“Minimally invasive approach for myomectomy.”
Agdi, M. and T. Tulandi (2010).
Seminars in Reproductive Medicine 28(3): 228-234.
Uterine fibroids are the most common benign tumor of the uterus in women of reproductive age. However, most of them are asymptomatic and do not require any treatment. Menorrhagia and pelvic pain are the most usual symptoms, and some women may present with infertility or pregnancy-related complications. In those with abnormal uterine bleeding, one should exclude other causes of abnormal vaginal bleeding including endometrial cancer. Diagnosis of uterine fibroid is established by pelvic ultrasonography with or without saline infusion hysterosonography. Management options depend on the patient’s fertility potential and desire for future pregnancy. Submucous myoma should be treated by a hysteroscopic approach. Intramural and subserous myomas in women who opt for nonsurgical treatment could be treated with uterine artery embolization (UAE), high-intensity focused ultrasound (HIFU), or medical treatment such as selective gonadotropin-releasing hormone agonists, progesterone receptor modulators, or aromatase inhibitors. All interventions aside from hysterectomy provide temporary relief, although myomectomy, UAE, and HIFU provides more durable symptom relief relative to current medical management. Patients wishing to preserve their fertility are best treated by myomectomy, which can be done by laparoscopy. A laparoscopic approach is more advantageous than laparotomy, but laparoscopic suturing is more demanding. This can be overcome by robotic-assisted laparoscopic myomectomy.
“Robot-assisted laparoscopic sacrouteropexy for pelvic organ prolapse in classical bladder exstrophy.”
Benson, A. D., B. A. Kramer, et al. (2010).
Journal of Endourology 24(4): 515-519.
Classical bladder exstrophy is a rare congenital anomaly with male predominance. When occurring in women, the accompanying anatomical and functional abnormalities, including pelvic organ prolapse (POP), may cause significant problems in both pediatric and adult patients. The robotic surgical approach to POP has not been described for bladder exstrophy as it has been in otherwise normal women. We report our technique with the first robot-assisted laparoscopic sacrouteropexy for Baden-Walker grade-four POP in an 18-year-old classical bladder exstrophy patient. At 12 months of follow-up, there were no issues or symptoms/evidence of recurrence of POP. To our knowledge, this is the first reported robot-assisted laparoscopic sacrouteropexy for POP in a previously repaired bladder exstrophy case. This procedure may be a viable option in selected patients.
“Minimally Invasive Hysterectomies-A Survey on Attitudes and Barriers among Practicing Gynecologists.”
Einarsson, J. I., K. A. Matteson, et al. (2010).
Journal of Minimally Invasive Gynecology 17(2): 167-175.
“A novel method for training residents in robotic hysterectomy.”
Finan, M. A., M. E. Clark, et al. (2010).
Journal of Robotic Surgery: 1-7.
Standard surgeon training for robotic hysterectomy currently includes the use of a porcine lab to gain experience using the daVinci Surgical System. Residents in obstetrics/gynecology are taught using a novel dry lab which mimics the tasks specific to a robotic hysterectomy. This technique may ultimately aid in the credentialing of gynecologic surgeons, obviating the need for the porcine lab. A lab simulating the anatomy of key tasks in the hysterectomy with salpingo-oophorectomy has been developed using readily available materials. Residents perform simulated tasks under direct supervision. Time to complete, a subjective grading score, and any errors made are recorded and compared amongst the participants. From April 2007 through April 2008, 16 residents participated in the lab. Mean times (range, standard deviation) to perform simulated procedures were: 177.3 s (100-270, 48.2) for dexterity training, 71.9 s (32-171, 34.6) for identification of the ureter and sealing/dividing the infundibulopelvic ligament, 157.8 s (60-300, 76.8) for dissecting the bladder flap, 77 s (25-148, 34.8) for skeletonizing the uterine arteries, and 516 s (270-946, 237.8) for suturing the vaginal cuff. Since completing the lab, five residents have completed a total of 16 robotic hysterectomies on live patients, with no training-related patient complications. This lab closely mimics those segments of a hysterectomy on humans. Here, we describe a technique to train residents for robotic hysterectomy and bilateral salpingo-oophorectomy without the use of a porcine lab. © 2010 Springer-Verlag London Ltd.
