Postoperative Telephone-Based Questionnaire on Quality of Life after Robotic-Assisted Laparoscopic Hysterectomy versus Conventional Total Laparoscopic Hysterectomy

The first robotic-assisted hysterectomy below the bikini line with the Dexter robotic system™

Background

Robotic-assisted hysterectomy (RAH) is a widely accepted minimally invasive approach for uterus removal. However, as RAH is typically performed in the umbilical region, it usually results in scars in cosmetically suboptimal locations. This is the first case of RAH with cervicosacropexy performed below the bikini line, using the new Dexter robotic system™.

Objectives

The aim of this article is to show the surgical steps of the first RAH with cervicosacropexy performed below the bikini line with the new Dexter robotic system™ (Distalmotion), and furthermore assess the feasibility of this approach using this robotic platform.

Materials and Methods

A 43-year-old woman with uterine adenomyosis and recurrent uterine prolapse underwent a robotic-assisted subtotal hysterectomy with cervicosacropexy, performed below the bikini line, using the Dexter robotic system™, at the Clinic of Gynecology and Obstetrics at Universitätsklinikum Schleswig-Holstein (UKHS) in Kiel, Germany.

Main outcome measures

Perioperative data, surgical approach specifics, objective, and subjective outcomes of this new approach.

Results

The procedure was performed without intra-operative complications; estimated blood loss was 10 ml. Operative time was 150 minutes, console time 120 minutes, total docking time 6 minutes. Dexter performed as expected; no device-related issues or robotic arm collisions occurred. The patient did not require pain medication and was released on the second postoperative day.

Conclusion

RAH performed below the bikini line using the Dexter robotic system™ is a feasible, safe, and adequate procedure. These initial results should be confirmed and further extensively refurbished with larger patient cohorts, and functional and psychological outcomes need further investigation.

Expanding Robotic-Assisted Surgery in Gynecology Using the Potential of an Advanced Robotic System

Minimally invasive surgery (MIS) in gynecology was introduced to achieve the same surgical objectives as traditional open surgery while minimizing trauma to surrounding tissues, reducing pain, accelerating recovery, and improving overall patient outcomes. Minimally invasive approaches, such as laparoscopic and robotic-assisted surgeries, have become the standard for many gynecological procedures. In this review, we aim to summarize the advantages and main limitations to a broader adoption of robotic-assisted surgery compared to laparoscopic surgeries in gynecology. We present a new surgical system, the Dexter Robotic System™ (Distalmotion, Switzerland), that facilitates the transition from laparoscopy expertise to robotic-assisted surgery.

Robotic-assisted benign hysterectomy compared with laparoscopic, vaginal, and open surgery: a systematic review and meta-analysis

The potential benefits and limitations of benign hysterectomy surgical approaches are still debated. We aimed at evaluating any differences with a systematic review and meta-analysis. PubMed, MEDLINE, and EMBASE databases were last searched on 6/2/2021 to identify English randomized controlled trials (RCTs), prospective cohort and retrospective independent database studies published between Jan 1, 2010 and Dec 31, 2020 reporting perioperative outcomes following robotic hysterectomy versus laparoscopic, open, or vaginal approach (PROSPERO #CRD42022352718). Twenty-four articles were included that reported on 110,306 robotic, 262,715 laparoscopic, 189,237 vaginal, and 554,407 open patients. The robotic approach was associated with a shorter hospital stay (p < 0.00001), less blood loss (p = 0.009), and fewer complications (OR: 0.42 [0.27, 0.66], p = 0.0001) when compared to the open approach. The main benefit compared to the laparoscopic and vaginal approaches was a shorter hospital (R/L WMD: - 0.144 [- 0.21, - 0.08], p < 0.0001; R/V WMD: - 0.39 [- 0.70, - 0.08], p = 0.01). Other benefits seen were sensitive to the inclusion of database studies. Study type differences in outcomes, a lack of RCTs for robotic vs. open comparisons, learning curve issues, and limited robotic vs. vaginal publications are limitations. While the robotic approach was mainly comparable to the laparoscopic approach, this meta-analysis confirms the classic benefits of minimally invasive surgery when comparing robotic hysterectomy to open surgery. We also reported the advantages of robotic surgery over vaginal surgery in a patient population with a higher incidence of large uterus and prior surgery.

