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Oliveira MAP, Raymundo TS, Pereira TD, de Souza RJ, Lima FV, De Wilde RL, Brollo LC. Robotic Surgery for Bladder Endometriosis: A Systematic Review and Approach. J Clin Med 2023; 12:5416. [PMID: 37629459 PMCID: PMC10455656 DOI: 10.3390/jcm12165416] [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: 07/08/2023] [Revised: 08/01/2023] [Accepted: 08/17/2023] [Indexed: 08/27/2023] Open
Abstract
INTRODUCTION Women with bladder endometriosis often present with more advanced stages of endometriosis. Robotic surgery has emerged as a promising approach to the management of bladder endometriosis. This systematic review aims to analyze the current literature on robotic surgery for bladder endometriosis and describe our systematic approach to surgical treatment. METHODS This review followed the PRISMA guidelines, which ensured a comprehensive and transparent approach to selecting and evaluating relevant studies. We conducted a thorough literature search to identify studies that investigated the use of robotic surgery for bladder endometriosis. Relevant databases were searched, and inclusion and exclusion criteria were applied to select eligible studies. Data extraction and analysis were performed to assess the outcomes and effectiveness of robotic surgery for the treatment of bladder endometriosis. RESULTS We did not find any randomized clinical trials with the use of robotics in the treatment of bladder endometriosis. We found only two retrospective studies comparing robotic surgery with laparoscopy, and another retrospective study comparing robotic surgery, laparoscopy, and laparotomy in the treatment of bladder endometriosis. All the other 12 studies were solely case reports. Despite the lack of robust evidence in the literature, the studies demonstrated that robotic surgery is feasible and is associated with reduced postoperative pain, shorter hospital stays, and faster recovery. CONCLUSIONS The utilization of robotic technology is a promising option for the surgical management of bladder endometriosis. We advocate a surgical systematic approach for the robotic treatment of bladder endometriosis. Robotic technology, with its 3D vision, instrumental degrees of freedom, and precision, particularly in suturing, may provide potential benefits over traditional laparoscopy.
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Affiliation(s)
- Marco Aurelio Pinho Oliveira
- Department of Gynecology, State University of Rio de Janeiro, Rio de Janeiro 20551-030, Brazil; (T.S.R.); (T.D.P.); (R.J.d.S.); (L.C.B.)
| | - Thiers Soares Raymundo
- Department of Gynecology, State University of Rio de Janeiro, Rio de Janeiro 20551-030, Brazil; (T.S.R.); (T.D.P.); (R.J.d.S.); (L.C.B.)
- Department of Gynecology, Cardoso Fontes Federal Hospital, Rio de Janeiro 22745-130, Brazil
| | - Thiago Dantas Pereira
- Department of Gynecology, State University of Rio de Janeiro, Rio de Janeiro 20551-030, Brazil; (T.S.R.); (T.D.P.); (R.J.d.S.); (L.C.B.)
| | - Ricardo José de Souza
- Department of Gynecology, State University of Rio de Janeiro, Rio de Janeiro 20551-030, Brazil; (T.S.R.); (T.D.P.); (R.J.d.S.); (L.C.B.)
| | - Felipe Vaz Lima
- Department of Urology, Gaffrée e Guinle University Hospital, Rio de Janeiro 20270-004, Brazil;
| | - Rudy Leon De Wilde
- Department of Gynecology, University Hospital for Gynecology, Pius Hospital, 26121 Oldenburg, Germany;
| | - Leila Cristina Brollo
- Department of Gynecology, State University of Rio de Janeiro, Rio de Janeiro 20551-030, Brazil; (T.S.R.); (T.D.P.); (R.J.d.S.); (L.C.B.)
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Tomasi MC, Ribeiro PAA, Farah D, Vidoto Cervantes G, Nicola ALD, Abdalla-Ribeiro HS. Symptoms and Surgical Technique of Bladder Endometriosis: A Systematic Review. J Minim Invasive Gynecol 2022; 29:1294-1302. [PMID: 36252916 DOI: 10.1016/j.jmig.2022.10.003] [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: 08/02/2022] [Revised: 10/05/2022] [Accepted: 10/07/2022] [Indexed: 11/05/2022]
Abstract
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.
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Affiliation(s)
- Mariana Carpenedo Tomasi
- Gynecological Endoscopy and Endometriosis Clinic, Faculdade de Ciências Médicas da Santa Casa de Misericordia de São Paulo (Drs.Tomasi, Ribeiro, Cervantes, Nicola, Abdalla-Ribeiro).
