
5 / Computer Assisted Surgery/ use emez / 6364
6 / exp Specialties, Surgical/ use mesz,acp,cctr,coch,clcmr,dare,clhta,cleed / 156607
7 / exp Surgical Procedures, Operative/ use mesz,acp,cctr,coch,clcmr,dare,clhta,cleed / 2477488
8 / exp Surgery/ use emez / 3248581
9 / or/6-8 / 5845208
10 / Robotics/ / 36884
11 / 9 and 10 / 22070
12 / (((computer aid* adj2 surg*) or (computer assist* adj2 surg*) or (image guid* adj2 surg*) or davinci or da vinci or (robot* or telerobotic*)) adj2 surg*).mp. / 76837
13 / or/4-5,11-12 / 84826
14 / 3 and 13 / 1884
15 / Limit 14 to English language [limit not valid in CDSR, ACP Journal club, DARE, CLCMR; records were retained] / 1808
16 / limit 15 to yr="2009 -Current" [Limit not valid in DARE; records were retained] / 1520
17 / remove duplicates from 16 / 1236

Appendix 2: List of Excluded Studies

Author, year / Study title / Study design / Reason for exclusion
Fanning, 2008 / Robotic radical hysterectomy / Case series / No comparison group
Maggioni, 2009 / Robotic approach for cervical cancer: Comparison with laparotomy A case control study / Case control / Case control study; not part of our inclusion criteria for study design
Nezhat, 2009 / Laparoscopic Hysterectomy with and without a
Robot: Stanford Experience / Prospective with historic controls / Hysterectomy included benign conditions
Shashoua, 2009 / Robotic-Assisted Total Laparoscopic Hysterectomy Versus Conventional Total Laparoscopic Hysterectomy / Chart review / Hysterectomy included benign conditions
Pasic, 2010 / Comparing Robot-Assisted with Conventional Laparoscopic Hysterectomy: Impact on Cost and Clinical Outcomes / Retrospective database / Hysterectomy including benign conditions
Folkins, 2010 / Evaluation of vascular space involvement in
endometrial adenocarcinomas: laparoscopic
vs abdominal hysterectomies / Prospective cohort study / Outcome not of interest, vascular invasion
Sarlos, 2010 / Robotic hysterectomy versus conventional laparoscopic hysterectomy: Outcome and cost analyses of a matched case–control study / Prospective matched case–control study / Hysterectomy for benign conditions
Feuer, 2011 / Surgical technique enhances the efficiency of robotic hysterectomy / Retrospective cohort study / Hysterectomy for benign conditions, no comparison group
Krizova, 2011 / Histologic Artifacts in Abdominal, Vaginal, Laparoscopic, and Robotic Hysterectomy Specimens: A Blinded, Retrospective Review / Retrospective cohort study / No clinical outcome of interest. Retrospective histopathological review of 266 hysterectomy specimens
Landeen, 2011 / Clinical and Cost Comparisons for Hysterectomy via Abdominal, Standard Laparoscopic, Vaginal and Robot-Assisted Approaches / Retrospective / Reported hysterectomy for benign conditions
Anderson, 2012 / The First National Examination of Outcomes and
Trends in Robotic Surgery in the United States / Retrospective / Mixed population of both benign and malignant
Geller, 2012 / Analysis of Robotic Performance Times to Improve Operative Efficiency / Retrospective / No comparison group
Wright, 2012 / Comparative Effectiveness of Robotic Versus Laparoscopic Hysterectomy for Endometrial Cancer / Administrative database / Vaginal hysterectomy was not of interest
Lau, 2012 / Outcomes and cost comparisons after introducing a robotics program for endometrial cancer surgery. / Prospective with historic control / Unable to acquire data separately for the mixed population of comparison group
Göçmen, 2012 / Robot-assisted hysterectomy vs total laparoscopic
hysterectomy: a comparison of short-term surgical outcomes / Retrospective / Reported hysterectomy for benign conditions
Gallo,2012 / Robotic-Assisted Laparoscopic Hysterectomy:
Outcomes in Obese and Morbidly Obese Patients / Retrospective / Mixed population of both benign and malignant
Paraiso, 2013 / A randomized trial comparing conventional and robotically assisted total laparoscopic hysterectomy / Randomized controlled trial / Hysterectomy for benign conditions
Martínez-Maestre, 2013 / Total Laparoscopic Hysterectomy With and Without Robotic Assistance: A Prospective Controlled Study / Prospective cohort study / Hysterectomy for benign conditions

Appendix 3: Detailed Description of Intervention and Comparator

ENDOMETRIAL CANCER
Author, Year / Robotic Surgery / Comparator / Comments
Seamon, 2009 (5) / -Two primary surgeons performed all robotic surgeries
-Data was collected prospectively from all women who underwent robotic hysterectomy and lymphadenectomy from January 2006 to April 2008 / -Two primary surgeons performed all laparoscopic surgeries
-Retrospectively comparing consecutive laparoscopic hysterectomy and lymphadenectomy cases from January 1998 to December 2005, prior to the centers robotic experience / -No significant difference between the two groups in median age or uterine weight
-However, BMI for patients in the robotics group was significantly higher than patients undergoing laparoscopy (34 vs. 29, P<0.001).
