Abstrakt Gynekologie Květen 2010

“Minimally invasive approach for myomectomy.”

Agdi, M. and T. Tulandi (2010).

Seminars in Reproductive Medicine 28(3): 228-234.


Uterine fibroids are the most common benign tumor of the uterus in women of reproductive age. However, most of them are asymptomatic and do not require any treatment. Menorrhagia and pelvic pain are the most usual symptoms, and some women may present with infertility or pregnancy-related complications. In those with abnormal uterine bleeding, one should exclude other causes of abnormal vaginal bleeding including endometrial cancer. Diagnosis of uterine fibroid is established by pelvic ultrasonography with or without saline infusion hysterosonography. Management options depend on the patient’s fertility potential and desire for future pregnancy. Submucous myoma should be treated by a hysteroscopic approach. Intramural and subserous myomas in women who opt for nonsurgical treatment could be treated with uterine artery embolization (UAE), high-intensity focused ultrasound (HIFU), or medical treatment such as selective gonadotropin-releasing hormone agonists, progesterone receptor modulators, or aromatase inhibitors. All interventions aside from hysterectomy provide temporary relief, although myomectomy, UAE, and HIFU provides more durable symptom relief relative to current medical management. Patients wishing to preserve their fertility are best treated by myomectomy, which can be done by laparoscopy. A laparoscopic approach is more advantageous than laparotomy, but laparoscopic suturing is more demanding. This can be overcome by robotic-assisted laparoscopic myomectomy.




“Hysterectomy or a minimal invasive alternative? A systematic review on quality of life and satisfaction.”

Brölmann, H. A. M., A. J. BijdeVaate, et al. (2010).

Gynecological Surgery: 1-6.


Nowadays, an increasing number of minimal invasive treatment alternatives to hysterectomy may be offered to the patient. In determining the appropriate treatment option, the patient has a distinct dilemma if a minimal invasive treatment with lesser effect than hysterectomy should be chosen or if a hysterectomy should be chosen which is a major surgery and requires longer recovery than the minimal invasive alternative. Quality-of-life (QoL) questionnaires that take subjective health perception into account are currently used to assess the treatment effects. The objective of this literature study is to determine and discuss the role of QoL as an outcome in randomized controlled trials (RCT) or systematic reviews of RCTs that study the treatment effect of hysterectomy compared to that of minimal invasive alternatives. A systematic literature search was performed in the PubMed database and in the Cochrane database to find randomized trials and systematic reviews of randomized trials, comparing hysterectomy with minimal invasive or conservative treatment options with sufficient follow-up using satisfaction, health status, and quality of life as outcomes. The results were based on nine randomized trials and two systematic reviews. The differences are mostly in favor of hysterectomy. In two out of four studied treatment alternatives, the satisfaction or health status is different in favor of hysterectomy while the QoL is equivalent. After 2 years of follow-up, differences between both groups have disappeared, possibly because of the crossover effect. Possible reasons for the lesser response of QoL compared to satisfaction or health status are discussed. The fundamental question if patients have a better quality of life at all times if they choose for a minimal invasive alternative of hysterectomy remains unresolved. Information, individualization, and freedom of choice before surgery probably best serve the sense of well being and quality of life thereafter. © 2010 The Author(s).




“Use of a bidirectional barbed suture in robot-assisted sacrocolpopexy.”

Ghomi, A. and R. Askari (2010).

Journal of Robotic Surgery: 1-3.


Abdominal sacrocolpopexy is an effective and durable surgical procedure that is conventionally reserved for management of vaginal vault prolapse. With the availability of robotic technology in recent years, sacrocolpopexy has become more commonly performed in a minimally invasive fashion. Peritoneal closure can be a tedious and time-consuming step in robot-assisted sacrocolpopexy. We describe a novel technique utilizing a bidirectional barbed suture to re-approximate the peritoneum in robot-assisted sacrocolpopexy, making the procedure more time-efficient. © 2010 Springer-Verlag London Ltd.




“Is robotic sacrocolpopexy a marketing gimmick or a technological advancement?”

Kim, J. H. and J. T. Anger (2010).

Current Opinion in Urology.


PURPOSE OF REVIEW: Robot-assisted laparoscopic sacrocolpopexy (RALS) is a new surgical technique for the treatment of symptomatic vaginal vault prolapse that is rapidly gaining popularity among both urologists and gynecologists. This article will summarize the available published data to assess the potential advantages and disadvantages of this new procedure and its current role in female pelvic floor reconstruction. RECENT FINDINGS: The literature on RALS is limited mainly to single-institution retrospective studies, which suggest minimal morbidity, technical feasibility, and short-term efficacy comparable to open abdominal sacrocolpopexy. What remains uncertain is whether this approach will be superior to the other established minimally invasive transvaginal and laparoscopic approaches in terms of subjective and objective outcomes and quality of life. Other relevant issues, such as overall cost-effectiveness and extended application for multicompartment defects and uterine-sparing procedures, remain largely unexplored. SUMMARY: The use of RALS will likely continue to expand secondary to increased access and the popularity of the robotic apparatus among both surgeons and patients. Well designed large randomized multicenter comparative studies based on validated measurement instruments are needed to evaluate its advantage over conventional approaches, including open abdominal sacrocolpopexy and various transvaginal and laparoscopic techniques.




