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Gynecology_Novak. 14. Stovall TG, Ling FW, Crawford DA. Hysterectomy for chronic pelvic pain of presumed uterine etiology. Obstet Gynecol 1990;75: 676–679. 15. ACOG Committee on Practice Bulletins—Gynecology. ACOG Practice Bulletin No. 113. Management of endometriosis. Obstet Gynecol 2010;116:223–236. 16. Shakiba K, Bena JF, McGill KM, et al. Surgical treatment of endometriosis: a 7-year follow-up on the requirement for further surgery. Obstet Gynecol 2008;111:1285–1292. 17. Gambone JC, Reiter RC, Lench JB. Short-term outcome of incidental hysterectomy at the time of adnexectomy for benign disease. J Womens Health 1992;1:197–200. 18. American College of Obstetricians and Gynecologists. ACOG Practice Bulletin No. 84. Prevention of deep vein thrombosis and pulmonary embolism. Obstet Gynecol 2007;110:429–440. 19. Lethaby A, Ivanova V, Johnson NP. Total versus subtotal hysterectomy for benign gynecological conditions. Cochrane Database Syst Rev 2006;2:CD004993. 20.


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Gynecology_Novak. 19. Lethaby A, Ivanova V, Johnson NP. Total versus subtotal hysterectomy for benign gynecological conditions. Cochrane Database Syst Rev 2006;2:CD004993. 20. Ghomi A, Hantes J, Lotze EC. Incidence of cyclical bleeding after laparoscopic supracervical hysterectomy. J Minim Invasive Gynecol 2005;12:201–205. 21. American College of Obstetricians and Gynecologists. ACOG Practice Bulletin No. 89. Elective and risk reducing salpingooophorectomy. Obstet Gynecol 2008;111:231–241. 22. Berek JS, Chalas E, Edelson M, et al. Prophylactic and risk-reducing bilateral salpingo-oophorectomy: recommendations based on risk of ovarian cancer. Obstet Gynecol 2010;116:733–743. 23. Asante A, Whiteman MK, Kulkarni A, et al. Elective oophorectomy in the United States. Trends and in-hospital complications, 1998–2006. Obstet Gynecol 2010;116:1088–1095. 24.


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Gynecology_Novak. 23. Asante A, Whiteman MK, Kulkarni A, et al. Elective oophorectomy in the United States. Trends and in-hospital complications, 1998–2006. Obstet Gynecol 2010;116:1088–1095. 24. Parker WH, Broder MS, Chang E, et al. Ovarian conservation at the time of hysterectomy and long-term health outcomes in the Nurses’ Health Study. Obstet Gynecol 2009;113:1027–1037. 25. Ingelsson E, Lundholm C, Johansson ALV, et al. Hysterectomy and risk of cardiovascular disease: a population based cohort study. Eur Heart J 2011;32:745–750. 26. Parker WH, Broder MS, Liv Z, et al. Ovarian conservation at the time of hysterectomy for benign disease. Obstet Gynecol 2005;106: 219–226. 27. Ryan PJ, Harrison R, Blake GM, et al. Compliance with hormone replacement therapy (HRT) after screening for postmenopausal osteoporosis. Br J Obstet Gynaecol 1992;99:1325–1328. 28.


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Gynecology_Novak. 27. Ryan PJ, Harrison R, Blake GM, et al. Compliance with hormone replacement therapy (HRT) after screening for postmenopausal osteoporosis. Br J Obstet Gynaecol 1992;99:1325–1328. 28. Kauff ND, Satagopan JM, Robson ME, et al. Risk-reducing salpingo-oophorectomy in women with a BRCA1 or BRCA2 mutation. N Engl J Med 2002;346:1609–1615. 29. Rebbeck TR, Lynch HT, Neuhausen SL, et al. Prevention and Observation of Surgical End Points Study Group. Prophylactic oophorectomy in carriers of BRCA1 or BRCA2 mutations. N Engl J Med 2002;346:1616–1622. 30. Levanon K, Crum C, Drapkin R. New Insights into the pathogenesis of serous ovarian cancer and its clinical import. J Clin Oncol 2008;26:5284–5293. 31. Greene MH, Mai PL, Schwartz PE. Does bilateral salpingectomy with ovarian retention warrant consideration as a temporary bridge to risk-reducing bilateral oophorectomy in BRCA1/2 mutation carriers? Am J Obstet Gynecol 2011;204:19.e1–e6 32.


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Gynecology_Novak. Sheth SS. The place of oophorectomy at vaginal hysterectomy. Br J Obstet Gynaecol 1991;98:662–666. 33. Ballard LA, Walters MD. Transvaginal mobilization and removal of ovaries and fallopian tubes after vaginal hysterectomy. Obstet Gynecol 1996;87:35–39. 34. Falcone T, Walters MD. Hysterectomy for benign disease. Obstet Gynecol 2008;111:753–767. 35. Salom EM, Schey D, Penalver M, et al. The safety of incidental appendectomy at the time of abdominal hysterectomy. Am J Obstet Gynecol 2003;189:1563–1568. 36. Kovac SR, Cruikshank SH. Incidental appendectomy during vaginal hysterectomy. Int J Gynaecol Obstet 1993;43:62–63. 37. Murray JM, Gilstrap LC, Massey FM. Cholecystectomy and abdominal hysterectomy. JAMA 1980;244:2305–2306. 38. Hester TR, Baird W, Bostwick J, et al. Abdominoplasty combined with other major surgical procedures: safe or sorry? Plast Reconstr Surg 1989;83:997–1004. 39.


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Gynecology_Novak. 38. Hester TR, Baird W, Bostwick J, et al. Abdominoplasty combined with other major surgical procedures: safe or sorry? Plast Reconstr Surg 1989;83:997–1004. 39. Voss SC, Sharp HC, Scott JR. Abdominoplasty combined with gynecologic surgical procedures. Obstet Gynecol 1986;67:181–186. 40. Kovac SR. Vaginal hysterectomy combined with liposuction. Mo Med 1989;86:165–168. 41. Le Tohic A, Dhainaut C, Yazbeck C, et al. Hysterectomy for benign uterine pathology among women without previous vaginal delivery. Obstet Gynecol 2008;111:829–837. 42. Johnson N, Barlow D, Lethaby A, et al. Surgical approach to hysterectomy for benign gynecological disease. Cochrane Database Syst Rev 2006;2:CD 003677. 43. Falcone T, Paraiso MF, Mascha E. Prospective randomized clinical trial of laparoscopically assisted vaginal hysterectomy versus total abdominal hysterectomy. Am J Obstet Gynecol 1999;180:955–961. 44.


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Gynecology_Novak. 44. Sculpher M, Manca A, Abbott J, et al. Cost effectiveness of laparoscopic hysterectomy compared with standard hysterectomy: results from a randomized trial. BMJ 2004;328:134–140. 45. Garry R, Fountain J, Mason S, et al. The eVALuate study: two parallel randomized trials, one comparing laparoscopic with abdominal hysterectomy, the other comparing laparoscopic with vaginal hysterectomy. BMJ 2004;328:129–136. 46. Guenaga KF, Matos D, Castro AA, et al. Mechanical bowel preparation for elective colorectal surgery. Cochrane Database Syst Rev 2003;2:CD001544. 47. Tulandi T, Al-Jaroudi D. Nonclosure of peritoneum: a reappraisal. Am J Obstet Gynecol 2003;89:609–612. 48. Orr JW Jr, Orr PF, Barrett JM, et al. Continuous or interrupted fascial closure: a prospective evaluation of no. 1 Maxon suture in 402 gynecologic procedures. Am J Obstet Gynecol 1990;163:1485–1489. 49.


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Gynecology_Novak. 49. Kore S, Vyavaharkar M, Akolekar R, et al. Comparison of closure of subcutaneous tissue versus non-closure in relation to wound disruption after abdominal hysterectomy in obese patients. J Postgrad Med 2000;46:26–28. 50. Walters MD, Barber MD. Complications of hysterectomy. In: Walters MD, Barber MD, eds. Hysterectomy for benign disease. Philadelphia, PA: Saunders, Elsevier, 2010:195–212. 51. Walters MD. Vaginal hysterectomy and trachelectomy: basic surgical techniques. In: Walters MD, Barber MD, eds. Hysterectomy for benign disease. Philadelphia, PA: Saunders, Elsevier, 2010:123–134. 52. Harmanli OH, Khilnani R, Dandolu V, et al. Narrow pubic arch and increased risk of failure for vaginal hysterectomy. Obstet Gynecol 2004;104:697–700. 53. Barber MD. Difficult vaginal hysterectomy. In: Walters MD, Barber MD, eds. Hysterectomy for benign disease. Philadelphia, PA: Saunders, Elsevier, 2010:135–160. 54.


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Gynecology_Novak. 53. Barber MD. Difficult vaginal hysterectomy. In: Walters MD, Barber MD, eds. Hysterectomy for benign disease. Philadelphia, PA: Saunders, Elsevier, 2010:135–160. 54. Taylor SM, Romero AA, Krammerer-Doak N, et al. Abdominal hysterectomy for the enlarged myomatous uterus compared with vaginal hysterectomy with morcellation. Am J Obstet Gynecol 2003;189:1579–1583. 55. Payne TN, Dauterive R. A comparison of total laparoscopic hysterectomy to robotically assisted hysterectomy: surgical outcomes in a community practice. J Minim Invasive Gynecol 2008;15:286–291. 56. Gaia G, Holloway RW, Santoro L, et al. Robotic-Assisted hysterectomy for endometrial cancer compared with traditional laparoscopic and laparotomy approaches. Obstet Gynecol 2010;116:1422–1431. 57. Lenihan JP, Kovanda C, Seshadri-Kreaden U. What is the learning curve for robotic assisted gynecologic surgery? J Minim Invasive Gynecol 2008;15:589–594. 58.


