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Park Y, Song A, Jee J, Bae N, Oh S, Shin JH, Kim YJ. Changes in anti-Müllerian hormone values for ovarian reserve after minimally invasive benign ovarian cystectomy: comparison of the Da Vinci robotic systems (Xi and SP) and the laparoscopic system. Sci Rep 2024; 14:9099. [PMID: 38643310 PMCID: PMC11032402 DOI: 10.1038/s41598-024-59935-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2023] [Accepted: 04/16/2024] [Indexed: 04/22/2024] Open
Abstract
To investigate the impact on the ovarian reserve after minimally invasive ovarian cystectomy using two platforms, the Da Vinci robotic system (Xi and SP) and the laparoscopic system. Patients underwent laparoscopic or Da Vinci robotic (Xi or SP) ovarian cystectomy for benign ovarian cysts between January 1, 2018, and December 31, 2022 at Guro Hospital, Korea University Medical center. We measured the change of AMH values (%) = [(postAMH - preAMH)] × 100/preAMH. No significant differences in preoperative age, cyst size, estimated blood loss during surgery, hemoglobin drop, length of hospital stay, adhesion detachment rate and cyst rupture rate were observed. However, the operative time was significantly shorter in the laparoscopic group than that in the robotic group (67.78 ± 30.58 min vs. 105.17 ± 38.87 min, p < 0.001) The mean preAMH and postAMH were significantly higher with the Da Vinci robotic group than with the laparoscopic group (preAMH: 5.89 ± 4.81 ng/mL vs. 4.01 ± 3.59 ng/mL, p = 0.02, postAMH: 4.36 ± 3.31 ng/mL vs. 3.08 ± 2.60 ng/mL, p = 0.02). However, the mean ΔAMH was not significantly different between two groups. ΔAMH also did not demonstrate significant differences among the three groups; laparoscopic, Xi and SP robotic. Even in the patient groups with preAMH < 2 and diagnosed with endometriosis, the ΔAMH did not show significant differences between the laparoscopic and robotic groups. The Da Vinci robotic system is no inferior to conventional laparoscopic systems in preserving ovarian function.
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Affiliation(s)
- Yunjeong Park
- Department of Obstetrics and Gynecology, Korea University College of Medicine, 148 Gurodong-ro, Guro-Gu, Seoul, 08308, South Korea
| | - Ayoung Song
- Department of Obstetrics and Gynecology, Korea University College of Medicine, 148 Gurodong-ro, Guro-Gu, Seoul, 08308, South Korea
| | - Junghyun Jee
- Department of Obstetrics and Gynecology, Korea University College of Medicine, 148 Gurodong-ro, Guro-Gu, Seoul, 08308, South Korea
| | - Nayoung Bae
- Department of Obstetrics and Gynecology, Korea University College of Medicine, 148 Gurodong-ro, Guro-Gu, Seoul, 08308, South Korea
| | - Sumin Oh
- Department of Obstetrics and Gynecology, Korea University College of Medicine, 148 Gurodong-ro, Guro-Gu, Seoul, 08308, South Korea
| | - Jung-Ho Shin
- Department of Obstetrics and Gynecology, Korea University College of Medicine, 148 Gurodong-ro, Guro-Gu, Seoul, 08308, South Korea
| | - Yong Jin Kim
- Department of Obstetrics and Gynecology, Korea University College of Medicine, 148 Gurodong-ro, Guro-Gu, Seoul, 08308, South Korea.