“Cost-containment and the need for medical justice reform.”
Howard, P. K. (2010).
Obstetrics and Gynecology 115(3): 489-494.
“Robotic-assisted laparoscopic gynecologic procedures in a fellowship training program.”
Lee, P. S., A. Bland, et al. (2009).
Journal of the Society of Laparoendoscopic Surgeons 13(4): 467-472.
Background and Objective: The robotic surgical platform is an alternative technique to traditional laparoscopy and requires the development of new surgical skills for both the experienced surgeon and trainee. Our goal was to perform an early evaluation of the feasibility of training fellows in robotic-assisted gynecologic procedures at the outset of our incorporation of this technology into clinical practice. Methods: A systematic approach to fellow training included (1) didactic and hands-on training with the robotic system, (2) instructional videos, (3) assistance at the operating table, and (4) performance of segments of gynecologic procedures in tandem with the attending physician. Time to complete the entire procedure, individual segments, rate of conversion to laparotomy, and complications were recorded. Results: Twenty-one robotic-assisted gynecologic procedures were performed from April 2006 to January 2007. Fellows participated as the console surgeon in 14/21 cases. Thirteen patients (62%) had prior abdominal surgery. Median values with ranges were age 51 years (range, 33 to 90); BMI 28 (range, 19.4 to 43.8); EBL 25 mL (range, 25 to 250); and hospital stay 1 day (range, 1 to 4). No significant difference existed between fellow and attending mean total operative and individual segment times. One conversion to laparotomy was necessary. No major surgical complications occurred. Conclusion: These data suggest that it is feasible to incorporate a systematic approach to robotic-assisted laparoscopic training for trainees at the outset of incorporation of this technology into current practice. © 2009 by JSLS.
“Robotically assisted hysterectomy: 100 cases after the learning curve.”
Payne, T. N. and F. R. Dauterive (2010).
Journal of Robotic Surgery: 1-7.
To report on perioperative outcomes of robotic hysterectomy after the learning curve, we performed a retrospective review of our second 100 consecutive robotic hysterectomies performed by two surgeons between January 2007 and February 2008. Operative time following our learning curve was 79.3 ± 36.1 min. Patient age was 44.2 ± 9.6 years, body mass index (BMI) was 30.9 ± 8.3 kg/m<sup>2</sup>, and uterine weight was 223.7 ± 195.8 g. Indications for surgery included fibroids, menstrual disorders, and endometriosis. We performed total robotic-assisted laparoscopic hysterectomy type IVE. There were no conversions, no blood transfusions, and one cystotomy, repaired intraoperatively. Blood loss was 68.8 ± 105.8 cc, and average length of stay was 1.1 ± 0.3 days. There were no postoperative complications. Perioperative outcomes demonstrate low average operative times with a high level of safety on a broadened patient population, suggesting a potential advantage to using the robotic platform. © 2010 Springer-Verlag London Ltd.
“Optimizing Efficiency with robotic-assisted laparoscopic sacrocolopopexy.”
Salamon, Shariati, et al. (2010).
The Female Patient.
“Robotic hysterectomy versus conventional laparoscopic hysterectomy: outcome and cost analyses of a matched case-control study.”
Sarlos, D., L. Kots, et al. (2010).
European Journal of Obstetrics, Gynecology, and Reproductive Biology 150(1): 92-96.
