The robotic single-port platform for gynecologic surgery: a systematic review of the literature and meta-analysis

Robotic platforms in gynaecological surgery: past, present, and future

Background

More than two decades ago, the advent of robotic laparoscopic surgery marked a significant milestone, featuring the introduction of the AESOP robotic endoscope control system and the ZEUS robotic surgery system. The latter, equipped with distinct arms for the laparoscope and surgical instruments, was designed to accommodate remote connections, enabling the practice of remote telesurgery as early as 2001. Subsequent technological progress has given rise to a range of options in today's market, encompassing multi-port and single-port systems, both rigid and flexible, across various price points, with further growth anticipated.

Objective

This article serves as an indispensable guide for gynaecological surgeons with an interest in embracing robotic surgery.

Materials and methods

Drawing insights from the experience of the Strasbourg training centre for minimally invasive surgery (IRCAD), this article offers a comprehensive overview of existing robotic platforms in the market, as well as those in development.

Results

Robotic surgical systems not only streamline established operative methods but also broaden the scope of procedures, including intra- and transluminal surgeries. As integral components of the digital surgery ecosystem, these robotic systems actively contribute to the increasing integration and adoption of advanced technologies, such as artificial intelligence-based data analysis and support systems.

Conclusion

Robotic surgery is increasingly being adopted in clinical practice. With the growing number of systems available on the marketplace, the primary challenge lies in identifying the optimal platform for each specific procedure and patient. The seamless integration of robotic systems with artificial intelligence, image-guided surgery, and telesurgery presents undeniable advantages, enhancing the precision and effectiveness of surgical interventions.

What is new?

This article provides a guide to the robotic platforms available on the market and those in development for gynaecologists interested in robotic surgery.

Feasibility and Surgical Outcomes of Hybrid Robotic Single-Site Hysterectomy Compared with Single-Port Access Total Laparoscopic Hysterectomy

We compared surgical outcomes between single-port access total laparoscopic hysterectomy (SPA-TLH) and hybrid robotic single-site hysterectomy (RSSH), a new technique of combining the benefits of SPA-TLH with RSSH in this study. A total of 64 patients were retrospectively analyzed. They underwent either hybrid RSSH or SPA-TLH for benign gynecologic disease between December 2018 and August 2021. To assess the feasibility of hybrid RSSH, the clinical characteristics and surgical outcomes were compared between the hybrid RSSH group (n = 29) and the SPA-TLH group (n = 35). All of the surgeries were completed without requiring additional ports or conversion to laparotomy. The surgical outcomes including total operative time, uterine weight, estimated blood loss, hemoglobin changes, length of hospital stay, and postoperative pain scores were not significantly different between the two groups. The colpotomy time, including the detachment of the uterosacral and cardinal ligaments, was shorter in the hybrid RSSH group than in the SPA-TLH group (8.0 min vs. 14.0 min; p = 0.029). However, the vaginal cuff closure time was longer in the hybrid RSSH group than in the SPA-TLH group (15.0 min vs.10.0 min; p = 0.001). No difference was observed with regards to intraoperative and postoperative complications. Hybrid RSSH appears to be a feasible procedure for hysterectomy in patients with benign gynecologic diseases.

The value of ultrasonography combined with carbohydrate antigen 125 and 19-9 detection in the diagnosis of borderline ovarian tumors and prediction of recurrence

Objective

This study aimed to investigate the clinical value of ultrasonography combined with tumor markers in the diagnosis and prediction of recurrence of borderline ovarian tumors (BOTs) and analyze the value of the combination of two different auxiliary examinations in the diagnosis and prediction of recurrence of BOTs.

Methods

Here, 221 patients with BOTs confirmed by postoperative pathology were enrolled. Their clinical data, including the ultrasonography features, tumor markers, and clinicopathological data, were retrospectively analyzed.

Results

The statistical data of the 221 cases with BOTs were as follows: 94 (42.5%) with left-sided lesions, 102 (46.2%) with right-sided lesions, and 25 (11.3%) with bilateral lesions. Moreover, 93 cases (42.1%) had a borderline serous tumor, 110 (49.8%) had a borderline mucinous tumor, 12 (5.4%) had a borderline serous mucinous tumor, 2 (0.9%) had a borderline endometrioid tumor, 1 (0.5%) had a borderline Brenner tumor, and 2 (0.9%) had a clear cell BOT. There were 104 cases (47.1%) with a tumor diameter of ≤10 cm and 117 cases (52.9%) with a tumor diameter of >10 cm as suggested by ultrasonography. There were 89 cases (40.3%) with septation, 44 (19.9%) with papilla, and 97 (43.9%) with blood flow as demonstrated by ultrasonography. Carbohydrate antigen 125 (CA 125) was elevated in 132 cases (59.7%), and CA 19-9 was elevated in 52 cases (23.5%).