| | - Paulo Augusto Ayroza Ribeiro
- Gynecological Endoscopy and Endometriosis Clinic, Faculdade de Ciências Médicas da Santa Casa de Misericordia de São Paulo (Drs.Tomasi, Ribeiro, Cervantes, Nicola, Abdalla-Ribeiro)
| | - Daniela Farah
- Department of Gynecology, Health Technologies Assessment Center - Universidade Federal de São Paulo, Sao Paulo, Brazil (Drs. Farah)
| | - Graziele Vidoto Cervantes
- Gynecological Endoscopy and Endometriosis Clinic, Faculdade de Ciências Médicas da Santa Casa de Misericordia de São Paulo (Drs.Tomasi, Ribeiro, Cervantes, Nicola, Abdalla-Ribeiro)
| | - Ana Luiza De Nicola
- Gynecological Endoscopy and Endometriosis Clinic, Faculdade de Ciências Médicas da Santa Casa de Misericordia de São Paulo (Drs.Tomasi, Ribeiro, Cervantes, Nicola, Abdalla-Ribeiro)
| | - Helizabet Salomão Abdalla-Ribeiro
- Gynecological Endoscopy and Endometriosis Clinic, Faculdade de Ciências Médicas da Santa Casa de Misericordia de São Paulo (Drs.Tomasi, Ribeiro, Cervantes, Nicola, Abdalla-Ribeiro)
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Abstract
BACKGROUND This is an updated merged review of two originally separate Cochrane reviews: one on robot-assisted surgery (RAS) for benign gynaecological disease, the other on RAS for gynaecological cancer. RAS is a relatively new innovation in laparoscopic surgery that enables the surgeon to conduct the operation from a computer console, situated away from the surgical table. RAS is already widely used in the United States for hysterectomy and has been shown to be feasible for other gynaecological procedures. However, the clinical effectiveness and safety of RAS compared with conventional laparoscopic surgery (CLS) have not been clearly established and require independent review. OBJECTIVES To assess the effectiveness and safety of RAS in the treatment of women with benign and malignant gynaecological disease. SEARCH METHODS For this update, we searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE via Ovid, and EMBASE via Ovid, on 8 January 2018. We searched www.ClinicalTrials.gov. on 16 January 2018. SELECTION CRITERIA Randomised controlled trials (RCTs) comparing RAS versus CLS or open surgery in women requiring surgery for gynaecological disease. DATA COLLECTION AND ANALYSIS Two review authors independently assessed studies for inclusion and risk of bias, and extracted study data and entered them into an Excel spreadsheet. We examined different procedures in separate comparisons and for hysterectomy subgrouped data according to type of disease (non-malignant versus malignant). When more than one study contributed data, we pooled data using random-effects methods in RevMan 5.3. MAIN RESULTS We included 12 RCTs involving 1016 women. Studies were at moderate to high overall risk of bias, and we downgraded evidence mainly due to concerns about risk of bias in the studies contributing data and imprecision of effect estimates. Procedures performed were hysterectomy (eight studies) and sacrocolpopexy (three studies). In addition, one trial examined surgical treatment for endometriosis, which included resection or hysterectomy. Among studies of women undergoing hysterectomy procedures, two studies involved malignant disease (endometrial cancer); the rest involved non-malignant disease.• RAS versus CLS (hysterectomy)Low-certainty evidence suggests there might be little or no difference in any complication rates between RAS and CLS (risk ratio (RR) 0.92, 95% confidence interval (CI) 0.54 to 1.59; participants = 585; studies = 6; I² = 51%), intraoperative complication rates (RR 0.77, 95% CI 0.24 to 2.50; participants = 583; studies = 6; I² = 37%), postoperative complications (RR 0.81, 95% CI 0.48 to 1.34; participants = 629; studies = 6; I² = 44%), and blood transfusions (RR 1.94, 95% CI 0.63 to 5.94; participants = 442; studies = 5; I² = 0%). There was no statistical difference between malignant and non-malignant disease subgroups with regard to complication rates. Only one study reported death within 30 days and no deaths occurred (very low-certainty evidence). Researchers reported no survival outcomes.Mean total operating time was longer on average in the RAS arm than in the CLS arm (mean difference (MD) 41.18 minutes, 95% CI -6.17 to 88.53; participants = 148; studies = 2; I² = 80%; very low-certainty evidence), and the mean length of hospital stay was slightly shorter with RAS than with CLS (MD -0.30 days, 95% CI -0.53 to -0.07; participants = 192; studies = 2; I² = 0%; very low-certainty evidence).• RAS versus CLS (sacrocolpopexy)Very low-certainty evidence suggests little or no difference in rates of any complications between women undergoing sacrocolpopexy by RAS or CLS (RR 0.95, 95% CI 0.21 to 4.24; participants = 186; studies = 3; I² = 78%), nor in intraoperative complications (RR 0.82, 95% CI 0.09 to 7.59; participants = 108; studies = 2; I² = 47%). Low-certainty evidence on postoperative complications suggests these might be higher with RAS (RR 3.54, 95% CI 1.31 to 9.56; studies = 1; participants = 68). Researchers did not report blood transfusions and deaths up to 30 days.Low-certainty evidence suggests that RAS might be associated with increased operating time (MD 40.53 min, 95% CI 12.06 to 68.99; participants = 186; studies = 3; I² = 73%). Very low-certainty evidence suggests little or no difference between the two techniques in terms of duration of stay (MD 0.26 days, 95% CI -0.15 to 0.67; participants = 108; studies = 2; I² = 0%).• RAS versus open abdominal surgery (hysterectomy)A single study with a total sample size of 20 women was included in this comparison. For most outcomes, the sample size was insufficient to show any possible differences between groups.• RAS versus CLS for endometriosisA single study with data for 73 women was included in this comparison; women with endometriosis underwent procedures ranging from relatively minor endometrial resection through hysterectomy; many of the women included in this study had undergone previous surgery for their condition. For most outcomes, event rates were low, and the sample size was insufficient to detect potential differences between groups. AUTHORS' CONCLUSIONS Evidence on the effectiveness and safety of RAS compared with CLS for non-malignant disease (hysterectomy and sacrocolpopexy) is of low certainty but suggests that surgical complication rates might be comparable. Evidence on the effectiveness and safety of RAS compared with CLS or open surgery for malignant disease is more uncertain because survival data are lacking. RAS is an operator-dependent expensive technology; therefore evaluating the safety of this technology independently will present challenges.