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Gynecology_Novak. 57. Lenihan JP, Kovanda C, Seshadri-Kreaden U. What is the learning curve for robotic assisted gynecologic surgery? J Minim Invasive Gynecol 2008;15:589–594. 58. Pasic RP, Rizzo JA, Fang H, et al. Comparing robot-assisted with conventional laparoscopic hysterectomy: Impact on cost and clinical outcomes. J Minim Invasive Gynecol 2010;17:729–738. 59. Hur HC. Vaginal cuff dehiscence after hysterectomy. Up to Date 2010. Available online at: http://www.uptodate.com/contents/vaginal 60. Kho RM, Akl MN, Cornella JL, et al. Incidence and characteristics of patients with vaginal cuff dehiscence after robotic procedures. Obstet Gynecol 2009;114:231–235. 61. Escobar PF, Starks D, Nickles Fader A, et al. Single port and natural orifice surgery in gynecology. Fertil Steril 2010;94:2497–2502. 62. Jelovsek JE, Chiung C, Chen G, et al. Incidence of lower urinary tract injury at the time of total laparoscopic hysterectomy. JSLS 2007;11:422–427. 63.


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Gynecology_Novak. 62. Jelovsek JE, Chiung C, Chen G, et al. Incidence of lower urinary tract injury at the time of total laparoscopic hysterectomy. JSLS 2007;11:422–427. 63. Loos MJ, Scheltinga MR, Mulders LG, et al. The Pfannenstiel incision as a source of chronic pain. Obstet Gynecol 2008;111:839–846. 64. Hartman KE, Ma C, Lamvu GM, et al. Quality of life and sexual function after hysterectomy in women with preoperative pain and depression. Obstet Gynecol 2004;104:701–709. Javier F. Magrina Robotic surgery is a form of facilitated laparoscopy that utilizes robotic technology to enhance the performance of the operation by placing a computerized interface between patient and surgeon. Two of the most important differences between conventional laparoscopic instruments and robotic instruments are articulation and intuitive movements.


Gynecology_Novak

Gynecology_Novak. Two of the most important differences between conventional laparoscopic instruments and robotic instruments are articulation and intuitive movements. The robotic system offers advantages for the surgeon, but it is particularly useful in four circumstances: obese patients, long surgeries, and operations requiring extensive suturing or high precision. High precision and absence of tremor are useful for retroperitoneal lymphadenectomy, adhesiolysis, parametrial ureteral dissection, and accurate suturing, in such procedures as ureteral anastomosis or reimplantation, and genitourinary fistula repair. Applications of robotic technology include simple hysterectomy, myomectomy, appendectomy (in conjunction with other procedures), adnexectomy, excision of severe endometriosis, tubal anastomosis, and rectovaginal or vesicovaginal fistulas, especially those in the upper vagina.


Gynecology_Novak

Gynecology_Novak. Studies show the feasibility of robotics for the treatment of patients with cervical, endometrial, tubal, and ovarian cancer, with apparent similar or better perioperative outcomes compared to laparoscopy and with improved outcomes compared to laparotomy. Robotic technology as applied to laparoscopy utilizes robotic technology to facilitate the performance of the operation by placing a computerized interface between patient and surgeon. Although originally designed for cardiovascular surgery and approved for that use by the U.S. Food and Drug Administration (FDA) in 2003, it has found applications in urology and gynecology, and more recently in otolaryngology and colorectal surgery.


Gynecology_Novak

Gynecology_Novak. There are studies showing that the use of robotic technology for the performance of preset laboratory exercises results in faster performance times, increased accuracy, enhanced dexterity, easier and faster suturing, and a lower number of errors when compared to conventional laparoscopic instrumentation (1–4). The physical stress for medical students learning robotics is significantly less than what they encounter when learning the same tasks by laparoscopy (5). The technological advantages of robotics can facilitate learning surgical techniques when compared to acquiring similar skills in laparoscopy, as demonstrated by a shorter learning curve for robotic surgery. There is a ﬂattening of the operating time after 20 to 50 robotic hysterectomies, while for laparoscopically assisted vaginal hysterectomy (LAVH) a similar facility with the requisite skills does not occur until after 80 procedures (6–9). In gynecologic oncology, a ﬂattening of the operating time was noted after 20


Gynecology_Novak

Gynecology_Novak. vaginal hysterectomy (LAVH) a similar facility with the requisite skills does not occur until after 80 procedures (6–9). In gynecologic oncology, a ﬂattening of the operating time was noted after 20 procedures for endometrial cancer when using the robotic technology (10).


Gynecology_Novak

Gynecology_Novak. Robotic Technology and Differences with Laparoscopy There is only one robotic system available, brand-named Da Vinci (Intuitive Inc, Sunnyvale, CA), which received FDA approval for the performance of hysterectomy in 2005. A second generation of the device, the Da Vinci S, was released in 2006, and the third generation of the Da Vinci robotic system, the SI model, was released in 2009 and incorporates a resident teaching console. A robotic system is composed primarily of a robotic column, which holds the robotic arms (Fig. 25.1) and a surgeon’s console (Fig. 25.2). The robotic arms that hold the robotic instruments (Fig. 25.3) are fastened to the robotic trocars (Fig. 25.4). Commonly used robotic instruments for gynecologic surgeries are shown in Figure 25.5A-F. Figure 25.1 Robotic column with robotic arms. Figure 25.2 Robotic console with hand controls and foot switches.


Gynecology_Novak

Gynecology_Novak. Figure 25.1 Robotic column with robotic arms. Figure 25.2 Robotic console with hand controls and foot switches. Robotic Column The robotic column has three or four robotic arms, depending on the selection at the time of purchase (Fig. 25.1). The fourth arm is extremely useful for assisting with tissue retraction. The robotic arms always function in the direction toward the robotic column and not away from it. For this reason the robotic column must be positioned strategically in response to the location of the surgery that will be performed.


Gynecology_Novak

Gynecology_Novak. For pelvic surgery the robotic column is commonly situated between the patient’s legs (Fig. 25.6), while for upper abdominal surgery it is positioned at the patient’s head. For procedures to the right or left of the abdomen, the robotic column is positioned at the opposite side of the patient. For instance, for extraperitoneal left aortic lymphadenectomy, the robotic column is at the patient’s right side. For procedures where easy access to the entrance of Figure 25.3 Robotic laparoscope and two robotic arms with robotic instruments inserted. The tip of the instruments can be appreciated in the insert. Figure 25.4 The robotic trocars are metallic and can be seen to the right of the picture. The escape valve was added because the original trocars did not have it. The three types of available trocar obturators are on the left of the picture: blunt (left), tissue-spreading (middle) and cutting (right).


Gynecology_Novak

Gynecology_Novak. Figure 25.5 Robotic instruments commonly used in gynecologic surgeries. A: Monopolar curved scissors. B: Monopolar spatula. Figure 25.5 (Continued) C: PK (plasma kinetic) dissecting forceps, bipolar. D: Prograsp forceps, bipolar. the vagina and rectum is necessary, the robotic column is positioned lateral to the right or to the left of the patient’s legs. Robotic Console The surgeon sits at the console (Fig. 25.2) away from the patient (Fig. 25.7) and the assistant sits next to the patient (Fig. 25.6). The surgeon has a stereoscopic image, which is different from the laparoscopic image, and controls the movements of the robotic arms using two hand Figure 25.5 (Continued) E: Tenaculum forceps used for myomectomy. F: Needle grasper used for suturing.


Gynecology_Novak

Gynecology_Novak. Figure 25.5 (Continued) E: Tenaculum forceps used for myomectomy. F: Needle grasper used for suturing. controls and five foot switches: clutch, camera, focusing, monopolar (cutting and coagulating), and bipolar. The surgeon’s arms and hands can be maintained in a comfortable working position, because pressing the clutch foot switch disengages the robotic arms from the surgeon hands. This allows the surgeon to reposition the arms to an appropriate and comfortable position without moving the portion of the robotic arms connected to the patient. Figure 25.6 The robotic column is usually positioned between the patient legs for pelvic surgery. The assistant is seated to the left of the patient and is scrubbed for the procedure. Figure 25.7 The surgeon is seated at the console and is able to maintain a relaxed position for the arms and legs.


Gynecology_Novak

Gynecology_Novak. Figure 25.7 The surgeon is seated at the console and is able to maintain a relaxed position for the arms and legs. Because the surgeon is separated from the patient, there is a time delay that permits the performance of telesurgery, as long as the latency time does not exceed 150 milliseconds. The surgeon can control the movements of the robotic arms and instruments in a patient located at a different geographic location (11). Telementoring allows the mentor surgeon to guide another surgeon through a surgical procedure at a remote location by using superimposed electronic signals (telestration), direct voice commands, and control of the laparoscope via joystick and the electrosurgical instruments (12). Robotic movements are intuitive; the tip of the instrument mimics the movement of the surgeon’s hands, in contrast to the experience in laparoscopy when the movements of the tip of the instrument are counterintuitive, opposite to the movements of the surgeon’s hands.


Gynecology_Novak

Gynecology_Novak. Other technological advantages include downscaling of movements, absence of tremor, and stillness. In laparoscopy the amplitude of movement of the tip of the instrument is the same as the amplitude of the movement of the surgeon’s hands, whereas in robotics it can be downsized, resulting in increased precision. The computerized interface between surgeon hands and robotic instruments eliminates unwanted tremor, increasing precision. When placed in a specific position, such as for retracting bowel or uterus, the robotic instruments remain in place until repositioned, which can be a difference from human assistance.


Gynecology_Novak

Gynecology_Novak. The lack of tactile feedback (haptics) is a drawback for the neophyte, but the stereoscopic view rapidly compensates for it. There is a degree of resistance felt at the hand controls of the console, which, coupled with the stereoscopic view, allows the surgeon to determine the consistency of tissues, whether soft or hard, such as “to palpate” the rim of the cervical cup of a uterine manipulator, or “feel” a hard probe introduced in the rectum. The lack of tactile feedback is an advantage when operating in obese patients, because the surgeon cannot feel the resistance of the instruments being inserted through a thick abdominal wall, a difference from laparoscopy. Another potential advantage of the robotic laparoscopy technique compared to laparoscopy without the assistance of robotics is that it may decrease the number of injuries in surgeons.