Cardenas-Goicoechea, 2010 (6) / -Surgery was performed by a single board certified gynecologist oncologist at Pennsylvania Hospital from December 2007 to July 2009 using a robotic-assisted approach. / -Data from the same surgeon collected between January 2003 and December 2007 using a traditional laparoscopic approach. / -The groups were comparable in baseline characteristics including age, body mass index, medical and surgical histories, uterine weight, stage or tumor type suggesting the internal validity of comparison between the cohorts.
Martino, 2011 (7) / -Robotic surgeries were performed by one of three board-certified gynecologic oncologic surgeons (after completion of training on the da Vinci S surgical system) from September 2005 to June 2010. / -Laparoscopic surgeries were performed by one of three board-certified gynecologic oncologic surgeons from September 2005 to June 2010. / -There were no significant differences between the groups in age, BMI, clinical stage, and comorbidities.
Boruta, 2011 (8) / -48 women underwent robotic surgery between December 2008 through December 2010 / -121 women underwent laparoscopic surgery between December 2008 through December 2010 / -Clinical early-stage endometrial cancer at a single academic teaching hospital with an American Board of Obstetrics and Gynecology-approved fellowship in gynecologic oncology were identified.
Lim, 2011 (9) / -Data from 122 consecutive patients who underwent robotic surgery were prospectively collected from March 2008 to July 2010. / -Data from a historical cohort of first 122 patients who underwent laparoscopic surgery from August 1998 to March 2006. / -The laparoscopic procedure that was performed during this time reflected a true learning curve for the laparoscopic procedure as the surgeon had minimal laparoscopic training out of fellowship program.
Fagotti, 2012 (10) / -75 women with presumed early endometrial cancer between February 2009 and June 2011 / -75 women with presumed early endometrial cancer between February 2009 and June 2011 / -Parameters, such as operative time, estimated blood loss, and hospital stay were slightly better in the cohort of patients undergoing the laparoscopic procedure. However, these differences that appear to have minimal clinical significance, may be the result of selection bias.
Leitao, 2012 (11) / -9 surgeons who were recently trained to perform robotic surgery between May 2007 and December 2010. / -data of same 9 surgeons who were experienced in laparoscopic procedure were retrospectively abstracted. / -Assessment of clinical and economic impacts of RBT surgery should be done to evaluate how the rate of laparotomy is altered.
Escobar, 2012 (12) / -30 women who underwent robotically assisted laparoscopy from 2004 to 2008 / -30 women who underwent traditional laparoscopy from 2004 to 2008 / -All participating centers were teaching hospitals with comprehensive cancer centers. Residents and fellows were participants in all procedures.
-The study design and sample size can cause susceptibility to all biases. There was some variability in performance of lymphadenectomy, based on physician preference. However, the vast majority of the patients in this study (92%) had low-grade, stage IA/IB with low-risk factors for lymph node involvement, and therefore it was deemed reasonable to consider omitting lymphadenectomy in select cases.
Turunen, 2013 (13) / -Two surgeons performed all robotic surgeries
-From the time of introduction of robotic surgery into end of study – May 2009 through February 2013
-The surgeons completed a training program that included product training, a course in a surgical laboratory and case observations, before receiving robotic surgical privileges / -Same two surgeons performed all laparoscopic surgeries as well / -During the study period, an open approach was chosen for 10.7% of patients (n=26) treated by robotic surgeons, primarily when uterine size was considered too large for vaginal removal without morcellation.
-Pelvic lymph node dissection was performed for grade 1 – 2 endometrioid carcinomas; however, lymph node dissection was omitted in tumours with <50% myometrial invasion according to magnetic resonance imaging (MRI) (after Jan 2012).
Cardenas-Goicoechea, 2013 (14) / -187 women who underwent robot-assisted endometrial cancer staging performed by three board certified gynecologic oncologists at two institutions. / -245 women who underwent laparoscopic endometrial cancer staging performed by three board certified gynecologic oncologists at two institutions. / -Cases performed by one physician from Pennsylvania Hospital between December 2007 and April 2010 for robotic-assisted surgeries and between January 2003 and December 2007 for laparoscopic procedures. Similarly, all the robotic-assisted and laparoscopic procedures for endometrial cancer were collected for two physicians from White Plain Medical Center between May 2005 and December 2009.
