Robot-assisted surgery in gynaecology

Robotic-assisted benign hysterectomy compared with laparoscopic, vaginal, and open surgery: a systematic review and meta-analysis

The potential benefits and limitations of benign hysterectomy surgical approaches are still debated. We aimed at evaluating any differences with a systematic review and meta-analysis. PubMed, MEDLINE, and EMBASE databases were last searched on 6/2/2021 to identify English randomized controlled trials (RCTs), prospective cohort and retrospective independent database studies published between Jan 1, 2010 and Dec 31, 2020 reporting perioperative outcomes following robotic hysterectomy versus laparoscopic, open, or vaginal approach (PROSPERO #CRD42022352718). Twenty-four articles were included that reported on 110,306 robotic, 262,715 laparoscopic, 189,237 vaginal, and 554,407 open patients. The robotic approach was associated with a shorter hospital stay (p < 0.00001), less blood loss (p = 0.009), and fewer complications (OR: 0.42 [0.27, 0.66], p = 0.0001) when compared to the open approach. The main benefit compared to the laparoscopic and vaginal approaches was a shorter hospital (R/L WMD: - 0.144 [- 0.21, - 0.08], p < 0.0001; R/V WMD: - 0.39 [- 0.70, - 0.08], p = 0.01). Other benefits seen were sensitive to the inclusion of database studies. Study type differences in outcomes, a lack of RCTs for robotic vs. open comparisons, learning curve issues, and limited robotic vs. vaginal publications are limitations. While the robotic approach was mainly comparable to the laparoscopic approach, this meta-analysis confirms the classic benefits of minimally invasive surgery when comparing robotic hysterectomy to open surgery. We also reported the advantages of robotic surgery over vaginal surgery in a patient population with a higher incidence of large uterus and prior surgery.

Robotic and laparoscopic gynaecological surgery: a prospective multicentre observational cohort study and economic evaluation in England

OBJECTIVE

To compare the health-related quality of life and cost-effectiveness of robot-assisted laparoscopic surgery (RALS) versus conventional 'straight stick' laparoscopic surgery (CLS) in women undergoing hysterectomy as part of their treatment for either suspected or proven gynaecological malignancy.

DESIGN

Multicentre prospective observational cohort study.

SETTING

Patients aged 16+ undergoing hysterectomy as part of their treatment for gynaecological malignancy at 12 National Health Service (NHS) cancer units and centres in England between August 2017 and February 2020.

PARTICIPANTS

275 patients recruited with 159 RALS, 73 CLS eligible for analysis.

OUTCOME MEASURES

Primary outcome was the European Organisation for Research and Treatment of Cancer Quality of Life measure (EORTC). Secondary outcomes included EuroQol-5 Dimension (EQ-5D-5L) utility, 6-minute walk test (6MWT), NHS costs using pounds sterling (£) 2018-2019 prices and cost-effectiveness. The cost-effectiveness evaluation compared EQ-5D-5L quality adjusted life years and costs between RALS and CLS.

RESULTS

No difference identified between RALS and CLS for EORTC, EQ-5D-5L utility and 6MWT. RALS had unadjusted mean cost difference of £556 (95% CI -£314 to £1315) versus CLS and mean quality adjusted life year (QALY) difference of 0.0024 (95% CI -0.00051 to 0.0057), non-parametric incremental cost-effectiveness ratio of £231 667per QALY. For the adjusted cost-effectiveness analysis, RALS dominated CLS with a mean cost difference of -£188 (95% CI -£1321 to £827) and QALY difference of 0.0024 (95% CI -0.0008 to 0.0057).

CONCLUSIONS

Findings suggest that RALS versus CLS in women undergoing hysterectomy (after adjusting for differences in morbidity) is cost-effective with lower costs and QALYs. Results are highly sensitive to the usage of robotic hardware with higher usage increasing the probability of cost-effectiveness. Non-inferiority randomised controlled trial would be of benefit to decision-makers to provide further evidence on the cost-effectiveness of RALS versus CLS but may not be practical due to surgical preferences of surgeons and the extensive roll out of RALS.

Sentinel lymph node mapping with fluorescent and radioactive tracers in vulvar cancer patients

PURPOSE

Application of radioactive tracers for sentinel lymph node biopsy (SLNB) in vulvar cancer has been established, however, the use of radioisotopes is expensive and requires complex logistics. This exploratory study evaluated the feasibility of near-infrared fluorescence-based SLNB in comparison to the gold standard using radioactive guidance.

