Robotic treatment of bowel endometriosis

Comparative Analysis of da Vinci® Xi and hinotori™ SRS Robot-Assisted Surgery Systems for Gynecologic Disorders: A Retrospective Study

Background and Objectives: This study aims to evaluate and compare the safety and efficacy of the da Vinci® Xi and hinotori™ SRS robot-assisted surgical systems for gynecologic disorders. Materials and Methods: We conducted a retrospective study of 401 cases (43 benign uterine tumors; 88 pelvic organ prolapses; 270 low-risk endometrial cancers) of robot-assisted surgery performed at Kagoshima University Hospital between January 2017 and October 2024. Surgical factors such as the operative time, blood loss, and complication rates were analyzed and compared between the da Vinci® Xi (332 cases) and hinotori™ SRS (69 cases) systems. Complications were classified according to the Clavien-Dindo classification, with Grade 2 or higher considered significant. Results: Significant differences were observed between the two groups in terms of age, body mass index, cockpit/console time, and median time from roll-in to cockpit/console start. The cockpit/console time was significantly longer for the hinotori™ SRS system (173 min) compared to the da Vinci® Xi (156 min; p = 0.047). No significant differences were observed in the total operative time, blood loss, or length of hospital stay. Intraoperative complications were minimal, with one case of bladder injury and one case of vascular injury recorded for the da Vinci® Xi. The overall postoperative complication rate was approximately 4%. Conclusions: Robot-assisted surgery using both the da Vinci® Xi and hinotori™ SRS systems was found to be safe, with minimal blood loss and a low complication rate. The hinotori™ SRS system demonstrated operative outcomes comparable to those of the da Vinci Xi® system, suggesting that it may serve as a viable alternative. Further prospective studies are warranted to evaluate the efficacy and safety of these systems.

Laparoscopic Robotic Assisted Surgery in Reproductive Medicine

Laparoscopic Robot-assisted surgery is one of the most promising and rapidly developing surgical advancements of the twenty-first century with a potential to make significant contributions to reproductive medicine and preservation of fertility. Presently, laparoscopic robotic assisted surgery is used for various benign and malignant gynecological procedures, including fertility enhancing procedures. Laparoscopic Robot-assisted surgery is superior to traditional open procedures with regards to post-surgical hospital stay and blood loss; however, the difference is comparable to laparoscopic surgery. Regarding operative times, the results have been inconsistent due to variations in surgeons' experience. The primary drawbacks of robotic systems are their high installation and maintenance costs and historical lack of tactile feedback; however, this has been overcome by the most recent evolution of robotic systems. Along with the major advances in cancer therapy, the number of female cancer survivors of reproductive age has dramatically increased. Consequently, fertility preservation and fertility enhancement have gained more emphasis in reproductive surgery in the last decade. A broad range of surgical procedures such as tubal reanastomosis, myomectomy, treatment of deep infiltrating endometriosis, ovarian transposition, radical trachelectomy, and ovarian transplantation has been introduced to restore or preserve fertility using Laparoscopic Robot-assisted surgery. In this article, we aim to present the current applications, advantages, and disadvantages of Laparoscopic Robot-assisted surgical technology in the field of reproductive surgery, including the more recent advances of Artificial Intelligence (AI) in the field.

A Gender Perspective on Coloproctological Diseases: A Narrative Review on Female Disorders

Coloproctological diseases, including both benign and malignant conditions, are among the most common diagnoses in clinical practice. Several disorders affect both men and women, while others are unique to women, or women are at a greater risk of developing them. This is due to anatomical, biological, and social conditions and also due to females' exclusive capabilities of reproduction and pregnancy. In this context, the same proctological disease could differ between men and women, who can experience different perceptions of health and sickness. There is a raised awareness about the impact of different diseases in women and a growing need for a personalized approach to women's health. In this review, we aim to summarize the specific features of the main coloproctological diseases, specifically in the female population. This includes common complaints during pregnancy, conditions linked to vaginal delivery, functional consequences after colorectal resections, and conditions presenting a gender disposition.

