Robot-assisted Laparoscopy Research Articles

Evolution Of Robot Assisted Pancreatico-Duodenectomy Over 7-years, Where Do We Stand?

Background: Robot-assisted laparoscopy was introduced more than 20 years ago and its adaptation in the field of pancreatic surgery is still evolving due to technical challenges. The aim of this study is to analyze the progress of robot-assisted pancreatico-duodenectomy (R-PD) in the U.S over 7 years to help optimize the development and adaptation of this challenging procedure.

Does Obesity Forbid Robotic Gynecological Surgeries? An Urban Legend.

Introduction: Obesity is a worldwide problem that considered to be a challenge in optimal surgical management. A breakthrough in the technologies of minimal invasive surgery over the last ten years has turned robotic approach into the widespread method for surgical management of obese population. Aim: In this study we emphasize the benefits of the robotic assisted laparoscopy versus open laparotomy and conventional laparoscopy in obese women with gynecological disorders. Methods: We conducted a single center experience retrospective study of obese women (BMI 30 Kg/m2) that underwent robotic assisted gynecologic procedures from January 2020 till January 2023. "Iavazzo" score was used in order to predict preoperatively the feasibility of robotic approach as well as the overall operative time. The perioperative management a well as the postoperative course of obese patients were documented and analyzed. Results: 93 obese women underwent robotic surgical management for benign and malignant gynecological disorders. 62 of these women had BMI between 30 and 35 kg/m2 and 31 had BMI 35 kg/m2. None of them was converted into laparotomy. All of the patients had a smooth postoperative course without any complications and were discharged at the first postoperative day. Mean operative time was 150 min. Conclusions: Our 3-year experience in robotic-assisted gynecologic surgery in obese patients has revealed numerous benefits concerning perioperative management and postoperative rehabilitation.

Robot-assisted laparoscopic extravesical ureteral reimplantation (RALUR-EV): a narrative review.

In the last two decades, the treatment of vesicoureteral reflux (VUR) benefits from the introduction of robot-assisted laparoscopy surgery in pediatric population. This article aims to review the advantages of robot-assisted laparoscopic extravesical ureteral reimplantation (RALUR-EV) in pediatric patients with VUR and provides an update on surgical outcomes. A literature search of PubMed and MEDLINE databases was conducted. All the articles, published between 2010 and 2022, describing clinical outcomes of patients with VUR after treatment with RALUR-EV, were considered to be relevant for the purpose of the study. The results were synthetized as a narrative review. Twenty-one studies were included. Of them, 19 (90.5%) presented a retrospective design. These articles involved 1,321 children and 1,914 ureters who underwent RALUR-EV. The mean age at the procedure was 6 years, and the mean follow-up length was 20.4 months. The overall success rate of surgery was 92.2% for patients and 90.9% per ureter. The mean operational time was 175.4 minutes for unilateral reimplantation and 200.3 minutes for bilateral reimplantation. The mean length of stay was 1.9 days. The article discusses the adoption of RALUR-EV, its advantages, the heterogeneity of study protocols, and the evolution of surgical techniques. It also highlights the need for standardized protocols and prospective studies to further understand the advantages of RALUR-EV.

Retracted: Application Effect of Robot-Assisted Laparoscopy in Hepatectomy for Colorectal Cancer Patients with Liver Metastases.

[This retracts the article DOI: 10.1155/2022/5492943.].

From laparoscopic to robotic-assisted Heller myotomy for achalasia in a single high-volume visceral surgery center: postoperative outcomes and quality of life

