“In Reply.”
Advincula, A. P. and A. G. Visco (2009).
Obstetrics and Gynecology 114(1): 168-169.
“The first 100 da Vinci hysterectomies: an analysis of the learning curve for a single surgeon.”
Bell, M. C., J. L. Torgerson, et al. (2009).
South Dakota medicine : the journal of the South Dakota State Medical Association 62(3).
BACKGROUND: Robotic gynecologic procedures were FDA-approved in March 2005. Published average times for robotic hysterectomies vary from 192 minutes to 242 minutes and one report indicated operative times ranging from 4.5 to ten hours. Many critics cite learning curves and increased operative times as a deterrent to performing robotic hysterectomies. METHODS: This is a retrospective review of surgical times (learning curve) for the first 100 consecutive extrafascial hysterectomies with or without salpingo-oophorectomy for a single surgeon. Operating times were recorded by operating room nursing staff for each case. The times reported are from “skin to skin,” which is defined as from when the surgeon started to place anything vaginally until the last suture was placed to close the trocar sites. We report average times for hysterectomy per 20 cases. RESULTS: The average time for hysterectomies was as follows: First 20 cases–124 minutes, second 20 cases–94 minutes, third 20 cases–85 minutes, fourth 20 cases–88 minutes, fifth 20 cases–81 minutes. Age, body mass index and uterine weights were comparable between groups. Complications were highest in the first 20 at 15 percent, compared with 5 percent for the remaining groups, but this did not reach statistical significance. CONCLUSIONS: The learning curve for da Vinci hysterectomies is steep, with the maximum improvement in surgical times in the first 20 cases. Minimal improvement was demonstrated after this.
“Incidence and characteristics of patients with vaginal cuff dehiscence after robotic procedures.”
Kho, R. M., M. N. Akl, et al. (2009).
Obstet Gynecol 114(2 Pt 1): 231-235.
OBJECTIVE:: To estimate the incidence and characteristics of patients with vaginal cuff dehiscence after robotic cuff closure. METHODS:: We reviewed medical records from March 2004 to December 2008 of all patients with vaginal cuff dehiscence after a robotic simple and radical hysterectomy, trachelectomy, and upper vaginectomy using the robotic da Vinci Surgical System. RESULTS:: Twenty-one of 510 patients were identified with vaginal cuff dehiscence (incidence 4.1%, 95% confidence interval 2.3-5.8%). In nine patients, the robotic procedure was performed for a gynecologic malignancy. Coitus was the triggering event in 10 patients. Patients most commonly presented with vaginal bleeding and sudden gush of watery vaginal discharge. Bowel evisceration was associated in six patients. Median time to presentation was 43 days or 6.1 weeks. Nineteen cases were repaired through a vaginal approach and one combined vaginal and laparoscopic. Three of 21 patients experienced a repeat dehiscence and required a second repair. CONCLUSION:: Vaginal cuff dehiscence should be considered in patients with vaginal bleeding and sudden watery discharge after robotic cuff closure. The incidence is similar as previously reported for laparoscopic procedures. Contributing factors remain unknown but thermal effect and vaginal closure technique probably play major roles. LEVEL OF EVIDENCE:: III.
“Robotic assisted total pelvic exenteration: A case report.”
Lim, P. C. (2009).
Gynecol Oncol.
“Robot-assisted laparoscopic myomectomy; a feasible technique for removal of unfavorably localized myomas.”
Lonnerfors, C. and J. Persson (2009).
Acta Obstet Gynecol Scand: 1-6.
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.
“Robot-assisted gynecological surgery in a community setting.”
Piquion-Joseph, J. M., A. Nayar, et al. (2009).
Journal of Robotic Surgery 3(2): 61-64.
The objective of this study is to review our experience using the da Vinci robotic system to perform various gynecological surgeries for benign indications. Between July 2005 and April 2008, 110 patients underwent robot-assisted gynecological surgeries in Rochester General Hospital, NY. The records of these patients were retrospectively reviewed by an independent data collector to analyze the safety, effectiveness, and outcome of the surgeries done using the robotic system. The parameters reviewed include indication for surgery, type of procedure, operative time, blood loss, hospital stay, and intraoperative and post operative complications. The procedures completed include 74 hysterectomies including hysterectomies with bilateral salpingoophorectomy, 15 hysterectomies with sacrocolpopexy and other concomitant procedures, 18 myomectomies, and 3 oophorectomies. All procedures were completed robotically without the need for conversion to an open approach. The mean operation time was 2.15 h. Average estimated blood loss was 160 cc. Complications encountered include one cystotomy which was identified immediately and repaired in addition to one vault dehiscence and two post operative infections. The mean hospital stay was 1 day, with more than half of the patients being discharged within 24 h after the surgery. Post operative pain level was in the range of 0-6 in a scale of 0-10 (0: no pain, 10: worst pain in their life) and relieved by non-steroidal anti-inflammatory drugs. Robot-assisted laparoscopic benign surgical procedures are feasible techniques in a community setting. Robot-assisted laparoscopy has a promising future in minimally invasive surgery as it proved beneficial for our patients who experienced low complication rate and overall fast recovery compared to other approaches. © 2009 Springer-Verlag London Ltd.
