Robotic-assisted Hysterectomy Research Articles

8281 Anterior Cul-De-Sac Obliteration: Dissection of a Difficult Bladder Flap

<h3>Study Objective</h3> This video highlights techniques for dissection of an obliterated anterior cul-de-sac in a patient undergoing hysterectomy. <h3>Design</h3> N/A. <h3>Setting</h3> This surgery was performed at a tertiary academic referral center. <h3>Patients or Participants</h3> This is a 56-year-old with history of 3 cesarean sections and a large central anterior fibroid who has failed medical management for abnormal uterine bleeding. <h3>Interventions</h3> The patient underwent a robotic-assisted hysterectomy with bilateral salpingo-oophorectomy. The fibroid was densely involved in adhesions to the bladder flap area. The colpotomy cup was not visible. The posterior leaf of the broad ligament was incised to skeletonize the uterine artery. This posterior approach helped show both the artery and the colpotomy cup. The anterior leaf of the left broad ligament was dissected. Filmy serosal attachments along the fibroid were taken down. This process was repeated on the right side. There were thick attachments near the adhesive band, and bleeding was encountered. To decrease the vascular supply to the uterus, bilateral uterine arteries were ligated. Subsequently, the band was taken down with minimal blood loss. This is typically the area of the thickest scar tissue. The surgeon can place an instrument inferior and lateral to the adhesions and create a tunnel to guide the dissection. We backfilled the bladder with sterile saline to clearly delineate the extent of the adhesions. Once the scar was incised, the bladder flap was further developed. The uterine arteries were separated and the colpotomy was completed. The vaginal cuff was closed, and the procedure was concluded. <h3>Measurements and Main Results</h3> The patient was seen for 3 years for medical management, and she opted for surgery due to ongoing symptoms. She was seen for a 6-week follow-up visit. <h3>Conclusion</h3> It is imperative to safely dissect the bladder away from the uterus in cases of anterior obliteration. Techniques include backfilling the bladder, approaching adhesions laterally and inferiorly, and de-vascularizing uterus.

Erosion of calcified uterine leiomyoma into the urinary bladder: A case report

Introduction: Uterine leiomyomas are benign smooth muscle tumors that affect approximately 70–80% of women worldwide. Erosion of leiomyomas into surrounding tissues is a rare complication. We present a case of a postmenopausal female with uterine leiomyoma eroding into the urinary bladder. Case Report: A 55-year-old, postmenopausal female with history of uterine fibroids previously treated with uterine artery embolization presented with recurrent bladder stones, hematuria, and pelvic pain. Pelvic magnetic resonance imaging described a 4.3 cm heterogenous mass involving the ventral uterine fundus and bladder dome concerning for malignancy. She underwent robotic-assisted total laparoscopic hysterectomy, right salpingo-oophorectomy, left salpingectomy, and partial bladder cystectomy. Pathology was significant for benign calcified leiomyoma and benign calcifications within the bladder mucosa. Conclusion: Erosion of leiomyoma through the bladder mucosa is rare complication but should be considered in the differential diagnosis for patients presenting with hypercalciuria and recurrent bladder stones in the setting of uterine fibroids previously treated with uterine artery embolization.

Radical Hysterectomy for Early Stage Cervical Cancer.

Radical hysterectomy and plus pelvic node dissection are the primary methods of treatment for patients with early stage cervical cancer. During the last decade, growing evidence has supported the adoption of a minimally invasive approach. Retrospective data suggested that minimally invasive surgery improves perioperative outcomes, without neglecting long-term oncologic outcomes. In 2018, the guidelines from the European Society of Gynaecological Oncology stated that a “minimally invasive approach is favored” in comparison with open surgery. However, the phase III, randomized Laparoscopic Approach to Cervical Cancer (LACC) trial questioned the safety of the minimally invasive approach. The LACC trial highlighted that the execution of minimally invasive radical hysterectomy correlates with an increased risk of recurrence and death. After its publication, other retrospective studies investigated this issue, with differing results. Recent evidence suggested that robotic-assisted surgery is not associated with an increased risk of worse oncologic outcomes. The phase III randomized Robotic-assisted Approach to Cervical Cancer (RACC) and the Robotic Versus Open Hysterectomy Surgery in Cervix Cancer (ROCC) trials will clarify the pros and cons of performing a robotic-assisted radical hysterectomy (with tumor containment before colpotomy) in early stage cervical cancer.