“Use of Anti-Skid Material and Patient-Positioning To Prevent Patient Shifting during Robotic-Assisted Gynecologic Procedures.”

Klauschie, J., M. E. Wechter, et al. (2010).

Journal of Minimally Invasive Gynecology.


STUDY OBJECTIVE: To estimate patient shifting with the current practice of use of an antiskid material and patient positioning during robotic procedures in gynecology. DESIGN: Pilot observational study (Canadian Task Force classification). SETTING: Tertiary referral center. PATIENTS: Twenty-two women undergoing robotic-assisted gynecologic procedures. INTERVENTION: Antiskid material (egg-crate pink foam) was placed beneath patients and patient positioning was used during robotic-assisted procedures. MEASUREMENTS AND MAIN RESULTS: Patient position was marked before and after surgery. Measurements of shift distance before and after surgery were determined for each patient. Median (range) shift distance was 1.3 (0-7.5) cm. There was no significant association between shift in position and either body mass index or duration of the Trendelenburg position. No shoulder neuropathic injuries were observed during the study. CONCLUSION: Minimal patient shifting is observed with the use of an antiskid material and patient positioning described, without the use of shoulder braces and straps.




“Robotic versus standard laparoscopy for the treatment of endometriosis.”

Nezhat, C., M. Lewis, et al. (2010).

Fertility and Sterility.


Objective: To compare robot assisted laparoscopic platform to standard laparoscopy for the treatment of endometriosis. Design: A retrospective cohort controlled study. Setting: Tertiary referral center. Patient(s): Seventy-eight reproductive aged women. Intervention(s): Robot assisted or standard laparoscopy for the treatment of endometriosis between January 2008 and January 2009. Main Outcome Measure(s): Operative time, estimated blood loss, hospitalization time, intraoperative and postoperative complications. Result(s): Seventy-eight patients underwent treatment of endometriosis, 40 by robot assisted laparoscopy and 38 by standard laparoscopy. The two groups were matched for age, body mass index (BMI), stage of endometriosis, and previous abdominal surgery. Mean operative time with the robot was 191 minutes (range 135-295 minutes) compared with 159 minutes (range 85-320 minutes) during standard laparoscopy. There were no significant differences in blood loss, hospitalization, intraoperative or postoperative complications. There were no conversions to laparotomy. Conclusion(s): Both robot assisted laparoscopic and standard laparoscopic treatment of endometriosis have excellent outcomes. The robotic technique required significantly longer surgical and anesthesia time, as well as larger trocars. © 2010 American Society for Reproductive Medicine.




“A pilot study to assess the feasibility, safety and cost of robotic assisted total hysterectomy and bilateral salpingo-oophorectomy.”

Raju, K. S., A. J. Papadopoulos, et al. (2010).

Journal of Robotic Surgery: 1-4.


The aim of this study was to evaluate the safety, feasibility and cost-effectiveness of robotic assisted total hysterectomy and bilateral salpingo-oophorectomy (RATHBSO). Sixteen women underwent this new procedure for a variety of gynaecological indications. Outcome measures included operating time, estimated blood loss, length of hospital stay and cost. No intra-operative complications were recorded. Fifteen patients were discharged on day 1 following the procedure, and one patient stayed an extra day for pain relief. The cost of the procedure compared favourably with other surgical hysterectomy techniques. We conclude that RATHBSO is a feasible and safe surgical technique with all the advantages of minimal access surgery and equivalent cost. © 2010 Springer-Verlag London Ltd.




“Robotic hysterectomy versus conventional laparoscopic hysterectomy: outcome and cost analyses of a matched case-control study.”

Sarlos, D., L. Kots, et al. (2010).

European Journal of Obstetrics, Gynecology, and Reproductive Biology 150(1): 92-96.


