Abstrakt Gynekologie Listopad 2010

“Robotic-assisted laparoscopic ovarian tissue transplantation.”

Akar, M. E., A. J. Carrillo, et al. (2010).

Fertility and Sterility.


Objective: To describe a technique for frozen-banked ovarian tissue transplantation using robotic-assisted laparoscopy. Design: Case study. Setting: Academic tertiary care center. Patient(s): A 38-year-old patient in remission for non-Hodgkin lymphoma, whose ovarian tissue had been frozen for 3 years. Intervention(s): Robotic-assisted laparoscopic transplantation of thawed ovarian cortical tissue to the remaining ovary and peritoneum. Main Outcome Measure(s): Resumption of spontaneous menses, follicular development, and ovulation as demonstrated by ultrasound, and serum E<sub>2</sub> and P levels. Result(s): The patient experienced cyclic spontaneous menstruation 6 months after the transplantation. Ovulation was confirmed by ultrasound and serum E<sub>2</sub> and P levels at month 11 after surgery. Conclusion(s): Robotic-assisted laparoscopic surgery may be a good, minimally invasive alternative for the ovarian tissue transplantation procedure to restore ovarian function. © 2010 American Society for Reproductive Medicine.




“The future of gynaecological endoscopy: From the work presented in the Free Communications during the ESGE Meeting in Florence October 2009.”

Garry, R. and E. Downes (2010).

Gynecological Surgery7(2): 101-104.




“Evaluation of the introduction of robotic technology on route of hysterectomy and complications in the first year of use.”

Matthews, C. A., N. Reid, et al. (2010).

American Journal of Obstetrics and Gynecology203(5).


Objective We sought to determine the differential rates and complications of hysterectomy type in the year prior to and following the introduction of robotic technology. Study Design This was a retrospective chart review of 461 hysterectomies performed from July 2007 through June 2008 (period 1) and July 2008 through June 2009 (period 2) at Virginia Commonwealth University Medical Center. Results In all, 199 vs 262 hysterectomies were performed in periods 1 and 2: open, 52.3% vs 43.1%; laparoscopic, 18.1% vs 8.0%; robotic, 2.5% vs 24.8%; and vaginal, 27.4% vs 24.1%, respectively. The increase in robotic hysterectomies in period 2 was associated only with a decline in laparoscopic hysterectomy (P < .0001). Major morbidity by route was 23.04% open, 11/1% vaginal, 7.02% laparoscopic, and 4.29% robotic (P < .0001). Conclusion Route of hysterectomy changed significantly after the introduction of robotic technology primarily due to a change in management of pelvic organ prolapse. Open hysterectomy was associated with significantly higher complication rates. © 2010 Published by Mosby, Inc.




“Robotic resection of pheochromocytoma in the second trimester of pregnancy.”

Podolsky, E. R., L. Feo, et al. (2010).

JSLS : Journal of the Society of Laparoendoscopic Surgeons / Society of Laparoendoscopic Surgeons14(2): 303-308.


Pheochromocytoma is a rare neuroendocrine tumor diagnosed in 1:50,000 pregnancies. Normal physiologic changes associated with pregnancy often make early recognition difficult and diagnosis delayed. Treatment consists of medical followed by surgical intervention. This case of a 34-year African-American female diagnosed with an adrenal pheochromocytoma during her second trimester of pregnancy is the first reported case of successful robotic resection. The robot provided advantages, such as enhanced visualisation and freedom of dissection, within this confined space. These added benefits over traditional laparoscopy provide a means for performing difficult procedures within decreased space possibly allowing for interventions in later or larger pregnancies.




“Robotic-assisted hysterectomy for endometrial cancer compared with traditional laparoscopic and laparotomy approaches: a systematic review.”

Gaia, G., R. W. Holloway, et al. (2010).

Obstetrics and Gynecology116(6): 1422-1431.


