Robotic nipple-sparing mastectomy for cancer risk reduction: demonstration of applicability and surgical results

In recent years, nipple-sparing mastectomy is increasingly being used for both risks reducing surgery and cancer treatment.1 2 The aesthetic aspect that comes from it, made new surgical techniques to be thought of for a better result. Small incisions, oncoplastic techniques, endoscopic techniques, and even robotics are being practiced providing the best aesthetic result.

Robotic surgery has been a great advance in all surgical areas. Numerous studies in recent years have demonstrated the benefits of this technique, especially in urological, gynecological, and coloproctological surgeries.

In the field of mastology, robotic nipple sparing mastectomy (RNSM) is performed by few surgeons in the world, who are already reporting on articles better aesthetic results and fewer complications compared to the open mastectomy technique. At the European Institute of Oncology, in Milan, breast surgery robots have been a reality since 2015. The creator of the technique, Dr. Antonio Toesca, made it possible for us to learn the surgery, and we decided to bring this new oncological treatment tool.5 6

The first robotic surgery in Latin America was performed on January 29^th, 2019 at Hospital Erasto Gaertner by a team led by the mastologist José Clemente Linhares. By December 2020, four robotic surgeries were performed.

The purpose of this article is to describe the surgical technique, demonstrate the aesthetic results, complications of RNSM, and spread the knowledge of this new technique.

The study was approved by the research ethics committee of the Erasto Gaertner Hospital, opinion number 5,046,233. The participants who met the inclusion criteria and agreed to participate in the study signed the informed consent form, thus agreeing to have their information used, maintaining the confidentiality of not being identified.

For the surgery, we determined that the breast should be small or medium volume and with ptosis up to grade 2 by Regnault classification, all surgeries being risk-reducing. We performed prior to the surgeries, mammograms, and MRI scans to establish that the patients were probably not breast cancer at the time of surgery.

In total, there were four patients who underwent risk-reducing NSRM. The first was due to mutation of the CHEK2 gene, the second due to mutation of BRCA1, the third surgery due to BRCA2, and the last one due to mutation in the RAD51 gene.

So on clinical analysis, on the recommendation of the geneticist at Hospital Erasto Gaertner, adenomastectomy was indicated. Three of these patients had unilateral robotic nipple sparing mastectomy and only one had bilateral surgery (Figures 3, 4, 5, 6, 7 and 8).

The initial duration of surgery, from patient positioning, incision and allocation of the robotic arms was reduced from 01h20min in the first surgery to 35 min in the last one. Related to mammary gland extirpation, it took about 5hrs in the first unilateral adenomastectomy surgery to 01h45min in the last one for the same type of surgery. In total, the first surgery took 06h20mmin to 3h in the last one (Figure 9).

No serious complications were observed, such as prosthesis loss, extrusion or infection, nipple necrosis or suture dehiscence. In two surgeries, we found burns on the skin caused by electrocautery. These, however, were resolved within weeks, with no need for surgical intervention. We did not see complications such as seroma, hematoma, significant pain, infection, or subcutaneous emphysema due to carbon dioxide.

Skin and nipple preserving mastectomy via open technique as oncologic treatment is widely accepted. For surgeons, this technique incites several questions. The first challenging point of the surgery is the technical difficulty, that even through large incisions, access to quadrants distant from the incision is difficult, with the risk that resection of the entire breast parenchyma will not occur. The second topic observed are the complication rates that can reach up to 50% of the surgeries, as demonstrated in the article by Endara et al. (2013),1 such as skin and areola-papillary complex necrosis, extrusion of the prosthesis and other minor ones, such as hypertrophic scars and keloids.

The innovative technique of robotic breast surgery is described in several articles by Italian, French, and Taiwanese authors, which demonstrate its oncological safety, and is available in scientific journals and newspapers worldwide.5-8

It was essential to observe in loco the robotic mastectomy at the European Institute of Oncology since there are many details to be considered in its execution. At the oncogynecology and mastology department of the Hospital Erasto Gaertner, robotic surgery is offered for several neoplasms, a fact that provided a quick adaptation to the RNSM technique, without the need for a learning curve in robotic surgery.

The robotic mastectomy surgery has the advantage of lower complication rates because there is no ischemia and skin trauma caused by retractors in relation to open surgery, and the insufflation of carbon dioxide is sufficient to visualize the mammary gland, making it possible to safely dissect all quadrants of the breast, even those that are far from the incision.

Other advantages are the tenfold magnification of the surgical field, the correction of the delicate movements performed by the robot, and the fact that the operation is more comfortable for the surgeon and the entire surgical team. Undoubtedly the main benefit is aesthetic, and the scar in the axillary region, far from the breast, is the most positive factor pointed out by patients. The main disadvantage is still the higher cost than open surgery.

Complication rates are low, as demonstrated by Lai et al. (2019)8 who, analyzing their case series, evidenced the highest complication rate being transient nipple ischemia (10.3%), but no nipple necrosis or prosthesis loss. Safarti et al. (2018),7 on the other hand, reported a prosthesis loss due to infection (1.6%). Of these articles, no nipple necrosis or prosthesis extrusion occurred.7 8

In the cases operated on at the Hospital Erasto Gaertner, the aesthetic results were very well evaluated both by the patients and by the plastic surgery and mastology teams. Minor complications were resolved within weeks, maintaining an excellent outcome. The learning curve of the robotic technique was extremely fast, with an important reduction of surgical time.

We believe that innovative robotic surgery can contribute to the advancement of breast surgery in the world. The excellent aesthetic results were very satisfactory in the immediate and late postoperative period. The drastic reduction in the surgical time of the first in relation to the last RNSM demonstrates the ease of learning the technique. This article may contribute to further studies on robotic breast surgery and encourage new surgeons to perform the technique.