{"paper_id":"ffd9c739-936f-448e-968a-c8f6716694e8","body_text":"Abstract\nPurpose\nDrug resistance and severe pelvic pain often warrant surgical intervention for treating deep endometriosis (DE); however, damage to the autonomic nervous system can occur because of anatomical considerations. We aimed to investigate the advantages of robotic technology in enabling precise dissection, even in DE.\nMethods\nWe retrospectively compared the surgical outcomes of robot-assisted (RA) and conventional laparoscopic (CL) nerve-sparing modified radical hysterectomies (NSmRHs) for DE.\nResults\nBetween the two groups (RA-NSmRH group, n = 50; CL-NSmRH group, n = 18), no differences were identified based on patient demographics, such as age, body mass index, previous surgery, revised American Society of Reproductive Medicine classification, Enzian classification, uterine weight, number of removed DE lesions, and concomitant procedures. All patients in both groups achieved complete removal of the DE lesions with complete bilateral pelvic autonomic nerve preservation. The mean operative time (OT) was significantly longer (130 ± 46 vs. 98 ± 22 min, p < 0.01), and estimated blood loss (EBL) was lower (35 ± 44 vs. 131 ± 49 ml, p < 0.01) in the RA-NSmRH group than in the CL-NSmRH group. The hospitalization days (4.3 ± 1.3 vs. 4.1 ± 0.2 days, p = 0.45) and perioperative complications with Clavien–Dindo classification ≥ grade III (0% vs. 0%) were not significant in both the groups. None of the patients required self-catheterization after surgery.\nConclusion\nCompared with CL-NSmRH, RA-NSmRH was associated with longer OT and lower EBL, whereas the number of hospitalization days and complications were similar in both groups. Our results imply that nerve-sparing surgery can be safely and reproducibly performed using conventional or robotic laparoscopic modalities to treat DE.\nSimilar content being viewed by others\nData availability\nThe data that support the findings of this study are not openly available due to reasons of sensitivity and are available from the corresponding author upon reasonable request.\nReferences\nChapron C, Chopin N, Borghese B, Foulot H, Dousset B, Vacher-Lavenu MC, Hasan W, Bricou A (2006) Deeply infiltrating endometriosis: pathogenetic implications of the anatomical distribution. Hum Reprod 21:1839–1845. https://doi.org/10.1093/humrep/del079\nChiantera V, Petrillo M, Abesadze E, Sozzi G, Dessole M, Catello Di Donna M, Scambia G, Sehouli J, Mechsner S (2018) Laparoscopic neuronavigation for deep lateral pelvic endometriosis: clinical and surgical implications. J Minim Invasive Gynecol 25:1217–1223. https://doi.org/10.1016/j.jmig.2018.02.015\nManieri Rocha R, Leonardi M, Eathorne A, Armour M, Condous G (2023) Anatomical distribution of endometriosis: a cross-sectional analysis of transvaginal ultrasound in symptomatic patients. Australas J Ultrasound Med 26:131–141. https://doi.org/10.1002/ajum.12327\nVesale E, Roman H, Moawad G, Benoit L, Touboul C, Darai E, Bendifallah S (2020) Voiding dysfunction after colorectal surgery for endometriosis: a systematic review and meta-analysis. J Minim Invasive Gynecol 27:1490-1502.e3. https://doi.org/10.1016/j.jmig.2020.07.019\nImboden S, Bollinger Y, Härmä K, Knabben L, Fluri M, Nirgianakis K, Mohr S, Kuhn A, Mueller MD (2021) Predictive factors for voiding dysfunction after surgery for deep infiltrating endometriosis. J Minim Invasive Gynecol 28:1544–1551. https://doi.org/10.1016/j.jmig.2021.01.009\nMabrouk M, Raimondo D, Arena A, Iodice R, Altieri M, Sutherland N, Salucci P, Moro E, Seracchioli R (2019) Parametrial endometriosis: the occult condition that makes the hard harder. J Minim Invasive Gynecol 26:871–876. https://doi.org/10.1016/j.jmig.2018.08.022\nSoares M, Mimouni M, Oppenheimer A, Nyangoh Timoh K, du Cheyron J, Fauconnier A (2021) Systematic nerve sparing during surgery for deep-infiltrating posterior endometriosis improves immediate postoperative urinary outcomes. J Minim Invasive Gynecol 28(6):1194–1202. https://doi.org/10.1016/j.jmig.2020.10.016\nRob L, Halaska M, Robova H (2010) Nerve-sparing and individually tailored surgery for cervical cancer. Lancet Oncol 11:292–301. https://doi.org/10.1016/S1470-2045(09)70191-3\nLong Y, Yao DS, Pan XW, Ou TY (2014) Clinical efficacy and safety of nerve-sparing radical hysterectomy for cervical cancer: a systematic review and meta-analysis. PLoS ONE 9:e94116. https://doi.org/10.1371/journal.pone.0094116\nVolpi E, Ferrero A, Sismondi P (2004) Laparoscopic