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Hebert T. Robotic assisted laparoscopy for deep infiltrating endometriosis. Best Pract Res Clin Obstet Gynaecol 2024; 92:102422. [PMID: 38007964 DOI: 10.1016/j.bpobgyn.2023.102422] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2023] [Revised: 10/09/2023] [Accepted: 10/22/2023] [Indexed: 11/28/2023]
Abstract
Deep infiltrative endometriosis is a condition affecting up to 15 % of women of childbearing age, defined by extra uterine location of endometrial like tissues. The symptoms of endometriosis range from severe dysmenorrhea to infertility, chronic pelvic pain, bowel dysfunction and urinary tract involvement to name the most common. Endometriosis has an impact on the quality of life of patients, with personal and social consequences. Although medical treatment is indicated in the first instance, surgery may be necessary. Standard laparoscopy has become the gold standard for this surgery. However, surgery for deep infiltrative endometriosis is known to be highly complex, and the significant development of robotic assistance in recent years has had an impact on the evolution of surgical practice. This comprehensive review of the literature provides an overview of the contributions of robotic surgery in the field of endometriosis and gives an insight into the next steps in its development.
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Affiliation(s)
- T Hebert
- Centre Olympe de Gouges, Gynecologic Surgery Department, University Hospital, Tours, France.
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Csirzó Á, Kovács DP, Szabó A, Fehérvári P, Jankó Á, Hegyi P, Nyirády P, Sipos Z, Sára L, Ács N, Szabó I, Valent S. Robot-assisted laparoscopy does not have demonstrable advantages over conventional laparoscopy in endometriosis surgery: a systematic review and meta-analysis. Surg Endosc 2024; 38:529-539. [PMID: 38062181 PMCID: PMC10830624 DOI: 10.1007/s00464-023-10587-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2023] [Accepted: 11/04/2023] [Indexed: 02/02/2024]
Abstract
BACKGROUND Endometriosis is a chronic condition affecting 6-10% of women of reproductive age, with endometriosis-related pain and infertility being the leading symptoms. Currently, the gold standard treatment approach to surgery is conventional laparoscopy (CL); however, the increasing availability of robot-assisted surgery is projected as a competitor of CL. This study aimed to compare the perioperative outcomes of robot-assisted laparoscopy (RAL) and CL in endometriosis surgery. OBJECTIVES We aimed to compare the effectiveness and safety of these two procedures. METHODS A systematic search was conducted in three medical databases. Studies investigating different perioperative outcomes of endometriosis-related surgeries were included. Results are presented as odds ratios (OR) or mean differences (MD) with 95% confidence intervals (CI). RESULTS Our search yielded 2,014 records, of which 13 were eligible for data extraction. No significant differences were detected between the CL and RAL groups in terms of intraoperative complications (OR = 1.07, CI 0.43-2.63), postoperative complications (OR = 1.3, CI 0.73-2.32), number of conversions to open surgery (OR = 1.34, CI 0.76-2.37), length of hospital stays (MD = 0.12, CI 0.33-0.57), blood loss (MD = 16.73, CI 4.18-37.63) or number of rehospitalizations (OR = 0.95, CI 0.13-6.75). In terms of operative times (MD = 28.09 min, CI 11.59-44.59) and operating room times (MD = 51.39 min, CI 15.07-87.72;), the RAL technique remained inferior. CONCLUSION RAL does not have statistically demonstrable advantages over CL in terms of perioperative outcomes for endometriosis-related surgery.
