Abstrakt Gynekologie Březen 2011 | Česká společnost robotické chirurgie ČLS JEP

GYN_Benign (5)

Escobar, P. F., J. Knight, et al. (2012). “da Vinci(R) single-site platform: anthropometrical, docking and suturing considerations for hysterectomy in the cadaver model.” Int J Med Robot.

BACKGROUND: The paper describes specific technical requirements, limitations, anthropometrical, docking and suturing considerations on the performance of robotic hysterectomy using the da Vinci(R) Single-Site Platform in the cadaver model METHODS: A data set was collected for each procedure including port placement, docking sequence, robotic arms placement and angles, robotic instrumentation, optimal ergonomics, operative time, and cadaver anthropometrical measurements. Pearson correlation coefficients were calculated to determine whether age, BMI or docking approach were correlated with docking difficulty and likelihood of successful procedure completion. Analysis of the data was performed using SPSS v19.0.0. RESULTS: The planned surgical procedure was successfully completed with single-port robotics in 87.5% of cases. High BMI was correlated with difficulty docking the robot, correlation coefficient 0.98. CONCLUSIONS: Further work is needed in the development and advancement of single-site robotic platforms, articulated instrumentation, and optics. Copyright (c) 2012 John Wiley & Sons, Ltd.

Hoffman, M. S. (2012). “Simulation of robotic hysterectomy utilizing the porcine model.” American Journal of Obstetrics and Gynecology.

Objective: This article describes the simulation of robotically assisted hysterectomy utilizing the porcine model. Study design: Utilizing 3 domestic pigs, a technique for robotically assisted hysterectomy was developed. An edited video clip of the model was assessed by 6 gynecological surgeons. Results: The steps of the operation are described in detail and are shown in a video clip. Overall the procedure simulated that done in the human both anatomically and surgically. Some of the evaluators rated the identification of the cervicovesical junction to be more difficult and division of the paracervical ligaments to be relatively easier in the model. Conclusion: Reported here is a technique for robotically assisted hysterectomy in the domestic pig that may be useful for training purposes. © 2012.

Hur, H. C., N. Donnellan, et al. (2012). “Vaginal cuff dehiscence after different modes of hysterectomy.”Obstetrics and Gynecology 119(2 PART 1): 382-383.

Jacome, E. G., A. E. Hebert, et al. (2012). “Comparative analysis of vaginal versus robotic-assisted hysterectomy for benign indications.” Journal of Robotic Surgery: 1-8.

We aimed to compare perioperative outcomes of robotic-assisted hysterectomy versus vaginal hysterectomy in patients with benign gynecologic conditions, using a retrospective chart review of 240 consecutive benign hysterectomies from May 2008 to April of 2010 performed by a single surgical team at the Eisenhower Medical Center. The analysis included an equal number of cases in each group: 120 robotic-assisted total laparoscopic hysterectomies and 120 total vaginal hysterectomies. Consecutive cases met the inclusion criteria of benign disease. There were no statistically significant differences related to age, body mass index, history of prior abdominal surgery, or uterine weight. Operative times in the robotic group were significantly longer by an average of 59 min (p < 0.001). Patients with robotic-assisted hysterectomy had clinically equivalent estimated blood loss (55.5 ml vs. 84.7 ml, p < 0.001) and the intraoperative complication rates were 1.7% vaginal versus 0% robotic (p = 0.156). There was one conversion in the vaginal group due to pelvic adhesions and no conversions in the robotic group. Length of hospital stay was 1 day for both groups. The perioperative complication rates were equivalent between groups (6.7 vs. 11.7%, p = 0.180), but there were more major complications in the vaginal group (0 vs. 3.3%, p = 0.044). We conclude that, in a comparable group of patients, robotic-assisted hysterectomy takes longer to complete but results in fewer major complications. © 2012 Springer-Verlag London Ltd.

Soto, E., Y. Lo, et al. (2011). “Total laparoscopic hysterectomy versus da Vinci robotic hysterectomy: Is using the robot beneficial?” Journal of Gynecologic Oncology 22(4): 253-259.

