{"paper_id":"e7d96b54-9770-4035-aaac-1fc97d5b016c","body_text":"Endometriosis is a gynecologic disorder defined as the presence of endometrial glands\nand stroma outside the uterine cavity. It affects as many as 15% of fertile\nwomen and up to 50% of infertile women. 1  Endometriosis most commonly affects the pelvic organs. When\nfound outside the pelvis, it is termed extragenital or extrapelvic endometriosis.\nThe most common sites of extragenital endometriosis are the intestine and urinary\ntract. Less commonly, endometriosis can affect distant sites including the lung and\ndiaphragm. 2\nLaparoscopic management of extensive extragenital endometriosis has been reported by\nour group since the mid to late 1980s. (See Nezhat, C. Nezhat, F. Presentation of\nEvaluation of safety of videolaparoscopic treatment of bowel endometriosis at\nScientific Paper and Poster Sessions, 44th Annual Meeting of the American Fertility\nSociety. October 8-13, 1988. Atlanta, Georgia). 3 – 12  Recently,\nrobot-assisted laparoscopy has been used to manage pelvic endometriosis. 13 – 21\nUsing a computer-enhanced robotic system has multiple advantages. It provides a\n3-dimensional view, excellent visualization of the surgical field, and tremor-free\nmovement. The simulation of an open surgical environment facilitates the successful\ncompletion of complex procedures that are not otherwise easily accomplished\nlaparoscopically by less experienced surgeons. Thus, the robot can enable\nlaparoscopic surgical management of inherently complex procedures such as treatment\nof severe extragenital endometriosis.\nHere, we report our experience with successful robotic-assisted laparoscopic\ntreatment of endometriosis of the bowel, bladder, and ureter in 5 patients. Although\nstandard laparoscopic management of this pathology has been reported since the late\n1980s, it is not widely practiced. The addition of computer-enhanced technology may\nfacilitate the conversion of these procedures from laparotomy to laparoscopy. We\nwill describe our procedures and discuss the potential benefits afforded by robotics\nin these cases.\n\nIn each case, laparoscopy was assisted by the da Vinci Robotic Surgical System\n(Intuitive Surgical Inc., Sunnyvale, CA). Our surgical techniques have been\ndescribed previously. 17 , 19  In summary, all patients were\nplaced in the dorsal lithotomy position. A Foley catheter was placed followed by\ninsertion of a HUMI uterine manipulator. Four laparoscopic ports were inserted: one\n12-mm umbilical, two 8-mm midlateral, and one 5-mm to 12-mm suprapubic or one right\nupper quadrant port. We began each procedure using standard laparoscopy with\nsubsequent introduction of the robot into the surgical field. During robot-assisted\nlaparoscopy, the primary surgeon controlled the robot remotely from the console,\nwhich displayed a high-definition, highly magnified 3D image of the surgical field.\nThe suprapubic port was used by the assistant to provide ancillary laparoscopic\ninstruments as needed by the surgeon. Instruments used during the robotic procedures\nincluded a needle holder, a monopolar hook, a suction/irrigator, a grasper, and\nscissors. Additional equipment used during the laparoscopic portion of the\nprocedures included a vessel-sealing device, a CO 2  laser, a\nsuction/irrigator, a grasper, the Kleppinger bipolar system (Richard Wolf Medical\nInstruments Corporation, Vernon Hills, IL), and/or the PlasmaJet energy system\n(Plasma Surgical, Limited, Abingdon, Oxfordshire).\n\nTwo patients with endometriosis of the bowel, 2 patients with endometriosis of the\nureter, and 1 patient with endometriosis of the bladder are included in this report\n ( Table 1 ) . All patients\ngave their consent to be included in this case study.\nBasic Characteristics of Patients Included in Case Series\nOf the 2 patients with bowel endometriosis, the first underwent robotic-assisted\nlaparoscopic radical hysterectomy, bilateral salpingo-oophorectomy and segmental\nbowel resection, with reanastomosis. 5 , 6 , 10 , 20  The\npatient is a 41-year-old G1P1 with no medical comorbidities and a history of\nsevere endometriosis previously treated laparoscopically in 2000 and 2002. The\npatient also underwent a cesarean delivery in 2003. She complained\npreoperatively of diffuse pelvic pain, diarrhea, dyschezia, and dysmenorrhea\nthat had been relieved somewhat by prior surgical treatment but had\nrecurred.