Conclusion

In general, BOTs are difficult to diagnose preoperatively and have a certain recurrence rate. Ultrasonography combined with CA 125 and CA 19-9 is significant for the preoperative diagnosis and selection of surgical modality for BOTs and could be used as a guideline to achieve good preoperative preparation and avoid secondary surgery.

Transvaginal natural orifice endoscopic surgery for myomectomy: Can it be a conventional surgery?

INTRODUCTION

As a new minimally invasive surgery, transvaginal natural orifice transluminal endoscopic surgery (vNOTES) has been proved to be suitable for the treatment of a variety of gynecological benign diseases. However, compared with other minimally invasive surgeries that have been widely used, such as conventional multiport laparoscopy and transumbilical laparoendoscopic single-site surgery (LESS), their advantages and disadvantages and how to choose are still unknown. The purpose of our study is to compare the advantages and disadvantages of the three minimally invasive surgeries in myomectomy and to provide theoretical basis for the wider development of vNOTES surgery.

MATERIAL AND METHODS

This retrospective study included 282 patients at our hospital who underwent laparoscopic myomectomy from May 2021 to March 2022. Based on the surgical approach, patients were classified into multiport, transumbilical LESS, and vNOTES groups. The patients' demographic characteristics and follow-up data were collected during the perioperative period and at 1 month postoperatively.

RESULTS

Among the three procedures, vNOTES had the shortest anal exhaust time but also the highest postoperative infection rate. Multiple linear regression analysis showed that the operative time increased by 3.5 min for each 1 cm increase in myoma, and intraoperative bleeding increased by approximately 12 ml. The average duration of single pores increased by 25 min compared to that of multiports, and the operative duration increased by 10.48 min for each degree of adhesion.

CONCLUSIONS

For gynecologists who have mastered vNOTES, this procedure has the same efficacy and safety as the two existing minimally invasive surgeries in myomectomy, but it shows obvious advantages in postoperative recovery.

Early return to work: Single-port vs. multiport laparoscopic surgery for benign ovarian tumor

Objective

To compare the return to work (RTW) time between single-port laparoscopic surgery (SPLS) and multiport laparoscopic surgery (MPLS) for benign ovarian tumors.

Methods

A cross-sectional cohort study was conducted, which consisted of 335 women of reproductive age with benign ovarian tumors and who were keen on returning to work as early as possible. Surgical outcomes, postoperative pain score, postoperative satisfaction with the cosmesis score (CS), and the RTW time of the SPLS group were compared with those of the MPLS group. Besides, the RTW time and CS were calculated from the questionnaire survey by a single specialized gynecologist.

Results

Women who met the inclusion criteria were included in the SPLS (n = 106) and MPLS groups (n = 229). The RTW time in the SPLS group (22.13 ± 27. 06 days) was significantly shorter than that in the MPLS group (46.08 ± 57.86 days) (P < 0.001). The multivariate Cox analysis results showed that age (HR = 0.984, 95% CI, 0.971−0.997, P = 0.020), SPLS (HR = 3.491, 95% CI, 2.422−5. 032, P < 0.001), and return to normal activity time (HR = 0.980, 95% CI, 0.961−0.998, P = 0.029) were independent factors of the RTW time.

Conclusions

SPLS may be advantageous in terms of shortening the RTW time for women with benign ovarian tumors.

Can a single-port robot be safely used for robotic total gastrectomy for advanced gastric cancer? First experience using the da Vinci SP platform

Background

Many studies have shown the operative feasibility and safety of robotic gastrectomy. Surgeons are pursuing single-port (SP) surgery to leverage the advantages of minimally invasive gastrectomy. The purpose of this study was to describe technical considerations and short-term outcomes from the first reported SP robotic total gastrectomy (RTG) using the da Vinci SP platform.

