Faculty Bibliography

BACKGROUND AND OBJECTIVES/OBJECTIVE:To determine perioperative outcome differences in patients undergoing robotic-assisted laparoscopic surgery (RALS) versus conventional laparoscopic surgery (CLS) for advanced-stage endometriosis. METHODS:This retrospective cohort study at a minimally invasive gynecologic surgery center at 2 academically affiliated, urban, nonprofit hospitals included all patients treated by either robotic-assisted or conventional laparoscopic surgery for stage III or IV endometriosis (American Society for Reproductive Medicine criteria) between July 2009 and October 2012 by 1 surgeon experienced in both techniques. The main outcome measures were extent of surgery, estimated blood loss, operating room time, intraoperative and postoperative complications, and length of stay, with medians for continuous measures and distributions for categorical measures, stratified by body mass index values. Robotically assisted laparoscopy and conventional laparoscopy were then compared by use of the Wilcoxon rank sum, χ(2), or Fisher exact test, as appropriate. RESULTS:Among 86 conventional laparoscopic and 32 robotically assisted cases, the latter had a higher body mass index (27.36 kg/m(2) [range, 23.90-34.09 kg/m(2)] versus 24.53 kg/m(2) [range, 22.27-26.96 kg/m(2)]; P < .0079) and operating room time (250.50 minutes [range, 176-328.50 minutes] versus 173.50 minutes [range, 123-237 minutes]; P < .0005) than did conventional laparoscopy patients. After body mass index stratification, obese patients varied in operating room time (282.5 minutes [range, 224-342 minutes] for robotic-assisted laparoscopy versus 174 minutes [range, 130-270 minutes] for conventional laparoscopy; P < .05). No other significant differences were noted between the robotic-assisted and conventional laparoscopy groups. CONCLUSION/CONCLUSIONS:Despite a higher operating room time, robotic-assisted laparoscopy appears to be a safe minimally invasive approach for patients, with all other perioperative outcomes, including intraoperative and postoperative complications, comparable with those in patients undergoing conventional laparoscopy.

OBJECTIVES/OBJECTIVE:The objectives of this study were to evaluate the current evidence of the association of endometriosis and subsequent carcinoma of the ovary and to contextualize this evidence into daily practice issues. METHODS:This study is a critical review of observational and in vitro studies. RESULTS:Although the lifetime risk for ovarian cancer is low in general population and remains low in the broad spectrum of endometriosis, there may be clusters of individuals at higher risk of oncogenesis, whose identification would allow individualized surveillance and prophylactic interventions. Prevalence studies show that specific subtypes of ovarian cancer predominate in women with endometriosis. This has been validated in pathogenetic, genomic, immunobiologic, and hormonal studies. CONCLUSIONS:Taken together, these data provide a strong rationale for identifying, monitoring, counseling, and treating women with endometriosis who are at highest risk for cancer conversion.

Proper development of each component of the reproductive tract is imperative for successful natural reproduction. The aim was to investigate some morphological features of the fetal uterus in early phases of its development. The uteruses of 65 fetuses of different gestational age were included and each of them was measured in three dimensions: uterine length (UL), uterine width (BC) and the antero-posterior (sagittal) thickness of the uterine fundus (FT) using ImageJ computer program. It was observed that the most intense fetal uterus growth occurred between seventh and eighth month of gestational age (between week 25 and 31). The most intense rate of uterine growth had UL and it showed steeper growth curve from the fourth month of gestational age. The values of UL, BC, FT showed statistically highly positive Pearson's linear correlation with values of CRL, and GA, and among themselves. The strongest correlation was between UL and gestational age. Contrary to proved rising linear trends of UL/FT and UL/BC, BC/FT performed linear trend of decline. However, two divergent linear trends, one ascending (UL/FT), and other declining (BC/FT) have similar descent in values during the early gestational age, from week 12 to 15. Fetal uteruses did not grow at the same rate by all three measured dimensions, and each of measured dimensions has noticeable standard deviations during gestational periods, even with a resolution of a week, suggesting individuality of each human development/growth even during prenatal life.

