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Ferrari FA, Youssef Y, Naem A, Ferrari F, Odicino F, Krentel H, Moawad G. Robotic surgery for deep-infiltrating endometriosis: is it time to take a step forward? Front Med (Lausanne) 2024; 11:1387036. [PMID: 38504917 PMCID: PMC10948538 DOI: 10.3389/fmed.2024.1387036] [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: 02/16/2024] [Accepted: 02/26/2024] [Indexed: 03/21/2024] Open
Abstract
Endometriosis is a chronic debilitating disease that affects nearly 10% of women of the reproductive age. Although the treatment modalities of endometriosis are numerous, surgical excision of the endometriotic implants and nodules remains the sole cytoreductive approach. Laparoscopic excision of endometriosis was proven to be beneficial in improving the postoperative pain and fertility. Moreover, it was also proved to be safe and efficient in treating the visceral localization of deep endometriosis, such as urinary and colorectal endometriosis. More recently, robotic-assisted surgery gained attention in the field of endometriosis surgery. Although the robotic technology provides a 3D vision of the surgical field and 7-degree of freedom motion, the safety, efficacy, and cost-effectiveness of this approach are yet to be determined. With this paper, we aim to review the available evidence regarding the role of robotic surgery in the management of endometriosis along with the current practices in the field.
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Affiliation(s)
| | - Youssef Youssef
- Division of Minimally Invasive Gynecologic Surgery, Department of Obstetrics and Gynaecology-Maimonides Medical Center, Brooklyn, NY, United States
| | - Antoine Naem
- Faculty of Mathematics and Computer Science, University of Bremen, Bremen, Germany
- Department of Obstetrics, Gynecology, Gynecologic Oncology, and Senology, Bethesda Hospital Duisburg, Duisburg, Germany
| | - Federico Ferrari
- Department of Clinical and Experimental Sciences, Division of Obstetrics and Gynecology, University of Brescia, Brescia, Italy
| | - Franco Odicino
- Department of Clinical and Experimental Sciences, Division of Obstetrics and Gynecology, University of Brescia, Brescia, Italy
| | - Harald Krentel
- Department of Obstetrics, Gynecology, Gynecologic Oncology, and Senology, Bethesda Hospital Duisburg, Duisburg, Germany
| | - Gaby Moawad
- Department of Obstetrics and Gynecology, George Washington University, Washington, DC, United States
- The Center for Endometriosis and Advanced Pelvic Surgery, Washington, DC, United States
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Alves Martins BA, Filho ODM, Ghezzi TL, Melani AGF, Romagnolo LGC, Moreira Júnior H, de Almeida JPP, Araújo SEA, de Sousa JB, de Almeida RM. An Overview of Robotic Colorectal Surgery Adoption and Training in Brazil. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:1675. [PMID: 37763794 PMCID: PMC10535775 DOI: 10.3390/medicina59091675] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/30/2023] [Revised: 09/06/2023] [Accepted: 09/15/2023] [Indexed: 09/29/2023]
Abstract
Background and Objectives: Robotic surgical systems have rapidly become integrated into colorectal surgery practice in recent years, particularly for rectal resections, where the advantages of robotic platforms over conventional laparoscopy are more pronounced. However, as with any technological advancement, the initial high costs can be a limiting factor, leading to unequal health service access, especially in middle- and lower-income countries. Materials and Method: A narrative review was conducted with the objective of providing an overview of the escalating adoption, current training programmes, and certification process of robotic colorectal surgery in Brazil. Results: Brazil has witnessed a rapid increase in robotic platforms in recent years. Currently, there are 106 robotic systems installed nationwide. However, approximately 60% of the medical facilities which adopted robotic platforms are in the Southeast region, which is both the most populous and economically prosperous in the country. The Brazilian Society of Coloproctology recently established clear rules for the training programme and certification of colorectal surgeons in robotic surgery. The key components of the training encompass theoretical content, virtual robotic simulation, observation, assistance, and supervised procedures in colorectal surgery. Although the training parameters are well established, no colorectal surgery residency programme in Brazil has yet integrated the teaching and training of robotic surgery into its curriculum. Thus far, the training process has been led by private institutions and the industry. Conclusion: Despite the fast spread of robotic platforms across Brazil, several challenges still need to be addressed to democratise training and promote the widespread use of these platforms. It is crucial to tackle these obstacles to achieve greater integration of robotic technology in colorectal surgery throughout the country.
