Abstrakt Gynekologie Srpen 2011 | Česká společnost robotické chirurgie ČLS JEP

“Evolution of surgical management of early-stage endometrial cancer.”

Boruta, D. M., 2nd, W. B. Growdon, et al. (2011).

American Journal of Obstetrics and Gynecology.

OBJECTIVE: We sought to examine the evolution of surgical care for early-stage endometrial cancers and factors affecting use of laparoscopy. STUDY DESIGN: Women with surgically managed early-stage endometrial cancer were divided into 2 groups corresponding to before and after addition of faculty with formal fellowship training in laparoscopic staging and access to a robotic surgery platform. RESULTS: In all, 502 women were identified. Laparoscopic management increased from 24-69% between time periods (P < .0001). Performance of comprehensive surgical staging, and lymph node counts, increased (P < .0001) despite an increase in median body mass index (P = .001). A traditional “straight stick” technique was performed in 72% of laparoscopic cases during the later period. Laparoscopy patients had lower estimated blood losses and shorter hospital stays (each P < .0001) compared to laparotomy patients. CONCLUSION: Addition of faculty with formal fellowship training in laparoscopic staging and access to a robotic surgery platform shifted management of early-stage endometrial cancer toward laparoscopy.

“Women’s Preferences for Minimally Invasive Incisions.”

Bush, A. J., S. N. Morris, et al. (2011)

Journal of Minimally Invasive Gynecology.

STUDY OBJECTIVE: To determine whether traditional, robotic, or single-site laparoscopic incisions are more appealing to women. DESIGN: Descriptive study using a survey (Canadian Task Force classification III). SETTING: Single-specialty referral-based gynecology practice. PATIENTS: All patients older than 18 years who came for care to the Newton-Wellesley Hospital Minimally Invasive Gynecological Surgery Center from April 2, 2010, to June 30, 2010. INTERVENTIONS: Three identical photos of an unscarred female abdomen were each marked with a black pen to indicate typical incision lengths and locations for robotic, single-site, and traditional laparoscopic surgery. Subjects were then asked to rank these incisions in order of preference. Additional demographic and surgical history questions were included in the survey. MEASUREMENTS AND MAIN RESULTS: Two-hundred fifty of 427 patients (58.5%) returned surveys, and of these, 241 completed critical survey elements. Preference for traditional laparoscopic incisions was 56.4% (95% confidence interval [CI], 50.1%-62.7%), for a single incision was 41.1% (95% CI, 34.8%-47.3%), and for robotic surgery was 2.5% (95% CI, 0.5%-4.5%). Two-sample test of proportion (Z test) showed the difference in preference for traditional over the other methods to be significant: p = .007 for a single incision and p < .001 for robotic surgery. Multivariatble analysis for factors influencing choice of single-site incision demonstrated that Latina/Hispanic ethnicity was the only significant factor (p = .02). CONCLUSION: Women prefer both single-site and traditional laparoscopic incisions over robotic procedures. Inasmuch as aesthetics are an important consideration for many women and clinical outcomes are similar, during the informed-consent procedure, location and length of incisions should be included in the discussion of risks, benefits, and alternatives.

“Robot-assisted laparoscopic hysterectomy in obese and morbidly obese women. Surgical technique and comparison to open surgery.”

Geppert, B., C. Lonnerfors, et al. (2011).

Acta Obstetricia et Gynecologica Scandinavica.

Objective. Comparison of surgical results on obese patients undergoing hysterectomy by robot-assisted laparoscopy or laparotomy. Setting. University hospital. Methods. All women (n= 114) with a BMI >/=30kg/m(2) who underwent a simple hysterectomy as the main surgical procedure between November 2005 and November 2009 were identified. Robot-assisted procedures (n= 50) were separated into an early (learning phase) and a late (consolidated phase) group whereas open hysterectomy was considered an established method. Relevant data were retrieved from prospective protocols (robot) or from computerized patient charts (laparotomy) until 12 months after surgery. Complications leading to prolonged hospital stay, readmission/reoperation, intravenous antibiotic treatment or blood transfusion were considered significant. The surgical technique used for morbidly obese patients is described. Results. Women in the late robot group (n= 25) had shorter inpatient time (1.6 compared to 3.8 days, p<0.0001), less bleeding (100 compared to 300 mL, p< 0.0001) and fewer complications (2/25 compared to 23/64, p = 0.006) than women with open surgery (n = 64) but a longer operating time (136 minutes compared to 110 minutes, p = 0.0004). For women with a BMI >/=35 kg/m(2) surgical time in the late robot group and the laparotomy group was equal (136 minutes compared to 128 minutes, p = 0.31). Conclusions. Robot-assisted laparoscopic hysterectomy in a consolidated phase on obese women is associated with shorter hospital stay, less bleeding and less complications compared to laparotomy but, apart from women with BMI >/=35, a longer operative time.