identification of pelvic nerves in patients with deep infiltrating endometriosis. Surg Endosc 18:1109–1112. https://doi.org/10.1007/s00464-003-9115-8\nKavallaris A, Banz C, Chalvatzas N, Hornemann A, Luedders D, Diedrich K, Bohlmann M (2011) Laparoscopic nerve-sparing surgery of deep infiltrating endometriosis: description of the technique and patients’ outcome. Arch Gynecol Obstet 284:131–135. https://doi.org/10.1007/s00404-010-1624-9\nCeccaroni M, Clarizia R, Bruni F, D’Urso E, Gagliardi ML, Roviglione G, Minelli L, Ruffo G (2012) Nerve-sparing laparoscopic eradication of deep endometriosis with segmental rectal and parametrial resection: the Negrar method. A single-center, prospective, clinical trial. Surg Endosc 26:2029–2045. https://doi.org/10.1007/s00464-012-2153-3\nde Resende JA, Júnior CLT, Crispi CP, de Freitas FM (2017) Risk of urinary retention after nerve-sparing surgery for deep infiltrating endometriosis: a systematic review and meta-analysis. Neurourol Urodyn 36:57–61. https://doi.org/10.1002/nau.22915\nRabischong B, Botchorishvili R, Bourdel N, Curinier S, Campagne-Loiseau S, Pouly JL, Canis M (2018) Nerve sparing techniques in deep endometriosis surgery to prevent urinary or digestive functional disorders: techniques and results: CNGOF-HAS Endometriosis Guidelines. [article in French]. Gynecol Obstet Fertil Senol 46:309–313. https://doi.org/10.1016/j.gofs.2018.02.031\nErcoli A, Bassi E, Ferrari S, Surico D, Fagotti A, Fanfani F, De Cicco F, Surico N, Scambia G (2017) Robotic-assisted conservative excision of retrocervical-rectal deep infiltrating endometriosis: a case series. J Minim Invasive Gynecol 24:863–868. https://doi.org/10.1016/j.jmig.2017.03.011\nRoman H, Crestani A, Merlot B (2022) Excision of deep endometriosis nodules of the sciatic nerve using robotic assistance, with video. J Visc Surg 159:74–76. https://doi.org/10.1016/j.jviscsurg.2021.11.007\nFerrari FA, Youssef Y, Naem A, Ferrari F, Odicino F, Krentel H, Moawad G (2024) Robotic surgery for deep-infiltrating endometriosis: is it time to take a step forward? Front Med (Lausanne) 11:1387036. https://doi.org/10.3389/fmed.2024.1387036\nTuttlies F, Keckstein J, Ulrich U et al (2005) ENZIAN-score, a classification of deep infiltrating endometriosis. [article in German]. Zentralbl Gynakol 127:275–281. https://doi.org/10.1055/s-2005-836904\nKeckstein J, Hudelist G (2021) Classification of deep endometriosis (DE) including bowel endometriosis: from r-ASRM to #Enzian-classification. Best Pract Res Clin Obstet Gynaecol 71:27–37. https://doi.org/10.1016/j.bpobgyn.2020.11.004\nKanno K, Andou M, Aiko K, Yoshino Y, Sawada M, Sakate S, Yanai S (2021) Fertility- and nerve-sparing laparoscopic eradication of deep endometriosis with total posterior compartment peritonectomy: the Kurashiki method. J Minim Invasive Gynecol 28:170–171. https://doi.org/10.1016/j.jmig.2020.05.028\nKanno K, Andou M, Aiko K, Yoshino Y, Sawada M, Sakate S, Yanai S (2021) Robot-assisted nerve plane-sparing eradication of deep endometriosis with double-bipolar method. J Minim Invasive Gynecol 28:757–758. https://doi.org/10.1016/j.jmig.2020.07.018\nKinugasa Y, Murakami G, Suzuki D, Sugihara K (2007) Histological identification of fascial structures posterolateral to the rectum. Br J Surg 94:620–626. https://doi.org/10.1002/bjs.5540\nHöckel M, Horn LC, Hentschel B, Höckel S, Naumann G (2003) Total mesometrial resection: high resolution nerve-sparing radical hysterectomy based on developmentally defined surgical anatomy. Int J Gynecol Cancer 13:791–803. https://doi.org/10.1111/j.1525-1438.2003.13608.x\nCanis M, Donnez JG, Guzick DS, Halme JK, Rock JA, Schenken RS, Vernon MW (1997) Revised American Society for Reproductive Medicine classification of endometriosis: 1996. Fertil Steril 67:817–821. https://doi.org/10.1016/S0015-0282(97)81391-X\nDindo D, Demartines N, Clavien PA (2004) Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg 240:205–213. https://doi.org/10.1097/01.sla.0000133083.54934.ae\nBarry MJ, Fowler FJ Jr, O’Leary MP, Bruskewitz RC, Holtgrewe HL, Mebust WK, Cockett ATK (1992) The American Urological Association symptom index for benign prostatic hyperplasia. The Measurement Committee of the American Urological Association. J Urol 148(5 Part 1):1549–1557. https://doi.org/10.1016/S0022-5347(17)36966-5\nKanno K, Aiko K, Yanai S, Sawada M, Sakate S, Andou M (2021) Clinical use of indocyanine green during nerve-sparing surgery for deep endometriosis. Fertil Steril 116:269–271. https://doi.org/10.1016/j.fertnstert.2021.03.014\nNezhat