Comparison between 155 cases of robotic vs. 150 cases of open surgical staging for endometrial cancer.

OBJECTIVE: To compare the outcomes of 155 cases of endometrial cancer who had robot-assisted surgical staging to 150 open cases. METHODS: Retrospective chart review of cases of endometrial cancer that underwent staging two different ways by two surgeons at an academic institution. RESULTS: Mean age was 62.4 years in the robotic arm and 65 (P=0.04) in the open arm. Mean body mass index was 34.5 Kg/m(2) in the robotic arm and 33 Kg/m(2) in the open arm (P=0.2). Pelvic and para-aortic lymph node dissection were performed in 94.8% and 67.7% of the robotic cases versus 95.3% and 74% of the open cases, respectively. Mean operative time was 127 min in the robotic arm, and 141 min in the open arm (P=0.0001). Mean lymph node count was 20.3 in the robotic arm, and 20 in the open arm (P=0.567). Mean estimated blood loss was 119 ml in the robotic arm and 185 in the open arm (P=0.015). Mean hospital stay was 1.5 days in the robotic arm, and 4 days in the open arm (P=0.0001). The incidence of postoperative ileus (0.6% vs. 10.7%, P=0.0001), infections (5.2% vs. 24%, P=0.0001), anemia/transfusion (1.3% vs. 7.7%, P=0.005), and cardiopulmonary complications (3.2% vs.14.7%, P=0.003) was significantly lower in the robotic arm vs. the open arm. There was one death in the robotic arm attributed to pre-existing cardiac condition. CONCLUSION: Robotic-assisted staging reaps the benefits of minimally invasive surgery without compromising the adequacy of the procedure. Dedication to the technique shortens the operative time.

Robotic-assisted laparoscopic hysterectomy: outcomes in obese and morbidly obese patients.

OBJECTIVE: To describe patient characteristics and perioperative outcomes among women undergoing roboticassisted laparoscopic hysterectomy and to evaluate the characteristics of nonobese, obese, and morbidly obese patients. METHODS: A retrospective review was conducted of 442 cases of women who underwent robotic-assisted laparoscopic hysterectomy for benign and malignant conditions over a 4-y period at an academic and community teaching hospital. Patient demographics, surgical indications, operative outcomes, and complications were evaluated for patients with a body mass index (BMI) <30 kg/m(2), 30 kg/m(2) to 39.9 kg/m(2), and ≥40 kg/m(2). RESULTS: Of the 442 patients, 257 (58%) were obese or morbidly obese, with a BMI of ≥30 kg/m(2). Overall, the median estimated blood loss was 100 mL (range, 10 to 800), the operative time was 135 min (range, 40 to 436), and the length of stay was 1 d (range, 0 to 22). These did not differ significantly by BMI group. Overall, 11.9% of patients experienced complications (7.9% minor, 4.1% major), and this did not differ significantly across BMI groups. CONCLUSION: Robotic hysterectomy can be performed safely in obese and morbidly obese patients, with surgical outcomes and complications similar to those in nonobese patients.

Vaginal cuff dehiscence in robotic-assisted total hysterectomy.

STUDY OBJECTIVE: The aim of this study was to estimate the cumulative incidence of vaginal cuff dehiscence in robotic-assisted total hysterectomies in our patients and to provide recommendations to decrease the incidence of vaginal cuff dehiscence. METHODS: This was an observational case series, Canadian Task Force Classification II-3 conducted at an academic and community teaching hospital. A total of 654 patients underwent robotic-assisted total laparoscopic hysterectomy for both malignant and benign reasons from September 1, 2006 to March 1, 2011 performed by a single surgeon. The da Vinci Surgical System was used for robotic-assisted total laparoscopic hysterectomy. RESULTS: There were 3 cases of vaginal cuff dehiscence among 654 robotic-assisted total laparoscopic hysterectomies, making our cumulative incidence of vaginal cuff dehiscence 0.4%. The mean time between the procedures and vaginal cuff dehiscence was 44.3 d (6.3 wk). All patients were followed up twice after surgery, at 3 to 4 wk and 12 to 16 wk. CONCLUSION: In our study, the incidence of vaginal cuff dehiscence after robotic-assisted total laparoscopic hysterectomy compares favorably to that of total abdominal and vaginal hysterectomy. Our study suggests that the incidence of vaginal cuff dehiscence is more likely related to the technique of colpotomy and vaginal cuff suturing than to robotic assisted total hysterectomy per se. With proper technique and patient education, our vaginal dehiscence rate has been 0.4%, which is 2.5 to 10 times less than the previously reported vaginal cuff dehiscence rate in the literature.