\nUpon entry with the laparoscope, we noted extensive adhesions of the rectum and\nrectosigmoid colon to the uterus and adnexa, resulting in complete posterior\ncul-de-sac obliteration. In addition, there was a stricture of the rectosigmoid\ncolon approximately 30cm from the dentate line. We performed a cystoscopy and\ninserted ureteral catheters bilaterally before proceeding with the radical\nhysterectomy and bilateral salpingo-oophorectomy. Our surgical techniques have\nbeen described previously. 18 \nWe then mobilized the rectosigmoid colon down to the rectovaginal fascia. The\nrectosigmoid segment and the distal sigmoid colon were severely foreshortened by\nthe large volume of surrounding fibrosis and endometriosis. Careful dissection\nwas carried laterally to mobilize the descending colon as well as a fibrotic\nsigmoid endometrioma. The left ureter was identified, dissected, and left free\nin the retroperitoneal space. The endometrioma and rectosigmoid segment were\nshifted and retracted laterally. Dissection was continued to free the cuff of\nthe upper rectum, which was then divided with an Endo-GIA that had been placed\nthrough the ancillary port. The mesocolon was also divided at the level of the\nsigmoid colon in anticipation of reanastomosis. In sum, a 10-cm segment of the\nrectosigmoid colon more than 30cm from the dentate line was removed. The\nsuprapubic incision was enlarged to 4cm, and the Alexis wound protector was\ninserted. The excised rectosigmoid segment was removed through the enlarged\nsuprapubic incision. An EEA stapler was inserted into the rectum after\nsufficient dilatation, and the rectal stump was reanastomosed to the sigmoid\ncolon. We ensured that there was no tension at the level of the anastomosis. The\nproximal sigmoid colon was then obliterated by compression, and the anastomosis\nwas submerged under saline solution. The rectum was insufflated with air under\npressure to assure there was no leak. The patient did well after surgery and was\ndischarged on the third postoperative day. Pathology revealed severe bowel\nendometriosis. This patient is doing well and is pain free 10 months later.\nThe second patient with bowel endometriosis underwent robotic-assisted\nlaparoscopic disc excision of the rectal wall. 3 , 11 , 12 , 22  The patient is a 30-year-old G0 with a history of\ncongenital absence of the left kidney and left adnexa as well as unicornuate\nuterus. She presented with constipation and dyschezia. Prior to our involvement\nin her case, she had been evaluated for these symptoms and was found to have a\npalpable mass on rectal examination. A colonoscopy revealed a 4-cm submucosal\nmass approximately 10cm from the anal verge. An exploratory laparoscopy was\nperformed and confirmed the presence of severe endometriosis after which the\npatient was referred to our center.\nUpon entry with the laparoscope, we noted evidence of complete posterior\ncul-de-sac obliteration as well as a 4-cm saddle lesion on the anterior\nrectosigmoid colon approximately 18cm from the dentate line and attached to the\nposterior aspect of the vagina and unicornuate uterus. We proceeded with careful\ndissection and mobilization of the rectosigmoid colon. Right and left pararectal\nareas were entered laterally. Superiorly, we entered the presacral space at the\nlevel of the sacral promontory, and inferiorly we entered the rectovaginal\nspace. This process was complicated by the severe nodularity and fibrosis\ncreated by extensive endometriosis in this area. After mobilization, we excised\nthe lesion approximately 20cm from the dentate line using the da Vinci Robot\ngrasper and scissors. The excised portion of bowel measured 4.3cm in total. We\nrepaired the defect with multiple interrupted 2-0 Vicryl sutures using the da\nVinci Robot needle holders. Sigmoidoscopy was performed to confirm adequate\nrepair. Pathology revealed extensive endometriosis of the rectum, rectovaginal\nseptum, and bowel. Postoperatively, the patient is doing well and is pain free\n12 months later.\nOf the 2 patients with ureteral endometriosis, the first underwent\nrobotic-assisted laparoscopic hysterectomy and right ureteroneocystostomy with a\npsoas hitch. 4 , 8 , 19 , 23  The patient is a 49-year-old\nG2P2 with no medical comorbidities who presented with diffuse pelvic pain,\ndysmenorrhea, and significant genitourinary symptoms including urgency and\nfrequency.\nUpon entry with the laparoscope, we noted severe endometriosis of the posterior\ncul-de-sac and lower portion of the broad ligament as well as evidence of\npartial right hydroureter. We proceeded first with hysterectomy. Our surgical\ntechnique has been described previously. 