BackgroundLaparoscopic (LSC) Heller myotomy (HM) is considered the standard procedure for the treatment of achalasia. Robotic platforms, established over the last years, provide important advantages to surgeons, such as binocular 3-dimensional vision and improvement of fine motor control. However, whether perioperative outcomes and long-term results of robotic-assisted laparoscopic (RAL) HM are similar or even superior to LSC technique, especially concerning long-term follow-up, is still debated. Therefore, the aim of the present study was to evaluate intra- and postoperative results as well as long-term quality of life after RAL compared to LSC surgery for achalasia in a single high-volume visceral surgery center.MethodsBetween August 2007 and April 2020, 43 patients undergoing minimally invasive HM for achalasia in a single high-volume Swiss visceral surgery center, were included in the present study. Intra- and postoperative outcome parameters were collected and evaluated, and a long-term follow-up was performed using the gastroesophageal-reflux disease health-related quality of life (GERD-Hr-QuoL) questionnaire.ResultsA total of 11 patients undergoing RAL and 32 undergoing LSC HM were analyzed. Baseline demographics and clinical characteristics were similar. A trend (p = 0.052) towards a higher number of patients with ASA III score treated with RAL was detectable. Operation time was marginally, but significantly, shorter in LSC (140 min, IQR: 136–150) than in RAL (150 min, IQR: 150–187, p = 0.047). Postoperative complications graded Clavien-Dindo ≥ 3 were only observed in one patient in each group. Length of hospital stay was similar in both groups (LSC: 11 days, IQR: 10–13 vs. RAL: 11 days, IQR: 10–14, p = 0.712). Long-term follow-up (LSC: median 89 months, vs. RAL: median 28 months, p = 0.001) showed comparable results and patients from both groups expressed similar levels of satisfaction (p = 0.181).ConclusionsLSC and RAL HM show similar peri- and postoperative results and a high quality of life, even in long-term (> 24 months) follow-up. Prospective, randomized, controlled multicenter trials are needed to overcome difficulties associated to small sample sizes in a rare condition and to confirm the equality or demonstrate the superiority of robotic-assisted procedures for achalasia. Meanwhile, the choice of the treatment technique could be left to the operating surgeon’s preferences.

8091 Robot-Assisted Laparoscopic Hysterectomy with Retroperitoneal Uterine Fibroid

<h3>Study Objective</h3> Demonstrate a Robot-Assisted Laparoscopic (RAL) Hysterectomy with a cul-de-sac uterine fibroid, and discuss the benefit of a RAL surgery in these procedures <h3>Design</h3> Narrated video of RAL hysterectomy and exeresis of retroperitoneal mass compatible with fibroid. <h3>Setting</h3> Surgery performed with the patient in lithotomy and Trendelenburg position. Robot was in left lateral pelvic angle. <h3>Patients or Participants</h3> Female, 50 years old, previously diagnosed with fibroid for 8 years. Patient experienced pelvic pain, hypermenorrhea, constipation, and other compressive symptoms. The latter persisted after menopause, with no significant mass reduction. Ultrasound described a 76cc uterus with a solid formation along right lateral uterine wall measuring 12 × 9.4 × 9.3cm. Clinical examination revealed a palpable uterus 3 cm above pubic symphysis, endorsed by imaging findings. <h3>Interventions</h3> Identified a 15cm mobile tumor, suggestive of fibroids in retro uterine region, adhered to the right ovarian fossa with lateralization of the rectum. Ureterolysis was performed and the mass released from the ovarian fossa to the peritoneal reflection of the rectum and uterine torus, aiming the removal of the fibroid en bloc during hysterectomy. <h3>Measurements and Main Results</h3> Operation time was three hours. Patient was early discharged from the hospital, on the first post-operative day with excellent pain control. She evolved without complications during follow-up, being fully discharged with complete symptom improvement. <h3>Conclusion</h3> Minimally invasive surgery has become the standard of therapy for an extensive number of gynecological diseases especially for patients with benign afflictions. Despite most studies proving absence of benefits with RAL when compared to Conventional Laparoscopy, in specific cases, especially when analyzing abnormal form uteri due to myomas, some studies have shown benefit in performing RAL. Increasing accuracy, flexibility and ergonomics can improve results and lead to easier bleeding control as observed in the presented case.

