Faculty Bibliography

This article reveals our surgical approach for treatment of a patient with severe pelvic and infiltrative bladder endometriosis with mucosal involvement using robotic-assisted laparoscopic excision and cystotomy repair. To our knowledge, this is the first case of total robotic-assisted laparoscopic partial bladder resection for the treatment of endometriosis. This article also discusses the pros and cons of robotic-assisted surgery and the current literature on infiltrative bladder endometriosis.

A combined pelvic lymphadenectomy with radical vaginal trachelectomy is an alternative to radical hysterectomy in the treatment of young women with cervical cancer desiring fertility preservation. This technique requires advanced vaginal surgery skills not commonly acquired. In an attempt to simplify the procedure we preformed what we believe to be the first case of robotic-assisted radical trachelectomy. A 30-year-old woman, gravida 1, para 1, desiring fertility preservation was given the diagnosis of invasive adenocarcinoma on cervical cone excision. The patient was treated with robotic-assisted pelvic lymphadenectomy and radical trachelectomy. We hope robotic-assisted radical trachelectomy will become an option for select women with early-stage cervical cancer who desire fertility preservation.

The role of laparoscopy has evolved from a diagnostic tool to an integral approach to management of gynecologic malignancies. This surgical approach has afforded patients the benefits of shorter hospitalizations, more rapid recoveries, smaller incisions, less need for analgesics, and fewer complications. Additionally, specific to gynecologic malignancies, improved visualization and shorter intervals to postoperative treatments are advantages to minimally invasive surgery. However, laparoscopy is limited by its long learning curve, counterintuitive motions, and two-dimensional views. To overcome these challenges of laparoscopy, technology has expanded to include computer-enhanced technology in the form of robotics. Robotic-assisted surgery provides three-dimensional views, intuitive motions, less operator fatigue, tremor filtration facilitating more precise movements, and possesses a shorter learning curve. Robotic-assisted surgery has also paved a pathway to telesurgery and telementoring. This may expand the availability of advanced minimally invasive surgeries throughout the globe. However, robotic-assisted procedures are not without limitations-cost, bulky size, lack of haptic feedback, limited instrumentation, and larger required incisions.

STUDY OBJECTIVE: To assess the effect of laparoscopic surgery on the survival of women with early-stage endometrial cancer and to analyze the factors that affect survival. DESIGN: Retrospective cohort study (Canadian Task Force classification II-2). SETTING: Tertiary teaching hospital. PATIENTS: Women with clinical stage I and II endometrial cancer (International Federation of Gynecology and Obstetrics staging, 1971) from January 1993 through June 2003. INTERVENTION: Demographic, surgical, perioperative, and pathologic characteristics of women treated with laparoscopy or laparotomy were compared by use of Fisher's exact test or the Student t test. Recurrence-free and overall survival was calculated by use of the Kaplan-Meier method. Stratified analyses were performed with the log-rank test for factors affecting survival (surgical stage, histologic study, and grade). MEASUREMENTS AND MAIN RESULTS: Sixty-seven and 127 women were treated with laparoscopy and laparotomy, respectively. Median follow-up was 36.3 months for the laparoscopy group and 29.6 months for the laparotomy group. The complication rates in the 2 groups were comparable. Women undergoing laparoscopy had shorter hospital stay and less morbidity related to infection. The 2- and 5-year estimated recurrence-free survival rates for the laparoscopy and laparotomy groups (93 % vs 91.7% and 88.5% vs 85%, respectively), as well as the overall 2- and 5-year survival rates (100% vs 99.2% and 100% vs 97%, respectively) were similar. CONCLUSIONS: Laparoscopic surgery in women with early-stage endometrial carcinoma resulted in survival rates similar to laparotomy, although a small sample size precludes definitive conclusions. A larger randomized comparison of the 2 techniques is needed to validate these findings.

OBJECTIVE: To determine the effect of patient clinical factors on the utilization of hysterectomy and alternatives of hysterectomy. STUDY DESIGN: The database of Empire Blue Cross Blue Shield was abstracted for all claims relating to a hysterectomy procedure or a hysterectomy-associated diagnosis during the 48 consecutive months of May 2001-April 2005. Two hundred ninety-five thousand one hundred forty-eight claim lines were abstracted and analyzed by CPT and diagnostic grouping codes. RESULTS: One thousand nine hundred seventy-two hysterectomies were performed during the time analyzed, and 5,077 hysterectomy alternatives. The mean age of all patients encountered was 39.1 years. Patients undergoing a hysterectomy alternative or hysterectomy had mean ages of 46.0 and 49.7 years, respectively. Abnormal bleeding was associated with the most encounters, while leiomyomata was associated with the most hysterectomies performed. CONCLUSION: Patients who undergo hysterectomy are, on average, older than those undergoing office management or hysterectomy alternatives. Procedures are most commonly associated with diagnosis of bleeding, leiomyomata, or cancer. Bleeding typically results in a hysterectomy alternative, while leiomyomata has the highest association with hysterectomy.