C, Nguyen K, Ackroyd E, Roman RA, Rambhatla A, Nezhat A, Asiaii A (2020) Nerve-sparing modified radical hysterectomy for severe endometriosis and complex pelvic pathology. Cureus 12:e9882. https://doi.org/10.7759/cureus.9882\nChong GO, Lee YH, Hong DG, Cho YL, Park IS, Lee YS (2013) Robot versus laparoscopic nerve-sparing radical hysterectomy for cervical cancer: a comparison of the intraoperative and perioperative results of a single surgeon’s initial experience. Int J Gynecol Cancer 23:1145–1149. https://doi.org/10.1097/IGC.0b013e31829a5db0\nAleksandrov A, Smith AV, Botchorishvili R, Rabischong B (2022) How to dissect the pelvic nerves: from microanatomy to surgical rules. An evidencebased clinical review. Facts Views Vis Obgyn 14(1):17–29\nZhao D, Li B, Wang Y, Liu S, Zhang Y, Yuan G (2020) Clinical outcomes in early cervical cancer patients treated with nerve plane-sparing laparoscopic radical hysterectomy. J Minim Invasive Gynecol 27:687–696. https://doi.org/10.1016/j.jmig.2019.04.025\nLi K, He X, Zheng Y (2021) An optimal surgical plane for laparoscopic functional total mesorectal excision in rectal cancer. J Gastrointest Surg 25:2726–2727. https://doi.org/10.1007/s11605-021-05035-9\nLi K, He X, Tong S, Zheng Y (2021) Nerve plane: an optimal surgical plane for laparoscopic rectal cancer surgery? Med Hypotheses 154:110657. https://doi.org/10.1016/j.mehy.2021.110657\nIshikawa K, Nakao S, Nakamuro M, Huang TP, Nakano H (2016) The retroperitoneal interfascial planes: current overview and future perspectives. Acute Med Surg 3:219–229. https://doi.org/10.1002/ams2.188\nDonnez O, Roman H (2017) Choosing the right surgical technique for deep endometriosis: shaving, disc excision, or bowel resection? Fertil Steril 108:931–942. https://doi.org/10.1016/j.fertnstert.2017.09.006\nDonnez O (2021) Conservative management of rectovaginal deep endometriosis: shaving should be considered as the primary surgical approach in a high majority of cases. J Clin Med 10:5183. https://doi.org/10.3390/jcm10215183\nHaas D, Chvatal R, Habelsberger A, Schimetta W, Wayand W, Shamiyeh A, Oppelt P (2013) Preoperative planning of surgery for deeply infiltrating endometriosis using the ENZIAN classification. Eur J Obstet Gynecol Reprod Biol 166:99–103. https://doi.org/10.1016/j.ejogrb.2012.10.012\nThomassin-Naggara I, Lamrabet S, Crestani A, Bekhouche A, Wahab CA, Kermarrec E, Touboul C, Daraï E (2020) Magnetic resonance imaging classification of deep pelvic endometriosis: description and impact on surgical management. Hum Reprod 35:1589–1600. https://doi.org/10.1093/humrep/deaa103\nFunding\nThe authors declare that no funds, grants, or other support was received during the preparation of this manuscript.\nAuthor information\nAuthors and Affiliations\nContributions\nAll the authors contributed to the study conception and data collection. The design, management, data analysis, and manuscript writing/editing were performed by Kiyoshi Kanno. All the authors commented on the previous versions of the manuscript. All the authors have read and approved the final version of the manuscript.\nCorresponding author\nEthics declarations\nConflict of interests\nThe authors have no relevant financial or non-financial interests to disclose.\nEthical approval\nThis study was approved by the Institutional Review Board of the Kurashiki Medical Center (No. 861) and performed in line with the principles of the Declaration of Helsinki.\nConsent to participate\nInformed consent was obtained from all the individual participants included in the study.\nAdditional information\nPublisher's Note\nSpringer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.\nRights and permissions\nSpringer Nature or its licensor (e.g. a society or other partner) holds exclusive rights to this article under a publishing agreement with the author(s) or other rightsholder(s); author self-archiving of the accepted manuscript version of this article is solely governed by the terms of such publishing agreement and applicable law.\nAbout this article\nCite this article\nKanno, K., Yanai, S., Masuda, S. et al. Comparison of surgical outcomes between robot-assisted and conventional laparoscopic nerve-sparing modified radical hysterectomy for deep endometriosis. Arch Gynecol Obstet 310, 1677–1685 (2024). https://doi.org/10.1007/s00404-024-07674-0\nReceived:\nAccepted:\nPublished:\nVersion of record:\nIssue date:\nDOI: https://doi.org/10.1007/s00404-024-07674-0","source_license":"CC0","license_restricted":false}