What Do Women Want? Hysterectomy

<h3>Study Objective</h3> We set out to explore patients' perceptions regarding hysterectomy. <h3>Design</h3> A nationwide quantitative survey study. <h3>Setting</h3> USA-based patient-filled online survey. <h3>Patients or Participants</h3> Women expecting a hysterectomy (preoperative group) or who had a hysterectomy in the past ten years (postoperative group) were recruited via an online banner. <h3>Interventions</h3> N/A. <h3>Measurements and Main Results</h3> 296 preoperative and 130 postoperative patients completed a survey regarding their perceptions on hysterectomy, sources of information, preferred surgical approach, personal view of surgical outcomes and complications, and their considerations when choosing a surgeon. Most participants were 45-64-year-old (55.74%, 69.23%; preoperative and postoperative, respectively). The most frequent surgical approach was laparoscopic (43%, 37%) followed by robotic (7%, 21%), abdominal (18%, 24%), and vaginal (21%, 18%). Most patients didn't seek a second opinion (38%, 52%) or received a second opinion that didn't change their plan (18%, 34%). The most important surgical outcomes in both groups were a low complication rate (47.6%), short recovery time (24.2%), and low postoperative pain (25.6%). The importance of the abdominal scar decreased with age. Postoperative pain was more important preoperatively, whereases recovery time was more appreciated postoperatively. When choosing a surgeon, the most notable factors are the surgeon's experience, insurance and out-of-pocket costs, and recommendations from other providers. The patients' favorite approach is robotic-assisted laparoscopy (44.9%, 56.9%) compared with vaginal (35.14%) and abdominal approach (19.9%). <h3>Conclusion</h3> Hysterectomy is the most common non-obstetrical surgical procedure for women in the United States. However, very few evidence-based studies include patient-centered data. Patients' perspectives and goals may differ from the clinical definition of a favorable surgical outcome. This is the first large-scale nationwide quantitive survey study, without interviewer mediation, to describe patients' perceptions of hysterectomy. We describe a preference for the robotic approach and prioritization of low complication rate, fast recovery time, and low postoperative pain. Additional large-scale patient-centered studies are required to confirm and generalize these results.

Diagnosis and Treatment of Vesico-Peritoneal Fistula after Robotic Surgical Treatment of Deep Endometriosis

<h3>Study Objective</h3> Demonstrate the diagnosis and surgical treatment of vesico-peritoneal fistula after robotic surgical treatment of deep endometriosis. <h3>Design</h3> Case report illustrated with a video. <h3>Setting</h3> Patient is placed in the semi-gynecological position on both surgical approaches. <h3>Patients or Participants</h3> A 38-year-old woman reports right iliac fossa pain, dysuria, and deep dyspareunia for 4 years. A 3 cm hard and painful nodule was palpable in the right iliac region of abdominal wall. MRI shows a 3.0 × 1.4 × 1.3 cm retrocervical lesion and irregular thickening of the uterosacral ligament insertion, suggestive of deep endometriosis. A 2.7 cm endometrioma on left ovary. And a 6 × 3 × 1.5 cm intramuscular nodule on the inferior abdominal aspect that affects virtually the entire muscle thickness. <h3>Interventions</h3> Robotic-assisted laparoscopic resection of pelvic endometriosis and abdominal wall nodules, with abdominal mesh placement. On the 7th postoperative day, the patient developed acute abdominal pain due to abdominal wall abscess and bladder catheter mechanical obstruction. Collection drainage was US-guided, but patient kept having recurrent urinary tract infections. CT showed a fistulous path communicating the bladder dome and the extraperitoneal space, and cystoscopy confirmed the fistula. Robotic-assisted laparoscopy was performed, Retzius space was developed for better exposure of the bladder and fistulous tract, with subsequent resection of the fistula and partial cystectomy with resection of the necrotic segment and part of synthetic mesh. <h3>Measurements and Main Results</h3> We obtained efficient diagnosis and treatment. The patient had complete resolution of the symptoms. <h3>Conclusion</h3> Vesico peritoneal fistula is a rare entity of epithelialized communication between peritoneal cavity and bladder, and it is usually associated with postoperative complications. As it has no specific symptoms, diagnosis is difficult.