“Vaginal Cuff Dehiscence After Robotic Total Laparoscopic Hysterectomy.”
Robinson, B. L., J. B. Liao, et al. (2009).
Obstet Gynecol 114(2, Part 1): 369-371.
BACKGROUND:: Vaginal cuff dehiscence with small bowel evisceration after hysterectomy is a rare event that may be occurring more frequently with the advent of robotic laparoscopic hysterectomies. CASES:: Two women underwent robotic total laparoscopic hysterectomy for menorrhagia and stage I endocervical adenocarcinoma, respectively. Each presented 7-8 weeks postoperatively with abdominal pain and vaginal pressure after intercourse. The small bowel protruded into the vagina through the dehisced vaginal cuff. Both cuffs were repaired vaginally with delayed absorbable suture. One repair required revision 7 weeks after the initial repair. CONCLUSION:: Robotic total laparoscopic hysterectomy may be associated with increased risk of vaginal cuff dehiscence and small bowel evisceration. This observation may be because of thermal spread and cuff tissue damage from electrosurgery used for colpotomy.
“Comprehensive surgical staging for endometrial cancer in obese patients.”
Cohn, D. E., L. G. Seamon, et al. (2009).
Obstetrics and Gynecology 114(1): 16-21.
OBJECTIVE: To compare adequacy and outcomes of surgical staging for endometrial cancer in obese women by robotics or laparotomy. METHODS: Clinical stage I or occult stage II endometrial cancer patients with body mass indexes (BMIs) of at least 30 (BMI is calculated as weight (kg)/[height (m)] 2) were identified undergoing robotic staging and matched 1:2 with laparotomy patients. Patient characteristics, operative times, complications, and pathologic factors were collected. An adequate lymphadenectomy was defined arbitrarily as at least 10 total nodes removed, and adequate pelvic and paraaortic lymphadenectomy was defined as at least six and at least four nodes removed, respectively. RESULTS: A total of 109 patients underwent surgery with the intent of robotic staging and were matched to 191 laparotomy patients. The mean BMI was 40 for each group. The robotic conversion rate was 15.6% (95% confidence interval [CI] 9.5-24.2%). Ninety-two completed robotic patients were compared with 162 matched laparotomy patients. The two groups were comparable regarding total lymph node count (25±13 compared with 24±12, P=.45) and the percentage of patients undergoing adequate lymphadenectomy (85% compared with 91%, P=.16) and adequate pelvic (90% compared with 95%, P=.16) and aortic lymphadenectomy (76% compared with 79%, P=.70) for robotic and laparotomy patients, respectively, but there was limited power to detect this difference. The blood transfusion rate (2% compared with 9%, odds ratio [OR] 0.22, 95% CI 0.05-0.97, P=.046), the number of nights in the hospital (1 compared with 3, P<.001), complications (11% compared with 27%, OR 0.29, 95% CI 0.13-0.65 P=.003), and wound problems (2% compared with 17%, OR 0.10, 95% CI 0.02-0.43, P=.002) were reduced for robotic surgery.CONCLUSION: In obese women with endometrial cancer, robotic comprehensive surgical staging is feasible. Importantly, obesity may not compromise the ability to adequately stage patients robotically. © 2009 by The American College of Obstetricians and Gynecologists.
“Robotic radical hysterectomy.”
Fanning, J., R. Hojat, et al. (2009).
Minerva Ginecologica 61(1): 53-55.
Robotic radical hysterectomy is increasingly being utilized In the treatment of cervical cancer and Initial studies are promising. Compared to open radical hysterectomy, robotic radical hysterectomy is expected to result in decreased pain, infection, length of stay, and adhesions and quicker return to activity. Prospective randomized controlled trials are needed to compare robotic, laparoscopic and open radical hysterectomy for the treatment of cervical cancer.
“Incorporating laparoscopy in the practice of a gynecologic oncology service: Actual impact beyond clinical trials data.”
