Abstrakt Gynekologie Červen 2009

“Robotic Gynecologic Surgery.”

Advincula, A. P. and A. G. Visco (2009).

Obstet Gynecol 114(1): 168-169.

“Robotics in gynecologic surgery.”

Frick, A. C. and T. Falcone (2009).

Minerva Ginecol 61(3): 187-99.

Robotic surgery has evolved from an investigational surgical approach to a clinically useful adjunct in multiple surgical specialties over the past decade. Advocates of robotic-assisted gynecologic surgery revere the system’s wristed instrumentation, ergonomic positioning, and three-dimensional high-definition vision system as significant improvements over laparoscopic equipment’s four degrees of freedom and two-dimensional laparoscope that demand the surgeon stand throughout a procedure. The cost, lack of haptic feedback, and the bulky size of the equipment make robotics less attractive to others. Studies evaluating outcomes in robotic-assisted gynecologic surgery are limited. Multiple small retrospective studies demonstrate the safety and feasibility of robotic hysterectomy. With increased surgeon experience, operative times are similar to, or shorter than, laparoscopic cases. Robotic assistance can facilitate suturing in laparoscopic myomectomies, and is associated with decreased blood loss and a shorter hospital stay, although may require longer operative times. Robotic assistance has also been applied to multiple procedures in the subspecialties of infertility, urogynecology and gynecologic oncology with good success and relatively low morbidity. However, further research is warranted to better evaluate the relative benefits and costs of robotic assisted gynecologic surgery.

“Robotic repair of complex vesicouterine fistula with and without hysterectomy.”

Hemal, A. K., N. Sharma, et al. (2009).

Urol Int 82(4): 411-5.

OBJECTIVE: To present robotic repair of vesicouterine fistulae (VUF) with and without hysterectomy in 3 cases and to discuss the technique with its outcome. METHODS: Three patients were diagnosed with VUF, of whom 2 had a prior history of multiple cesarean sections and 1 had obstructed labor. Preoperative diagnosis of VUF was based on classic history, cystoscopy and imaging studies. All patients underwent pure robotic repair of VUF with hysterectomy in 1 case. The steps of the technique are cystoscopy, bilateral ureteral catheterization, port placement, adhesiolysis, separation of bladder and uterus and excision of the VUF with freshening of margins, closure of the uterus and bladder, hysterectomy in 1 case, and omental interposition. RESULTS: Robotic repair of VUF was successful in all cases with mean operative time of 127.5 min and average blood loss of 120 ml. One patient underwent simultaneous robotic hysterectomy. All patients were ambulatory on day 1 and were discharged on day 3 with indwelling Foley’s catheter, which was removed on day 10. conclusion: Robotic repair of VUF is safe and effective with successful outcome in all cases and has all the advantages of open and laparoscopic surgery. If required, concomitant robotic hysterectomy can also be performed. This is the first case series in the world.

“Robot-assisted laparoscopic surgery in gynecology: scientific dream or reality?”

Nezhat, C., O. Lavie, et al. (2009).

Fertil Steril 91(6): 2620-2.

OBJECTIVE: To analyze the feasibility, safety, advantages, and disadvantages of using robotic technology for gynecologic surgeries in a large group of patients. DESIGN: Retrospective study (Canadian Task Force classification II-3). SETTING: Tertiary endoscopic referral centers. PATIENT(S): Eighty-seven patients requiring laparoscopic treatments for benign gynecologic conditions. INTERVENTION(S): Charts reviewed from robotic-assisted gynecologic operative laparoscopies. MAIN OUTCOME MEASURE(S): Length of surgery, time for robot assembly and disassembly, rate of conversion to laparotomies, and complications. RESULT(S): Between January 2006 and August 2007, 137 robotically assisted gynecologic procedures were performed in 87 patients. The da Vinci Surgical System was used. The average length of the surgeries was 205 minutes (60-420 minutes). Assembly of the robot lasted 16 minutes (10-27 minutes) when disassembly took 2.5 minutes (2-6 minutes). There were no conversions to laparotomy. There were three complications. CONCLUSION(S): Robotic-assisted technology, in its present state, is enabling more surgeons to perform endoscopic surgery. Its advantages are 3D Vision and a faster learning curve for suturing and operating while sitting. It’s an exciting enabling technology with a great future.

