Robotics in gynecologic surgery.

Robotic surgery has evolved from an investigational surgical approach to a clinically useful adjunct in multiple surgical specialties over the past decade. Advocates of robotic-assisted gynecologic surgery revere the system's wristed instrumentation, ergonomic positioning, and three-dimensional high-definition vision system as significant improvements over laparoscopic equipment's four degrees of freedom and two-dimensional laparoscope that demand the surgeon stand throughout a procedure. The cost, lack of haptic feedback, and the bulky size of the equipment make robotics less attractive to others. Studies evaluating outcomes in robotic-assisted gynecologic surgery are limited. Multiple small retrospective studies demonstrate the safety and feasibility of robotic hysterectomy. With increased surgeon experience, operative times are similar to, or shorter than, laparoscopic cases. Robotic assistance can facilitate suturing in laparoscopic myomectomies, and is associated with decreased blood loss and a shorter hospital stay, although may require longer operative times. Robotic assistance has also been applied to multiple procedures in the subspecialties of infertility, urogynecology and gynecologic oncology with good success and relatively low morbidity. However, further research is warranted to better evaluate the relative benefits and costs of robotic assisted gynecologic surgery.

Hysteropexy. A review.

Uterine prolapse is a common problem in women that negatively affects one's quality of life. Surgical treatment commonly involves a hysterectomy followed by vaginal vault suspension of some type. Hysteropexy to treat uterovaginal prolapse has a long history dating back to the 1800s and has gone through many changes. Recent literature describes vaginal, open abdominal and laparoscopic approaches. Vaginal sacrospinous hysteropexy is well-supported by the scientific literature. Favorable postoperative outcomes range from 62-100% and additional data show improved quality of life and sexual function. Anatomic outcomes appear to be comparable to vaginal hysterectomy with sacrospinous ligament vault suspension. Additionally, encouraging outcomes following pregnancy have been described. The sacrohysteropexy, performed through a laparotomy incision or laparoscopically, also has favorable data, with cure rates ranging from 91-100%. Studies supporting this procedure also describe improvements in quality of life and sexual function. Complications related to these procedures are similar to those described after vaginal vault suspension using comparable techniques, although most studies report shorter operative times and less blood loss. At the present time, hysteropexy, either transvaginal or abdominal, seems to be a safe procedure with acceptable results in women who desire uterine preservation. As these procedures gain popularity and data become available, questions related to patient selection, surgical durability, outcomes following pregnancy, and complications related to risk of uterine pathology will likely be answered.