METHODS

At Evangelische Kliniken Essen-Mitte (Essen, Germany) between 02/2015 and 04/2019, 33 patients with squamous cell vulvar cancer and unifocal tumors (32 midline, 1 lateral) smaller than 4 cm underwent SLNB as part of their routine primary surgical therapy. Radiolabeled nanocolloid technetium 99 (99mTc) was injected preoperatively and indocyanine green (ICG) intraoperatively. Demographic and clinical data were retrieved from patients' records, and descriptive statistics were applied. The detection rate of the ICG fluorescence technique was compared with the standard radioactive approach.

RESULTS

In patients with midline tumors, bilateral SLNB was attempted. SLNB was feasible in 61/64 (95.3%) groins with 99mTc and in 56/64 (87.5%) with ICG. In total, 125 SLNs were excised; all SLNs were radioactive and 117 (93.6%) also fluorescent. In 8 patients with BMI > 30 kg/m2, SLNB was successful in 14/15 groins (93.3%) with 99mTc and 13/15 groins (86.7%) with ICG. Upon final histology, infiltrated nodes were present in 9/64 (14.1%) groins and 10/125 SLNs; one positive SLN was not detected with ICG.

CONCLUSIONS

SLNB using ICG is a promising technique, however, the detection rate obtained was slightly lower than with 99mTc. The detection rate increased over time indicating that experience and training may play an important role besides further methodological refinements.

Obesity and Kidney Stone Procedures

Obesity is a chronic disease that has increased in prevalence in the United States and is a risk factor for the development of nephrolithiasis. As with other medical conditions, obesity should be considered when optimizing surgical management and choosing kidney stone procedures for patients. In this review, we outline the various procedures available for treating stone disease and discuss any discrepancies in outcomes or complications for the obese cohort.

Outcomes of Robotic Hysterectomy for Treatment of Benign Conditions: Influence of Patient Complexity

INTRODUCTION

Robotic hysterectomy may offer advantages for complex cases over the conventional laparoscopic approach.

OBJECTIVE

To assess the association of surgical approach (robotic vs conventional) with blood loss, risks of readmission, reoperation, complications, and average operative time.

METHODS

In a retrospective cohort study, we used the electronic medical records of Kaiser Permanente Northern California, 2011 to 2015, to estimate outcomes of robotic and conventional laparoscopic hysterectomy among women with complex or noncomplex benign disease. Mixed-effects regression models accounted for patient characteristics and surgeon volume.

RESULTS

The study included 560 robotic and 6785 conventional laparoscopic cases. Overall, 1836 patients (25%) met criteria for being complex. The average operative time was 152 minutes for robotic hysterectomy and 157 minutes for conventional laparoscopic hysterectomy (p < 0.0001). Complex surgical cases averaged 190 minutes and noncomplex cases averaged 144 minutes. The difference in operative time for high-volume surgeons treating complex patients with robotic hysterectomy vs conventional hysterectomy was 21 minutes faster (p < 0.05). After adjustment, the risk of blood loss at least 51 mL was lower for robotic surgery than for conventional surgery for complex and noncomplex patients. Other than risk of urinary tract complications, we observed no differences in the risks of complications or risk of reoperation between robotic and conventional laparoscopy for complex and noncomplex patients.

CONCLUSION

For women with complex disease, the robotic approach, when used by a higher-volume surgeon, may be associated with shorter operative time and slightly less blood loss, but not with lower risk of complications.

Pediatric and adolescent gynecology: Treatment perspectives in minimally invasive surgery

Minimally invasive surgery (MIS) is widely utilized across multiple surgical disciplines, including gynecology. To date, laparoscopy is considered a common surgical modality in children and adolescents to treat gynecological conditions. Robotic surgical devices were developed to circumvent the limitations of laparoscopy and have expanded the surgical armamentarium with better magnification, dexterity enhanced articulating instruments with 5-7 degrees of freedom, and ability to scale motion thus eliminating physiologic tremor. There are well-documented advantages of MIS over laparotomy, including decreased post-operative pain, shorter recovery times, and better cosmetic results. Indications for MIS in pediatric gynecology are reported in this review and technical considerations are described to highlight new treatment perspectives in children and adolescents, which have already been described in the literature regarding adult patients.