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Affiliation(s)
- Ádám Csirzó
- Centre for Translational Medicine, Semmelweis University, Üllői út 26, 1082, Budapest, Hungary
- Department of Obstetrics and Gynecology, Semmelweis University, Budapest, Hungary
| | - Dénes Péter Kovács
- Centre for Translational Medicine, Semmelweis University, Üllői út 26, 1082, Budapest, Hungary
- Department of Obstetrics and Gynecology, Semmelweis University, Budapest, Hungary
| | - Anett Szabó
- Centre for Translational Medicine, Semmelweis University, Üllői út 26, 1082, Budapest, Hungary
- Department of Urology, Semmelweis University, Budapest, Hungary
| | - Péter Fehérvári
- Centre for Translational Medicine, Semmelweis University, Üllői út 26, 1082, Budapest, Hungary
- Department of Biostatistics, University of Veterinary Medicine Budapest, Budapest, Hungary
| | - Árpád Jankó
- Centre for Translational Medicine, Semmelweis University, Üllői út 26, 1082, Budapest, Hungary
| | - Péter Hegyi
- Centre for Translational Medicine, Semmelweis University, Üllői út 26, 1082, Budapest, Hungary
- Institute of Pancreatic Diseases, Semmelweis University, Budapest, Hungary
| | - Péter Nyirády
- Centre for Translational Medicine, Semmelweis University, Üllői út 26, 1082, Budapest, Hungary
- Department of Urology, Semmelweis University, Budapest, Hungary
| | - Zoltán Sipos
- Medical School, Institute for Translational Medicine, University of Pécs, Pecs, Hungary
- Medical School, Institute of Bioanalysis, University of Pécs, Pecs, Hungary
| | - Levente Sára
- Centre for Translational Medicine, Semmelweis University, Üllői út 26, 1082, Budapest, Hungary
- Department of Obstetrics and Gynecology, Semmelweis University, Budapest, Hungary
| | - Nándor Ács
- Centre for Translational Medicine, Semmelweis University, Üllői út 26, 1082, Budapest, Hungary
- Department of Obstetrics and Gynecology, Semmelweis University, Budapest, Hungary
| | - István Szabó
- Department of Obstetrics and Gynecology, Semmelweis University, Budapest, Hungary
| | - Sándor Valent
- Centre for Translational Medicine, Semmelweis University, Üllői út 26, 1082, Budapest, Hungary.
- Department of Obstetrics and Gynecology, Semmelweis University, Budapest, Hungary.
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Lee JH, Park SY, Jeong K, Yun HY, Chung HW. What is the role of robotic surgery in ovarian cystectomy with fertility preservation? J Robot Surg 2023; 17:2743-2747. [PMID: 37690086 PMCID: PMC10678793 DOI: 10.1007/s11701-023-01704-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2023] [Accepted: 08/19/2023] [Indexed: 09/12/2023]
Abstract
To investigate the role of robotic single-site (RSS) ovarian cystectomy in fertility preservation, which was compared with single-port laparoscopic (SPL) surgery based on AMH changes. We retrospectively analyzed medical records of total 156 patients who underwent SPL (n = 72) or RSS (n = 84) surgery with the da Vinci® Si or Xi system. The pre/post-operative AMH levels and total diameter of ovarian cysts were measured. In addition to the surgical method, AMH changes were compared according to the laterality, multiplicity, and pathology of ovarian cysts. A comparison of the characteristics of the SPL group and RSS group, revealed that there were no significant differences in the average age, the diameter of the ovarian cyst, and the number of locule. There were also no statistical differences between the pre-operative and post-operative AMH levels and the average surgical time including the docking time in robotic surgery. A comparison based on the surgical methods, revealed that the decrease in post-operative AMH was lower in the RSS group (24.2 ± 35.9%) than in the SPL group (34.9 ± 29.1%) significantly (p = 0.044). In patients with endometriosis, the decrease in AMH was greater, than that in patients without endometriosis. A longer operation time, larger ovarian cysts and multi-locular cysts were associated with lower AMH level in both the SPL and RSS groups (Pearson correlation coefficient: - 0.320, p = 0.0001, - 0.218, p = 0.007, - 0.236, p = 0.003, respectively). RSS ovarian cystectomy could be a promising new therapeutic option for fertility preservation in complex cases to avoid an additional side port.
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Affiliation(s)
- Ju Hye Lee
- Department of Obstetrics and Gynecology, College of Medicine, Ewha Womans University Mokdong Hospital, Ewha Womans University, 1071, AnYangCheon-Ro, YangCheon-Gu, Seoul, 07985, Korea
| | - So Yun Park
- Department of Obstetrics and Gynecology, Ewha Womans University Seoul Hospital, College of Medicine, Ewha Womans University, Seoul, South Korea
| | - Kyungah Jeong
- Department of Obstetrics and Gynecology, College of Medicine, Ewha Womans University Mokdong Hospital, Ewha Womans University, 1071, AnYangCheon-Ro, YangCheon-Gu, Seoul, 07985, Korea.