Surgical approach to hysterectomy for benign gynaecological disease

BACKGROUND

Currently, there are five major approaches to hysterectomy for benign gynaecological disease: abdominal hysterectomy (AH), vaginal hysterectomy (VH), laparoscopic hysterectomy (LH), robotic-assisted hysterectomy (RH) and vaginal natural orifice hysterectomy (V-NOTES). Within the LH category we further differentiate the laparoscopic-assisted vaginal hysterectomy (LAVH) from the total laparoscopic hysterectomy (TLH) and single-port laparoscopic hysterectomy (SP-LH).

OBJECTIVES

To assess the effectiveness and safety of different surgical approaches to hysterectomy for women with benign gynaecological conditions.

SEARCH METHODS

We searched the following databases (from their inception to December 2022): the Cochrane Gynaecology and Fertility Specialised Register of Controlled Trials, CENTRAL, MEDLINE, Embase, CINAHL and PsycINFO. We also searched the trial registries and relevant reference lists, and communicated with experts in the field for any additional trials.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) in which clinical outcomes were compared between one surgical approach to hysterectomy and another.

DATA COLLECTION AND ANALYSIS

At least two review authors independently selected trials, assessed risk of bias and performed data extraction. Our primary outcomes were return to normal activities, satisfaction and quality of life, intraoperative visceral injury and major long-term complications (i.e. fistula, pelvic-abdominal pain, urinary dysfunction, bowel dysfunction, pelvic floor condition and sexual dysfunction).

MAIN RESULTS

We included 63 studies with 6811 women. The evidence for most comparisons was of low or moderate certainty. The main limitations were poor reporting and imprecision. Vaginal hysterectomy (VH) versus abdominal hysterectomy (AH) (12 RCTs, 1046 women) Return to normal activities was probably faster in the VH group (mean difference (MD) -10.91 days, 95% confidence interval (CI) -17.95 to -3.87; 4 RCTs, 274 women; I2 = 67%; moderate-certainty evidence). This suggests that if the return to normal activities after AH is assumed to be 42 days, then after VH it would be between 24 and 38 days. We are uncertain whether there is a difference between the groups for the other primary outcomes. Laparoscopic hysterectomy (LH) versus AH (28 RCTs, 3431 women) Return to normal activities may be sooner in the LH group (MD -13.01 days, 95% CI -16.47 to -9.56; 7 RCTs, 618 women; I2 = 68%, low-certainty evidence), but there may be more urinary tract injuries in the LH group (odds ratio (OR) 2.16, 95% CI 1.19 to 3.93; 18 RCTs, 2594 women; I2 = 0%; moderate-certainty evidence). This suggests that if the return to normal activities after abdominal hysterectomy is assumed to be 37 days, then after laparoscopic hysterectomy it would be between 22 and 25 days. It also suggests that if the rate of ureter injury during abdominal hysterectomy is assumed to be 0.2%, then during laparoscopic hysterectomy it would be between 0.2% and 2%. We are uncertain whether there is a difference between the groups for the other primary outcomes. LH versus VH (22 RCTs, 2135 women) We are uncertain whether there is a difference between the groups for any of our primary outcomes. Both short- and long-term complications were rare in both groups. Robotic-assisted hysterectomy (RH) versus LH (three RCTs, 296 women) None of the studies reported satisfaction rates or quality of life. We are uncertain whether there is a difference between the groups for our other primary outcomes. Single-port laparoscopic hysterectomy (SP-LH) versus LH (seven RCTs, 621 women) None of the studies reported satisfaction rates, quality of life or major long-term complications. We are uncertain whether there is a difference between the groups for rates of intraoperative visceral injury. Total laparoscopic hysterectomy (TLH) versus laparoscopic-assisted vaginal hysterectomy (LAVH) (three RCTs, 233 women) None of the studies reported satisfaction rates or quality of life. We are uncertain whether there is a difference between the groups for rates of intraoperative visceral injury or major long-term complications. Transvaginal natural orifice transluminal endoscopic surgery (V-NOTES) versus LH (two RCTs, 96 women) We are uncertain whether there is a difference between the groups for rates of bladder injury. Our other primary outcomes were not reported. Overall, adverse events were rare in the included studies.