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Affiliation(s)
| | - Oswaldo de Moraes Filho
- Department of Colorectal Surgery, Hospital Universitário de Brasília, Brasilia 70840-901, Brazil
| | | | | | | | - Hélio Moreira Júnior
- Department of Surgery, Colorectal Service, School of Medicine, Federal University of Goias, Goias 74605-050, Brazil
| | | | | | - João Batista de Sousa
- Department of Colorectal Surgery, Hospital Universitário de Brasília, Brasilia 70840-901, Brazil
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Raimondo D, Alboni C, Orsini B, Aru AC, Farulla A, Maletta M, Arena A, Del Forno S, Sampogna V, Mastronardi M, Petrillo M, Seracchioli R. Comparison of perioperative outcomes between standard laparoscopic and robot-assisted approach in patients with rectosigmoid endometriosis. Acta Obstet Gynecol Scand 2021; 100:1740-1746. [PMID: 33999408 PMCID: PMC8453718 DOI: 10.1111/aogs.14170] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Revised: 04/15/2021] [Accepted: 05/04/2021] [Indexed: 12/29/2022]
Abstract
INTRODUCTION Robot-assisted laparoscopic surgery (RALS) has gained widespread application in several surgical specialties. Previous studies on the feasibility and safety of RALS vs standard laparoscopy (S-LPS) for rectosigmoid endometriosis are limited and reported conflicting data. This study aims to compare S-LPS and RALS in patients with rectosigmoid endometriosis in terms of perioperative surgical and clinical data. MATERIAL AND METHODS This is a multicentric, observational, prospective cohort study including 44 patients affected by rectosigmoid endometriosis referred to two tertiary referral centers for endometriosis from September 2018 to September 2019. Patients were divided into two groups: 22 patients underwent S-LPS, and 22 underwent RALS. Our primary outcome was to compare operative time (from skin incision to suture) between the two groups. Secondary outcomes included: operative room time (patient entry into operative room and patient out), estimated blood loss, laparotomic conversion rate, length of hospital stay, perioperative complications, and evaluation of endometriosis-related symptoms at 12-month follow up. RESULTS The two groups were comparable regarding preoperative and surgical data, except for higher rates of hysterectomies and bilateral uterosacral ligament removal procedures in the RALS group. Also after adjusting for these discrepancies, operative time was similar between S-LPS and RALS. Operative room time was statistically longer in the RALS group compared with that of S-LPS. No statistically significant difference was found concerning other study outcomes. Pain and bowel symptoms improved in both groups at 12-month follow up. CONCLUSIONS If performed by expert teams, RALS provides similar perioperative outcomes compared with S-LPS in rectosigmoid endometriosis surgical treatment, except for longer operative room time.
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Affiliation(s)
- Diego Raimondo
- Division of Gynecology and Human Reproduction Physiopathology, Department of Medical and Surgical Sciences (DIMEC), IRCCS, Sant'Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
| | - Carlo Alboni
- Department of Obstetrics and Gynecology, Azienda Ospedaliero-Universitaria Policlinico di Modena, Modena, Italy
| | - Benedetta Orsini
- Division of Gynecology and Human Reproduction Physiopathology, Department of Medical and Surgical Sciences (DIMEC), IRCCS, Sant'Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
| | - Anna Chiara Aru
- Division of Gynecology and Human Reproduction Physiopathology, Department of Medical and Surgical Sciences (DIMEC), IRCCS, Sant'Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
| | - Antonino Farulla
- Department of Obstetrics and Gynecology, Azienda Ospedaliero-Universitaria Policlinico di Modena, Modena, Italy
| | - Manuela Maletta
- Division of Gynecology and Human Reproduction Physiopathology, Department of Medical and Surgical Sciences (DIMEC), IRCCS, Sant'Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
| | - Alessandro Arena
- Division of Gynecology and Human Reproduction Physiopathology, Department of Medical and Surgical Sciences (DIMEC), IRCCS, Sant'Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
| | - Simona Del Forno
- Division of Gynecology and Human Reproduction Physiopathology, Department of Medical and Surgical Sciences (DIMEC), IRCCS, Sant'Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
| | - Veronica Sampogna
- Department of Obstetrics and Gynecology, Azienda Ospedaliero-Universitaria Policlinico di Modena, Modena, Italy
| | - Manuela Mastronardi
- Division of Gynecology and Human Reproduction Physiopathology, Department of Medical and Surgical Sciences (DIMEC), IRCCS, Sant'Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
| | - Marco Petrillo
- Department of Medical, Surgical and Experimental Science, Gynecologic and Obstetric Clinic, University of Sassari, Sassari, Italy
| | - Renato Seracchioli
- Division of Gynecology and Human Reproduction Physiopathology, Department of Medical and Surgical Sciences (DIMEC), IRCCS, Sant'Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
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Full robotic multivisceral resections: the Modena experience and literature review. Updates Surg 2021; 73:1177-1187. [PMID: 33570711 DOI: 10.1007/s13304-020-00939-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Accepted: 12/07/2020] [Indexed: 12/29/2022]
Abstract
The robotic platform is becoming a multidisciplinary tool, versatile, and suitable for multiple procedures. Combined multivisceral resections may represent an alternative to sequential procedures with a potential favorable impact on postoperative morbidity, and on the timing of administration of adjuvant chemotherapy. We herein present our initial experience with full robotic multivisceral resections, and a review of the literature available. Between January 2018 and April 2020, 11 patients underwent multivisceral full robotic abdominal surgery: 4 patients presented with two synchronous tumors, 4 with primary cancer associated with a benign condition and 3 cases involved deep infiltrating endometriosis. Surgical teams enrolled were: General Surgery, Urology and Gynecology. A systematic bibliographic research up to April 2020 was conducted in PubMed. 4 colorectal resections combined with partial or radical nephrectomy were performed, as well as 2 right colectomies in combination with right adrenalectomy and gastric banding removal, 2 radical prostatectomies with Nissen Fundoplication and abdominal wall hernia repair, and 3 resections of deep pelvic endometriosis with colorectal involvement. Mean total operative time was 367 min. No intraoperative complication or conversion to open was registered. Overall postoperative complication rate was 18.2%. 26 papers were included in the review (10 case series and 16 case reports) with a total of 156 combined multivisceral robotic procedures recorded. Robotic combined multivisceral resections proved to be safe and feasible when performed in high volume centers by expert surgeons. The heterogeneity of reports does not allow for a standardization of the procedure. Further studies and accumulation of experience are needed.