Robotic Rectosigmoid Resection with Totally Intracorporeal Colorectal Anastomosis (TICA) for Recurrent Ovarian Cancer: A Case Series and Description of the Technique

BACKGROUND

Most patients with ovarian cancer relapse within 2 years. Prospective randomized trials, such as DESKTOP III and SOC-I, have shown the role of secondary cytoreduction in improving oncological outcomes in selected patients, when complete tumor resection is achieved. Recent retrospective series suggest that minimally invasive surgery is a feasible option in oligometastatic recurrences, such as rectal ones.

METHODS

Five patients with an isolated rectal recurrence infiltrating the bowel wall underwent a robotic rectosigmoid resection with totally intracorporeal colorectal anastomosis. The procedure began with retroperitoneal access to manage the vascular structures, followed by visceral resection with a minimally invasive approach. The standard steps of an en-bloc pelvic resection, including intracorporeal end-to-end anastomosis, were performed. The treatment data were evaluated.

RESULTS

The mean age of the patients was 54 years, and their mean body mass index was 30. All patients had at least one previous abdominal surgery and 60% had high-grade serous ovarian cancer at their initial diagnosis. Their mean platinum-free interval was 17.4 months. Complete secondary cytoreduction was achieved in all cases, with histopathology confirming bowel infiltration. The mean procedure duration was 294 min, with an estimated blood loss of 180 mL. No intraoperative complications occurred. The mean hospital stay was 8 days. One patient had a grade 2 postoperative complication. The mean follow-up period was 14 months, with only one patient experiencing a recurrence at the level of the abdominal wall.

CONCLUSIONS

Robotic rectosigmoid resection is a viable option for complete cytoreduction in isolated recurrent ovarian cancer.

Role of robot-assisted laparoscopy in deep infiltrating endometriosis with bowel involvement: a systematic review and application of the IDEAL framework

AIMS

This review aims to evaluate the feasibility of robot-assisted laparoscopic surgery (RALS) as an alternative to standard laparoscopic surgery (SLS) for the treatment of bowel deep-infiltrative endometriosis. Additionally, it aims to provide guidance for future study design, by gaining insight into the current state of research, in accordance with the IDEAL framework.

METHOD

A systematic review was conducted to identify relevant studies on RALS for bowel deep infiltrating endometriosis in Medline, Embase, Cochrane Library and PubMed databases up to August 2023 and reported in keeping with PRISMA guidelines. The study was registered with PROSPERO Registration: CRD42022308611 RESULTS: Eleven primary studies were identified, encompassing 364 RALS patients and 83 SLS patients, from which surgical details, operative and postoperative outcomes were extracted. In the RALS group, mean operating time was longer (235 ± 112 min) than in the standard laparoscopy group (171 ± 76 min) (p < 0.01). Patients in the RALS group experienced a shorter hospital stay (5.3 ± 3.5 days vs. 7.3 ± 4.1 days) (p < 0.01), and appeared to have fewer postoperative complications compared to standard laparoscopy. Research evidence for RALS in bowel DE is at an IDEAL Stage 2B of development.

CONCLUSION

RALS is a safe and feasible alternative to standard laparoscopy for bowel endometriosis treatment, with a shorter overall length of stay despite longer operating times. Further robust randomized trials recommended to delineate other potential advantages of RALS.

Robotic surgery for deep-infiltrating endometriosis: is it time to take a step forward?

Endometriosis is a chronic debilitating disease that affects nearly 10% of women of the reproductive age. Although the treatment modalities of endometriosis are numerous, surgical excision of the endometriotic implants and nodules remains the sole cytoreductive approach. Laparoscopic excision of endometriosis was proven to be beneficial in improving the postoperative pain and fertility. Moreover, it was also proved to be safe and efficient in treating the visceral localization of deep endometriosis, such as urinary and colorectal endometriosis. More recently, robotic-assisted surgery gained attention in the field of endometriosis surgery. Although the robotic technology provides a 3D vision of the surgical field and 7-degree of freedom motion, the safety, efficacy, and cost-effectiveness of this approach are yet to be determined. With this paper, we aim to review the available evidence regarding the role of robotic surgery in the management of endometriosis along with the current practices in the field.

