Abstrakt Gynekologie Září 2009

“Robot-assisted laparoscopic myomectomy; a feasible technique for removal of unfavorably localized myomas.”

Lönnerfors, C. and J. Persson (2009).

Acta obstetricia et gynecologica Scandinavica 88(9): 994-999.


OBJECTIVE: To describe the feasibility of robot-assisted laparoscopic myomectomy for unfavorably localized myomas using the da Vinci surgical system. DESIGN: Prospective observational. SETTING: University hospital. METHOD: Between April 2006 and March 2008, a robot-assisted laparoscopic myomectomy was performed on 13 women selected for having deep intramural myomas with probable impact on fertility and/or later pregnancy. The alternative surgical approach for all 13 was myomectomy via laparotomy. A transvaginal ultrasonography (TVUS) mapping of the myomas was performed to enable an optimal approach during surgery. Using a prospective protocol, relevant times at the operating theater as well as postoperative and follow-up data, were obtained. RESULTS: Median time for surgery was 132 minutes (range 94-209 minutes). Median blood loss was 50 ml (range 25-200 ml). No significant complication occurred during or after surgery. Median postoperative hospital stay was one day (range 1-3 days). At follow-up, including TVUS, no unexpected residual myomas larger than 5 mm were identified. Of eight women with an active wish for conception, six have become pregnant a median time of 15 months after surgery. All additional symptoms associated with the myomas were alleviated. CONCLUSION: Robot-assisted laparoscopic myomectomy is a feasible technique for removal of deep intramural myomas unfavorably localized for traditional laparoscopy. The properties of the da Vinci robot facilitate dissection and suturing comprising the major surgical parts of myomectomy.




“Robotic adnexectomy compared with laparoscopy for adnexal mass.”

Magrina, J. F., M. Espada, et al. (2009).

Obstetrics and Gynecology 114(3): 581-584.


OBJECTIVE: To evaluate whether the application of robotic technology in the performance of adnexectomy resulted in benefits for the patient when compared with patients operated by laparoscopy. METHODS: Evaluation of 85 patients undergoing robotic adnexectomy and comparison with a group of 91 patients operated on by laparoscopy during the same period of time and by the same surgeons. Patients were compared by age, body mass index (BMI), American Society of Anesthesiologists (ASA) physical status classification, indications, unilateral compared with bilateral adnexectomy, adhesions, size or weight or both of the adnexal mass, and previous abdominal or pelvic surgery. Univariate and multivariate analysis was used to determine factors favorable to each technique. Comparison between the groups was evaluated using the Fisher exact test from a one-way analysis of variance. RESULTS: The robotic group had an increased number of obese (BMI 30 or more) and higher anesthetic risk (ASA classification 2 and 3) patients as compared with laparoscopy patients. The mean operating time was 12 minutes longer in the robotic group (P=.01). The mean blood loss (80 mL robotic, 71 mL laparoscopic), length of hospital stay (0.15 days robotic, 0.28 days laparoscopic), intraoperative complications (1% robotic, 2% laparoscopic), and postoperative complications (12% robotic, 11% laparoscopic) were similar in both groups. CONCLUSION: Laparoscopy and robotics provided similar results for the performance of adnexectomy, with similar blood loss, intraoperative and postoperative complications, and length of hospital stay. Robotics mean operating time was 12 minutes longer. © 2009 The American College of Obstetricians and Gynecologists.




“Early experience of robotic-assisted laparoscopy for extraperitoneal para-aortic lymphadenectomy up to the left renal vein.”

Narducci, F., E. Lambaudie, et al. (2009).

Gynecologic Oncology 115(1): 172-174.


Objective: To describe our early experience with robotic-assisted laparoscopy for extraperitoneal para-aortic lymphadenectomy up to the left renal vein, including Da Vinci robot positioning. Methods: Six patients underwent robotic-assisted laparoscopy using the Da Vinci apparatus. The patients included a man with a pT2 non-seminomatous germ cell tumour of the left testicle treated by chemotherapy with an incomplete response (mature teratoma), four women with locally advanced cervical cancer, and one case of bulky cancer of the vaginal cuff. The procedure was carried out using four port sites: one for the camera, one each for the no. 1 and no. 3 arms of the Da Vinci robot system, and one for the assistant. Results and conclusion: Robotic-assisted lymphadenectomy carried out using the Da Vinci system was safe and effective with a short learning period for an experienced oncological team. A larger prospective study is now required to evaluate this procedure further. © 2009 Elsevier Inc.