Objective: To compare the outcomes of total laparoscopic to robotic approach for hysterectomy and all indicated procedures after controlling for surgeon and other confounding factors. Methods: Retrospective chart review of all consecutive cases of total laparoscopic and da Vinci robotic hysterectomies between August 2007 and July 2009 by two gynecologic oncology surgeons. Our primary outcome measure was operative procedure time. Secondary measures included complications, conversion to laparotomy, estimated blood loss and length of hospital stay. A mixed model with a random intercept was applied to control for surgeon and other confounders. Wilcoxon rank-sum, chi-square and Fisher’s exact tests were used for the statistical analysis. Results: The 124 patients included in the study consisted of 77 total laparoscopic hysterectomies and 47 robotic hysterectomies. Both groups had similar baseline characteristics, indications for surgery and additional procedures performed. The difference between the mean operative procedure time for the total laparoscopic hysterectomy group (111.4 minutes) and the robotic hysterectomy group (150.8 minutes) was statistically significant (p=0.0001) despite the fact that the specimens obtained in the total laparoscopic hysterectomy group were significantly larger (125 g vs. 94 g, p=0.002). The robotic hysterectomy group had statistically less estimated blood loss than the total laparoscopic hysterectomy group (131.5 mL vs. 207.7 mL, p=0.0105) however no patients required a blood transfusion in either group. Both groups had a comparable rate of conversion to laparotomy, intraoperative complications, and length of hospital stay. Conclusion: Total laparoscopic hysterectomy can be performed safely and in less operative time compared to robotic hysterectomy when performed by trained surgeons. © 2011. Asian Society of Gynecologic Oncology, Korean Society of Gynecologic Oncology.

GYN_Cancer (6)

Backes, F. J., L. A. Brudie, et al. (2012). “Short- and long-term morbidity and outcomes after robotic surgery for comprehensive endometrial cancer staging.” Gynecologic Oncology.

Objective: Although intra-operative and immediate postoperative complications of robotic surgery are relatively low, little is known about long-term morbidity. We set out to assess both short- and long-term morbidities after robotic surgery for endometrial cancer staging. Methods: All patients who underwent robotic staging for EMCA between 2006 and 2009 from two institutions were identified. Patient charts were retrospectively reviewed for surgical complications and postoperative morbidities. Results: Five hundred three patients were identified. No differences in complication rates were found between 2006-2007 and 2008-2009, even though the median BMI increased from 29.9 (range 19-52) to 32 (range 17-70) (p = 0.03). 6.4% of cases were converted to laparotomy. Median length of stay was one day (range 1-46). No cystotomies, two enterotomies, one ureteric injury, and five vessel injuries occurred (1.6% intra-operative complications). Thirty-eight (7.6%) patients developed major postoperative complications, 11 (2.2%) had wound infections, and 15 (3%) required a transfusion in the 30-day peri-operative period. The total venous thromboembolism (VTE) rate for robotic cases was 1.7%. Partial cuff dehiscence managed conservatively occurred in 5 (1%) and complete dehiscence requiring closure in 7 (1.4%) patients; Sixty-three (13.4%) patients who had robotic staging developed lymphedema, with 40 (8%) requiring physical therapy. Conclusions: This study provides one of the largest cohorts of patients with robotic-assisted hysterectomy and lymphadenectomy (in 92.6%) with an assessment of morbidity. Our data demonstrates that robotic surgical staging can be safely performed with a low risk of short-term complications and lymphedema is the most frequent long-term morbidity. © 2012 Elsevier Inc. All rights reserved.

Fagotti, A., M. L. Gagliardi, et al. (2012). “Perioperative outcomes of total laparoendoscopic single-site hysterectomy versus total robotic hysterectomy in endometrial cancer patients: A multicentre study.”Gynecologic Oncology.

OBJECTIVE: To compare the peri-operative outcomes between total laparo-endoscopic single-site (LESS) and robotic approaches for the staging and treatment of early stage endometrial cancer patients. METHODS: A multicentre retrospective study involving three Italian gynaecological groups and one American centre. The peri-operative outcomes of LESS and robotic approach were compared in similar groups of patients, with regard to surgical outcomes and intra- and post-operative parameters and complications. RESULTS: During the study period, 75 patients submitted to a total LESS hysterectomy and 75 patients received a total robotic hysterectomy. The median operative time – 122 versus 175min (p=0.0001) – and the estimated blood loss – 50 versus 80mL (p=0.03) – were slightly more favourable in the LESS group. The intra-operative complications were equally distributed (p=0.99); in the robotic group there were 4 (5.3%) post-operative grade IIIb complications versus 1 (1.3%) in the LESS group (p=0.172). CONCLUSIONS: The LESS and robotic approaches both appear reasonable and each may have benefits and limitations depending upon the patient population. Further studies are needed to validate these preliminary conclusions.