Ghezzi, F., A. Cromi, et al. (2009).
Annals of Surgical Oncology 16(8): 2305-2314.
Background: Feasibility and safety of laparoscopic management of gynecologic cancers have been established by numerous clinical trials. However, the degree to which such results are achievable outside the context of formal research programs and the actual extent of laparoscopy uptake since its introduction are unclear. Purpose of this study was to examine the impact upon operative and cancer outcomes of the incorporation of laparoscopy into the surgical practice of our gynecologic oncology service. Methods: Data from 383 consecutive women undergoing surgery for the treatment of an apparently early-stage gynecologic cancer between 2000 and 2008 were analyzed. Integration of minimally access surgery for the treatment of invasive malignancies began with borderline ovarian tumors in 2001 and proceeded sequentially to include endometrial, ovarian, and cervical cancer patients. Results: The annual proportion of laparoscopic cases has increased significantly over the study period from 7.7% in 2001 to 90.9% in 2008 (P < 0.0001 for trend). A temporal trend toward reduction in estimated blood loss was observed in both endometrial cancer and cervical cancer patients (P < 0.0001). There was a significant decrease in the percentage of patients requiring blood transfusions [18 (17.1%) during the period 2000-2002, 19 (13.6%) during 2003-2005, and 8 (5.8%) during 2006-2008; P = 0.005 for trend]. Length of hospital stay has decreased significantly over time for all disease sites (P < 0.0001 for endometrial and cervical cancer; P = 0.02 for ovarian cancer). No difference was found in median operative time, number of lymph nodes harvested, complication rates, 1- and 2-year disease-free survival, and overall survival when data of subsequent time periods were compared. Conclusions: Substantial utilization of laparoscopy in the existing practice of a gynecologic oncology service provided benefits to patients without detrimental effects on clinical outcomes. The relatively short follow-up time of laparoscopic cases disallows firm conclusions on long-term survival. © 2009 Society of Surgical Oncology.
“Incidence and characteristics of patients with vaginal cuff dehiscence after robotic procedures.”
Kho, R. M., M. N. Akl, et al. (2009).
Obstet Gynecol 114(2 Pt 1): 231-235.
OBJECTIVE:: To estimate the incidence and characteristics of patients with vaginal cuff dehiscence after robotic cuff closure. METHODS:: We reviewed medical records from March 2004 to December 2008 of all patients with vaginal cuff dehiscence after a robotic simple and radical hysterectomy, trachelectomy, and upper vaginectomy using the robotic da Vinci Surgical System. RESULTS:: Twenty-one of 510 patients were identified with vaginal cuff dehiscence (incidence 4.1%, 95% confidence interval 2.3-5.8%). In nine patients, the robotic procedure was performed for a gynecologic malignancy. Coitus was the triggering event in 10 patients. Patients most commonly presented with vaginal bleeding and sudden gush of watery vaginal discharge. Bowel evisceration was associated in six patients. Median time to presentation was 43 days or 6.1 weeks. Nineteen cases were repaired through a vaginal approach and one combined vaginal and laparoscopic. Three of 21 patients experienced a repeat dehiscence and required a second repair. CONCLUSION:: Vaginal cuff dehiscence should be considered in patients with vaginal bleeding and sudden watery discharge after robotic cuff closure. The incidence is similar as previously reported for laparoscopic procedures. Contributing factors remain unknown but thermal effect and vaginal closure technique probably play major roles. LEVEL OF EVIDENCE:: III.
“Indications and teaching of fertility preservation in the surgical management of gynecologic malignancies: European perspective.”
Leblanc, E., F. Narducci, et al. (2009).
Gynecologic Oncology 114(2 SUPPL.).
Young women affected by a malignant tumor have to cope, after the announcement of diagnosis, with the treatment and its secondary effects. Indeed, some of them may definitively impact on their fertility potential. Especially in pelvic tumors, treatments are more or less mutilating, either by a direct surgical resection of pelvic organs or by destruction of their functioning after chemotherapy or radiation therapy. Surgeons are often at the front line in the management of gynecologic tumors. It is important for them to be aware not only of the surgical techniques currently available to preserve fertility, but as well of their indications and limits, according to the tumor type or its treatment. This knowledge will enable them to deliver fair information to the patient or couple, keeping in mind that, multidisciplinarity is of a paramount importance and referring a patient to a more experienced team, is sometimes the best solution. Through a literature review, we report on the most recent results of the different options available today according to cancer localization as well as some opinions concerning indications, management, organization of care, and teaching of these techniques. © 2009 Elsevier Inc. All rights reserved.
