Comparison of robotic surgery and laparoscopy to perform total hysterectomy with pelvic adhesions or large uterus.

BACKGROUND: Currently, benefits of robotic surgery in patients with benign gynecological conditions remain unclear. In this study, we compared the surgical outcome of robotic and laparoscopic total hysterectomies and evaluated the feasibility of robotic surgery in cases with pelvic adhesions or large uterus. MATERIALS AND METHODS: A total of 216 patients receiving total hysterectomy via robotic or laparoscopic approach were included in this study. Of all 216 patients, 88 underwent robotic total hysterectomy and 128 underwent laparoscopic total hysterectomy. All cases were grouped by surgical type, adhesion score, and uterine weight to evaluate the interaction or individual effect to the surgical outcomes. The perioperative parameters, including operation time, blood loss, postoperative pain score, time to full diet resumption, length of hospital stay, conversion rate, and surgery-related complications were compared between the groups. RESULTS: Operation time and blood loss were affected by both surgical type and adhesion score. For cases with severe adhesions (adhesion score greater than 4), robotic surgery was associated with a shortened operation time (113.9 ± 38.4 min versus 164.3 ± 81.4 min, P = 0.007) and reduced blood loss (187.5 ± 148.7 mL versus 385.7 ± 482.6, P=0.044) compared with laparoscopy. Moreover, robotic group showed a lower postoperative pain score than laparoscopic group, as the effect was found to be independent of adhesion score or uterine weight. The grade-II complication rate was also found to be lower in the robotic group. CONCLUSIONS: Comparing to laparoscopic approach, robotic surgery is a feasible and potential alternative for performing total hysterectomy with severe adhesions.

Comparing robotic surgery with conventional laparoscopy and laparotomy for cervical cancer management.

OBJECTIVE: The aim of this study was to compare the outcomes of robotic surgery, laparoscopy, and laparotomy for the surgical treatment of stage IA to IIB cervical cancer. METHODS: This retrospective study was carried out in a university-affiliated teaching hospital. A total of 100 women with an initial diagnosis of stage IA to IIB cervical cancer, without preoperative brachytherapy or chemotherapy, were included in this study. With selection of the cases, 44 patients received laparotomy surgery, 32 patients received laparoscopic surgery, and 24 patients received robotic surgery. The perioperative parameters measured included operation time, blood loss, transfusion rate, lymph node yield, adhesion score, laparotomy conversion rate, postoperative and 24-hour pain scores, time to full diet resumption, and hospital stay. The perioperative complication and disease-free survival were also evaluated. RESULTS: The robotic group showed a shorter operation time, less blood loss, lower transfusion rate, and lower laparotomy conversion rate than the laparoscopic or laparotomy group. As for the postoperative parameters, the robotic group showed reduced postoperative and 24-hour pain scores, shortened length of hospital stay, and decreased time to full diet resumption compared with the other 2 surgical groups. No significant differences were found between the groups in perioperative complication rate or disease-free survival. CONCLUSIONS: The data suggested that robotic surgery is a feasible and potentially optimal option for the treatment of stage IA to IIB cervical cancer with favorable short-term surgical outcomes.

Capacitation suppression by mouse seminal vesicle autoantigen involves a decrease in plasma membrane Ca2+-ATPase (PMCA)-mediated intracellular calcium.

Successful fertilization is tightly regulated by capacitation and decapacitation processes. Without appropriate decapacitation regulation, sperm would undergo a spontaneous acrosome reaction which leads to loss of fertilization ability. Seminal plasma is known to negatively regulate sperm capacitation. However, the suppressive mechanisms still remain unclear. In this study, we demonstrate the decapacitation mechanism of mouse seminal vesicle autoantigen (SVA) might target membrane sphingomyelin (SPM) and regulate plasma membrane Ca(2+)-ATPase (PMCA) activity. The SVA was shown to suppress sperm capacitation induced by a broad panel of capacitation factors (bovine serum albumin (BSA), PAF, and cyclodextrin (CD)). Furthermore, SVA significantly decreased [Ca(2+)](i) and NaHCO(3)-induced [cAMP](i). Cyclic AMP agonists bypassed the SVA's suppressive ability. Importantly, the SVA may regulate PMCA activity which was evidenced by the fact that the SVA decreased the [Ca(2+)](i) and intracellular pH (pH(i)) of sperm; meanwhile, a PMCA inhibitor (carboxyeosin) could reverse SVA's suppression of [Ca(2+)](i). The potential target of the SVA on membrane SPM/lipid rafts was highlighted by the high binding affinity of SPM-SVA (with a K(d) of ~3 µM) which was close to the IC(50) of SVA's suppressive activity. Additionally, treatment of mink lung epithelial cells with the SVA enhanced plasminogen activator inhibitor (PAI)-1 expression stimulated by tumor growth factor (TGF)-ß and CD. These observations supported the membrane lipid-raft targeting of SVA. In summary, in this paper, we demonstrate that the decapacitation mechanism of the SVA might target membrane sphingolipid SPM and regulate PMCA activity to lower [Ca(2+)](i), thereby decreasing the [cAMP](i) level and preventing sperm pre-capacitation.