Gynecology_Novak

Gynecology_Novak. Another potential advantage of the robotic laparoscopy technique compared to laparoscopy without the assistance of robotics is that it may decrease the number of injuries in surgeons. There are multiple reports of laparoscopic-related surgeon morbidity syndromes, resulting from the unnatural forced position of wrists, fingers, elbows, and shoulders and the awkward standing position of the surgeon (13). A recent study revealed a lower number of surgeon injuries and lower perception of surgeon’s pain, numbness, and fatigue using robotics compared to conventional laparoscopy (14).


Gynecology_Novak

Gynecology_Novak. Instrumentation Two of the most important differences between conventional laparoscopic instruments and robotic instruments are articulation and intuitive movements. The tip of a laparoscopic instrument is rigid and the instrument only has 4 degrees of freedom. The tip of robotic instruments are articulated with 7 degrees of freedom, reproducing the movements of the human wrist and fingers (Fig. 25.3) (EndoWrist instruments, Intuitive Surgery Inc, Sunnyvale, CA). The articulation allows the performance of complex maneuvers in small spaces; it accommodates the instrument to the correct plane of dissection (instead of forcing the tissue to the direction of the instrument as in laparoscopy), eliminates changing instruments from one port to another as in conventional laparoscopy, and facilitates suturing and intracorporeal knot tying. As indicated above, the movement of the robotic instruments is intuitive, following the movement of the surgeon hands. Types of Instruments


Gynecology_Novak

Gynecology_Novak. Types of Instruments Robotic instruments useful for gynecological surgery include ProGrasp forceps, PK dissecting forceps, tenaculum forceps, SutureCut needle driver, monopolar curved scissors, and monopolar cautery spatula (Fig. 25.5A-F). Trocars The robotic trocars are metallic and have three different types of obturators: blunt, tissue-spreading, and cutting (Fig. 25.4). The robotic trocars are placed in a different configuration than conventional laparoscopy trocars because of technical limitations imposed by the robotic arms. They are usually placed at the level of the umbilicus or higher for pelvic surgery and must be 10 cm apart from each other and from the laparoscope to prevent collision of the robotic arms (Fig. 25.8). At least one assistant trocar is necessary, which must be placed 3 to 5 cm away from any of the other trocars.


Gynecology_Novak

Gynecology_Novak. Figure 25.8 Trocar position for robotic pelvic surgery. The optical trocar is at the umbilicus. Two robotic trocars are placed 10 cm lateral to the right and left of the umbilicus, respectively. The assistant white trocar is 3 cm cranial and equidistant between the umbilical and left robotic trocar. An additional robotic trocar is 3 cm cranial and equidistant between the umbilical and the right robotic trocar. Docking Docking is a robotic term defined as the attachment of the robotic arms to the robotic trocars inserted in the patient. A mean docking time of about 3 minutes was reported in an initial study of 88 patients undergoing robotic hysterectomy (6). Docking times improved progressively after groups of 10 patients each.


Gynecology_Novak

Gynecology_Novak. There is a mandatory training course of 2 days to obtain certification in robotics provided by the manufacturing company Intuitive, Inc (Sunnyvale, CA) in centers located in the United States, Europe, and Asia. The gynecologist learns the robotic system and logs about 8 hours of dry and animal laboratory tasks. Residents or fellows completing training programs with robotics must demonstrate proficiency with documented basic robotic training and successfully perform a minimum of 10 robotic surgeries, preferably of the same type, and obtain a letter from the program director attesting to their level of robotic proficiency. Credentialing is dependent on each hospital credentialing body and is different for each institution: while some require robotic practice in five animals and having a proctor for the first five robotic surgeries, others mandate having a proctor for only two to five robotic procedures prior to obtaining robotic privileges.


Gynecology_Novak

Gynecology_Novak. Assistant An assistant is needed for docking, switching robotic instruments, solving robotic arm collision, retrieving small specimens, retracting tissue, and for the use of instruments not available with robotic technology, such as a vessel-sealing device and suction and irrigation. The assistant must be trained in robotics and be very knowledgeable about the procedure, because the surgeon is seated in a separate place and not scrubbed.


Gynecology_Novak

Gynecology_Novak. The assistant must be trained in robotics and be very knowledgeable about the procedure, because the surgeon is seated in a separate place and not scrubbed. The robotic teaching console allows the surgeon and the resident or fellow to each have his or her own console while having dual control. The surgeon is able to demonstrate the performance of a specific task to the trainee, or to assist the resident with one robotic arm, or prevent an imminent injury by disengaging the robotic arms from the resident’s hands, while both surgeon and resident are seated and viewing the stereoscopic image. The benefits of the teaching console were not compared to standard laparoscopic teaching to evaluate advantages. The half million dollar cost of the teaching console is a large disadvantage.


Gynecology_Novak

Gynecology_Novak. Previous laparoscopic experience was considered an advantage to learning robotics. Multiple reports show that transitioning from laparotomy to robotics is easier than transitioning from laparoscopy to robotics (15). A large number of gynecologic oncologists and gynecologists incorporated robotics into their daily practice without having incorporated laparoscopy into their practice or performing advanced laparoscopic procedures. In one study the initiation of robotics in a gynecologic oncology program reduced laparotomy from 78% to 35% in the first year of implementation and it increased the number of minimally invasive procedures from 22% performed by laparoscopy to 65% being robotic assisted (15). Thus, robotic technology is relatively easy to use, associated with a short learning curve, and comfortable for the surgeon (15– 17). It is less stressful to learn robotics than laparoscopy. Reduced stress and ease of learning with robotics compared to laparoscopy was demonstrated when 16


Gynecology_Novak

Gynecology_Novak. and comfortable for the surgeon (15– 17). It is less stressful to learn robotics than laparoscopy. Reduced stress and ease of learning with robotics compared to laparoscopy was demonstrated when 16 medical students were exposed to both techniques (5).


Gynecology_Novak

Gynecology_Novak. The robotic system offers advantages for the surgeon, but it is particularly useful in four circumstances: obese patients, long surgeries, and operations requiring extensive suturing or high precision. There is no resistance felt by the surgeon hands to the movement of the robotic instruments, regardless of the thickness of the patient’s abdominal wall. Suturing and intracorporeal knot tying are greatly facilitated by the articulation of the robotic instruments. Surgeon’s fatigue is decreased when seated for long operations. High precision and absence of tremor is useful for retroperitoneal lymphadenectomy, adhesiolysis, parametrial ureteral dissection, and accurate suturing, such as for ureteral anastomosis or reimplantation and genitourinary fistula repair. Applications of robotic technology include simple hysterectomy, myomectomy, appendectomy (in conjunction with other procedures), adnexectomy, excision of severe endometriosis, tubal anastomosis, and rectovaginal or vesicovaginal


Gynecology_Novak

Gynecology_Novak. include simple hysterectomy, myomectomy, appendectomy (in conjunction with other procedures), adnexectomy, excision of severe endometriosis, tubal anastomosis, and rectovaginal or vesicovaginal fistulas, especially those in the upper vagina (1,4). Robotic surgery is associated with a similar or shorter surgical time than conventional laparoscopy for the performance of simple hysterectomy and myomectomy, with a reduced blood loss, complication rates, and hospital stays (2,4).


Gynecology_Novak

Gynecology_Novak. Hysterectomy Laparoscopic-assisted vaginal hysterectomy was introduced in 1989. By 2005, only 14% of hysterectomies in United States were laparoscopic (18). By contrast, 3 years after FDA approval of robotic hysterectomy in 2005, 10% of hysterectomies were performed robotically in 2008 (Intuitive, Inc).


Gynecology_Novak

Gynecology_Novak. A report on 91 patients undergoing a robotic simple hysterectomy demonstrated a mean surgical time of 127.8 minutes, blood loss of 78.6 mL, and hospital stay of 1.4 days. One enterotomy was repaired robotically. There were no conversions to laparoscopy or laparotomy. Postoperative complications included single instances of exacerbation of congestive heart failure, ileus, vaginal cuff abscess, and Clostridium difficile colitis (19). A retrospective comparison of robotic and laparoscopic hysterectomy showed a longer operating time for robotics (27 minutes) but a lower blood loss and shorter hospital stay (19). Postoperative complications were similar. The conversion rate was higher for laparoscopy compared to robotic operations (9% vs. 4%, respectively).


Gynecology_Novak

Gynecology_Novak. Myomectomy Laparoscopic myomectomy provides less morbidity and a shorter recovery time compared to open myomectomy in two prospective randomized studies (20,21). Similarly, robotic myomectomy morbidity and recovery times appear preferable to open myomectomy. In a comparison of both techniques, robotic patients experienced less blood loss, no blood transfusions, lower postoperative complications, and shorter hospital stays. The operating time and cost were increased in the robotic group (22). In an initial series of 35 patients undergoing robotic myomectomy, the mean operating time was 230.8 minutes, mean blood loss was 169 mL, and median hospital stay was 1 day (23). Two patients (8.6%) required conversion to laparotomy, resulting from inadequate robotic instrumentation for myomectomy.


Gynecology_Novak

Gynecology_Novak. Robotic myomectomy provided comparable perioperative results to laparoscopy in two retrospective studies of patients with symptomatic myomas (24,25). No significant differences were noted between both groups for blood loss, complications, and hospital stay. The robotic operating time was longer than laparoscopy in one of the studies and no different in the other (24,25). In our comparison study, we noted differences favorable to the robotic group relative to operating time (141 vs. 166 minutes), blood loss (100 vs. 250 mL), and hospital stay over 2 days (12% vs. 23%). There were no significant differences between groups when patients were adjusted for uterine size and myoma weight. There were no differences in intra-or postoperative complications. Postmyomectomy pregnancy rates, uterine rupture, and late operative complications using robotics remain undetermined.


