Postoperative pain and recovery after conventional laparoscopy compared with robotically assisted laparoscopy.

OBJECTIVE: To compare postoperative pain after conventional laparoscopic and robotically assisted laparoscopic surgery in gynecology. METHODS: This is a prospective nonrandomized analysis of patients undergoing conventional laparoscopy or robotically assisted laparoscopy in a university-affiliated hospital between March 2011 and March 2012. Postoperative pain was measured using the Numeric Rating Scale and the narcotic use converted to morphine sulfate equivalents. The primary outcome was the Numeric Rating Scale pain score obtained on the first postoperative day. RESULTS: One hundred ten patients were enrolled; 91 were included in the statistical analysis. Both groups were similar with regard to race, history of abdominopelvic surgeries, psychiatric history, and substance abuse. Patients undergoing robotically assisted laparoscopy were 6 years older and had a body mass index 6 points higher. Median length of hospital stay for conventional laparoscopy and robotically assisted laparoscopy was 2 days and 3 days, respectively (P<.001); median to being off narcotics was 4 days and 4.5 days, respectively (P=.336); and median return to normal activities was 13 days and 21 days, respectively (P=.021). There were no significant differences in mean Numeric Rating Scale pain scores over time (P=.499) or mean narcotic requirements (P=.393) between groups. CONCLUSION: Robotically assisted laparoscopy is equivalent to conventional laparoscopy in terms of subjective and objective measures of postoperative pain.

Laparoscopy for the management of early-stage endometrial cancer: from experimental to standard of care.

We performed a search of PUBMED and MEDLINE for articles concerning surgical management of early stage endometrial cancer from 1950 to 2011. From the articles collected we extracted data such as estimated blood loss, operating room time, complications, conversion to laparotomy, and length of hospital stay. Forty-seven relevant sources were analyzed. The patients in the laparoscopy group had less blood loss, fewer complications, longer operating room times, and a shorter length of stay. Lymph node count was similar in both groups. Although obesity is not a contraindication to laparoscopy, it does lead to a higher conversion rate. Route of surgical treatment had no impact on recurrence or survival. Robotic surgery has significant advantages over laparotomy, but advantages over laparoscopy are not as distinct. Laparoscopic hysterectomy offers several advantages over laparotomy. These advantages relate to improvements in patient care with comparable clinical outcome. After careful analysis we believe laparoscopy should be the standard of care for surgical management of early stage endometrial cancer.

Robotic-assisted laparoscopic transection and repair of an obturator nerve during pelvic lymphadenectomy for endometrial cancer.

BACKGROUND: Obturator nerve injury may occur in gynecologic surgery, particularly in cases in which extensive pelvic sidewall retroperitoneal dissection is performed. The lack of tactile feedback from the robotic surgical system may contribute to obturator nerve injury. If surgical division occurs, microsurgical end-to-end anastomosis of the obturator nerve may be performed. CASE: A 76-year-old woman with stage IA endometrial adenocarcinoma sustained a left obturator nerve transection during pelvic lymphadenectomy that was recognized immediately. Robotic-assisted laparoscopic repair was performed successfully, with the patient experiencing no residual neuropathy 6 months postoperatively. CONCLUSION: Robotic-assisted laparoscopic repair is feasible for the treatment of obturator nerve injury.

Leiomyoma recurrent at the cervical stump: report of two cases.

Although supracervical hysterectomy is an increasingly popular modality for surgical management of benign uterine conditions data exploring all of its consequences are still forth coming. This case report will discuss the scenario of leiomyoma recurrence at the cervical stump after supracervical hysterectomy. After supracervical hysterectomy, the remnant cervix has the potential for leiomyoma formation. Surgeons performing supracervical hysterectomy should be aware of this possible outcome.

Robotic-assisted laparoscopic repair of a vesicouterine fistula.

BACKGROUND: As cesarean sections become a more common mode of delivery, they have become the most likely cause of vesicouterine fistula formation. The associated pathology with repeat cesarean deliveries may make repair of these fistulas difficult. Computer-enhanced telesurgery, also known as robotic-assisted surgery, offers a 3-dimensional view of the operative field and allows for intricate movements necessary for complex suturing and dissection. These qualities are advantageous in vesicouterine fistula repair. CASE: A healthy 34-year-old woman who underwent 4 cesarean deliveries presented with a persistent vesicouterine fistula. Conservative management with bladder decompression and amenorrhea-inducing agents failed. RESULTS: Robotic-assisted laparoscopic repair was successfully performed with the patient maintaining continence after surgery. CONCLUSION: Robotic-assisted laparoscopic repair of vesicouterine fistulas offers a minimally invasive approach to treatment of a complex disease process.

Hysterosalpingography versus sonohysterography for intrauterine abnormalities.

OBJECTIVE: The hysterosalpingogram is commonly used to evaluate the uterine cavity and the fallopian tubes in the workup of infertile couples. The sonohysterogram is gaining popularity as part of this evaluation. This study compares hysterosalpingography to sonohysterography for the detection of polyps, cavitary fibroids, adhesions, and septae in infertile patients. METHODS: We conducted a retrospective chart review of 149 infertility patients seen at a University Hospital Center, divisions of Reproductive Endocrinology and Interventional Radiology. Patients underwent hysterosalpingography and sonohysterography as part of their infertility evaluation. The reports were reviewed and findings like polyps, fibroids, adhesions, and septae were compared to the findings obtained at the time of hysteroscopy. Sensitivity, specificity, and accuracy of radiologic tests were the main outcome measures. RESULTS: The sensitivity of hysterosalpingography and sonohysterography was 58.2% and 81.8%, respectively. The specificity for hysterosalpingography and sonohysterography was 25.6% and 93.8%. The differences in sensitivity and specificity were both statistically significant. Hysterosalpingography had a general accuracy of 50.3%, while sonohysterography had a significantly higher accuracy of 75.5%. CONCLUSION: Although hysterosalpingography is the standard screening test for the diagnosis of tubal infertility and can provide useful information about the uterine cavity, sonohysterography is more sensitive, specific, and accurate in the evaluation of the uterine cavity.