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Affiliation(s)
- Theresa A Lawrie
- Office 305, 3rd floorE‐MBC LtdNorthgate HouseUpper Borough WallsBathUKBA1 1RG
| | - Hongqian Liu
- West China Second University Hospital, Sichuan UniversityDepartment of Obstetrics and GynecologyNo. 17, Section Three, Ren Min Nan Lu AvenueChengduSichuanChina610041
| | - DongHao Lu
- West China Second University Hospital, Sichuan UniversityDepartment of Obstetrics and GynecologyNo. 17, Section Three, Ren Min Nan Lu AvenueChengduSichuanChina610041
| | - Therese Dowswell
- The University of LiverpoolC/o Cochrane Pregnancy and Childbirth Group, Department of Women's and Children's HealthFirst Floor, Liverpool Women's NHS Foundation TrustCrown StreetLiverpoolUKL8 7SS
| | - Huan Song
- University of IcelandCenter of Public Health Sciences, Faculty of MedicineReykjavíkIceland
| | - Lei Wang
- West China Second University Hospital, Sichuan UniversityDepartment of OrthopedicsNo. 37, Guo Xue XiangChengduSichuanChina610041
| | - Gang Shi
- West China Second University Hospital, Sichuan UniversityDepartment of Obstetrics and GynecologyNo. 17, Section Three, Ren Min Nan Lu AvenueChengduSichuanChina610041
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Bolze PA, Paparel P, Golfier F. [Urinary tract involvement by endometriosis. Techniques and outcomes of surgical management: CNGOF-HAS Endometriosis Guidelines]. ACTA ACUST UNITED AC 2018. [PMID: 29526792 DOI: 10.1016/j.gofs.2018.02.016] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
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).
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Affiliation(s)
- P-A Bolze
- Université Claude-Bernard Lyon 1, hôpitaux universitaires de Lyon, centre hospitalier Lyon-Sud, service de chirurgie gynécologique et oncologique - obstétrique, 165, chemin du Grand-Revoyet, 69495 Pierre-Bénite, France.
| | - P Paparel
- Université Claude-Bernard Lyon 1, hôpitaux universitaires de Lyon, centre hospitalier Lyon-Sud, service de chirurgie urologique, 165, chemin du Grand Revoyet, 69495 Pierre-Bénite
| | - F Golfier
- Université Claude-Bernard Lyon 1, hôpitaux universitaires de Lyon, centre hospitalier Lyon-Sud, service de chirurgie gynécologique et oncologique - obstétrique, 165, chemin du Grand-Revoyet, 69495 Pierre-Bénite, France
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Leone Roberti Maggiore U, Ferrero S, Candiani M, Somigliana E, Viganò P, Vercellini P. Bladder Endometriosis: A Systematic Review of Pathogenesis, Diagnosis, Treatment, Impact on Fertility, and Risk of Malignant Transformation. Eur Urol 2016; 71:790-807. [PMID: 28040358 DOI: 10.1016/j.eururo.2016.12.015] [Citation(s) in RCA: 84] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2016] [Accepted: 12/15/2016] [Indexed: 02/03/2023]
Abstract
CONTEXT The bladder is the most common site affected in urinary tract endometriosis. There is controversy regarding the pathogenesis, clinical management (diagnosis and treatment), impact on fertility, and risk of malignant transformation of bladder endometriosis (BE). OBJECTIVE To systematically evaluate evidence regarding the pathogenesis, diagnosis, medical and surgical treatment, impact on female fertility, and risk of malignant transformation of BE. EVIDENCE ACQUISITION A systematic review of PubMed/Medline from inception until October 2016 was performed in accordance with the Preferred Reporting Items for Systematic Review and Meta-analysis (PRISMA) statement and was registered in the PROSPERO registry (www.crd.york.ac.uk/prospero; CRD42016039281). Eighty-seven articles were selected for inclusion in this analysis. EVIDENCE SYNTHESIS BE is defined as the presence of endometrial glands and stroma in the detrusor muscle. Ultrasonography is the first-line technique for assessment of BE owing to its accuracy, safety, and cost. Clinical management can be conservative, using hormonal therapies, or surgical. When conservative treatment is preferred, estrogen-progestogen combinations and progestogens should be chosen because of their favorable profile that allows long-term therapy. Surgery should guarantee complete removal of the bladder nodule to minimize recurrence, so transurethral surgery alone should be avoided in favor of segmental bladder resection. There is not a strong rationale for hypothesizing a detrimental impact of BE per se on fertility. Furthermore, current evidence does not support the removal of bladder endometriotic lesions because of the potential risk of malignant transformation since this phenomenon is exceedingly rare. CONCLUSIONS BE is a challenging condition, and the common coexistence of other types of endometriosis means that clinical management of BE should involve collaboration between gynecologists and urologists. PATIENT SUMMARY In this article we review available knowledge on bladder endometriosis. The review provides a useful tool to guide physicians in the management of this complex condition.