Gynecology_Novak

Gynecology_Novak. Adnexectomy Numerous studies show the benefits of laparoscopy over laparotomy for patients with an adnexal mass. Robotics provides similar perioperative outcomes when compared to laparoscopy for patients with an adnexal mass. Outcomes were improved with robotics for obese patients (body mass index [BMI] ≥30) with an adnexal mass. In a comparison series of 176 patients with an adnexal mass, 85 operations were by robotics and 91 by laparoscopy (26). The operating time was 12 minutes longer for the entire robotic group (83 vs. 71 minutes), but it was similar to laparoscopy when comparing only patients with a BMI 30 or more (80 vs. 71 minutes). Blood loss was similar for both groups (39.1 vs. 41.2 mL), but lower for the robotic group when comparing only obese patients (BMI ≥30) (39 vs. 60 mL). The length of hospital stay, as measured by the number of patients staying longer than 2 days (0 vs. 3) was similar for both groups.


Gynecology_Novak

Gynecology_Novak. Tubal Reversal Robotic tubal reversal may be preferable to laparotomy. In a prospective study comparing both techniques on patients with a previous tubal ligation, the operating time was longer using robotics (201 vs. 155 minutes), but the hospital stay (4 hours vs. 1.3 days), and recovery time to normal activities (11.1 vs. 28.1 days) were improved for robotic patients (27). Both groups had similar pregnancy rates (62.5% vs. 50%). In another retrospective case-control study of outpatient tubal anastomosis performed by robotics or minilaparotomy, perioperative outcomes were similar except for a longer operating time, increased cost, and a shorter time to patient’s recovery with robotics (28).


Gynecology_Novak

Gynecology_Novak. Appendectomy Reported results on 107 robotic appendectomies performed in conjunction with other pelvic procedures had a mean time for appendectomy of 3.4 minutes. No perioperative complications related to appendectomy were encountered. Increased abnormal pathological findings were observed in patients with pelvic pain compared to those without pain (37% vs. 15%, respectively). Appendiceal metastases were found in 43% of patients with ovarian malignancy (29). Sacrocolpopexy The robotic approach to sacrocolpopexy may be better than conventional laparoscopy because of the ease of suturing and of intracorporeal knot tying. A report of feasibility experience with 80 patients demonstrated total operating time of 197.9 minutes, and most patients underwent additional procedures at the same surgical setting (30). There was a 25.4% decrease of the operating time after the first 10 surgeries. Complications were minimal. Other reported operating times are 317 and 328 minutes (31,32).


Gynecology_Novak

Gynecology_Novak. Robotic sacrocolpopexy may be preferable to laparotomy because of improved perioperative outcomes and similar anatomical results. A comparison of 73 robotic with 105 laparotomy sacrocolpopexies for vaginal and uterine prolapse revealed a longer operating time (328 vs. 225 minutes) but reduced blood loss (103 vs. 255 mL) and shorter hospital stay (1.3 vs. 2.7 days) for the robotic group. Anatomical improvement was similar for both groups as determined by pelvic organ prolapse quantification (POP-Q) C point (−9 vs. −8) (see Chapter 27) (32). Late complications, such as erosion rate and long-term anatomical results of robotic sacrocolpopexy are unknown.


Gynecology_Novak

Gynecology_Novak. Studies show the feasibility of robotics for the treatment of patients with cervical, endometrial, tubal, and ovarian cancer, with apparent similar or better perioperative outcomes, compared to conventional laparoscopy and with improved outcomes compared to laparotomy (33–39). A survey of Society of Gynecologic Oncologists members indicated 24% are regular users of robotics and 66% believed their use would increase (33). Endometrial Cancer Laparoscopy provides similar or longer operative times, less blood loss, fewer postoperative complications, shorter hospital stay and recovery times, with similar recurrence and survival rates compared to laparotomy (34–39). Robotic technology may be preferable to conventional laparoscopy in selected patients for surgery for endometrial cancer, especially in morbidly obese patients. In expert hands, the use of minimally invasive techniques—laparoscopy and robotics— may facilitate the operations.


Gynecology_Novak

Gynecology_Novak. Studies comparing robotics to laparotomy suggest improved perioperative outcomes for robotics. Operative times are similar or longer, blood loss and hospital stay are reduced, the number of lymph nodes is comparable or higher, and postoperative complications are similar or decreased with robotics (15–17,40–44). Studies comparing robotics with conventional laparoscopy for endometrial cancer show similar or superior results for robotics. Some showed reduced blood loss, shorter hospital stay, increased lymph node yield, and lower morbidity with robotics compared to conventional laparoscopy (41). Others reported longer operating time but reduced blood loss, lower transfusion rate, lower conversion rate to laparotomy, and reduced hospital stay, even though the robotic patients had a higher BMI compared to laparoscopy (44). Robotics, as with laparoscopy, resulted in a shorter recovery time for endometrial cancer patients compared to laparotomy (40,45).


Gynecology_Novak

Gynecology_Novak. In an initial review of 38 patients with robotics operations, the perioperative outcomes were similar to patients treated by laparoscopy (n = 22). Results were similar to patients treated by laparotomy (n = 16) other than a larger blood loss and longer hospital stay for this group of patients. The operating times were similar for the three groups, blood loss was lower for the robotic and laparoscopy groups (283, 222, and 517 mL), and length of hospital stay was shorter for the robotic and laparoscopy groups (2, 2.5, and 6 days). There was no difference relative to the number of lymph nodes removed (18.4, 26.3, and 18.4, for robotics, laparoscopy, and laparotomy, respectively), number of lymph node metastases, positive cytological findings, or tumor recurrence. Postoperative complications were comparable among the three groups.


Gynecology_Novak

Gynecology_Novak. Boggess et al. compared 103 robotic patients with 81 laparoscopy patients and 138 laparotomy patients (41). The operating times for robotic and laparoscopy procedures were similar, but longer than laparotomy (191.2 minutes, 213.4 minutes, and 146.5 minutes, respectively). The blood loss, hospital stay, and number of nodes were all improved for the robotic group. Bell et al. compared a group of 40 robotic patients with 30 patients operated by laparoscopy and 40 patients operated by laparotomy (40). Robotic and laparoscopy operating times were comparable (184 minutes and 171 minutes, respectively) and longer than laparotomy (108.6 minutes). Blood loss was similar to laparoscopy, and both were lower than the laparotomy group. The number of lymph nodes removed was similar among the three groups. Postoperative complications were lower in the robotic group compared to the other two groups (7.5%, 27.5%, and 20%, respectively).


Gynecology_Novak

Gynecology_Novak. Another study evaluated the results of robotics and conventional laparoscopy for obese and morbidly obese patients (BMI 30–60) with endometrial cancer (42). Robotics was found to be preferable to the laparoscopic approach because of a shorter operative time, reduced blood loss, increased number of lymph nodes removed, and shorter hospital stay. The benefits of robotics for obese patients was noted with simple robotic hysterectomy, where the operating time remained unchanged in spite of the patient’s increased BMI (6). This may result from the absent awareness of the resistance of the robotic instruments being inserted through a thick abdominal wall because of the lack of tactile feedback.


Gynecology_Novak

Gynecology_Novak. The application of robotics for endometrial cancer can result in improvements of the perioperative outcomes (43). The operating time decreased by 47 minutes, vaginal cuff delayed healing decreased from 16% to 0%, and the number of pelvic and aortic lymphadenectomies and number of nodes retrieved increased per quarter analyzed from the initiation of robotics. The increased costs of this technology is a criticism of robotics. Because cost is tied to frequency of use, when used on a regular basis the cost becomes similar to laparoscopy and less expensive than laparotomy as a result of shorter hospital stay. A comparison study of costs for robotics, conventional laparoscopy, and laparotomy for endometrial cancer showed a significantly reduced cost for robotics and laparoscopy compared to laparotomy and comparable costs for robotics and laparoscopy (40).


Gynecology_Novak

Gynecology_Novak. Early Cervical Cancer Robotic and laparoscopic radical hysterectomy may provide patient benefits over a laparotomy approach relative to blood loss, blood transfusions, and length of hospital stay. Operating times and postoperative complications are lower or similar (46–52). Recurrence and survival rates remain unchanged when comparing the results of both techniques (46–48,51,52). A prospective randomized trial is under way comparing laparoscopic or robotic radical hysterectomy with laparotomy (53). The surgical technique for robotic radical hysterectomy is described elsewhere (54). A rapid learning curve is noted with robotic radical hysterectomy, with a 44-minute reduction in operating time after the first 34 procedures in association with a low complication rate and high nodal count (55).


Gynecology_Novak

Gynecology_Novak. In several retrospective studies comparing laparotomy with robotic radical hysterectomy, there was a shorter, similar, or longer operating time; reduced blood loss; shorter hospital stay; lower, similar, or higher number of lymph nodes removed; and similar rate of postoperative complications (49,56–58). In comparison with laparoscopy, robotics is associated with a shorter, similar, or longer operating time; reduced blood loss; shorter hospital stay; similar or lower postoperative complications; and comparable or higher number of nodes (49,50,57). Tumor recurrence does not appear increased with robotics compared to laparoscopy. At a mean length of follow-up of 31.1 months (range, 10 to 50 months), none of the patients in the robotic group experienced recurrence, and there was no difference with the laparoscopy group (50).


Gynecology_Novak

Gynecology_Novak. 62.5 mL, no intraoperative complications, no blood transfusions, no conversions to laparotomy, and a median length of hospital stay of 1.5 days (63). The median number of pelvic lymph nodes removed was 20. The laparoscopic approach to pelvic and aortic lymphadenectomy prior to chemoirradiation for patients with advanced cervical cancer is well documented, both transperitoneal and extraperitoneal (64–69). There are many studies discussing robotic pelvic and aortic lymphadenectomy included in the treatment of patients with different types of gynecologic malignancies, including cervical, endometrial, and ovarian malignancies (16,49,50,55–58,70,71).