| | - Ha Yeoung Yun
- Department of Obstetrics and Gynecology, College of Medicine, Ewha Womans University Mokdong Hospital, Ewha Womans University, 1071, AnYangCheon-Ro, YangCheon-Gu, Seoul, 07985, Korea
| | - Hye Won Chung
- Department of Obstetrics and Gynecology, College of Medicine, Ewha Womans University Mokdong Hospital, Ewha Womans University, 1071, AnYangCheon-Ro, YangCheon-Gu, Seoul, 07985, Korea
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Kang JH, Chang CS, Noh JJ, Kim TJ. Does Robot Assisted Laparoscopy (RAL) Have an Advantage in Preservation of Ovarian Reserve in Endometriosis Surgery? Comparison of Single-Port Access (SPA) RAL and SPA Laparoscopy. J Clin Med 2023; 12:4673. [PMID: 37510787 PMCID: PMC10380253 DOI: 10.3390/jcm12144673] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Revised: 07/12/2023] [Accepted: 07/12/2023] [Indexed: 07/30/2023] Open
Abstract
The purpose of this study was to compare single-port access (SPA) laparoscopy and SPA robot assisted laparoscopy (RAL) for endometriosis with respect to ovarian reserve preservation and surgical outcomes. Clinical factors affecting any reduction in ovarian function after surgery were also evaluated. Patients with endometriosis who underwent SPA laparoscopy (n = 87) or RAL (n = 78) were retrospectively reviewed. Patients' baseline characteristics, including the severity of endometriosis and surgical outcomes including surgical complexity, were collected. To assess the preservation of ovarian reserve after surgery, serum anti-Müllerian hormone (AMH) levels before surgery, at two weeks, and at three months after surgery were collected. Age, ovarian cyst size, location of cyst, complexity of surgery, and the severity of endometriosis were associated with the reduction in AMH levels after surgery. The severity of endometriosis was higher in the RAL group than in the SPA group. There were no significant differences in other clinical baseline characteristics, including preoperative AMH levels. For surgical outcomes, radical surgery was more frequently performed in the RAL group. In univariate and multivariate linear regression analyses, age, ovarian cyst size, location of cyst, complexity of surgery, and the severity of endometriosis were associated with the reduction in AMH levels after surgery. Incorporating surgical approaches and risk factors for postoperative ovarian function decrease, RAL was more beneficial than SPA laparoscopy for the preservation of ovarian reserve in patients with mild endometriosis (stage I/II) (postoperative 3 month AMH reduction rate (%), SPA laparoscopy vs. RAL, 33.51 ± 19.98 vs. 23.58 ± 14.98, p = 0.04) and in patients who underwent non-complex surgery (postoperative 3 month AMH reduction rate (%), SPA laparoscopy vs. RAL, 37.89 ± 22.37 vs. 22.37 ± 17.49, p = 0.022). SPA RAL may have advantages over SPA laparoscopy in ovarian function preservation, especially in patients with mild endometriosis and patients who have undergone a non-complex surgery.