AUTHORS' CONCLUSIONS

Among women undergoing hysterectomy for benign disease, VH appears to be superior to AH. When technically feasible, VH should be performed in preference to AH because it is associated with faster return to normal activities, fewer wound/abdominal wall infections and shorter hospital stay. Where VH is not possible, LH has advantages over AH including faster return to normal activities, shorter hospital stay, and decreased risk of wound/abdominal wall infection, febrile episodes or unspecified infection, and transfusion. These advantages must be balanced against the increased risk of ureteric injury and longer operative time. When compared to LH, VH was associated with no difference in time to return to normal activities but shorter operative time and shorter hospital stay. RH and V-NOTES require further evaluation since there is a lack of evidence of any patient benefit over conventional LH. Overall, the evidence in this review has to be interpreted with caution as adverse event rates were low, resulting in low power for these comparisons. The surgical approach to hysterectomy should be discussed with the patient and decided in the light of the relative benefits and hazards. Surgical expertise is difficult to quantify and poorly reported in the available studies and this may influence outcomes in ways that cannot be accounted for in this review. In conclusion, when VH is not feasible, LH has multiple advantages over AH, but at the cost of more ureteric injuries. Evidence is limited for RH and V-NOTES.

Outcomes of robotic and laparoscopic surgery for benign gynaecological disease: a systematic review

Benign gynaecological diseases are usually treated with minimally invasive approaches. Robotic surgery seems an alternative to laparoscopic surgery. No definitive conclusions have yet been made regarding comparison of robotic versus laparoscopic surgery for benign diseases. In this scenario, we performed a systematic review in order to assess the advantages and disadvantages of laparoscopy versus robotic surgery and conclude whether laparoscopy should be replaced by robotic surgery for the treatment of benign gynaecological conditions, following the Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) Statement. We included 64 studies: no significant difference was observed regarding overall complication rate; no significant benefit of robotic approach was demonstrated regarding length of hospital stay and conversion to laparotomy; furthermore, robotic surgery is more easily used by non-experienced surgeons, while it is more expensive and characterised by longer operative time. In conclusion, current evidence indicates neither statistically significant nor clinically meaningful differences in surgical outcomes between robotic and laparoscopic surgeries for benign gynaecological diseases. Impact statementWhat is already known on this subject? Benign gynaecological diseases are usually treated with minimally invasive approaches. Nevertheless, no definitive conclusions have yet been made regarding comparison of robotic versus laparoscopic surgery for benign diseases.What do the results of this study add? No significant difference was observed regarding overall complication rate; no significant benefit of robotic approach was demonstrated regarding length of hospital stay and conversion to laparotomy; furthermore, robotic surgery is more easily used by non-experienced surgeon, while it is more expensive and characterised by longer operative time.What are the implications of these findings for clinical practice and/or further research? Robotic surgery should not replace laparoscopy for the treatment of benign gynaecological conditions; in addition, gynaecologic surgeon should offer robotic surgery for benign diseases only after a proper counselling and a balanced decision-making process involving the patient.

