[Partial cystectomy for bladder endometriosis: Robotic assisted laparoscopy versus standard laparoscopy]

Bladder Endometriosis: What do we know and what is left to find out? A narrative review

Bladder endometriosis accounts for 70-85% of urinary tract endometriosis cases. Urinary tract endometriosis occurs in approximately 1% of those living with endometriosis. Underlying aetiology and pathogenesis are not fully understood, but there are several plausible theories. As well as the typical pain symptoms, those with bladder endometriosis can experience several urinary tract symptoms. The manifestation of these symptoms can have complex pathways and processes. Imaging is accurate in the diagnosis of bladder endometriosis and clinicians should be mindful of the risk of silent kidney loss. Management should be guided by symptoms; both medical and surgical options are feasible. Surgical management offers potentially definitive treatment. Excisional surgery via bladder shave or partial cystectomy offers good improvement in symptoms with relatively low rates of serious complications and recurrence.

Efficacy between Conventional Laparoscopy and Robotic Surgery in Mexican Patients with Endometriosis: A Comparative Study

Background. Surgical management of endometriosis is essential, and deep endometriosis involves the invasion of endometrial tissue into other organs such as the bladder, ureters, and rectum. In Latin American countries, significant expertise has been achieved in conventional laparoscopy (CL); however, there is less experience in robot-assisted laparoscopy (RAL) because of the high cost of this technique. For this reason, studies comparing CL and RAL for the treatment of deep endometriosis in patients are scarce, making this study the first to share the experience of Mexican patients. Aim. The efficacy of CL vs. RAL in the management of deep endometriosis in Mexican patients was compared. Materials and Methods. We performed a retrospective and comparative study. We considered all patients treated with minimally invasive surgery for deep endometriosis between 2015 and 2023. Results. A total of 93 patients were included; 56 patients were treated with CL, and 37 patients were treated with RAL. A significant difference (p < 0.05) was observed in the postoperative length of stay, which was longer in patients treated with CL compared with those treated with RAL. Additionally, postoperative pain was less frequent in patients treated with RAL than in those treated with CL (p < 0.05). We did not observe a significant difference in operative time, blood loss, or perioperative complications between the two surgical techniques (p < 0.05). Conclusions. CL and RAL are effective methods for managing endometriosis in Mexican patients; however, RAL is beneficial for the treatment of deep endometriosis because patients experience postoperative pain less frequently than CL patients and have a shorter postoperative length of stay.

Robotic assisted laparoscopy for deep infiltrating endometriosis

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.

Robot-assisted laparoscopy does not have demonstrable advantages over conventional laparoscopy in endometriosis surgery: a systematic review and meta-analysis

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.

Urological procedures performed by gynecologists: Activity profile in a gynecological surgery department, 10-year observation cohort

INTRODUCTION

The proximity of the urinary tract to the female genital tract explains its possible involvement in pelvic gynaecological cancer or deep endometriosis. Surgical treatment is aimed at improving overall survival and recurrence-free survival of patients, as well as restoring normal anatomy and functional integrity depending on the pathology. These operations are accompanied by significant post-operative complications. Thus, the urological procedures performed must be rigorously justified, and the different resection and reconstruction techniques adapted to the pathology and the level of infiltration.

OBJECTIVE

To describe the activity profile, over the last ten years, of a gynaecological surgery department in terms of urological procedures in the management of patients with deep endometriosis and pelvic carcinology.

STUDY DESIGN

This is a monocentric retrospective observational study, including all patients who underwent a urological procedure by a gynaecological surgeon only, as part of the management of pelvic gynaecological cancers or deep endometriosis, at the University Hospital Centre (CHU) of Strasbourg, between January 1st 2010 and April 31st 2021. The variables studied were early postoperative complications, the rate of surgical reintervention, operating time, length of hospital stay, the need for peri-operative drainage or transfusion, and post-operative functional disorders.

