{"paper_id":"c3ece8af-d437-4585-8595-891ecc2519ff","body_text":"review article 147\nRobotic Management of Endometriosis: \nDiscussion of Use, Criteria and Advantages: \na Review of the Literature\nIoannis D. Gkegkes 1, *, Christos Iavazzo 2 , George Iatrakis 3 , Paraskevi-Evangelia Iavazzo 4 , Fani Pechlivani 5 , \nEvangelia Antoniou 5 , Konstadia Bakalianou 6\nABSTRACT\nEndometriosis is a very common benign condition affecting fertility and quality of life. Different methods, either definitive or fertility \nsparing are used for its management by using open, laparoscopic, and robotic techniques. This is a literature review presenting the role \nand the advantages of robotic surgery in endometriosis. Such a management is effective, safe, and feasible in hands of well-trained \nmultidisciplinary teams even for severe cases of endometriosis.\nKEYWORDS\nda Vinci ©  robot; endometriosis; treatment; advantages; criteria; quality of life\nAUTHOR AFFILIATIONS\n1  Department of Surgery, Royal Devon and Exeter NHS Foundation Trust, Exeter, UK\n2  Department of Gynaecological Oncology, The Christie Hospital, Manchester, UK\n3  Department of Obstetrics and Gynaecology, T echnological Educational Institution of Athens, Athens, Greece\n4  Department of Paediatrics, General Hospital of Rethymno, Rethymno, Greece\n5  Department of Obstetrics and Gynaecology, T echnological Educational Institution of Athens, Athens, Greece\n6  Department of Obstetrics and Gynecology, General Hospital “Agia Olga” , Athens, Greece\n* Corresponding author: 17C James House Residential Village, EX2 5DS, Bovemoors Lane, Exeter, UK; e-mail: ioannisgkegkes@gmail.com\nReceived: 4 July 2019\nAccepted: 17 November 2019\nPublished online: 10 February 2020\nActa Medica (Hradec Králové) 2019; 62(4): 147–149\nhttps:/ /doi.org/10.14712/18059694.2020.3\n© 2019 The Authors. This is an open-access article distributed under the terms of the Creative Commons Attribution License  \n(http:/ /creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium,  \nprovided the original author and source are credited.\nAM_4_2019.indd   147AM_4_2019.indd   147 07.02.20   10:0807.02.20   10:08\n\n\n148 Ioannis D. Gkegkes et al.  Acta Medica (Hradec Králové)\n \nINTRODUCTION\nEndometriosis occurs in 5–15% of the general population \nand although a benign condition, sometimes it might re-\nquire difficult surgical dissections as it could be locally in-\nfiltrative, invasive, and widely disseminated. The typical \npatient is nulliparous, infertile, and around 30-years-old. \nThe most common sites of endometriosis intra-abdomi-\nnally include adnexae (two out of three cases), pouch of \nDouglas, uterosacral and broad ligaments, uterovesical \nfold, ureters, bladder, appendix, rectosigmoid colon or \ncaecum, and small bowel loops (1, 2).\nThe treatment options of endometriosis include med-\nical (e.g. progestins, danazol, GnRH- analogues) or sur-\ngical options which could be classified as most definitive \n(including hysterectomy and bilateral salpingo-oophorec-\ntomy) or fertility-sparing with the aim to excise all perito-\nneal endometriotic implants and adhesions but preserve \nfertility (3–6). Laparoscopic or open techniques, depend-\ning on each surgeon’s preference and experience, are of-\nfered as treatment options, while recently robotic proce-\ndures are also suggested.\nThe da Vinci© surgical system received FDA approval \nin 2005. Robotic procedures have been introduced in or-\nder to improve surgical performance. Increased dexterity , \ngreater range of motion, and better depth perception are \nthe main advantages of robotic-assisted techniques (7). Its \nlimitations include lack of tactile feedback and increased \ncost (8). Robotic procedures combine the advantages of \nopen and laparoscopic procedures and are another alter-\nnative in the management of endometriosis.