Faculty Bibliography

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.

To focus on the recent adoption, patents, experience, and future of Robotic assisted surgery (RAS) applications in gynecologic surgery, a computer aided and manual search for clinical and systematic reviews, randomized controlled trials, prospective observational studies, retrospective studies and case reports published between 1970 and January of 2011 has been performed. The use of RAS in gynecologic patients includes hysterectomy, myomectomy, tubal reanastomoses, radical hysterectomy, lymph node dissection, and sacrocolpopexies. Although individual studies vary, gynecological RAS is often associated with longer operating room time but similar clinical outcomes, decreased blood loss, and shorter hospital stay. RAS procedures on women have, however, their own limitations: the patented equipment is very large, bulky, and expensive, the staff must be trained specifically on draping and docking the instruments, the lack of surgical haptic feedback, a limited vaginal access, a limited specific instrumentation, and the need for larger port incisions requiring fascial closure. The RAS significantly facilitates gynecologic surgery, even if well-designed, prospective studies are needed to fully assess the value of this equipments in particular studies with well-defined clinical and long-term outcomes, including complications, cost, pain, return to normal activity, and quality of life. The future of robotic surgery in gynecology may be bright, but currently, caution is advisable and clinically meaningful long-term outcomes are needed. These recent patents, however, has exciting potential for future applications, especially in long-distance telesurgery and might change the paradigm of gynecologic surgery in the future.

Chylous ascites is an uncommon postoperative complication of gynecological surgery. We report a case of chylous ascites following a robotic lymph node dissection for a cervical carcinoma. A 38-year-old woman with IB2 cervical adenocarcinoma with a palpable 3 cm left external iliac lymph node was taken to the operating room for robotic-assisted laparoscopic pelvic and para-aortic lymph node dissection. Patient was discharged on postoperative day 2 after an apparent uncomplicated procedure. The patient was readmitted the hospital on postoperative day 9 with abdominal distention and a CT-scan revealed free fluid in the abdomen and pelvis. A paracentesis demonstrated milky-fluid with an elevated concentration of triglycerides, confirming the diagnosis of chylous ascites. She recovered well with conservative measures. The risk of postoperative chylous ascites following lymph node dissection is still present despite the utilization of new technologies such as the da Vinci robot.

OBJECTIVE: To compare the feasibility and safety of the laparoscopic management of adnexal masses appearing preoperatively benign with those suspicious for malignancy. METHODS: Retrospective study of 694 women that underwent laparoscopic management of an adnexal mass. RESULTS: Laparoscopic management of an adnexal mass was completed in 678 patients. Six hundred and thirty five patients had benign pathology (91.5%) and 53 (7.6%) had primary ovarian cancers. Sixteen patients (2.3%) were converted to laparotomy; there were 13 intraoperative (1.9%) and 16 postoperative complications (2.3%). Patients divided in 2 groups: benign and borderline/malignant tumors. Patients in the benign group had a higher incidence of ovarian cyst rupture (26% vs. 8.7%, p<0.05). Patients in the borderline/malignant group had a statistically significant higher conversion rate to laparotomy (0.9% vs. 16.9%, p<0.001), postoperative complications (1.9% vs. 12.2%, p<0.05), blood loss, operative time, and duration of hospital stay. The incidence of intraoperative complications was similar between the 2 groups. CONCLUSION: Laparoscopic management of masses that are suspicious for malignancy or borderline pathology is associated with an increased risk in specific intra-operative and post-operative morbidities in comparison to benign masses. Surgeons should tailor the operative risks with their patients according to the preoperative likelihood of the mass being carcinoma or borderline malignancy.

OBJECTIVE:To describe 3 cases of peritoneal mesothelioma associated with endometriosis that were managed laparoscopically. DESIGN/METHODS:Case series. SETTING/METHODS:University and community hospitals. PATIENTS/METHODS:Three women with well-differentiated papillary mesothelioma of the peritoneum associated with endometriosis. INTERVENTIONS/METHODS:Laparoscopic excision and treatment of mesothelioma and endometriosis. RESULTS:Three patients underwent laparoscopy for treatment of endometriosis and were found to have peritoneal mesothelioma. All 3 patients underwent total laparoscopic excision of the lesions and were followed up regularly for surveillance of possible recurrence. CONCLUSIONS:In selected cases of well-differentiated papillary mesothelioma associated with pelvic endometriosis, operative laparoscopy can be used effectively to diagnose and treat this condition.

OBJECTIVES: To describe our experience with laparoscopic primary or interval tumor debulking in patients with presumed advanced ovarian, fallopian tube, or peritoneal cancers. METHODS: This is a retrospective analysis of a prospective case series. Women with presumed advanced (FIGO stage IIC or greater) ovarian, fallopian tube, or primary peritoneal cancers deemed appropriate candidates for laparoscopic debulking by the primary surgeon(s) were recruited. RESULTS: The study comprised 32 patients who underwent laparoscopic evaluation. Seventeen underwent total laparoscopic primary or interval cytoreduction, with 88.2% optimal cytoreduction. Eleven underwent diagnostic laparoscopy and conversion to laparotomy for cytoreduction, with 72.7% optimal cytoreduction. Four patients had biopsies, limited cytoreduction, or both. In the laparoscopy group, 9 patients have no evidence of disease (NED), 6 are alive with disease (AWD), and 2 have died of disease (DOD), with mean follow-up time of 19.7 months. In the laparotomy group, 3 patients are NED, 5 are AWD, and 3 are DOD, with mean follow-up of 25.8 months. Estimated blood loss and length of hospital stay were less for the laparoscopy group (P=0.008 and P=0.03), while operating time and complication rates were not different. Median time to recurrence was 31.7 months for the laparoscopy group and 21.5 months for the laparotomy group (P=0.3). CONCLUSIONS: Laparoscopy can be used for diagnosis, triage, and debulking of patients with advanced ovarian, fallopian tube, or primary peritoneal cancer and is technically feasible in a well-selected population

The objectives of this article were to review the published scientific literature about robotics and its application to gynecologic oncology to date and to summarize findings of this advanced computerenhanced laparoscopic technique. Relevant sources were identified by a search of PUBMED from January 1950 to January 2009 using the key words Robot or Robotics and Cervical cancer, Endometrial cancer, Gynecologic oncology, and Ovarian cancer. Appropriate case reports, case series, retrospective studies, prospective trials, and review articles were selected. A total of 38 articles were identified on the subject, and 27 were included in the study. The data for gynecologic cancer show comparable results between robotic and laparoscopic surgery for estimated blood loss, operative time, length of hospital stay, and complications. Overall, there were more wound complications with the laparotomy approach compared with laparoscopy and robotic-assisted laparoscopy. There were more lymphocysts, lymphoceles, and lymphedema in the robotic-assisted laparoscopic group compared with the laparoscopy and laparotomy groups in patients with cervical cancer. Infectious and lung-related morbidity, postoperative ileus, and bleeding or clot formation were more commonly reported in the laparotomy group compared with the other 2 cohorts in patients with endometrial cancer. Computer-enhanced technology may enable more surgeons to convert laparotomies to laparoscopic surgery with its associated benefits. It seems that in the hands of experienced laparoscopic surgeons, final outcomes are the same with or without use of the robot. There is good evidence that robotic surgery facilitates laparoscopic surgery, with equivalent if not better operative time and comparable surgical outcomes, shorter hospital stay, and fewer major complications than with surgeries using the laparotomy approach