Faculty Bibliography

The role of lymphadenectomy in the management of endometrial carcinoma remains controversial in gynecologic oncology. Comprehensive pelvic and paraaortic lymphadenectomy should be performed in patients with intermediate- and high-risk endometrial cancer.

BACKGROUND:Obturator nerve injury may occur in gynecologic surgery, particularly in cases in which extensive pelvic sidewall retroperitoneal dissection is performed. The lack of tactile feedback from the robotic surgical system may contribute to obturator nerve injury. If surgical division occurs, microsurgical end-to-end anastomosis of the obturator nerve may be performed. CASE/METHODS:A 76-year-old woman with stage IA endometrial adenocarcinoma sustained a left obturator nerve transection during pelvic lymphadenectomy that was recognized immediately. Robotic-assisted laparoscopic repair was performed successfully, with the patient experiencing no residual neuropathy 6 months postoperatively. CONCLUSION/CONCLUSIONS:Robotic-assisted laparoscopic repair is feasible for the treatment of obturator nerve injury.

Although supracervical hysterectomy is an increasingly popular modality for surgical management of benign uterine conditions data exploring all of its consequences are still forth coming. This case report will discuss the scenario of leiomyoma recurrence at the cervical stump after supracervical hysterectomy. After supracervical hysterectomy, the remnant cervix has the potential for leiomyoma formation. Surgeons performing supracervical hysterectomy should be aware of this possible outcome.

With the continued expansion of endoscopic techniques and instruments, laparoscopy and minimally invasive techniques are quickly emerging as a feasible alternative to laparotomy in managing adnexal masses and ovarian cancer.Laparoscopy has the potential to completely and successfully treat both benign and malignant adnexal pathology while decreasing unnecessary morbidity among patients. Further advances in technology, techniques, and instruments can only increase this potential.

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.

BACKGROUND:The aim of this study was to retrospectively compare the safety, morbidity, and recurrence rate of total laparoscopic radical hysterectomy (TLRH) with lymphadenectomy and total robotic radical hysterectomy (RRH) with lymphadenectomy for early cervical carcinoma in a series of 99 consecutive women. MATERIALS AND METHODS/METHODS:We studied 99 consecutive patients with FIGO stage Ia1 (LVSI), Ia2, Ib1, Ib2, and IIa cervical cancer, 76 of whom underwent TLRH and 23 underwent RRH with pelvic lymph node dissection. Para-aortic lymphadenectomy, with the superior border of the dissection being the inferior mesenteric artery, was performed in all cases with positive pelvic lymph nodes discovered at frozen section evaluation. RESULTS:The mean blood loss was 157 ml in the RRH group (95% confidence interval [95% CI] 50-400) and 95 ml in the TLRH group (95% CI 30-500) (not significant [NS]). The median length of hospital stay was 3 days in the RRH group (95% CI 2-7) and 4 days in the TLRH group (95% CI 3-7) (NS). The mean operating time was 255 min for the TLRH group (95% CI 182-415) compared with 323 min in the RRH group (95% CI 161-433) (P < 0.05). No significant difference was found between the 2 groups when comparing the recurrence rate. CONCLUSIONS:Robotic radical hysterectomy can be considered a safe and effective therapeutic procedure for managing early-stage cervical cancer without significant differences, if compared with laparoscopic radical hysterectomy, in terms of the recurrence rate and intraoperative and postoperative complications, although multicenter randomized clinical trials with longer follow-up are necessary to evaluate the overall oncologic outcomes of this procedure.

BACKGROUND:As cesarean sections become a more common mode of delivery, they have become the most likely cause of vesicouterine fistula formation. The associated pathology with repeat cesarean deliveries may make repair of these fistulas difficult. Computer-enhanced telesurgery, also known as robotic-assisted surgery, offers a 3-dimensional view of the operative field and allows for intricate movements necessary for complex suturing and dissection. These qualities are advantageous in vesicouterine fistula repair. CASE/METHODS:A healthy 34-year-old woman who underwent 4 cesarean deliveries presented with a persistent vesicouterine fistula. Conservative management with bladder decompression and amenorrhea-inducing agents failed. RESULTS:Robotic-assisted laparoscopic repair was successfully performed with the patient maintaining continence after surgery. CONCLUSION/CONCLUSIONS:Robotic-assisted laparoscopic repair of vesicouterine fistulas offers a minimally invasive approach to treatment of a complex disease process.