When more is not better: 10 'don'ts' in endometriosis management. An ETIC * position statement

A network of endometriosis experts from 16 Italian academic departments and teaching hospitals distributed all over the country made a critical appraisal of the available evidence and definition of 10 suggestions regarding measures to be de-implemented. Strong suggestions were made only when high-quality evidence was available. The aim was to select 10 low-value medical interventions, characterized by an unfavorable balance between potential benefits, potential harms, and costs, which should be discouraged in women with endometriosis. The following suggestions were agreed by all experts: do not suggest laparoscopy to detect and treat superficial peritoneal endometriosis in infertile women without pelvic pain symptoms; do not recommend controlled ovarian stimulation and IUI in infertile women with endometriosis at any stage; do not remove small ovarian endometriomas (diameter <4 cm) with the sole objective of improving the likelihood of conception in infertile patients scheduled for IVF; do not remove uncomplicated deep endometriotic lesions in asymptomatic women, and also in symptomatic women not seeking conception when medical treatment is effective and well tolerated; do not systematically request second-level diagnostic investigations in women with known or suspected non-subocclusive colorectal endometriosis or with symptoms responding to medical treatment; do not recommend repeated follow-up serum CA-125 (or other currently available biomarkers) measurements in women successfully using medical treatments for uncomplicated endometriosis in the absence of suspicious ovarian cysts; do not leave women undergoing surgery for ovarian endometriomas and not seeking immediate conception without post-operative long-term treatment with estrogen-progestins or progestins; do not perform laparoscopy in adolescent women (<20 years) with moderate-severe dysmenorrhea and clinically suspected early endometriosis without prior attempting to relieve symptoms with estrogen-progestins or progestins; do not prescribe drugs that cannot be used for prolonged periods of time because of safety or cost issues as first-line medical treatment, unless estrogen-progestins or progestins have been proven ineffective, not tolerated, or contraindicated; do not use robotic-assisted laparoscopic surgery for endometriosis outside research settings. Our proposal is to better address medical and surgical approaches to endometriosis de-implementing low-value interventions, with the aim to prevent unnecessary morbidity, limit psychological distress, and reduce the burden of treatment avoiding medical overuse and allowing a more equitable distribution of healthcare resources.

Symptoms and Health Quality After Laparoscopic and Robotic Myomectomy

Background and Objectives:

To compare the symptom severity and health quality outcomes of women who underwent laparoscopic and robotic myomectomy.

Methods:

This was a prospective nonrandomized cohort study. The Uterine Fibroid Symptom and Health Related Quality of Life Questionnaire was administered to 33 laparoscopic myomectomy and 31 robotic myomectomy patients before and year after surgery. Symptom severity and health quality scores were compared between the preoperative and postoperative periods for laparoscopic and robotic myomectomy procedures.

Results:

The mean age, operation time, estimated blood loss, body mass index, largest fibroid diameter, length of hospital stay, and number of fibroids removed were comparable for both groups (P > .05). Symptom severity scores decreased significantly for both laparoscopic and robotic myomectomy patients at year after surgery (P < .05), and health-related quality of life scores increased significantly in both groups at 1 year after surgery (P < .05). Improvement in symptom severity and health quality was higher in the laparoscopy group; however, this was not statistically different from the robotic myomectomy group (P > .05).

Conclusion:

Laparoscopic and robotic myomectomy provide significant reductions in fibroid-associated symptom severity and significant improvement in quality of life at 1 year after surgery. The rate of improvement was comparable for both procedures.

Robotic renal cyst decortication with calyceal diverticulectomy in a toddler - technical practicalities: a case report

Background

Incidence of simultaneous renal cyst with calyceal diverticula in contralateral kidney is rare in children. A minimally invasive procedure in different sittings is often recommended.

Case presentation

A Chinese 15-month-old boy presented to the Urology department of a tertiary care center with right flank pain. He was subjected to magnetic resonance urography and was diagnosed as having right renal cyst and contralateral calyceal diverticula. He underwent robotic cyst decortication and calyceal diverticulectomy using da Vinci robot. His postoperative period was uneventful. He was discharged on fifth postoperative day. Histopathology was consistent with simple renal cyst.

Conclusions

Robotic combined cyst decortication and contralateral diverticulectomy is feasible in selected small children. However, it demands adequate technical skill and experience.

A systematic review about costing methodology in robotic surgery: evidence for low quality in most of the studies

OBJECTIVES

The main objective of this review was to evaluate the methodological design in studies reporting resource use and costs related to robotic surgery in gynecology.

METHODS

Systematic searches were performed in the databases PubMed, Embase, Scopus, and The Centre for Reviews and Dissemination database for relevant studies before May 2016. The quality of the methodological design was assessed with items regarding methodology from the Consolidated Health Economic Evaluation Reporting Standards (CHEERS). The systematic review was reported according to the PRISMA guidelines.

RESULTS

Thirty-two relevant studies were included. None of the reviewed studied fully complied with the CHEERS methodological checklist. Background and objectives, Target population and subgroups and Setting and location were covered in sufficient details in all studies whereas the Study perspective, Justification of the time horizon, Discount rate, and Estimating resources and costs were covered in less than 50%. Most of the studies (29/32) used the health care sector perspective whereas the societal perspective was applied in three studies. The time horizon was stated in 18/32 of the studies.