Utilization of lymph node evaluation at hysterectomy for cervical carcinoma in situ.

This study examined the utilization and characteristics of lymph node evaluation at hysterectomy for carcinoma in situ of the uterine cervix. This retrospective cohort study queried the Healthcare Cost and Utilization Project's National Inpatient Sample, evaluating 7395 patients with cervical carcinoma in situ who underwent hysterectomy from 2016 to 2019. A multivariable binary logistic regression model was fitted to identify independent characteristics related to lymph node evaluation. A classification-tree was constructed with recursive partitioning analysis to examine utilization patterns of lymph node evaluation. Lymph node evaluation at hysterectomy was performed in 4.6%. In amultivariable analysis, older age, higher income, use of robotic-assisted hysterectomy, and surgery at large bed capacity or urban teaching centers in the northeast US region were associated with increased likelihood of lymph node evaluation (all, p < 0.05). Of those independent factors, robotic-assisted surgery exhibited the largest effect size (adjusted odds ratio 3.23, 95% confidence interval 2.54-4.10). Utilization pattern analysis identified nine unique characteristics, of which robotic-assisted surgery was the primary indicator for cohort allocation (12.4% vs. 3.2%, p < 0.001). The difference between the lowest-highest patterns was 33.3% (range, 0%-33.3%). Lymph node evaluation was rarely performed for cervical carcinoma in situ overall and robotic surgery was associated with increased utilization of lymph node evaluation.

The RECOURSE study: Long-term oncologic outcomes associated with robotically-assisted minimally invasive hsyterectomy performed in patients with endometrial cancer: A meta-analysis (540)

Objectives: To compare long-term oncologic outcomes of robotic- assisted (ROBOT) procedures with laparoscopy (LAP) and laparo- tomic (OPEN) hysterectomy based on comparative studies in the published literature. Methods: A systematic literature review and meta-analysis for timedependent oncologic outcomes were conducted in accordance with the PRISMA statement, the Cochrane guidelines and registered with PROSPERO. PubMed, Scopus, and Embase databases were searched. Studies included those comparing robotic to non-robotic hysterectomy with 20 or more cases for each comparator from January 1, 2010, to September 1, 2020. Additionally, studies needed to report on hysterectomy for cancer, distinguish robotic from non-robotic cases, with a minimum follow-up of 12 months or more, and report at least one outcome of interest; disease-free/recurrence-free (DFS) or overall survival (OS). A hierarchical decision tree was developed to calculate and combine hazard ratios (HR) based on information available in each paper, maximizing the number of studies for consideration. Comparisons of long-term oncologic results for ROBOT versus OPEN and LAP were reported. Results: There were 6,477 unique references identified from initial search from which 19 studies were included based on an adjusted analysis of HRs with heterogeneity tests. The weighted HR for DFS for ROBOT (n=1152) versus LAP (n=1029) was 0.94 (95% CI: 0.71-1.26; p=0.68; I2=0%), and ROBOT (n=887) versus OPEN (n=1035) was 0.84 (95% CI: 0.64-1.11; p=0.22; I2=0%). The weighted HR for OS for ROBOT (n=4675) versus LAP (n=2643) was 0.98 (95% CI: 0.82-1.16; p=0.78; I2=0%) and ROBOT (n=27,647) versus OPEN (n=23,923) was 0.77 (95% CI: 0.71-0.83; p<0.0001; I2=18%). Conclusions: When compared with OPEN and LAP hysterectomy, ROBOT hysterectomy does not result in worse oncologic outcomes with respect to DFS and shows improved OS results compared to OPEN. The noted improved outcomes with ROBOT need further validation and investigation. Objectives: To compare long-term oncologic outcomes of robotic- assisted (ROBOT) procedures with laparoscopy (LAP) and laparo- tomic (OPEN) hysterectomy based on comparative studies in the published literature. Methods: A systematic literature review and meta-analysis for timedependent oncologic outcomes were conducted in accordance with the PRISMA statement, the Cochrane guidelines and registered with PROSPERO. PubMed, Scopus, and Embase databases were searched. Studies included those comparing robotic to non-robotic hysterectomy with 20 or more cases for each comparator from January 1, 2010, to September 1, 2020. Additionally, studies needed to report on hysterectomy for cancer, distinguish robotic from non-robotic cases, with a minimum follow-up of 12 months or more, and report at least one outcome of interest; disease-free/recurrence-free (DFS) or overall survival (OS). A hierarchical decision tree was developed to calculate and combine hazard ratios (HR) based on information available in each paper, maximizing the number of studies for consideration. Comparisons of long-term oncologic results for ROBOT versus OPEN and LAP were reported. Results: There were 6,477 unique references identified from initial search from which 19 studies were included based on an adjusted analysis of HRs with heterogeneity tests. The weighted HR for DFS for ROBOT (n=1152) versus LAP (n=1029) was 0.94 (95% CI: 0.71-1.26; p=0.68; I2=0%), and ROBOT (n=887) versus OPEN (n=1035) was 0.84 (95% CI: 0.64-1.11; p=0.22; I2=0%). The weighted HR for OS for ROBOT (n=4675) versus LAP (n=2643) was 0.98 (95% CI: 0.82-1.16; p=0.78; I2=0%) and ROBOT (n=27,647) versus OPEN (n=23,923) was 0.77 (95% CI: 0.71-0.83; p<0.0001; I2=18%). Conclusions: When compared with OPEN and LAP hysterectomy, ROBOT hysterectomy does not result in worse oncologic outcomes with respect to DFS and shows improved OS results compared to OPEN. The noted improved outcomes with ROBOT need further validation and investigation.

