Robotic-assisted versus conventional laparoscopic management of deep endometriosis involving the sacral plexus and sciatic nerve: A comparative before and after study.

OBJECTIVE: To compare robotic-assisted laparoscopy (RAL) and laparoscopy (LPS) for intraoperative and postoperative outcomes, and functional results after a 6-month follow-up period among patients having undergone excision of deep endometriosis (DE) involving the sacral plexus (SP) and sciatic nerve (SN). METHODS: A retrospective analysis of 100 patients included in our prospective database, who underwent surgical eradication of DE involving the SP and SN at our tertiary referral centre between September 2018 and June 2023. Patients were managed by LPS (n = 71) until 2021, and subsequently by RAL (n = 29). RESULTS: Baseline symptoms and distribution of DE lesions were comparable in the two groups. Nerve dissection, nerve shaving, and intra-nerve dissection were performed in 55 (77.5%), 14 (19.7%), and 2 (5.6%) patients in the LPS group, respectively. Nerve dissection and nerve shaving were performed and in 24 (82.8%) and 5 (17.2%) patients in the RAL group, while no cases of intra-nerve dissection were observed (P = 0.434). Mean operative times were 183.71 ± 85.32 min and 177.41 ± 77.19 min, respectively (P = 0.734). There were no reported cases of conversion to open surgery. Intraoperative and early postoperative complications were comparable between the two groups. At 6 months follow up, we observed a significant reduction in sciatic pain in both the LPS group (39.1% vs 15.6%, P < 0.001) and RAL group (37.5% vs 25%, P = 0.001), with no differences in terms of outcomes (P = 0.1). CONCLUSION: Both LPS and RAL result in significant long-term relief of symptoms associated with SP and SN endometriosis. Although surgeons found that RAL improved the quality of excision of these specific DE localizations, our study did not reveal significant advantages in terms of its outcomes.

Robotic-assisted Laparoscopy Excision of a Severe Form of Diaphragmatic Endometriosis: A Retrospective Study of 60 Patients.

STUDY OBJECTIVE: To assess the feasibility, effectiveness, and safety of the robotic surgical approach in the treatment of severe diaphragmatic endometriosis (DE). DESIGN: Retrospective single-center study using data prospectively recorded in the Franco-European Multidisciplinary Institute of Endometriosis database and the National Observatory for Endometriosis database. SETTING: Tertiary referral center. Endometriosis care center. PATIENTS: Sixty consecutive patients undergoing robotic excision of severe DE from January 2020 to July 2023. INTERVENTIONS: Robotic excision of severe DE. MEASUREMENT AND MAIN RESULTS: Categorical and continuous variables were evaluated and compared using descriptive statistics. A p value of <.05 was considered statistically significant. Full-thickness diaphragmatic resection was performed in 76.7% of patients (46 of 60) and partial diaphragmatic muscle resection in 10% of cases (6 of 60). Peritoneal stripping technique was performed in 60% of patients (36 of 60), divided as follows: as the only technique in the case of extensive superficial diaphragmatic involvement in 13.3% of cases (8 of 60), in addition to full-thickness or partial diaphragmatic resection in the case of concomitant multiple foci in 46.7% of patients (28 of 60). Median operative time was 79.6 minutes with no statistically significative difference related to the surgeon performing surgery (p >.05). Intraoperative and postoperative complications occurred in 1.7% (1 of 60) and 6.6% of cases (4 of 60), respectively. Diaphragmatic hernia (Clavien-Dindo 3b) was the most common postoperative complication and required surgical repair in all cases. Median hospital stay was 24 hours. The rate of patients with complete recovery from DE symptoms has gradually increased during follow-up, reaching 89% after 12 months from surgery. CONCLUSION: In this case series, robotic treatment of severe DE in expert hands was feasible, effective, and safe.

Low rectal resection for low rectal endometriosis and rectal adenocarcinoma: Are we discussing the same risks?

OBJECTIVE: To evaluate the rate and risk factors for anastomosis leakage in patients undergoing colorectal resection with low anastomosis for rectal endometriosis and rectal adenocarcinoma. METHODS: A retrospective cohort study evaluating prospectively collected data was conducted. Patients undergoing colorectal resection for rectal endometriosis and rectal adenocarcinoma with low anastomosis (<7 cm from the anal verge [AV]) from September 2018 to January 2023 were included in the analysis. The main outcome was the rate of anastomosis leakage. A multivariate logistic regression was conducted to evaluate risk factors for anastomosis leakage in both groups. RESULTS: A total of 159 patients underwent colorectal resection with low anastomosis due to rectal endometriosis (n = 99) and rectal adenocarcinoma (n = 60). Patients with endometriosis were significantly younger than those with adenocarcinoma (35.7 ± 5.1 vs 63.7 ± 12.6; P = 0.001). The leakage rate was similar between the endometriosis (n = 12, 12.1%) and adenocarcinoma (n = 9, 15.0%) patients (P = 0.621). The anastomosis height less than 5 cm from the AV (adjusted odds ratio [aOR] 12.12, 95% confidence interval [CI] 2.24-23.54) was significantly associated with the anastomosis leakage. Protective stoma was associated with the decrease of the leakage risk (aOR 0.12, 95% CI 0.01-0.72). The type of disease (rectal endometriosis or adenocarcinoma) was not associated with the anastomosis leakage (aOR 2.87, 95% CI 0.34-21.23). CONCLUSIONS: Despite the different pathogenesis, the risk of anastomotic leakage was found to be similar between patients with low rectal endometriosis and those with rectal adenocarcinoma. These results must be considered by the gynecologist and colorectal surgeon to deliver proper information before rectal surgery for endometriosis.