Lau, S., Z. Vaknin, et al. (2012). “Outcomes and cost comparisons after introducing a robotics program for endometrial cancer surgery.” Obstetrics and Gynecology 119(4): 717-724.

OBJECTIVE: : To evaluate the effect of introducing a robotic program on cost and patient outcome. METHODS: : This was a prospective evaluation of clinical outcome and cost after introducing a robotics program for the treatment of endometrial cancer and a retrospective comparison to the entire historical cohort. RESULTS: : Consecutive patients with endometrial cancer who underwent robotic surgery (n=143) were compared with all consecutive patients who underwent surgery (n=160) before robotics. The rate of minimally invasive surgery increased from 17% performed by laparoscopy to 98% performed by robotics in 2 years. The patient characteristics were comparable in both eras, except for a higher body mass index in the robotics era (median 29.8 compared with 27.6; P<.005). Patients undergoing robotics had longer operating times (233 compared with 206 minutes), but fewer adverse events (13% compared with 42%; P<.001), lower estimated median blood loss (50 compared with 200 mL; P<.001), and shorter median hospital stay (1 compared with 5 days; P<.001). The overall hospital costs were significantly lower for robotics compared with the historical group (Can$7,644 compared with Can$10,368 [Canadian dollars]; P<.001) even when acquisition and maintenance cost were included (Can$8,370 compared with Can$10,368; P=.001). Within 2 years after surgery, the short-term recurrence rate appeared lower in the robotics group compared with the historic cohort (11 recurrences compared with 19 recurrences; P<.001). CONCLUSION: : Introduction of robotics for endometrial cancer surgery increased the proportion of patients benefitting from minimally invasive surgery, improved short-term outcomes, and resulted in lower hospital costs. LEVEL OF EVIDENCE: : II.

Lowery, W. J., C. A. Leath, 3rd, et al. (2012). “Robotic surgery applications in the management of gynecologic malignancies.” Journal of Surgical Oncology 105(5): 481-487.

This review evaluates the use of robotic-assisted laparoscopic surgery in the treatment of gynecologic malignancies and objectively evaluates the use of these systems in performing radical hysterectomies and surgical staging of gynecologic malignancies. The review focuses on surgical length, blood loss, complications, recovery time, and adequacy of surgical staging of robotic-assisted surgery compared to abdominal and non-robotically assisted laparoscopic surgery for malignancies. J. Surg. Oncol. 2012; 105:481-487. Published 2012. This article is a U.S. Government work and is in the public domain in the USA.

Narducci, F., M. Jean-Laurent, et al. (2012). “Surgical approaches for endometrial cancer?” Voies d’abord chirurgicales pour le cancer de l’endomètre? 99(1): 29-34.

The recommendations of the Institut national du cancer and of the Société francaise d’oncologie gynécologique in endometrial carcinoma (2010) reported that laparoscopy is the standard surgical approach for patients with apparent stage FIGO I in preoperative outcomes including MRI (www.e-cancer.fr). For patients with stage FIGO greater than I, laparotomy is the standard surgical approach. In case of lymph nodes or peritoneal restaging, the laparoscopy could be a good option especially by extraperitoneal route in patients with recent first surgery. ©John Libbey Eurotext.

Tang, K. Y., S. K. Gardiner, et al. (2012). “Robotic surgical staging for obese patients with endometrial cancer.” American Journal of Obstetrics and Gynecology.

OBJECTIVE: To compare surgical outcomes for robotic vs laparotomy staging in obese endometrial cancer patients. STUDY DESIGN: This was a retrospective cohort study of patients with body mass index >/=30 kg/m(2) staged in a community gynecologic oncology practice. Patients undergoing robotic staging were compared with historic laparotomy controls. RESULTS: One hundred twenty-nine patients underwent robotic staging, compared with 110 laparotomy patients. The robotic cohort had fewer abdominal wound complications (13.9% vs 32.7%, P < .001), but more vaginal cuff complications (4.7% vs 0%, P = .032). Blood loss was lower in the robotic group (P < .001), as was length of stay (P < .001). Surgical times were longer in the robotic group (P < .001). There was no difference in terms of percentage of patients undergoing pelvic or paraaortic lymph node dissection. CONCLUSION: Robotic staging for endometrial cancer is feasible in obese women, with fewer abdominal wound complications, but more vaginal cuff complications.