Robotic surgery for bowel endometriosis: a multidisciplinary management of a complex entity

BACKGROUND

Bowel endometriosis impacts quality of life. Treatment requires complex surgical procedures with associated morbidity. Precision approach with robotic surgery leads to organ preservation. Bowel endometriosis requires a multidisciplinary management to improve patient outcomes. This study evaluates perioperative outcomes of bowel endometriosis undergoing multidisciplinary planning and robotic surgery.

METHODS

Consecutive cases of multidisciplinary robotic bowel endometriosis procedures (January 2021-December 2022) were evaluated from a prospectively maintained database in a national endometriosis accredited centre. Patients were managed through a multidisciplinary setting including gynaecologists, colorectal robotic surgeons, and other specialists. Dyschezia (menstrual and non-cyclical) and quality of life were assessed pre- and postoperatively (6 months) through validated questionnaires.

RESULTS

Sixty-eight consecutive cases of robotic bowel endometriosis were included. Median age was 35.0 (30.2-42.0) years. Median body mass index was 24.0 (21.0-26.7) kg/m2. Procedures performed were 48 (70.6%) shavings, 11 (16.2%) deep shavings, 3 (4.4%) disc excisions, and 6 (8.8%) segmental resections. One (1.5%) patient required temporary stoma. Median operating time was 150 (120-180) min. There were no conversions/return to theatre postoperatively. Median endometriotic nodule size was 25.0 (15.5-40.0) mm. Two (2.9%) patients developed postoperative complications. Median length of postoperative stay was 2 (2-4) days. Median follow-up was 12 (7-17) months. One (1.5%) patient recurred. Median menstrual dyschezia score improved from 5.0 (2.0-8.0) to 1.0 (0.0-5.7). Median non-cyclical dyschezia significantly improved (p < 0.001) from 1.0 (0.0-5.7) to 0.0 (0.0-2.0). Median quality of life score improved from 52.5 (35.0-70.0) to 74.5 (60.0-80.0).

CONCLUSIONS

Robotic multidisciplinary approach to bowel endometriosis provides good perioperative outcomes with improvement of dyschezia and quality of life.

Breaking the silence: The role of extracellular vesicles in unraveling the diagnosis and treatment of endometriosis

Cell-to-cell communication is believed to be facilitated by membrane-bound vesicles called extracellular vesicles (EVs), which are released by cells. Protein, lipids, and nucleic acids are major cargo of EVs and are transported in these vesicles. Depending on the parent and recipient cell types, they can affect a wide variety of biological processes in the tissues to which they are delivered. EVs are essential for embryo implantation and endometriosis, and they are located in the uterine cavities of different species, where they promote blastocyst and endometrial preparation for implantation. This review focuses on what is currently understood regarding pathologic and diagnostic characteristics, and the potential therapeutic value of EVs in the context of endometriosis, where they can be used for drug delivery and targeted therapy due to their ability to carry bioactive molecules to specific cells or tissues. The findings of this review highlight the potential for a wide range of clinical applications that involve endometrial EVs in the areas of treatment, such as surgical and pharmacological, diagnostic biomarker development, and drug delivery systems, all with the ultimate goal of improving pregnancy success rates.

miR-424-5p combined with miR-17-5p has high diagnostic efficacy for endometriosis

PURPOSE

Endometriosis (EMT) is a chronic benign disease with high prevalence. This study investigated the diagnostic value of serum miR-17-5p, miR-424-5p, and their combined expressions for EMT.