“Update on laparoscopic, robotic, and minimally invasive vaginal surgery for pelvic floor repair.”

Ross, J. W. and M. R. Preston (2009).

Minerva Ginecol 61(3): 173-86.

Advanced laparoscopic surgery marked the beginning of minimally invasive pelvic surgery. This technique lead to the development of laparoscopic hysterectomy, colposuspension, paravaginal repair, uterosacral suspension, and sacrocolpopexy without an abdominal incision. With laparoscopy there is a significant decrease in postoperative pain, shorter length of hospital stay, and a faster return to normal activities. These advantages made laparoscopy very appealing to patients. Advanced laparoscopy requires a special set of surgical skills and in the early phase of development training was not readily available. Advanced laparoscopy was developed by practicing physicians, instead of coming down through the more usual academic channels. The need for special training did hinder widespread acceptance. Nonetheless by physician to physician training and society training courses it has continued to grow and now has been incorporated in most medical school curriculums. In the last few years there has been new interest in laparoscopy because of the development of robotic assistance. The 3D vision and 720 degree articulating arms with robotics have made suture intensive procedures much easier. Laparosco-pic robotic-assisted sacrocolpopexy is in the reach of most surgeons. This field is so new that there is very little data to evaluate at this time. There are short comings with laparoscopy and even with robotic-assisted procedures it is not the cure all for pelvic floor surgery. Laparoscopic procedures are long and many patients requiring pelvic floor surgery have medical conditions preventing long anesthesia. Minimally invasive vaginal surgery has developed from the concept of tissue replacement by synthetic mesh. Initially sheets of synthetic mesh were tailored by physicians to repair the anterior and posterior vaginal compartment. The use of mesh by general surgeons for hernia repair has served as a model for urogynecology. There have been rapid improvements in biomaterials and specialized kits have been developed by industry. The purpose of this article is to present an update in urogynecologic laparoscopy, robotic surgery, and minimally invasive vaginal surgery.

“Robotic gynecologic surgery.”

von Gruenigen, V. E. and W. W. Hurd (2009).

Obstet Gynecol 114(1): 168.

“Erratum: Robotic gynecologic surgery: A brave new world (Obstetrics and Gynecology (2008) 112 (1198-1200)).”

Whiteside, J. L. (2009).

Obstetrics and Gynecology 113(2 PART 1): 438.

“Advances in surgical management of cervical cancer.”¨

Ercoli, A., V. Iannone, et al. (2009).

Minerva Ginecol 61(3): 227-37.

Cervical cancer (CC) remains an important health problem representing the second most frequent malignancy in women, with 470 000 new cases/year and 280 000 deaths, 80% of which occur in developing countries. In the last few years, new theoretical developments and advances in technology resulted in novel surgical approaches aimed at improving the therapeutic efficacy and/or reducing treatment related side effects. In particular, the authors focused their attention on the most relevant novelties related to the laparoscopic approach to CC treatment, and on the issue of modulation of surgical radicality. Moreover, the possible perspectives of sentinel lymph node concept and robotic surgery, as well as clinical issues related to conservative procedures including ”nerve sparing” and ”fertility sparing” strategies, have been evaluated.

“A case matched analysis of robotic radical hysterectomy with lymphadenectomy compared with laparoscopy and laparotomy.”

Estape, R., N. Lambrou, et al. (2009).

Gynecol Oncol 113(3): 357-61.