Gynecology_Novak

Gynecology_Novak. A novel technique and the results of robotic transperitoneal infrarenal aortic lymphadenectomy in 33 patients with different gynecologic cancers was reported (72). The requirement of this technique was the placement of the robotic column at the patient’s head, which mandated the rotation of the operating table 180 degrees after completion of the robotic pelvic operation and the insertion of additional trocars in the lower pelvis (72). The mean console time was 42 minutes, the mean number of nodes 12.9, and the mean number of positive nodes 2.6. There was one conversion to laparotomy caused by bleeding. These results are comparable to those reported with laparoscopic aortic lymphadenectomy. Placing the robotic column at the patient’s head and inserting additional trocars in the lower pelvis were requirements to remove the infrarenal aortic nodes with robotics. Previous attempts to remove the left infrarenal aortic lymph nodes in a frozen cadaver were unsuccessful when the robotic


Gynecology_Novak

Gynecology_Novak. pelvis were requirements to remove the infrarenal aortic nodes with robotics. Previous attempts to remove the left infrarenal aortic lymph nodes in a frozen cadaver were unsuccessful when the robotic column was stationed at the level of the patient’s feet.


Gynecology_Novak

Gynecology_Novak. The feasibility of the extraperitoneal robotic approach to aortic lymphadenectomy was reported (73,74). The development of the robotic extraperitoneal technique in frozen cadavers, successfully applied to a patient with cervical cancer stage IB2 presenting with enlarged left aortic lymph nodes, is reported (73). It was noted that appropriate placement of the robotic trocars and the robotic column is necessary to prevent robotic arm collision and to reach the different aortic lymph nodal areas. The operating, docking, and console times were 103, 3.5, and 49 minutes, respectively. The blood loss was 30 mL. Selective removal of five enlarged aortic lymph nodes revealed no evidence of metastases.


Gynecology_Novak

Gynecology_Novak. Another study by Vergote et al. reported the development of their technique for inframesenteric aortic lymphadenectomy in five patients (74). All console times were less than 1 hour. The operating times and number of aortic lymph nodes in both studies are within the range of those reported with the laparoscopic approach. Both studies concluded that the robotic approach was technically easier than the conventional laparoscopy procedure (73,74).


Gynecology_Novak

Gynecology_Novak. Robotic anterior pelvic exenteration was described in three patients with recurrent cervical cancer (75). The operating times (range, 480 to 600 minutes) are longer than for laparotomy, but blood loss (range, 200 to 500 mL) is markedly lower. The length of hospital stay was similar or longer than by laparotomy (range, 25 to 53 days). Patients required a pararectal incision (10 cm) for the pouch construction, and one patient with vaginal reconstruction had a perineal phase. Whether the robotic approach to pelvic exenteration will become preferable to laparotomy is unknown.


Gynecology_Novak

Gynecology_Novak. Ovarian Cancer Surgery for ovarian cancer requires access to all four abdominal quadrants. The ability to operate in all four quadrants using robotics can only be achieved by rotating the operating table and positioning the robotic column at the patient’s head. In this position it is possible to excise the aortic lymph nodes to the level of the renal vessels and to perform resection of upper abdominal metastases, including small bowel, diaphragm, liver, and supracolic omental disease. Initial experience with 21 patients with ovarian cancer who underwent operations by robotics was reported (76). Included were 12 primary, 4 interval, and 5 secondary cytoreductive surgeries for ovarian cancer. In addition to primary tumor excision, major procedures included modified posterior pelvic exenteration, rectosigmoid resection, small bowel resection, diaphragm resection, and resection of liver metastases. The operating times had a wide range (103 to 454 minutes) resulting from the extent of


Gynecology_Novak

Gynecology_Novak. rectosigmoid resection, small bowel resection, diaphragm resection, and resection of liver metastases. The operating times had a wide range (103 to 454 minutes) resulting from the extent of procedures. Blood loss was low (25 to 300 mL). Postoperative complications were low but increased with the number of procedures.


Gynecology_Novak

Gynecology_Novak. There are reports of robotics for ovarian cancer consisting of an occasional patient included within a series of patients with different types of gynecologic cancers and with no comparison Disadvantages of Robotics to laparoscopy or laparotomy (77–81). Robotics may be useful for selected patients with ovarian cancer. Because of the need for operating table rotation and the insertion of additional trocars, it may not become widely accepted. The use of the surgical robotic system can be advocated in the case of isolated recurrences of ovarian cancer, such as in the pelvis, or in the upper abdomen, diaphragm, liver, and spleen. Isolated left liver metastases were removed successfully in three patients with recurrent ovarian cancer with no complications (82).


Gynecology_Novak

Gynecology_Novak. In conclusion, robotics and laparoscopy have advantages compared to laparotomy for selected patients with cervical, endometrial and early ovarian cancer. Although prospective randomized trials are desirable, the retrospective evidence supports the selected use of minimally invasive surgery for endometrial and cervical cancer patients and selected patients with primary or recurrent ovarian cancer. Complications Unique to Robotics Because there is no tactile feedback, the robotic arms can injure any organ not under visual control. The potential for injury is higher with the fourth retracting arm when out of the visual field and repositioned without visual control. Constant visual control of the robotic instrument position is mandatory for the prevention of injuries. Collision of the robotic arms is felt as an unwanted resistance, which is realized when the instruments are brought under view. Constant pressure of the robotic arms on the patient thighs or arms may result in injury.


Gynecology_Novak

Gynecology_Novak. Constant pressure of the robotic arms on the patient thighs or arms may result in injury. This can be prevented during positioning of the trocars and robotic arms. A rapid move by the surgeon on any robotic instrument may result in hitting the assistant near the operating table with the robotic arm. Moving a robotic arm by anyone other than the surgeon may result in patient internal injury.


Gynecology_Novak

Gynecology_Novak. Because the robotic trocars are fastened to the robotic arms, and the arms are fixed to the robotic column, any sudden loss of the pneumoperitoneum may result in the instruments being pulled off the anterior abdominal wall as it becomes ﬂattened. Similarly, any sliding of the patient on the operating table as a result of the Trendelenburg position will result in pressure at the trocars site and potential injury or increased postoperative trocar site pain. The robotic column must be positioned at the level of the patient’s feet or lateral to the legs in order to prevent access to the vagina, rectum, or urethra. The present robotic system has limited surgical field reach. It allows for pelvic or abdominal surgery, but not both, unless the robotic column is repositioned from the patient’s feet to the patient’s head. This repositioning increases surgical time and requires the insertion of additional trocars.


Gynecology_Novak

Gynecology_Novak. The available robotic instrumentation is appropriate for gynecological surgery, but there is no vessel sealing cutting device or suction-irrigation device. An assistant is necessary, at the surgical site away from the surgeon, and therefore, all orders or corrections are verbal. Although the grasping pressure of the robotic instruments is high and can damage tissue, tissue traction is not as efficient as with conventional laparoscopic instruments. Because there is no tactile feedback when grasping a tissue, there is only visual control of the traction exerted upon any structure. The lack of tactile feedback is an advantage in obese patients (see above technology), but can be a disadvantage when the instruments are not in the visual field.


Gynecology_Novak

Gynecology_Novak. Cost is a common reason why many institutions have delayed the initiation of robotic programs. The initial purchase of the robotic system is high, about $1.5 million, with an additional annual maintenance fee, and all robotic instruments become functionless after ten uses, so they are disposed. The robotic column and its arms are bulky, with a total weight of 1,200 lb. An operating room must have adequate space, preferably about 600 square feet. There must be a dedicated team for robotic surgery and preferably a specific team for each surgical specialty. The surgical assistant must be versed in robotic technology and be able to provide the required maneuvers without direct interaction because the surgeon is away at a console and not in a surgical sterile condition. 1. Moorthy K, Munz Y, Dosis A, et al. Dexterity enhancement with robotic surgery. Surg Endosc 2004;18:790–795. 2.


Gynecology_Novak

Gynecology_Novak. 1. Moorthy K, Munz Y, Dosis A, et al. Dexterity enhancement with robotic surgery. Surg Endosc 2004;18:790–795. 2. Prasad SM, Prasad SM, Maniar HS, et al. Surgical robotics: impact of motion scaling on task performance. J Am Coll Surg 2004;199:863– 868. 3. Sarle R, Tewari A, Shrivastava A, et al. Surgical robotics and laparoscopic training drills. J Endourol 2004;18:63–67. 4. Yohannes P, Rotariu P, Pinto P, et al. Comparison of robotic versus laparoscopic skills: is there a difference in the learning curve? Urology 2002;60:39–45. 5. van der Schatte Olivier RH, Van’t Hullenaar CD, Ruurda JP, et al. Ergonomics, user comfort, and performance in standard and robot-assisted laparoscopic surgery. Surg Endosc 2009;23:1365–1371. 6. Kho RM, Hilger WS, Hentz JG, et al. Robotic hysterectomy: technique and initial outcomes. Am J Obstet Gynecol 2007;197:113.e111– e114. 7.


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Gynecology_Novak. 6. Kho RM, Hilger WS, Hentz JG, et al. Robotic hysterectomy: technique and initial outcomes. Am J Obstet Gynecol 2007;197:113.e111– e114. 7. Kreiker GL, Bertoldi A, Larcher JS, et al. Prospective evaluation of the learning curve of laparoscopic-assisted vaginal hysterectomy in a university hospital. J Am Assoc Gynecol Laparosc 2004;11:229–235. 8. Lenihan JP, Jr., Kovanda C, Seshadri-Kreaden U. What is the learning curve for robotic assisted gynecologic surgery? J Minim Invasive Gynecol 2008t;15:589–594. 9. Pitter MC, Anderson P, Blissett A, et al. Robotic-assisted gynaecological surgery-establishing training criteria; minimizing operative time and blood loss. Int J Med Robot 2008;4:114–120. 10. Seamon LG, Fowler JM, Richardson DL, et al. A detailed analysis of the learning curve: robotic hysterectomy and pelvic-aortic lymphadenectomy for endometrial cancer. Gynecol Oncol 2009;114:162– 167. 11.