Institutional Trends in Hysterectomy Volume and Route of Surgery

<h3>Study Objective</h3> To report the trends in hysterectomy volume and route of surgery at a single tertiary-care institution as the overall surgical landscape has shifted towards minimally invasive surgery. <h3>Design</h3> Retrospective cohort study. <h3>Setting</h3> Large academic medical center and affiliated community hospital. <h3>Patients or Participants</h3> All patients who underwent hysterectomy for benign and malignant indications between January 2010 and August 2021. <h3>Interventions</h3> N/A. <h3>Measurements and Main Results</h3> During the study period, there were 4722 hysterectomies performed at our institution: 4059 total (86%) and 663 supracervical (14%). Hysterectomy volume rose steadily from 2010 (306 annual cases), peaked in 2016 (483 annual cases), and remained relatively stable through 2021. The laparoscopic approach (conventional laparoscopic, robotic, and laparoscopic-assisted vaginal hysterectomy) was the most common route of hysterectomy overall (59.3%, n=2799), followed by abdominal (30.2%, n=1425) and vaginal (10.5%, n=498) (P < .0001). Among the laparoscopic hysterectomies, there were 1546 robot-assisted laparoscopic hysterectomies (32.7%), 1097 conventional laparoscopic hysterectomies (23.2%), and 156 laparoscopic-assisted vaginal hysterectomies (3.3%). The distribution of route of hysterectomy changed from 2010 (44.8% abdominal, 41.2% laparoscopic, 14.1% vaginal) to 2021 (22.6% abdominal, 66.1% laparoscopic, 11.3% vaginal) (P < .0001). While abdominal hysterectomies constituted the largest proportion of cases in the beginning of our study period, the proportion dropped substantially by the end. Most notably, robot-assisted hysterectomies had the greatest increase from 6.2% of cases in 2010 to 41.1% of cases in 2021, while conventional laparoscopic hysterectomies slightly increased from 21.6% of cases to 24.3%, and vaginal hysterectomies slightly decreased from 14.1% to 11.3%. <h3>Conclusion</h3> There has been a large shift towards laparoscopic hysterectomies in the last 10 years, with the most substantial increase in robot-assisted laparoscopy. This trend reflects the increasing popularity of minimally invasive surgery in the gynecology field as a whole.

Temporary Occlusion of the Uterine Artery at the Origin Using Titanium Clips for Laparoscopic Myomectomy

<h3>Study Objective</h3> To demonstrate retroperitoneal dissection to skeletonize and temporarily occlude the uterine arteries at the origin using titanium clips at the time of a laparoscopic myomectomy and to demonstrate simulation of clip application and removal. <h3>Design</h3> N/A. <h3>Setting</h3> Robotic-assisted pelvic laparoscopy. <h3>Patients or Participants</h3> Patient with large fibroid uterus undergoing myomectomy. <h3>Interventions</h3> Placement of titanium clips on the uterine arteries at the origin. <h3>Measurements and Main Results</h3> Minimization of blood loss at the time of myomectomy. <h3>Conclusion</h3> Temporary occlusion of the uterine arteries at the origin with titanium clips can be used to minimize blood loss at the time of laparoscopic myomectomy and other laparoscopic pelvic and uterine surgeries where high blood loss is expected or for patients with a low starting hemoglobin or other pertinent medical co-morbidities.

Robotic-Assisted Resection of Pelvic Arteriovenous Malformation Utilising Intraoperative Video Angiography with Indocyanine Green

<h3>Study Objective</h3> Surgical resection of pelvic arteriovenous malformations (AVM) can be challenging, and pre-operative imaging may not clearly identify feeding vessels. We describe a case of pelvic AVM in a young woman and demonstrate the robotic surgical resection utilising video angiography with indocyanine green (ICG). <h3>Design</h3> Case report and surgical video. <h3>Setting</h3> Four-arm robotic assisted laparoscopy. <h3>Patients or Participants</h3> A nullipara with pelvic AVM. <h3>Interventions</h3> Robotic-assisted resection of pelvic AVM guided by intraoperative ICG angiography. <h3>Measurements and Main Results</h3> A 22-year-old woman presented with progressively worsening left pelvic pain. Pelvic ultrasound demonstrated a 7cm left adnexal vascular mass and magnetic resonance angiogram confirmed a left pelvic AVM. The patient was counselled regarding the risks of embolization versus surgery and decided on the latter. Using a robotic surgical system, the left pelvic side wall was opened at the pelvic brim and careful dissection of the retroperitoneal alveolar tissue was performed. 3mL of a 2.5mg/mL solution of ICG was injected peripherally, followed by 10mL bolus of normal saline. Using the near infra-red imaging of the robotic system, the ICG demonstrates small efferent vessels arising from the left ovarian vessels and a large vein communicating with the left external iliac vein. Vascular clips were applied to the aberrant vein prior to ligation. The AVM was carefully dissected away from the surrounding tissues, with use of bipolar diathermy for coagulation of smaller vessels. A further dose of ICG was injected after resection to ensure haemostasis and to confirm the perfusion of remaining organs. Mesosalpinx and pelvic side wall peritoneum were closed with 2-0 barbed suture. The patient was discharged the following day with complete resolution of left pelvic pain and normal pelvic ultrasound scan 6 weeks later. <h3>Conclusion</h3> Robotic surgical resection of pelvic AVM is enhanced with guidance from intraoperative ICG video angiography to ensure haemostasis and complete excision.

