Robotic Assistance Confers Ambidexterity to Laparoscopic Surgeons.

STUDY OBJECTIVE: To examine whether a robotic surgical platform can complement the fine motor skills of the nondominant hand, compensating for the innate difference in dexterity between surgeon's hands, thereby conferring virtual ambidexterity. DESIGN: Crossover intervention study (Canadian Task Force classification II-1). SETTING: Centers for medical simulation in 2 tertiary care hospitals of Harvard Medical School. PARTICIPANTS: Three groups of subjects were included: (1) surgical novices (medical graduates with no robotic/laparoscopic experience); (2) surgeons in training (postgraduate year 3-4 residents and fellows with intermediate robotic and laparoscopic experience); and (3) advanced surgeons (attending surgeons with extensive robotic and laparoscopic experience). INTERVENTIONS: Each study group completed 3 dry laboratory exercises based on exercises included in the Fundamentals of Laparoscopic Surgery (FLS) curriculum. Each exercise was completed 4 times: using the dominant and nondominant hands, on a standard laparoscopic FLS box trainer, and in a robotic dry laboratory setup. Participants were randomized to the handedness and setting order in which they tackled the tasks. MEASUREMENTS AND MAIN RESULTS: Performance was primarily measured as time to completion, with adjustments based on errors. Means of performance for the dominant versus nondominant hand for each task were calculated and compared using repeated-measures analysis of variance. A total of 36 subjects were enrolled (12 per group). In the laparoscopic setting, the mean overall time to completion of all 3 tasks with the dominant hand differed significantly from that with the nondominant hand (439.4 seconds vs 568.4 seconds; p = .0008). The between-hand performance difference was nullified with the robotic system (374.4 seconds vs 399.7 seconds; p = .48). The evaluation of performance for each individual task also revealed a statistically significant disparate performance between hands for all 3 tasks when the laparoscopic approach was used (p = .003, .02, and .01, respectively); however, no between-hand difference was observed when the tasks were performed robotically. On analysis across the 3 surgeon experience groups, the performance advantage of robotic technology remained significant for the surgical novice and intermediate-level experience groups. CONCLUSION: Robot-assisted laparoscopy may eliminate the operative handedness observed in conventional laparoscopy, allowing for virtual ambidexterity. This ergonomic advantage is particularly evident in surgical trainees. Virtual ambidexterity may represent an additional aspect of surgical robotics that facilitates mastery of minimally invasive skills.

Mullerian dysgenesis: a critical review of the literature.

PURPOSE: To present an update of the genetic, clinical, diagnostic, and therapeutic aspects of Mayer-Rokitansky-Kuster-Hauser (MRKH) syndrome. METHODS: Studies were considered eligible if they have evaluated patients with MRKH syndrome. Eligible articles were identified by a search of MEDLINE bibliographical database from 1950 to August 2016. A purely descriptive approach was adopted concerning all outcomes examined by the individual studies. RESULTS: MRKH syndrome is defined as congenital aplasia of the upper vagina and impairment of uterine development in normal 46XX females. Accounting for 1:4500 women, MRKH is the second most common cause of primary amenorrhea following gonadal dysgenesis. Potential association of MRKH syndrome to specific genes has been the focus of recent research. Null-association results of HOXA genes and Wnt5a, Wnt7a, and Wnt9a have been reported, while point mutations of the WNT4 gene point mutations have been associated with an MRKH-like syndrome characterized by Mullerian duct regression and hyperandrogenism. Ultrasound and Magnetic Resonance Imaging (MRI) are the main techniques to establish an accurate diagnosis of the syndrome. Several non-surgical and surgical procedures have been reported for the creation of a functional neovagina; in general, non-surgical treatment should be the first initially pursued. Along with psychological support, recent developments in assisted reproductive technologies of IVF techniques and the availability of gestational surrogacy, as well as the recent breakthrough of successful uterus transplantation, enable women with MRKH syndrome to attain their own genetic child. CONCLUSION(S): MRKH syndrome is a medical modality with important social, legal, and ethical projections that require a multi-disciplinary approach.

Flexible Carbon Dioxide Laser Fiber Versus Ultrasonic Scalpel in Robot-Assisted Laparoscopic Myomectomy.