OBJECTIVE: The purpose of this study was to determine the effect of physician gender and specialty on the utilization of hysterectomy and alternatives to hysterectomy. STUDY DESIGN: The database of Empire Blue Cross Blue Shield was abstracted for all claims relating to a hysterectomy procedure or a hysterectomy-associated diagnosis during the 48 consecutive months May 2001-April 2005. Two hundred ninety-five thousand, one hundred forty-eight claim lines were abstracted and analyzed by CPT and diagnostic grouping codes. RESULTS: One thousand nine hundred seventy-two hysterectomies were performed during the time analyzed, as well as 5077 hysterectomy alternatives. These 7049 procedures represented 2.4% of all coded physician encounters. Male physicians utilize hysterectomy and hysterectomy alternatives at the same rate as female physicians. Physicians who practice gynecology-only or gynecologic oncology utilize laparoscopically assisted vaginal hysterectomy more often than their counterparts who practice obstetrics as well as gynecology. CONCLUSION: Gender does not influence the rate of hysterectomy for similar clinical diagnoses. Subspecialty physicians utilize laparoscopic assisted vaginal hysterectomies more frequently than general obstetricians and gynecologists.

PURPOSE OF REVIEW: To review the recent literature regarding modifications of abdominal radical hysterectomy as well as development of new approaches including laparoscopic, vaginal, and robotic radical hysterectomy. RECENT FINDINGS: Nerve-sparing radical hysterectomy technique allows for significant reduction in postoperative bladder morbidity. Radical vaginal hysterectomy with laparoscopic lymph node dissection is a well-recognized technique that offers excellent cure rates with absence of abdominal entry as well as reduced postoperative febrile and gastrointestinal morbidity. Total laparoscopic radical hysterectomy is a minimally invasive alternative to a traditional abdominal radical hysterectomy approach that yields comparable safety profile with a significant reduction in blood loss and hospital stay. Robotic surgery is becoming more widely accepted in the management of gynecologic cancers and larger series describing successful treatment of cervical cancer with robotic radical hysterectomy are soon to be published. SUMMARY: There are a number of approaches to performing radical hysterectomy. The feasibility and safety of these techniques have been well established. Preliminary oncologic outcome data are encouraging. The decision to utilize newer techniques depends on the patient and type of practice, as well as the surgeon's comfort level with laparoscopy, robotics, or vaginal surgery.

OBJECTIVE: To review the malignant potential of endometriosis based on epidemiologic, histopathologic, and molecular data. DESIGN: Literature review. RESULT(S): The pathogenesis of endometriosis remains unclear. The histopathologic development of endometriosis has undergone long-term investigation. Studies have confirmed histologic transition from benign endometriosis to ovarian malignancy, including malignant transformation of extraovarian endometriosis. The prevalence of endometriosis in patients with epithelial ovarian cancer, especially in endometrioid and clear cell types, has been confirmed to be higher than in the general population. Ovarian cancers and adjacent endometriotic lesions have shown common genetic alterations, such as PTEN, p53, and bcl gene mutations, suggesting a possible malignant genetic transition spectrum. Furthermore, endometriosis has been associated with a chronic inflammatory state leading to cytokine release. These cytokines act in a complex system in which they induce or repress their own synthesis and can cause unregulated mitotic division, growth and differentiation, and migration or apoptosis similar to malignant mechanisms. CONCLUSION(S): The malignant potential of endometriosis holds serious implications for management, such as the need for earlier and more meticulous surgical intervention for complete disease treatment.

BACKGROUND AND OBJECTIVES: To compare intraoperative, pathologic and postoperative outcomes of robotic radical hysterectomy (RRH) to total laparoscopic radical hysterectomy (TLRH) in patients with early stage cervical carcinoma. METHODS: We prospectively analyzed cases of TLRH or RRH with pelvic lymphadenectomy performed for treatment of early cervical cancer between 2000 and 2008. RESULTS: Thirty patients underwent TLRH and pelvic lymphadenectomy for cervical cancer from August 2000 to June 2006. Thirteen patients underwent RRH and pelvic lymphadenectomy for cervical cancer from April 2006 to January 2008. There were no differences between groups for age, tumor histology, stage, lymphovascular space involvement or nodal status. No statistical differences were observed regarding operative time (323 vs 318 min), estimated blood loss (157 vs 200 mL), or hospital stay (2.7 vs 3.8 days). Mean pelvic lymph node count was similar in the two groups (25 vs 31). None of the robotic or laparoscopic procedures required conversion to laparotomy. The differences in major operative and postoperative complications between the two groups were not significant. All patients in both groups are alive and free of disease at the time of last follow up. CONCLUSION: Based on our experience, robotic radical hysterectomy appears to be equivalent to total laparoscopic radical hysterectomy with respect to operative time, blood loss, hospital stay, and oncological outcome. We feel the intuitive nature of the robotic approach, magnification, dexterity, and flexibility combined with significant reduction in surgeon's fatigue offered by the robotic system will allow more surgeons to use a minimally invasive approach to radical hysterectomy.