“Prospective comparison of short-term functional outcomes obtained after pure laparoscopic and robot-assisted laparoscopic sacrocolpopexy.”

Seror, J., D. R. Yates, et al. (2011).

World Journal of Urology.

OBJECTIVE: To prospectively compare short-term functional outcomes achieved by laparoscopic or robot-assisted sacrocolpopexy for pelvic organ prolapse. MATERIALS AND METHODS: We prospectively collected clinical and operative data over 24 months for female patients who underwent either pure laparoscopic sacrocolpopexy (LSCP) or robot-assisted laparoscopic sacrocolpopexy (RALSCP). Clinical data included age, BMI and assessment of PFDI-20 score. Perioperative data included operative time and complications. Post-operative outcomes included hospital stay, length of catheterisation, pain and functional outcomes as assessed by clinical examination and PFDI-20 score assessment. RESULTS: Overall, 67 women with a median age of 65 were included: 47 in the LSCP arm and 20 in the RALSCP arm. RALSCP was superior in terms of blood loss (median 55mls vs. 280; P = 0.03) and strict operative time (median 125 min vs. 220; P < 0.0001), but this time advantage was nullified when comparing overall operating room time (215 min vs. 220). With a median follow-up of 16 months, the overall anatomic repair rate was 98.5%, and there was an improvement in overall PFDI-20 score before and after surgery (P = 0.001) but with no difference between the two surgical approaches. CONCLUSIONS: RALSCP allows for a safe and effective repair of pelvic organ prolapse in female patients. Whilst being equivalent to LSCP in terms of functional outcome, it is superior in terms of blood loss and strict operative time. These results are based on short-term assessment, and further studies of larger populations with longer follow-up and objective assessments of outcome are needed to make any definitive statement.

“Robot-assisted laparoscopic hysterectomy in obese and morbidly obese women. Surgical technique and comparison to open surgery.”

Geppert, B., C. Lonnerfors, et al. (2011).

Acta Obstetricia et Gynecologica Scandinavica.

“Robotic single-port transumbilical total hysterectomy: a pilot study.”

Nam, E. J., S. W. Kim, et al. (2011).

Journal of Gynecologic Oncology 22(2): 120-126.

OBJECTIVE: To evaluate the feasibility of robotic single-port transumbilical total hysterectomy using a home-made surgical glove port system. METHODS: We retrospectively reviewed the medical records of patients who underwent robotic single-port transumbilical total hysterectomy between January 2010 and July 2010. All surgical procedures were performed through a single 3-4-cm umbilical incision, with a multi-channel system consisting of a wound retractor, a surgical glove, and two 10/12-mm and two 8 mm trocars. RESULTS: Seven patients were treated with robotic single-port transumbilical total hysterectomy. Procedures included total hysterectomy due to benign gynecological disease (n=5), extra-fascial hysterectomy due to carcinoma in situ of the cervix (n=1), and radical hysterectomy due to cervical cancer IB1 (n=1). The median total operative time was 109 minutes (range, 105 to 311 minutes), the median blood loss was 100 mL (range, 10 to 750 mL), and the median weight of the resected uteri was 200 g (range, 40 to 310 g). One benign case was converted to 3-port robotic surgery due to severe pelvic adhesions, and no post-operative complications occurred. CONCLUSION: Robotic single-port transumbilical total hysterectomy is technically feasible in selected patients with gynecological disease. Robotics may enhance surgical skills during single-port transumbilical hysterectomy, especially in patients with gynecologic cancers.

“Early experience with the da Vinci surgical system robot in gynecological surgery at King Abdulaziz University Hospital.”

Sait, K. H. (2011).

Int J Womens Health 3: 219-226.

