Abstrakt Gynekologie Květen 2011

“Robot-assisted surgical staging for ovarian cancer in pregnant women.”
Al-Badawi, I. A., M. Al-Aker, et al. (2011).
Journal of Robotic Surgery: 1-4.

The use of the da Vinci Surgical System is becoming popular among surgeons as it allows more control than the standard laparoscopic approach, with comparable benefits and risks. The use of the da Vinci Surgical System during pregnancy was reported earlier and showed to be as safe as laparoscopy. The use of the da Vinci Surgical System in ovarian cancer during pregnancy has not been reported before. To our knowledge, this is the first report of robot-assisted surgical staging for presumed early ovarian cancer. Two women aged 29 and 39 underwent laparotomy for ovarian cystectomy, for presumed benign pathology; the final pathology showed ovarian malignancy. Both patients were referred to a tertiary center and meanwhile became pregnant, and decided to keep the pregnancy. The staging was achieved using robot-assisted surgery in mid-trimester. The use of the da Vinci Surgical System during pregnancy is feasible and safe at mid-trimester. More robot-assisted surgeries during pregnancy will be needed before final recommendations can be made. © 2011 Springer-Verlag London Ltd.

“Late onset hemorrhage caused by ruptured uterine artery pseudoaneurysm after robotic-assisted total hysterectomy.”
Gerardi, M. A. and T. P. Díaz-Montes (2011).
Journal of Robotic Surgery: 1-4.

Robotic surgery has been used increasingly for the management of benign or malignant gynecologic conditions. Vaginal hemorrhage after hysterectomy is fairly uncommon. Uterine artery pseudoaneurysm is a rare phenomenon causing late onset hemorrhage that could be potentially life-threatening. This case describes the management of vaginal bleeding due to ruptured uterine artery pseudoaneurysm after robotic-assisted total hysterectomy. This is the first known reported case of a ruptured uterine artery pseudoaneurysm after a robotic-assisted hysterectomy. © 2011 Springer-Verlag London Ltd.

“Relationship between body mass index and robotic surgery outcomes of women diagnosed with endometrial cancer.”
Lau, S., K. Buzaglo, et al. (2011).
International Journal of Gynecological Cancer 21(4): 722-729.

OBJECTIVE: : This is a prospective evaluation of the outcome of minimal invasive surgery using robotics in function of the body mass index (BMI) of patients. METHODS: : This is a prospective cohort study of consecutive women undergoing surgery for endometrial cancer at a tertiary care facility since the initiation of a robotic program in December 2007. Surgical and personal outcome variables as well as quality of life and postoperative recovery were assessed using a combination of objective and subjective/self-report questionnaires. Women were divided into 3 groups based on their BMI. Comparative analyses among nonobese (n = 52), obese (n = 33) and morbidly obese (n = 23) women were performed on the outcome measures after surgery. RESULTS: : The mean BMI and the range in each of the BMI categories was 25 kg/m (18.7-29.4 kg/m), 34 kg/m (30.1-38.4 kg/m), and 46 kg/m (40.0-58.8 kg/m). Women with higher BMI tended to be more frequently affected with comorbidities such as diabetes (15.4%, 26.0%, and 27.3%, respectively; P = 0.32) and hypertension (55.8%, 69.6%, and 69.7%, respectively; P = 0.19). Despite these differences, surgical console time (P = 0.20), major postoperative complications (P = 0.52), overall wound complications (P = 0.18), and median length of hospitalization in days (P = 0.17) were not statistically different among the 3 groups. Only 5.6% of women needed a mini laparotomy all of which were performed for the removal of their enlarged uterus, which could not be delivered safely via the vagina, at the end of the surgical procedure. There was no increased conversion to laparotomy due to increased BMI. Women in all 3 groups reported rapid resumption of hygiene regimens and chores, little need for narcotic analgesia, and high satisfaction with the procedure. CONCLUSIONS: : Obese and morbidly obese patients with endometrial cancer are also good candidates for robotic surgery. These women benefit considerably from minimal invasive surgery and have little perioperative complications.

“Does size matter? The effect of uterine weight on robot-assisted total laparoscopic hysterectomy outcomes.”
Orady, M. E., A. Karim Nawfal, et al. (2011).
Journal of Robotic Surgery: 1-6.