OBJECTIVE: Robotic surgery, with its technical advances, promises to open a new window to minimally invasive surgery in gynaecology. Feasibility and safety of this surgical innovation have been demonstrated in several studies, and now a critical analysis of these new developments regarding outcome and costs is in place. So far only a few studies compare robotic with conventional laparoscopic surgery in gynaecology. Our objective was to evaluate our initial experience performing total robot-assisted hysterectomy with the da Vinci surgical system and compare peri-operative outcome and costs with total laparoscopic hysterectomy. STUDY DESIGN: For this prospective matched case-control study at our institution, peri-operative data from our first 40 consecutive total robot-assisted hysterectomies for benign indications were recorded and matched 1:1 with total laparoscopic hysterectomies according to age, BMI and uterus weight. Surgical costs were calculated for both procedures. Surgeons’ subjective impressions of robotics were evaluated with a self-developed questionnaire. RESULTS: No conversions to laparotomy or severe peri-operative complications occurred. Mean operating time was 109 (113; 50-170) min for the robotic group and 83 (80; 55-165) min for the conventional laparoscopic group. Mean postoperative hospitalisation for robotic surgery was 3.3 (3; 2-6) days versus 3.9 (4; 2-7) days for the conventional laparoscopic group. Average surgical cost of a robot-assisted laparoscopic hysterectomy was 4067 euros compared to 2151 euros for the conventional laparoscopic procedure at our institution. For the robotic group wider range of motion of the instruments and better ergonomics were considered to be an advantage, and lack of direct access to the patient was stated as a disadvantage. CONCLUSION: Robot-assited hysterectomy is a feasible and interesting new technique with comparable outcome to total laparoscopic hysterectomy. Operating times of total laparoscopic hysterectomy seem to be achieved quickly especially for experienced laparoscopic surgeons. However, costs of robotic surgery are still higher than for conventional laparoscopy. Randomised clinical trials need to be conducted to further evaluate benefits of this new technology for patients and surgeons and analyse its cost-effectiveness in gynaecology.




“Extragenital endometriosis.”

Veeraswamy, A., M. Lewis, et al. (2010).

Clinical Obstetrics and Gynecology 53(2): 449-466.


In recent years, there have been significant changes in many aspects of extragenital endometriosis ranging from the epidemiology to the management of the disease. Advances in minimally invasive surgery and expansion of the field have lead to further research in management of extragenital endometriosis. As a result, treatment has shifted from medical management toward a surgical, multidisciplinary approach. Surgery for extragenital endometriosis clearly improves outcome through relief of symptoms, improved quality-of-life, increased fertility rates, and reduced recurrences. Endoscopy has a pivotal role as both a diagnostic and therapeutic tool.




“A trainee’s point of view.”

Balasubramani, L., D. Kolomainen, et al. (2010).

BJOG: An International Journal of Obstetrics and Gynaecology 117(7): 896.




“Robotic-assisted laparoscopic exenteration in recurrent cervical cancer Robotics improved the surgical experience for 2 women with recurrent cervical cancer.”

Davis, M. A., S. Adams, et al. (2010).

American Journal of Obstetrics and Gynecology 202(6): 663 e661.


Pelvic exenteration can be used to cure women with a central pelvic recurrence or persistence of gynecologic malignancy after initial definitive therapy. Refinements in patient selection, operative techniques, and surgical instrumentation have significantly improved outcomes over the past 60 years, but the procedure is still associated with significant mortality, morbidity, and recovery time. New technologies have made it possible to approach radical gynecologic surgeries in a minimally invasive fashion. We present 2 patients successfully treated with robotic-assisted anterior pelvic exenteration for treatment of persistent or recurrent cervical cancer after definitive radiotherapy.




“Robotically assisted laparoscopic radical hysterectomy compared with open radical hysterectomy.”

Geisler, J. P., C. J. Orr, et al. (2010).

International Journal of Gynecological Cancer 20(3): 438-442.


BACKGROUND: Radical hysterectomy is a common and effective treatment of early cervical cancer. Modern advances include the use of robotic assistance to perform equivalent minimally invasive procedures. The purpose was to compare surgical and short-term outcomes, as well as margins, between robotic-assisted laparoscopic radical hysterectomy and open radical hysterectomy. METHODS: The first 30 cases of robotically assisted type III radical hysterectomy for cervical cancer were compared with the 30 previous cases of open type III radical hysterectomy. Body mass index, length of operation, nodal yield, margins, estimated blood loss, hospital stay, and complications were all documented and compared. RESULTS: The 30 patients undergoing robotically assisted laparoscopic radical hysterectomy were similar in body mass index to the women undergoing open radical hysterectomy (34 kg/m robotic, 32 kg/m open, P = 0.22). The mean operating time was 154 minutes compared with 166 minutes in the open arm (P = 0.36). The mean blood loss was 165 mL compared with 323 mL in the open arm (P = 0.001). The mean pelvic nodal yield was 25 nodes compared with 26 nodes in the open group (P = 0.45). The mean parametrial margin size was not significantly different between groups. The mean postoperative length of stay was 1.4 days compared with 2.8 days for the open cases (P < 0.001). Urinary retention was significantly more common in the robotic arm. CONCLUSIONS: Radical surgery for cervical cancer can be accomplished using the da Vinci surgical system (Intuitive Surgical, Sunnyvale, Calif) with acceptable blood loss, operating time, parametrial margins, and nodal yield. Future studies need to address long-term outcomes.




“Robotic-assisted minimally invasive surgery and ovarian cancer.”

Vaknin, Z. and W. H. Gotlieb (2010).

Therapy 7(3): 217-219.