BACKGROUND: The purpose of this study was to review our experience and the challenges of using the da Vinci((R)) surgical system robot during gynecological surgery at King Abdulaziz University Hospital. METHODS: A retrospective study was conducted to review all cases of robot-assisted gynecologic surgery performed at our institution between January 2008 and December 2010. The patients were reviewed for indications, complications, length of hospital stay, and conversion rate, as well as console and docking times. RESULTS: Over the three-year period, we operated on 35 patients with benign or malignant conditions using the robot for a total of 62 surgical procedures. The docking times averaged seven minutes. The mean console times for simple hysterectomy, bilateral salpingo-oophorectomy, and bilateral pelvic lymphadenectomy were 125, 47, and 62 minutes, respectively. In four patients, laparoscopic procedures were converted to open procedures, giving a conversion rate of 6.5%. All of the conversions were among the first 15 procedures performed. The average hospital stay was 3 days. Complications occurred in five patients (14%), and none were directly related to the robotic system. CONCLUSION: Our early experience with the robot show that with proper training of the robotic team, technical difficulty with the robotic system is limited. There is definitely a learning curve that requires performance of gynecological surgical procedures using the robot.

“Evolution of surgical management of early-stage endometrial cancer.”

Boruta, D. M., 2nd, W. B. Growdon, et al. (2011).

American Journal of Obstetrics and Gynecology.

“Development of a teaching tool for women with a gynecologic malignancy undergoing minimally invasive robotic-assisted surgery.”

Castiglia, L. L., N. Drummond, et al. (2011).

Clinical Journal of Oncology Nursing 15(4): 404-410.

Women undergoing minimally invasive robotic-assisted surgery for a gynecologic malignancy have many questions and concerns related to the cancer diagnosis and surgery. The provision of information enhances coping with such illness-related challenges. A lack of print materials for these patients prompted the creation of a written teaching tool to improve informational support. A booklet was developed using guidelines for the design of effective patient education materials, including an iterative process of collaboration with healthcare providers and women who had undergone robotic-assisted surgery, as well as attention to readability. The 52-page booklet covers the trajectory of the woman’s experience and includes the physical, psychosocial, and sexual aspects of recovery.

“Fertility preserving options in patients with gynecologic malignancies.”

Eskander, R. N., L. M. Randall, et al. (2011).

American Journal of Obstetrics and Gynecology 205(2): 103-110.

A proportion of reproductive age women are affected by gynecologic malignancies. This patient population is faced with difficult decisions, related to their cancer care and treatment, as well as future childbearing potential. Therefore, it is important for gynecologists to be familiar with fertility sparing management options in patients with cervical, ovarian, and endometrial cancer. In addition to understanding the surgical approaches available, providers should be able to counsel patients regarding their eligibility for and the indications and limitations of fertility sparing therapy for gynecologic cancer, allowing for appropriate referrals. A comprehensive PUBMED literature search was conducted using the key words “fertility preservation,” “cervical cancer,” “endometrial cancer,” “ovarian cancer,” “borderline tumor of the ovary,” “germ cell tumor,” “obstetrical outcomes,” “chemotherapy,” and “radiation.” The following review summarizes fertility sparing options for patients with cervical, ovarian and endometrial cancer, with an emphasis on appropriate patient selection, oncologic, and obstetric outcomes. © 2011 Mosby, Inc.

“Robotic radical parametrectomy for unstaged invasive endometrial carcinoma.”

Frey, M. K., M. J. Worley, Jr., et al. (2011).

International Journal of Gynaecology and Obstetrics.

A 51-year-old woman underwent total laparoscopic hysterectomy for complex hyperplasia; however, final postoperative pathology revealed a deeply invasive high-grade adenocarcinoma. The patient was, therefore, unstaged. Forty-five days later, she underwent robot-assisted radical parametrectomy, upper vaginectomy, and bilateral salpingo-oophorectomy with pelvic and para-aortic lymph node dissection.

“Fallopian tube carcinoma in a patient with a pelvic kidney: surgical management with the da Vinci robot.”

Hoffman, M. S. (2011).

Journal of Robotic Surgery: 1-4.

A patient with a known pelvic kidney and early fallopian tube carcinoma was managed with robotically assisted surgery. Associated conginital anomalies were noted and described. The final stage of the cancer was 1C, grade 3 and she is without evidence of recurrent cancer 2 years following completion of chemotherapy. © 2011 Springer-Verlag London Ltd.

“Early experience with the da Vinci surgical system robot in gynecological surgery at King Abdulaziz University Hospital.”

Sait, K. H. (2011).

Int J Womens Health 3: 219-226.

“Entirely robotic total pelvic exenteration.”

Vasilescu, C., S. Tudor, et al. (2011).

Surgical Laparoscopy, Endoscopy and Percutaneous Techniques 21(4): e200-202.