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Gynecology_Novak. 11. Anvari M, McKinley C, Stein H. Establishment of the world’s first telerobotic remote surgical service: for provision of advanced laparoscopic surgery in a rural community. Ann Surg 2005;241:460–464. 12. Rodrigues Netto N Jr, Mitre AI, Lima SV, Fugita OE, et al. Telementoring between Brazil and the United States: initial experience. J Endourol 2003;17:217–220. 13. Reyes DA, Tang B, Cuschieri A. Minimal access surgery (MAS)related surgeon morbidity syndromes. Surg Endosc 2006;20:1–13. 14. Gofrit ON, Mikahail AA, Zorn KC, et al. Surgeons’ perceptions and injuries during and after urologic laparoscopic surgery. Urology 2008;71:404–407. 15. Peiretti M, Zanagnolo V, Bocciolone L, et al. Robotic surgery: changing the surgical approach for endometrial cancer in a referral cancer center. J Minim Invasive Gynecol 2009;16:427–431. 16.


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Gynecology_Novak. 15. Peiretti M, Zanagnolo V, Bocciolone L, et al. Robotic surgery: changing the surgical approach for endometrial cancer in a referral cancer center. J Minim Invasive Gynecol 2009;16:427–431. 16. DeNardis SA, Holloway RW, Bigsby GEt, et al. Robotically assisted laparoscopic hysterectomy versus total abdominal hysterectomy and lymphadenectomy for endometrial cancer. Gynecol Oncol 2008;111:412–417. 17. Veljovich DS, Paley PJ, Drescher CW, et al. Robotic surgery in gynecologic oncology: program initiation and outcomes after the first year with comparison with laparotomy for endometrial cancer staging. Am J Obstet Gynecol 2008;198:679.e671–e679. 18. Jacoby VL, Autry A, Jacobson G, et al. Nationwide use of laparoscopic hysterectomy compared with abdominal and vaginal approaches. Obstet Gynecol 2009;114:1041–1048. 19.


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Gynecology_Novak. 18. Jacoby VL, Autry A, Jacobson G, et al. Nationwide use of laparoscopic hysterectomy compared with abdominal and vaginal approaches. Obstet Gynecol 2009;114:1041–1048. 19. Payne TN, Dauterive FR. A comparison of total laparoscopic hysterectomy to robotically assisted hysterectomy: surgical outcomes in a community practice. J Minim Invasive Gynecol 2008;15:286–291. 20. Mais V, Ajossa S, Guerriero S, et al. Laparoscopic versus abdominal myomectomy: a prospective, randomized trial to evaluate benefits in early outcome. Am J Obstet Gynecol 1996;174:654–658. 21. Seracchioli R, Rossi S, Govoni F, et al. Fertility and obstetric outcome after laparoscopic myomectomy of large myomata: a randomized comparison with abdominal myomectomy. Hum Reprod 2000;15:2663–2668. 22. Advincula AP, Xu X, Goudeau St, et al. Robot-assisted laparoscopic myomectomy versus abdominal myomectomy: a comparison of short-term surgical outcomes and immediate costs. J Minim Invasive Gynecol 2007;14:698–705.


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Gynecology_Novak. 23. Advincula AP, Song A, Burke W, et al. Preliminary experience with robot-assisted laparoscopic myomectomy. J Am Assoc Gynecol Laparosc 2004;11:511–518. 24. Bedient CE, Magrina JF, Noble BN, et al. Comparison of robotic and laparoscopic myomectomy. Am J Obstet Gynecol 2009;201:566.e561– e565. 25. Nezhat C, Lavie O, Hsu S, et al. Robotic-assisted laparoscopic myomectomy compared with standard laparoscopic myomectomy—a retrospective matched control study. Fertil Steril 2009;91:556–569. 26. Magrina JF, Espada M, Munoz R, et al. Robotic adnexectomy compared with laparoscopy for adnexal mass. Obstet Gynecol 2009;114:581–584. 27. Dharia Patel SP, Steinkampf MP, Whitten SJ, et al. Robotic tubal anastomosis: surgical technique and cost effectiveness. Fertil Steril 2008;90:1175–1179. 28. Rodgers AK, Goldberg JM, Hammel JP, et al. Tubal anastomosis by robotic compared with outpatient minilaparotomy. Obstet Gynecol 2007;109:1375–1380. 29.


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Gynecology_Novak. 28. Rodgers AK, Goldberg JM, Hammel JP, et al. Tubal anastomosis by robotic compared with outpatient minilaparotomy. Obstet Gynecol 2007;109:1375–1380. 29. Akl MN, Magrina JF, Kho RM, et al. Robotic appendectomy in gynaecological surgery: technique and pathological findings. Int J Med Robot 2008;4:210–213. 30. Akl MN, Long JB, Giles DL, et al. Robotic-assisted sacrocolpopexy: technique and learning curve. Surg Endosc 2009;23:2390–2394. 31. Daneshgari F, Kefer JC, Moore C, et al. Robotic abdominal sacrocolpopexy/sacrouteropexy repair of advanced female pelvic organ prolapse (POP): utilizing POP-quantification-based staging and outcomes. BJU Int 2007;100:875–879. 32. Visco AG, Advincula AP. Robotic gynecologic surgery. Obstet Gynecol 2008;112:1369–1384. 33. Mabrouk M, Frumovitz M, Greer M, et al. Trends in laparoscopic and robotic surgery among gynecologic oncologists: a survey update. Gynecol Oncol 2009;112:501–505. 34.


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Gynecology_Novak. 33. Mabrouk M, Frumovitz M, Greer M, et al. Trends in laparoscopic and robotic surgery among gynecologic oncologists: a survey update. Gynecol Oncol 2009;112:501–505. 34. Magrina JF, Weaver AL. Laparoscopic treatment of endometrial cancer: five-year recurrence and survival rates. Eur J Gynaecol Oncol 2004;25:439–441. 35. Malur S, Possover M, Michels W, et al. Laparoscopic-assisted vaginal versus abdominal surgery in patients with endometrial cancer—a prospective randomized trial. Gynecol Oncol 2001;80:239– 244. 36. Nezhat F, Yadav J, Rahaman J, et al. Analysis of survival after laparoscopic management of endometrial cancer. J Minim Invasive Gynecol 2008;15:181–187. 37. Cho YH, Kim DY, Kim JH, et al. Laparoscopic management of early uterine cancer: 10-year experience in Asian Medical Center. Gynecol Oncol 2007;106:585–590. 38. Magrina JF. Outcomes of laparoscopic treatment for endometrial cancer. Curr Opin Obstet Gynecol 2005;17:343–346. 39.


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Gynecology_Novak. 38. Magrina JF. Outcomes of laparoscopic treatment for endometrial cancer. Curr Opin Obstet Gynecol 2005;17:343–346. 39. Magrina JF, Mutone NF, Weaver AL, et al. Laparoscopic lymphadenectomy and vaginal or laparoscopic hysterectomy with bilateral salpingo-oophorectomy for endometrial cancer: morbidity and survival. Am J Obstet Gynecol 1999;181:376–381. 40. Bell MC, Torgerson J, Seshadri-Kreaden U, et al. Comparison of outcomes and cost for endometrial cancer staging via traditional laparotomy, standard laparoscopy and robotic techniques. Gynecol Oncol 2008;111:407–411. 41. Boggess JF, Gehrig PA, Cantrell L, et al. A comparative study of 3 surgical methods for hysterectomy with staging for endometrial cancer: robotic assistance, laparoscopy, laparotomy. Am J Obstet Gynecol 2008;199:360.e361–e369. 42.


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Gynecology_Novak. 42. Gehrig PA, Cantrell LA, Shafer A, et al. What is the optimal minimally invasive surgical procedure for endometrial cancer staging in the obese and morbidly obese woman? Gynecol Oncol 2008;111: 41–45. 43. Holloway RW, Ahmad S, DeNardis SA, et al. Robotic-assisted laparoscopic hysterectomy and lymphadenectomy for endometrial cancer: analysis of surgical performance. Gynecol Oncol 2009;115: 447–452. 44. Seamon LG, Cohn DE, Henretta MS, et al. Minimally invasive comprehensive surgical staging for endometrial cancer: robotics or laparoscopy? Gynecol Oncol 2009;113:36–41. 45. Zullo F, Palomba S, Russo T, et al. A prospective randomized comparison between laparoscopic and laparotomic approaches in women with early stage endometrial cancer: a focus on the quality of life. Am J Obstet Gynecol 2005;193:1344–1352. 46.


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Gynecology_Novak. 46. Frumovitz M, dos Reis R, Sun CC, et al. Comparison of total laparoscopic and abdominal radical hysterectomy for patients with early-stage cervical cancer. Obstet Gynecol 2007;110:96–102. 47. Holloway RW, Finkler NJ, Pikaart DP, et al. Comparison of total laparoscopic and abdominal radical hysterectomy for patients with early-stage cervical cancer. Obstet Gynecol 2007;110:1174–1175. 48. Magrina JF. Robotic surgery in gynecology. Eur J Gynaecol Oncol 2007;28:77–82. 49. Magrina JF, Kho RM, Weaver AL, et al. Robotic radical hysterectomy: comparison with laparoscopy and laparotomy. Gynecol Oncol 2008;109:86–91. 50. Nezhat FR, Datta MS, Liu C, et al. Robotic radical hysterectomy versus total laparoscopic radical hysterectomy with pelvic lymphadenectomy for treatment of early cervical cancer. JSLS 2008;12:227–237. 51.