19  We then directed our attention to the extensive\nendometriosis creating a stricture of the right ureter. We first mobilized the\nureter beginning approximately 7cm from the insertion of the ureter to the\nbladder. Given the extensive disease burden in this area, we transected the\naffected portion of the ureter and made a fish mouth incision using robotic\nscissors. Retroperitoneal mobilization of the ureter was then carried up above\nthe pelvic brim. A bladder flap was developed, and the space of Retzius was\nentered to complete mobilization. Three 1-0 interrupted delayed absorbable\nsutures were placed through the bladder dome to the psoas tendon and were\nsecured. A cystotomy was then made in the dome of the bladder and a 0.38 Benson\nguidewire was passed through this cystotomy into the intraperitoneal space and\nthen retrograde up the right ureter into the renal pelvis. The ureter was then\nanastomosed to the bladder by using 4 interrupted, full-thickness 4-0\npolydioxanone sutures placed at 3, 6, 9, and 12 o’clock. These sutures\nincorporated the serosa, muscularis, and mucosa of the bladder and ureter. The\nureteral stent was retained for 4 weeks. Pathology revealed severe endometriosis\nof the uterosacral cardinal ligament complex and endometriosis of the right\nureter. Postoperatively, the patient is doing well and has been pain free for\nover 4 years.\nThe second patient with endometriosis of the ureter also had severe endometriosis\nof the left pelvic sidewall affecting the left external iliac artery and vein,\nthe left common iliac artery and vein, and the superior and inferior hypogastric\nplexi. The patient is a 36-year-old G1 with chronic hypertension. She presented\nwith diffuse pelvic pain, constipation, dyspareunia, severe left lower quadrant\npain, and left lower extremity pain, swelling, and paresthesia. Given this\nhistory, her physician had recommended life long anti coagulation therapy. The\npatient presented to us after a previous attempt at curative open surgery had\nbeen unsuccessful. Her surgeons had indicated that further attempts at surgical\ntreatment might result in loss of her leg or death. Prior to surgery, imaging\nrevealed an infiltrative soft tissue process within the left pelvis, which\nexerted a mass effect upon the left ureter causing severe hydronephrosis and\nhydroureter. A renal scan revealed severe cortical thinning and only 15%\nremaining kidney function.\nThe patient underwent robotic-assisted laparoscopic left nephrectomy, right\nureterolysis, resection of endometriosis of the rectovaginal septum, and removal\nof endometriosis of the major vessels of the left pelvic wall. Upon entry with\nthe laparoscope, we noted extensive adhesions of the rectum and rectosigmoid\ncolon to the fundus of the uterus obliterating the posterior cul-de-sac and then\nextending superiorly. We first proceeded with enterolysis and ureterolysis. The\nleft ureter was occluded 10cm from the ureterovesical junction. Superior to this\npoint, severe hydronephrosis was noted consistent with previous imaging. The\ninferior obliterated portion of the left ureter was resected and a left simple\nnephrectomy was performed. Multiple pathology specimens from the right and left\nsidewalls, right ureteral serosa, the left ureter, the rectal bulb, the left\nexternal iliac artery and vein, the left common iliac artery and vein, and the\nbowel were positive for endometriosis. The excised left kidney had evidence of\nchronic obstructive pyelonephritis. Postoperatively, after 8 months of\nfollow-up, the patient has done well. Her left lower extremity swelling and\nnumbness have resolved. She is pain-free and spontaneously achieved pregnancy 5\nmonths after surgery. She delivered a healthy child in August 2011.\nThe final patient with endometriosis of the bladder underwent robotic-assisted\nlaparoscopic segmental bladder resection and repair. The patient is a\n31-year-old G0 with no medical comorbidities who presented with frequency and\ndysuria mostly during menses. The patient had no past surgical history.\nPreoperatively, a cystoscopy was performed and confirmed the presence of a 2-cm\nby 3-cm mass in the midline 3cm behind the intraureteric ridge.