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Affiliation(s)
- Umberto Leone Roberti Maggiore
- Academic Unit of Obstetrics and Gynecology, IRCCS AOU San Martino, Genoa, Italy; Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, University of Genoa, Genoa, Italy
| | - Simone Ferrero
- Academic Unit of Obstetrics and Gynecology, IRCCS AOU San Martino, Genoa, Italy; Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, University of Genoa, Genoa, Italy.
| | - Massimo Candiani
- Department of Obstetrics and Gynecology, Vita Salute San Raffaele University School of Medicine, IRCCS, Ospedale San Raffaele, Milan, Italy
| | - Edgardo Somigliana
- Department of Clinical Sciences and Community Health, Università degli Studi di Milano and Department of Obstet-Gynecol, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Paola Viganò
- Reproductive Sciences Laboratory, Division of Genetics and Cell Biology, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Paolo Vercellini
- Department of Clinical Sciences and Community Health, Università degli Studi di Milano and Department of Obstet-Gynecol, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
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le Carpentier M, Merlot B, Bot Robin V, Rubod C, Collinet P. [Partial cystectomy for bladder endometriosis: Robotic assisted laparoscopy versus standard laparoscopy]. ACTA ACUST UNITED AC 2016; 44:315-21. [PMID: 27032760 DOI: 10.1016/j.gyobfe.2016.02.006] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2015] [Accepted: 02/03/2016] [Indexed: 11/29/2022]
Abstract
OBJECTIVES To compare robot-assisted laparoscopy (RL) and conventional laparoscopy (CL) in surgery for bladder endometriosis. METHODS A retrospective study was conducted between January 2007 and December 2013, including patients with bladder endometriosis receiving at least a partial cystectomy by RL or CL. The primary endpoint was the presence of a radiological recurrence at bladder level. RESULTS We included 15 patients in the RL group and 22 in the CL group. The median age was 29 years±7 years. The symptoms were similar in the 2 groups. Pre-surgical mapping of the lesions was carried out with MRI. Sixty percent of patients in the RL group vs 91% in the CL group had other associated endometriosis lesions, P=0.04. The median size of the bladder lesion was 30±8mm in the RL group vs 23±7mm in the CL group, P=0.03. The median operative time was 210 vs 225min, P=0.8. We did not find any significant difference in intraoperative and early and late postoperative complications between the 2 groups. The median length of stay was 5 days vs 6 days. The proportion of relapse was 20 vs 23%, P>0.05. Clinical improvement was similar between the groups, i.e. 93 vs 86%, P=0.6 and the pregnancy rate was 93 vs 86%, P=0.6. CONCLUSIONS Robot-assisted laparoscopy in the surgical treatment of bladder endometriosis as compared to traditional laparoscopy does not seem to have an adverse effect neither on the risk of recurrence nor on the occurrence of intra- and postoperative complications.
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Affiliation(s)
- M le Carpentier
- Chirurgie gynécologique, clinique de gynécologie, hôpital Jeanne-de-Flandre, CHRU de Lille, 59037 Lille cedex, France.
| | - B Merlot
- Chirurgie gynécologique, clinique de gynécologie, hôpital Jeanne-de-Flandre, CHRU de Lille, 59037 Lille cedex, France
| | - V Bot Robin
- Chirurgie gynécologique, clinique de gynécologie, hôpital Jeanne-de-Flandre, CHRU de Lille, 59037 Lille cedex, France
| | - C Rubod
- Chirurgie gynécologique, clinique de gynécologie, hôpital Jeanne-de-Flandre, CHRU de Lille, 59037 Lille cedex, France
| | - P Collinet
- Chirurgie gynécologique, clinique de gynécologie, hôpital Jeanne-de-Flandre, CHRU de Lille, 59037 Lille cedex, France
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Abstract
This review is being withdrawn as now superceded by a new review covering both malignant an benign disease: Lawrie TA, Liu H, Lu D, Dowswell T, Song H, Wang L, Shi G. Robot‐assisted surgery in gynaecology. Cochrane Database of Systematic Reviews 2019, Issue 4. Art. No.: CD011422. DOI: 10.1002/14651858.CD011422.pub2 (https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD011422.pub2/full ) The editorial group responsible for this previously published document have withdrawn it from publication.
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Affiliation(s)
- Gang Shi
- West China Second University Hospital, Sichuan UniversityDepartment of Obstetrics and GynecologyNo. 20, 3rd Section of Ren Min Nan RoadChengduSichuanChina610041
| | - DongHao Lu
- West China Second University Hospital, Sichuan UniversityDepartment of Obstetrics and GynecologyNo. 20, 3rd Section of Ren Min Nan RoadChengduSichuanChina610041
| | - Zhihong Liu
- West China Hospital, Sichuan UniversityNo. 37, Guo Xue XiangChengduSichuanChina610041
| | - Dan Liu
- West China Hospital, Sichuan UniversityWest China School of MedicineNo. 37, Guo Xue XiangChengduSichuanChina610041
| | - Xiaoyan Zhou
- West China Hospital, Sichuan UniversityWest China School of MedicineNo. 37, Guo Xue XiangChengduSichuanChina610041
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Abstract
This review is being withdrawn as now superceded by a new review covering both malignant an benign disease: Lawrie TA, Liu H, Lu D, Dowswell T, Song H, Wang L, Shi G. Robot‐assisted surgery in gynaecology. Cochrane Database of Systematic Reviews 2019, Issue 4. Art. No.: CD011422. DOI: 10.1002/14651858.CD011422.pub (https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD011422.pub2/full ). The editorial group responsible for this previously published document have withdrawn it from publication.