OBJECTIVE:: To summarize comparative studies describing clinical outcomes of robotic-assisted surgeries compared with traditional laparoscopic or laparotomy techniques for the treatment of endometrial cancer. DATA SOURCES:: Using search words “robotic hysterectomy” and “endometrial cancer,” 22 citations were identified from Medline and PubMed (2005 to February 2010). METHODS OF STUDY SELECTION:: We selected English language studies reporting at least 25 robotic cases compared with laparoscopic or laparotomy cases that also addressed surgical technique, complications, and perioperative outcomes. Patients underwent total hysterectomy, bilateral salpingo-oophorectomy, and lymphadenectomy. TABULATION, INTEGRATION, AND RESULTS:: Eight eligible comparative studies were identified that included 1,591 patients (robotic=589, laparoscopic=396, and laparotomy=606). Pooled means of the resected aortic lymph nodes for robotic hysterectomy and laparoscopy were 10.3 and 7.8 (P=.15), and robotic hysterectomy and laparotomy were 9.4 and 5.7 (P=.28). Pooled means of pelvic lymph nodes for robotic and laparoscopic hysterectomy were 18.5 and 17.8 (P=.95) and 18.0 compared with 14.5 (P=.11) for robotic hysterectomy compared with laparotomy. Estimated blood loss was reduced in robotic hysterectomy compared with laparotomy (P<.005) and laparoscopy (P=.001). Length of stay was shorter for both robotic and laparoscopic cases compared with laparotomy (P<.01). Operative time for robotic hysterectomy was similar to laparoscopic cases but was greater than laparotomy (P<.005). Conversion to laparotomy for laparoscopic hysterectomy was 9.9% compared with 4.9% for robotic cases (P=.06). Vascular, bowel, and bladder injuries; cuff dehiscence; and thromboembolic complications were similar for each surgical method. Transfusions for robotic hysterectomy compared with laparotomy was 1.7% and 7.2% (P=.06) and robotic hysterectomy compared were laparoscopy was 2.6% and 5.0% (P=.22). CONCLUSION:: Perioperative clinical outcomes for robotic and laparoscopic hysterectomy appear similar with the exception of less blood loss for robotic cases and longer operative times for robotic and laparoscopy cases.




“Comparison of robotic-assisted surgery outcomes with laparotomy for endometrial cancer staging in Turkey.”

Göçmen, A., F. Şanlikan, et al. (2010).

Archives of Gynecology and Obstetrics282(5): 539-545.


Purpose: To compare the results of patients on whom staging was applied by robotic-assisted laparoscopic surgery and laparotomy for endometrial cancer. Method: The study included 10 patients who had undergone robotic-assisted endometrial staging (group 1) and 12 patients staged by open surgery (group 2). Demographical characteristics and operative outcomes of all patients were compared. Body mass index, age, previous abdominal surgeries, histopathologic characteristics, performed operative procedure, operation time, complications, hospitalization duration, estimated blood loss and number of resected lymph nodes were recorded for all patients. Results: Mean age of the patients in the robotic surgery group was 55.7 years (37-66) and in the laparotomy group 56.4 years (47-75). Body mass index was calculated as 32.7 kg/m<sup>2</sup> (24.5-40.3) in group 1 and 30.3 kg/m<sup>2</sup> (25.9-35.8) in group 2. Total duration of operation was 234.6 min (137-300) and 168.5 min (102-232) in group 1 and 2, respectively. Mean duration of hospitalization in group 1 was 2.8 days (2-5) and in group 2 was 8.8 days (6-13). Estimates of blood loss were 95 ml (20-210 ml) in the robotic surgery group and 255 ml (80-420) in the other group. The mean number of resected lymph nodes was 42 (13-86) and 46.5 (26-107) in the robotic-assisted surgery group and laparotomy group, respectively. None of the cases in the robotic-assisted endometrial staging group required transition to laparotomy. Conclusion: Robotic surgery may be preferred over laparotomy with respect to the advantages observed in the duration of hospitalization, estimated amount of blood loss and complications. There was no significant difference between the two methods in terms of number of resected lymph nodes. Despite the limited number of patients in this study, these results are important as they represent the first data on robotic surgery in Turkey. © 2010 Springer-Verlag.




“Robotic radical hysterectomy: comparison of outcomes and cost.”

Halliday, D., S. Lau, et al. (2010).

Journal of Robotic Surgery: 1-6.


Operative and peri-operative outcomes, complications, and cost for radical hysterectomy for cervical cancer with negative sentinel nodes have been compared for robotics and laparotomy. Forty patients underwent radical hysterectomy with/out bilateral salpingo-oophorectomy, for early-stage cervical cancer. All cases were performed by one of two surgeons, at a single institution (16 robotic, 24 laparotomy). The data for the robotic group were collected prospectively and compared with data for a historic cohort who underwent laparotomy. The data included demographics and peri-operative variables including operative time, estimated blood loss, lymph node count, hospital stay, and complications. Additionally, real direct hospital cost was compared for both modalities. Patients undergoing robotic radical hysterectomy experienced longer operative time than the laparotomy cohort (351 min vs. 283 min P = 0.0001). Estimated blood loss was significantly lower for the robotic cohort than for the laparotomy cohort (106 ml vs. 546 ml P < 0.0001). The minor complication rate was lower in the robotic cohort than for laparotomy (19% vs. 63% P = 0.003). Average hospital stay for the robotic patients was significantly shorter than for those undergoing laparotomy (1.9 days versus 7.2 days, P < 0.0001). Lymph node retrieval did not differ between the two groups (robotic 15 nodes, laparotomy 13 nodes). The total average peri-operative costs for radical hysterectomy with lymphadenectomy completed via laparotomy was CAN $11,764 ± 6,790, and for robotic assistance 8,183 ± 1,089 (P = 0.002). When amortization of the robot was included, there remained a trend in favor of the robotic approach, but it did not reach statistical significance. Whereas robotics takes longer to perform than traditional laparotomy, it provides the patient with a shorter hospital stay, less need for pain medications, and reduced peri-operative morbidity. In addition real average hospital costs tend to be lower. © 2010 Springer-Verlag London Ltd.