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Le Gac M, Ferrier C, Touboul C, Owen C, Arfi A, Boudy AS, Jayot A, Bendifallah S, Daraï E. Comparison of robotic versus conventional laparoscopy for the treatment of colorectal endometriosis: Pilot study of an expert center. J Gynecol Obstet Hum Reprod 2020; 49:101885. [PMID: 32738498 DOI: 10.1016/j.jogoh.2020.101885] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2020] [Revised: 07/23/2020] [Accepted: 07/26/2020] [Indexed: 12/14/2022]
Abstract
INTRODUCTION Surgical management of deep endometriosis with colorectal involvement remains an option after failure of medical treatments. Conventional laparoscopy is currently considered the standard approach for surgical treatment. Recently, assisted-robotic laparoscopy emerged as an alternative to conventional laparoscopy but with low evidence. METHODS From March 2019 to September 2019, we conducted a prospective cohort study of 48 patients undergoing a surgical treatment for colorectal endometriosis (rectal shaving, discoid excision or segmental resection). The interventions were either performed by robotic or conventional laparoscopy. Patients' characteristics, operative and post-operative data were compared between the robotic and the conventional laparoscopic group. RESULTS 48 patients were included, 25 in the conventional laparoscopy group and 23 in the robotic group. Patients' characteristics and operative findings were similar between the two groups, except for a trend in a higher incidence of associated surgical urinary or digestive procedures in the robotic group (p = 0.06). The mean total surgical room occupancy time and operating time were longer in the in the robotic group (281 ± 97 min vs 208 ± 85 min; p = 0.008) and (221 ± 94 min vs 163 ± 83 min (p = 0.03), respectively. The mean intra operative blood loss, the incidence of intra operative, post-operative complication (according to Clavien-Dindo classification) rates and voiding dysfunction were similar in the two groups. The rate of grade III complication was higher in the robotic group (13 % vs 0%) without reaching a significance (p = 0.17). The mean hospital stay was 8 ± 4.4 days in the robotic group and 6.5 ± 2.6 days in the conventional laparoscopy group (p = 0.18). CONCLUSION Despite our initial experience in robotic surgery, our results support that robotic surgery is an adequate alternative to conventional laparoscopy for endometriosis colorectal resection.
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Affiliation(s)
- Marjolaine Le Gac
- Department of Gynecology-Obstetrics and Medicine of Reproduction, Hôpital Tenon, Sorbonne University, Assistance Publique des Hôpitaux de Paris, France
| | - Clément Ferrier
- Department of Gynecology-Obstetrics and Medicine of Reproduction, Hôpital Tenon, Sorbonne University, Assistance Publique des Hôpitaux de Paris, France
| | - Cyril Touboul
- Department of Gynecology-Obstetrics and Medicine of Reproduction, Hôpital Tenon, Sorbonne University, Assistance Publique des Hôpitaux de Paris, France; Groupe de Recherche Clinique in endometriosis (GRC-6 Sorbonne University), Centre Expert En Endometriose (C3E), France; UMRS-938 Sorbonne University, France
| | - Clémentine Owen
- Department of Gynecology-Obstetrics and Medicine of Reproduction, Hôpital Tenon, Sorbonne University, Assistance Publique des Hôpitaux de Paris, France
| | - Alexandra Arfi
- Department of Gynecology-Obstetrics and Medicine of Reproduction, Hôpital Tenon, Sorbonne University, Assistance Publique des Hôpitaux de Paris, France
| | - Anne-Sophie Boudy
- Department of Gynecology-Obstetrics and Medicine of Reproduction, Hôpital Tenon, Sorbonne University, Assistance Publique des Hôpitaux de Paris, France
| | - Aude Jayot
- Department of Gynecology-Obstetrics and Medicine of Reproduction, Hôpital Tenon, Sorbonne University, Assistance Publique des Hôpitaux de Paris, France
| | - Sofiane Bendifallah
- Department of Gynecology-Obstetrics and Medicine of Reproduction, Hôpital Tenon, Sorbonne University, Assistance Publique des Hôpitaux de Paris, France; Groupe de Recherche Clinique in endometriosis (GRC-6 Sorbonne University), Centre Expert En Endometriose (C3E), France; UMRS-938 Sorbonne University, France
| | - Emile Daraï
- Department of Gynecology-Obstetrics and Medicine of Reproduction, Hôpital Tenon, Sorbonne University, Assistance Publique des Hôpitaux de Paris, France; Groupe de Recherche Clinique in endometriosis (GRC-6 Sorbonne University), Centre Expert En Endometriose (C3E), France; UMRS-938 Sorbonne University, France.
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Robotic treatment of bowel endometriosis. Best Pract Res Clin Obstet Gynaecol 2020; 71:129-143. [PMID: 32684433 DOI: 10.1016/j.bpobgyn.2020.05.012] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Revised: 05/05/2020] [Accepted: 05/07/2020] [Indexed: 12/18/2022]
Abstract
Endometriosis describes a condition with the presence of ectopic endometrial glands and stroma outside the endometrial cavity that affects up to 15% of reproductive-aged women. Of women affected with endometriosis, 3.8-37% will have endometriosis involving the bowel, primarily the rectosigmoid colon. While medical management is often recommended as a first-line therapy, it is not curative, and surgery is often required as an adjunct for the management of symptoms. Minimally invasive surgery has become the standard of care for managing these patients. The use of robotic-assisted laparoscopy offers benefits that may allow surgeons to perform these challenging surgical cases using a minimally invasive technique. For lesions that affect the colon, there are three primary techniques used for removal which include: 1) rectal shaving, 2) discoid excision and 3) segmental resection. The decision to pursue one approach over another is largely dependent on the number of lesions present, a lesion's size and depth of invasion as well as the involved circumference of the bowel. The available evidence of using robotic-assisted laparoscopy in cases of bowel endometriosis is limited in the literature. In this review, we will summarize the role of robotic-assisted laparoscopy in the management of bowel endometriosis.