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Affiliation(s)
- Jun-Hyeok Kang
- Department of Obstetrics and Gynecology, Uijeongbu Eulji Medical Center, Eulji University School of Medicine, Uijeongbu-si 11759, Gyeonggi-do, Republic of Korea
| | - Chi-Son Chang
- Department of Obstetrics and Gynecology, Chung-Ang University Gwang-Myung Hospital, Chung-Ang University College of Medicine, Gwangmyeong-si 14353, Gyeonggi-do, Republic of Korea
| | - Joseph J Noh
- Department of Obstetrics and Gynecology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 06351, Republic of Korea
| | - Tae-Joong Kim
- Department of Obstetrics and Gynecology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 06351, Republic of Korea
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LONGO M, GAIA G, AFONINA M, ALBONI C, LA MARCA A. Robotic-assisted laparoscopy in reproductive surgery: what is new? GAZZETTA MEDICA ITALIANA ARCHIVIO PER LE SCIENZE MEDICHE 2023. [DOI: 10.23736/s0393-3660.22.04959-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/10/2023]
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Bottura¹ B, Porto² B, Moretti-Marques² R, Barison² G, Zlotnik² E, Podgaec² S, Gomes² MTV. Surgeon experience, robotic perioperative outcomes, and complications in gynecology. Rev Assoc Med Bras (1992) 2022; 68:1514-1518. [PMID: 36449767 PMCID: PMC9720764 DOI: 10.1590/1806-9282.20220113] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2022] [Accepted: 08/15/2022] [Indexed: 12/23/2022] Open
Abstract
OBJECTIVE Robotic surgery is currently on the rise and has been widely applied all over the world. Gynecology offers great opportunities for the development of innovative techniques due to the magnitude of surgical needs. The aim of this study was to correlate perioperative complications, surgical time, and length of hospital stay with surgical diagnosis, procedure performed, and surgeon experience in robot-assisted gynecological surgeries in a 10-year period. METHODS This was a retrospective, transversal, cross-sectional study involving 632 patients who underwent robotic gynecological surgery from January 2008 to December 2017 in a community hospital in Sao Paulo, Brazil. Medical records of robot-assisted gynecological operations were searched for perioperative complications, operative time, and length of hospital stay, correlating these outcomes with surgical diagnosis, procedure performed, and surgeon experience, considering those with 20 or less robotic procedures and surgeons with more than 20 cases in their career as in-training or qualified surgeons, respectively. RESULTS Endometriosis (381 cases) was the most common surgical indication, followed by uterine myoma (171 patients). Qualified surgeons had 64% less complications than in-training surgeons (p=0.03) and achieved 20% lower surgical time and 15% shorter length of hospital stay. CONCLUSION In this study, qualified surgeons with more than 20 robotic procedures had better perioperative outcomes and less complications than in-training surgeons during their first 20 robotic surgeries.
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Affiliation(s)
- Bruna Bottura¹
- Hospital Israelita Albert Einstein, Medical Residency Program in Obstetrics and Gynecology – São Paulo (SP), Brazil.,Corresponding author:
| | - Beatriz Porto²
- Hospital Israelita Albert Einstein, Department of Obstetrics and Gynecology – São Paulo (SP), Brazil
| | - Renato Moretti-Marques²
- Hospital Israelita Albert Einstein, Department of Obstetrics and Gynecology – São Paulo (SP), Brazil
| | - Gustavo Barison²
- Hospital Israelita Albert Einstein, Department of Obstetrics and Gynecology – São Paulo (SP), Brazil
| | - Eduardo Zlotnik²
- Hospital Israelita Albert Einstein, Department of Obstetrics and Gynecology – São Paulo (SP), Brazil
| | - Sergio Podgaec²
- Hospital Israelita Albert Einstein, Department of Obstetrics and Gynecology – São Paulo (SP), Brazil
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Tang Y, Li Y. Evaluation of Serum AMH, INHB Combined with Basic FSH on Ovarian Reserve Function after Laparoscopic Ovarian Endometriosis Cystectomy. Front Surg 2022; 9:906020. [PMID: 35662819 PMCID: PMC9158433 DOI: 10.3389/fsurg.2022.906020] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2022] [Accepted: 04/25/2022] [Indexed: 12/02/2022] Open
Abstract
