Robotic Management of Endometriosis: Discussion of Use, Criteria and Advantages: a Review of the Literature

of Use, Criteria and Advantages: a Review of the Literature Ioannis D. Gkegkes 1, *, Christos Iavazzo 2 , George Iatrakis 3 , Paraskevi-Evangelia Iavazzo 4 , Fani Pechlivani 5 , Evangelia Antoniou 5 , Konstadia Bakalianou 6

Endometriosis is a very common benign condition affecting fertility and quality of life. Different methods, either definitive or fertility sparing are used for its management by using open, laparoscopic, and robotic techniques. This is a literature review presenting the role and the advantages of robotic surgery in endometriosis. Such a management is effective, safe, and feasible in hands of well-trained multidisciplinary teams even for severe cases of endometriosis.

da Vinci © robot; endometriosis; treatment; advantages; criteria; quality of life AUTHOR AFFILIATIONS 1 Department of Surgery, Royal Devon and Exeter NHS Foundation Trust, Exeter, UK 2 Department of Gynaecological Oncology, The Christie Hospital, Manchester, UK 3 Department of Obstetrics and Gynaecology, T echnological Educational Institution of Athens, Athens, Greece 4 Department of Paediatrics, General Hospital of Rethymno, Rethymno, Greece 5 Department of Obstetrics and Gynaecology, T echnological Educational Institution of Athens, Athens, Greece 6 Department of Obstetrics and Gynecology, General Hospital “Agia Olga” , Athens, Greece * Corresponding author: 17C James House Residential Village, EX2 5DS, Bovemoors Lane, Exeter, UK; e-mail: [email protected] Received: 4 July 2019 Accepted: 17 November 2019 Published online: 10 February 2020 Acta Medica (Hradec Králové) 2019; 62(4): 147–149 https:/ /doi.org/10.14712/18059694.2020.3 © 2019 The Authors. This is an open-access article distributed under the terms of the Creative Commons Attribution License (http:/ /creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. AM_4_2019.indd 147AM_4_2019.indd 147 07.02.20 10:0807.02.20 10:08 148 Ioannis D. Gkegkes et al.  Acta Medica (Hradec Králové)

Endometriosis occurs in 5–15% of the general population and although a benign condition, sometimes it might re- quire difficult surgical dissections as it could be locally in- filtrative, invasive, and widely disseminated. The typical patient is nulliparous, infertile, and around 30-years-old. The most common sites of endometriosis intra-abdomi- nally include adnexae (two out of three cases), pouch of Douglas, uterosacral and broad ligaments, uterovesical fold, ureters, bladder, appendix, rectosigmoid colon or caecum, and small bowel loops (1, 2). The treatment options of endometriosis include med- ical (e.g. progestins, danazol, GnRH- analogues) or sur- gical options which could be classified as most definitive (including hysterectomy and bilateral salpingo-oophorec- tomy) or fertility-sparing with the aim to excise all perito- neal endometriotic implants and adhesions but preserve fertility (3–6). Laparoscopic or open techniques, depend- ing on each surgeon’s preference and experience, are of- fered as treatment options, while recently robotic proce- dures are also suggested. The da Vinci© surgical system received FDA approval in 2005. Robotic procedures have been introduced in or- der to improve surgical performance. Increased dexterity , greater range of motion, and better depth perception are the main advantages of robotic-assisted techniques (7). Its

include lack of tactile feedback and increased cost (8). Robotic procedures combine the advantages of open and laparoscopic procedures and are another alter- native in the management of endometriosis. The aim of this narrative review is to present the use, the criteria, and the advantages of robotic surgery in the treatment of endometriosis.