The objective of this study was to determine whether uterine weight affects the surgical outcomes of robot-assisted total laparoscopic hysterectomy (RH) procedures. The design of this study is retrospective cohort study. The classification of the study design is level II-2 evidence. The study setting is the Henry Ford Health System’s Community Teaching Hospitals. One-hundred and thirty-five patients underwent RH for benign indications at one of two hospitals between January1, 2008, and June 1, 2010. Interventions were scheduled RH without concomitant uro-gynecologic procedures as the intention to treat. Patient demographics, age, height, weight, estimated blood loss (EBL), procedure duration, uterine weight, pathology, length of hospital stay (LOS), and any complications were obtained from a detailed review of electronic medical records. Uterine weight ranged from 47 to 1,290 g (<250 g, n = 87; 250-500 g, n = 28; >500 g, n = 18). Overall, uterine weight was highly correlated with procedure duration (r = .53, P < .001.). Median procedure duration increased from 150 min for the <250 g group, to 205 min for the 250-500 g group, and to 295 min for the >500 g group. Uterine weight was also moderately correlated with EBL (r = .30, P = .0005). Median EBL increased from 50 ml for uteri <250 g to 87.5 ml for the 250-500 g group, and 100 ml for the >500 g group. This correlation did not persist in the assessment of decrease in peri-operative hemoglobin (r = .09, P = .30). Ninety-one women had a LOS of 1 day (67.4%), 31 women had a LOS of 2 days (23%), and 13 women had a LOS of greater than 2 days (9.6%). Uterine weight was not correlated with LOS (r = .14, P = .10) and was not associated with increased major or minor complications (WRS P = .79) re-admission (WRS P = .35), or blood transfusion (n = 3). RH can be performed on patients with large uteri exceeding 500 g without associated adverse outcomes. Although procedure duration is increased, there is no significant effect on EBL and no increase in the occurrence of complications or length of stay. © 2011 Springer-Verlag London Ltd.

“Chylous ascites following robotic lymph node dissection on a patient with metastatic cervical carcinoma.”
Soto, E., C. Soto, et al. (2011).
Journal of Gynecologic Oncology 22(1): 61-63.

Chylous ascites is an uncommon postoperative complication of gynecological surgery. We report a case of chylous ascites following a robotic lymph node dissection for a cervical carcinoma. A 38-year-old woman with IB2 cervical adenocarcinoma with a palpable 3 cm left external iliac lymph node was taken to the operating room for robotic-assisted laparoscopic pelvic and para-aortic lymph node dissection. Patient was discharged on postoperative day 2 after an apparent uncomplicated procedure. The patient was readmitted the hospital on postoperative day 9 with abdominal distention and a CT-scan revealed free fluid in the abdomen and pelvis. A paracentesis demonstrated milky-fluid with an elevated concentration of triglycerides, confirming the diagnosis of chylous ascites. She recovered well with conservative measures. The risk of postoperative chylous ascites following lymph node dissection is still present despite the utilization of new technologies such as the da Vinci robot. © 2011. Asian Society of Gynecologic Oncology, Korean Society of Gynecologic Oncology and Colposcopy.

“Robot assisted laparoscopic surgery in gynaecological oncology.”
Verheijen, R. H. M. (2011).
Obstetrics and Gynaecology Forum 21(2): 11-12.

“Robot-assisted removal of a lymphocyst causing severe neuralgic pain and adductor atrophy.”
Cazzaniga, G., C. Borgfeldt, et al. (2011).
Journal of Robotic Surgery: 1-4.

Following a robot-assisted radical hysterectomy and pelvic lymphadenectomy for early-stage cervical cancer, a 53-year-old woman was diagnosed with a 50-mm right-sided pelvic lymphocyst by the use of vaginal ultrasonography. She gradually developed intermittent increasingly severe neuralgic pain mimicking a meralgia paresthetica. A neurolysis was proposed by the neurosurgeons. Awaiting this intervention, a pelvic MRI revealed a partial atrophy of the ipsilateral adductor muscles and a probable entrapment of the obturator nerve by the lymphocyst as an alternative cause of the pain. Using a four-arm da Vinci-S-HD robot the lymphocyst, located deep in the right obturator fossa and surrounding the obturator nerve, was completely removed, sparing the partially atrophic obturator nerve. No bleeding occurred. The surgery time was 95 min. At 10 months’ follow-up the patient was relieved of her pain with no signs of a new lymphocyst. © 2011 Springer-Verlag London Ltd.

“Treatment and surveillance strategies in achalasia: an update.”
Eckardt, A. J. and V. F. Eckardt (2011).
Nature Reviews Gastroenterology and Hepatology.

Controversy exists with regard to the optimal treatment for achalasia and whether surveillance for early recognition of late complications is indicated. Currently, surgical myotomy and pneumatic dilation are the most effective treatments for patients with idiopathic achalasia, and a multicenter, randomized, international trial has confirmed similar efficacy of these treatments, at least in the short term. Clinical predictors of outcome, patient preferences and local expertise should be considered when making a decision on the most appropriate treatment option. Owing to a lack of long-term benefit, endoscopic botulinum toxin injection and medical therapies are reserved for patients of advanced age and those with clinically significant comorbidites. The value of new endoscopic, radiologic or surgical treatments, such as peroral endoscopic myotomy, esophageal stenting and robotic-assisted myotomy has not been fully established. Finally, long-term follow-up data in patients with achalasia support the notion that surveillance strategies might be beneficial after a disease duration of more than 10-15 years.