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Gynecology_Novak. 51. Puntambekar SP, Palep RJ, Puntambekar SS, et al. Laparoscopic total radical hysterectomy by the Pune technique: our experience of 248 cases. J Minim Invasive Gynecol 2007;14:682–689. 52. Zakashansky K, Lerner DL. Total laparoscopic radical hysterectomy for the treatment of cervical cancer. J Minim Invasive Gynecol 2008;15:387–388. 53. Obermair A, Gebski V, Frumovitz M, et al. A phase III randomized clinical trial comparing laparoscopic or robotic radical hysterectomy with abdominal radical hysterectomy in patients with early stage cervical cancer. J Minim Invasive Gynecol 2008;15:584–588. 54. Magrina JF, Kho R, Magtibay PM. Robotic radical hysterectomy: technical aspects. Gynecol Oncol 2009;113:28–31. 55. Persson J, Reynisson P, Borgfeldt C, et al. Robot assisted laparoscopic radical hysterectomy and pelvic lymphadenectomy with short and long term morbidity data. Gynecol Oncol 2009;113:185–190. 56.


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Gynecology_Novak. Persson J, Reynisson P, Borgfeldt C, et al. Robot assisted laparoscopic radical hysterectomy and pelvic lymphadenectomy with short and long term morbidity data. Gynecol Oncol 2009;113:185–190. 56. Boggess JF, Gehrig PA, Cantrell L, et al. A case-control study of robot-assisted type III radical hysterectomy with pelvic lymph node dissection compared with open radical hysterectomy. Am J Obstet Gynecol 2008;199:357.e351–e357. 57. Estape R, Lambrou N, Diaz R, et al. A case matched analysis of robotic radical hysterectomy with lymphadenectomy compared with laparoscopy and laparotomy. Gynecol Oncol 2009;113:357–361. 58. Maggioni A, Minig L, Zanagnolo V, et al. Robotic approach for cervical cancer: comparison with laparotomy: a case control study. Gynecol Oncol 2009;115:60–64. 59. Ramirez PT, Schmeler KM, Wolf JK, et al. Robotic radical parametrectomy and pelvic lymphadenectomy in patients with invasive cervical cancer. Gynecol Oncol 2008;111:18–21. 60.


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Gynecology_Novak. 59. Ramirez PT, Schmeler KM, Wolf JK, et al. Robotic radical parametrectomy and pelvic lymphadenectomy in patients with invasive cervical cancer. Gynecol Oncol 2008;111:18–21. 60. Diaz-Feijoo B, Gil-Moreno A, Puig O, et al. Total laparoscopic radical trachelectomy with intraoperative sentinel node identification for early cervical stump cancer. J Minim Invasive Gynecol 2005;12:522– 524. 61. Zanagnolo V, Magrina JF. Robotic radical trachelectomy after supracervical hysterectomy for cut-through endometrial adenocarcinoma stage IIB: a case report. J Minim Invasive Gynecol 2009;16:655– 657. 62. Persson J, Kannisto P, Bossmar T. Robot-assisted abdominal laparoscopic radical trachelectomy. Gynecol Oncol 2008;111:564–567. 63. Ramirez PT, Schmeler KM, Malpica A, et al. Safety and feasibility of robotic radical trachelectomy in patients with early-stage cervical cancer. Gynecol Oncol 2010;116:512–515. 64.


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Gynecology_Novak. 63. Ramirez PT, Schmeler KM, Malpica A, et al. Safety and feasibility of robotic radical trachelectomy in patients with early-stage cervical cancer. Gynecol Oncol 2010;116:512–515. 64. Burnett AF, O’Meara AT, Bahador A, et al. Extraperitoneal laparoscopic lymph node staging: the University of Southern California experience. Gynecol Oncol 2004;95:189–192. 65. Gil-Moreno A, Franco-Camps S, Diaz-Feijoo B, et al. Usefulness of extraperitoneal laparoscopic paraaortic lymphadenectomy for lymph node recurrence in gynecologic malignancy. Acta Obstet Gynecol Scand 2008;87:723–730. 66. Kehoe SM, Abu-Rustum NR. Transperitoneal laparoscopic pelvic and paraaortic lymphadenectomy in gynecologic cancers. Curr Treat Options Oncol 2006;7:93–101. 67. Marnitz S, Kohler C, Roth C, et al. Is there a benefit of pretreatment laparoscopic transperitoneal surgical staging in patients with advanced cervical cancer? Gynecol Oncol 2005;99:536–544. 68.


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Gynecology_Novak. Marnitz S, Kohler C, Roth C, et al. Is there a benefit of pretreatment laparoscopic transperitoneal surgical staging in patients with advanced cervical cancer? Gynecol Oncol 2005;99:536–544. 68. Querleu D, Dargent D, Ansquer Y, et al. Extraperitoneal endosurgical aortic and common iliac dissection in the staging of bulky or advanced cervical carcinomas. Cancer 2000;88:1883–1891. 69. Tillmanns T, Lowe MP. Safety, feasibility, and costs of outpatient laparoscopic extraperitoneal aortic nodal dissection for locally advanced cervical carcinoma. Gynecol Oncol 2007;106:370–374. 70. Fanning J, Fenton B, Purohit M. Robotic radical hysterectomy. Am J Obstet Gynecol 2008;198:649.e641–e644. 71. Kim YT, Kim SW, Hyung WJ, et al. Robotic radical hysterectomy with pelvic lymphadenectomy for cervical carcinoma: a pilot study. Gynecol Oncol 2008;108:312–316. 72.


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Gynecology_Novak. 71. Kim YT, Kim SW, Hyung WJ, et al. Robotic radical hysterectomy with pelvic lymphadenectomy for cervical carcinoma: a pilot study. Gynecol Oncol 2008;108:312–316. 72. Magrina JF, Long JB, Kho RM, et al. Robotic transperitoneal infrarenal aortic lymphadenectomy: technique and results. Int J Gynecol Cancer 2010;20:184–187. 73. Magrina JF, Kho R, Montero RP, et al. Robotic extraperitoneal aortic lymphadenectomy: development of a technique. Gynecol Oncol 2009;113:32–35. 74. Vergote I, Pouseele B, Van Gorp T, et al. Robotic retroperitoneal lower para-aortic lymphadenectomy in cervical carcinoma: first report on the technique used in 5 patients. Acta Obstet Gynecol Scand 2008;87:783–787. 75. Lambaudie E, Narducci F, Leblanc E, et al. Robotically-assisted laparoscopic anterior pelvic exenteration for recurrent cervical cancer: report of three first cases. Gynecol Oncol 2010;116:582–583. 76.


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Gynecology_Novak. 76. Bandera CA, Magrina JF. Robotic surgery in gynecologic oncology. Curr Opin Obstet Gynecol 2009;21:25–30. 77. Diaz-Arrastia C, Jurnalov C, Gomez G, et al. Laparoscopic hysterectomy using a computer-enhanced surgical robot. Surg Endosc 2002;16:1271–1273. 78. Field JB, Benoit MF, Dinh TA, et al. Computer-enhanced robotic surgery in gynecologic oncology. Surg Endosc 2007;21:244–246. 79. Lambaudie E, Houvenaeghel G, Walz J, et al. Robot-assisted laparoscopy in gynecologic oncology. Surg Endosc 2008;22:2743– 2747. 80. Reynolds RK, Burke WM, Advincula AP. Preliminary experience with robot-assisted laparoscopic staging of gynecologic malignancies. JSLS 2005;9:149–158. 81. van Dam PA, van Dam PJ, Verkinderen L, et al. Robotic-assisted laparoscopic cytoreductive surgery for lobular carcinoma of the breast metastatic to the ovaries. J Minim Invasive Gynecol 2007;14:746–749. 82.


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Gynecology_Novak. 82. Choi SB, Park JS, Kim JK, et al. Early experiences of robotic-assisted laparoscopic liver resection. Yonsei Med J 2008;49:632–638. Shawn A. Menefee Ingrid Nygaard Bladder storage and emptying depend on a complex interplay between the brain, spinal cord, bladder, urethra, and pelvic ﬂoor. Urinary incontinence is common in women and generally is treated successfully with a range of nonsurgical and surgical treatments. Stress urinary incontinence occurs with increases in abdominal pressure (such as coughing, running, lifting) and can be treated with pelvic muscle exercises, vaginal devices, lifestyle changes, and surgery. Urgency urinary incontinence occurs with a sudden sense of urgency (such as on the way to the bathroom or when washing hands) and can be treated with bladder training, medications, lifestyle changes, and neuromodulation. Bladder pain remains a challenging and poorly understood entity. Physiology of Micturition


Gynecology_Novak

Gynecology_Novak. Bladder pain remains a challenging and poorly understood entity. Physiology of Micturition The bladder is a complex organ that has a relatively simple function: to store urine effortlessly, painlessly, and without leakage and to discharge urine voluntarily, effortlessly, completely, and painlessly. To meet these demands, the bladder must have normal anatomic support and normal neurophysiologic function.


Gynecology_Novak

Gynecology_Novak. Normal urethral closure is maintained by a combination of intrinsic and extrinsic factors. The extrinsic factors include the levator ani muscles, the endopelvic fascia, and their attachments to the pelvic sidewalls and the urethra. This structure forms a hammock beneath the urethra that responds to increases in intra-abdominal pressure by tensing, allowing the urethra to be closed against the posterior supporting shelf (Fig. 26.1). When this supportive mechanism becomes faulty for some reason—the endopelvic fascia has detached from its normal points of fixation, muscular support has weakened, or a combination of these two processes—normal support is lost and anatomic hypermobility of the urethra and bladder neck develops. For many women, this loss of support is severe enough to cause loss of closure during


Gynecology_Novak

Gynecology_Novak. Figure 26.1 Lateral view of the pelvic ﬂoor drawn from a three-dimensional reconstruction with the urethra, vagina, and fascial tissues transected at the level of the vesical neck. Note how the urethra is compressed against the underlying supportive tissues by the downward force (arrow) generated by a cough or sneeze. (From Delancey J. Structural support of the urethra as it relates to stress urinary incontinence: the hammock hypothesis. Am J Obstet Gynecol 1994;170:1718, with permission.) periods of increased intra-abdominal pressure, resulting in stress incontinence. However, many women remain continent in spite of loss of urethral support (1).