Surgical Management of Endometriosis of the Bladder and Ureter

<h3>Study Objective</h3> To demonstrate a step-by-step approach for the surgical management of urinary tract endometriosis using conventional laparoscopy for partial cystectomy and robotic-assisted laparoscopy for ureteroneocystostomy. <h3>Design</h3> Surgical video. <h3>Setting</h3> Academic tertiary referral center for endometriosis. <h3>Patients or Participants</h3> The first patient was a 38-year-old G3P3 with a history of hysterectomy presenting with dysuria had an MRI which revealed a T2 hypointense bladder nodule consistent with endometriosis. The second patient was a 25-year-old nulliparous woman with history of stage IV endometriosis with DIE into the bowel and both ureters causing subsequent hydronephrosis requiring bilateral ureteral stents and subsequently bilateral percutaneous nephrostomy tubes. <h3>Interventions</h3> In the first case, a cystoscopy was performed to confirm MRI findings of bladder lesion and to delineate borders and depth of invasion. Conventional laparoscopy was utilized to perform bilateral ureterolysis, bladder mobilization, partial cystectomy for complete excision of the lesion, and two-layered bladder closure. Use of indigo carmine assisted with ureteral orifice identification. In the second case, cystoscopy was performed with injection of ICG to assist with ureteral identification. After ureterolysis, distal ureteric obstruction due to extensive disease was confirmed on laparoscopy and ureteroscopy. Bilateral ureteroneocystostomy with placement of Double-J ureteral stents was performed using a robotic-assisted approach. Each patient had indwelling foley catheter for bladder decompression during recovery. <h3>Measurements and Main Results</h3> Both patients had an uneventful postoperative course. A postoperative retrograde cystogram confirmed adequate repair prior to removal of each foley catheter. Patient two had office stent removal 6 weeks postoperative. <h3>Conclusion</h3> Endometriosis is an increasingly common condition. It is important for gynecological surgeons to have the proper understanding of anatomy, surgical technique, and multidisciplinary care needed with urology for safe and complete excision of bladder and ureter endometriosis.

Robotic Assisted Laparoscopic Excision of a Placenta Percreta

<h3>Study Objective</h3> To illustrate the steps of a robotic-assisted laparoscopic excision of a placenta percreta. <h3>Design</h3> Placenta accreta spectrum (PAS) is a group of disorders characterized by various degrees of placental invasion through the myometrium and uterine serosa. Incidence has increased in recent years following the increase in cesarean deliveries. Risk factors include previous uterine surgeries, multiple cesarean deliveries and the presence of placenta previa. Ultrasound is the primary diagnostic modality. Most PAS cases are diagnosed in the second trimester, and guidelines for early recognition are sparse. A cesarean hysterectomy is the mainstay of management. This video shows an alternative, fertility-sparing treatment for PAS when diagnosed early. <h3>Setting</h3> The video displays a patient in the operating room in the supine position, with Trendelenburg positioning and a bedside assist for robotic-assisted laparoscopy. <h3>Patients or Participants</h3> We present a case of a 32-year-old G5P1121 with a history of one prior cesarean section and a dilation and curettage who was had early imaging concerning for CS scar ectopic and placenta accreta spectrum. <h3>Interventions</h3> The patient was counseled on termination of pregnancy and given her desire for fertility, counseled on attempted resection of invading pregnancy with uterine repair. <h3>Measurements and Main Results</h3> Key surgical steps illustrated include the following: 1. Lysis of adhesions and separation of bladder 2. Identification of the borders of the pregnancy 3. Injection of vasopressin 4. Laparoscopic guided suction dilation and curettage 5. Dissection invading pregnancy 6. Circumferential resection of the invading pregnancy 7. Full thickness myometrial closure in multiple layers <h3>Conclusion</h3> Early diagnosis of placenta accreta spectrum provides options for alternative fertility-sparing treatment.

