Robotic Shaving Technique in 25 Patients Affected by Deep Infiltrating Endometriosis of the Rectovaginal Space.

Minimally invasive surgery represents the gold standard for the management of deep infiltrating endometriosis (DIE) involving the rectovaginal septum (RVS). This analysis aimed to evaluate the feasibility of robotic-assisted laparoscopy (RAL) and clinical outcomes in terms of long-term complications, pain relief, and recurrence rate for the treatment of DIE of the RVS. A prospective cohort study of robotic procedures was performed between October 2010 and July 2014, including removal of endometriotic nodules from the RVS with rectal shaving alone or in combination with accessory procedures. In all cases, the revised American Society for Reproductive Medicine (rASRM) score for endometriosis was >40 points (stage IV). Twenty-five consecutive patients underwent RAL, with a successful complete nodule debulking by the wall shaving technique. Pathology confirmed the adequacy of the surgical specimen and the median largest endometriotic nodule was of 21 mm (range, 10-60 mm), with free margins in all cases. The median operative time from skin opening to closure was 174 minutes (range, 75-300 minutes), and blood loss was close to 0 mL. The median revised Enzian score for location A (RVS) was 2 (range, 1-3). The most frequent Enzian class was A2B0C0 (48%), followed by A3B0C0 (12%). In 3 cases (12%), partial vaginal resection was required to remove endometriotic nodules of the RVS (1 each in classes A3B0C1FI, A3B0C0FO, and A3B0C0). No intraoperative complications occurred. This series has a median long-term follow up of 22 months (range, 6-50 months) currently available with an optimal operative time, demonstrating good long-term outcomes. Our data support robotics as a safe and attractive alternative for comprehensive surgical treatment of DIE.

Cost analysis of minimally invasive hysterectomy vs open approach performed by a single surgeon in an Italian center.

Despite the rapid uptake of robotic surgery, the effectiveness of robotically assisted hysterectomy (RAH) remains uncertain, due to the costs widely variable. Observed the different related costs of robotic procedures, in different countries, we performed a detailed economic analysis of the cost of RAH compared with total laparoscopic (TLH) and open hysterectomy (OH). The three surgical routes were matched according to age, BMI, and comorbidities. Hysterectomy costs were collected prospectively from September 2014 to September 2015. Direct costs were determined by examining the overall medical pathway for each type of intervention. Surgical procedure cost for RAH was €3598 compared with €912 for TLH and €1094 for OH. The cost of the robot-specific supplies was €2705 per intervention. When considering overall medical surgical care, the patient treatment average cost of a RAH was €4695 with a hospital stay (HS) of 2 days (range 2-4) compared with €2053 for TLH and €2846 for OH. The main driver of additional costs is disposable instruments of the robot, which is not compensated by the hospital room costs and by an experienced team staff. Implementation of strategies to reduce the cost of robotic instrumentation is due. No significant cost difference among the three procedures was observed; however, despite the optimal operative time, the experienced, surgeon and the lower HS, RAH resulted 2, 3 times and 1, 6 times more expensive in our institution than TLH and OH, respectively.