Cumulative Summation Analysis of Learning Curve for Robotic-assisted Hysterectomy in Patients With Gynecologic Tumors

This study aimed to evaluate the learning curve and perioperative outcomes of robot-assisted hysterectomy (RAH). We retrospectively analyzed data from 45 patients who underwent RAH using the da Vinci Xi surgical system. The learning curve was evaluated using the cumulative summation method. Demographic data and various perioperative parameters, including total operative time, docking time, and console time, were obtained from the medical records. Cumulative summation analysis indicated that proficiency regarding hysterectomy time was reached after 33 cases. There were two unique phases of the learning curve for console time: the introduction phase identified by the bottom point in the curve, and the proficient phase, identified by an upward line after the bottom point in the curve. There were no significant differences between the two phases in terms of patient age and body mass index. Total operative time, docking time, and console time were significantly decreased in the proficient phase compared with those in the introduction phase. There was a significant reduction in blood loss during operation in the proficient phase. The perioperative complication rates were 12.1% in the introduction phase and 0% in the proficient phase (p=0.5606). No blood transfusion or conversion to laparotomy was required in either phase. The introduction and proficient phases identified by cumulative summation analysis demonstrated progressive improvement of surgical performance in surgeons carrying out RAH.

Effect of intraoperative alveolar recruitment maneuver on intraoperative oxygenation and postoperative pulmonary function tests in patients undergoing robotic-assisted hysterectomy: a single-blind randomized study

BackgroundRobotic-Assisted Hysterectomies (RAH) require Trendelenburg positioning and pneumoperitoneum, which further accentuate alteration in respiratory mechanics induced by general anesthesia. The role of Recruitment Maneuver (RM) as a lung-protective strategy during intraoperative surgical settings has not been much studied. We planned this study to evaluate the effect of RM on perioperative oxygenation and postoperative spirometry using PaO2/FiO2 and FEV1/FVC, respectively in patients undergoing RAH. MethodsSixty-six ASA I‒II female patients scheduled for elective RAH were randomized into group R (recruitment maneuver, n = 33) or group C (control, n = 33). Portable spirometry was done one day before surgery. Patients were induced with general anesthesia, and mechanical ventilation started with volume control mode, with Tidal Volume (TV) of 6–8 mL.kg−1, Respiratory Rate (RR) of 12 min, inspiratory-expiratory ratio (I: E ratio) of 1:2, FiO2 of 0.4, and Positive End-Expiratory Pressure (PEEP) of 5 cmH2O. Patients in group R received recruitment maneuvers of 30 cmH2O every 30 minutes following tracheal intubation. The primary objectives were comparison of oxygenation and ventilation between two groups intraoperatively and portable spirometry postoperatively. Postoperative pulmonary complications, like desaturation, pulmonary edema, pneumonia, were monitored. ResultsPatients who received RM had significantly higher PaO2 (mmHg) (203.2+-24.3 vs. 167.8+-27.3, p < 0.001) at T2 (30 min after the pneumoperitoneum). However, there was no significant difference in portable spirometry between the groups in the postoperative period (FVC, 1.40 ± 0.5 L vs. 1.32 ± 0.46 L, p = 0.55). ConclusionThis study concluded that intraoperative recruitment did not prevent deterioration of postoperative spirometry values; however, it led to improved oxygenation intraoperatively.