Methods

A 75-year-old patient with a body-mass index of 19.8 kg/m² and clinical stage III cancer (cT3N+M0) underwent SP RTG on 22 January 2022 at the Department of General Surgery, the Chinese PLA General Hospital. All procedures were performed successfully using the da Vinci SP robotic platform.

Results

The SP RTG was successfully performed with D2 lymphadenectomy including No. 10 lymph-nodes dissection and extracorporeal Roux-en-Y anastomosis. Except for subcutaneous emphysema, no severe adverse events occurred during the operation. According to a visual analogue scale (VAS), the subjective feeling of post-operative pain was given a VAS score of 3 of 10 on Post-Operative Day 1 (POD 1), 1 of 10 on POD 3, and 1 of 10 on POD 7. We removed the gastric tube on POD 2 and advised sipping water, a liquid diet, and a soft diet on PODs 2, 4, and 6, respectively. The patient was discharged without any complications on POD 8.

Conclusion

RTG is technically feasible and safe using the da Vinci SP robotic platform. To our knowledge, this is the first study using the da Vinci SP platform in RTG for advanced gastric cancer in elderly patients. To verify its superior operative outcomes, further clinical trials are needed.

Effect of Psychological Intervention on Pelvic Floor Function and Psychological Outcomes After Hysterectomy

Background

Hysterectomy is one of the most frequently performed operations worldwide. However, postoperative complications and body image changes may induce psychological distress after hysterectomy. The study aimed to evaluate the effect of psychological intervention on pelvic floor function and psychological outcomes following hysterectomy among patients with benign indications.

Methods

Ninety-nine patients underwent hysterectomy were randomly divided into intervention group (n = 50) and control group (n = 49). Patients in the control group received routine postoperative nursing care, while extra psychological intervention was provided to patients in the intervention group, including psychological support, regular lectures and family support. After 6 months, patient's psychological statuses were assessed by Generalized Anxiety Disorder scale (GAD-7) and Patient Health Questionnaire-9 (PHQ-9). The pelvic floor function of patients was evaluated using Pelvic Floor Impact Questionnaire (PFIQ-7) and Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire (PISQ-12). Furthermore, the incidence of postoperative complications, including uracratia, pelvic organ prolapses, sexual dysfunction and chronic pelvic pain, was evaluated.

Results

After 6-month intervention, the GAD-7 and PHQ-9 scores were significantly decreased in the intervention group (p < 0.001 and p = 0.018 respectively). Both scored were significantly lower than that in the control group (p < 0.001 and p < 0.001). Compared with control group, the incidence of uracratia, pelvic organ prolapse, sexual dysfunction and chronic pelvic pain for intervention group was significantly lower (p = 0.003, p = 0.027, p = 0.001, p = 0.002 respectively) and the pelvic floor muscle strength was significantly stronger (p = 0.001). Besides, the postoperative Urinary Incontinence Impact Questionnaire (UIQ-7), Pelvic Organ Prolapse Impact Questionnaire (POPIQ-7), and Colorectal-Anal Impact Questionnaire (CRAIQ-7) scores were significantly lower (p = 0.025, p = 0.04, p < 0.001) and PISQ-12 score was significantly higher in intervention group (p < 0.001).

Conclusion

Psychological intervention could effectively improve the psychological condition of patients with hysterectomy, which may facilitate patients' postoperative recovery in pelvic floor function. These findings emphasized the necessity of psychological intervention in routine postoperative nursing care.

Analysis of Short-Term Efficacy of Gasless Single-Port Laparoscopic Inguinal Lymphadenectomy Through Vulva Incision for Vulvar Cancer

Objective

To investigate the feasibility and short-term efficacy of gasless single-port laparoscopic inguinal lymphadenectomy through vulva incision (VEIL-V).

Methods

The data of 9 patients diagnosed as vulvar squamous cell carcinoma who underwent single-port laparoscopic inguinal lymph node dissection through vulvectomy incision were retrospectively analyzed. And 13 patients who underwent laparoscopic inguinal lymph node dissection through lower abdominal subcutaneous approach as the control group (VEIL-H). The operation time, blood loss, numbers of unilateral lymph nodes, hospitalization time, and complications between the two groups were compared.