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Ferrero S, Stabilini C, Barra F, Clarizia R, Roviglione G, Ceccaroni M. Bowel resection for intestinal endometriosis. Best Pract Res Clin Obstet Gynaecol 2020; 71:114-128. [PMID: 32665125 DOI: 10.1016/j.bpobgyn.2020.05.008] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Accepted: 05/13/2020] [Indexed: 01/12/2023]
Abstract
Over the last twenty years, segmental resection (SR) has been the technique most frequently used to treat bowel endometriosis. Nowadays, it is most commonly performed by laparoscopy; however, there is evidence that it can be safely performed by robotic-assisted laparoscopic surgery. Rectovaginal fistula and anastomotic leakage are the two major complications of SR; other complications include pelvic abscess, postoperative bleeding, ureteral damage, and anastomotic stricture. Several studies showed that SR causes improvement in pain and intestinal symptoms; nerve-sparing SR may improve the functional outcomes. The rates of postoperative recurrence of bowel endometriosis vary across the studies, possibly because of the different definitions of recurrence.
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Affiliation(s)
- Simone Ferrero
- Academic Unit of Obstetrics and Gynecology, IRCCS Ospedale Policlinico San Martino, Largo R. Benzi 10, Genoa, 16132, Italy; Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DiNOGMI), University of Genoa, Italy
| | - Cesare Stabilini
- Department of Surgical Science, IRCCS Ospedale Policlinico San Martino, Largo R. Benzi 10, Genoa, 16132, Italy; Department of Surgical Sciences and Integrated Diagnostics (DISC), University of Genoa, Italy
| | - Fabio Barra
- Academic Unit of Obstetrics and Gynecology, IRCCS Ospedale Policlinico San Martino, Largo R. Benzi 10, Genoa, 16132, Italy; Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DiNOGMI), University of Genoa, Italy.
| | - Roberto Clarizia
- Department of Obstetrics and Gynecology, Gynecologic Oncology and Minimally-Invasive Pelvic Surgery, International School of Surgical Anatomy, IRCCS "Sacro Cuore - Don Calabria" Hospital, Via Don A. Sempreboni 5, Negrar, 37024, Verona, Italy
| | - Giovanni Roviglione
- Department of Obstetrics and Gynecology, Gynecologic Oncology and Minimally-Invasive Pelvic Surgery, International School of Surgical Anatomy, IRCCS "Sacro Cuore - Don Calabria" Hospital, Via Don A. Sempreboni 5, Negrar, 37024, Verona, Italy
| | - Marcello Ceccaroni
- Department of Obstetrics and Gynecology, Gynecologic Oncology and Minimally-Invasive Pelvic Surgery, International School of Surgical Anatomy, IRCCS "Sacro Cuore - Don Calabria" Hospital, Via Don A. Sempreboni 5, Negrar, 37024, Verona, Italy
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Gkegkes ID, Iavazzo C, Iatrakis G, Iavazzo PE, Pechlivani F, Antoniou E, Bakalianou K. Robotic Management of Endometriosis: Discussion of Use, Criteria and Advantages: a Review of the Literature. ACTA MEDICA (HRADEC KRÁLOVÉ) 2020; 62:147-149. [PMID: 32036846 DOI: 10.14712/18059694.2020.3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Endometriosis is a very common benign condition affecting fertility and quality of life. Different methods, either definitive or fertility sparing are used for its management by using open, laparoscopic, and robotic techniques. This is a literature review presenting the role and the advantages of robotic surgery in endometriosis. Such a management is effective, safe, and feasible in hands of well-trained multidisciplinary teams even for severe cases of endometriosis.
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Affiliation(s)
- Ioannis D Gkegkes
- Department of Surgery, Royal Devon and Exeter NHS Foundation Trust, Exeter, UK.
| | - Christos Iavazzo
- Department of Gynaecological Oncology, The Christie Hospital, Manchester, UK
| | - George Iatrakis
- Department of Obstetrics and Gynaecology, Technological Educational Institution of Athens, Athens, Greece
| | | | - Fani Pechlivani
- Department of Obstetrics and Gynaecology, Technological Educational Institution of Athens, Athens, Greece
| | - Evangelia Antoniou
- Department of Obstetrics and Gynaecology, Technological Educational Institution of Athens, Athens, Greece
| | - Konstadia Bakalianou
- Department of Obstetrics and Gynecology, General Hospital "Agia Olga", Athens, Greece
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Poujois J, Mézan De Malartic C, Callec R, Bresler L, Hubert N, Judlin P, Morel O. Deep infiltrating endometriosis: Interest of the robotic approach for a fledgling team. JOURNAL OF ENDOMETRIOSIS AND PELVIC PAIN DISORDERS 2019. [DOI: 10.1177/2284026519850369] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
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.