OBJECTIVE: Robotic surgery, with its technical advances, promises to open a new window to minimally invasive surgery in gynaecology. Feasibility and safety of this surgical innovation have been demonstrated in several studies, and now a critical analysis of these new developments regarding outcome and costs is in place. So far only a few studies compare robotic with conventional laparoscopic surgery in gynaecology. Our objective was to evaluate our initial experience performing total robot-assisted hysterectomy with the da Vinci surgical system and compare peri-operative outcome and costs with total laparoscopic hysterectomy. STUDY DESIGN: For this prospective matched case-control study at our institution, peri-operative data from our first 40 consecutive total robot-assisted hysterectomies for benign indications were recorded and matched 1:1 with total laparoscopic hysterectomies according to age, BMI and uterus weight. Surgical costs were calculated for both procedures. Surgeons’ subjective impressions of robotics were evaluated with a self-developed questionnaire. RESULTS: No conversions to laparotomy or severe peri-operative complications occurred. Mean operating time was 109 (113; 50-170) min for the robotic group and 83 (80; 55-165) min for the conventional laparoscopic group. Mean postoperative hospitalisation for robotic surgery was 3.3 (3; 2-6) days versus 3.9 (4; 2-7) days for the conventional laparoscopic group. Average surgical cost of a robot-assisted laparoscopic hysterectomy was 4067 euros compared to 2151 euros for the conventional laparoscopic procedure at our institution. For the robotic group wider range of motion of the instruments and better ergonomics were considered to be an advantage, and lack of direct access to the patient was stated as a disadvantage. CONCLUSION: Robot-assited hysterectomy is a feasible and interesting new technique with comparable outcome to total laparoscopic hysterectomy. Operating times of total laparoscopic hysterectomy seem to be achieved quickly especially for experienced laparoscopic surgeons. However, costs of robotic surgery are still higher than for conventional laparoscopy. Randomised clinical trials need to be conducted to further evaluate benefits of this new technology for patients and surgeons and analyse its cost-effectiveness in gynaecology.
“Survey of obstetrics and gynecology residents’ training and opinions on robotic surgery.”
Smith, A. L., K. M. Schneider, et al. (2010).
Journal of Robotic Surgery: 1-5.
To investigate obstetrics and gynecology residents’ access to training in robotics and their opinions of its utility and future in gynecologic surgery a 31-item questionnaire was developed and distributed to Ob/Gyn residents in the United States via email. Results were tabulated via SurveyMonkey.com<sup>©</sup>. A total of 470 residents representative of all ACOG districts and PGY levels responded. A total of 72% of residents reported ≥3 staff surgeons performing robotic gynecologic surgery at their institution and 70% had participated in robotic surgery in the past 12 months. Robotic hysterectomy (81%) and oncologic surgery (76%) were the most frequently performed procedures. A total of 79% believe their institution should provide formal training in robotics, but only 38% report access to it. A total of 23% have operated at the surgeon console, and 44% plan to incorporate robotic surgery into their practice after completing residency. A total of 3.6% feel equipped to perform robotic surgery without additional training. A total of 63% believe robotic surgery in gynecology will continue to increase in popularity. Exposure to gynecologic robotic procedures during residency is increasing. Although residents believe robotics has a place in gynecology, many feel formalized training has not been successfully implemented into their residency. Development of a structured program for training residents in robotics merits further investigation. © 2010 Springer-Verlag London Ltd.
“Robotic radical parametrectomy in benign disease: report of two cases.”
Zapardiel, I., V. Zanagnolo, et al. (2010).
Acta Obstetricia et Gynecologica Scandinavica.
Abstract Radical parametrectomy is rarely performed for benign diseases given the considerable risk of complications, however, some benign conditions require wide excision of the pelvic tissue, including parametria. We report on two cases of robotic radical parametrectomy performed for benign diseases. An electronic search was also carried out in PubMed database online to review this subject. Robotic surgery for radical parametrectomy seems safe and feasible and may be the preferred approach in terms of both lower complication rates, and shorter hospital stay compared to laparotomy, with the same results in terms of improvement of symptoms of chronic pelvic pain, although further studies are needed to confirm this observation.
“Robotically assisted laparoscopic radical hysterectomy compared with open radical hysterectomy.”
Geisler, J. P., C. J. Orr, et al. (2010).
International Journal of Gynecological Cancer 20(3): 438-442.