STUDY OBJECTIVE: To compare the effectiveness and safety of a flexible carbon dioxide (CO2) laser fiber to the ultrasonic scalpel when employed through a robotic surgical system. DESIGN: Retrospective cohort study. DESIGN CLASSIFICATION: Level II-2 evidence. SETTING: Reproductive surgery practice at an academic hospital. PATIENTS: Two hundred thirty-six women who had undergone robot-assisted laparoscopic myomectomy with either CO2 laser (n = 85) or the ultrasonic scalpel (n = 151). INTERVENTIONS: Robot-assisted laparoscopic myomectomy employing either a flexible CO2 laser fiber or a robotic ultrasonic scalpel as the primary energy tool. MEASUREMENTS AND MAIN RESULTS: Perioperative outcomes (estimated blood loss, operative time, length of hospital stay) of patients undergoing robot-assisted myomectomy with a flexible laser fiber or ultrasonic scalpel. Estimated blood loss and operative time were comparable (p = .95 and p = .55, respectively) between the 2 groups after adjusting for all confounders, whereas length of hospital stay remained significantly different (p = .004). Odds ratio for complications was 0.35 (95% confidence interval 0.08-1.56; p = .17), which denotes no difference in the risk for complications between the 2 groups. CONCLUSION: Robot-assisted laparoscopic myomectomy with a flexible CO2 laser fiber is safe and has comparable operative outcomes to the ultrasonic scalpel. The small size and flexibility of this device allows robotic surgeons to employ safe focal energy without sacrificing operative ergonomics.

Cytochrome P450 1A1 (CYP1A1) gene polymorphisms and ovarian cancer risk: a meta-analysis.

This meta-analysis aims to examine whether the genotype status of MspI, Ile462Val, and Thr461Asn polymorphisms in Cytochrome P450 1A1 (CYP1A1) is associated with ovarian cancer risk. Eligible case-control studies were identified through search in MEDLINE (end of search: October 2010). Pooled odds ratios (ORs) were appropriately derived from fixed effects or random effects models. Concerning MspI polymorphism, seven studies were eligible (1,051 cases and 1,613 controls); 11 studies were eligible (1,680 cases and 3,345 controls) for Ile462Val and three studies were eligible (349 cases and 785 controls) for Thr461Asn. Ile462Val polymorphism seemed to confer elevated ovarian cancer risk concerning homozygous carriers (pooled OR = 2.65, 95 % CI: 1.40-5.03, p = 0.003, fixed effects), as well as at the recessive model (pooled OR = 2.10, 95 % CI: 1.13-3.92, p = 0.020, fixed effects); these findings were replicated upon Caucasian subjects. MspI polymorphism was not associated with ovarian cancer risk (for heterozygous TC vs TT carriers pooled OR = 1.10, 95 % CI: 0.91-1.34, p = 0.329, fixed effects; for homozygous CC vs. TT carriers pooled OR = 1.11, 95 % CI: 0.65-1.90, p = 0.693, fixed effects). With respect to Thr461Asn polymorphism a finding of borderline statistical significance emerged, pointing to marginally elevated ovarian cancer risk in heterozygous Thr/Asn carriers (pooled OR = 1.62, 95 % CI: 0.97-2.70, p = 0.066, fixed effects), but not in homozygous Asn/Asn carriers (pooled OR = 1.40, 95 % CI: 0.18-10.89, p = 0.749, fixed effects). Ile462Val status seems to represent a meaningful risk factor for ovarian cancer in Caucasians. Additional case-control studies of high methodological quality are needed in order to further substantiate and enrich the present findings. Special attention should be paid upon the design of future studies; Asian and African populations should represent points of focus.

Cytochrome P450 1A1 (CYP1A1) gene polymorphisms and cervical cancer risk: a meta-analysis.

This meta-analysis aims to examine whether the genotype status of MspI and Ile462Val polymorphisms in Cytochrome-P450 1A1 (CYP1A1) is associated with cervical cancer risk. Eligible case-control studies were identified through search in MEDLINE (end of search: October 2010). Pooled odds ratios (ORs) were appropriately derived from fixed-effects or random effects models. Concerning MspI polymorphism, six studies were eligible (722 cases and 770 controls); four studies were eligible (350 cases and 519 controls) for Ile462Val. MspI polymorphism was associated with elevated cervical cancer risk (for heterozygous TC vs. TT carriers OR = 1.50, 95% CI: 0.93-2.42, random effects; for homozygous CC vs. TT carriers OR = 2.66, 95% CI: 1.14-6.19, random effects). Similarly, Ile462Val polymorphism was associated with elevated cervical cancer risk (for heterozygous Ile/Val vs. Ile/Ile carriers OR = 2.36, 95% CI: 1.10-5.08, random effects; for homozygous Val/Val vs. Ile/Ile carriers OR = 2.73, 95% CI: 1.21-6.15, fixed effects). The results were replicated upon Caucasian subjects, who represented the majority of existing data. The two examined CYP1A1 genotype polymorphisms seem to confer additional risk for cervical cancer. Accumulation of further data seems mandatory for future race-specific analyses and for the demonstration of CYP1A1-smoking interactions.