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Affiliation(s)
- Julie Poujois
- Department of Obstetrics and Gynecology, Maternité, CHRU de Nancy, Nancy, France
| | | | - Ronan Callec
- Department of Obstetrics and Gynecology, Maternité, CHRU de Nancy, Nancy, France
| | - Laurent Bresler
- Department of Digestive Surgery, Hôpital Brabois Adultes, CHRU de Nancy, Nancy, France
| | - Nicolas Hubert
- Department of Urology, Hôpital Brabois Adultes, CHRU de Nancy, Nancy, France
| | - Philippe Judlin
- Department of Obstetrics and Gynecology, Maternité, CHRU de Nancy, Nancy, France
| | - Oliver Morel
- Department of Obstetrics and Gynecology, Maternité, CHRU de Nancy, Nancy, France
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Totally intracorporeal robotic en bloc resection for deep infiltrating endometriosis of the rectovaginal wall with natural orifice specimen extraction. Tech Coloproctol 2019; 23:589-591. [PMID: 31037578 DOI: 10.1007/s10151-019-01989-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2019] [Accepted: 04/08/2019] [Indexed: 10/26/2022]
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Affiliation(s)
- Youn-Jee Chung
- Department of Obstetrics and Gynecology, Seoul St. Mary's Hospital, The Catholic University of Korea, Seoul, Korea
- Seoul St. Mary's Fibroid Center, Seoul St. Mary's Hospital, The Catholic University of Korea, Seoul, Korea
| | - Mee-Ran Kim
- Department of Obstetrics and Gynecology, Seoul St. Mary's Hospital, The Catholic University of Korea, Seoul, Korea
- Seoul St. Mary's Fibroid Center, Seoul St. Mary's Hospital, The Catholic University of Korea, Seoul, Korea
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12
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Balla A, Quaresima S, Subiela JD, Shalaby M, Petrella G, Sileri P. Outcomes after rectosigmoid resection for endometriosis: a systematic literature review. Int J Colorectal Dis 2018; 33:835-847. [PMID: 29744578 DOI: 10.1007/s00384-018-3082-y] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/02/2018] [Indexed: 02/04/2023]
Abstract
PURPOSE "Endometriosis" is defined such as the presence of endometrial glands and stroma outside the uterine cavity. This ectopic condition may develop as deeply infiltrating endometriosis (DIE) when a solid mass is located deeper than 5 mm underneath the peritoneum including the intestinal wall. The ideal surgical treatment is still under search, and treatment may range from simple shaving to rectal resection. The aim of the present systematic review is to report and analyze the postoperative outcomes after rectosigmoid resection for endometriosis. METHODS We performed a systematic review according to Meta-analysis of Observational Studies in Epidemiology guidelines. The search was carried out in the PubMed database, using the keywords: "rectal resection" AND "endometriosis" and "rectosigmoid resection" AND "endometriosis." The search revealed 380 papers of which 78 were fully analyzed. RESULTS Thirty-eight articles published between 1998 and 2017 were included. Three thousand seventy-nine patients (mean age 34.28 ± 2.46) were included. Laparoscopic approach was the most employed (90.3%) followed by the open one (7.9%) and the robotic one (1.7%). Overall operative time was 238.47 ± 66.82. Conversion rate was 2.7%. In more than 80% of cases, associated procedures were performed. Intraoperative complications were observed in 1% of cases. The overall postoperative complications rate was 18.5% (571 patients), and the most frequent complication was recto-vaginal fistula (74 patients, 2.4%). Postoperative mortality rate was 0.03% and mean hospital stay was 8.88 ± 3.71 days. CONCLUSIONS Despite the large and extremely various number of associated procedures, rectosigmoid resection is a feasible and safe technique to treat endometriosis.
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Affiliation(s)
- Andrea Balla
- Department of General Surgery and Surgical Specialties "Paride Stefanini", Sapienza, University of Rome, Viale del Policlinico 155, 00161, Rome, Italy.
| | - Silvia Quaresima
- Department of General Surgery and Surgical Specialties "Paride Stefanini", Sapienza, University of Rome, Viale del Policlinico 155, 00161, Rome, Italy
| | - José D Subiela
- Department of Urology, Fundació Puigvert, Carrer de Cartegena 340, Universidad Autónoma de Barcelona, 08025, Barcelona, Spain
| | - Mostafa Shalaby
- Department of General Surgery, University of Rome "Tor Vergata", Viale Oxford 81, 00133, Rome, Italy
| | - Giuseppe Petrella
- Department of General Surgery, University of Rome "Tor Vergata", Viale Oxford 81, 00133, Rome, Italy
| | - Pierpaolo Sileri
- Department of General Surgery, University of Rome "Tor Vergata", Viale Oxford 81, 00133, Rome, Italy
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Vercellini P, Facchin F, Buggio L, Barbara G, Berlanda N, Frattaruolo MP, Somigliana E. Management of Endometriosis: Toward Value-Based, Cost-Effective, Affordable Care. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2018; 40:726-749.e10. [DOI: 10.1016/j.jogc.2017.07.011] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2017] [Accepted: 07/12/2017] [Indexed: 12/13/2022]
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14
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Ballester M, Roman H. [Surgical management of deep endometriosis with colorectal involvement: CNGOF-HAS Endometriosis Guidelines]. ACTA ACUST UNITED AC 2018. [PMID: 29534879 DOI: 10.1016/j.gofs.2018.02.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
Deep endometriosis with colorectal involvement is considered one of the most severe forms of the disease due to its impact on patients' quality of life and fertility but also by the difficulties encountered by the clinicians when proposing a therapeutic strategy. Although the literature is very rich, evidence based medicine remains poor explaining the great heterogeneity concerning the management of such patients. Surgery therefore remains a therapeutic option. It improves the intensity of gynecological, digestive and general symptoms and the quality of life. Concerning the surgical approach, it appears that laparoscopy should be the first option; the laparoscopic robot-assisted route can also be proposed. The techniques of rectal shaving, discoid resection and segmental resection are the three techniques used for surgical excision of colorectal endometriosis. The parameters taken into account for the use of either technique are: the surgeon's experience, the depth of infiltration of the lesion within the rectosigmoid wall, the lesion size and circumference, multifocality and the distance of the lesion from the anal margin. In the case of deep endometriosis with colorectal involvement, performing an incomplete surgery increases the rate of pain recurrence and decreases postoperative fertility. In case of surgery for colorectal endometriosis, pregnancy rates are similar to those obtained after ART in non-operated patients. Existing data are insufficient to formally recommend first line surgery or ART in infertile patients with colorectal endometriosis. The surgery for colorectal endometriosis exposes to a risk of postoperative complications and recurrence of which the patients should be informed preoperatively.