“Laparoscopic hysterectomy with and without a robot: Stanford experience.”

Nezhat, C., O. Lavie, et al. (2009).

JSLS : Journal of the Society of Laparoendoscopic Surgeons / Society of Laparoendoscopic Surgeons 13(2): 125-128.


OBJECTIVE: To compare robotic-assisted laparoscopic hysterectomy (RALH) with a matched control group of standard laparoscopic hysterectomy (LH). METHODS: A retrospective chart review of all RALH was performed. All cases were compared with a matched control group of standard LH. Comparisons were based on Fisher’s exact, Mann-Whitney, and exact chi-square tests. RESULTS: Between January 2006 and August 2007, 26 consecutive RALH were performed (10 with bilateral salpingo-oophorectomy). These were compared with 50 matched control standard LH (22 with bilateral salpingo-oophorectomy). The 2 groups were matched by age (P=0.49), body mass index (P=0.25), gravidity (P=0.11), previous abdomino-pelvic surgery (P=0.37), and size of the excised uterus (P=0.72). Mean surgical time for RALH was 276 minutes (range, 150 to 440) compared with 206 minutes (range, 110 to 420) for standard LH (P=0.01). Blood loss, hospitalization length, and postoperative complications were not significantly different. No conversion to laparotomy was reported in either group. CONCLUSION: Robotic technology was successfully used for hysterectomy with a similar surgical outcome to that of standard LH. This technology offers exciting potential applications, especially for remote telesurgery, and to facilitate teaching of endoscopic surgery.




“Robot-assisted total laparoscopic hysterectomy in obese and morbidly obese women.”

Rebeles, S. A., H. G. Muntz, et al. (2009).

Journal of Robotic Surgery: 1-7.


Total laparoscopic hysterectomy (TLH) in obese patients is challenging. We sought to evaluate whether total laparoscopic hysterectomies using the da Vinci robotic system in obese patients, in comparison with non-obese patients, is a reasonable surgical approach. One-hundred consecutive robot-assisted TLHs were performed over a 17-month period. Obesity was not a contraindication to robotic surgery, assuming adequate respiratory function to tolerate Trendelenburg position and, for cancer cases, a small enough uterus to allow vaginal extraction without morcellation. Data were prospectively collected on patient characteristics, total operative time, hysterectomy time, estimated blood loss, length of stay, and complications. Outcomes with non-obese and obese women were compared. The median age, weight, and BMI of the 100 patients who underwent robot-assisted TLH was 57.6 years (30.0-90.6), 82.1 kg (51.9-159.6), and 30.2 kg/m2 (19.3-60.2), respectively. Fifty (50%) patients were obese (BMI ≥ 30); 22 patients were morbidly obese (BMI ≥ 40). There was no increase in complications (p = 0.56) or blood loss (p = 0.44) with increasing BMI. While increased BMI was associated with longer operative times (p = 0.05), median time increased by only 36 min when comparing non-obese and morbidly obese patients. Median length of stay was one day for all weight categories (p = 0.42). Robot-assisted TLH is feasible and can be safely performed in obese patients. More data are needed to compare robot-assisted TLH with other hysterectomy techniques in obese patients. Nonetheless, our results are encouraging. Robot-assisted total laparoscopic hysterectomy may be the preferred technique for appropriately selected obese patients. © 2009 Springer-Verlag London Ltd.




“Single-port Laparoscopic Abdominal Sacral Colpopexy: Initial Experience and Comparative Outcomes.”

White, W. M., R. K. Goel, et al. (2009).