CONCLUSIONS

The methodological quality of studies evaluating costs of robotic surgery was low. The longest follow-up was 4 months and in general, the use of detailed cost data were lacking in most of the investigations. Key determinants, such as purchasing, maintenance costs of the robotic platform, and the use of surgical equipment, were rarely reported. If health care cost analyses lack transparency regarding cost drivers included it may not provide a true foundation for decision-making.

Cost effectiveness of preoperative screening for healthy patients undergoing robotic hysterectomy

The objective of this study was to determine whether routine preoperative type and screen blood testing is cost effective and medically warranted for benign diagnosis in healthy patients undergoing robotic hysterectomy. The study was designed as a cross sectional retrospective descriptive study. Four hundred and twenty two medical records of American Society of Anesthesiologists (ASA) Classifications I and II patients undergoing robotically-assisted laparoscopic hysterectomy between 1 June 2011 and 31 May 2014 at a 211 bed regional medical center were analysed. The results from this study paralleled the findings of other published research. Preoperative type and screen testing was performed on 249 (59%) of the patients in the study. Ten patients (2.4% of the group) converted to open laparotomy. Mean estimated blood loss was 59.59ml. No perioperative transfusions were required. The results indicate that preoperative type and screen testing is not warranted for patients meeting the inclusion criteria.

Robot-assisted laparoscopic surgery versus conventional laparoscopic surgery in randomized controlled trials: A systematic review and meta-analysis

Importance

This review provides a comprehensive comparison of treatment outcomes between robot-assisted laparoscopic surgery (RLS) and conventional laparoscopic surgery (CLS) based on randomly-controlled trials (RCTs).

Objectives

We employed RCTs to provide a systematic review that will enable the relevant community to weigh the effectiveness and efficacy of surgical robotics in controversial fields on surgical procedures both overall and on each individual surgical procedure.

Evidence review

A search was conducted for RCTs in PubMed, EMBASE, and Cochrane databases from 1981 to 2016. Among a total of 1,517 articles, 27 clinical reports with a mean sample size of 65 patients per report (32.7 patients who underwent RLS and 32.5 who underwent CLS), met the inclusion criteria.

Findings

CLS shows significant advantages in total operative time, net operative time, total complication rate, and operative cost (p < 0.05 in all cases), whereas the estimated blood loss was less in RLS (p < 0.05). As subgroup analyses, conversion rate on colectomy and length of hospital stay on hysterectomy statistically favors RLS (p < 0.05).

Conclusions

Despite higher operative cost, RLS does not result in statistically better treatment outcomes, with the exception of lower estimated blood loss. Operative time and total complication rate are significantly more favorable with CLS.

Error reporting from the da Vinci surgical system in robotic surgery: A Canadian multispecialty experience at a single academic centre

INTRODUCTION

The goal of the study is to evaluate and report on the third-generation da Vinci surgical (Si) system malfunctions.

METHODS

A total of 1228 robotic surgeries were performed between January 2012 and December 2015 at our academic centre. All cases were performed by using a single, dual console, four-arm, da Vinci Si robot system. The three specialties included urology, gynecology, and thoracic surgery. Studied outcomes included the robotic surgical error types, immediate consequences, and operative side effects. Error rate trend with time was also examined.

RESULTS

Overall robotic malfunctions were documented on the da Vinci Si systems event log in 4.97% (61/1228) of the cases. The most common error was related to pressure sensors in the robotic arms indicating out of limit output. This recoverable fault was noted in 2.04% (25/1228) of cases. Other errors included unrecoverable electronic communication-related in 1.06% (13/1228) of cases, failed encoder error in 0.57% (7/1228), illuminator-related in 0.33% (4/1228), faulty switch in 0.24% (3/1228), battery-related failures in 0.24% (3/1228), and software/hardware error in 0.08% (1/1228) of cases. Surgical delay was reported only in one patient. No conversion to either open or laparoscopic occurred secondary to robotic malfunctions. In 2015, the incidence of robotic error rose to 1.71% (21/1228) from 0.81% (10/1228) in 2014.

CONCLUSIONS

Robotic malfunction is not infrequent in the current era of robotic surgery in various surgical subspecialties, but rarely consequential. Their seldom occurrence does not seem to affect patient safety or surgical outcome.

Perioperative surgical outcome of conventional and robot-assisted total laparoscopic hysterectomy

BACKGROUND

To evaluate surgical outcome in a consecutive series of patients with conventional and robot assisted total laparoscopic hysterectomy.

METHODS

A retrospective cohort study was performed among patients with benign and malignant indications for a laparoscopic hysterectomy. Main surgical outcomes were operation room time and skin to skin operating time, complications, conversions, rehospitalisation and reoperation, estimated blood loss and length of hospital stay.