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Affiliation(s)
- M Ballester
- Service de gynécologie-obstétrique et médecine de la reproduction, CHU de Tenon, AP-HP, 4, rue de la Chine, 75020 Paris, France.
| | - H Roman
- Centre expert de diagnostic et prise en charge multidisciplinaire de l'endométriose, clinique gynécologique et obstétricale, CHU Charles-Nicolle, 1, rue de Germont, 76031 Rouen, France
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15
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Berlanda N, Frattaruolo MP, Aimi G, Farella M, Barbara G, Buggio L, Vercellini P. 'Money for nothing'. The role of robotic-assisted laparoscopy for the treatment of endometriosis. Reprod Biomed Online 2017. [PMID: 28624343 DOI: 10.1016/j.rbmo.2017.05.010] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Despite higher costs for robotic-assisted laparoscopy (RAL) than standard laparoscopy (SL), RAL treatment of endometriosis is performed without established indications. PubMed/MEDLINE was searched for 'robotic surgery' and 'endometriosis' or 'gynaecological benign disease' from January 2000 to December 2016. Full-length studies in English reporting original data were considered. Among 178 articles retrieved, 17 were eligible: 11 non-comparative (RAL only) and six comparative (RAL versus SL). Non-comparative studies included 445 patients. Mean operating time, blood loss and hospital stay were 226 min, 168 ml and 4 days. Major complications and laparotomy conversions were 3.1% and 1.3%. Eight studies reported pain improvement at 15-month follow-up. Comparative studies were all retrospective; 749 women underwent RAL and 705 SL. Operating time was longer for RAL in five studies. Major complications and laparotomy conversions for RAL and SL were 1.5% versus 0.3% and 0.3% versus 0.5%. One study reported pain reduction for RAL at 6-month follow-up. RAL treatment of endometriosis did not provide benefits over SL, overall and among subgroups of women with severe endometriosis, peritoneal endometriosis and obesity. Available evidence is low-quality, and data regarding long-term pain relief and pregnancy rates are lacking. RAL treatment of endometriosis should be performed only within controlled studies.
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Affiliation(s)
- Nicola Berlanda
- Unità Operativa Dipartimentale Ginecologia Chirurgica e Endometriosi, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico Ca' Granda Ospedale Maggiore Policlinico, Università degli Studi di Milano, Italy.
| | - Maria Pina Frattaruolo
- Unità Operativa Dipartimentale Ginecologia Chirurgica e Endometriosi, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico Ca' Granda Ospedale Maggiore Policlinico, Università degli Studi di Milano, Italy
| | - Giorgio Aimi
- Unità Operativa Dipartimentale Ginecologia Chirurgica e Endometriosi, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico Ca' Granda Ospedale Maggiore Policlinico, Università degli Studi di Milano, Italy
| | - Marilena Farella
- Unità Operativa Dipartimentale Ginecologia Chirurgica e Endometriosi, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico Ca' Granda Ospedale Maggiore Policlinico, Università degli Studi di Milano, Italy
| | - Giussy Barbara
- Unità Operativa Dipartimentale Ginecologia Chirurgica e Endometriosi, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico Ca' Granda Ospedale Maggiore Policlinico, Università degli Studi di Milano, Italy
| | - Laura Buggio
- Unità Operativa Dipartimentale Ginecologia Chirurgica e Endometriosi, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico Ca' Granda Ospedale Maggiore Policlinico, Università degli Studi di Milano, Italy
| | - Paolo Vercellini
- Unità Operativa Dipartimentale Ginecologia Chirurgica e Endometriosi, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico Ca' Granda Ospedale Maggiore Policlinico, Università degli Studi di Milano, Italy
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16
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Prodromidou A, Pergialiotis V, Pavlakis K, Korou LM, Frountzas M, Dimitroulis D, Vaos G, Perrea DN. A Novel Experimental Model of Colorectal Endometriosis. J INVEST SURG 2017; 31:275-281. [DOI: 10.1080/08941939.2017.1317374] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Affiliation(s)
- Anastasia Prodromidou
- Laboratory of Experimental Surgery and Surgical Research N.S. Christeas, National and Kapodistrian University of Athens, Athens, Greece
| | - Vasilios Pergialiotis
- Laboratory of Experimental Surgery and Surgical Research N.S. Christeas, National and Kapodistrian University of Athens, Athens, Greece
| | - Kitty Pavlakis
- Department of Pathology, National and Kapodistrian University of Athens, Athens, Greece
| | - Laskarina Maria Korou
- Laboratory of Experimental Surgery and Surgical Research N.S. Christeas, National and Kapodistrian University of Athens, Athens, Greece
| | - Maximos Frountzas
- Laboratory of Experimental Surgery and Surgical Research N.S. Christeas, National and Kapodistrian University of Athens, Athens, Greece
| | - Dimitrios Dimitroulis