Intermittent Self-catheterization for Bladder Dysfunction After Deep Endometriosis Surgery: Duration and Factors that Might Affect the Recovery Process.

STUDY OBJECTIVE: To assess the duration needed for regaining normal bladder voiding function in patients with postoperative bladder dysfunction requiring intermittent self-catheterization after deep endometriosis surgery and identify risk factors that might affect the recovery process. DESIGN: Retrospective study based on data recorded in a large prospective database. SETTING: Endometriosis referral center. PATIENTS: From September 2018 to June 2022, 1900 patients underwent excision of deep endometriosis in our center; 61 patients were discharged with recommendation for intermittent self-catheterization and were thus included in the study. INTERVENTIONS: Intermittent self-catheterization after endometriosis surgery. MEASUREMENTS AND MAIN RESULTS: A total of 43 patients (70.5%) stopped self-catheterization during the follow-up period. Median follow-up was 25 weeks (range, 7-223 wk). Surgery was performed laparoscopically in 48 patients (78.7%) and robotically in 13 (21.3%); 47 patients (77%) had nodules involving the digestive tract, 11 (18%) had urinary tract involvement, 29 had parametrial nodules (47.5%), and 13 (21.3%) had sacral plexus involvement. The probability of bladder voiding function recovery and arrest of self-catheterization was 24.5%, 54%, 59%, 72%, and 77% at 4, 8, 12, 52, and 78 weeks, respectively. Cox's multivariate model identified preoperative bladder dysfunction as the only statistically significant independent predictor for arrest of self-catheterization (hazard ratio, 0.36; 95% confidence interval, 0.15-0.83). CONCLUSION: Patients requiring intermittent self-catheterization for bladder dysfunction after deep endometriosis excision may spontaneously recover bladder function in 77% of cases. Symptoms suggesting preoperative bladder voiding dysfunction should be reviewed before planning surgery, and patients should be informed of the higher postoperative risk of long-term bladder voiding dysfunction.

Combined Cystoscopic-Abdominal Versus Abdominal-Only Route for Complete Excision of Large Deep Endometriosis Nodules Infiltrating the Supratrigonal Area of the Bladder: A Comparative Study.

STUDY OBJECTIVE: Surgical excision of large deep endometriosis nodules infiltrating the bladder may be challenging, particularly when the nodule limits are close to the trigone and ureteral orifice. Bladder nodules have classically been approached abdominally. However, combining a cystoscopic with an abdominal approach may help to better identify the mucosal borders of the lesion to ensure complete excision without unnecessary resection of healthy bladder. This study aimed to compare classical excision of large bladder nodules by abdominal route with a combined cystoscopic-abdominal approach. DESIGN: Retrospective comparative study on data prospectively recorded in a database. Patients were managed from September 2009 to June 2022. SETTING: Two tertiary referral endometriosis centers. PATIENTS: A total of 175 patients with deep endometriosis infiltrating the bladder more than 2 cm undergoing surgical excision of bladder nodules. INTERVENTIONS: Excision of bladder nodules by either abdominal or combined cystoscopic-abdominal approaches. MEASUREMENTS AND MAIN RESULTS: A total of 141 women (80.6%) were managed by abdominal route and 34 women (19.4%) underwent a combined cystoscopic-abdominal approach. In 99.4% of patients, the approach was minimally invasive. Patients with nodules requiring the combined approach had a lower American Fertility Society revised score and endometriosis stage and less associated digestive tract nodules, but larger bladder nodules. They were less frequently associated with colorectal resection and preventive stoma. Operative time was comparable. The rate of early postoperative complications was comparable (8.8% vs 22%), as were the rates of ureteral fistula (2.2% vs 2.9%), bladder fistula (2.2% vs 0), and vesicovaginal fistula (0.7% vs 2.9%). CONCLUSION: In our opinion, the combined cystoscopic-abdominal approach is useful in patients with large bladder nodules with limits close to the trigone and ureteral orifice. These large deep bladder nodules seemed paradoxically associated to less nodules on the digestive tract, resulting in an overall comparable total operative time and complication rate.