Objective The value of serum AMH, INHB, and bFSH levels in assessing postoperative ovarian reserve function was analyzed by measuring serum anti-Mullerian hormone (AMH), inhibin B (INHB), and basal follicle-stimulating hormone (bFSH) levels in patients after laparoscopic cystectomy for endometrioma. Methods From June 2019 to December 2021, 124 patients underwent laparoscopic cystectomy for endometrioma in our hospital were selected, and the serum AMH, INHB, bFSH level, antral follicle count (AFC) of all patients before and after operation were detected and compared. According to the results of postoperative testing, all the patients were divided into normal group (n = 86), diminished ovarian reserve (DOR) group (n = 27), and premature ovarian failure (POF) group (n = 11). Pearson correlation model and subject operating characteristic curve (ROC) were used to analyze the correlation and diagnostic value of serum AMH, INHB and bFSH levels with postoperative ovarian reserve function, respectively. Results After operation, the levels of serum AMH, INHB and AFC in the DOR group and POF group decreased compared with those before the operation, and the serum bFSH levels increased (p < 0.05). After operation, the levels of serum AMH, INHB and AFC in DOR group and POF group were lower than those in normal group,and the serum bFSH levels were higher than the normal group; the levels of serum AMH, INHB and AFC in POF group were lower than those in DOR group, and the serum bFSH levels were higher than the DOR group (p < 0.05). Pearson analysis showed that serum AMH and INHB levels were negatively correlated with bFSH, and positively correlated with the number of AFC, the serum bFSH level was negatively correlated with the number of AFC (p < 0.05). The diagnostic values of serum AMH, bFSH, INHB and the combination of the three tests for postoperative abnormal ovarian reserve function were 0.866 (95% CI, 0.801–0.923), 0.810 (95% CI, 0.730–0.890), 0.774 (95% CI, 0.687–0.860) and 0.940 (95% CI, 0.900–0.981), respectively. Conclusion Serum AMH and INHB levels decreased and bFSH levels increased in patients after laparoscopic cystectomy for endometrioma, both of which were closely related to postoperative ovarian reserve function, and both could evaluate ovarian reserve function after ovarian cyst debulking, and the combined test could significantly improve the detection rate.
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Affiliation(s)
- Yan Tang
- Department of Obstetrics and Gynecology, The Third Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Yanning Li
- Department of Obstetrics and Gynecology, The Third Affiliated Hospital of Chongqing Medical University, Chongqing, China
- Correspondence: Yanning Li
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Andres MP, Souza C, Villaescusa M, Vieira M, Abrao MS. The current role of robotic surgery in endometriosis management. Expert Rev Endocrinol Metab 2022; 17:63-73. [PMID: 35073819 DOI: 10.1080/17446651.2022.2031976] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Accepted: 01/17/2022] [Indexed: 10/19/2022]
Abstract
INTRODUCTION Endometriosis is a chronic inflammatory disease that affects approximately 10%-15% of women of childbearing age. Laparoscopic surgery is the preferred surgical approach. Recently, robotic surgery has been used for benign gynecologic surgery, but its role in the treatment of endometriosis is still unknown. AREAS COVERED We included studies that evaluated the outcomes of robotic surgery for endometriosis. Using the keywords 'endometriosis' and 'robotics', a comprehensive literature search on PubMed, Embase, and the Cochrane Library was performed in July 2021. EXPERT OPINION Robotic surgery for endometriosis has similar outcomes as conventional laparoscopy, with no evidence of increased complication rates. Despite the non-inferiority of the surgical route, the associated costs of robotic surgery limit its availability. Rapid development of robot-assisted surgery necessitates long-term prospective randomized controlled trials. However, the limitations of robotic surgery should not be overlooked. If robotic surgery can facilitate the spread of minimally invasive surgery, it will be necessary to evaluate the cost, availability, complexity of the lesions, and most importantly, the results of patient satisfaction and values of value-based medicine.
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Affiliation(s)
- Marina Paula Andres
- Departamento de Obstetricia E Ginecologia, Hospital Das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, Brazil
- Division of Gynecologic, BP - A Beneficência Portuguesa de São Paulo, São Paulo, Brazil
| | - Carolina Souza
- Division of Gynecologic, BP - A Beneficência Portuguesa de São Paulo, São Paulo, Brazil
| | - Marina Villaescusa
- Division of Gynecologic, BP - A Beneficência Portuguesa de São Paulo, São Paulo, Brazil
| | - Marcelo Vieira
- Gynecologic Oncology, Barretos Cancer Hospital/Pio XII Foundation, Barretos, São Paulo, Brazil
| | - Mauricio S Abrao
- Departamento de Obstetricia E Ginecologia, Hospital Das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, Brazil
- Division of Gynecologic, BP - A Beneficência Portuguesa de São Paulo, São Paulo, Brazil
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