OBJECTIVE: We present an entirely robotic total pelvic exenteration and extended lymphadenectomy with “barreled ureterocutaneostomy” and end colostomy for recurrent endometrial cancer. In 1948, Brunschwig first described a pelvic exenteration as treatment of advanced recurrent malignancy in the pelvis. Currently it represents the only potentially curative option for patients with recurrent endometrial cancer. METHODS: A 69-year-old female with perineal recurrence invading urethral and vaginal walls, lower rectum and anal sphincter was the perfect candidate for total pelvic exenteration. RESULTS: Total operative time was 250 minutes, with a console time of 175 minutes. The estimated blood loss was 365 mL. CONCLUSIONS: Good oncological results are expected after robotic total pelvic exenteration owing to the accurate, precise dissection and the extension of lymphadenectomy in the narrow space of the deep pelvis similar to robotic prostatectomy and total mesorectal excision.

“Robotic surgery in the obese gynecologic patient.”

Burke, W. M., G. Gossner, et al. (2011).

Clinical Obstetrics and Gynecology 54(3): 420-430.

Despite robust interest in minimally invasive surgery for obese gynecologic patients, widespread use by gynecologic surgeons has been hindered by the technical difficulty of completing these procedures. The use of robotic assistance to overcome these challenges continues to increase. This study discusses the problem of obesity in the United States, provides basic definitions and calculations related to the disease, reviews some of the literature supporting laparoscopic surgery in obese patients, explores the emergence of robotics in this patient population, and offers “surgical pearls” to aid in the successful completion of minimally invasive robotic gynecologic procedures in heavier patients.

“Women’s Preferences for Minimally Invasive Incisions.”

Bush, A. J., S. N. Morris, et al. (2011).

Journal of Minimally Invasive Gynecology.

“[Is there a real place for robotics in proximal tubal surgery?].”

Delotte, J., O. Mialon, et al. (2011).

Gynecologie, Obstetrique et Fertilite.

Tubal surgery requires a fine gesture. Its complexity, the difficulty of learning, the low recognition at the time of T2A and the success of Assisted Reproductive Technology (ART) could have announced the obituary of this surgery. However, in well-trained hands, tubal surgery avoids unnecessary ARTs and even allows pregnancies when medical technology fails. In this context, it is legitimate to ask whether the contribution of new technologies in the operating theatre, such as robotic surgery, can lead to an easy realization of microsurgery on a particularly complex portion of Fallopian tubes: the proximal segment.

“Robotics in gynecological surgery: The story so far and a glimpse into the future.”

Falcone, T. (2011).

Expert Review of Obstetrics and Gynecology 6(4): 361-363.

“Fertility preservation and the role of robotics.”

Gargiulo, A. R. (2011).

Clinical Obstetrics and Gynecology 54(3): 431-448.

Reproductive surgery employs microsurgical techniques to achieve preservation of natural fertility and enhancement of assisted reproductive technologies. The minimalist approach of this branch of gynecology has made it the natural trailblazer of laparoscopic surgery. Minimally invasive conservative treatment of uterine, tubal, ovarian, and peritoneal pathology has long been the gold standard for women of reproductive age. Advanced laparoscopic surgery provides clear advantages over classic microsurgery, at the cost of significant technical challenges. Robot-assisted laparoscopic surgery is now posed to bridge this technical gap and promises to be the next revolution in the field of reproductive surgery.

“Robotic-assisted sacrocolpopexy/sacrocervicopexy repair of pelvic organ prolapse: initial experience.”

Göçmen, A., F. Şanlikan, et al. (2011).

Archives of Gynecology and Obstetrics: 1-6.