Different techniques including open, laparoscopic or ro- botic procedures can equally be used in the management of endometriosis (9–11). The patient is preoperatively as- sessed with imaging scans including ultrasound and MRI and she signs the informed consent when she is informed about the type of planned procedure and possible risks of it including infection, bleeding, and injury of adjacent organs. Multidisciplinary experts, including gynaecolo- gists, urologists, and general surgeons, should cooperate in order to achieve the optimal outcome in the most severe cases. Fertility-sparing techniques are used in order to de- stroy all endometriotic implants and remove all the possi- ble adhesions. Removal and not lysis of them is preferred. Endometriomas larger than 3 cm are also excised either with cystectomy , or if that is not technically possible, with oophorectomy. If tubes are affected, salpingectomy is performed and IVF procedures are used for pregnancy achievement. If both adnexae are affected and bilateral salpingo-oophorectomy is essential, the uterus is pre- served and donor eggs could be used for pregnancy . In ro- botic cases, all endometriotic implants are either excised or destroyed with scissors or diathermy . Segmental bowel resections, rectal shaving, and partial bladder resection are described in the literature (12). Ureteral endometriosis could be treated with partial ureterectomy and ureterone- ocystostomy (13). Special care should be taken during the excision from small or large bowel and/or urinary tract to avoid any injuries. However, deep infiltrative endometri- osis of the rectovaginal septum is one of the most severe types of endometriosis (14). For this reason, any hidden endometriosis should be completely excised to avoid de- veloping deeper nodular lesions in the future (14). It was recently shown that infiltrating colorectal endometriosis could be safely and effectively treated robotically even by performing a rectosigmoidectomy if that is essential (1). In case of most definitive techniques, total or even modified radical hysterectomies plus bilateral salpingooophorecto- mies might be essential to treat the disease. Of course, as in open and laparoscopic techniques, preoperative use of GnRH analogues for three to six months can improve sur- gical success. Robotic system preserves the advantages of conven - tional laparoscopy while it offers the possibility to the gynaecologist to dissect down and into the narrow pel- vic floor. It is suggested that a  diagnostic laparoscopy should be used in order to clarify the range of the disease in the upper abdomen before docking the robot in order to know exactly where the disease is. In robotic systems, the CO2 pressure required for exposure is often lower in correlation with traditional laparoscopy as result of the mechanical lift of the robot (15). Robotic procedures can be safely performed after taking into account the physi- ological changes of pneumoperitoneum and steep Tren- delenburg position during a  preoperative anaesthetic review (16). Robotics, also shares similar benefits of lapa- roscopy including smaller incisions (at most 10 to 12 mm) (15). The three-dimensional stereoscopic vision by the use of binocular optics, the filtration of the tremor, and the less operator fatigue are some of the obvious advantages of such operations. The articulated instruments permit a wide range of motions while they increase the ability of the surgeon to work efficiently. All the above mentioned advantages can lead to more anatomical procedures. In addition, the 360° motion of the robotic wrist permits the fine adhesiolysis and removal of any suspicious nodule, even if it is quite deep. More specifically , Patzkowsky et al., comparing robotic to laparoscopic treatment in over 500 patients, showed that age, body mass index, opera- tive time, and estimated blood loss were not statistical- ly different between the two procedures. Furthermore, robotic techniques could be easier used in larger uterus, cases with more severe adhesions, and stage III-IV endo- metriosis (17). However, the rates of urinary tract infec- tions were higher in the robotic group (17). According to another study , including women treated with robotic-as- sisted laparoscopy for stage III and IV endometriosis, the median actual surgical time was 145 minutes (ranging from 67 to 325 minutes), while the median blood loss was 100 ml (ranging from 20 to 400 ml) depending on the se- verity of the case and the experience of the surgeon (18). Another study group, showed that uterine weight higher than 250 grams and older age predispose to longer surgi- cal time (19). In all those studies, the rates of conversion AM_4_2019.indd 148AM_4_2019.indd 148 07.02.20 10:0807.02.20 10:08 Robotic Management of Endometriosis 149 to open surgery and blood transfusion are minimal. So, the robotic assisted surgery also permits the realization of a key hole operation which can be interpreted into sig- nificantly less blood loss, less pain, shorter recovery time, as well as shorter hospital stay and better aesthetic result. Additionally , a shorter hospital stay and a quicker return to normal activity may mean less postoperative problems such as infection or pulmonary embolism. Last but not least, the use of robotic systems gives the opportunity of rapid acquisition of surgical skills required in order to perform laparoscopic surgery , while at the same time en- able gynaecologists to reach at least as good clinical out- comes as conventional laparoscopy and within shorter operating times once they exceed the initial stage of the learning curve. On the other hand, the high costs of use, the bulky machinery , and the need for staff training are the most important drawbacks in the utilization of robot in such operations. Of course, entry of new robotic systems in the market, as well as the use of the robot by different surgi- cal teams, and in a high volume of patients could decrease the cost disadvantage. Short term complications include vaginal cuff abscess (18), ureterovaginal fistulas (20), and higher rates of urinary tract infection caused by extend- ed use of Folley catheter for urinary retention (21). A rare case of rhabdomyolysis and compartment syndrome, after a 12-hour duration robotic operation, is also presented in the literature (22), showing the need for training and time managing of such operations. Although larger prospective studies as well as longer follow-up periods are necessary to clarify the long term outcomes including fertility results, pain, and quality of life, it seems that robotic management of even severe cases of endometriosis is an effective, fea- sible, and safe alternative in well-trained hands as it was also shown in a recent systematic review (23) and can be used without compromising the principles of open or lap- aroscopic operations. CONFLICT OF INTEREST No conflict of interest was declared by the authors. FINANCIAL DISCLOSURE The authors declared that this study has received no finan- cial support.