Fagotti, 2013 (15) / -19 women underwent robotic assisted laparoscopy between December 2011 and January 2013 for the treatment of early endometrial cancer / -38 women with early endometrial cancer who underwent laparoscopic hysterectomy between December 2011 and January 2013 for treatment of early endometrial cancer at a different institution / -All women underwent class A radical hysterectomy and bilateral salpingo-oophorectomy without pelvic and para-aortic lymphadenectomy.
Author, Year / Robotic Surgery / Comparator / Comments
Lim, 2010 (24) / -Single surgeon performed robotic-assisted hysterectomy between March 2008 and July 2009 were prospectively collected. / -Comparators were open and laparoscopic surgery performed by the same surgeon immediately after fellowship training between August 1998 and June 2002. / -Significant difference was observed in intraoperative complications between robotic and laparoscopic procedures.
Nevadunsky, 2010 (16) / -66 women with endometrial cancer who underwent robotic hysterectomy between August 2006 and January 2009 / -43 women underwent total abdominal hysterectomy before minimally invasive techniques were utilized for staging of endometrial cancer at their institution (October 2003 to June 2005). / -All cases were performed by one of two gynecologic oncologists with one assistant of various levels of training including attending gynecologic oncologist, attending general gynecologist, gynecologic oncology fellow, and third year resident.
Paley, 2011 (17) / -377 women who underwent endometrial cancer staging with robotic surgery from May 2006 to December 2009.
-Robotic surgeries were performed by 5 surgeons with the da Vinci surgical system. / -131 women underwent abdominal hysterectomy. / -There were no significant differences in the group with respect to age, BMI, medical comorbidities, or number of previous abdominal surgeries.
Goel, 2011 (18) / -Robotic surgery was performed by one surgeon during June 2006–June 2008. / -Open surgery patients were also performed by the same surgeon and were operated between January 2003 and December 2005 / -Robotic surgery resulted in less blood loss and shorter hospital stay and yielded comparable number of lymph nodes, which were adequate for staging.
-There was no significant difference in other medical co-morbidities between these groups.
Subramaniam, 2011 (19) / -73 women underwent robotic surgery between March 2006 and March 2009. / - 104 women underwent open laparotomy for biopsy proven complex atypical hyperplasia or endometrial cancer between March 2006 and March 2009. / -All surgeries were performed by the gynecologic oncology attending.
-The choice of procedure was secondary to physician discretion and randomization was not employed.
Bernardini, 2012 (20) / -Data was prospectively collected on women who have undergone a robotic procedure between November 2008 and November 2010. / -Data was collected retrospectively from a historical cohort of morbidly obese women (at least class II) between 2006 and January 2009. / -Minimally invasive surgery was feasible in this population, reducing operative and postoperative complications, increasing assessment of lymph nodes, and reducing length of hospital stay.
Tang, 2012 (21) / -129 obese women underwent robotic assisted surgery from June 2007 through February 2010. / -110 consecutive historical controls undergoing staging via laparotomy from January 2005 through January 2010. / -All cases were performed in single community-based gynecologic oncology practice, consisting of 6 surgeons
Elshawi, 2012 (22) / -155 women underwent robotic-assisted surgical staging for endometrial cancer from September 2006 to September 2010. / -150 consecutive cases of endometrial cancer were surgically staged via a laparotomy from September 2006 to September 2010. / -Robotic surgery was done by a single surgeon and a different surgeon performed laparotomy during the same period.
Mok, 2012 (23) / -34 women underwent robot-assisted surgical staging starting in August 2008 / -90 women underwent open endometrial cancer staging during the same period and the year before the introduction of robotics for endometrial cancer staging. / -All eligible women who sought care at the National University Hospital were offered the option of robot-assisted cancer staging surgery.
-Patients opted for robotic surgery and were not selected based on any predetermined preoperative criteria.
- All surgeries, robotic and open, were performed by 3 surgeons
Coronado, 2012 (25) / -71 women with primary endometrial adenocarcinoma from 2007 to June 2011 / -84 women underwent laparoscopy and 192 by laparotomy from 2003 to June 2011. / -All approaches were performed by the same gynecologic oncologic team.
Estape, 2012 (26) / -102 consecutive patients underwent robotic total hysterectomy / -Historical cohorts of 104 patients undergoing laparoscopic and 78 patients undergoing abdominal total hysterectomy (laparotomy) / -Both minimally invasive approaches reduced morbidity. Robotic assistance resulted in improved lymph node yield.
-Triple comparison with the same surgeons performing all three types of surgeries.
