Initial experience of robotically assisted endometriosis surgery with a novel robotic system: first case series in a tertiary care center.

Endometriosis is a benign disease requiring surgery if medical treatment can not achieve symptom control. Laparoscopy remains the gold standard and robotic assistance can be beneficial in complex cases. Robot-assisted radical endometriosis excision using the Hugo™ RAS system is a novel approach. The aim of this study is to describe its setting and outcomes in a series of patients in a robotic surgery center. Endometriosis patients who consecutively underwent robot-assisted surgery with the Hugo™ RAS system (Medtronic, USA) were retrospectively enrolled. Disease-specific symptoms before and after surgery, endometriosis stage, as well as perioperative and intraoperative variables including system setup were collected. Early post-operative complications (< 30 days) and follow-up (up to 3 months) were reported. All procedures were completed robotically. Port placement followed the "bridge" configuration with a "compact" docking. The median operative time was 186.5 min (IQR 174-220), the median estimated blood loss 50 ml (IQR 0-100). An intraoperative complication occurred in one patient (6.6%), a bladder laceration with postoperative antibiotic treatment. The median lenght of hospital stay (LOS) was 3 days (IQR 3-4). Surgery achieved a statistically significant decrease in symptoms: mean dysmenorrhea (9.50 ± 0.83 versus 1.7 ± 2.26; p = 0.001), dyschezia (4.27 ± 3.61 versus 2.40 ± 2.92; p = 0.026), dysuria (2.73 ± 3.39 versus 1.87 ± 2.41; p = 0.358), dyspareunia (6.53 ± 3.15 versus 2.93 ± 2.89; p = 0.002) and chronic pelvic pain (8.8 ± 1.20 versus 3.20 ± 2.39; p = 0.001). The integration of this platform in the described configuration was safe with regular perioperative outcomes and significant improvement in symptoms. Prospective comparative studies with a larger cohort and longer follow-up are needed to assess potential advantages over the current gold standard.

Vascular- and nerve-sparing bowel resection for deep endometriosis: A retrospective single-center study.

OBJECTIVE: Surgical management of bowel endometriosis is still controversial. Recently, many authors have pointed out the potential benefits of preserving the superior rectal artery, thus ensuring better perfusion of the anastomosis. The aim of this study was to evaluate the complication rate and functional outcomes of a bowel resection technique for deep endometriosis (DE) involving a nerve- and vascular-sparing approach. METHODS: A single-center retrospective study was conducted by enrolling patients who underwent segmental resection of the rectus sigmoid for DE in our department between September 2019 and April 2022. Intraoperative and postoperative complications were recorded for each woman, and functional outcomes relating to the pelvic organs were assessed using validated questionnaires (Knowles-Eccersley-Scott-Symptom [KESS] questionnaire and Gastro-Intestinal Quality of Life Index [GIQLI] for bowel function, Bristol Female Lower Urinary Tract Symptoms [BFLUTS] for urinary function, and Female Sexual Function Index [FSFI] for sexual function). These were evaluated preoperatively and postoperatively after 6 months from surgery. RESULTS: Sixty-one patients were enrolled. No patients had Clavien-Dindo grade 3 or 4 complications, there were no rectovaginal fistulas or ureteral lesions, and in no cases was it necessary to reoperate. Temporary bladder voiding deficits were reported in 8.2% of patients, which were treated with self-catheterizations, always resolving within 45 days of surgery. Gastrointestinal function evaluated by KESS and GIQLI improved significantly after surgery, whereas sexual function appeared to worsen, although without reaching the level of statistically significant validity. CONCLUSION: Our vascular- and nerve-sparing segmental bowel resection technique for DE had a low intraoperative and postoperative complication rate and produced an improvement in gastrointestinal function after surgery.

Preoperative diagnosis of ureteral medial deviations secondary to deep endometriosis using transvaginal ultrasound examinations: Can we predict the need for ureterolysis during laparoscopic surgery?

OBJECTIVE: To evaluate ureteral involvement using transvaginal sonography (TVS) regarding the distortion of the course of the ureters caused by deep endometriosis (DE), which can facilitate predicting the need for ureterolysis during surgery, even in the absence of ureteral stenosis or dilatation. METHODS: This is a single-center, observational, retrospective pilot study of 88 consecutive patients who later underwent surgery for DE that used ultrasound preoperative diagnosis of ureteral medial deviation of one or both ureters between January 2019 and January 2022. At TVS, the course of the ureter was considered medialized if, in longitudinal and transversal section, any distance was detectable between the ureter and the cervix at the point where the ureter crosses the uterine artery. The primary end point was to determine sensitivity, specificity, and positive and negative predictive values of "ureteral medial deviation" diagnosed using TVS, in order to predict the need for ureterolysis. RESULTS: Our series included 88 women with a median age of 39 (interquartile range 33-43) years. Ureteral medialization showed a relatively low false-positive rate (10.9%), with a specificity of 89.1% (95% confidence interval [CI] 81.4%-96.7%) and a sensitivity of 86.6% (95% CI 80.3%-92.9%), along with a high positive predictive value of 93.3% (95% CI 88.4%-98.1%), and a lower negative predictive value of 79.1% (95% CI 69.8%-88.5%), respectively. CONCLUSIONS: This study introduced a new ultrasound sign with a high degree of accuracy to predict ureterolysis and this may have positive implications in the management and surgical planning of patients with ureteral endometriosis.