“Robotic surgery for endometrial cancer.”

He, L. and Y. Zhang (2010).

Chinese Journal of Clinical Oncology37(19): 1132-1135.


As a new treatment modality, robotic-assisted laparoscopic surgery has advantages over conventional laparoscopy and enables more surgeons to perform minimally invasive surgery. Robotic-assisted surgery has been used in the management of gynecologic malignancies with promising results. In this article the application of a robotic surgical system in treating endometrial cancer is reviewed. This article evaluates the advantages, limitations and future direction of robotic-assisted surgery.




“Comparison of robot-assisted total laparoscopic hysterectomy and total abdominal hysterectomy for treatment of endometrial cancer in obese and morbidly obese patients.”

Nevadunsky, N., R. Clark, et al. (2010).

Journal of Robotic Surgery: 1-6.


The objective of our study was to compare clinical and pathologic outcomes of robot-assisted and open abdominal techniques for treatment of uterine cancer in obese patients. Institutional review board approval was obtained. Patient demographic data, pathological data, and surgical data were collected by retrospective chart review. Data were analyzed using SAS statistical software. One-hundred and eighty-nine consecutive cases of suspected uterine cancer were identified from October 2003 until January 2009. Of these, 116 patients (61%) had a body mass index (BMI) over 30. There were 66 completed robot-assisted hysterectomies (RAHs), 43 total abdominal hysterectomies (TAHs), and seven patients that were converted from RAH to open abdominal hysterectomy. There were no significant differences in preoperative patient demographics, including body mass index (BMI), medical co-morbidities, or preoperative cytology, except for parity. There were no differences in postoperative grade, stage, lymph vascular space invasion, positive pelvic washings, mean number of pelvic lymph nodes, or proportion of patients undergoing pelvic lymphadenectomy. Length of stay and estimated blood loss were lower for the robotic technique; RAHs had a significantly longer operative time, however. Postoperative blood transfusions and wound infections were more frequent in the TAH group. Of the RAH group there were seven conversions to TAH (10%). Differences in surgical times with and without lymphadenectomy were least in patients in the largest BMI category of >50. Length of time required for RAH was significantly longer then TAH in obese and morbidly obese patients, however benefits to patients of a minimally invasive approach included reduced incidence of wound infections, reduced transfusion rates, reduced blood loss, and shortened length of stay. These data also suggest the greatest advantage of robotic technology over laparotomy in patients with BMI over 50. © 2010 Springer-Verlag London Ltd.




“Technical modifications in the robotic-assisted surgical approach for gynaecologic operations.”

Peeters, F., Z. Vaknin, et al. (2010).

Journal of Robotic Surgery: 1-5.


To investigate the development of new technical approaches for improving the implementation of robotics in gynaecologic surgery, we conducted a prospective evaluation of five technical modifications developed during the implementation of a robotics program that included 171 robotic endometrial staging procedures from December 2007 until May 2010. Modification of the use of a Hohl uterine manipulator by applying only the intravaginal component minimizes the theoretical risk of spillage of endometrial cancer cells, without losing the capability of delineating the vaginal fornices. Entry to the peritoneal cavity under visual control using a left upper quadrant approach and a 5-mm endoscope through a 5-mm Endopath<sup>®</sup> trocar is quick and decreases the risk of bowel or vessel injury. Use of 12-mm Endopath<sup>®</sup> trocars with blunt tips without closure of the fascia was not associated with post-operative hernias. Positioning the Da Vinci<sup>®</sup> Surgical System at a 30° angle at the side of the patient allows easy access to the vagina for removal of large surgical specimens and does not interfere with proper movements of the robotic arms. Use of a tissue specimen bag introduced via the vagina at completion of surgery allows removal of large uteri vaginally to avoid (mini-)laparotomy and its morbidities. Finally, suturing of the vault using interrupted delayed absorbable monofilament sutures was not associated with vaginal cuff dehiscence. Early evaluation of evolving minor technical and surgical approaches was associated with low morbidity, and appears to benefit patients undergoing robotic surgery for gynaecologic cancers. © 2010 Springer-Verlag London Ltd.




“Robotic radical hysterectomy: applying principles of the laparoscopic Pune technique.”

Puntambekar, S. P., G. A. Agarwal, et al. (2010).