RESULTS

A total of 86 patients were included, 27 in the pelvic gynaecological cancer group and 59 in the deep endometriosis group. 61.6% of patients received uretero-vesical catheterization, 60.5% partial cystectomy, 10.5% psoic bladder ureteral reimplantation, and 3.5% trans-ileal Bricker skin ureterostomy. The mean operating time was 316 min in the pelvic gynaecological cancer group and 198.9 min in the deep endometriosis group. The average hospital stay was 11.5 days, 22.3 days for patients treated for pelvic cancer and 6.3 days for those treated for endometriosis. The rate of minor post-operative complications was 8.2% of cases, and major post-operative complications 17.4% of cases, the majority of which were in the gynecological cancer group. There were no cases of intra- or early post-operative death. Early postoperative urinary complications affected 14.0% of the total patients, mostly in the gynaecological cancer group with 33.3% of patients, but only 5.1% of patients in the deep endometriosis group. The total reoperation rate within 60 days postoperatively was 15.1%, 40.7% for patients treated for gynaecological cancer and 3.4% for those treated for deep pelvic endometriosis. The rate of reoperations for urinary complications was 11.6% of total patients, or 76.9% of total reoperations. 15 patients received labile blood products intra- or postoperatively, 11 in the pelvic gynaecological cancer group and 4 in the endometriosis group.

CONCLUSION

Our overall results appear comparable to those reported in the literature and are particularly satisfactory in terms of post-operative complications after partial cystectomy in the management of deep endometriosis compared to other gynaecological departments. This work encourages us to continue and improve the training of gynaecological surgeons in terms of multidisciplinary surgical procedures, including urological ones, to obtain a global vision of the pathology and to allow an optimal quality of care for the patients.

ROBOTIC SURGERY IMPLEMENTATION IN AN ISOLATED OVERSEAS TERRITORY – THE CASE OF REUNION ISLAND

INTRODUCTION

In February 2020, robotic surgery was introduced in University Hospital of St Pierre in Reunion Island. The aim of this study was to evaluate the implementation of robotic assisted surgery in the hospital and its impact on operating times and patient outcomes.

METHODS

Date was prospectively collected on patients undergoing laparoscopic robotic assisted surgery between February 2020 and February 2022. Information included patient demographics, type of surgery, operating times and length of stay.

RESULTS

Over the two-year study period, 137 patients underwent laparoscopic robotic assisted surgery performed by 6 different surgeons. 89 of the surgeries were in gynecology, including 58 hysterectomies, 37 were in digestive surgery, and 11 in urology. The installation and docking times decreased across all specialties and were found to be significantly reduced when comparing the first and last 15 hysterectomies: mean installation time decreased from 18.7 to 14.5 minutes (p=0.048), mean docking time decreased from 11.3 to 7.1 minutes (p = 0.009).

CONCLUSIONS

The implementation of robotic assisted surgery in an isolated territory such as Reunion Island was slow due to a lack of trained surgeons, supply difficulties and Covid crisis. Despite these challenges, the use of robotic surgery allowed for technically more challenging surgeries and demonstrated similar learning curves to other centers.

Symptoms and Surgical Technique of Bladder Endometriosis: A Systematic Review

OBJECTIVE

This systematic review aimed to review all the available evidence regarding bladder endometriosis (BE) surgical techniques, resolution of symptoms, and nodule size.

DATA SOURCES

We conducted systematic searches in PubMed MEDLINE, Embase, Latin American and Caribbean Centre on Health Sciences Information, Cochrane Library, and Web of Science databases from inception to December 2021.

METHODS OF STUDY SELECTION

Using Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, the literature search yielded 1279 articles. Two reviewers independently screened abstracts and reviewed full-text articles to meet the eligibility criteria: women diagnosed as having BE, treated surgically to remove the BE nodule, and reported of the nodule size and/or symptoms after the surgery. We included 28 studies, which mainly were case reports and case series.

