Robotic or Laparoscopic Surgery for the Treatment of Endometriosis?
and the reconstruction. This is demonstrated in a case report by Walid and Heaton.22
Nezhat et al. reported on the laparoscopic management of
15 patients with infiltrating endometriosis of the bladder and a case of primary intravesical endometroid adenosarcoma.23
Laparoscopic and
cystoscopic evaluation confirmed that the endometriotic lesions were penetrating through the bladder wall. In eight patients the lesions were located in the dome of the bladder. In the remaining seven, the lesions were in the posterior wall, above the trigone. It was possible to treat all the lesions by performing a laparoscopic partial cystectomy without major morbidity. There were no conversions to laparotomy. One patient was diagnosed with endometriosis on frozen section, but proved to have an adenosarcoma of the bladder upon final pathology.
Smith and Cooper described their experience of management of ureteric endometriosis.24
In a series of 126 patients undergoing
ureterolysis for ureteric endometriosis, 13 were found as having ureteric obstruction. Seven of them could be successfully managed with ureterolysis only, three by ureterolysis and placement of a double-J ureteric stent and three required segmental ureteric resection. In 12 of the 13 cases the procedure was attempted laparoscopically. Five out of the 13 cases were converted to open procedures due to extensive associated pelvic or bowel endometriosis. There was one incidence of inadvertent thermal ureteric injury which was managed with a ureteric stent. In a recent review on the subject it was concluded that in cases of moderate to severe hydronephrosis due to ureteral endometriosis laparoscopic resection with ureterostomy or uretercystoneostomy provides good results with low recurrence rates.25
Robotic Surgery
There are only a few case reports describing the feasibility of robotic-assisted surgical removal of extragenital deeply infiltrating endometriosis. Averbach et al. reported a case of robotic-assisted colorectal resection by a multidisciplinary team in a 35-year-old woman with deep infiltrating endometriosis and rectal involvement.26
The
operation was uneventful and the specimen was removed by enlarging the trocar incision in the right iliac fossa. The surgery took five hours. The patient could leave the hospital on the fifth post-operative day and was free of recurrent endometriosis 15 months after the surgery.
Zapardiel et al. described a robotic radical parametrectomy in two patients with endometriotic involvement of the sacrouterine ligaments.27
Williams et
al. reported on a robot-assisted laparoscopic ureteroneocystostomy in a patient with infiltrative endometriosis.28
A case of a combined transurethral
and laparoscopic partial cystectomy and robot-assisted bladder repair for the treatment of a deeply infiltrating four centimetre bladder endometrioma was published by Sener et al.29
surgery to perform a partial cystectomy with concomitant excision of endometrial nodules from the rectum and an ovarian endometrioma in 23-year-old patient.30
Chammas et al. used robotic This patient became pregnant with in vitro
fertilization two years later. The above procedures seem safe and feasible and resulted in improvement of the symptoms of chronic pelvic pain.
Bot-Robin et al. reported the early experience of the Lille group with robotic-assisted surgical treatment of deep infiltrating endometriosis.31 They used the robot in six patients to perform four partial bladder and two uterosacral ligament resections. Mean operative time was 173 minutes
US OBSTETRICS & GYNECOLOGY
(range 156–244 minutes) and median length of hospital stay was three days (range two to five days). Complete resection was possible in all cases, there were no conversions to laparotomy and no major perioperative complications. Nisolle et al. described 17 patients operated on for endometriosis using robotic-assisted laparoscopy in their department between February 2009 and June 2010.32
Even in cases with
complete obliteration of the pouch of Douglas, deep infiltrating vaginal nodules could be removed by robotics. No conversions to laparotomy and major complications were noted. These authors felt that the main advantage of robotic-assisted surgery for extensive endometriosis is the three dimensional vision of fibrotic lesion, precise and easier dissection of the rectovaginal septum and shaving resection of endometriotic lesions. Moreover, vaginal suturing could be performed laparoscopically due to the articulation of the instruments. This vaginal closure is sometimes difficult by conventional laparoscopy as the posterior vaginal fornix is removed with the uterosacral ligaments, meaning that the vaginal wall has to be sutured to the posterior part of the cervix.
Nezhat et al. performed a retrospective controlled cohort study comparing robot-assisted with standard laparoscopy for the treatment of endometriosis between January 2008 and January 2009 in a tertiary referral centre.33
Forty patients were operated by robot-assisted laparoscopy and 38 by standard laparoscopy. The two groups were matched for age, body mass index (BMI), stage of endometriosis and previous abdominal surgery. Mean operative time with the robot was 191 minutes (range 135–295 minutes) compared with 159 minutes (range 85–320 minutes) during standard laparoscopy. There were no significant differences in blood loss, hospitalization, intra-operative, or post-operative complications. There were no conversions to laparotomy. The authors concluded that both techniques have excellent outcomes but that robotic surgery required significantly longer surgical and anesthesia time, as well as larger trocars.
A case report by Deras et al., shows that robotic surgery occasionally leads to severe complications which are partially related to the technique.34 These authors describe a case of a 30-year-old obese patient who underwent a 12-hour robotic-assisted laparoscopic operation for severe endometriosis. Due to the extreme Trendelenburg position and the long duration of the surgery, she developed bilateral rhabdomyolysis of the forearms, complicated by a subsequent Rhabdomyolysis compartment syndrome (RCS) with multiple neuropathy. Galyon et al. published a similar case of a 53-year-old man having a robotic cystoprostatectomy.35
The
pathogenesis comprized increased intracompartimental pressure and hypoperfusion, resulting in ischemia and tissue necrosis due to prolonged lithotomy position. Krarup and Rawashdeh reviewed the PubMed database on this subject and found 38 case reports with a total of 58 patients who developed RCS.36
RCS has also been described after laparoscopic and
However, robotic surgeons should be particularly attentive to this complication as the extreme Trendelenburg position used for robotics and the long duration of this type of surgery are crucial risk factors for RCS. Prevention, early diagnosis and treatment are of paramount importance to avoid this invalidating and potentially life-threatening problem. Tomassetti et al. could reduce the occurrence of RCS as a complication of laparoscopic laser surgery for severe endometriosis to nearly zero by the application of a new patient positioning method.37
abdominal surgery.37 This includes maximal avoidance of the lithotomy position, patient positioning in a modified supine position, mobilization of 125
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