Objectives: To determine the efficacy and safety of single-port laparoscopic abdominal sacral colpopexy (ASC) for the treatment of female pelvic organ prolapse (POP). Methods: A retrospective cohort study was performed to assess perioperative outcomes among women who were treated for symptomatic POP with laparoscopic, robotic, or single-port laparoscopic ASC. All patients underwent preoperative history and physical examination including POP quantification (POP-Q) staging and urodynamics. ASC with or without anti-incontinence surgery was performed via the aforementioned approaches. Demographic and perioperative data were obtained. Patients were followed up postoperatively at 3 and 6 months with POP-Q evaluation. Statistical analysis was performed. Results: From October 2005 to July 2008, 30 female patients with symptomatic Stage II (6 patients), Stage III (23 patients), or Stage IV (1 patient) POP were treated with laparoscopic (10), robotic (10), or single-port laparoscopic (10) ASC. Mean age of the entire cohort was 61.1 years. Mean body mass index was 26.7 kg/m2. Seventeen patients demonstrated stress urinary incontinence and underwent concomitant sling placement. No intraoperative complications were encountered. No significant difference was noted in the 3 cohorts with respect to operative time, blood loss, mean visual analog pain score at discharge, or duration of hospitalization. At 6 months following surgery, 27 patients underwent follow-up POP-Q, with all patients demonstrating excellent apical support and prolapse reduction. Conclusions: Single-port laparoscopic ASC offers comparable efficacy and superior cosmesis compared to alternative approaches. Long-term follow-up is needed to confirm durability of repair. © 2009 Elsevier Inc. All rights reserved.




“Robotic Radical Trachelectomy for Preservation of Fertility in Early Cervical Cancer: Case Series and Description of Technique.”

Burnett, A. F., P. J. Stone, et al. (2009).

Journal of Minimally Invasive Gynecology 16(5): 569-572.


Study Objective: To present a case series of robotic radical trachelectomy for preservation of fertility in early cervical cancer. Design: Descriptive study. Design: Canadian Task Force Classification III. Setting: Tertiary referral center. Patients: Women with early cervical cancer who wish to maintain fertility potential. Interventions: Robotic radical trachelectomy with bilateral pelvic lymphadenectomy. The procedure also uses a cervical cerclage and permits preservation of the ascending branches of the uterine arteries to the uterus. Measurements and Main Results: Report of the technique, and operative and immediate postoperative complications. To date, 6 women have undergone robotic radical trachelectomy, with preservation of the uterine arteries in all patients. One patient underwent completion hysterectomy when the frozen section of the trachelectomy margin revealed inability to clear the cancer. Five women have maintained their fertility potential after the procedure. Conclusion: Robotic radical trachelectomy is a feasible technique that permits radical removal of the cervix. Improved visualization with the robot and fine dissection permissible with the instrument facilitate this procedure. © 2009 AAGL.




“Laparoscopy and gynecologic oncology.”

Cho, J. E., C. Liu, et al. (2009).

Clinical Obstetrics and Gynecology 52(3): 313-326.


Laparoscopy was used for a second-look assessment in ovarian cancer patients back in the 1970s. However, it is only with the advent of new developments in equipment in the late 1980s and early 1990s along with the vision of pioneers in laparoscopic surgery that has made operative laparoscopy in gynecologic oncology feasible. Laparoscopy has multiple benefits in the cancer patients, including image magnification to visualize metastatic or recurrent disease and improved dissection in challenging areas such as the paravesical and pararectal spaces. There is limited bleeding from small vessels because of the pressure from pneumoperitoneum, decreased hospital stay, and rapid recovery. Postoperative chemotherapy or radiation can be initiated earlier, and radiation complications from bowel adhesions are minimized. Significant progress has been made in the last 2 decades in gynecologic malignancy. In this study, the application of laparoscopy in cervical, endometrial, and ovarian cancer will be presented. © 2009 Lippincott Williams & Wilkins, Inc.




“Operative treatment of endometrial cancer.”

Hasenbein, K. and C. Köhler (2009).

Operative Therapie des Endometriumkarzinoms: 1-8.


Surgery is the therapy of choice in the primary treatment of patients with endometrial cancer. With the rising incidence of obesity, the number of patients with endometrial cancer will also increase. However, operations in obese patients are more challenging. Laparotomy as standard therapy in patients with endometrial cancer stages I and II should be replaced by laparoscopic approaches. Laparoscopy is oncologically equivalent to open procedures and offers many advantages to patients, especially those with relevant comorbidities. Robotic surgery for endometrial cancer is still under evaluation. The most controversial point of treatment today is the indication for and extent of lymphadenectomy in different stages. In advanced tumor stages, optimal debulking should be performed to improve the effectiveness of adjuvant chemotherapy and/or radiation therapy. © 2009 Springer Medizin Verlag.