Comparing robotic surgery with laparoscopy and laparotomy for endometrial cancer management: a cohort study.

INTRODUCTION: Robotic surgery has been applied in managing various types of gynecologic cancers. The purpose of this study is to compare the surgical outcomes of robotic surgery, laparoscopy and laparotomy for managing endometrial cancer. METHODS: A total of 365 patients received surgical staging for treating IA to IIIC endometrial cancer were retrospectively enrolled. Patient demography, peri-operative parameters, and survival outcomes were studied. RESULTS AND DISCUSSIONS: Robotic surgery showed a significant lower blood loss and 24-h pain score as compared to other surgical types. Moreover, compared to laparotomy, robotic and laparoscopic surgeries were associated with reduced operation time, decreased time to full diet resumption, and shortened hospital stay. No significant differences were found between the groups in terms of overall complication rate. Eighteen-month follow-up of the patients indicated no significant differences in disease-free survival and overall survival. CONCLUSION: Compared to conventional approaches, robotic surgery showed favorable short-term outcomes with comparable survival. It is suggested that robotic surgery is a feasible tool for endometrial cancer management.

Successful pregnancy in a woman with symptomatic fibroids who underwent laparoscopic bipolar coagulation of uterine vessels.

OBJECTIVE: To report a case of successful pregnancy after laparoscopic bipolar coagulation of uterine vessels (LBCUV). DESIGN: Case report. SETTING: University-affiliated tertiary referral center. PATIENT(S): One woman, treated with LBCUV for symptomatic fibroids, who subsequently had a successful pregnancy. INTERVENTION(S): Laparoscopic bipolar coagulation of uterine arteries and anastomotic sites of uterine arteries with ovarian arteries. MAIN OUTCOME MEASURE(S): Patient evaluation by physical and ultrasound examinations. RESULT(S): Complete resolution of menorrhagia and dysmenorrhea was found after LBCUV. Reduction in fibroid size was seen by ultrasound. Two months later, the patient conceived a singleton pregnancy without the use of assisted reproductive technologies. The woman delivered by cesarean section. Neither myoma recurrence nor abnormality in uterine function was observed. CONCLUSION(S): Although fecundity- and pregnancy-related complications after LBCUV for managing uterine fibroids are still unclear, this first case report of successful pregnancy after LBCUV is promising. LBCUV might be a safe and effective alternative to myomectomy and hysterectomy.

Short-term advantages of laparoscopic uterine vessel occlusion in the management of women with symptomatic myoma.

OBJECTIVE: The aim of this study was to evaluate the short-term therapeutic outcome of women with symptomatic uterine myomas treated with laparoscopic uterine vessel occlusion (LUVO) or laparoscopic myomectomy (LM). METHODS: Ninety-five patients with symptomatic, uncomplicated myomas warranting surgical treatment who expressed a strong desire to retain their uterus were included in this study. Fifty-two patients underwent LUVO and 43 underwent LM. The outcome was measured by comparing blood loss, surgical time, postoperative recovery, postoperative pain (visual analog scale), complications, and success rate in both groups. RESULTS: The general characteristics of the patients were similar in both groups. There were no statistical differences in febrile morbidity, complications, success rate, therapeutic efficacy (symptom relief), and satisfaction rate between the two groups. LUVO had advantages over LM, including less surgical time, minimal blood loss, lower visual analog scale score, and rapid postoperative recovery. CONCLUSIONS: Both LUVO and LM might be effective in the management of symptomatic myomas in selected cases, but LUVO seemed to be more acceptable and less invasive in this 1-year short-term follow-up.

Uterine preservation in a woman with spontaneous uterine rupture secondary to placenta percreta on the posterior wall: a case report.

Several cases in which uteruses have been preserved in women with placenta percreta have been reported. We herein report a 38-year-old woman with a history of previous cesarean section who was admitted with lower abdominal pain and vaginal bleeding at 31 weeks of gestation. An urgent exploratory laparotomy revealed active bleeding from the uterine rupture on the posterior uterine wall. A female infant weighing 1560 g, with Apgar scores of 1,1, and 3 at 1, 5, and 10 min, respectively, was delivered, and the placenta was removed. We performed bilateral uterine vessel occlusion, followed by wedge resection of the ruptured uterine wall with the aid of an intrauterine muscle injection of 20 IU oxytocin, a local injection of diluted vasopressin (1:60) into the myometrium around and into the rupture site, and an intramuscular injection of 0.2 mg methylergonovine, primary repair of the defect, and an additional 24-h postoperative oxytocin infusion (30 IU in 5% dextrose 500 mL) to preserve the uterus successfully. Although the overall blood loss was 3700 mL, no disseminated intravascular coagulopathy occurred after the patient had received adequate blood transfusion. The postoperative pathological diagnosis was placenta percreta with uterine rupture. The patient and her baby were discharged uneventfully. In some cases of spontaneous uterine rupture secondary to placenta percreta, we can preserve the uterus by performing bilateral uterine vessel occlusion and wedge resection of the ruptured uterine wall.