“A Multiinstitutional Experience With Robotic-Assisted Hysterectomy With Staging for Endometrial Cancer.”
Lowe, M. P., P. R. Johnson, et al. (2009).
Obstet Gynecol 114(2, Part 1): 236-243.
OBJECTIVE:: To report perioperative outcomes and learning curve characteristics from a multiinstitutional experience with robotic-assisted surgical staging for endometrial cancer. METHODS:: A multiinstitutional robotic surgical consortium was created to evaluate the usefulness of robotics for gynecologic oncology surgery. An analysis of a multiinstitutional database of all patients who underwent robotic surgery for endometrial carcinoma between April 2003 and January 2009 was performed. Records were reviewed for demographic data and perioperative outcomes. Individual surgeon outcomes were analyzed as well in an attempt to evaluate characteristics of learning with incorporation of robotic technology. RESULTS:: Four hundred five patients were identified who underwent robotic surgery for endometrial cancer. Mean age was 62.2 years and mean body mass index was 32.4. Fifty-five percent of patients reported a prior abdominal surgery. Final pathologic analysis demonstrated that 89.6% of all patients had stage I and II disease. Mean operative time was 170.5 minutes. Mean estimated blood loss was 87.5 mL. Mean lymph node count was 15.5. Mean hospital stay was 1.8 days. Intraoperative complications occurred in 3.5% of the patients and conversion to laparotomy occurred in 6.7%. Postoperative complications were reported in 14.6% of the patients. For the group, fewer than 10 cases were required to achieve proficiency with the procedure. CONCLUSION:: Robotic technology may level the playing field between the novice and expert laparoscopist for endometrial cancer staging. Prospective trials should be undertaken to compare robotic and laparoscopic approaches to treat endometrial cancer. LEVEL OF EVIDENCE:: III.
“Robotic approach for cervical cancer: Comparison with laparotomy A case control study.”
Maggioni, A., L. Minig, et al. (2009).
Gynecol Oncol.
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.
“Minimally invasive surgery in gynecologic oncology.”
Magrina, J. F. (2009).
Gynecologic Oncology 114(2 SUPPL.).
“Emergence of robotic assisted surgery in gynecologic oncology: American perspective.”
Mendivil, A., R. W. Holloway, et al. (2009).
Gynecologic Oncology 114(2 SUPPL.).
Objectives: To discuss the emergence of robotic surgery in gynecologic oncology and describe the growth of robotic surgery in a university medical center and a community based practice. Methods: In addition to the historical evolution of the robotic assisted surgery medicine, a survey of robotic cases was performed on two robotic programs since the inception of the programs. A review of the current literature on the use of the da Vinci robot in gynecologic oncology was also performed. Results: The robotic surgery programs at UNC Hospital and Florida Hospital are growing steadily since the inception of the programs in 2005 and 2006, respectively. Since 2005 there have also been numerous publications detailing the effectiveness, safety, and efficiency of the robot. Conclusions: Robotic surgery is gaining acceptance and is rapidly growing as evidenced by an increased number of publications on the topic; these publications demonstrate the safety, efficacy, and improved outcomes compared to open surgery and conventional laparoscopy. © 2009.
“Robot-assisted laparoscopic surgery in gynaecological oncology; initial experience at Oslo Radium Hospital and 16 months follow-up.”
Sert, M. B. and R. Eraker (2009).
Int J Med Robot.
BACKGROUND: This study aimed to report our initial experience using the Da Vinci((R)), a three-armed Intuitive Surgical robotic unit, in relation to gynae-oncological operations. METHODS: A prospective database was used in this retrospective analysis of 53 consecutive women with gynae-oncological diseases who were operated by the same surgeon in a single institution. All the patients were informed of the risks inherent with each surgical procedure as well as the potential advantages. RESULTS: 125 different procedures were performed, including total robotic radical hysterectomy (n = 25), restaging with total hysterectomy and bilateral salpingo-oophorectomy, total omentectomy, appendectomy, bilateral pelvic and para-aortic node dissections. Mean age of the patients, 45.8 (range 27-70) years; mean operative time, 219 (range 110-530) min; mean console time, 170 (range 60-445) min; mean estimated blood loss, 57 (range 10-300) ml; mean post-operative stay, 3 (range 1-6) days. No robot-related complications occurred. No conversions were reported. Mean follow-up time was 16 (range 0-28) months. CONCLUSIONS: Our preliminary experience with robotic surgery suggest that it is a safe technique and could allow complex radical operations to be performed with greater precision. Copyright (c) 2009 John Wiley & Sons, Ltd.