\nUpon laparoscopic entry, we noted an endometriotic lesion near the dome of the\nbladder that corresponded to the lesion observed during cystoscopy. We then\nproceeded with resection of this bladder mass. We first entered the\nvesicovaginal space and mobilized the bladder posteriorly. We then entered the\nright and left paravesical spaces as well as the space of Retzius to mobilize\nthe bladder anteriorly. The endometriotic nodule and a surrounding segment of\nbladder, measuring 3.2cm in total, were removed. We then repaired the bladder\nwith a running stitch and then with multiple interrupted stitches of Vicryl\nusing da Vinci Robotic instruments. A cystoscopy was performed to confirm\nadequate repair. Pathology revealed endometriosis of the bladder wall.\nPostoperatively, the patient is doing well and is pain free after 12 months.\n\nDespite early criticism, advanced operative laparoscopy is slowly replacing\nlaparotomy as the gold standard of operative management for a large proportion of\nprocedures. 24 – 27  Minimally invasive surgery has progressed to include\nadvanced procedures previously thought possible only by open incision. As early as\n1988, our group successfully managed bowel endometriosis with laparoscopic\nsurgery. 3 , 5  More recently, in 2010, a randomized comparison of\nlaparoscopically assisted versus open colectomy for colon cancer published in the\n New England Journal of Medicine  demonstrated beneficial results\nin favor of minimally invasive procedures. 24  There is now a substantial body of evidence to support the\nlaparoscopic approach as the preferred method for many procedures, including surgery\nfor malignancies. 26\nDespite the clear advantages of minimally invasive surgery, a majority of procedures\ntoday still are performed by laparotomy. This preference for open procedures is\nlikely due to the lack of trained endoscopic surgeons, the difficulty in obtaining\nproper instruments, and the long learning curve of operative laparoscopy.\nThe recent advent of computer-enhanced technology, more sophisticated instruments and\nbetter energy sources may provide the bridge necessary for surgeons to incorporate\nlaparoscopic surgery into their practice. The da Vinci Robot is one example of how\ntechnology can assist in this regard. Since Nezhat's collaborative work with\nrobotic pioneers Ajit Shah and Phil Green of the Stanford Research Institute who\ndeveloped the Da Vinci robot in the 1990s, this technology has been successfully\napplied to multiple fields. The robot enables visualization of the surgical field in\n3 dimensions, eliminates tremors, has more wrist motions, and decreases the learning\ncurve for suturing, 28  all while\nallowing the surgeon to sit. The advantages of the robot are especially useful to\nthe inexperienced laparoscopic surgeon during complex procedures such as those\ndescribed here. The addition of robotic assistance may lead more surgeons to adopt\nminimally invasive techniques for complex cases when otherwise they might have\nresorted to laparotomy. This is especially true in a training program such as ours.\nThe procedures described here require advanced laparoscopic suturing skills and thus\nmay not be feasible for fellows in training with more limited laparoscopic\nexperience. Robotic-assisted laparoscopic surgery may shorten the learning curve for\nthese surgeons. Nevertheless, research to date has not shown superior patient\noutcomes using computer enhanced technology (robotic assistance) when compared to\nstandard laparoscopy.\nThe additional cost of the robot when compared to standard laparoscopy is not\nnegligible. This additional cost includes, not only the cost of the system itself\nbut also maintenance, the need for specially trained staff, and additional operating\nroom time. However, this cost might be outweighed by the benefit to the public in\ngeneral should robotic technology result in a greater proportion of cases being\nperformed by minimally invasive techniques with the potential result of shorter\nhospital stays, decreased postoperative morbidity, and fewer recovery days away from\nwork. The cases reported here are some of the first examples of robot-assisted\nlaparoscopic treatment of multiorgan endometriosis involving the bowel, bladder, and\nureter. The patients in this series overall had favorable outcomes after treatment.\nThis would suggest that robotic assistance in the treatment of extragenital\nendometriosis is feasible and safe. However, further randomized trials are needed to\nfully assess the benefits afforded by robotic assistance in this patient\npopulation.","source_license":"CC0","license_restricted":false}