RESULTS

A total of 294 patients were evaluated: 123 in the conventional total laparoscopic hysterectomy (TLH) group and 171 in the robot TLH group. After correction for differences in basic demographics with a multivariate linear regression analysis, the skin to skin operating time was a significant 18 minutes shorter in robot assisted TLH compared to conventional TLH (robot assisted TLH 92m, conventional TLH 110m, p0.001). The presence or absence of previous abdominal surgery had a significant influence on the skin to skin operating time as did the body mass index and the weight of the uterus. Complications were not significantly different. The robot TLH group had significantly less blood loss and lower rehospitalisation and reoperation rates.

CONCLUSIONS

This study compares conventional TLH with robot assisted TLH and shows shorter operating times, less blood loss and lower rehospitalisation and reoperation rates in the robot TLH group.

Total intravenous anaesthesia versus inhalational anaesthesia for adults undergoing transabdominal robotic assisted laparoscopic surgery

BACKGROUND

Rapid implementation of robotic transabdominal surgery has resulted in the need for re-evaluation of the most suitable form of anaesthesia. The overall objective of anaesthesia is to minimize perioperative risk and discomfort for patients both during and after surgery. Anaesthesia for patients undergoing robotic assisted surgery is different from anaesthesia for patients undergoing open or laparoscopic surgery; new anaesthetic concerns accompany robotic assisted surgery.

OBJECTIVES

To assess outcomes related to the choice of total intravenous anaesthesia (TIVA) or inhalational anaesthesia for adults undergoing transabdominal robotic assisted laparoscopic gynaecological, urological or gastroenterological surgery.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL; 2016 Issue 5), Ovid MEDLINE (1946 to May 2016), Embase via OvidSP (1982 to May 2016), the Cumulative Index to Nursing and Allied Health Literature (CINAHL) via EBSCOhost (1982 to May 2016) and the Institute for Scientific Information (ISI) Web of Science (1956 to May 2016). We also searched the International Standard Randomized Controlled Trial Number (ISRCTN) Registry and Clinical trials gov for ongoing trials (May 2016).

SELECTION CRITERIA

We searched for randomized controlled trials (RCTs) including adults, aged 18 years and older, of both genders, treated with transabdominal robotic assisted laparoscopic gynaecological, urological or gastroenterological surgery and focusing on outcomes of TIVA or inhalational anaesthesia.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures of Cochrane. Study findings were not suitable for meta-analysis.

MAIN RESULTS

We included three single-centre, two-arm RCTs involving 170 participants. We found one ongoing trial. All included participants were male and were undergoing radical robotic assisted laparoscopic radical prostatectomy (RALRP). The men were between 50 and 75 years of age and met criteria for American Society of Anesthesiologists physical classification scores (ASA) I, ll and III.We found evidence showing no clinically meaningful differences in postoperative pain between the two types of anaesthetics (mean difference (MD) in visual analogue scale (VAS) scores at one to six hours was -2.20 (95% confidence interval (CI) -10.62 to 6.22; P = 0.61) in a sample of 62 participants from one study. Low-quality evidence suggests that propofol reduces postoperative nausea and vomiting (PONV) over the short term (one to six hours after surgery) after RALRP compared with inhalational anaesthesia (sevoflurane, desflurane) (MD -1.70, 95% CI -2.59 to -0.81; P = 0.0002).We found low-quality evidence suggesting that propofol may prevent an increase in intraocular pressure (IOP) after pneumoperitoneum and steep Trendelenburg positioning compared with sevoflurane (MD -3.90, 95% CI -6.34 to -1.46; P = 0.002) with increased IOP from baseline to 30 minutes in steep Trendelenburg. However, it is unclear whether this surrogate outcome translates directly to clinical avoidance of ocular complications during surgery. No studies addressed the secondary outcomes of adverse effects, all-cause mortality, respiratory or circulatory complications, cognitive dysfunction, length of stay or costs. Overall the quality of evidence was low to very low, as all studies were small, single-centre trials providing unclear descriptions of methods.

AUTHORS' CONCLUSIONS

It is unclear which anaesthetic technique is superior - TIVA or inhalational - for transabdominal robotic assisted surgery in urology, gynaecology and gastroenterology, as existing evidence is scarce, is of low quality and has been generated from exclusively male patients undergoing robotic radical prostatectomy.An ongoing trial, which includes participants of both genders with a focus on quality of recovery, might have an impact on future evidence related to this topic.