Journal of Robotic Surgery: 1-6.


Minimal access surgery is an accepted treatment modality in cervical cancer. Despite the advantages of laparoscopy, the surgical technique of laparoscopic radical hysterectomy is not very commonly performed. Robotic surgery is an emerging field with rapid acceptance because of the 3-dimensional image, dexterity of instruments and autonomy of camera control. We report here our technique of performing robotic radical hysterectomy using the Da Vinci surgical system. Twenty patients with cervical cancer stage 1a1-1b2 underwent robotic radical hysterectomy since December 2009. The median duration of surgery was 122 min, and the average blood loss was 100 ml. Postoperative ureteric fistulas occurred in two patients and were managed by ureteric stenting. The median lymph node retrieval was 30 nodes (range 18-38). We compared our robotic results with our published data on laparoscopic radical hysterectomy (Pune technique). We were able to complete all 20 cases robotically with minimal morbidity, and could duplicate our laparoscopic steps in robotic radical hysterectomy. © 2010 Springer-Verlag London Ltd.




“Fertility-preserving surgical procedures for patients with gynecologic malignancies.”

Rasool, N. and P. G. Rose (2010).

Clinical Obstetrics and Gynecology53(4): 804-814.


Gynecologic malignancies often affect young women who are at the peak of their reproductive potential. The treatment for gynecologic malignancies often consists of removal of the ovaries or uterus, affecting the future fertility of these patients. Advances in surgical management have allowed patients to undergo more conservative treatment with preservation of their fertility. This review summarizes fertility-sparing surgical procedures for patients with gynecologic malignancies evaluating the role of radical trachelectomy and ovarian transposition in cervical cancer, hormonal therapy and hysteroscopic resection in endometrial cancer, and conservative surgery in ovarian cancer. © 2010, Lippincott Williams & Wilkins.




“Asian society of gynecologic oncology workshop 2010.”

Suh, D. H., J. W. Kim, et al. (2010).

Journal of Gynecologic Oncology21(3): 137-150.


This workshop was held on July 31-August 1, 2010 and was organized to promote the academic environment and to enhance the communication among Asian countries prior to the 2nd biennial meeting of Australian Society of Gynaecologic Oncologists (ASGO), which will be held on November 3-5, 2011. We summarized the whole contents presented at the workshop. Regarding cervical cancer screening in Asia, particularly in low resource settings, and an update on human papillomavirus (HPV) vaccination was described for prevention and radical surgery overview, fertility sparing and less radical surgery, nerve sparing radical surgery and primary chemoradiotherapy in locally advanced cervical cancer, were discussed for management. As to surgical techniques, nerve sparing radical hysterectomy, optimal staging in early ovarian cancer, laparoscopic radical hysterectomy, one-port surgery and robotic surgery were introduced. After three topics of endometrial cancer, laparoscopic surgery versus open surgery, role of lymphadenectomy and fertility sparing treatment, there was a special additional time for clinical trials in Asia. Finally, chemotherapy including neo-adjuvant chemotherapy, optimal surgical management, and the basis of targeted therapy in ovarian cancer were presented.




“Outcome and quality of life in a prospective cohort of the first 100 robotic surgeries for endometrial cancer, with focus on elderly patients.”

Vaknin, Z., T. Perri, et al. (2010).

International Journal of Gynecological Cancer20(8): 1367-1373.


OBJECTIVE: Evaluation of surgical outcomes, including quality of life, in patients with endometrial cancer in the early phase of implementation of a robotic surgery program, comparing elderly with younger patients. METHODS: Prospective evaluation of perioperative data and a postoperative quality-of-life survey of the first 100 robotic surgeries for endometrial cancer performed in the Division of Gynecologic Oncology at a tertiary cancer center. Women were divided in 2 groups based on age, allowing comparison of outcomes between the elderly (>/=70 years) and younger groups (<70 years). RESULTS: Of the first 100 patients, 41 were elderly (mean age, 78 years). The elderly group had significantly higher number of comorbidities and more advanced disease when compared with the younger women. Despite this, elderly women had similar mean operative times (252 vs 243 minutes), mean console times (171 vs 175 minutes), and mean blood loss (83 vs 81 mL) as compared with the younger group. Conversion rate to minilaparotomy was 6%, all of which were performed at the end of surgery for the removal of enlarged uteri that could not be delivered vaginally. The overall perioperative complication rates were not statistically different between the age groups. Median hospital stay tended to be longer for the elderly women (2 vs 1 day) but was not statistically significant. The postoperative quality-of-life assessment revealed that patients young and old alike were highly satisfied with the procedure. CONCLUSIONS: Prospective evaluation indicates that even in the early phases of implementation of a robotic surgical program for endometrial cancer, the procedure seems safe and confers an excellent quality of life for elderly patients.