- Second Department of Surgery, Laiko Univesity Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Georgios Vaos
- Laboratory of Experimental Surgery and Surgical Research N.S. Christeas, National and Kapodistrian University of Athens, Athens, Greece
- Department of Paediatric Surgery, “ATTIKON” University General Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Despina N. Perrea
- Laboratory of Experimental Surgery and Surgical Research N.S. Christeas, National and Kapodistrian University of Athens, Athens, Greece
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17
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Robotic-assisted laparoscopy in reproductive surgery: a contemporary review. J Robot Surg 2017; 11:97-109. [PMID: 28194637 DOI: 10.1007/s11701-017-0682-4] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2016] [Accepted: 02/03/2017] [Indexed: 10/20/2022]
Abstract
Robotic surgery is a conceptual fusion of the conventional open surgery and the minimally invasive laparoscopic surgery. We reviewed the current role of robotic-assisted laparoscopy in the field of reproductive surgery by a literature search in PubMed database. We analyzed the reported advantages and limitations of the use of robotics in reproductive surgeries like myomectomy, tubal reanastomosis, endometriosis, ovarian tissue cryopreservation, and ovarian transposition. Overall, robotic assistance in reproductive surgery resulted in decreased blood loss, less post-operative pain, shorter hospital stay, and faster convalescence, whereas reproductive outcomes were similar to open/laparoscopic approaches. The main drawbacks of robotic surgery were higher cost and longer operating times. It is as safe and effective as the conventional laparoscopy and represents a reasonable alternate to abdominal approach. Procedures that are technically challenging with the conventional laparoscopy can be performed with robotic assistance. It has advantages of improved visualization and Endowrist™ movements allowing precise suturing. This helps to overcome the limitations of laparoscopy, especially in complicated procedures, and may shorten the steep learning curve in minimal invasive surgery. Randomized controlled trials looking at both short- and long-term outcomes are warranted to strengthen the role of robotic surgery in the field of reproductive surgery.
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18
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Daraï E, Cohen J, Ballester M. Colorectal endometriosis and fertility. Eur J Obstet Gynecol Reprod Biol 2017; 209:86-94. [DOI: 10.1016/j.ejogrb.2016.05.024] [Citation(s) in RCA: 53] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2016] [Revised: 05/03/2016] [Accepted: 05/13/2016] [Indexed: 02/08/2023]
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19
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Arian SE, Munoz JL, Kim S, Falcone T. Robot-assisted laparoscopic myomectomy: current status. ROBOTIC SURGERY : RESEARCH AND REVIEWS 2017; 4:7-18. [PMID: 30697559 PMCID: PMC6193424 DOI: 10.2147/rsrr.s102743] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Robotic-assisted surgery has seen a rapid development and integration in the field of gynecology. Since the approval of the use of robot for gynecological surgery and considering its several advantages over conventional laparoscopy, it has been widely incorporated especially in the field of reproductive surgery. Uterine fibroids are the most common benign tumors of the female reproductive tract. Many reproductive-aged women with this condition demand uterine-sparing surgery to preserve their fertility. Myomectomy, the surgical excision of uterine fibroids, remains the only surgical management option for fibroids that entails preservation of fertility. In this review, we focus on the role of robotic-assisted laparoscopic myomectomy and its current status, in comparison with other alternative approaches for myomectomy, including open, hysteroscopic, and traditional laparoscopic techniques. Several different surgical techniques have been demonstrated for robotic myomectomy. This review endeavors to share and describe our surgical experience of using the standard laparoscopic equipment for robotic-assisted myomectomy, together with the da Vinci Robot system. For the ideal surgical candidate, robotic-assisted myomectomy is a safe minimally invasive surgical procedure that can be offered as an alternative to open surgery. The advantages of using the robot system compared to open myomectomy include a shorter length of hospital stay, less postoperative pain and analgesic use, faster return to normal activities, more rapid return of the bowel function, and enhanced cosmetic results due to smaller skin incision sizes. Some of the disadvantages of this technique include high costs of the robotic surgical system and equipment, the steep learning curve of this novel system, and prolonged operative and anesthesia times. Robotic technology is a novel and innovative minimally invasive approach with demonstrated feasibility in gynecological and reproductive surgery. This technology is expected to take the lead in gynecological surgery in the upcoming decade.