1. Neme RM, Schraibman V , Okazaki S, et al. Deep infiltrating colorec- tal endometriosis treated with robotic-assisted rectosigmoidectomy . JSLS 2013; 17(2): 227–34. 2. Gui B, Valentini AL, Ninivaggi V , Marino M, Iacobucci M, Bonomo L. Deep pelvic endometriosis: don’t forget round ligaments. Review of anatomy, clinical characteristics, and MR imaging features. Abdom Imaging 2014; 39(3): 622–32. 3. Jacobson TZ. Potential cures for endometriosis. Ann N Y Acad Sci 2011; 1221: 70–4. 4. Grandi G, Xholli A, Napolitano A, Palma F, Cagnacci A. Pelvic pain and quality of life of women with endometriosis during quadriphasic estradiol valerate/dienogest oral contraceptive: a patient-preference prospective 24-week pilot study . Reprod Sci 2015; 22(5): 626–32. 5. Agarwal S, Fraser MA, Chen I, Singh SS. Dienogest for the treatment of deep endometriosis: case report and literature review. J Obstet Gy- naecol Res 2015; 41(2): 309–13. 6. Yamaguti EM, Brito MB, Ferriani RA, Garcia AA, Rosa-e-Silva JC, Vie- ira CS. Comparison of the hemostatic effects of a levonorgestrel-re- leasing intrauterine system and leuprolide acetate in women with endometriosis: a randomized clinical trial. Thromb Res 2014; 134(6): 1193–7. 7. Iavazzo C, Gkegkes ID. Single-site port robotic-assisted hysterecto- my: a systematic review. Arch Gynecol Obstet 2014; 289(4): 725–31. 8. Iavazzo C, Papadopoulou EK, Gkegkes ID. Cost assessment of robotics in gynecologic surgery: a systematic review. J Obstet Gynaecol Res 2014; 40(11): 2125–34. 9. Duffy JM, Arambage K, Correa FJ, et al. Laparoscopic surgery for en- dometriosis. Cochrane Database Syst Rev 2014; (4): CD011031. 10. Roman H. Endometriosis surgery and preservation of fertility , what surgeons should know. J Visc Surg 2018; 155 Suppl 1: S31–S36. 11. Nezhat C, Lewis M, Kotikela S, et al. Robotic versus standard lapa- roscopy for the treatment of endometriosis. Fertil Steril 2010; 94(7): 2758–60. 12. Siesto G, Ieda N, Rosati R, Vitobello D. Robotic surgery for deep endo- metriosis: a paradigm shift. Int J Med Robot 2014; 10(2): 140–6. 13. Frick AC, Barakat EE, Stein RJ, Mora M, Falcone T. Robotic-assisted laparoscopic management of ureteral endometriosis. JSLS 2011; 15(3): 396–9. 14. Nezhat FR, Mahmoud MS. Allen masters peritoneal defect: a poten- tial pathway to deep infiltrating rectovaginal endometriosis? J Minim Invasive Gynecol 2014; 21(3): 321–2. 15. Iavazzo C, Gkegkes ID. Port site metastases after robot-assisted sur- gery: a systematic review. Int J Med Robot 2013; 9(4): 423–7. 16. Gupta K, Mehta Y , Sarin Jolly A, Khanna S. Anaesthesia for robotic gynaecological surgery . Anaesth Intensive Care 2012; 40(4): 614–21. 17. Patzkowsky KE, As-Sanie S, Smorgick N, Song AH, Advincula AP . Perioperative outcomes of robotic versus laparoscopic hysterectomy for benign disease. JSLS 2013; 17(1): 100–6. 18. Bedaiwy MA, Rahman MY , Chapman M, et al. Robotic-assisted hys- terectomy for the management of severe endometriosis: a retrospec- tive review of short-term surgical outcomes. JSLS 2013; 17(1): 95–9. 19. Giep BN, Giep HN, Hubert HB. Comparison of minimally invasive surgical approaches for hysterectomy at a community hospital: ro- botic-assisted laparoscopic hysterectomy , laparoscopic-assisted vaginal hysterectomy and laparoscopic supracervical hysterectomy . J Robot Surg 2010 Sep; 4(3): 167–75. 20. McAchran SE, Paolone DR. The iatrogenic ureterovaginal fistula. Urology 2013; 81(6): e35. 21. Smorgick N, DeLancey J, Patzkowsky K, Advincula A, Song A, As- Sanie S. Risk factors for postoperative urinary retention after lap- aroscopic and robotic hysterectomy for benign indications. Obstet Gynecol 2012; 120(3): 581–6. 22. Deras P , Amraoui J, Boutin C, Laporte S, Ripart J. [Rhabdomyolysis and compartment syndrome of two forearms after robotic assisted prolonged surgery]. Ann Fr Anesth Reanim 2010; 29(4): 301–3. 23. Carvalho L, Abrão MS, Deshpande A, Falcone T. Robotics as a new surgical minimally invasive approach to treatment of endometriosis: a systematic review. Int J Med Robot 2012; 8(2): 160–5. AM_4_2019.indd 149AM_4_2019.indd 149 07.02.20 10:0807.02.20 10:08