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Affiliation(s)
- Hongqian Liu
- West China Second University Hospital, Sichuan UniversityDepartment of Obstetrics and GynecologyNo. 17, Section Three, Ren Min Nan Lu AvenueChengduSichuanChina610041
| | - DongHao Lu
- West China Second University Hospital, Sichuan UniversityDepartment of Obstetrics and GynecologyNo. 17, Section Three, Ren Min Nan Lu AvenueChengduSichuanChina610041
| | - Gang Shi
- West China Second University Hospital, Sichuan UniversityDepartment of Obstetrics and GynecologyNo. 17, Section Three, Ren Min Nan Lu AvenueChengduSichuanChina610041
| | - Huan Song
- University of IcelandCenter of Public Health Sciences, Faculty of MedicineReykjavíkIceland
| | - Lei Wang
- West China Second University Hospital, Sichuan UniversityDepartment of OrthopedicsNo. 37, Guo Xue XiangChengduSichuanChina610041
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Abstract
BACKGROUND This is an updated merged review of two originally separate Cochrane reviews: one on robot-assisted surgery (RAS) for benign gynaecological disease, the other on RAS for gynaecological cancer. RAS is a relatively new innovation in laparoscopic surgery that enables the surgeon to conduct the operation from a computer console, situated away from the surgical table. RAS is already widely used in the United States for hysterectomy and has been shown to be feasible for other gynaecological procedures. However, the clinical effectiveness and safety of RAS compared with conventional laparoscopic surgery (CLS) have not been clearly established and require independent review. OBJECTIVES To assess the effectiveness and safety of RAS in the treatment of women with benign and malignant gynaecological disease. SEARCH METHODS For this update, we searched the Cochrane Central Register of Controlled Trials (CENTRAL) (2014, Issue 5) and the Cochrane Gynaecological Cancer Review Group Trials Register. We also searched MEDLINE and EMBASE databases, to complement the searches of the original malignant and benign disease reviews (conducted up to July 2010 and November 2011, respectively), from July 2010 to June 2014. SELECTION CRITERIA Randomised controlled trials (RCTs) of RAS compared with CLS or open surgery in women requiring surgery for gynaecological disease. DATA COLLECTION AND ANALYSIS Two review authors independently assessed the studies for inclusion and risk of bias, and extracted study data and entered them into an Excel spreadsheet. We subgrouped data according to type of procedure and pooled data using random-effects methods in RevMan 5.3. We performed sensitivity analyses by excluding studies at high risk of bias. MAIN RESULTS We included six RCTs involving 517 women. Most were at low to moderate overall risk of bias; one was at high risk of bias. Four studies evaluated RAS for hysterectomy (371 women), and two studies evaluated RAS for sacrocolpopexy (146 women). All studies compared RAS with CLS, except for one study, which compared RAS with CLS or a vaginal surgical approach for hysterectomy. Confidence intervals for the risk of intraoperative and postoperative complications included benefits with either approach when they were analysed together (risk ratio (RR) 0.95, 95% confidence interval (CI) 0.46 to 1.99; participants = 513; studies = 6; I(2) = 74%) and separately (low-quality evidence). Moderate-quality evidence was found for the effects of RAS on intraoperative injury when compared with CLS (RR 1.23, 95% CI 0.44 to 3.46; participants = 415; studies = 5; I(2) = 0%), along with low-quality evidence for bleeding and infection complications.Mean total operating time was consistent across procedures and on average was about 42 minutes longer in the RAS arm compared with the CLS arm (95% CI 17 to 66 minutes; participants = 294; studies = 4; I(2) = 82%; moderate-quality evidence). Mean hospital stay for hysterectomy procedures was on average about seven hours shorter in the RAS arm than in the CLS arm (mean difference (MD) -0.30 days, 95% CI -0.54 to -0.06; participants = 217; studies = 2; I(2) = 0%; low-quality evidence). The estimated effect of conversion with RAS compared with CLS was imprecise (RR 1.28, 95% CI 0.40 to 4.12; participants = 337; studies = 4; I(2) = 0%; moderate-quality evidence). Limited data from two studies suggest that RAS for sacrocolpopexy may be associated with increased postoperative pain compared with CLS; this needs further investigation. We identified five ongoing trials-four of cancer surgery. AUTHORS' CONCLUSIONS We are uncertain as to whether RAS or CLS has lower intraoperative and postoperative complication rates because of the imprecision of the effect and inconsistency among studies when they are used for hysterectomy and sacrocolpopexy. Moderate-quality evidence suggests that these procedures take longer with RAS but may be associated with a shorter hospital stay following hysterectomy. We found limited evidence on the effectiveness and safety of RAS compared with CLS or open surgery for surgical procedures performed for gynaecological cancer; therefore its use should be limited to clinical trials. Ongoing trials are likely to have an important impact on evidence related to the use of RAS in gynaecology.