OBJECTIVE: The objective of this study was to examine perioperative outcomes, including complication rates, of conventional laparoscopy (CL) versus robotic-assisted laparoscopy (RALS) in the evaluation and management of early, advanced, and recurrent ovarian, fallopian tube, and peritoneal cancer. METHODS: This is a retrospective analysis of a prospectively maintained database of surgery performed from July 2008 to December 2012. Sixty-three women had 83 surgeries performed; 22 surgeries for early-stage disease (International Federation of Gynecology and Obstetrics stage I) and 61 for advanced and/or recurrent disease. RESULTS: Of the 22 for early stage, 10 were CL, 9 were RALS, and 3 were laparoscopy converted to laparotomy (LP). There was no significant difference between CL and RALS in estimated blood loss (EBL, P = 0.27) or length of stay (LOS, P = 0.43); however, both had significantly less EBL (P = 0.03 and 0.03, respectively) and LOS (P = 0.03 and 0.03) than LP. There was no difference in OR time among the groups (P = 0.79). One patient (33%) had an intraoperative complication in LP. One patient (10%) had a postoperative complication in CL, 2 (22%) in RALS, and 1 (33%) in LP, with no significant difference (P = 0.61).Among the 42 patients with advanced/recurrent disease, 61 surgeries were performed: 14 diagnostic procedures and 47 cytoreductive surgeries. Of the 47, there was no difference in operating room time (P = 0.10). There was no difference in EBL or LOS between CL and RALS (P = 0.82, P = 0.87); however, both were less in CL (P < 0.001 and P = 0.02) and RALS (P = 0.01 and P = 0.02) compared with LP. There were 5 (63%) intraoperative transfusions in LP and none in CL or RALS. When including all surgeries for advanced/recurrent disease, there was 1 intraoperative complication (12%) in LP. There was no difference in postoperative complications between groups (P = 0.89); 8 patients (19%) had postoperative complications in CL, 2 (18%) in RALS, and 2 (25%) in LP. Overall, there were no grade 4 or 5 complications and no perioperative or intraoperative deaths. CONCLUSIONS: In our experience, perioperative outcomes are comparable between CL and RALS in both early and advanced/recurrent disease and not inferior to laparotomy, making CL and RALS an acceptable approach in selected patients.

STUDY OBJECTIVE: To compare the outcome of robotic-assisted laparoscopy vs conventional laparoscopy in the management of ovarian masses. DESIGN: Retrospective cohort (Canadian Task Force classification II-3). SETTING: Academic medical centre in the northeast United States. PATIENTS: Retrospective medical record review of 71 consecutive patients with presumed benign ovarian masses. INTERVENTION: Robotic-assisted laparoscopy in 30 patients with presumed benign ovarian masses was compared with conventional laparoscopy in 41 patients. MEASUREMENTS AND MAIN RESULTS: Operative outcomes including operative time, estimated blood loss, length of hospital stay, and complications were recorded. Standard statistical analysis was used to compare the outcomes in the 2 groups. Mean (SD) operative time in the robotic group was 1.95 (0.63) hours, which was significantly longer than in the conventional laparoscopic group, 1.28 (0.83) hours (p = .04). Estimated blood loss in the robotic group was 74.52 (56.23) mL, which was not significantly different from that in the conventional laparoscopic group, 55.97 (49.18) mL. There were no significant differences in length of hospital stay between the robotic and conventional laparoscopic groups: 1.20 (0.78) days and 1.48 (0.63). Conversion to laparotomy was not necessary in either group of patients. Intraoperative and postoperative complications were similar between the 2 groups. CONCLUSION: Robotic-assisted laparoscopy is a safe and efficient technique for management of various types of ovarian masses. However, conventional laparoscopy is preferred for management of ovarian masses because of shorter operative time. Prospective studies are needed to evaluate the outcomes of robotic-assisted laparoscopic management of benign and malignant ovarian neoplasms.

