We appreciate the opportunity to address the questions raised by Iavazzo et al regarding our recently published study entitled “Obesity and perioperative pulmonary complications in robotic gynecologic surgery.”

As Iavazzo et al stated, there is significant comorbidity between some types of gynecologic cancer and obesity, with 70-90% of patients with type I endometrial cancer also meeting criteria for obesity. We agree that patients undergoing robotic gynecologic surgery for treatment of oncologic conditions may spend more time in Trendelenburg position and may have longer operative times than patients undergoing robotic gynecologic surgery for benign indications. However, this was accounted for in our study in the multivariate analysis, which showed that neither operative time nor time in Trendelenburg position were associated with a higher rate of pulmonary complications. In fact, on this multivariate analysis, only older age was associated with a higher rate of pulmonary complications, with an odds ratio of 1.04 (95% confidence interval, 1.01–1.08).

In the subgroup analysis requested by Iavazzo et al, we found 54 patients who underwent robotic radical hysterectomy for treatment of cervical cancer. Of these patients, 9 experienced any complication (17.3%) and only 1 had a pulmonary complication (1.9%). We additionally found 240 patients who underwent robotic hysterectomy with pelvic and paraaortic lymphadenectomy for treatment of endometrial cancer. Of these patients, 34 had any complication (14.2%) and 6 had a pulmonary complication (2.5%). Given the small size of these subgroups, there is inadequate power to detect a statistical difference between these subgroups and patients undergoing surgery for benign indications. Nonetheless, the complication rates are similar to our overall study group (14% all-cause complication rate and 3% pulmonary complication rate), suggesting that there is no clinical difference between patients who undergo robotic gynecologic surgery for oncologic vs benign indications.