\nThe aim of this narrative review is to present the use, \nthe criteria, and the advantages of robotic surgery in the \ntreatment of endometriosis.\nDISCUSSION\nDifferent techniques including open, laparoscopic or ro-\nbotic procedures can equally be used in the management \nof endometriosis (9–11). The patient is preoperatively as-\nsessed with imaging scans including ultrasound and MRI \nand she signs the informed consent when she is informed \nabout the type of planned procedure and possible risks \nof it including infection, bleeding, and injury of adjacent \norgans. Multidisciplinary experts, including gynaecolo-\ngists, urologists, and general surgeons, should cooperate \nin order to achieve the optimal outcome in the most severe \ncases.\nFertility-sparing techniques are used in order to de-\nstroy all endometriotic implants and remove all the possi-\nble adhesions. Removal and not lysis of them is preferred. \nEndometriomas larger than 3 cm are also excised either \nwith cystectomy , or if that is not technically possible, \nwith oophorectomy. If tubes are affected, salpingectomy \nis performed and IVF procedures are used for pregnancy \nachievement. If both adnexae are affected and bilateral \nsalpingo-oophorectomy is essential, the uterus is pre-\nserved and donor eggs could be used for pregnancy . In ro-\nbotic cases, all endometriotic implants are either excised \nor destroyed with scissors or diathermy . Segmental bowel \nresections, rectal shaving, and partial bladder resection \nare described in the literature (12). Ureteral endometriosis \ncould be treated with partial ureterectomy and ureterone-\nocystostomy (13). Special care should be taken during the \nexcision from small or large bowel and/or urinary tract to \navoid any injuries. However, deep infiltrative endometri-\nosis of the rectovaginal septum is one of the most severe \ntypes of endometriosis (14). For this reason, any hidden \nendometriosis should be completely excised to avoid de-\nveloping deeper nodular lesions in the future (14). It was \nrecently shown that infiltrating colorectal endometriosis \ncould be safely and effectively treated robotically even by \nperforming a rectosigmoidectomy if that is essential (1). In \ncase of most definitive techniques, total or even modified \nradical hysterectomies plus bilateral salpingooophorecto-\nmies might be essential to treat the disease. Of course, as \nin open and laparoscopic techniques, preoperative use of \nGnRH analogues for three to six months can improve sur-\ngical success.\nRobotic system preserves the advantages of conven -\ntional laparoscopy while it offers the possibility to the \ngynaecologist to dissect down and into the narrow pel-\nvic floor. It is suggested that a  diagnostic laparoscopy \nshould be used in order to clarify the range of the disease \nin the upper abdomen before docking the robot in order \nto know exactly where the disease is. In robotic systems, \nthe CO2  pressure required for exposure is often lower in \ncorrelation with traditional laparoscopy as result of the \nmechanical lift of the robot (15). Robotic procedures can \nbe safely performed after taking into account the physi-\nological changes of pneumoperitoneum and steep Tren-\ndelenburg position during a  preoperative anaesthetic \nreview (16). Robotics, also shares similar benefits of lapa-\nroscopy including smaller incisions (at most 10 to 12 mm) \n(15). The three-dimensional stereoscopic vision by the use \nof binocular optics, the filtration of the tremor, and the \nless operator fatigue are some of the obvious advantages \nof such operations. The articulated instruments permit \na wide range of motions while they increase the ability of \nthe surgeon to work efficiently. All the above mentioned \nadvantages can lead to more anatomical procedures. In \naddition, the 360° motion of the robotic wrist permits the \nfine adhesiolysis and removal of any