BACKGROUND: Radical hysterectomy is a common and effective treatment of early cervical cancer. Modern advances include the use of robotic assistance to perform equivalent minimally invasive procedures. The purpose was to compare surgical and short-term outcomes, as well as margins, between robotic-assisted laparoscopic radical hysterectomy and open radical hysterectomy. METHODS: The first 30 cases of robotically assisted type III radical hysterectomy for cervical cancer were compared with the 30 previous cases of open type III radical hysterectomy. Body mass index, length of operation, nodal yield, margins, estimated blood loss, hospital stay, and complications were all documented and compared. RESULTS: The 30 patients undergoing robotically assisted laparoscopic radical hysterectomy were similar in body mass index to the women undergoing open radical hysterectomy (34 kg/m robotic, 32 kg/m open, P = 0.22). The mean operating time was 154 minutes compared with 166 minutes in the open arm (P = 0.36). The mean blood loss was 165 mL compared with 323 mL in the open arm (P = 0.001). The mean pelvic nodal yield was 25 nodes compared with 26 nodes in the open group (P = 0.45). The mean parametrial margin size was not significantly different between groups. The mean postoperative length of stay was 1.4 days compared with 2.8 days for the open cases (P < 0.001). Urinary retention was significantly more common in the robotic arm. CONCLUSIONS: Radical surgery for cervical cancer can be accomplished using the da Vinci surgical system (Intuitive Surgical, Sunnyvale, Calif) with acceptable blood loss, operating time, parametrial margins, and nodal yield. Future studies need to address long-term outcomes.
“Feasibility, safety, and cost outcomes of laparoscopic management of early endometrial and cervical malignancy.”
Hilaris, G. E., T. Tsoubis, et al. (2009).
Journal of the Society of Laparoendoscopic Surgeons 13(4): 489-495.
Background: The role of laparoscopy in the management of early stage endometrial and cervical cancer is continuously validated by many reports throughout the world. Interestingly, such data are still unavailable in many European countries, as it is in Greece. In this prospective study, we report on initial feasibility, safety, and cost outcomes of laparoscopic management of early stage endometrial and cervical cancer, recently introduced in our country. Materials and Methods: This was a prospective pilot study comprising a case series. Patients referred to a tertiary referral medical center with a recent diagnosis of endometrial or cervical cancer were evaluated, and those meeting inclusion criteria were offered laparoscopic surgical staging. Results: Out of 64 patients evaluated, 17 with early clinical stage endometrial cancer and 8 with early clinical stage cervical cancer underwent successful laparoscopic staging. Mean patient age was 61.6 and 39.2 years, mean BMI was 32.3 and 24.1kg/m<sup>2</sup>, mean operative time was 243 and 284 minutes, mean estimated blood loss was 190mL and 270mL, mean lymph node count was 27.2 and 29.1, and mean hospital stay was 2 and 3 days for endometrial and cervical cancer cases, respectively. The overall costs for the procedures performed were not greater than their laparotomy counterpart. One intraoperative complication was managed laparoscopically, and 2 cases occurred of postoperative lymphocyst formation. Conclusion: To our knowledge, this is the first study of laparoscopic management of early endometrial and cervical cancer in Greece. Our preliminary data support the feasibility, safety, and cost effectiveness of laparoscopic management of early endometrial and cervical cancer in our country and are in accordance with series reported in the international literature. © 2009 by JSLS.
“Placental site trophoblastic tumor presenting as an intramural mass with negative markers: an opportunity for novel diagnosis and treatment with robotic hysterectomy.”
Namaky, D., J. Basil, et al. (2010).
Journal of Robotic Surgery: 1-3.
A patient presented with persistent levels of quantitative human chorionic gonadotropin despite therapy with methotrexate. A dilation and curettage procedure did not provide a pathologic diagnosis. Gestational trophoblastic disease was suspected, but serum biomarkers were unable to provide a pre-operative diagnosis. A mass was found in the uterus by ultrasound and subsequent computed tomography scans. There was no evidence of extrauterine disease, but the uterine mass was continuous with the endometrial cavity, evoking the suspicion of an invasive endometrial mass. The patient underwent robotic hysterectomy for both therapy and diagnosis of suspected gestational trophoblastic disease (GTD). The final pathologic diagnosis was placental site trophoblastic tumor. The robotic approach allows for a minimally invasive surgical procedure with thorough examination of the pelvic cavity and adnexae and does not require a uterine manipulator which may be contra-indicated in the setting of uterine GTD. For patients with suspected persistent uterine GTD who are otherwise candidates for minimally invasive surgery, a robotic procedure offers advantages when compared to traditional laparoscopy or vaginal hysterectomy. © 2010 Springer-Verlag London Ltd.
“From open radical hysterectomy to robot-assisted laparoscopic radical hysterectomy for early stage cervical cancer: aspects of a single institution learning curve.”