Variations in Procedures for Ureterolysis with Sharp Dissection in Minimally Invasive Hysterectomy.

To safely perform minimally invasive hysterectomy (MIH), including laparoscopic hysterectomy and robot-assisted hysterectomy, partial ureterolysis, or visualizing only the ureter without dissection is often inadequate. Moreover, careless blunt dissection could injure the blood vessels. We present our surgical method for ureterolysis using sharp dissection during MIH. First, the outer portion of the ureter is dissected. Dissecting between the pelvic sidewall and the posterior leaf of the broad ligament creates a pararectal space outside the ureter, enabling the easy identification of the ureter running on the posterior leaf. Second, the inner portion of the ureter is dissected. After determining the location of the ureter, a better partial dissection of the ureter can be performed from the posterior leaf, instead of dissecting along the entire circumference. If fine surgery has to be performed, the ureter can be dissected by enclosing it within its sheath. We primarily perform dissections using a monopolar device, which allows a sharp dissection. Furthermore, in our method, we often include the dissection of the ureteral tunnel. It is important to understand the anatomy and membrane structure of the ureter in each patient and adjust the extent of ureterolysis based on individual differences.

Learning curve analysis of multiport robot-assisted hysterectomy.

The purpose of this study was to evaluate the surgical outcomes and learning curve of multiport robot-assisted hysterectomy. Eighty-eight patients were identified who underwent multiport robot-assisted surgery for hysterectomy. A retrospective analysis was performed. The cumulative summation technique (CUSUM) was used to investigate the learning curve in surgical proficiency by analyzing total operative, docking, and console times. The patients' median age was 51years. In addition, the median operative time was 120.5min (range 56-344min). The most common indication for surgery was myoma (33.0%). The median estimated blood loss was 30mL (range 5-200mL). There was no conversion to laparoscopic or open surgery. No transfusion was required, and only one complication including umbilical incisional hernia was reported. A tendency of decline in total operative time following the first 23 cases was found. The CUSUM graph for total operative time indicated the generation of three distinct performance phases: learning (n = 23), competence (n = 36), and mastery (n = 29). The median docking time was 3min (range 1-10min) and median console time was 70min (range 24-298min). The multiport robot-assisted surgery is an easy and safe procedure with minimal postoperative complications and can be quickly learned. The learning curve was 23 cases to significantly decrease the operative time.

Prevention and management of vaginal cuff dehiscence: an updated review.

Minimally invasive hysterectomy has gained popularity because of its many benefits. However, laparoscopic and robotic assisted hysterectomy have been associated with increased risk of vaginal cuff dehiscence. This review is meant to address risk management and prevention of vaginal cuff dehiscence in patients undergoing minimally invasive hysterectomy. Recent findings in the literature focus on addressing modifiable risk factors in patients and on using good surgical technique to help minimize the risk of vaginal cuff dehiscence. The focus of this review is to help surgeons identify patient risk factors and address them preoperatively and to review surgical techniques that can minimize the risk of vaginal cuff dehiscence.

The Use of near Infra-Red Radiation Imaging after Injection of Indocyanine Green (NIR-ICG) during Laparoscopic Treatment of Benign Gynecologic Conditions: Towards Minimalized Surgery. A Systematic Review of Literature.