Robotic-assisted hysterectomy: patient selection and perspectives

Minimally invasive hysterectomy via the laparoscopic or vaginal approach is beneficial to patients when compared with laparotomy, but has not been offered in the past to all women because of the technical difficulties and the long learning curve required for laparoscopic hysterectomy. Robotic-assisted hysterectomy for benign indications may allow for a shorter learning curve but does not offer clear advantages over conventional laparoscopic hysterectomy in terms of surgical outcomes. In addition, robotic hysterectomy is invariably associated with increased costs. Nevertheless, this surgical approach has been widely adopted by gynecologic surgeons. The aim of this review is to describe specific indications and patients who may benefit from robotic-assisted hysterectomy. These include hysterectomy for benign conditions in cases with high surgical complexity (such as pelvic adhesive disease and endometriosis), hysterectomy and lymphadenectomy for treatment of endometrial carcinoma, and obese patients. In the future, additional evidence regarding the benefits of single-site robotic hysterectomy may further modify the indications for robotic-assisted hysterectomy.

Robot-assisted laparoscopic myomectomy: current status

Robotic-assisted surgery has seen a rapid development and integration in the field of gynecology. Since the approval of the use of robot for gynecological surgery and considering its several advantages over conventional laparoscopy, it has been widely incorporated especially in the field of reproductive surgery. Uterine fibroids are the most common benign tumors of the female reproductive tract. Many reproductive-aged women with this condition demand uterine-sparing surgery to preserve their fertility. Myomectomy, the surgical excision of uterine fibroids, remains the only surgical management option for fibroids that entails preservation of fertility. In this review, we focus on the role of robotic-assisted laparoscopic myomectomy and its current status, in comparison with other alternative approaches for myomectomy, including open, hysteroscopic, and traditional laparoscopic techniques. Several different surgical techniques have been demonstrated for robotic myomectomy. This review endeavors to share and describe our surgical experience of using the standard laparoscopic equipment for robotic-assisted myomectomy, together with the da Vinci Robot system. For the ideal surgical candidate, robotic-assisted myomectomy is a safe minimally invasive surgical procedure that can be offered as an alternative to open surgery. The advantages of using the robot system compared to open myomectomy include a shorter length of hospital stay, less postoperative pain and analgesic use, faster return to normal activities, more rapid return of the bowel function, and enhanced cosmetic results due to smaller skin incision sizes. Some of the disadvantages of this technique include high costs of the robotic surgical system and equipment, the steep learning curve of this novel system, and prolonged operative and anesthesia times. Robotic technology is a novel and innovative minimally invasive approach with demonstrated feasibility in gynecological and reproductive surgery. This technology is expected to take the lead in gynecological surgery in the upcoming decade.

Randomized controlled trial comparing operative times between standard and robot-assisted laparoscopic hysterectomy

OBJECTIVE

To compare the operative time between robot-assisted laparoscopic hysterectomies and standard laparoscopic hysterectomies.

METHODS

A prospective, randomized controlled trial enrolled women aged 18-80 years attending Penn State Hershey Medical Center between April 23 and October 20, 2014 to undergo hysterectomy. Participants were randomized using a random number generator to undergo either robot-assisted or standard laparoscopic hysterectomy. The primary outcome was the total operative time (surgeon incision to surgeon stop, including robot docking time, if applicable). Intention-to-treat analyses were performed and the operative time was compared between the two treatments for non-inferiority, defined as a difference in operative time of no longer than 15 minutes.

RESULTS

There were 72 patients randomized to each treatment arm. The mean operative time was 73.9 minutes (median 67.0 minutes; interquartile range 59.0-83.0 minutes) in the robot-assisted hysterectomy group and 74.9 minutes (median 65.5 minutes; interquartile range 57.0-90.5 minutes) in the standard laparoscopic hysterectomy group. The upper bound of the 95% confidence interval of the difference in operative time was 6.6 minutes, below the 15-minute measure of non-inferiority.

CONCLUSION

When performed by a surgeon experienced in both techniques, the operative time for robot-assisted laparoscopic hysterectomy was non-inferior to that achieved with standard laparoscopic hysterectomy. CLINICALTRIALS.GOV: NCT02118974.

Comparison of robotic and other minimally invasive routes of hysterectomy for benign indications

BACKGROUND

Despite a lack of evidence showing improved clinical outcomes with robotic-assisted hysterectomy over other minimally invasive routes for benign indications, this route has increased in popularity over the last decade.

OBJECTIVE

We sought to compare clinical outcomes and estimated cost of robotic-assisted vs other routes of minimally invasive hysterectomy for benign indications.

STUDY DESIGN

A statewide database was used to analyze utilization and outcomes of minimally invasive hysterectomy performed for benign indications from Jan. 1, 2013, through July 1, 2014. A 1-to-1 propensity score-match analysis was performed between women who had a hysterectomy with robotic assistance vs other minimally invasive routes (laparoscopic and vaginal, with or without laparoscopy). Perioperative outcomes, intraoperative bowel and bladder injury, 30-day postoperative complications, readmissions, and reoperations were compared. Cost estimates of hysterectomy routes, surgical site infection, and postoperative blood transfusion were derived from published data.