GYN_General (7)

Collins, S. A., P. K. Tulikangas, et al. (2012). “Effect of surgical approach on physical activity and pain control after sacral colpopexy.” American Journal of Obstetrics and Gynecology.

Objective: We sought to compare recovery of activity and pain control after robotic (ROB) vs abdominal (ABD) sacral colpopexy. Study design: Women undergoing ROB and ABD sacral colpopexy wore accelerometers for 7 days preoperatively and the first 10 days postoperatively. They completed postoperative pain diaries and Short Form-36 questionnaires before and after surgery. Results: At 5 days postoperatively, none of the 14 subjects in the ABD group and 4 of 28 (14.3%) in the ROB group achieved 50% total baseline activity counts (P = .283). At 10 days, 5 of 14 (35.7%) in the ABD group and 8 of 26 (30.8%) in the ROB group (P = .972) achieved 50%. Postoperative pain was similar in both groups. Short Form-36 vitality scores were lower (P = .017) after surgery in the ABD group, but not in the ROB group. Conclusion: Women undergoing ROB vs ABD sacral colpopexy do not recover physical activity faster, and pain control is not improved. © 2012 Mosby, Inc. All rights reserved.

Geller, E. J., B. A. Parnell, et al. (2012). “Robotic vs abdominal sacrocolpopexy: 44-month pelvic floor outcomes.” Urology 79(3): 532-536.

Objective: To evaluate longer-term clinical outcomes after robotic vs abdominal sacrocolpopexy for the treatment of advanced pelvic organ prolapse (POP). Material and Methods: This was a retrospective cohort assessment of women undergoing either robotic or abdominal sacrocolpopexy between March 2006 and October 2007. Pelvic floor support was measured using Pelvic Organ Prolapse Quantification (POP-Q) examination, and pelvic floor function was assessed via validated questionnaires, including the Pelvic Floor Distress Inventory (PFDI-20), Pelvic Floor Impact Questionnaire (PFIQ-7), and Pelvic Organ Prolapse/Urinary Incontinence Sexual Function Questionnaire (PISQ-12). Results: The analysis included 51 subjects: 23 robotic and 28 abdominal. Mean time since surgery was 44.2 ± 6.4 months. Postoperative POP-Q improved similarly from baseline in both the robotic and abdominal groups: C (-8 vs -7), Aa (-2.5 vs -2.25), Ap (-2 vs -2) (all P >.05 based on route of surgery). Pelvic floor function also improved similarly in both groups: PFDI-20 (61.0 vs 54.7), PFIQ-7 (19.1 vs 15.7), with high sexual function PISQ-12 (35.1 vs 33.1) (all P >.05 based on route of surgery). Two mesh exposures occurred in each group for a rate of 8% and 7%, respectively. Conclusion: Robotic sacrocolpopexy demonstrates similar long-term outcomes compared with abdominal sacrocolpopexy. The robotic approach offers an effective treatment alternative to abdominal sacrocolpopexy for the lasting treatment of advanced POP. © 2012 Elsevier Inc.

Kara, M. (2012). “Robotic surgery in gynecology practice: Current approaches.” Pakistan Journal of Medical Sciences 28(1): 238-241.

Laparoscopic surgery has been widely used in gynecology practice for more than 20 years. Despite the advent of laparoscopy led to advances, it has not been widely used in gynecology because of some disadvantages, including two-dimensional imaging, unstable camera platform, limited mobility of laparoscopic instruments. The aim of this study was to evaluate the advantage and disadvantages of the robotic surgery, especially the da Vinci system. Robotic surgery utilization in gynecology field has been studied in many trials. The literature was searched, advantages and disadvantages of robotic surgery were evaluated. This paper showed that previous studies which have been done suggest robotic surgery can be used in gynecologic interventions. Twodimensional imaging is replaced with three dimensional technique in the da Vinci robot with increased perception and magnification. Moreover, tremor and motion scaling which complicate the operation are not seen in the robotic surgery and the surgical procedures that are typically difficult can be done easier than laparoscopy. However, the price and the loss of tactual feeling are accepted as big disadvantages of robotic surgeries. This manuscript will highlight the science behind the robotic surgery, recent advances in minimally invasive surgery, the most recent clinical trial results and important issues we need to consider prior to implementation of the robot in Turkey.