suspicious nodule, \neven if it is quite deep. More specifically , Patzkowsky et \nal., comparing robotic to laparoscopic treatment in over \n500 patients, showed that age, body mass index, opera-\ntive time, and estimated blood loss were not statistical-\nly different between the two procedures. Furthermore, \nrobotic techniques could be easier used in larger uterus, \ncases with more severe adhesions, and stage III-IV endo-\nmetriosis (17). However, the rates of urinary tract infec-\ntions were higher in the robotic group (17). According to \nanother study , including women treated with robotic-as-\nsisted laparoscopy for stage III and IV endometriosis, the \nmedian actual surgical time was 145 minutes (ranging \nfrom 67 to 325 minutes), while the median blood loss was \n100 ml (ranging from 20 to 400 ml) depending on the se-\nverity of the case and the experience of the surgeon (18). \nAnother study group, showed that uterine weight higher \nthan 250 grams and older age predispose to longer surgi-\ncal time (19). In all those studies, the rates of conversion \nAM_4_2019.indd   148AM_4_2019.indd   148 07.02.20   10:0807.02.20   10:08\n\nRobotic Management of Endometriosis 149\nto open surgery and blood transfusion are minimal. So, \nthe robotic assisted surgery also permits the realization \nof a key hole operation which can be interpreted into sig-\nnificantly less blood loss, less pain, shorter recovery time, \nas well as shorter hospital stay and better aesthetic result. \nAdditionally , a shorter hospital stay and a quicker return \nto normal activity may mean less postoperative problems \nsuch as infection or pulmonary embolism. Last but not \nleast, the use of robotic systems gives the opportunity of \nrapid acquisition of surgical skills required in order to \nperform laparoscopic surgery , while at the same time en-\nable gynaecologists to reach at least as good clinical out-\ncomes as conventional laparoscopy and within shorter \noperating times once they exceed the initial stage of the \nlearning curve.\nOn the other hand, the high costs of use, the bulky \nmachinery , and the need for staff training are the most \nimportant drawbacks in the utilization of robot in such \noperations. Of course, entry of new robotic systems in the \nmarket, as well as the use of the robot by different surgi-\ncal teams, and in a high volume of patients could decrease \nthe cost disadvantage. Short term complications include \nvaginal cuff abscess (18), ureterovaginal fistulas (20), and \nhigher rates of urinary tract infection caused by extend-\ned use of Folley catheter for urinary retention (21). A rare \ncase of rhabdomyolysis and compartment syndrome, after \na 12-hour duration robotic operation, is also presented in \nthe literature (22), showing the need for training and time \nmanaging of such operations. Although larger prospective \nstudies as well as longer follow-up periods are necessary to \nclarify the long term outcomes including fertility results, \npain, and quality of life, it seems that robotic management \nof even severe cases of endometriosis is an effective, fea-\nsible, and safe alternative in well-trained hands as it was \nalso shown in a recent systematic review (23) and can be \nused without compromising the principles of open or lap-\naroscopic operations.\nCONFLICT OF INTEREST\nNo conflict of interest was declared by the authors.\nFINANCIAL DISCLOSURE\nThe authors declared that this study has received no finan-\ncial support.\nREFERENCES\n 1. Neme RM, Schraibman V , Okazaki S, et al. Deep infiltrating colorec-\ntal endometriosis treated with robotic-assisted rectosigmoidectomy . \nJSLS 2013; 17(2): 227–34.\n 2. Gui B, Valentini AL, Ninivaggi V , Marino M, Iacobucci M, Bonomo L. \nDeep pelvic endometriosis: don’t forget round ligaments. Review of \nanatomy, clinical characteristics, and MR imaging features. Abdom \nImaging 2014; 39(3): 622–32.