“Robotic-assisted laparoscopic hysterectomy and lymphadenectomy for endometrial cancer: Analysis of surgical performance.”

Holloway, R. W., S. Ahmad, et al. (2009).

Gynecologic Oncology.


Objectives: To provide an objective analysis of surgical performance of robotic-assisted laparoscopic hysterectomy (RALH) with lymphadenectomy for endometrial cancer during the learning phase of the procedure and to assess opportunities for improvement. Methods: From July 2006 to March 2008, 100 patients with endometrial cancer underwent RALH with lymphadenectomy using the da Vinci® Robotic Surgical System. Data were analyzed for operative time (OT), estimated blood loss (EBL), length of stay (LOS), intra-operative complications, surgical-pathologic factors, and post-operative complications using an intent-to-treat analysis. A comparison of the data on a quartile (Q) basis was performed for the 100 RALH cases and separately for the 65 cases that had a complete pelvic-and-aortic lymphadenectomy (PAL). Results: Age and body mass index (BMI) did not change significantly during the study. More grade 3 tumors were treated in the last 50 cases (22% vs. 10%, p < 0.05). Stage III tumors were identified in 18.7% cases in Q2-4 and none in Q1 (p < 0.05). The number of patients undergoing complete PAL and the number of aortic lymph nodes (LN) removed per case increased each quarter. There were 4 (4%) conversions to laparotomy. Delayed vaginal cuff healing decreased from 16% in Q1 to 0% in Q3-4. No case required blood transfusion. Comparing first 10 cases to the last 10 cases, the total LN counts increased from 15 to 21 nodes, the aortic LN counts increased from 4.7 to 8.0, and the OT decreased from 203 to 160 min. Intra-surgeon analysis revealed an improvement in the total LN yields from first 50 to second 50 cases for each surgeon. Conclusions: Operative times decreased and aortic dissections improved with increasing LN counts during the first 100 cases of RALH. Furthermore, patient safety and improvement in surgical performance was demonstrated. © 2009 Elsevier Inc. All rights reserved.




“Role of robotic surgery in endometrial cancer.”

Lin, P. S., M. T. Wakabayashi, et al. (2009).

Current Treatment Options in Oncology 10(1-2): 33-43.


Uterine cancer is the most common gynecologic cancer in women in the United States with an estimated number of 40,100 women diagnosed in 2008, the great majority of which belongs to endometrial classification. The traditional approach to treatment of endometrial cancer has been primarily surgery via an open, laparotomy incision. Minimally invasive approaches with smaller incisions, i.e., laparoscopy for the management of endometrial cancer was initially reported in 1992; however, its adoption has been slow due to the prolonged learning curve needed to become proficient in such a technique. Robotic-assisted surgery, a further advancement of traditional laparoscopy, using computer-based controls has been developed enabling the performance of complex procedures that otherwise had been too difficult to accomplish in a minimally invasive fashion. Robotic-assisted laparoscopic radical prostatectomy is one such example that has gained rapid acceptance in recent years. Although the use of robotic-assisted laparoscopy for endometrial cancer is still in its early phase, this approach is anticipated to become similarly, a common approach to the management of endometrial cancer in the future. © Springer Science+Business Media, LLC 2009.




“Robotic approach for cervical cancer: Comparison with laparotomy. A case control study.”

Maggioni, A., L. Minig, et al. (2009).

Gynecologic Oncology 115(1): 60-64.


Objective: To compare the surgical outcome of robotic radical hysterectomy (RRH) versus abdominal radical hysterectomy (ARH) for the treatment of early stage cervical cancer. Methods: A prospective collection of data of all RRH for stages IA2-IIA cervical cancer was done. The procedures were performed at the European Institute of Oncology, Milan, Italy, between November 1, 2006 and February 1, 2009. Results: A total of 40 RRH were analyzed, and compared with 40 historic ARH cases. The groups did not differ significantly in body mass index, stage, histology, or intraoperative complications, but in age (p = 0.035). The mean (SD) operative time was significantly shorter for ARH than RRH, 199.6 (65.6) minutes and 272.27 (42.3) minutes respectively (p = 0.0001). The mean (SD) estimated blood loss (EBL) was 78 ml (94.8) in RRH group and 221.8 ml (132.4) in ARH. This difference was statistically significant in favor of RRH group (p < 0.0001). Statistically significantly higher number of pelvic lymph nodes was removed by ARH than by RRH, mean (SD) 26.2 (11.7) versus 20.4 (6.9), p < 0.05. Mean length of stay was significantly shorter for the RRH group (3.7 versus 5.0 days, p < 0.01). There was no significant difference in terms of postoperative complications between groups. Conclusion: This study shows that RRH is safe and feasible. However, a comparison of oncologic outcomes and cost-benefit analysis is still needed and it has to be carefully evaluated in the future. © 2009.