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Affiliation(s)
- Hongqian Liu
- West China Second University Hospital, Sichuan UniversityDepartment of Obstetrics and GynecologyNo. 17, Section Three, Ren Min Nan Lu AvenueChengduChina610041
| | - Theresa A Lawrie
- Royal United HospitalCochrane Gynaecological, Neuro‐oncology and Orphan Cancer GroupEducation CentreBathUKBA1 3NG
| | - DongHao Lu
- West China Second University Hospital, Sichuan UniversityDepartment of Obstetrics and Gynaecology20, 3rd Section, Ren Min Nan RdChengduChina610041
| | - Huan Song
- Karolinska InstitutetDepartment of Medical Epidemiology and BiostatisticsBox 281StockholmSwedenSE‐17177
| | - Lei Wang
- West China Hospital, Sichuan UniversityDepartment of OrthopedicsNo. 37, Guo Xue XiangChengduChina610041
| | - Gang Shi
- West China Second University Hospital, Sichuan UniversityDepartment of Obstetrics and GynecologyNo. 17, Section Three, Ren Min Nan Lu AvenueChengduChina610041
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Place de la robotique dans l’endométriose pelvienne profonde : à propos du registre de la SERGS. ACTA ACUST UNITED AC 2014; 42:744-8. [DOI: 10.1016/j.gyobfe.2014.09.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2014] [Accepted: 09/09/2014] [Indexed: 11/17/2022]
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Diaphragmatic Endometriosis: Review of the Literature and First Case of Robot-Assisted Laparoscopic Treatment. JOURNAL OF ENDOMETRIOSIS AND PELVIC PAIN DISORDERS 2014. [DOI: 10.5301/je.5000179] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Background Thoracic endometriosis is a rare disorder affecting women in reproductive age. The etiopathogenesis of this disease is not well understood. The symptoms appear, but not necessarily, during periods in person affected by the condition. Methods A 35-year-old woman came to our clinic, the Infertility and Assisted Reproduction Center of the University of Pisa, for infertility treatment. She described a clinical history of abdominal pain with irradiation up to the right shoulder, depending on her breathing or position, during menstruation. She also reported that she did not experience these symptoms while taking an oral contraceptive. Pelvic ultrasound examination and thorax X-ray were normal. The patient also underwent thoracic and abdominal pelvis magnetic resonance imaging (MRI). Thoracic MRI revealed a nodule on the right hemidiaphragm. It was decided to perform surgical removal of the nodule. Robotic-assisted surgery was used because of its multiple advantages in comparison with laparoscopic surgery, such as a 3-dimensional view, a decrease in surgeon fatigue and tremors, and an increase of wrist motion with improved dexterity and greater surgical precision. The surgery was performed in May 2012. The patient was put on the left lateral bedside. Pneumoperitoneum with CO2 was established with an intra-abdominal pressure of 12 mm Hg using a Veress needle. Robotic trocars of 8-mm diameter were introduced at the diaphragmatic level and connected to the robot arms. Her pelvic and abdominal organs appeared healthy. The right hemidiaphragm presented adherence with the liver due to endometriosis disease. We removed the adhesion, and we performed the excision of the diaphragmatic endometriotic nodule. The nodule was extracted through an endobag. Operative time lasted 2 hours. Conclusions The postoperative evolution was satisfactory, and the patient left the hospital on the third postoperative day. No complications occurred. We showed that this approach is feasible and safe, without conversion to laparotomy.
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Collinet P, Leguevaque P, Neme RM, Cela V, Barton-Smith P, Hébert T, Hanssens S, Nishi H, Nisolle M. Robot-assisted laparoscopy for deep infiltrating endometriosis: international multicentric retrospective study. Surg Endosc 2014; 28:2474-9. [DOI: 10.1007/s00464-014-3480-3] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2013] [Accepted: 02/03/2014] [Indexed: 12/21/2022]
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Rajakumar C, Vilos GA, Vilos AG, Marks JL, Ettler HC, Pautler SS. Combined Transurethral and Laparoscopic Partial Cystectomy and Robotically Assisted Bladder Repair for the Treatment of Bladder Endocervicosis: Case Report and Review of the Literature. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2014; 36:141-145. [DOI: 10.1016/s1701-2163(15)30660-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Maccagnano C, Pellucchi F, Rocchini L, Ghezzi M, Scattoni V, Montorsi F, Rigatti P, Colombo R. Ureteral Endometriosis: Proposal for a Diagnostic and Therapeutic Algorithm with a Review of the Literature. Urol Int 2013; 91:1-9. [DOI: 10.1159/000345140] [Citation(s) in RCA: 58] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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Quemener J, Boulanger L, Rubod C, Cosson M, Vinatier D, Collinet P. The place of robotics in gynecologic surgery. J Visc Surg 2012; 149:e289-301. [PMID: 22951086 DOI: 10.1016/j.jviscsurg.2012.07.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Robot-assisted laparoscopic gynecologic surgery has undergone widespread development in recent years. The surgical literature on this subject continues to grow. The goal of this article is to summarize the principal indications for robotic assistance in gynecologic surgery and to offer a general overview of the principal articles dealing with robotic surgery for both benign and malignant disease.
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Affiliation(s)
- J Quemener
- Service de Gynécologie, Hôpital Jeanne-de-Flandres, CHRU de Lille, avenue Eugène-Avinée, 59037 Lille, France.