Background and Objectives: To assess the use of near infrared radiation imaging after injection of indocyanine green (NIR–ICG) during laparoscopic treatment of benign gynecologic conditions. Materials and Methods: A systematic review of the literature was performed searching 7 electronic databases from their inception to March 2022 for all studies which assessed the use of NIR–ICG during laparoscopic treatment of benign gynecological conditions. Results: 16 studies (1 randomized within subject clinical trial and 15 observational studies) with 416 women were included. Thirteen studies assessed patients with endometriosis, and 3 studies assessed non-endometriosis patients. In endometriosis patients, NIR–ICG use appeared to be a safe tool for improving the visualization of endometriotic lesions and ureters, the surgical decision-making process with the assessment of ureteral perfusion after conservative surgery and the intraoperative assessment of bowel perfusion during recto-sigmoid endometriosis nodule surgery. In non-endometriosis patients, NIR–ICG use appeared to be a safe tool for evaluating vascular perfusion of the vaginal cuff during total laparoscopic hysterectomy (TLH) and robotic-assisted total laparoscopic hysterectomy (RATLH), and intraoperative assessment of ovarian perfusion in adnexal torsion. Conclusions: NIR–ICG appeared to be a useful tool for enhancing laparoscopic treatment of some benign gynecologic conditions and for moving from minimally invasive surgery to minimalized surgery. In particular, it might improve treatment of endometriosis (with particular regard to deep infiltrating endometriosis), benign diseases requiring TLH and RATLH and adnexal torsion. However, although preliminary findings appear promising, further investigation with well-designed larger studies is needed.

ROCC/GOG-3043: A randomized non-inferiority trial of robotic versus open radical hysterectomy for early-stage cervical cancer.

TPS5605 Background: Minimally invasive surgery (MIS) is associated with improved perioperative safety outcomes, but, in 2018, the Laparoscopic Approach to Cervical Cancer (LACC) trial, a non-inferiority study comparing laparoscopic versus open radical hysterectomy for early stage cervical cancer, reported significantly worse disease-specific (DSS) and overall survival (OS) in the MIS group. Criticisms of the LACC trial include lack of proper preoperative imaging and assessment, use of transcervical uterine manipulators, and lack of proper tumor containment leading to peritoneal contamination. Subsequent retrospective studies have reported conflicting results. Given the potential benefit of MIS, the ROCC trial seeks to address the limitations of the LACC trial. Methods: ROCC is a multi-center, prospective, randomized, non-inferiority trial. The primary objective is to determine whether robotic-assisted (RBT) radical hysterectomy is not inferior to abdominal (OPEN) approach with respect to 3-year disease-free survival (DFS). Secondary objectives include DSS, OS, patterns of recurrence, peri- and postoperative complications, long-term morbidity, impact on patient-reported outcome (PRO) measures and development of lower extremity lymphedema (LEL). Key inclusion criteria include patients with histologically confirmed adenocarcinoma, squamous cell, and adenosquamous cell carcinoma of FIGO 2018 stage IA2-IB2. All patients must have a preoperative pelvic MRI confirming that the cervical tumor is &lt; 4 cm in size, no obvious evidence of extracervical extension and no nodal or other regional metastasis. Intraoperatively, the use of transcervical uterine manipulators is not allowed and specific detailed surgical techniques for proper tumor containment is required. Photographic evidence of specimen with tumor contained is mandated. We estimate the 3-year DFS to be 92% in the control (OPEN) arm. If the DFS does not differ by more than 7% and the one-sided 95% CI does not cross the non-inferiority boundary, then the RBT arm will be deemed non-inferior. 840 patients will be enrolled (420 per arm, 89 events total), which provides 90% power to exclude an absolute decrease in DFS by 7% (HR &lt; = 1.375) with a log-rank test for non-inferiority with a one-sided alpha of 0.05. The primary analysis will be conducted in all randomized patients (ITT). Given the LACC findings of worse oncologic outcomes with MIS, a formal DSMC will conduct periodic reviews of safety including two planned formal interim analyses for futility (harm) after accrual of 370 and 640 patients using an aggressive Lan-DeMets beta-spending function similar to a Pocock boundary. Results of this trial may be practice changing and will either support or refute the findings of the LACC trial. The study is currently activating sites for enrollment. Clinical trial information: NCT04831580.

The effect of steep head-down tilt on respiratory status in endometrial cancer patients with obesity during robot-assisted hysterectomy