The transferability of laparoscopic and open surgical skills to robotic surgery

BackgroundWithin the last decades, robotic surgery has gained popularity. Most robotic surgeons have changed their main surgical activity from open or laparoscopic without prior formal robotic training. With the current practice, it is of great interest to know whether there is a transfer of surgical skills. In visualization, motion scaling, and freedom of motion, robotic surgery resembles open surgery far more than laparoscopic surgery. Therefore, our hypothesis is that open-trained surgeons have more transfer of surgical skills to robotic surgery, compared to surgeons trained in laparoscopy.MethodsThirty-six surgically inexperienced medical students were randomized into three groups for intensive simulation training in an assigned modality: open surgery, laparoscopy, or robot-assisted laparoscopy. The training period was, for all study subjects, followed by performing a robot-assisted bowel anastomosis in a pig model. As surrogate markers of surgical quality, the anastomoses were tested for resistance to pressure, and video recordings of the procedure were evaluated by two blinded expert robotic surgeons, using a global rating scale of robotic operative performance (Global Evaluative Assessment of Robotic Skills (GEARS)).ResultsThe mean leak pressure of bowel anastomosis was 36.25 (7.62–64.89) mmHg in the laparoscopic training group and 69.01 (28.02–109.99) mmHg in the open surgery group, and the mean leak pressure for the robotic training group was 108.45 (74.96–141.94) mmHg. The same pattern was found with GEARS as surrogate markers of surgical quality. GEARS score was 15.71 (12.37–19.04) in the laparoscopic training group, 18.14 (14.70–21.58) in the open surgery group, and 22.04 (19.29–24.79) in the robotic training group. In comparison with the laparoscopic training group, the robotic training group had a statistically higher leak pressure (p = 0.0015) and GEARS score (p = 0.0023). No significant difference, for neither leak pressure nor GEARS, between the open and the robotic training group.ConclusionIn our study, training in open surgery was superior to training in laparoscopy when transitioning to robotic surgery in a simulation setting performed by surgically naive study subjects.

Shared decision-making in opioid prescribing for minimally invasive hysterectomy: A prospective randomized controlled trial.

To determine the impact of shared decision-making in postsurgical opioid prescribing in women who underwent minimally invasive (MIS) hysterectomy. A randomized controlled trial. A single, tertiary care, academic center. From January 2019 through April 2020, 73 women aged 18 years and older who had a planned MIS hysterectomy with the Department of Gynecology were enrolled into the study (36 in the standard arm and 37 in the patient-directed arm). Participants were assigned either to the standard arm (30 tablets) or patient-directed arm (0-30 tablets) of oxycodone 5 mg. The primary outcome was the percentage of excess opioid tablets, calculated by the number of unused tablets divided by the number of tablets prescribed. Secondary outcomes included total opioid tablets used, frequency of obtaining additional opioid tablets after discharge, frequency of unscheduled post-operative visits, and patient satisfaction with number of opioid tablets prescribed. Age, race, and body mass index did not differ between groups. Hysterectomies were performed via laparoscopy (16.9 percent), robotic-assisted laparoscopy (38.5 percent), and vaginal routes (44.6 percent). The median (IQR) number of oxycodone prescribed in the patient-directed arm was 15.0 (12.0 and 24.0) tablets. The standard arm had a greater percentage of excess oxycodone tablets 73.6 percent (0.03) than the patient-directed arm 56.3 percent (0.03, p < .01). However, there was no difference in the total number of oxycodone used by patients in the standard (mean 7.9 [0.5] tablets) and patient-directed arms (mean 8.4 [0.5] tablets, p = .50). The mean number of oxycodone used for the entire cohort was 8.1 (0.4) tablets. Shared decision-making significantly decreased the percent of excess oxycodone tablets but did not decrease the total number of oxycodone tablets used in patients undergoing MIS hysterectomy. Patients used about 22 tablets less than the standard 30 tablets prescribed.