TABULATION, INTEGRATION, AND RESULTS

The following information was extracted from the included studies: author, country, publication year, study design, number of patients, age, surgery performed, follow-up time, operation time, nodule location, nodule size, and postsurgical symptoms. Patients' ages range from 26 to 44 years and most women were nulliparous. The BE nodule size ranged from 0.7 to 5.5 cm, and the most frequent location (63.57%) was the posterior wall. Dysuria was reported by 27.18% of women and generic lower urinary tract symptoms were reported by 27.95%. After surgery, the recurrence rate of urinary symptoms was 7.34%. Most studies performed a partial cystectomy to remove the nodule, showing that the disease affects the bladder mucosa frequently.

CONCLUSION

Surgical treatment with complete excision of BE lesion was shown to improve complaints of urinary symptoms in patients with BE. Given that most of the studies evaluated were descriptive, additional studies with a large sample population and a better level of evidence for this condition are needed.

Robot-assisted laparoscopy for deep infiltrating endometriosis: a retrospective French multicentric study (2008-2019) using the Society of European Robotic Gynecological Surgery endometriosis database

OBJECTIVE

This study aimed at assessing perioperative results of robot-assisted laparoscopy (RAL) in the context of deep infiltrating endometriosis (DIE).

METHODS

This retrospective French multicentric study included all patients with DIE who underwent surgical treatment managed by RAL (Da Vinci® System). From November 2008 to June 2019, patients were included in a single European database, in Robotic Assisted Laparoscopic Gynecologic Surgery, with Society of European Robotic Gynecological Surgery collaboration. Patients had different DIE sites as follows: gynecological, urological, or digestive, or combinations of these. Surgical procedures and perioperative complications were evaluated. To assess complications, patients were divided into the following four groups according to surgical procedure and DIE site: gynecological only; gynecological and urological; gynecological and digestive; and gynecological, urological, and digestive.

RESULTS

A total of 460 patients treated at one of eight health-care facilities from November 2008 to June 2019 were included. Median operative time was 245 min (IQR 186-320), surgeon console time was 138 ± 75 min and estimated blood loss was 70.0 mL ± 107 mL. Among this patient sample, 42.1% had a multidisciplinary surgical approach with a digestive or urology surgeon in addition to gynecology surgeon (25.5% and 16.6% of cases, respectively). Among those with intraoperative complications (n = 25, 5.4%) were primarily conversion to laparotomy (n = 6, 2.0%), transfusion (n = 2, 0.6%), and organ wounds (n = 8, 1.7%). Overall, 5.6% had severe postoperative complications (Clavien-Dindo classification ≥ Grade 3).

CONCLUSION

This is among the largest published series addressing RAL for DIE. Interest in this procedure appears promising, with no observed increases in blood loss or in peri- or post-operative complications. DIE laparoscopic surgery can require complex surgical procedures performed by multidisciplinary surgical teams. Thus, it may be one of the best candidates for RAL within gynecology surgery.

The current role of robotic surgery in endometriosis management

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.

Outcomes of Laparoscopic Partial Cystectomy of Bladder Endometriosis: A Report of 18 Thai Women

Aim: To determine the outcomes of laparoscopic partial cystectomy (LPC) for bladder endometriosis (BE).

Methods: This was a retrospective study using medical records of women who underwent LPC for BE between January 2009 and December 2017. Demographic characteristics, surgical findings, including surgical site and size of the bladder lesion, endometriosis at other locations, and pre- and postoperative hormonal treatment data were collected.

Results: We analyzed data of 18 women with full-thickness BE. The patients had a mean age of 34 (range, 26–45) years and body mass index of 21.6 (range, 16.1–25) kg/m². All women had dysmenorrhea. Other symptoms noted include dysuria, gross hematuria, and infertility. BE with a mean diameter of 2.7 cm (range, 1–5) was most commonly found at the posterior wall of the bladder (94.4%). Peritoneal endometriosis (94.4%), endometrioma (33.3%), and deep endometriotic nodules (22.2%) in the posterior compartment were also found. No surgical complications were observed. Postoperative hormonal treatment was administered to 14 (77.8%) patients. All symptoms improved after the surgery. No recurrence was found after 30 (range, 12–74) months of follow-up.

Conclusion: LPC is an effective treatment option for BE.