ObjectiveTo evaluate the effect of head-down tilt on airway pressure in gynecologic patients with obesity duringrobot-assisted hysterectomy. MethodsWe retrospectively reviewed the records of 27 patients with body mass index (BMI) ≥ 25 kg/m2 who underwent robot-assisted hysterectomy for endometrial cancer and endometrial atypical hyperplasia using the da Vinci Xi system.Mechanical ventilation was performed using pressure-controlled ventilation (PCV). Surgery was performed at 20° (group A, n = 17) or 25° head-down tilt(group B, n = 10). Respiratory parameters, including positive end-expiratory pressure (PEEP), tidal volume (TV), mean airway pressure (P mean), and peak airway pressure (P peak), were measured before (T1) and after the head-down tilt at 1 h (T2) and 2 h (T3) during anesthesia. ResultsThe median BMI was 37.5 (range 28–51) kg/m2, with no between-group variation. Oxygenation was maintained intraoperatively for all patients. The expiratory carbon dioxide partial pressure was 43.6 (95% confidence interval (CI) 42.2–45.0) mmHg. The P mean peak at T2 in group B was significantly higher than in group A (P < 0.011); however, other parameters at T2 and T3 did not differ significantly between the groups. Patients with BMI ≥ 40 kg/m2 had significantly higher respiratory parameters than those with BMI < 40 kg/m2. In patients with BMI ≥ 40 kg/m2, the mean P means and P peaks at T3 were 17.3 cmH2O (95% CI 16.3–18.3) and 29.4 cmH2O (95% CI 27.1–31.7), respectively. DiscussionWith careful anesthetic management during PCV, robot-assisted surgery with a head-down tilt of 25° or below may be safe, even in patients with class III obesity.

Clinical Utility and Cost of Postoperative Hemoglobin Level Testing Following Robotic-assisted Hysterectomy for Endometrial Cancer.

Our aim was to assess the clinical utility of postoperative hemoglobin testing following hysterectomy. We carried out a retrospective cohort study of patients who underwent robotic surgery at an academic center during a 44-month study period. Data included demographics and perioperative outcomes. The mean postoperative decrease in hemoglobin level was evaluated using numerical and categorical variables. A total of 201 women were included. A total of 45 (22.4%) developed symptoms suggestive of hemodynamic compromise. When compared to asymptomatic patients, these patients were no different in operative time, estimated blood loss, pre- or post-operative hemoglobin levels, or the change in hemoglobin levels. Symptomatic patients did receive less fluid intraoperatively (1.2 vs. 1.5 l; p<0.0001). Perioperative outcomes were not associated with a greater postoperative decrease in hemoglobin (Hb). Postoperative anemia was associated with preoperative anemia (0% vs. 45%; p<0.0001). Patients with postoperative anemia were also more likely to be re-admitted within 30 days after surgery (7% vs. 23%; p=0.025). Of the three patients who received blood transfusions postoperatively, all three had preoperative Hb<9.5 g/dl, compared to 2.5% of those who were not transfused (p<0.0001). Using Institutional charges and Medicare reimbursement rates for blood hemoglobin testing, savings were estimated to be $3,629 and $1,236, respectively, during the study period. Postoperative Hb testing may be safely avoided unless starting Hb is less <10 g/dl. Clinical practice change can reduce healthcare costs without hindering patient care.

Peri- and postoperative outcomes in patients with endometriosis undergoing hysterectomy

ObjectivesTo assess whether hysterectomy in patients with endometriosis is associated with higher proportion of complications compared with patients without, and whether route of hysterectomy affects this outcome. Study designThis is a population-based retrospective cohort study. Data were prospectively obtained from three National Swedish Registers. Patients undergoing a benign hysterectomy between 2015 and 2017 in Sweden were included in the study and were grouped according to a histology-proven diagnosis of endometriosis. Different hysterectomy modes were compared in patients with endometriosis. Perioperative data and postoperative complications up to 1 year after surgery were collected and measured. ResultsIn all, 8,747 patients underwent a benign hysterectomy, and 1,166 patients with endometriosis was compared with 7,581 patients without. Patients with endometriosis had higher proportion of complications (adjusted Odds ratio aOR 1.2, 95% CI 1.0–1.4), were more often converted to abdominal hysterectomy (aOR 1.7, 95% CI 1.1–2.6), had higher estimated blood loss (EBL) (200–500 ml; aOR 1.8, 95% CI 1.4–2.3, >500 ml; aOR 3.1, 95% CI 2.2–4.4) and a longer operative time (1–2 h; aOR 2.1, 95% CI 1.4–3.2, >2 h; aOR 4.3, 95% CI 2.7–6.6) than endometriosis-free patients. The conversion rate was 13.8 times higher in total laparoscopic hysterectomy (TLH) compared with robotic-assisted laparoscopic hysterectomy (RATLH) (aOR 13.8, 95% CI 3.6–52.4). ConclusionHigher conversion rate, higher EBL and higher frequency of complications were seen in patients with endometriosis. RATLH was associated with lower conversion rate compared to TLH.