Comparison of two procedures for laparoscopic-assisted vaginal hysterectomy of large myomatous uteri.

STUDY OBJECTIVE: To evaluate whether laparoscopic bipolar coagulation of uterine vessels (LBCUV) and supracervical amputation improve laparoscopic-assisted vaginal hysterectomy (LAVH). DESIGN: Prospective, randomized, longitudinal study (Canadian Task Force classification II-1). SETTING: Private practice, university-affiliated hospital. PATIENTS: Sixty-four women (age 31-52 yrs) with symptomatic myomatous uteri larger than 12 weeks on bimanual examination. INTERVENTIONS: LAVH with or without LBCUV and laparoscopic supracervical amputation followed by trachelectomy. MEASUREMENTS AND MAIN RESULTS: LBCUV and laparoscopic supracervical amputation followed by trachelectomy and removal of the specimen vaginally were performed successfully in 29 women (group A). Hysterectomy was performed successfully in 32 comparable patients (group B) with severing of the round ligament, ovarian ligament, or infundibulopelvic ligament, and preparation of the bladder flap in the laparoscopic phase, and severing of uterine vessels and cardinal-uterosacral ligament complex through the vagina. Average blood loss was 169.8 and 308.7 ml in groups A and B, respectively (p <0.05); average operating time was 126.4 and 152.8 minutes, respectively (p <0.05); hemoglobin decreased on average 0.9 and 1.7 g/100 ml, respectively (p <0.05). Conclusion. LBCUV and laparoscopic supracervical amputation followed by trachelectomy reduce operating time and blood loss in LAVH, and allow conversion of many abdominal procedures to laparoscopy.

Laparoscopic bipolar coagulation of uterine vessels to manage delayed postpartum hemorrhage.

Postpartum hemorrhage (PPH) is a big challenge for obstetricians. Fertility-preserving procedures are encouraged, especially in young women. Bilateral hypogastric (internal iliac) artery ligation, bilateral uterine artery ligation after vaginal delivery or after cesarean delivery, and uterine artery embolization are well documented vascular occlusive methods for treating PPH. To our knowledge, the laparoscopic approach to uterine artery ligation has not been reported. A 29-year-old woman experienced delayed PPH. Although curettage of the uterine cavity to remove retained placenta was performed, bleeding did not stop. We successfully performed a relatively new method--laparoscopic bipolar coagulation of uterine vessels--to stop bleeding and preserve the uterus.

Rapid enlargement of uterine myomas after laparoscopic bipolar coagulation of uterine vessels.

Degenerative changes occur relatively frequently in uterine leiomyomas. Morphologic changes such as necrosis, hyalinization, and alterations in cellularity are described after uterine artery embolization. A modified method to interrupt the uterine blood supply is laparoscopic bipolar coagulation of uterine vessels (LBCUV). Although the success rate is good, occasional patients require hysterectomy because of complications or continuing symptoms. A woman with symptomatic myomas underwent LBCUV, but required hysterectomy due to rapid enlargement of myomas and intractable symptoms including pelvic pain and pressure, and acute urinary retention. The combination of degenerative and iatrogenic changes resulted in a histologic appearance resembling diffuse hyalinization and hydropic degeneration of the leiomyomas.

Pregnancy following treatment of symptomatic myomas with laparoscopic bipolar coagulation of uterine vessels.

BACKGROUND: Laparoscopic bipolar coagulation of uterine vessels (LBCUV) has been employed for women with symptomatic uterine myomas, but its effect on subsequent pregnancy has not been characterized. METHODS: Four-hundred and twenty-three women entered the study between March 1999 and December 2001. Of these, 142 women (33.6%) were under the age of 40 years at the time of LBCUV, 36 of whom (36/142, 25.3%) were sexually active without contraception. In a prospective study of 142 patients (<40 years old) undergoing LBCUV for symptomatic myomas, 15 women became pregnant (17 total pregnancies) and were evaluated by physical and ultrasound examinations. RESULTS: The volume of the dominant myoma was 117.4 +/- 118.4 and 36.8 +/- 56.8 cm(3) before and after LBCUV respectively. Volume of the dominant myoma after pregnancy was 46.2 +/- 76.7 cm(3) (mean +/- SD). There was a significant difference in myoma volume before and after LBCUV (P = 0.002), but no significant difference in myoma volume when comparing post-partum size with post-LBCUV size (P = 0.269). Pregnancy outcomes included seven miscarriages in the first trimester and one premature rupture of membrane (PPROM). Although the other pregnancies were regarded as uncomplicated, only two women were delivered of normal neonates as the other seven pregnancies were terminated secondary to patient request. CONCLUSIONS: The pregnancy and term pregnancy rates in sexually active women without contraception were 41.6% (15/36) and 5.6% (2/36) respectively. Because a relatively high rate (7/17, 41.2%) of early miscarriages was observed, we recommend that this procedure be employed only for women who do not desire additional children.