OBJECTIVE: To compare robotic radical hysterectomy to laparoscopic and radical abdominal hysterectomy in the treatment of cervical cancer. METHODS: Prospective analyses of thirty-two consecutive patients undergoing robotic radical hysterectomy were compared to 17 patients undergoing laparoscopic radical hysterectomy and 14 patients undergoing radical abdominal hysterectomy. RESULTS: Operative time for the robotic group was 2.4 h+/-0.8 and not significantly different from the laparoscopic group at 2.2 h+/-0.7, nor the laparotomy group (1.9 h+/-0.6, p=0.05). The estimated blood loss for patients undergoing robotic hysterectomy was 130 cm(3) +/-119.4. This was significantly less than the laparotomy group (621.4 mL+/-294.0, p<0.0001), but not the laparoscopic group (209.4 mL+/-169.9, p=0.09). The robotic group had an average of 32.4 total nodes retrieved, as compared to 18.6 and 25.7 nodes retrieved in the laparoscopy and laparotomy cohorts, respectively. All differences were significant (p<0.0001 and p<0.05). Mean length of hospital stay was 2.6, 2.3 and 4.0 days in the robotic, laparoscopic, and laparotomy cohorts respectively. The incidence of postoperative complications was less in the robotic cohort (18.8%) as compared to the laparoscopic (23.5%), and laparotomy cohorts (28.6%). CONCLUSIONS: Robotic total laparoscopic radical hysterectomy with pelvic and para-aortic lymphadenectomy is feasible and may be preferable over laparoscopic or radical abdominal hysterectomy.

“Robotic Surgery: Changing the Surgical Approach for Endometrial Cancer in a referral Cancer Center.”

Peiretti, M., V. Zanagnolo, et al.

Journal of Minimally Invasive Gynecology.

Study Objective: To study the effect of robotic surgery on the surgical approach to endometrial cancer in a gynecologic oncology center over a short time. Design: Prospective analysis of patients with early-stage endometrial cancer who underwent robotic surgery. Setting: Teaching hospital. Patients: Eighty patients who underwent robotic surgery. Interventions: Between November 2006 and October 2008, 80 consecutive patients with an initial diagnosis of endometrial cancer consented to undergo robotic surgery at the European Institute of Oncology, Milan, Italy. Measurements and Main Results: We collected all patient data for demographics, operating time, estimated blood loss, histologic findings, lymph node count, analgesic-free postoperative day, length of stay, and intraoperative and early postoperative complications. Mean (SD) patient age was 58.3 (11.5) years (95% confidence interval [CI], 55.7-60.9). Body mass index was 25.2 (6.1) kg/m2 (95% CI, 23.6-26.7). In 3 patients (3.7%), conversion to conventional laparotomy was required. Mean operative time was 181.1 (63.1) minutes (95% CI, 166.7-195.5). Mean docking time was 4.5 (1.1) minutes (95% CI, 2.2-2.7). Mean hospital stay was 2.5 (1.1) days (95% CI, 2.2-2.7), and 93% of patients were analgesic-free on postoperative day 2. Conclusions: Over a relatively short time using the da Vinci surgical system, we observed a substantial change in our surgical activity. For endometrial cancer, open surgical procedures decreased from 78% to 35%. Moreover, our preliminary data confirm that surgical robotic staging for early-stage endometrial cancer is feasible and safe. Age, obesity, and previous surgery do not seem to be contraindications. © 2009 AAGL.

“Robotic radical hysterectomy: A new standard of care?”

Ramirez, P. T. (2009).

Future Oncology 5(1): 23-25.

Minimally invasive surgery has been shown to be associated with a number of advantages to the patient, such as lower blood loss, lower transfusion rates, lesser requirements of pain medications, quicker return of bowel function and a shorter recovery period, as well as earlier resumption of daily activities. More recently, robotic surgery has become increasingly popular among gynecologic oncologists who perform minimally invasive surgery. Robotic surgery has allowed surgeons to be able to offer patients the same benefits of laparoscopy, while being able to perform procedures that require advanced surgical skills. This retrospective study showed that robotic radical hysterectomy was associated with less blood loss and a shorter length of stay compared with the open approach. In addition, the authors showed that intraoperative and postoperative complications were comparable. © 2009 Future Medicine.