\n 3. Jacobson TZ. Potential cures for endometriosis. Ann N Y Acad Sci \n2011; 1221: 70–4.\n 4. Grandi G, Xholli A, Napolitano A, Palma F, Cagnacci A. Pelvic pain \nand quality of life of women with endometriosis during quadriphasic \nestradiol valerate/dienogest oral contraceptive: a patient-preference \nprospective 24-week pilot study . Reprod Sci 2015; 22(5): 626–32.\n 5. Agarwal S, Fraser MA, Chen I, Singh SS. Dienogest for the treatment \nof deep endometriosis: case report and literature review. J Obstet Gy-\nnaecol Res 2015; 41(2): 309–13.\n 6. Yamaguti EM, Brito MB, Ferriani RA, Garcia AA, Rosa-e-Silva JC, Vie-\nira CS. Comparison of the hemostatic effects of a levonorgestrel-re-\nleasing intrauterine system and leuprolide acetate in women with \nendometriosis: a randomized clinical trial. Thromb Res 2014; 134(6): \n1193–7.\n 7. Iavazzo C, Gkegkes ID. Single-site port robotic-assisted hysterecto-\nmy: a systematic review. Arch Gynecol Obstet 2014; 289(4): 725–31.\n 8. Iavazzo C, Papadopoulou EK, Gkegkes ID. Cost assessment of robotics \nin gynecologic surgery: a systematic review. J Obstet Gynaecol Res \n2014; 40(11): 2125–34.\n 9. Duffy JM, Arambage K, Correa FJ, et al. Laparoscopic surgery for en-\ndometriosis. Cochrane Database Syst Rev 2014; (4): CD011031.\n10. Roman H. Endometriosis surgery and preservation of fertility , what \nsurgeons should know. J Visc Surg 2018; 155 Suppl 1: S31–S36.\n11. Nezhat C, Lewis M, Kotikela S, et al. Robotic versus standard lapa-\nroscopy for the treatment of endometriosis. Fertil Steril 2010; 94(7): \n2758–60.\n12. Siesto G, Ieda N, Rosati R, Vitobello D. Robotic surgery for deep endo-\nmetriosis: a paradigm shift. Int J Med Robot 2014; 10(2): 140–6.\n13. Frick AC, Barakat EE, Stein RJ, Mora M, Falcone T. Robotic-assisted \nlaparoscopic management of ureteral endometriosis. JSLS 2011; \n15(3): 396–9.\n14. Nezhat FR, Mahmoud MS. Allen masters peritoneal defect: a poten-\ntial pathway to deep infiltrating rectovaginal endometriosis? J Minim \nInvasive Gynecol 2014; 21(3): 321–2.\n15. Iavazzo C, Gkegkes ID. Port site metastases after robot-assisted sur-\ngery: a systematic review. Int J Med Robot 2013; 9(4): 423–7.\n16. Gupta K, Mehta Y , Sarin Jolly A, Khanna S. Anaesthesia for robotic \ngynaecological surgery . Anaesth Intensive Care 2012; 40(4): 614–21.\n17. Patzkowsky KE, As-Sanie S, Smorgick N, Song AH, Advincula AP . \nPerioperative outcomes of robotic versus laparoscopic hysterectomy \nfor benign disease. JSLS 2013; 17(1): 100–6.\n18. Bedaiwy MA, Rahman MY , Chapman M, et al. Robotic-assisted hys-\nterectomy for the management of severe endometriosis: a retrospec-\ntive review of short-term surgical outcomes. JSLS 2013; 17(1): 95–9.\n19. Giep BN, Giep HN, Hubert HB. Comparison of minimally invasive \nsurgical approaches for hysterectomy at a community hospital: ro-\nbotic-assisted laparoscopic hysterectomy , laparoscopic-assisted \nvaginal hysterectomy and laparoscopic supracervical hysterectomy . \nJ Robot Surg 2010 Sep; 4(3): 167–75.\n20. McAchran SE, Paolone DR. The iatrogenic ureterovaginal fistula. \nUrology 2013; 81(6): e35.\n21. Smorgick N, DeLancey J, Patzkowsky K, Advincula A, Song A, As-\nSanie S. Risk factors for postoperative urinary retention after lap-\naroscopic and robotic hysterectomy for benign indications. Obstet \nGynecol 2012; 120(3): 581–6.\n22. Deras P , Amraoui J, Boutin C, Laporte S, Ripart J. [Rhabdomyolysis \nand compartment syndrome of two forearms after robotic assisted \nprolonged surgery]. Ann Fr Anesth Reanim 2010; 29(4): 301–3.\n23. Carvalho L, Abrão MS, Deshpande A, Falcone T. Robotics as a new \nsurgical minimally invasive approach to treatment of endometriosis: \na systematic review. Int J Med Robot 2012; 8(2): 160–5.\nAM_4_2019.indd   149AM_4_2019.indd   149 07.02.20   10:0807.02.20   10:08","source_license":"CC-BY-4.0","license_restricted":false}