[Robotic surgery program in gynecology: Lessons from the first 100 procedures]

INTRODUCTION

The objective of this work is to report the first 6 months of a robotic program in a surgical gynecological team, trained in advanced laparoscopy, in terms of operating times, complication rate, analgesic consumption and average duration of hospitalization.

METHODS

This is a prospective observational study, intended to treat.

RESULTS

During the study period, 98 women underwent laparoscopic robot assisted surgery. The average BMI was 27.2kg/m² (±7). Malignant diseases accounted for 41% of operative indications. Comparing the first 30 procedures to the last 30 procedures, there is a significant decrease in docking times: 14.7min (±7.0) vs 8.9min (±5.0), P=0.009. There is also a trend towards a decrease in operative times for hysterectomy: 151.9min (±56.2) vs 113min (±51.4), P=0.08. The rates of complications were not significantly different at the beginning and end of inclusion during the study (10.0% vs 16.7%).

CONCLUSION

The implementation of a robotic surgery program in a gynecological surgery department does not lead to an increase in complications for the patients, including for the first procedures. The learning curve mainly allows a reduction in the robot's installation time.

Deep infiltrating endometriosis: Interest of the robotic approach for a fledgling team

Introduction:

Mini-invasive surgery of deep endometriosis is challenging. Surgical difficulties related to the technical limitations of classical laparoscopic approach might be overcome with the use of robotic assistance. The aim of this study was to evaluate the safety and feasibility of robotic surgery for deep infiltrating endometriosis in the learning phase of our team.

Methods:

The 20 first cases of robotic-assisted laparoscopies for endometriosis were included over a 2-year period. Baseline characteristics of patients and surgical data were reviewed. Surgical outcomes and follow-up information of the patients were analyzed.

Results:

Twenty women were included. The mean age was 31.9 years (range: 25–44) and mean body mass index was 23 kg/m2 (range: 16–35). Ten patients had rectovaginal or uterosacral location only (50%) and nine women had deep infiltrating endometriosis with digestive or urinary tract lesions (45%). In addition to the gynecologic surgeon, urologic or visceral surgeons were required in 10 cases, and there were 3 cases where the three specialties were needed. The mean operative time was 183.9 min (range: 85–398) and no difference was observed between the first five cases and the last five cases. There was one laparoconversion, and only two urologic postoperative complications occurred.

Conclusion:

Thanks to the use of robotic surgical assistance and a multidisciplinary approach, and despite the start of the team for deep endometriosis care, no learning curve effect was observed regarding surgical procedures’ success, safety, or duration. The use of robotic assistance might improve the quality of care for women facing deep endometriosis.

[Urinary tract involvement by endometriosis. Techniques and outcomes of surgical management: CNGOF-HAS Endometriosis Guidelines]

Urinary tract involvement by endometriosis is reported in 1% of endometriosis patients (NP3). Consequences range from pelvic pain for bladder localizations to silent kidney loss in case of chronic ureteral obstruction (NP3). The feasibility of laparoscopic management was widely proven (NP3) and may reduce hospital stay length (NP4). Radical surgery with partial cystectomy for bladder localizations was shown to significantly and durably reduce pain symptoms with low risk of a severe postoperative complications (NP3). Medical hormonal treatment also shows short-term reduction of pain symptoms (NP4). Transureteral resection of bladder endometriosis nodule is not recommended (grade C) because of a high postoperative recurrence rate (NP4). Given a high risk of silent kidney loss, it is recommended that patients with ureteral involvement by endometriosis are managed by a multidisciplinary team considering urinary and potential extra-urinary localizations of endometriosis (grade C). No recommendation can be made on which technique to prefer between conservative (ureterolysis) or radical surgical techniques or on benefit and length of ureteral stents in case of ureteral involvement. Surgical management of bladder and ureteral localizations of endometriosis do not seem to be associated with altered or improved postoperative fertility (NP4). Since late postoperative ureteral anastomosis stenosis were reported with silent kidney loss, repeated postoperative imaging monitoring is justified (expert opinion).