Assessing the accuracy of [18F]PSMA-1007 PET/CT for primary staging of lymph node metastases in intermediate- and high-risk prostate cancer patients

Background[18F]PSMA-1007 is a promising tracer for integrated positron emission tomography and computed tomography (PET/CT).ObjectiveOur aim was to assess the diagnostic accuracy of [18F]PSMA-1007 PET/CT for primary staging of lymph node metastasis before robotic-assisted laparoscopy (RALP) with extended lymph node dissection (ePLND).Design, Setting and ParticipantsThe study was a retrospective cohort in a tertiary referral center. Men with prostate cancer that underwent surgical treatment for intermediate- or high-risk prostate cancer between May 2019 and August 2021 were included.Interventions[18F]PSMA-1007 PET/CT for initial staging followed by RALP and ePLND.Outcome measurements and statistical analysesSensitivity and specificity were calculated both for the entire cohort and for patients with lymph node metastasis ≥ 3 mm. Positive (PPV) and negative (NPV) predictive values were calculated.Results and limitationsAmong 104 patients included in the analyses, 26 patients had lymph node metastasis based on pathology reporting and metastases were ≥ 3 mm in size in 13 of the cases (50%). In the entire cohort, the sensitivity and specificity of [18F]PSMA-1007 were 26.9% (95% confidence interval (CI); 11.6–47.8) and 96.2% (95% CI; 89.2–99.2), respectively. The sensitivity and specificity of [18F]PSMA-1007 to detect a lymph node metastasis ≥ 3 mm on PET/CT were 53.8% (95% CI; 25.1–80.8) and 96.7% (95% CI; 90.7–99.3), respectively. PPV was 70% and NPV 93.6%.ConclusionsIn primary staging of intermediate- and high-risk prostate cancer, [18F]PSMA-1007 PET/CT is highly specific for prediction of lymph node metastases, but the sensitivity for detection of metastases smaller than 3 mm is limited. Based on our results, [18F]PSMA-1007 PET/CT cannot completely replace ePLND.Patient summaryThis study investigated the use of an imaging method based on a prostate antigen-specific radiopharmaceutical tracer to detect lymph node prostate cancer metastasis. We found that it is unreliable to discover small metastasis.

Laparoscopic and robot-assisted suture versus mesh hysteropexy: a retrospective comparison

Introduction and hypothesisOur study was aimed at comparing the outcomes of laparoscopic and robot-assisted laparoscopic suture-based hysteropexy (SutureH) versus sacral hysteropexy using mesh (MeshH) for bothersome uterine prolapse. Our hypothesis is that MeshH is more successful and provides better uterine support than SutureH.MethodsA retrospective cohort study of 228 consecutive women who underwent re-suspension of the uterus using uterosacral ligaments (SutureH n=97) or a “U-shaped” mesh from the sacral promontory (MeshH, n=132). Surgery was performed by laparoscopy or robot-assisted laparoscopy. Subjects were assessed at baseline, 1 year, and beyond 1 year. The null hypothesis, that SutureH and MeshH have similar success, was based on a composite outcome (“composite success”), and that they provide the same level of uterine support, was based on POP-Q point C at 1 year. “Composite success” was defined as: POP-Q point C above the hymen; absence of a vaginal bulge; no repeat uterine prolapse surgery or pessary placement. Other outcomes included improvement in symptomology using Patient Global Impression of Improvement, POP-Q point C change and complications.ResultsFollow-up data were available for 191 out of 228 women. “Composite success” was not significantly different between MeshH and SutureH groups (81.7% vs 84.5%, p=0.616). MeshH provided better elevation of the uterus than SutureH (point C change: −7.38cm vs −6.99cm; p<0.001). Similar symptom improvement and low complications occurred in both groups.ConclusionsLaparoscopic and robot-assisted laparoscopic suture hysteropexy and mesh sacral hysteropexy provide women with minimally invasive, durable surgical options for uterine preservation. “Composite success” was similar in the two groups, but MeshH provided better uterine support than SutureH. However, SutureH gives women an effective mesh-free option.