Evaluation of the Pubocervical Fascia With 3-Dimensional Endovaginal Ultrasonography and Correlation With Intraoperative Findings During Robotic Sacrocervicopexy.

OBJECTIVES: To evaluate the pubocervical fascia (PF) in patients with pelvic organ prolapse (POP) using 3-dimensonal endovaginal ultrasonography (EVUS) and to correlate the PF appearance with both pelvic examination and intraoperative findings during ultrasonographic robotic-assisted laparoscopic sacrocervicopexy and pubocervical fascia reconstruction (u-RALS-PFR). METHODS: A retrospective analysis was performed in 120 women with symptomatic POP. Preoperative evaluation was done using EVUS. We identified areas of PF weakness based on pelvic examination as hypoechoic and hyperechoic defects (HHD) between the bladder and vagina. Study measurements included distance from the HHD to the pubic symphysis, HHD to the bladder neck, HHD to the posterior bladder wall, and hypoechoic-hyperechoic area. We correlated these metrics with the respective POP-Q stages and findings during u-RALS-PFR. RESULTS: Using the quantitative measures during EVUS, we found a significant association between mean HHD (2.7 cm) and POP-Q stage III, and between HHD and number of plications performed during surgery. The larger the HHD, the more severe the POP-Q stage of the anterior compartment of the vaginal wall; thus, more plications were performed on the PF (7-12 plications) during robotic sacrocervicopexy, and consequently the anterior arm of the Y-mesh was significantly trimmed (6-8 cm). CONCLUSION: HHD obtained by EVUS was associated with severe POP-Q stage III and seemed to correlate with the number of plications during robotic sacrocervicopexy. Performing these plications on the PF significantly decreased the length of the anterior vaginal mesh needed for the procedure. These findings may open new applications for preoperative ultrasonography in evaluation and treatment of patients with apical and anterior POP.

Ultrasonography and robotic-assisted laparoscopic sacrocervicopexy with pubocervical fascia reconstruction: comparison with standard technique.

The objective of this study was to evaluate our technique of ultrasonography and robotic-assisted sacrocervicopexy with pubocervical fascia reconstruction (u-RALS-PFR) versus standard robotic-assisted laparoscopic sacrocervicopexy (s-RALS) in the treatment of patients with symptomatic apical/anterior vaginal prolapse. A retrospective analysis was done using the data in two community hospitals. Thirty women presented with symptomatic vaginal apical prolapse and desired minimally invasive surgery (video): (a) standard robotic-assisted laparoscopic sacrocervicopexy (s-RALS) (n = 15) or (b) ultrasound and robotic-assisted sacrocervicopexy with pubocervical fascia reconstruction (u-RALS-PFR) (n = 15) were eligible to participate. All participants underwent a standardized evaluation, including a structured urogynecologic history and physical examination with pelvic organ prolapse quantitative staging. There was longer operating room time in the u-RALS-PFR group compared with the s-RALS group (average difference 35 min); however, sacral promontory dissection time was less in the u-RALS-PFR (average difference of 15 min). The anterior/posterior vaginal dissection and mesh tensioning time was longer in the u-RALS-PFR, as expected. There was only one surgical and anatomic failure (7%) in the s-RALS group after 6 months of surgery (POP Q = Aa + 1, Ba0, Ap-2, Bp-3, C-7). Our technique of ultrasonography and pubocervical fascia reconstruction during RALS appears to be feasible and safe. It aims to improve anterior and apical support, minimize the use of mesh and improve visualization during surgery. u-RALS-PFR approach will add some additional time during surgery but may provide better outcomes.

Robotic-assisted laparoscopic apical suspension: description of the spiral technique.

This video's objective was to describe our spiral technique and surgical steps of robotic-assisted laparoscopic apical suspension (RALAS) in the treatment of patients with symptomatic apical vaginal prolapse. A 70-year-old Caucasian woman, gravida 3, para 2 had symptomatic pelvic organ prolapse (POP) apical/anterior stage III. At pelvic ultrasound evaluation, the uterus was small and normal appearing of adnexa bilaterally. She failed pessaries and is sexually active. The most relevant complaints were vaginal bulging and pressure. She denied urinary incontinence. During the surgery, we used (1) 3-0, V-Loc™ (Covidien) and we reinforced these absorbable sutures with (2) 2-0, GORE-TEX® Suture (Gore Medical). The Si da Vinci Surgical System was used with 4 arms and 5 trocars configuration, docked on the patient's left side. On the right/left apical support, we used V-Loc and Gore-Tex and these provided the initial 2 points suspension on the uterosacral ligaments (USL). We like to attach the left to the right USL. We then developed the space between the bladder and vagina and proceed with a plication of the pubocervical fascia with V-loc sutures. Two anterior apical support sutures were taken from the vagina to the transversalis fascia on the anterior abdominal wall and then hid behind the bladder peritoneum. The tension of these sutures was maintained with Hem-o-lock (TeleFlex) and LAPRA-TY (Ethicon). With the spiral technique, we secured these sutures through aponeurosis of abdominal muscle inside-outside-inside using a Carter-Thomason (Cooper Surgical) laparoscopic port closure system. This technique may provide a better long-term support for the anterior apical compartment.