“Comprehensive Surgical Staging for Endometrial Cancer in Obese Patients: Comparing Robotics and Laparotomy.”

Seamon, L. G., S. A. Bryant, et al. (2009).

Obstet Gynecol 114(1): 16-21.

OBJECTIVE:: To compare adequacy and outcomes of surgical staging for endometrial cancer in obese women by robotics or laparotomy. METHODS:: Clinical stage I or occult stage II endometrial cancer patients with body mass indexes (BMIs) of at least 30 (BMI is calculated as weight (kg)/[height (m)]) were identified undergoing robotic staging and matched 1:2 with laparotomy patients. Patient characteristics, operative times, complications, and pathologic factors were collected. An adequate lymphadenectomy was defined arbitrarily as at least 10 total nodes removed, and adequate pelvic and paraaortic lymphadenectomy was defined as at least six and at least four nodes removed, respectively. RESULTS:: A total of 109 patients underwent surgery with the intent of robotic staging and were matched to 191 laparotomy patients. The mean BMI was 40 for each group. The robotic conversion rate was 15.6% (95% confidence interval [CI] 9.5-24.2%). Ninety-two completed robotic patients were compared with 162 matched laparotomy patients. The two groups were comparable regarding total lymph node count (25+/-13 compared with 24+/-12, P=.45) and the percentage of patients undergoing adequate lymphadenectomy (85% compared with 91%, P=.16) and adequate pelvic (90% compared with 95%, P=.16) and aortic lymphadenectomy (76% compared with 79%, P=.70) for robotic and laparotomy patients, respectively, but there was limited power to detect this difference. The blood transfusion rate (2% compared with 9%, odds ratio [OR] 0.22, 95% CI 0.05-0.97, P=.046), the number of nights in the hospital (1 compared with 3, P<.001), complications (11% compared with 27%, OR 0.29, 95% CI 0.13-0.65 P=.003), and wound problems (2% compared with 17%, OR 0.10, 95% CI 0.02-0.43, P=.002) were reduced for robotic surgery. CONCLUSION:: In obese women with endometrial cancer, robotic comprehensive surgical staging is feasible. Importantly, obesity may not compromise the ability to adequately stage patients robotically. LEVEL OF EVIDENCE:: II.

“A detailed analysis of the learning curve: Robotic hysterectomy and pelvic-aortic lymphadenectomy for endometrial cancer.”

Seamon, L. G., J. M. Fowler, et al. (2009).

Gynecol Oncol 114(2): 162-7.

OBJECTIVE: To define the learning curve for robotic hysterectomy and pelvic-aortic lymphadenectomy for endometrial carcinoma. METHODS: Patient demographics and segmental operative times on all patients at one institution who underwent robotic comprehensive surgical staging (hysterectomy, pelvic and aortic lymphadenectomy) for endometrial cancer were prospectively collected. Patients were arranged in order based on surgery date and outcomes were compared between quartiles (cases 1-20, 21-40, 41-60, and 61-79). Proficiency was defined as the point at which the slope of the curve becomes less steep for operative times. Efficiency was defined as the point at which the slope is zero. ANOVA or Fisher’s exact test was used to compare the procedure times. Locally weighted regression generated smoothed lines that represent operative time over the sequence of the operations. RESULTS: 79 patients were comprehensively staged robotically. While age, the percentage of patients with >/=2 co-morbidities, number of patients with previous laparotomy, EBL, LOS and lymph node counts do not differ between groups, the first 20 patients had a lower BMI compared to the next 20 (27 vs. 34 kg/m(2), P=0.009). Operative times decreased from the first 20 cases to next 20, but was not significantly changed over the next three quartiles. Each component of the procedure has a separate learning curve. CONCLUSIONS: Proficiency for robotic hysterectomy with pelvic-aortic lymphadenectomy for endometrial cancer is achieved after 20 cases; however, the number of procedures to gain efficiency varies for each portion of the case and continues to improve over time.