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Affiliation(s)
- Sara E Arian
- Department of Obstetrics, Gynecology, and Women's Health Institute, Cleveland Clinic, Cleveland, OH, USA,
| | - Jessian L Munoz
- Department of Obstetrics, Gynecology, and Women's Health Institute, Cleveland Clinic, Cleveland, OH, USA,
| | - Suejin Kim
- Department of Obstetrics, Gynecology, and Women's Health Institute, Cleveland Clinic, Cleveland, OH, USA,
| | - Tommaso Falcone
- Department of Obstetrics, Gynecology, and Women's Health Institute, Cleveland Clinic, Cleveland, OH, USA,
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20
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Management of deep infiltrating endometriosis by laparoscopic route with robotic assistance: 3-year experience. J Gynecol Obstet Hum Reprod 2017; 46:9-18. [DOI: 10.1016/j.jgyn.2015.12.003] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2015] [Revised: 11/24/2015] [Accepted: 12/17/2015] [Indexed: 11/20/2022]
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21
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Robot-assisted surgery for the radical treatment of deep infiltrating endometriosis with colorectal involvement: short- and mid-term surgical and functional outcomes. Int J Colorectal Dis 2016; 31:643-52. [PMID: 26686873 DOI: 10.1007/s00384-015-2477-2] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/14/2015] [Indexed: 02/05/2023]
Abstract
PURPOSE Sexual and urinary dysfunctions are complications in radical treatment of deep infiltrating endometriosis (DIE) with colorectal involvement. The aim of this article is to report the preliminary results of our single-institution experience with robotic treatment of DIE, evaluating intraoperative and postoperative surgical outcomes and focusing on the impact of this surgical approach on autonomic functions such as urogenital preservation and sexual well-being. METHODS From January 2011 through December 2013, a case series of 10 patients underwent robotic radical treatment of DIE with colorectal resection using the da Vinci System. Surgical data were evaluated, together with perioperative urinary and sexual function as assessed by means of self-administered validated questionnaires. RESULTS None of the patients reported significant postoperative complications. Questionnaires concerning sexual well-being, urinary function, and impact of symptoms on quality of life demonstrated a slight worsening of all parameters 1 month after surgery, while data were comparable to the preoperative period 1 year after surgery. Dyspareunia was the only exception, as it was significantly improved 12 months after surgery. CONCLUSIONS Robot-assisted surgery seems to be advantageous in highly complicated procedures where extensive dissection and proper anatomy re-establishment is required, as in DIE with colorectal involvement. Our preliminary results show that robot-assisted surgery could be associated with a low risk of complications and provide good preservation of urinary function and sexual well-being.
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22
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Jeelani S, Dany A, Anand B, Vandana S, Maheswaran T, Rajkumar E. Robotics and medicine: A scientific rainbow in hospital. J Pharm Bioallied Sci 2015; 7:S381-3. [PMID: 26538882 PMCID: PMC4606624 DOI: 10.4103/0975-7406.163460] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
The journey of robotics is a real wonder and astonishingly can be considered as a scientific rainbow showering surprising priceless power in the era of future technologies. The astonishing seven technologies discussed in this paper are da Vinci Robotic surgical system and sperm sorters for infertility, Veebot for blood investigation, Hanako the robotic dental patient for simulating the dental patient and helping a trainee dentist, RP-7 robot who is around-the-clock physician connecting the physician and patient, Robot for Interactive Body Assistance (RIBA) who is a RIBA serving as a nurse, Bushbot serving as a brilliant surgeon, and Virtibot helping in virtual autopsy. Thus, robotics in medicine is a budding field contributing a great lot to human life from before birth to afterlife in seven forms thus gracefully portraying a scientific rainbow in hospital environment.
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Affiliation(s)
- S Jeelani
- Department of Oral Medicine and Radiology, Indira Gandhi Institute of Dental Sciences, SBVU, Puducherry, India
| | - A Dany
- Department of Oral Medicine and Radiology, Sri Aurobindo College of Dentistry, Indore, Madhya Pradesh, India
| | - B Anand
- Department of Oral Medicine and Radiology, Ragas Dental College and Hospital, Chennai, India
| | - S Vandana
- Department of Oral Medicine and Radiology, Indira Gandhi Institute of Dental Sciences, SBVU, Puducherry, India
| | - T Maheswaran
- Department of Oral Pathology, Vivekanandha Dental College for Women, Tiruchengode, Namakkal, Tamil Nadu, India
| | - E Rajkumar
- Department of Prosthodontics and Crown and Bridge, Indira Gandhi Institute of Dental Sciences, SBVU, Puducherry, India
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23
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Pellegrino A, Damiani GR, Trio C, Faccioli P, Croce P, Tagliabue F, Dainese E. Robotic Shaving Technique in 25 Patients Affected by Deep Infiltrating Endometriosis of the Rectovaginal Space. J Minim Invasive Gynecol 2015; 22:1287-92. [DOI: 10.1016/j.jmig.2015.06.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2015] [Revised: 06/02/2015] [Accepted: 06/03/2015] [Indexed: 10/23/2022]
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24
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Computer-assisted reproductive surgery: why it matters to reproductive endocrinology and infertility subspecialists. Fertil Steril 2014; 102:911-21. [DOI: 10.1016/j.fertnstert.2014.08.028] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2014] [Revised: 08/24/2014] [Accepted: 08/25/2014] [Indexed: 11/18/2022]
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25
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Vercellini P, Consonni D, Barbara G, Buggio L, Frattaruolo MP, Somigliana E. Adenomyosis and reproductive performance after surgery for rectovaginal and colorectal endometriosis: a systematic review and meta-analysis. Reprod Biomed Online 2014; 28:704-13. [DOI: 10.1016/j.rbmo.2014.02.006] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2013] [Revised: 02/05/2014] [Accepted: 02/05/2014] [Indexed: 02/03/2023]
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