Purpose: To present the short-term surgical outcomes of robotic-assisted sacrocolpopexy and sacrocervicopexy. Methods: Between January 2009 and September 2010, 12 patients underwent robotic-assisted pelvic organ prolapse repair including six sacrocolpopexy and six sacrocervicopexy. Patients’ demographics, surgical procedures, operative and postoperative complications, hospital stay, conversion to laparotomy, time data including all operative times and estimated blood loss (EBL) were recorded. Results: All surgeries were completed robotically with no conversion to laparotomy. The average operative time for the robotic-assisted sacrocolpopexy (RASCP) was 150.5 ± 29.6 min (range 114-189) and the mean console time was calculated as 123.6 ± 34.2 min (range 84-166). The averages of the dissection and the suturation time were 34.8 ± 24.3 min (range 13-72) and 63.3 ± 21.8 min (range 28-95), respectively. The mean length of hospitalization was 2.8 ± 0.7 days (range 2-4) and the mean EBL was calculated as 12.5 ± 4.1 ml (range 10-20). There was one intraoperative complication. The mean age and body mass index of the patients underwent robotic-assisted sacrocervicopexy were 38.1 ± 6.5 years (29-47) and 28.4 ± 5.8 kg/m2 (18.6-34.4), respectively. The mean operating times were calculated as follows: set-up time was 25.6 ± 4.0 min, docking time was 3 ± 0.8 min, dissection time was 28.6±7.7 min, suturation time was 70.8 ± 10.9 min and console time was 123.1 ± 23.6 min. There were no recurrences during the follow-up period (12 months) in both groups of the patients. Conclusion: The use of the robotic system during pelvic organ prolapse repair is feasible, safe and may support the surgeon during dissection and suturing at the level of sacral promontory. © 2011 Springer-Verlag.

“The case of robotics and the infrarenal aortic nodes.”

Magrina, J. F. and P. M. Magtibay (2011).

Gynecologic Oncology.

“Robot-assisted techniques and outcomes in the realm of pelvic reconstructive surgery.”

Parnell, B. A. and C. A. Matthews (2011).

Clinical Obstetrics and Gynecology 54(3): 412-419.

Robotic-assisted surgery for the treatment of pelvic organ prolapse continues to grow in popularity as more surgeons adopt this technology. Encompassing all of the benefits of laparoscopic surgery, robotic-assisted techniques allow more surgeons the ability to perform complex tasks such as meticulous deep pelvic dissection and extensive suturing without having to resort to laparotomy. This chapter reviews the techniques involved in the robotic approach to pelvic reconstructive surgery and discusses the currently available information focusing on the outcomes of this procedure.

“Robotic-Assisted Surgery for the Community Gynecologist: Can it Be Adopted?”

Payne, T. N. and M. C. Pitter (2011).

Clinical Obstetrics and Gynecology 54(3): 391-411.

The American College of Obstetricians and Gynecologists and the American Association of Gynecologic Laparoscopists confirm advantages of conventional minimally invasive surgery over laparotomy for benign gynecological procedures; however, adoption remains low for the general gynecologist. A systematic search for gynecology publications was performed using Medline and Scopus. Available data on adoption rates and perioperative outcomes for hysterectomy, myomectomy, sacrocolpopexy, and endometriosis were reviewed. Robotic assistance may provide an improved rate of minimally invasive surgery adoption with equivalent perioperative outcomes to that of conventional techniques. Accessibility and cost remain controversial. Formal training programs are being created to address these issues.

“Prospective comparison of short-term functional outcomes obtained after pure laparoscopic and robot-assisted laparoscopic sacrocolpopexy.”

Seror, J., D. R. Yates, et al. (2011).

World Journal of Urology.

“Da vinci sacrocolpopexy in urogenital prolapse surgery.”

Struppl, D. (2011).

Da vinci sakrokolpopexe v chirurgii urogenitálního prolapsu 20(1): 24-28.

The surgical repair of pelvic organ prolapse (POP) has a major role to play nowadays, but due to aging of the population will be even more important in the future. There are many innovative changes in the concept of POP surgery during last decade, especially in new techniques and implants to reach the optimal tissue support. The POP is a multicompartmental disorder and usually consists of urethrocele, cystocele, uterine or vaginal vault prolapse, enterocoele or rectocele. We summarize the evolution of the newest techniques of sacrocolpopexy especially using the da Vinci surgical robotic system and we evaluate the current role of robotic sacrocolpopexy in POP surgery as well.

“Understanding the financial impact of robotics in gynecologic surgery.”

Swan, K. and A. P. Advincula (2011).

Clinical Obstetrics and Gynecology 54(3): 449-457.

As surgical innovation and technological advancements evolve, the associated costs cannot be overlooked. Currently, the United States health care system is undergoing an attempted overhaul with technology such as robotics sitting front and center of the financial debate. As patient demand for less invasive surgical options increases and standards of practice change, patient outcomes must be carefully evaluated to justify the costs increase from traditional, often more invasive treatments. The collection of financial data is quite varied among hospital systems and so is the models used to determine the costs of robotics. Although limited thus far, various cost data have been ascertained in the areas of reproductive surgery, hysterectomy (both benign and oncologic), and pelvic reconstructive surgery.