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Muhlstein J, Monceau E, Lamy C, Tran N, Marchal F, Judlin P, Malartic C, Morel O. Apport de la chirurgie robot-assistée dans la prise en charge de l’infertilité féminine. ACTA ACUST UNITED AC 2012; 41:409-17. [DOI: 10.1016/j.jgyn.2012.05.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2012] [Revised: 05/14/2012] [Accepted: 05/21/2012] [Indexed: 11/30/2022]
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Maccagnano C, Pellucchi F, Rocchini L, Ghezzi M, Scattoni V, Montorsi F, Rigatti P, Colombo R. Diagnosis and treatment of bladder endometriosis: state of the art. Urol Int 2012; 89:249-58. [PMID: 22813980 DOI: 10.1159/000339519] [Citation(s) in RCA: 66] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND The bladder is the most common affected site in urinary tract endometriosis, being diagnosed during gynecologic follow-up. The surgical urological treatment might lead to good results. STUDY OBJECTIVE To define the state of the art in the diagnosis and treatment of bladder endometriosis. METHODS We performed a literature review by searching the MEDLINE database for articles published between 1996 and 2011, limiting the searches to the words: urinary tract endometriosis, bladderendometriosis, symptoms, diagnosis and treatment. RESULTS Deep pelvic endometriosis usually involves the urinary system, with the bladder being affected in 85% of cases. The diagnosis has to be considered as a step-by-step procedure. Currently, the treatment is usually surgical, consisting of either transurethral resection or partial cystectomy, and eventually associated with hormonal therapy. The hormonal therapy alone counteracts only the stimulus of endometriotic tissue proliferation, with no effects on the scarring caused by this tissue. The overall recurrence rate is about 30% for combined therapies and about 35% for the hormonal treatment alone. CONCLUSIONS The bladder is the most common affected site in urinary tract endometriosis. Most of the time, this condition is diagnosed because of the complaint of urinary symptoms during gynecologic follow-up procedures for a deep pelvic endometriosis: a close collaboration between the gynecologist and the urologist is advisable, especially in highly specialized centers. The surgical urological treatment might lead to good results in terms of patients' compliance and prognosis.
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Affiliation(s)
- Carmen Maccagnano
- Department of Urology, San Raffaele Scientific Institute, Milan, Italy.
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Bedaiwy MA, Volsky J, Sandadi S, Fader AN. The expanding spectrum of robotic gynecologic surgery: A review. MIDDLE EAST FERTILITY SOCIETY JOURNAL 2012. [DOI: 10.1016/j.mefs.2011.11.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022] Open
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Combined transurethral approach with Versapoint® and laparoscopic treatment in the management of bladder endometriosis: technique and 12 months follow-up. Surg Endosc 2012; 26:2446-50. [DOI: 10.1007/s00464-012-2208-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2011] [Accepted: 01/27/2012] [Indexed: 10/28/2022]
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Abstract
BACKGROUND Robotic surgery is the latest innovation in the field of minimally invasive surgery. In the case of robotic surgery, instead of directly moving the instruments the surgeon uses a robotic system to control the instruments for surgical procedures. Robotic surgical systems have been used in various gynaecological surgeries for benign disease, such as hysterectomy (removal of the uterus), myomectomy (removal of uterine leiomyomas) and tubal reanastomosis (the reuniting of a divided tube). The mounting evidence demonstrates the feasibility and safety of robotic surgery in benign gynaecological disease. Robotic surgery is advertised as having promising advantages including more precise vision and procedures, improved ergonomics and shorter length of hospital stay. However, the main disadvantages of the robotic surgical system should not be overlooked, including the high cost of disposable instruments and retraining for both surgeons and nurses. OBJECTIVES To assess the effectiveness and safety of robot-assisted surgery in the treatment of benign gynaecological disease. SEARCH METHODS We searched the Cochrane Menstrual Disorders and Subfertility Group's Trial Register, the Cochrane Central Register of Controlled Trials (CENTRAL) (Issue 2, 2011), MEDLINE and EMBASE up to November 2011 and citation lists of relevant publications. SELECTION CRITERIA All randomised controlled trials (RCTs) comparing robotic surgery for benign gynaecological disease to laparoscopic or open surgical procedures. RCTs comparing different types of robotic assistants were also included. We contacted study authors for unpublished information, but failed in obtaining a response. DATA COLLECTION AND ANALYSIS Two review authors independently screened studies for inclusion. The domains assessed for risk of bias were allocation concealment, blinding, incomplete outcome data and selective outcome reporting. Odds ratios (OR) were used for reporting dichotomous data with 95% confidence intervals (CI), whilst mean differences (MD) were determined for continuous data. Statistical heterogeneity was assessed using the I(2) statistic. We contacted the primary authors for missing data but failed in obtaining a response. MAIN RESULTS Two trials involving 158 participants were included. Since one included trial was published in conference proceedings, limited usable data were available for further analysis. The only analysis in this trial showed comparable rates of conversions to open surgery between the robotic group and the laparoscopic group (OR 1.41, 95% CI 0.22 to 9.01; P = 0.72). One RCT showed longer operation time (MD 66.00, 95% CI 40.93 to 91.07; P < 0.00001), higher cost (MD 1936.00, 95% CI 445.69 to 3426.31; P = 0.01) in the robotic group compared with the laparoscopic group. Also, both studies reported that robotic and laparoscopic surgery seemed comparable regarding intraoperative outcome, complications, length of hospital stay and quality of life. AUTHORS' CONCLUSIONS Currently, the limited evidence showed that robotic surgery did not benefit women with benign gynaecological disease in effectiveness or in safety. Further well-designed RCTs with complete reported data are required to confirm or refute this conclusion.