METHODS

Total 80 EMT patients of reproductive age who underwent laparoscopy or laparotomy and were confirmed by pathological examination were included as the study subjects, and another 80 healthy women of reproductive age receiving gynecological examination and ultrasonography with no pelvic abnormalities were selected as the control group. The whole blood samples of enrolled subjects were collected and clinical characteristics were recorded. The miR-17-5p, miR-424-5p, VEGFA, IL-4, and IL-6 levels in the serum were measured. ROC curve was used to evaluate the diagnostic efficacy of miR-17-5p and miR-424-5p expressions for EMT. Pearson correlation was performed to analyze the correlation of miR-17-5p and miR-424-5p with clinical indexes in EMT patients.

RESULTS

miR-17-5p and miR-424-5p were downregulated in EMT patients. For diagnosing EMT, the AUC of miR-17-5p was 0.865 and cutoff value was 0.890 (91.3% sensitivity and 85% specificity), the AUC of miR-424-5p was 0.737, and cutoff value was 0.915 (98.8% sensitivity and 61.2% specificity), and the AUC of miR-424-5p combined with miR-17-5p was 0.938 and cutoff value was 2.205 (93.8% sensitivity and 88.7% specificity), with the diagnostic efficacy higher than miR-424-5p or miR-17-5p alone. miR-17-5p and miR-424-5p expressions were negatively correlated with dysmenorrhea, infertility, pelvic pain, and rASRM stage, but not with age, BMI, menstrual disorder, and nulliparity. VEGFA, IL-4, IL-6, and CA-125 were increased in EMT patients and were inversely associated with miR-17-5p and miR-424-5p.

CONCLUSION

miR-424-5p combined with miR-17-5p has high diagnostic efficacy for EMT.

Endometriosis: Epidemiology, Classification, Pathogenesis, Treatment and Genetics (Review of Literature)

Endometriosis is a “mysterious” disease and its exact cause has not yet been established. Among the etiological factors, congenital, environmental, epigenetic, autoimmune and allergic factors are listed. It is believed that the primary mechanism of the formation of endometriosis foci is retrograde menstruation, i.e., the passage of menstrual blood through the fallopian tubes into the peritoneal cavity and implantation of exfoliated endometrial cells. However, since this mechanism is also observed in healthy women, other factors must also be involved in the formation of endometriosis foci. Endometriosis is in many women the cause of infertility, chronic pain and the deterioration of the quality of life. It also represents a significant financial burden on health systems. The article presents a review of the literature on endometriosis—a disease affecting women throughout the world.

Robotic-assisted laparoscopy is a feasible method for resection of deep infiltrating endometriosis, especially in the rectosigmoid area

OBJECTIVE

This study aimed to compare outcomes of mini-invasive surgical treatment of endometriosis, especially conventional laparoscopy with robotic-assisted laparoscopy, and to evaluate the quality of life.

METHODS

One hundred three consecutive patients with endometriosis who had surgery from 2014 to 2017 owing to an indication of pain were enrolled in this retrospective study. The majority (n = 77, 75%) of patients underwent conventional laparoscopy and 18 (17%) had robotic-assisted laparoscopy. The quality of life was postoperatively assessed with a questionnaire.

RESULTS

The rates of parametrectomy (76% vs. 45%,) and rectovaginal resection (28% vs. 4%) were significantly higher in robotic-assisted laparoscopy than in laparoscopy. Additionally, the rate of bowel operations (50% vs. 17%), especially the shaving technique, was higher in robotic-assisted laparoscopy surgery than in laparoscopy (39% vs. 8%). There was no difference in the rate of postoperative complications between laparoscopy and robotic-assisted laparoscopy. Most (91%) of the patients who answered the questionnaire felt that surgical treatment had relieved their pain. In the laparoscopic and robotic-assisted groups, 88% of respondents felt that their quality of life had improved after surgery.

CONCLUSIONS

This study suggests that robotic-assisted laparoscopy is a feasible method to resect deep infiltrating endometriosis, especially in the rectosigmoid area.