Nevadunsky, 2012 (27) / -110 patients with primary surgical resection attempted by robotic surgery from inception of the robotics program (August 2006 to January 2009) / -123 underwent laparoscopic staging for endometrial cancer (June 2005 to January 2009)
-79 patients underwent abdominal hysterectomy staging of endometrial cancer at our institution (October 2003 to June 2005). / -All surgeries were performed by one of two surgeons.
CERVICAL CANCER
Author, Year / Robotic Surgery / Comparator / Comments
Maggioni, 2009 (30) / -Women with stages IA2–IIA cervical cancer undergoing robotically assisted laparoscopic procedure were performed at the European Institute of Oncology, Milan, Italy, between November 1, 2006 and February 1, 2009 / - Women with stages IA2–IIA cervical cancer compared with 40 historic controls who underwent abdominal radical hysterectomy / -
Geisler, 2010 (31) / -Robotically assisted laparoscopic radical hysterectomy for cervical cancer from January 2007 to June 2008. / -Previous 30 cases performed by open technique before the adoption of robotic techniques. / -
Cantrell, 2010 (32) / -63 consecutive women who underwent type III robotic radical hysterectomy (RRH) from June 2005 until July 31, 2008. / -A historical cohort of 64 patients who underwent type III radical hysterectomy by laparotomy from 1995 to 2007. / -The majority of robotic cases were performed by a single surgeon (94%), while the open cases were performed by six different gynecologic oncology surgeons.
-There was no statistically significant difference in progression-free (P=0.27) or overall (P=0.47) survival among the two groups.
Nam, 2010 (33) / -32 women with stage IA2YIIB cervical carcinoma underwent robotic radical hysterectomy between June 2006 and February 2009. / -Historic cohort of 32 women underwent abdominal radical hysterectomy / - All operations were completed robotically with no conversion to laparotomy
Schreuder, 2010 (34) / -13 women were operated with the use of the da Vinci robot between August 2006 and January 2008 / -14 women underwent an open radical hysterectomy between July 2004 and July 2006 / -All the operations were performed by the same surgical team
Go¨c¸men, 2010 (35) / -8 women underwent robotic assisted radical hysterectomy with pelvic lymphadenectomy between October 2008 and March 2010. / -7 women underwent abdominal radical hysterectomy with pelvic lymphadenectomy between October 2008 and March 2010. / -
Halliday, 2010 (36) / -16 women underwent robotic hysterectomy between January 2008 and December 2009 / -24 historic cohort of all cases of open radical hysterectomies performed at the same institution by the same team from March 2003 to December 2007 before the robotics program was implemented. / - All cases were performed by one of two surgeons, at a single institution. The surgical team consisted of at least one of the primary surgeons, a gynecologic oncology fellow or resident as bedside assistant or active surgeon, and a team of nurses dedicated to robotics.
Tinelli, 2011 (28) / -23 women with early cervical carcinoma who underwent robotic surgery between January 2003 and May 2010 / -76 women underwent total laparoscopic radical hysterectomy between January 2003 and May 2010 / -Disease free-survival showed no significant difference between the 2 groups (log-rank test, P = 0.29)
-No significant difference was found between the 2 groups when the recurrence rate was compared (P>0.05)
Sert, 2011 (37) / -35 patients underwent robot-assisted laparoscopic radical hysterectomy between November 2005 and November 2009 / -7 women underwent laparoscopic surgery between April 2004 and August 2005
-26 women underwent abdominal radical hysterectomy between March 2000 and March 2004 was also included for comparison / -All cases were performed by a single surgeon at a single academic center
Soliman, 2011 (38) / -34 consecutive women who underwent robotic radical hysterectomy from 2007 to 2010 were reviewed / -31 consecutive women who underwent laparoscopic radical hysterectomy from 2007 to 2010 were reviewed
-30 consecutive women who underwent open or abdominal radical hysterectomy from 2007 to 2010 were reviewed / -This is a single-institution study, the minimally invasive procedures were performed by 8 different faculty members with a broad range of minimally invasive surgery training and experience.
Wright, 2012 (39) / -67 women underwent robotic radical hysterectomy from 2006 to 2010 / -1610 and 217 women underwent laparoscopic and abdominal radical hysterectomy from 2006 to 2010 / -Data was collected from the perspective database. The Perspective database is a commercial data source developed to measure quality of care and resource utilization which includes samples from more than 500 acute-care hospitals throughout the USA
Chong, 2013 (29) / -50 consecutive women underwent robotic radical hysterectomy between January 2008 and March 2011 / -First 50 consecutive historic cohort of the patients who underwent nerve-sparing laparoscopic surgery between November 2003 and December 2006 / -All surgeries were completed by a single operator

Abbreviations: USA, United States of America; LP, laparoscopy; RB, robotic; OP, open; SD, standard deviation;