Cytochrome P450 1A1 gene polymorphisms and endometrial cancer risk: a meta-analysis.

INTRODUCTION: This meta-analysis aims to examine whether the genotype status of Msp1, Ile462Val, and Thr461Asn polymorphisms in cytochrome P450 1A1 (CYP1A1) is associated with endometrial cancer risk. METHODS: Eligible case-control studies were identified through search in MEDLINE (end of search: August 2010). Pooled odds ratios (ORs) were appropriately derived from fixed-effects or random-effects models. RESULTS: Concerning MspI polymorphism, 8 studies were eligible (1456 cases and 2371 controls); 9 studies were eligible (1889 cases and 3662 controls) for Ile462Val and 6 studies were eligible (1272 cases and 2122 controls) for Thr461Asn. MspI polymorphism was not associated with endometrial cancer risk (for heterozygous TC vs TT carriers: OR = 0.83, 95% confidence interval [CI], 0.59-1.15, random effects; for homozygous CC vs TT carriers: OR = 1.00, 95% CI, 0.55-1.82, fixed effects). Similarly, Ile462Val polymorphism was not associated with endometrial cancer risk (for heterozygous Ile/Val vs Ile/Ile carriers: OR = 1.27, 95% CI, 0.78-2.06, random effects; for homozygous Val/Val vs Ile/Ile carriers: OR = 1.16, 95% CI, 0.48-2.81, fixed effects). Accordingly, Thr461Asn status was not significantly associated with endometrial cancer risk. The same results were reproduced in Caucasians. CONCLUSIONS: The 3 examined CYP1A1 genotype polymorphisms do not seem to confer any additional risk for endometrial cancer in Caucasians. Accumulation of further data seems mandatory for future race-specific analyses.

GSTM1 polymorphism, GSTT1 polymorphism, and cervical cancer risk: a meta-analysis.

INTRODUCTION: A debate exists about whether glutathione S-transferase (GST) polymorphisms (GST mu-1 [GSTM1] null/present genotype and GST theta-1 [GSTT1] null/present genotype) confer additional risk for cervical cancer. This meta-analysis was aimed to examine the associations between the aforementioned polymorphisms and cervical cancer risk. METHODS: Thirteen studies were eligible for GSTM1 (1616 cervical cancer cases and 1970 controls), and 12 studies were eligible for GSTT1 (1393 cases and 1766 controls). Pooled odds ratios (OR) were appropriately derived from fixed effects or random effects models. Separate analyses were conducted on Chinese and non-Chinese populations. Metaregression with publication year was also performed. RESULTS: At the overall analysis, the GSTM1 null genotype was associated with increased cervical cancer risk (pooled OR = 1.272; 95% confidence interval [CI], 1.014-1.597, random effects). The association seemed confined to non-Chinese populations (pooled OR = 1.392; 95% CI, 1.003-1.932, random effects) given that the association was not significant in the subset of Chinese studies (pooled OR = 1.080; 95% CI, 0.870-1.340, fixed effects). On the other hand, at the overall analysis, the GSTT1 null genotype was not associated with increased cervical cancer risk (pooled OR = 1.301; 95% CI, 0.948-1.787, random effects). Similarly, no significant associations were detected in either non-Chinese or Chinese populations concerning the GSTT1 null genotype. CONCLUSIONS: The GSTM1 null genotype confers additional risk for cervical cancer in non-Chinese populations. The trend concerning GSTT1 has not reached significance.

Effect of antiobesity medications in patients with type 2 diabetes mellitus.

Obesity is considered as a major health problem, as its prevalence continuously rises worldwide. One of the common health consequences of obesity is type 2 diabetes mellitus. Therefore, antiobesity management is a prerequisite in treating diabetic patients. Lifestyle modifications combined with pharmacological agents appear to be an effective approach. Sibutramine is a serotonin-noradrenaline reuptake inhibitor, which acts centrally by promoting the feeling of satiety and decreasing caloric intake, thus resulting in weight loss. A potential association with cardiovascular side effects has been noted. Orlistat, a gastric and pancreatic lipase inhibitor, also achieves significant weight loss and improves glycaemic status, but it has gastrointestinal side effects. Rimonabant, the first endocannabinoid CB1 antagonist, is associated with weight reduction and it improves diabetic parameters; nevertheless, it is associated with psychiatric disorders; indeed, a recently conducted safety review led to the temporal suspension of its commercialization. The above-mentioned medications seem to be currently useful agents for treating obesity in patients with type 2 diabetes mellitus. Other medications used for diabetes management, such as exenatide, liraglutide and pramlintide, have also shown body weight reduction. Ongoing research is needed to scrutinize the precise impact of these agents in the daily clinical practice of management of obesity in patients with type 2 diabetes mellitus.