RESULTS

In all, 8313 hysterectomy cases were identified: 4527 performed using robotic assistance and 3786 performed using other minimally invasive routes. A total of 1338 women from each group were successfully matched using propensity score matching. Robotic-assisted hysterectomies had lower estimated blood loss (94.2 ± 124.3 vs 175.3 ± 198.9 mL, P < .001), longer surgical time (2.3 ± 1.0 vs 2.0 ± 1.0 hours, P < .001), larger specimen weights (178.9 ± 186.3 vs 160.5 ± 190 g, P = .007), and shorter length of stay (14.1% [189] vs 21.9% [293] ≥2 days, P < .001). Overall, the rate of any postoperative complication was lower with the robotic-assisted route (3.5% [47] vs 5.6% [75], P = .01) and driven by lower rates of superficial surgical site infection (0.07% [1] vs 0.7% [9], P = .01) and blood transfusion (0.8% [11] vs 1.9% [25], P = .02). Major postoperative complications, intraoperative bowel and bladder injury, readmissions, and reoperations were similar between groups. Using hospital cost estimates of hysterectomy routes and considering the incremental costs associated with surgical site infections and blood transfusions, nonrobotic minimally invasive routes had an average net savings of $3269 per case, or 24% lower cost, compared to robotic-assisted hysterectomy ($10,160 vs $13,429).

CONCLUSION

Robotic-assisted laparoscopy does not decrease major morbidity following hysterectomy for benign indications when compared to other minimally invasive routes. While superficial surgical site infection and blood transfusion rates were statistically lower in the robotic-assisted group, in the absence of substantial reductions in clinically and financially burdensome complications, it will be challenging to find a scenario in which robotic-assisted hysterectomy is clinically superior and cost-effective.

Medical Engineering and Microneurosurgery: Application and Future

Robotics and medical engineering can convert traditional surgery into digital and scientific procedures. Here, we describe our work to develop microsurgical robotic systems and apply engineering technology to assess microsurgical skills. With the collaboration of neurosurgeons and an engineering team, we have developed two types of microsurgical robotic systems. The first, the deep surgical systems, enable delicate surgical procedures such as vessel suturing in a deep and narrow space. The second type allows for super-fine surgical procedures such as anastomosing artificial vessels of 0.3 mm in diameter. Both systems are constructed with master and slave manipulator robots connected to local area networks. Robotic systems allowed for secure and accurate procedures in a deep surgical field. In cadaveric models, these systems showed a good potential of being useful in actual human surgeries, but mechanical refinements in thickness and durability are necessary for them to be established as clinical systems. The super-fine robotic system made the very intricate surgery possible and will be applied in clinical trials. Another trial included the digitization of surgical technique and scientific analysis of surgical skills. Robotic and human hand motions were analyzed in numerical fashion as we tried to define surgical skillfulness in a digital format. Engineered skill assessment is also feasible and should be useful for microsurgical training. Robotics and medical engineering should bring science into the surgical field and training of surgeons. Active collaboration between medical and engineering teams and academic and industry groups is mandatory to establish such medical systems to improve patient care.

Robotic Single-Site® Sacrocolpopexy: First Report and Technique Using the Single-Site® Wristed Needle Driver

The recently introduced da Vinci Single-Site® platform offers cosmetic benefits when compared with standard Multi-Site® robotic surgery. The innovative endowristed technology has increased the use of the da Vinci Single-Site® platform. The newly introduced Single-Site® Wristed Needle Driver has made it feasible to perform various surgeries that require multiple laparoscopic sutures and knot tying. Laparoscopic sacrocolpopexy is also a type of technically difficult surgery requiring multiple sutures, and there have been no reports of it being performed using the da Vinci Single-Site® platform. Thus, to the best of our knowledge, this is the first report of robotic single-site (RSS) sacrocolpopexy, and I found this procedure to be feasible and safe. All RSS procedures were completed successfully. The mean operative time was 122.17±22.54 minutes, and the mean blood loss was 66.67±45.02 mL. No operative or major postoperative complications occurred. Additional studies should be performed to assess the benefits of RSS sacrocolpopexy. I present the first six cases of da Vinci Single-Site® surgery in urogynecology and provide a detailed description of the technique.

Current training on the basics of robotic surgery in the Netherlands: Time for a multidisciplinary approach?

Introduction

The following research questions were answered: (1) What are the training pathways followed by the current robot professionals? (2) Are there any differences between the surgical specialties in robot training and robot use? (3) What is their opinion about multidisciplinary basic skills training?