Results

The operation time of VEIL-V was 56.11 ± 5.94 min, which were shorter than that of VEIL-H (74.62 ± 5.50 min; P = 0.013). Bleeding amount in the VEIL-H was 29.44 ± 2.56, which was significantly lower than that of the VEIL-H group (43.08 ± 4.14 ml; P = 0.021). In the two groups, the numbers of unilateral lymph nodes harvested were similar. The differences in the postoperative hospital stay, skin, and lymphatic complications were not statistically significant.

Conclusion

Compared with VEIL-H, gasless single-port laparoscopic inguinal lymphadenectomy through vulva incision reduces the difficulty of operation with shorter operation time, and less blood loss, which can be a safe and mini-invasive surgical approach.

Transvaginal Natural Orifice Transluminal Endoscopic Surgery for Surgical Staging of Early-Stage Ovarian Cancers: A Report of Two Cases

Surgical staging is essential in the management of ovarian cancers. This staging has traditionally been performed by laparotomy, but minimally invasive techniques are increasingly employed. Transvaginal natural orifice transluminal endoscopic surgery (vNOTES) is a promising technique in the field of gynecological oncology. We report 2 cases of vNOTES surgical staging for suspicious ovarian tumors. We operated on 2 patients aged of 81 and 62 years for low-grade serous ovarian carcinoma and ovarian cystadenofibroma, respectively. We performed surgical staging with a pure vNOTES technique for the first patient and used a hybrid approach for the second. No intraoperative or postoperative complications were observed. We suggest that vNOTES is a feasible and effective approach to surgically manage early-stage ovarian cancers.

Near-Infrared Imaging With Indocyanine Green for the Treatment of Endometriosis: Results From the Gre-Endo Trial

INTRODUCTION

A current challenge for endometriosis surgery is to correctly identify the localizations of disease, especially when small or hidden (occult endometriosis), and to exactly define their real extension. The use of near-infrared radiation imaging (NIR) after injection of indocyanine green (ICG) represents one of the most encouraging method. The aim of this study is to assess the diagnostic value of NIR-ICG imaging in the surgical treatment of endometriosis compared with the standard of treatment.

MATERIAL AND METHODS

The Gre-Endo trial is a prospective, single-arm study (NCT03332004). After exploring the operatory field using the white light (WL) mode, patients were injected with ICG and then observed in NIR mode. All suspected areas were classified and chronicled according to lesions visualized only in WL, NIR-ICG, or in the combination of both. Lesion not visualized in WL was considered as suspect occult lesion (s-OcL). In addition, a random control biopsy from an apparent negative peritoneum visualized in WL and NIR-ICG imaging was taken for all patients (control cases). All lesions removed were considered "suspect endometriosis" until pathology.

RESULTS

Fifty-one patients were enrolled between January 2016 and October 2019. A total of 240 suspected lesions have been identified with both methods (WL + NIR-ICG). Two hundred and seven (86.2%) lesions out of the overall 240 were visualized with WL imaging, and 200 were confirmed to be pathologic (true positive for WL). The remaining 33/240 (13.75%) (false negative for WL) lesions were identified only with NIR-ICG imaging and collected as s-OcL. All 33 s-OcLs removed were confirmed to be pathologic (c-OcL = 100%). NIR-ICG vision showed PPV of 98.5%, NPV of 87.1%, Se of 87%, and Sp of 98.5%, confirming that this kind of imaging is an excellent diagnostic and screening test (p = 0.001 and p = 0.835, according to McNemar's and Cohen's kappa tests, respectively).

CONCLUSIONS

The use of NIR-ICG vision alone and combined with WL showed good results in intraoperative detection rate and fluorescence-guided surgery of endometriosis. Furthermore, NIR-ICG allowed surgeons to remove occult lesions that otherwise would remain, leading to possible greater postoperative pain and a higher risk of persistence and relapse.

Sentinel Lymph Node in Aged Endometrial Cancer Patients "The SAGE Study": A Multicenter Experience

OBJECTIVE

The incidence of endometrial cancer is increasing in elderly people. Considering that aging progressively affects lymphatic draining function, we aimed to define its impact on IGC uptake during SLN mapping.

METHODS

A multicenter retrospective cohort of endometrial cancer patients with apparently early-stage endometrial cancer undergoing complete surgical staging with SLN dissection was identified in four referral cancer centers from May 2015 to March 2021. Patients were classified in Group 1 (<65 years old) and Group 2 (≥65 years old). The primary endpoint was the assessment of the overall, bilateral, and unsuccessful SLN mapping in the two groups. Secondary outcomes were the evaluation of SLN anatomical distribution and the identification of predictors for mapping failure applying a logistic regression.

