Surgery in 2009.9
Robotic surgery is minimally invasive, allows three dimensional vision, offers motion scaling, and avoids tremor. The robotic wrists enable surgeons to manipulate instruments and tissues from all kinds of angles.9,10 Recent case reports and small cohort studies have shown that robotic surgery may be an attractive option for most gynecological procedures.11,12 Several institutions state on their websites that robotic surgery for the resection of endometriosis is superior to other surgical approaches. They even claim that the technical advantage of robotic surgery results in improved outcomes as well as a reduced likelihood the patient will need future surgery. In the present paper we assess weather these statements can be substantiated by reviewing the literature on laparoscopic versus robotic surgery for endometriosis. A Medline search with the key word ‘robotics’, ‘laparoscopy’, and ‘endometriosis’ was performed.
Laparoscopic Surgery
Laparoscopy is widely accepted as the gold standard of surgical management of endometriosis. The aim of the surgery is to resect or destroy all visible endometriotic lesions. High-power density electrosurgical and laser instruments, combined with excellent vision have made removal of endometriosis possible with minimal complications.1
Hydrodissection and use of CO2 super pulsed lasers aid in the removal of adherent endometriotic implants without damage to
normal underlying structures. The laparoscopic approach to the management of endometriosis is favored over a laparotomy approach as it offers the advantage of a shorter hospital stay, faster patient recovery and decreased hospital costs.13
together with excision of all other implants. In all cases colonoscopy showed a normal mucosa. Mean operative time was 190 minutes (range 165–230 minutes). There were no anastomotic leaks and no major complications. Average length of hospital stay was 8.3 days (range 7–11 days). At median follow-up of 38.7 months (range 1–84 months) complete relief of pelvic symptoms was achieved in five out of seven patients (71 %), and there was improvement in one patient. In one patient complaining of persistent pain, a new colonic implant was diagnosed two years after surgery requiring reoperation. Radical en bloc hysterectomy, bilateral salpingo-oophorectomy, and colorectal resection is the ultimate radical surgery for extensive pelvic endometriosis. In a retrospective study, Darai et al. demonstrated that a laparoscopic approach to perform this procedure is as effective in terms of symptoms and improvement of quality of life, as a laparotomic approach.18
Four of the 16 patients of the
laparoscopic group required laparoconversion. The Leuven University group evaluated clinical outcomes after multidisciplinary laparoscopic excision of deep infiltrating colorectal endometriosis in a retrospective cohort study. Fifty-six patients were asked to complete questionnaires regarding quality of life (QoL), pain, fertility and sexuality to compare their status before and after surgery, and medical files were analyzed. Gynecological pain, QoL, and sexual activity improved significantly (p<0.008 for all) during a median follow-up of 29 months after surgery. Cumulative recurrence rate of endometriosis was 2 % and 7 % at one and four years after surgery, respectively, and cumulative pregnancy rate was 3 % and 70 % at one and four years, respectively.16
Although there are no reliable
prospective randomized studies available, some retrospective series suggest that laparoscopic treatment of endometriosis is at least as effective compared to laparatomic surgery regarding recurrent symptoms and pregnancy rates.8,14
Endometrioma is one of the most frequent pathologies in gynecological surgery and should be treated in patients with pain, infertility and in asymptomatic patients if the cyst diameter is greater than 4 cm.15
There
Surgery of deeply infiltrating endometriosis can be a major surgical challenge. This type of surgery is often difficult and requires specific skills, as endometriosis can cause a fibrotic reaction with dense adherence onto the surrounding tissues, or may even invade into pelvic organs. In many cases it is not easy to find the planes of dissection, and the bowel, ureter or a part of the bladder may need to be removed in order to eradicate the disease completely.16
is good evidence that excisional surgery for endometriomata provides a more favorable outcome than drainage and ablation with regard to the recurrence of the endometrioma, recurrence of pain symptoms, and in women who are previously subfertile, subsequent spontaneous pregnancy.13
Referral of patients with
deeply infiltrating endometriosis to a specialized multidisciplinary team should be recommended.
The rectosigmoid colon is affected by deep pelvic endometriosis in 3–37 % of cases.17
From March 1995 until March 2003,
29 consecutive patients with endometriosis requiring laparoscopic intervention were evaluated. In seven patients (24 %) colorectal involvement was identified prior to operation. A low anterior resection was performed in four patients (57 %) and a sigmoid resection in three (43 %),
124
Campagnacci et al. described their experience with complete laparoscopic management of deep pelvic endometriosis with bowel involvement.17
In the literature, there are no recommendations concerning the optimal management of endometriosis invading the rectum as no randomized clinical trials have been carried out until now. Some teams prefer to shave the endometriotic lesions from the rectal wall while others prefer to perform a bowel resection. Meuleman et al. reviewed the clinical outcome of surgical treatment of deeply infiltrating endometriosis with colorectal involvement.19
Out of 3,894 patients, 71 % had a bowel
resection with anastomosis, 10 % had a full thickness disc excision of endometriosis and 17 % were treated with superficial surgery. Post-operative complications were reported in 0–3 % of patients. Pain and quality of life improved in most studies, but prospective data on these items were only available in a minority of patients. Pregnancy rates were 23–57 %, with a cumulative pregnancy rate of 58–70 % within four years. The overall endometriosis recurrence rate in studies with more than two years follow-up was 5–25 % (average 10 %).
In a retrospective review of a database on surgical patients with endometriosis, Antonelli et al. found 2.6 % (mean age 33.1 years) of patients were affected by urologic endometriosis.20
Twelve out of
31 patients had bladder involvement, 15 involvement of the ureter(s), and four a combination of both. Bladder endometriosis was revealed by symptoms related to menses and showed a typical endoscopic picture, whereas ureteral involvement had a nonspecific or silent symptomatology. In this series no recurrences were seen after cystectomy or ureteroctomy with uretercystoneostomy. Some authors have recommended laparoscopic partial cyctectomy only in patients with bladder endometriosis that is distant from the bladder neck, the urethral orifices, and the trigone, in order to allow a resection margin of 1–2 cm.21
In the
hands of experienced laparoscopist there seems to be no reason to exclude these patients provided the surgeon can safely do the resection
US OBSTETRICS & GYNECOLOGY
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