Robotic and laparoendoscopic single-site utero-sacral ligament suspension for apical vaginal prolapse: evaluation of our technique and perioperative outcomes.

The objective of this study was to evaluate our technique and steps of robotic and laparoendoscopic single-site utero-sacral ligament suspension in the treatment of patients with symptomatic apical vaginal prolapse. A retrospective analysis was done using the data in 2 community hospital. Eighteen women presented with vaginal apex prolapse and desired minimally invasive surgery (video): (a) Laparoendoscopic single-site utero-sacral ligament suspension (LESS-UTSLS) (n = 13) or (b) robotic-assisted single-site utero-sacral ligament suspension (RASS-UTSLS) (n = 5) were eligible to participate. All participants underwent a standardized evaluation, including a structured urogynecologic history and physical examination with pelvic organ prolapse quantitative stage. Participants also completed validated questionnaire about pain scale. Multiples perioperative values were obtained to evaluate our minimally invasive approach. There were no differences in demographic, pre-operative anatomic, and functional data between groups. Concomitant anti-incontinence surgery with trans-obturator tape among the LESS-UTSLS vs RASS-UTSLS groups was performed in 2 (15 %) compared with 0 (0 %) and vaginal hysterectomy 2 (15 %) compared with supracervical hysterectomy 2 (40 %), respectively. The UTSLS operating time was similar in the RASS group compared with the LESS group (difference 9 min. There were only one POP (8 %) recurrence (stage 3) and one umbilical hernia (8 %) in the LESS-UTSLS group after 12 months of surgery. Two patients (15 %) developed stress urinary incontinence after LESS-UTSLS. We presented our technique and perioperative outcomes. RASS-UTSLS was similar operative times to LESS UTSL (+9 min), no differences in post-operative pain, anatomic support, or complications 6 months. We found that robotic surgical systems may accelerate the learning curve in the single-site surgery. Future investigations are warranted to discern the best applications for robotic single site technology in benign gynecologic surgery.

Robotic versus abdominal hysterectomy for very large uteri.

BACKGROUND AND OBJECTIVES: We sought to examine the outcomes of patients with myomatous uteri weighing >1000 g who underwent hysterectomy by one of two modalities, either with a robotic system or by laparotomy. METHODS: All patients who underwent robotic hysterectomy for uteri weighing >1000 g at our institution between May 2007 and January 2011 were identified, and a retrospective chart review was performed. These patients were matched to a laparotomy control group by body mass index and uterine weight, and the postoperative outcomes in both groups were analyzed and compared. RESULTS: Sixty patients with uteri weighing >1000 g underwent hysterectomy, 30 with the robotic system and 30 by laparotomy. The median body mass index was 31.8 kg/m(2) (range, 18.5-56.3 kg/m(2)) and the median uterine weight was 1259 g (range, >1000 -3543 g) in the robotic group versus 30.2 kg/m(2) (range, 18 - 48 kg/m(2)) and 1509 g (range, 1000 -3570 g), respectively, in the laparotomy group (P = .31). The median operating time was 255 minutes (range, 180 -372 minutes) in the robotic group versus 150 minutes (range, 100 -285 minutes) in the laparotomy group (P < .001). There were no conversions to laparotomy. In both groups the operative time was not increased with increasing specimen weight. The median blood loss was 150 mL in the robotic group versus 425 mL in the laparotomy group. Of 30 patients in the robotic group, 23 (76.6%) were discharged from the hospital on postoperative day 1. The median hospital stay for the robotic group was 1 day, and for the laparotomy group, it was 2.5 days (P < .01). CONCLUSION: Robotic surgeries for very large myomatous uteri are feasible and have minimal morbidity even in morbidly obese patients. The robotic surgery requires a longer operative time but results in a shorter hospital stay and decreased intraoperative blood loss.