Postoperative outcomes of minimally invasive adrenalectomy: do body mass index and tumor size matter? A single-center experience

BackgroundSince Gagner performed the first laparoscopic adrenalectomy in 1992, laparoscopy has become the gold-standard procedure in the treatment of adrenal surgical diseases. A review of the literature indicates that the rate of intra- and postoperative complications are not negligible. This study aims to describe the single-center experience of adrenalectomies; and explore the associations between body mass index (BMI) and tumor volume in main postoperative outcomes.MethodsRetrospective observational study with a prospective database in which we described patients who underwent adrenalectomy between January 2015 and December 2020. Operative time, intraoperative blood loss, conversion rate, complications, length of hospital stay, and comparison of the number of antihypertensive drugs used before and after surgery were analyzed. Analysis of BMI and tumor volume with postoperative outcomes such as anti-hypertensive change (AHC) in drug usage and pre-operative conditions were performed.ResultsForty-five adrenalectomies were performed, and all of them were carried out laparoscopically. Four were performed as a robot-assisted laparoscopy approach. Nineteen were women and 26 were men. Mean age was 54.9 ± 13.8 years. Mean tumor volume was 95.698 mm3 (3.75–1010.87). Mean operative time was shorter in right tumors (2.64 ± 0.75 h) than in left tumors (3.33 ± 2.73 h). Pearson correlation was performed to assess the relationship between BMI and AHC showing a direct relationship between increased BMI and higher change in anti-hypertensive drug usage at postoperative period r(45) = 0.92, p > 0.05 CI 95%. Higher tumor volume showed a longer operative time, r(45) = 0.6 (p = 0.000 CI 95%).ConclusionsObese patients could have an increased impact with surgery with an increased change in postoperative anti-hypertensive management. Tumor volume is associated with increased operative time and blood loss, our data suggest that it could be associated with increased rates of morbidity. However, further prospective studies with larger sample sizes are needed to validate our results.

Robotic surgery in gynaecology: Scientific Impact Paper No. 71 (July 2022).

The use of robotic-assisted keyhole surgery in gynaecology has expanded in recent years owing to technical advances. These include 3D viewing leading to improved depth perception, limitation of tremor, potential for greater precision and discrimination of tissues, a shorter learning curve and improved comfort for surgeons compared with conventional keyhole and open abdominal surgery. Robotic-assisted keyhole surgery, compared with conventional keyhole surgery, improves surgical performance without increasing operating time, minimises blood loss and intra- or postoperative complications, while reducing the need to revert to abdominal surgery. Moreover, surgeons using a robot experience fewer skeletomuscular problems of their own in the short and long term than those operating without a robot as an additional tool. This Scientific Impact Paper looks at the use of a robot in different fields of gynaecological surgery. A robot could be considered safe and a more effective surgical tool than conventional keyhole surgery for women who have to undergo complex gynaecology surgery or have associated medical issues such as body-mass index (BMI) at 30 kg/m2 or above or lung problems. The introduction of the use of robots in keyhole surgery has resulted in a decrease in the number of traditional open surgeries and the risk of conversion to open surgery after traditional keyhole surgery; both of which should be considered when examining the cost-benefit of using a robot. Limitations of robotic-assisted surgery remain the associated higher costs. In womb cancer surgery there is good evidence that introducing robotics into the service improves outcomes for women and may reduce costs.

Current situation and deliberating the application of open or minimally invasive surgery for the cervical cancer

Surgery is the primary treatment for early cervical cancer. Radical hysterectomy by laparotomy and minimally invasive surgery have been widely used for years. The results of the LACC study has overturned the clinical practice of the cervical cancer, and the radical hysterectomy by laparotomy is the only standard operation. Based on the studies of laparoscopy or robot-assisted laparoscopy comparing laparotomy for the risk factors of survival outcomes, as well as a series of methods for improving oncology outcomes, it suggests that the minimally invasive surgical approach in early cervical cancer should be reconsidered. Focusing on this topic, this paper discussed the risk factors that might affect the oncology outcome of minimally invasive surgery, and analyzed the surgical indications and recurrence patterns. Hence, to promote the standardized operation of "tumor-free" in the procedure of the minimally invasive surgery might be improve the patient survival outcomes.