“Surgery Illustrated – Surgical Atlas: Female robotic radical cystectomy.”

Mottrie, A., N. Buffi, et al. (2009).

BJU International 104(7): 1024-1035.




“Robot assisted laparoscopic radical hysterectomy and pelvic lymphadenectomy with short and long term morbidity.”

Sert, M. B. (2009).

Gynecologic Oncology 115(1): 164-165.




“Robotic Radical Trachelectomy after Supracervical Hysterectomy for Cut-Through Endometrial Adenocarcinoma Stage IIB: A Case Report.”

Zanagnolo, V. and J. F. Magrina (2009).

Journal of Minimally Invasive Gynecology 16(5): 655-657.


We report on a patient with a cut-through endometrial malignancy after supracervical hysterectomy treated by radical trachelectomy and staging via a robotic approach. A 58-year-old patient with incidental finding of a stage IIB G1 endometrial adenocarcinoma after a supracervical hysterectomy underwent robotic radical trachelectomy, bilateral pelvic lymphadenectomy, and ileal resection with anastomosis. The operative time was 360 minutes, and blood loss was 100 mL. The pathology report revealed no evidence of residual disease. The patient remains disease-free 18 months after her robotic procedure. Robotic radical trachelectomy and pelvic lymphadenectomy appear to be feasible and safe for the treatment of endometrial malignancy discovered after supracervical hysterectomy. We suggest use of the terms partial radical trachelectomy for fertility preservation procedures and radical trachelectomy after subtotal hysterectomy for the complete radical removal of the cervix. © 2009 AAGL.




“Current status of robotic assisted pelvic surgery and future developments.”

Ahmed, K., M. S. Khan, et al. (2009).

Int J Surg.


AIMS: The aim of this review is to assess the role of robotics in pelvic surgery in terms of outcomes. We have also highlighted the issues related to training and future development of robotic systems. MATERIALS AND METHODS: We searched MEDLINE, EMBASE and the Cochrane Databases from 1980 to 2009 for systematic reviews of randomised controlled trials, prospective observational studies, retrospective studies and case reports assessing robotic surgery. RESULTS: During the last decade, there has been a tremendous rise in the use of robotic surgical systems for all forms of precision operations including pelvic surgery. The short-term results of robotic pelvic surgery in the fields of urology, colorectal surgery and gynaecology have been shown to be comparable to the laparoscopic and open surgery. Robotic surgery offers an opportunity where many of these obstacles encountered during open and laparoscopic surgery can be overcome. CONCLUSIONS: Robotic surgery is a continually advancing technology, which has opened new horizons for performing pelvic surgery with precision and accuracy. Although its use is rapidly expanding in all surgical disciplines, particularly in pelvic surgery, further comparative studies are needed to provide robust guidance about the most appropriate application of this technology within the surgical armamentarium.




“Robotic gynecologic surgery: Past, present, and future.”

Chen, C. C. G. and T. Falcone (2009).

Clinical Obstetrics and Gynecology 52(3): 335-343.


Robotic techniques are increasingly being used to perform gynecologic surgical procedures including hysterectomies, performed for benign and malignant indications, myomectomies, tubal reanastomoses, and sacrocolpopexies. Robotic procedures seem to confer the same benefits as laparoscopic surgery without additional complications. It is unclear, however, whether robotic surgery imparts any additional benefits such as decreased operative times when compared with open or conventional laparoscopic techniques. The advantages to robotic surgery include improved visualization of the operative field with increased dexterity allowing more precise movements. Disadvantages include the learning curve associated with learning a new surgical technique and the equipment and operating costs of the robot and of using the robot. © 2009 Lippincott Williams & Wilkins, Inc.




“Letter to the Editor.”

Nezhat, C. and F. Nezhat (2009).

Journal of Minimally Invasive Gynecology 16(5): 661-662.