Coaxial robot-assisted laparoendoscopic single-site myomectomy.

We report our experience with coaxial robot-assisted laparoendoscopic single-site (RA-LESS) myomectomy, including a detailed description of the technique and outcomes from our first 21 cases. This was a retrospective cohort study carried out at the reproductive endocrinology and gynecologic oncology divisions at two academic medical centers. RA-LESS myomectomy was performed with the da Vinci Si Surgical System (Intuitive Surgical, Inc, Sunnyvale, CA, USA) employing standard rigid 8 or 5 mm instrumentation in a coaxial arrangement through a standard laparoendoscopic single-site (LESS) port (GelPOINT Advanced Access Platform, Applied Medical, Rancho Santa Margarita, CA, USA). Cases were completed between October 2011 and November 2013. Twenty-one patients underwent surgery. Mean age (±SD) was 38.1 ± 5.8 years, and mean BMI was 29.4 ± 4.7 kg/m2. Menorrhagia, pelvic pressure, and urinary frequency were the main presenting symptoms. Mean diameter of the largest tumor was 5.7 ± 1.9 cm (median 5.9 cm, range 2.1-9.5 cm), while mean number of tumors removed was 2.2 ± 1.8, ranging from 1 to 8 per surgery. Mean operative time was 154.2 ± 55.2 min (median 152 min, range 85-290 min). Mean blood loss was 57.9 ± 53.7 cc (median 50 cc, range 5-200 cc) and length of hospital stay ranged between 0 and 3 days (median 0). All procedures were successfully performed without conversion to conventional LESS surgery, multi-port laparoscopy or laparotomy. RA-LESS myomectomy with coaxial use of standard rigid instrumentation is a safe and reproducible addition to the minimally invasive surgeons' armamentarium, with excellent cosmetic and postoperative outcomes in selected patients. Further investigation is needed to define the patient groups that will most benefit from it.

Current trends and controversies in reproductive surgery.

Even in the context of the expansion of assisted reproductive technologies (ART), reproductive surgery continues to fulfill its deserved place in the arsenal of fertility treatments. Rather than being competitive, these two avenues of treatment can optimize fertility care when utilized as an adjunct to one another. Surgical indications and techniques in modern reproductive surgery continue to evolve based on new information about the effects of pelvic pathology on infertility and new technology. This review aims to disentangle some of the common clinical dilemmas facing reproductive specialists in regard to the effect of benign gynecologic pathology on fertility and the relevance of surgical intervention in enhancing or preserving fertility in women. To this end, we focus on the management of intramural myomata, adenomyosis, ovarian and peritoneal endometriosis and teratomas in women of reproductive age. In addition, we also review the role of recently developed techniques in the field of ovarian tissue preservation as well as uterine transplantation.

Follicular development, acquisition of mature oocytes, and pregnancy after 2 weeks of leuprolide acetate administration during the midluteal phase.

OBJECTIVE: To present a case of aberrant follicular development, acquisition of mature oocytes, and pregnancy after 2 weeks of leuprolide acetate administration during the midluteal phase. DESIGN: Case report. SETTING: Department of Obstetrics and Gynecology, Aretaieio University Hospital, Athens, Greece. PATIENT(S): A 37-year-old white woman who was scheduled to undergo ovarian stimulation according to the long luteal phase protocol for IVF and ET because of male factor infertility. INTERVENTION(S): Twenty-first day serum P level was 5.9 ng/dL, and a daily dose of 0.1 mg leuprolide acetate was initiated. Fifteen days later the patient presented for evaluation because of absence of uterine bleeding. Sonographic evaluation revealed the presence of five large follicles. Serum E(2) and P levels at this time were 1,895.0 pg/mL and 0.2 ng/mL, respectively. The patient received recombinant hCG (250 mg), and 36 hours later she underwent oocyte retrieval. Three oocytes were retrieved and fertilized by intracytoplasmic sperm injection. After the transfer of two embryos a singleton pregnancy was achieved, leading to an uneventful delivery. MAIN OUTCOME MEASURE(S): Serum E(2) and P and ultrasound evaluation of ovaries. RESULT(S): She had a singleton pregnancy, and she delivered at 39 weeks of gestation. CONCLUSION(S): The presence of recruitable follicles during the luteal phase of the cycle that responded to endogenous gonadotropins during the flare response before pituitary suppression could be a logical explanation of this observation.