Learning Curve Analysis of Single-Site Robot-Assisted Hysterectomy.

We aim to analyze the surgical outcomes and learning curve of single-site robot-assisted hysterectomy. This was a retrospective cohort study from a single academic medical center. A total of 123 patients who underwent single-site robotic surgery for gynecologic disease were enrolled. Gynecologic surgeries were performed by a single surgeon using single-site robot-assisted hysterectomy. The median age of enrolled patients was 49 years (range: 30–74 years). The median operation time was 131 min (range: 59–502 min) and the median docking time was 3 min (range: 1–10 min). In addition, the median console time was 76 min (range: 29–465 min). The cumulative sum (CUSUM) graph for total operation time indicated an initial decrease at case 41, generating 3 distinct performance phases: learning (n = 41 initial cases), competence (n = 54 middle cases), and mastery (n = 28 final cases). There was one case conversion to open surgery due to the difficulty in securing the field of view because of a 16-cm bulky mass protruding from the left pelvic wall. No patients required a transfusion and two complications including vaginal cuff dehiscence were identified. The single-site robot-assisted hysterectomy is a safe and feasible procedure. The learning curve consisted of 41 cases to significantly decrease the total operation time.

Effects of Pharmacologic Venous Thromboembolism Prophylaxis in Benign Hysterectomy

To evaluate whether the addition of pharmacologic prophylaxis to mechanical prophylaxis for venous thromboembolism (VTE) is associated with changes in perioperative outcomes in hysterectomy for benign indications. Retrospective cohort study. Michigan Surgical Quality Collaborative database. Patients who underwent hysterectomy between July 2012 and June 2015 when VTE prophylaxis data were collected. Patients who received mechanical prophylaxis alone were compared with those receiving dual prophylaxis (mechanical and pharmacologic). Minimally invasive surgeries (MIS) included laparoscopic, vaginal, robotic-assisted, and laparoscopic-assisted vaginal hysterectomies and were analyzed separately from abdominal (ABD) hysterectomy. Propensity score matching was used to minimize confounding because of the differences in demographic and perioperative characteristics. The primary outcome was estimated blood loss (EBL). The secondary outcomes were operative time, postoperative blood transfusion, VTE, surgical site infection, reoperation, readmission, and death. There were 1803 matched pairs in the MIS analysis. In the ABD hysterectomy analysis, 2:1 matching was used with a total of 1168 patients receiving mechanical prophylaxis alone matched to 616 patients receiving dual prophylaxis. EBL was higher by 54.5 mL (95% confidence interval [CI], 16.9-92.1) in those receiving dual prophylaxis in the ABD hysterectomy analysis but did not differ between groups in the MIS analysis. Operative time was significantly longer with dual prophylaxis in both MIS (18.3 minutes; 95% CI, 13.8-22.8) and ABD (15.3 minutes; 95% CI, 9.0-21.6) surgical approaches. There was no difference in other secondary outcomes. The addition of pharmacologic prophylaxis to mechanical prophylaxis in benign hysterectomy was associated with longer operative time, regardless of surgical approach and increased EBL in ABD hysterectomy. Given very low rates of VTE, no difference in other perioperative outcomes, and possible harm, it seems reasonable to encourage individualized rather than routine use of pharmacologic prophylaxis in patients undergoing benign hysterectomy receiving mechanical prophylaxis.

Robotic-assisted Laparoscopic Ureterolysis for Deep Infiltrating Endometriosis using Indocyanine Green Under Near-Infrared Fluorescence

To demonstrate safe identification of ureters in patients with deep infiltrating endometriosis or severe adhesive disease using indocyanine green (ICG) under near-infrared fluorescence (NIRF) on the robotic platform. Stepwise demonstration using narrated video footage. An academic tertiary care hospital. A 43 year old G0 with stage IV endometriosis presented with chronic pelvic pain. Her surgical history is notable for 2 aborted hysterectomies due to severe adhesive disease, despite extensive lysis of adhesions. She desired surgical intervention. In cases of stage IV endometriosis, localizing the ureters can be challenging due to severe adhesive disease, surrounding fibrotic tissue, and distorted anatomy. Intravenous ICG has previously been described to assist with resection of endometriosis [1-3]. Alternatively, we describe a technique that allows for easier identification of ureters using ICG injection retrogradely in ureteral stents while visualized under NIRF [4,5]. The patient underwent robotic-assisted total laparoscopic hysterectomy, bilateral salpingo-oophorectomy, bilateral ureterolysis, low anterior bowel resection with primary anastomosis, and resection of endometriosis without intraoperative complications or ureteral injury. Her postoperative course was unremarkable. At her 3 week postoperative visit, pelvic pain had completely resolved. This case demonstrates the use of intraureteral ICG and NIRF to identify the ureters and perform ureterolysis in cases of deep infiltrative endometriosis.