OBJECTIVE:Lymphoceles are among the most common postoperative complications of pelvic lymphadenectomy (PL), with a reported incidence of 1% to 50%. Symptoms are pelvic pain, leg edema, gastrointestinal obstruction, obstructive uropathy, and deep vein thrombosis, and severe complications such as sepsis and lymphatic fistula formation. After laparoscopic PL, we tested the prevention of lymphoceles using collagen patch coated with the human coagulation factors (TachoSil, Nycomed International Management GmbH, Zurich, Switzerland) on 55 patients with endometrial cancer stages IB to II who had undergone laparoscopy. MATERIALS AND METHODS/METHODS:The authors divided the patients into 2 laparoscopy groups: PL plus TachoSil (group 1: 26 patients) and PL without TachoSil in a control group (group 2: 29 patients), as historical cohort of patients who underwent PL between 2010 and 2012. We collected surgical parameters, and the patients underwent ultrasound examination on postoperative days 7, 14, and 28. The main outcome measures were the development of symptomatic or asymptomatic lymphoceles, the need for further surgical intervention, as adverse effect of surgery, and the drainage volume and duration. RESULTS:The same number of lymph nodes in both groups was removed; group 1 showed a lower drainage volume. Lymphoceles developed in 5 patients in group 1 and in 15 patients in group 2; of these, only 2 patients were symptomatic in group 1 and 5 patients were symptomatic in group 2, without statistical difference and no percutaneous drainage request. CONCLUSIONS:In this preliminary investigation, the intraoperative laparoscopy application of TachoSil seems to reduce the rate of postoperative lymphoceles after PL, providing a useful additional treatment option for reducing drainage volume and preventing lymphocele development after PL.

OBJECTIVE:To compare postoperative pain after conventional laparoscopic and robotically assisted laparoscopic surgery in gynecology. METHODS:This is a prospective nonrandomized analysis of patients undergoing conventional laparoscopy or robotically assisted laparoscopy in a university-affiliated hospital between March 2011 and March 2012. Postoperative pain was measured using the Numeric Rating Scale and the narcotic use converted to morphine sulfate equivalents. The primary outcome was the Numeric Rating Scale pain score obtained on the first postoperative day. RESULTS:One hundred ten patients were enrolled; 91 were included in the statistical analysis. Both groups were similar with regard to race, history of abdominopelvic surgeries, psychiatric history, and substance abuse. Patients undergoing robotically assisted laparoscopy were 6 years older and had a body mass index 6 points higher. Median length of hospital stay for conventional laparoscopy and robotically assisted laparoscopy was 2 days and 3 days, respectively (P<.001); median to being off narcotics was 4 days and 4.5 days, respectively (P=.336); and median return to normal activities was 13 days and 21 days, respectively (P=.021). There were no significant differences in mean Numeric Rating Scale pain scores over time (P=.499) or mean narcotic requirements (P=.393) between groups. CONCLUSION/CONCLUSIONS:Robotically assisted laparoscopy is equivalent to conventional laparoscopy in terms of subjective and objective measures of postoperative pain.

BACKGROUND:Recently, we have shown advantages of a direct optical entry (DOE) using a bladeless trocar in comparison with the open Hasson technique (OHT) in older reproductive-age women with previous operations, as well as in comparison with Veress needle entry in reproductive-age and postmenopausal women. OBJECTIVES/OBJECTIVE:A prospective multicenter randomized study to determine whether the DOE is feasible for establishing safe and rapid entry into the abdomen in comparison with those of the OHT in reproductive-age obese women. METHODS:Two types of surgical techniques were blindly applied in 224 obese reproductive-age women with benign neoplastic diseases of ovary and uterus. Namely, laparoscopic entry into the abdomen in 108 patients was performed by DOE and in 116 women by OHT. Following parameters (entry time in seconds needed to establish the intra-abdominal vision after pneumoperitoneum, blood loss, occurrence of vascular and/or bowel injuries) were compared during surgery as main outcomes. RESULTS:Main baseline characteristics of patients, including age (36.1 ± 4.5 vs 35.7 ± 5.8), body mass index (34.9 ± 5.1 vs 35.1 ± 4.9 kg/m(2)), and parity (2.1 ± 0.4 vs 1.9 ± 0.9), were not significantly different between the DOE and OHT groups (P > .05). While intraoperative parameters such as the entry time (71.9 ± 3.7 vs 215.1 ± 6.2 seconds) and blood loss value (9.7 ± 6.1 vs 12.2 ± 2.9 mL) were significantly reduced in the DOE group in comparison with those of OHT group (respectively, P < .0001 and < .01), there were also trends to slight decrease of the occurrence of the minor injuries, manifested as omental small vessels rupture (0 of 108 vs 4 of 116) and punctures and pinches of jejunal serosa (0 of 108 vs 3 of 116) in patients of the DOE group in comparison with those of OHT group (respectively, P = .0515 and = .0925). CONCLUSIONS:DOE reduced entry time and blood loss with trends to slightly decrease of the occurrence of the minor vascular and bowel injuries, thus enabling a possible alternative to OHT in obese women; however, further larger trials need to confirm the possible additional benefits of a DOE.