RESULTS

A total of 844 patients were enrolled in the study (499 in Group 1 and 395 in Group 2). The overall detection rate, the successful bilateral mapping, and the mapping failure rate of the SLN were 93.8% vs. 87.6% (p = 0.002), 77.1% vs. 66.8% (p = 0.001), and 22.9% vs. 33.2% (p = 0.001), respectively, in Group 1 vs. Group 2. The advanced age affects the anatomical distribution of the SLN leading to a stepwise reduction of "unexpected" mapping sites (left hemipelvis: p < 0.001; right hemipelvis: p = 0.058). At multivariate analysis age ≥ 65 (OR: 1.495, 95% CI: 1.095-2.042, p = 0.011), BMI (OR: 1.023, 95% CI: 1.000-1.046, p = 0.047), non-endometrioid histotype (OR: 1.619, 95% CI: 1.067-2.458, p = 0.024), and LVSI (OR: 1.407, 95% CI: 1.010-1.961, p = 0.044) represent independent predictors of unsuccessful mapping. Applying binomial logistic regression analysis, there was a 1.280-fold increase in the risk of failed mapping for every 10-year-old increase in age (OR: 1.280, 95% CI: 1.108-1.479, p = 0.001). A higher rate of surgical under-staging (0.9% vs. 3.3%, p = 0.012) and adjuvant undertreatment (p = 0.018) was reported in Group 2.

CONCLUSIONS

Old age represents a risk factor for SLN mapping failure both intrinsically and in relation to the greater incidence of other independent risk factors such as LVSI, non-endometrioid histotype, and BMI. Surgeons should target the usual uptake along UPP during the SLN dissection in this subgroup of patients to minimize mapping failure and the consequent risk of surgical under-staging and adjuvant undertreatment.

Robotic platforms for endometrial cancer treatment: review of the literature

INTRODUCTION

The cornerstone in the management of endometrial cancer (EC) is surgical staging. Over the last few decades, minimally invasive surgery has been widely accepted as a mainstay in the treatment of endometrial cancer. The first robotic-assisted gynecological surgery was performed in 1998.

EVIDENCE ACQUISITION

The literature search was conducted using MEDLINE, EMBASE and PUBMED databases from January 1998 to September 2020.

EVIDENCE SYNTHESIS

Several studies have reported the advantages of robotic-assisted surgery over laparoscopy in the management of EC. These are most pronounced in obese patients. Robotic-assisted surgery is also associated with a shorter learning curve, particularly for lymphadenectomy, which enables more surgeons to perform minimally invasive surgery for EC.

CONCLUSIONS

The effectiveness and oncological results of robotic surgery for EC appear to be similar to those of other surgical methods, but fewer intraoperative complications occur than with other methods.

Novelties of ultrasound imaging for endometrial cancer preoperative workup

INTRODUCTION

Endometrial cancer (EC) is the most frequent gynecological cancer. Transvaginal ultrasound (TVU) plays a leading role in the preoperative workup and often is the first diagnostic instrumental examination. Despite expert hands' ultrasound is recommended to assess myometrial invasion in early stage EC, this method is a strictly operator-dependent examination, and varying degrees of sensitivity and specificity have been reported. The present review aims to provide an update of ultrasound imaging in the preoperative work-up for EC patients.

EVIDENCE ACQUISITION

A double-blind search was performed from May to September 2020. The following keywords: "ultrasound," "transvaginal ultrasound" and "endometrial cancer" were searched in Pubmed search engines, Scopus, and Web of Science. The Prisma statement was followed for the selection of the articles included.

EVIDENCE SYNTHESIS

The initial search provided 958 studies, of which 11 were included in the analysis. non-English articles, not relevant to the purposes of this study, case reports and articles with fewer than 40 cases were excluded.

CONCLUSIONS

TVU sensitivity and specificity in myometrial infiltration and cervical invasion is comparable to MRI but has lower costs, greater patient tolerability, and does not require contrast agents. An expert operator should perform the ultrasound examination in patients with suspected EC The presence of myometrial lesions, such as leiomyomas, could lower the diagnostic accuracy of ultrasound, so special attention should be paid to patients with concomitant uterine lesions.