Genito Pelvic Pain/Penetration Disorder (GPPPD) in Spanish Women-Clinical Approach in Primary Health Care: Review and Meta-Analysis

Sexuality is a component of great relevance in humans. Sexual disorders are a major public health problem representing a high prevalence in the general population. DSM-5 genito-pelvic pain/penetration disorder (GPPPD) includes dyspareunia and vaginismus (DSM-IV-TR). To assess the importance of research on these disorders in Spain, we evaluated the Spanish scientific publications of primary and community care. The objective was to quantify the magnitude of the publications of GPPPD in Spanish women in primary and community care. For this, we used the method of conducting a systematic review and meta-analysis of studies evaluating GPPPD. As main results, of the 551 items found, we selected 11 studies that met the inclusion criteria. In primary care in Spain, one in nine women has these disorders; the percentage of women with GPPPD in this study (raw data) was 11.23% (95% CI: 0-29%) (vaginismus 5%; penetration pain 8.33%; dyspareunia 16.45%). These percentages can differ of those from other countries, and they are at the top of the data of the European countries (9-11.9%). There is much variability in the studies found in the world with respect to the prevalence of these health problems.

Long-term satisfaction of patients after laparoscopic and robotic-assisted hysterectomy

Introduction

Da-Vinci-Xi is the most recent device used in gynecologic robotic surgery. The aim of the present study was to compare the long-term satisfaction of patients who had undergone conventional laparoscopic hysterectomy or robotic assisted laparoscopic hysterectomy using the Da-Vinci-Xi surgical system.

Methods

All hysterectomies performed at the University Hospital of Luebeck from 2018 to 2019 were reviewed. Postoperative outcomes were compared between women who had undergone total hysterectomy with da Vinci Xi (n = 42) or conventional laparoscopy (n = 97). Postoperative outcomes included pain, elimination of complaints after surgery, bladder function, sexual function, satisfaction with the cosmetic outcome, positive experiences after robotic surgery, and satisfaction with the surgeon’s preoperative explanation. Obese patients were evaluated separately in a subgroup analysis.

Results

Both groups had similar baseline characteristics and complication rates. Preoperative complaints subsided after surgery in a little more than 90% of patients. No significant differences were noted between groups in this regard (p = 0.262), or with reference to postoperative pain after one week (p = 0.866) and one month (p = 0.580), stress incontinence (p = 0.343), sexual function (p = 0.766) and the cosmetic outcome of the abdominal incisions (p = 0.273). The majority of patients who had undergone robotic surgery (96.8%) would be willing to undergo the procedure again if necessary. The subgroup analysis of obese patients revealed no significant differences.

Conclusion

The Da-Vinci-Xi device did not improve the long-term surgical satisfaction of normal-weight or obese patients who underwent hysterectomy compared with patients who underwent conventional laparoscopy performed by experienced laparoscopic surgeons.

Didactic Benefits of Surgery on Body Donors during Live Surgery Events in Minimally Invasive Surgery

Background: Live surgery events serve as a valuable tool for surgical education, but also raise ethical concerns about patient safety and professional performance. In the present study, we evaluate the technical feasibility and didactic benefits of live surgery on body donors compared to real patients. Methods: A live surgery session performed on a body donor’s cadaver embalmed in ethanol–glycerol–lysoformin was integrated into the live surgery program presented at a major gynecological convention of minimally invasive surgery. Surgical procedures carried out in real patients were paralleled in the body donor, including the dissection and illustration of surgically relevant anatomical landmarks. A standardized questionnaire was filled by the participants (n = 208) to evaluate the appropriateness, effectiveness, and benefits of this novel concept. Results: The live surgery event was appreciated as a useful educational tool. With regard to the use of body donors, authenticity was rated high (85.5%), and the overall value of body donors for surgical education and training was rated very high (95.0%). The didactic benefit of simultaneous operations performed on body donors and real patients was considered particularly useful (95.5%), whereas complete replacement of real patients by body donors was not favored (14.5%). Conclusions: The study demonstrated both the technical feasibility and didactic benefits of performing minimally invasive surgery in body donors as part of live surgery events. This novel concept has the potential to enhance anatomical knowledge, providing insights into complex surgical procedures, and may serve to overcome yet unresolved ethical concerns related to live surgery events.