“Prolapse surgery: Which technique and when?”
Heesakkers, J. P. F. A. and M. E. Vierhout (2011).
Current Opinion in Urology.

PURPOSE OF REVIEW: More answers are nowadays available about certain aspects of pelvic organ prolapse (POP) treatment. In this overview some of those aspects are addressed that were considered important and published in 2010. RECENT FINDINGS: When stress urinary incontinence (SUI) is present concomitant with POP the strategy is still to perform an additional procedure for SUI. If there is no SUI the tendency is only to correct the POP. With masked SUI no firm conclusions can be drawn.The studies that look at mesh for POP provide some careful conclusions. Absorbable biomeshes do not have many benefits over repairs without mesh in the long term. Nonresorbable mesh tends to give better results but also higher complication rates and should be applied with care.A last item is how to perform a sacrocolpopexy. Laparoscopic sacrocolpopexy is a well tolerated but time-consuming and difficult procedure to treat prolapse. Comparison with other conventional techniques is lacking. Robotic surgery has the potential of enhancing the widespread introduction of laparoscopic procedures. SUMMARY: With these findings a better evidence-based choice for surgical technique can be made with regards to POP with or without SUI, the kind of mesh to use and which sacrocolpopexy technique should be chosen.

“Robotic surgery in gynecology – Surgery of the future or expensive PR gimmick? – A personal opinion.”
Kimmig, R. (2011).
Robotic Surgery in der Gynäkologie – Chirurgie der Zukunft oder teurer PR-Gag? – Eine persönliche Betrachtung: 1-3.

“Robotic approach in pelvic floor disorders: Should we believe?”
Meurette, G. (2011).
L’approche robotique dans les troubles de la statique pelvienne: Faut-il y croire ? 5(1): 18-20.

Ramirez, P., M. Frumovitz, et al. (2011).
Journal of Minimally Invasive Gynecology 18(3): 409-410.

“Short-term results of robotic sacrocolpopexy using the Quill SRS bi-directional polydioxanone (PDO) suture.”
Stubbs Iii, J. T. (2011).
Journal of Robotic Surgery: 1-7.

The aim of the study was to evaluate the short-term success of robotic sacrocolpopexy using the Quill bi-directional polydioxanone (PDO) suture. This was a retrospective observation study of women undergoing robotic sacrocolpopexy performed by a single surgeon between May 2008 and August 2010. Pelvic organ prolapse was determined using the pelvic organ prolapse quantification scale (POP-Q). Baseline exam were performed preoperatively and scheduled at 6 weeks, 3 months, and yearly thereafter. Treatment success defined as a POP-Q measurement of point C that did not descend for more than one-half the total vaginal length and a measurement for point Ba that was less than -1. A total of 36 patients were eligible for enrolment in the study. The mean age was 70 years (range 49-86 years), and mean body mass index was 27 kg/m2 (range 19-41 kg/m2). The mean interval follow-up was 166 days (median 116; range 34-772 days). Anatomic success was 92% (33/36). In the short term, the Quill SRS PDO suture provided sufficient fixation of an Amid type I polypropylene mesh to the vagina to result in excellent anatomic success with only rare complications. © 2011 Springer-Verlag London Ltd.

“Novel laparoscopic techniques in gynecologic surgery.”
Sziller, P. and Z. Langmár (2011).
Legújabb laparoszkópos technikák a nogyógyászati sebészetben 152(20): 785-792.

The practice of gynecologic surgery has been revolutionized by laparoscopic techniques in the past decades. Nowadays minimal invasive procedures are feasible and safe standard options in the management of most benign and malignant gynecologic diseases. Natural orifices transluminal endoscopic surgery (NOTES) and laparoendoscopic single-site surgery (LESS) have been developed in an attempt to further reduce the morbidity and scarring with minimal invasive procedures. These techniques share a common conception that a reduction in the number of transcutaneous points of access may benefit patients in terms of port-related complications, risk of hernia formation, recovery time, pain and cosmetics by potentially performing scarless surgery. The development of LESS has been facilitated by the concept of scarless surgical procedures. Increasing experience revealed by recent publications have allowed for the expansion of NOTES and LESS techniques in the gynecologic surgery. Almost all laparoscopic procedures can be performed by acquiring these concepts. Although these surgical methods are feasible and safe, certain technical problems (e.g. loss of triangulation, problems of visualization, ergonomic considerations) has yet to be solved and several questions must be answered before LESS and NOTES could gain widespread acceptance as single procedures. Despite successful technical developments these methods remain investigational approaches and refinement of indications as well as further development of instrumentation are expected to define its area of future application.