Uptake and outcomes of sentinel lymph node mapping in women undergoing minimally invasive surgery for endometrial cancer.

To examine the patterns and outcomes of sentinel lymph node (SLN) assessment in women with endometrial cancer. Retrospective cohort study. United States inpatient and outpatient hospital services. Women with endometrial cancer who underwent a laparoscopic or robotic-assisted hysterectomy. The Perspective Database from 2012 to 2018 was used. Performance of lymph node dissection was classified as SLN mapping, lymph node dissection or no nodal evaluation. Adjusted regression models were developed to examine the association between SLN mapping and morbidity and cost. Utilisation rates, morbidity and cost of both lymph node dissection and SLN mapping. Among 45381 patients, SLN mapping was performed for 7768 patients (17.1%), lymph node dissection was performed for 23214 patients (51.2%) and no lymphatic evaluation was performed for 14399 patients (31.7%). SLN mapping increased from 1.8% in 2012 to 35.3% in 2018, whereas the rate of lymph node dissection decreased from 63.5% to 39.1% (p<0.001). Among women who underwent nodal evaluation, residence in the west, White race and use of robotic-assisted hysterectomy were associated with SLN mapping (p<0.05 for all). The complication rate was 5.9% for SLN mapping, compared with 7.3% in those that underwent lymph node dissection (aRR0.85, 95%CI 0.77-0.95). The median hospital costs for women who underwent SLN mapping ($10479) and lymph node dissection ($10747) were higher than for those who did not undergo nodal assessment ($9149) (p<0.001). The performance of SLN mapping is increasing for endometrial cancer. Compared with lymph node dissection, SLN mapping is associated with lower morbidity. SLN mapping significantly increases the costs compared with hysterectomy alone. SLN mapping is increasing rapidly for endometrial cancer and is associated with decreased perioperative morbidity.

Minimally invasive hysterectomy for benign indications-surgical volume matters: a retrospective cohort study comparing complications of robotic-assisted and conventional laparoscopic hysterectomies.

The objective of this study was to evaluate the incidence of perioperative complications in robotic-assisted hysterectomies performed by high-volume robotic surgeons compared to conventional laparoscopic hysterectomies performed by all gynecologic surgeons. This retrospective cohort studywas performed at a single-center community based hospital and medical center. A total of 332 patients who underwent hysterectomy for benign indications were included in this study. Half of these patients (n = 166) underwent conventional laparoscopic hysterectomy and the other half underwent a robotic-assisted laparoscopic hysterectomy. The main outcome measures included composite complication rate, estimated blood loss (EBL), and hospital length of stay (LOS). Median (IQR) EBL was significantly lower for robotic hysterectomy [22.5 (30) mL] compared to laparoscopic hysterectomy [100 (150) mL, p < 0.0001]. LOS was significantly shorter for robotic hysterectomy (1.0 ± 0.2day) compared to laparoscopic hysterectomy (1.2 ± 0.7days, p = 0.04). Despite averaging 3.0 (IQR 1.0) concomitant procedures compared to 0 (IQR 1.0) for the conventional laparoscopic hysterectomies, the incidence of any type of complication was lower in the robotic hysterectomy group (2 vs. 6%, p = 0.05). Finally, in a logistic regression model controlling for multiple confounders, robotic-assisted hysterectomy was less likely to result in a perioperative complication compared to traditional laparoscopic hysterectomy [odds ratio (95% CI) = 0.2 (0.1, 0.90), p = 0.04]. In conclusion,robotic-assisted hysterectomy may reduce complications compared with conventional laparoscopic hysterectomy when performed by high volume surgeons, especially in the setting of other concomitant gynecologic surgeries.