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Affiliation(s)
- Hongqian Liu
- Department of Obstetrics and Gynecology, West China Second University Hospital, Sichuan University, Chengdu, China
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Nezhat C, Hajhosseini B, King LP. Robotic-assisted laparoscopic treatment of bowel, bladder, and ureteral endometriosis. JSLS 2011; 15:387-92. [PMID: 21985730 PMCID: PMC3183562 DOI: 10.4293/108680811x13125733356396] [Citation(s) in RCA: 55] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Robotic-assisted laparoscopic repair of a vesicouterine fistula allows for a
three-dimensional view of the operative filed and intricate movements necessary
for complex suturing and dissection. Background: Endometriosis commonly affects the pelvic organs but can also affect organs
outside the pelvis and is then termed extragenital endometriosis. Cases: Successful robotically assisted laparoscopic management of extragenital
endometriosis, specifically, endometriosis of the bowel, bladder, and ureter
in 5 patients. Conclusion: A substantial body of evidence supports the laparoscopic approach as the
preferred method for many procedures; yet, a majority of procedures today
still are performed by laparotomy. This preference for open procedures is
likely due to the lack of trained endoscopic surgeons, the difficulty in
obtaining proper instruments, and the long learning curve of operative
laparoscopy. The recent advent of computer-enhanced technology may provide
the bridge necessary for more surgeons to incorporate laparoscopic surgery
in the treatment of complex cases.
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Affiliation(s)
- Camran Nezhat
- Department of Obstetrics, Gynecology and Surgery, Stanford University, USA.
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Bot-Robin V, Rubod C, Zini L, Collinet P. Étude de faisabilité du traitement laparoscopique robot-assisté de lésions d’endométriose pelvienne profonde. ACTA ACUST UNITED AC 2011; 39:407-11. [DOI: 10.1016/j.gyobfe.2011.05.002] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2010] [Accepted: 02/15/2011] [Indexed: 11/29/2022]
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Abstract
Robotic surgery is the latest development in minimal invasive surgery. It provides superior visualisation and dexterity and therefore allows the surgeon to perform complex tasks that would exceed his/her abilities with conventional laparoscopy and would be associated with an increased morbidity if performed by laparotomy. Current evidence demonstrates the feasibility and safety of this technology in gynaecology. The costs of robotic surgery remain one of the main sources of controversy but are expected to come down with further developments of the technology. If evidence-based long-term outcome evaluations show the superiority of robotic surgery in comparison to conventional laparoscopic and open surgery, this technology will have a major impact on gynaecological surgery.
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Affiliation(s)
- Martin K Oehler
- Department of Gynaecological Oncology, Royal Adelaide Hospital, Adelaide, South Australia, Australia.
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The Journal of Minimally Invasive Gynecology. [Letter]. J Minim Invasive Gynecol 2009; 16:243; author reply 243. [PMID: 19249720 DOI: 10.1016/j.jmig.2008.12.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2008] [Accepted: 12/06/2008] [Indexed: 11/23/2022]
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Letters to the Editor. J Minim Invasive Gynecol 2009. [DOI: 10.1016/j.jmig.2008.12.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Pang ST, Chao A, Wang CJ, Lin G, Lee CL. Transurethral partial cystectomy and laparoscopic reconstruction for the management of bladder endometriosis. Fertil Steril 2008; 90:2014.e1-3. [DOI: 10.1016/j.fertnstert.2008.04.045] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2008] [Revised: 04/20/2008] [Accepted: 04/20/2008] [Indexed: 10/21/2022]
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Necrotic mass after transurethral resection of a bladder tumor: novel management with robotic partial cystectomy. J Robot Surg 2008; 1:257-61. [PMID: 25484974 PMCID: PMC4247438 DOI: 10.1007/s11701-007-0041-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2007] [Accepted: 09/04/2007] [Indexed: 11/25/2022]
Abstract
A 76-year-old female with a history of high-grade transitional cell carcinoma (TCC) of the bladder presented with persistent nocturia and urge incontinence and was diagnosed with a necrotic bladder lesion. Cystoscopy revealed a 4 cm area of necrosis, ulceration, calcification, and fat. Transurethral biopsy confirmed the lesion to be benign, and two attempts to re-epithelialize the area of necrosis with cold scraping of exudate failed. Decision was then made to proceed with removal of necrotic lesion with bladder preservation. With the aid of concomitant cystoscopic visualization of the necrotic lesion, a robotic partial cystectomy with bladder reconstruction was performed. The patient tolerated the procedure, had an uneventful post-operative course, and remains asymptomatic and disease-free at last follow-up of 6 months. To our knowledge, this case represents the first report of a necrotic lesion as a complication of transurethral resection of a bladder tumor (TURBT) and the first description of a robotic partial cystectomy for the management of either benign or malignant bladder disease.
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Bibliography. Current world literature. Minimally invasive gynecologic procedures. Curr Opin Obstet Gynecol 2007; 19:402-5. [PMID: 17625426 DOI: 10.1097/gco.0b013e3282ca75fc] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Biggerstaff ED. Laparoscopic surgery without the use of a robot. J Minim Invasive Gynecol 2006; 13:586; author reply 586-7. [PMID: 17097586 DOI: 10.1016/j.jmig.2006.06.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2006] [Accepted: 06/19/2006] [Indexed: 11/27/2022]
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Response. J Minim Invasive Gynecol 2006. [DOI: 10.1016/j.jmig.2006.07.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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