Magrina, J. F. and P. M. Magtibay (2012). “Robotic nerve-sparing radical parametrectomy: feasibility and technique.” Int J Med Robot.

BACKGROUND: The objective of this research was to evaluate the feasibility of robotic nerve-sparing radical parametrectomy for cervical cancer after simple hysterectomy. METHODS: A 41 year-old patient was diagnosed with invasive cervical adenocarcinoma after simple hysterectomy. Hysterectomy margins were negative. A robotic nerve-sparing radical parametrectomy was offered and performed 5 weeks later. RESULTS: Total operating time was 330 min, blood loss was 145 ml and length of hospitalization 2 days. Pathology revealed no residual tumour. Normal bladder function resumed on postoperative day 9. At a follow-up of 16 months, the patient remains with no evidence of disease and with normal bladder and bowel function. CONCLUSIONS: Robotic nerve-sparing radical parametrectomy is safe and feasible and can be offered to patients with indications for radical parametrectomy. Copyright (c) 2012 John Wiley & Sons, Ltd.

Siddiqui, N. Y., E. J. Geller, et al. (2012). “Symptomatic and anatomic 1-year outcomes after robotic and abdominal sacrocolpopexy.” American Journal of Obstetrics and Gynecology.

Objective: The purpose of this study was to compare symptomatic and anatomic outcomes 1 year after robotic vs abdominal sacrocolpopexy. Study Design: Our retrospective cohort study compared women who underwent robotic sacrocolpopexy (RSC) with 1 surgeon to those who underwent abdominal sacrocolpopexy (ASC) as part of the Colpopexy and Urinary Reduction Efforts trial. Our primary outcome was a composite measure of vaginal bulge symptoms or repeat surgery for prolapse. Results: We studied 447 women (125 with RSC and 322 with ASC). Baseline characteristics were similar. There were no significant differences in surgical failures 1 year after surgery based on our primary composite outcome (7/86 [8%] vs 12/304 [4%]; P = .16). When we considered anatomic failure, there were also no significant differences between RSC and ASC (4/70 [6%] vs 16/289 [6%]; P = .57). Conclusion: One year after sacrocolpopexy, women who underwent RSC have similar symptomatic and anatomic success compared with those women who underwent ASC. © 2012 Mosby, Inc. All rights reserved.

Silverman, S., L. Orbuch, et al. (2012). “Parallel side-docking technique for gynecologic procedures utilizing the da Vinci robot.” Journal of Robotic Surgery: 1-3.

Minimally invasive approaches to gynecologic surgery have quickly gained favor. The da Vinci surgical system robot as an option for minimally invasive surgery offers many advantages. As the placement of the system between the legs can be prohibitive, we propose a modification of the standard docking procedure by aligning the system parallel to the operating room table. Our experience is that parallel side-docking allows access to the perineum without compromising docking time and range of motion. © 2012 Springer-Verlag London Ltd.

Vitobello, D., G. Siesto, et al. (2012). “Robotic radical parametrectomy with pelvic lymphadenectomy: Our experience and review of the literature.” European Journal of Surgical Oncology.

Aims: To evaluate the feasibility and safety of robotic radical parametrectomy (RRP) and pelvic lymphadenectomy for the management of occult invasive cervical cancer or local recurrence of endometrial cancer and to compare our outcomes with the evidence available in the literature. Methods: Starting from 07/2008 consecutive patients submitted to RRP have been included in this study. A comprehensive literature review of published papers about this subject was carried out. Results: During the study period 11 patients were managed; 7 and 4 patients had an occult cervical cancer and a vaginal recurrence of endometrial cancer, respectively. One intra-operative and one post-operative complications were recorded. Neither conversion to laparotomy, nor blood transfusions occurred. Three women required further adjuvant therapies. After a median follow-up of 19 months (range 8-36) one recurrence has been detected. The outcomes of other 200 women from 15 different papers have been collected and compared to our findings. Conclusions: Robotic surgery represents an effective alternative to accomplish radical parametrectomy with comparable results of those reported in the literature in terms of feasibility and safety. RRP is certainly a demanding procedure which however avoids radiotherapy in more than 80% of cases. © 2012 Elsevier Ltd. All rights reserved.

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