Schreuder, H. W. R., R. P. Zweemer, et al. (2010).
Gynecological Surgery: 1-6.
We analysed the introduction of the robot-assisted laparoscopic radical hysterectomy in patients with early-stage cervical cancer with respect to patient benefits and surgeon-related aspects of a surgical learning curve. A retrospective review of the first 14 robot-assisted laparoscopic radical hysterectomies and the last 14 open radical hysterectomies in a similar clinical setting with the same surgical team was conducted. Patients were candidates for a laparoscopic sentinel node procedure, pelvic lymph node dissection and open radical hysterectomy (RH) before August 2006 and were candidates for a laparoscopic sentinel node procedure, pelvic lymph node dissection and robot-assisted laparoscopic radical hysterectomy (RALRH) after August 2006. Overall, blood loss in the open cases was significantly more compared with the robot cases. Median hospital stay after RALRH was 5 days less than after RH. The median theatre time in the learning period for the robot procedure was reduced from 9 h to less that 4 h and compared well to the 3 h and 45 min for an open procedure. Three complications occurred in the open group and one in the robot group. RALRH is feasible and of benefit to the patient with early stage cervical cancer by a reduction of blood loss and reduced hospital stay. Introduction of this new technique requires a learning curve of less than 15 cases that will reduce the operating time to a level comparable to open surgery. © 2010 The Author(s).
“Comparison between robot-assisted laparoscopic radical hysterectomy (RRH) and abdominal radical hysterectomy (ARH): A case control study from EIO/Milan.”
Sert, M. B. (2010).
Gynecologic Oncology 117(2): 389.
“Survey of obstetrics and gynecology residents’ training and opinions on robotic surgery.”
Smith, A. L., K. M. Schneider, et al. (2010).
Journal of Robotic Surgery: 1-5.
To investigate obstetrics and gynecology residents’ access to training in robotics and their opinions of its utility and future in gynecologic surgery a 31-item questionnaire was developed and distributed to Ob/Gyn residents in the United States via email. Results were tabulated via SurveyMonkey.com<sup>©</sup>. A total of 470 residents representative of all ACOG districts and PGY levels responded. A total of 72% of residents reported ≥3 staff surgeons performing robotic gynecologic surgery at their institution and 70% had participated in robotic surgery in the past 12 months. Robotic hysterectomy (81%) and oncologic surgery (76%) were the most frequently performed procedures. A total of 79% believe their institution should provide formal training in robotics, but only 38% report access to it. A total of 23% have operated at the surgeon console, and 44% plan to incorporate robotic surgery into their practice after completing residency. A total of 3.6% feel equipped to perform robotic surgery without additional training. A total of 63% believe robotic surgery in gynecology will continue to increase in popularity. Exposure to gynecologic robotic procedures during residency is increasing. Although residents believe robotics has a place in gynecology, many feel formalized training has not been successfully implemented into their residency. Development of a structured program for training residents in robotics merits further investigation. © 2010 Springer-Verlag London Ltd.
“Robot in endoscopic gynaecological surgery.”
Sturlese, E. and G. Gorchev (2009).
Il robot nella chirurgia ginecologica endoscopica 31(11-12): 465-467.
In the last decade, the robotic surgery has revolutionized the concept of minimally invasive surgery, representing, today, the more advanced form. The robotic surgery has overcome the difficulties and limits of laparoscopy, allowing to extend the minimally invasive surgeryadvantages on more complex operation too. The introduction of da Vinci Surgical System has enabled a innovative surgical technique that proved a gynaecological pathology. For this reason from 2008 we have started off clinic-operative and scientific search collaboration between Medical University of Pleven (Bulgaria), Gynaecological and Oncological division, where this system is operative, and Department of Gynaecological and Obstetrical Science and Reproductive Medicine University of Messina. In our study we have analyzed 15 patients undergone to hysterectomy or myomectomy in laparoscopic robot-assisted technique to evaluate the effective applicability, the advantages and security offered by this technique, which proves to have advantages as permit a precise surgery, less complications during and after operation and less time of hospital stay. The major limit of robotic surgery remains the high costs: a solution could be robot’s share in multidisciplinary. © Copyright 2010, CIC Edizioni Internazionali, Roma.