Methods

An online questionnaire was sent to 91 robot professionals in The Netherlands. The questionnaire contained 21 multiple-choice questions focusing on demographics, received robot training, and their opinion on basic skills training in robotic surgery.

Results

The response rate was 62 % (n = 56): 13 general surgeons, 16 gynecologists, and 27 urologists. The urologists performed significantly more robotic procedures than surgeons and gynecologists. The kind of training of all professionals varied from a training program by Intuitive Surgical, master-apprenticeship with or without duo console, fellowship, and self-designed training programs. The training did neither differ significantly among the different specialties nor the year of starting robotic surgery. Majority of respondents favor an obliged training program including an examination for the basics of robot skills training.

Conclusion

Training of the current robot professionals is mostly dependent on local circumstances and the manufacturer of the robot system. Training is independent of the year of start with robotic surgery and speciality. To guarantee the quality of future training of residents and fellows in robot-assisted surgery, clear training goals should be formulated and implemented. Since this study shows that current training of different specialities does not differ, training in robotic surgery could be started by a multidisciplinary basic skills training and assessment.

Electronic supplementary material

The online version of this article (doi:10.1007/s00464-016-4970-2) contains supplementary material, which is available to authorized users.

Indications and Route of Hysterectomy for Benign Diseases. Guideline of the DGGG, OEGGG and SGGG (S3 Level, AWMF Registry No. 015/070, April 2015)

Background: Official guideline "indications and methods of hysterectomy" to assign indications for the different methods published and coordinated by the German Society of Gynecology and Obstetrics (DGGG), the Austrian Society of Gynecology and Obstetrics (OEGGG) and the Swiss Society of Gynecology and Obstetrics (SGGG). Besides vaginal and abdominal hysterectomy, three additional techniques have been implemented due to the introduction of laparoscopy. Organ-sparing alternatives were also integrated. Methods: The guideline group consisted of 26 experts from Germany, Austria and Switzerland. Recommendations were developed using a structured consensus process and independent moderation. A systematic literature search and quality appraisal of benefits and harms of the therapeutic alternatives for symptomatic fibroids, dysfunctional bleeding and adenomyosis was done through MEDLINE up to 6/2014 focusing on systematic reviews and meta-analysis. Results: All types of hysterectomy led in studies to high rates of patient satisfaction. If possible, vaginal instead of abdominal hysterectomy should preferably be done. If a vaginal hysterectomy is not feasible, the possibility of a laparoscopic hysterectomy should be considered. An abdominal hysterectomy should only be done with a special indication. Organ-sparing interventions also led to high patient satisfaction rates, but contain the risk of symptom recurrence. Conclusion: As an aim, patients should be enabled to choose that therapeutic intervention for their benign disease of the uterus that convenes best to them and their personal life situation.

Robotic Versus Laparoscopic Hysterectomy for Benign Disease: A Systematic Review and Meta-Analysis of Randomized Trials

We conducted a systematic review and meta-analysis to assess the safety and effectiveness of robotic vs laparoscopic hysterectomy in women with benign uterine disease, as determined by randomized studies. We searched MEDLINE, EMBASE, the Cochrane Library, ClinicalTrials.gov, and Controlled-Trials.com from study inception to October 9, 2014, using the intersection of the themes "robotic" and "hysterectomy." We included only randomized and quasi-randomized controlled trials of robotic vs laparoscopic hysterectomy in women for benign disease. Four trials met our inclusion criteria and were included in the analyses. We extracted data, and assessed the studies for methodological quality in duplicate. For meta-analysis, we used random effects to calculate pooled risk ratios (RRs) and weighted mean differences. For our primary outcome, we used a modified version of the Expanded Accordion Severity Grading System to classify perioperative complications. We identified 41 complications among 326 patients. Comparing robotic and laparoscopic hysterectomy, revealed no statistically significant differences in the rate of class 1 and 2 complications (RR, 0.66; 95% confidence interval [CI], 0.23-1.89) or in the rate of class 3 and 4 complications (RR, 0.99; 95% CI, 0.22-4.40). Analyses of secondary outcomes were limited owing to heterogeneity, but showed no significant benefit of the robotic technique over the laparoscopic technique in terms of length of hospital stay (weighted mean difference, -0.39 day; 95% CI, -0.92 to 0.14 day), total operating time (weighted mean difference, 9.0 minutes; 95% CI, -31.27 to 47.26 minutes), conversions to laparotomy, or blood loss. Outcomes of cost, pain, and quality of life were reported inconsistently and were not amenable to pooling. Current evidence demonstrates neither statistically significant nor clinically meaningful differences in surgical outcomes between robotic and laparoscopic hysterectomy for benign disease. The role of robotic surgery in benign gynecology remains unclear.