Gynecology_Novak

Gynecology_Novak. The intrinsic factors contributing to urethral closure include the striated muscle of the urethral wall, vascular congestion of the submucosal venous plexus, the smooth muscle of the urethral wall and associated blood vessels, the epithelial coaptation of the folds of the urethral lining, urethral elasticity, and the tone of the urethra as mediated by α-adrenergic receptors of the sympathetic nervous system.


Gynecology_Novak

Gynecology_Novak. Effective urethral closure is maintained by the interaction of extrinsic urethral support and intrinsic urethral integrity, each of which is inﬂuenced by several factors (muscle tone and strength, innervation, fascial integrity, urethral elasticity, coaptation of urothelial folds, urethral vascularity). In the clinical setting, damaged urethral support is manifested clinically by urethral hypermobility, which often results in incompetent urethral closure during physical activity and presents as stress urinary incontinence. Intrinsic urethral functioning is more complicated and is not understood nearly as well as incontinence related to loss of urethral support (2). Clinical appreciation of the importance of extrinsic support and intrinsic urethral function led to the separation of stress incontinence into two broad types: 1. Incontinence caused by anatomic hypermobility of the urethra 2.


Gynecology_Novak

Gynecology_Novak. Surgical approaches are based on this arbitrary distinction, with a pubovaginal sling recommended for women with intrinsic sphincter deficiency and a colposuspension (also known as retropubic urethropexy) for those with hypermobility. This rationale was based initially on a small study in which women younger than age 50 years with urethral closure pressure less than 20 cm H2O had a higher failure rate after a Burch colposuspension than did women with a closure pressure greater than 20 cm H2O (3). No difference in outcome was seen in women older than 50 years. This dichotomy was called into question, based on the observation that all women with stress incontinence have some degree of sphincter weakness, regardless of whether they have hypermobility. Minimally invasive synthetic midurethral slings have largely replaced pubovaginal slings and retropubic urethropexy as the most commonly performed surgical procedures for stress urinary incontinence. The use of midurethral slings would seem


Gynecology_Novak

Gynecology_Novak. slings have largely replaced pubovaginal slings and retropubic urethropexy as the most commonly performed surgical procedures for stress urinary incontinence. The use of midurethral slings would seem to lessen the impact of a poorly functioning urethra; however, a similar debate is ongoing about the impact of poor urethral function with both retropubic and transobturator slings. It appears that women with poor urethral function are more likely to experience treatment failure irrespective of the type of procedure performed (4).


Gynecology_Novak

Gynecology_Novak. The Bladder The bladder is a bag of smooth muscle that stores urine and contracts to expel urine under voluntary control. It is a low-pressure system that expands to accommodate increasing volumes of urine without an appreciable rise in pressure. This function appears to be mediated primarily by the sympathetic nervous system. During bladder filling, there is an accompanying increase in outlet resistance. The bladder muscle (the detrusor) should remain inactive during bladder filling, without involuntary contractions. When the bladder has filled to a certain volume, fullness is registered by tension-stretch receptors, which signal the brain to initiate a micturition reﬂex. This reﬂex is controlled by cortical control mechanisms, depending on the social circumstances and the state of the patient’s nervous system. Normal voiding is accomplished by voluntary relaxation of the pelvic ﬂoor and urethra, accompanied by sustained contraction of the detrusor muscle, leading to complete bladder


Gynecology_Novak

Gynecology_Novak. nervous system. Normal voiding is accomplished by voluntary relaxation of the pelvic ﬂoor and urethra, accompanied by sustained contraction of the detrusor muscle, leading to complete bladder emptying.


Gynecology_Novak

Gynecology_Novak. Innervation The lower urinary tract receives its innervation from three sources: (i) the sympathetic and (ii) parasympathetic divisions of the autonomic nervous system, and (iii) the neurons of the somatic nervous system (external urethral sphincter). The autonomic nervous system consists of all efferent pathways with ganglionic synapses that lie outside the central nervous system. The sympathetic system primarily controls bladder storage, and the parasympathetic nervous system controls bladder emptying. The somatic nervous system plays only a peripheral role in neurologic control of the lower urinary tract through its innervation of the pelvic ﬂoor and external urethral sphincter.


Gynecology_Novak

Gynecology_Novak. The sympathetic nervous system originates in the thoracolumbar spinal cord, principally T11 through L2 or L3 (see Chapter 6). The ganglia of the sympathetic nervous system are located close to the spinal cord and use acetylcholine as the preganglionic neurotransmitter. The postganglionic neurotransmitter in the sympathetic nervous system is norepinephrine, and it acts on two types of receptors: α-receptors, located principally in the urethra and bladder neck, and βreceptors, located principally in the bladder body. Stimulation of α-receptors increases urethral tone and thus promotes closure, whereas α-adrenergic receptor blockers have the opposite effect. Stimulation of β-receptors decreases tone in the bladder body.


Gynecology_Novak

Gynecology_Novak. The parasympathetic nervous system controls bladder motor function—bladder contraction and bladder emptying. The parasympathetic nervous system originates in the sacral spinal cord, primarily in S2 to S4, as does the somatic innervation of the pelvic ﬂoor, urethra, and external anal sphincter. Sensation in the perineum is also controlled by sensory fibers that connect with the spinal cord at this level. For this reason, examination of perineal sensation, pelvic muscle reﬂexes, and pelvic muscle or anal sphincter tone is relevant to clinical evaluation of the lower urinary tract. The parasympathetic neurons have long preganglionic neurons and short postganglionic neurons, which are located in the end organ. Both the preganglionic and postganglionic synapses use acetylcholine as their neurotransmitter, acting on muscarinic receptors. Because acetylcholine is the main neurotransmitter used in bladder muscle contraction, virtually all drugs used to control detrusor muscle overactivity


Gynecology_Novak

Gynecology_Novak. acting on muscarinic receptors. Because acetylcholine is the main neurotransmitter used in bladder muscle contraction, virtually all drugs used to control detrusor muscle overactivity have anticholinergic properties.


Gynecology_Novak

Gynecology_Novak. Bladder storage and bladder emptying involve the interplay of the sympathetic and parasympathetic nervous systems. The modulation of these activities appears to be inﬂuenced by a variety of nonadrenergic, noncholinergic neurotransmitters and neuropeptides, which fine tune the system at various facilitative and inhibitory levels in the spinal cord and higher areas of the central nervous system (5–7). Neuropathology at almost any level of the neurourologic axis can have an adverse effect on lower urinary tract function.


Gynecology_Novak

Gynecology_Novak. Micturition Micturition is triggered by the peripheral nervous system under the control of the central nervous system. It is useful to consider this event as occurring at a micturition threshold, a bladder volume at which reﬂex detrusor contractions occur. The threshold volume is not fixed; rather, it is variable and can be altered depending on the contributions made by sensory afferents from the perineum, bladder, colon, rectum, and input from the higher centers of the nervous system. The micturition threshold is, therefore, a ﬂoating threshold that can be altered or reset by various inﬂuences.


Gynecology_Novak

Gynecology_Novak. The spinal cord and higher centers of the nervous system have complex patterns of inhibition and facilitation. The most important facilitative center above the spinal cord is the pontine-mesencephalic gray matter of the brainstem, often called the pontine micturition center, which serves as the final common pathway for all bladder motor neurons. Transection of the tracts below this level leads to disturbed bladder emptying, whereas destruction of tracts above this level leads to detrusor overactivity. The cerebellum serves as a major center for coordinating pelvic ﬂoor relaxation and the rate, force, and range of detrusor contractions, and there are multiple interconnections between the cerebellum and the brainstem reﬂex centers. Above this level, the cerebral cortex and related structures exert inhibitory inﬂuences on the micturition reﬂex. Thus, the upper cortex exerts facilitative inﬂuences that release inhibition, permitting the anterior pontine micturition center to send efferent


Gynecology_Novak

Gynecology_Novak. exert inhibitory inﬂuences on the micturition reﬂex. Thus, the upper cortex exerts facilitative inﬂuences that release inhibition, permitting the anterior pontine micturition center to send efferent impulses down the complex pathways of the spinal cord, where a reﬂex contraction in the sacral micturition center generates a detrusor contraction that causes bladder emptying.


Gynecology_Novak

Gynecology_Novak. A normal lower urinary tract is one in which the bladder and urethra store urine without pain until a socially acceptable time and place arises, at which point voiding occurs in a coordinated and complete fashion. Lower urinary tract disorders include disorders of storage (such as urinary incontinence), emptying (such as urinary hesitancy and retention), and sensation (such as urgency or pain). Current definitions for these disorders are depicted in Table 26.1.


Gynecology_Novak

Gynecology_Novak. Definitions Defining urinary incontinence would seem an easy task: women who leak urine must be “incontinent.” A joint report from the International Urogynecological Association and the International Continence Society made recommendations on the terminology of female pelvic ﬂoor dysfunction in an attempt to update the definitions by a female-specific approach and clinically based consensus. This report defined incontinence as “the complaint of any involuntary leakage of urine” (8). This definition does not take into account the wide variation in this symptom and the disruption it causes. For example, half of young nulliparous women report occasional minor urine leakage; for most this is neither a bother nor a symptom for which they would seek treatment. At the other extreme, 5% to 10% of adult women have severe leakage daily. These women often dramatically alter their lives because of leakage, curtailing activities, social outings, and intimacy. Many suffer marked deterioration in


Gynecology_Novak

Gynecology_Novak. of adult women have severe leakage daily. These women often dramatically alter their lives because of leakage, curtailing activities, social outings, and intimacy. Many suffer marked deterioration in self-esteem. In between these two extremes lies another one-third of adult women who report leakage at least weekly, but without the same degree of life-altering severity as the women previously noted.


Gynecology_Novak

Gynecology_Novak. Collectively, these women assume a substantial cost burden. The total annual cost to care for patients with incontinence in the United States is estimated at $11.2 billion in the community and $5.2 billion in nursing homes (9). In the United States, much of this cost is borne directly by women in the form of incontinence pads and excess laundry costs. Despite the burden imposed by leakage, many women do not discuss this symptom with a health care professional. For some women, this is because the leakage does not bother them, whereas others are embarrassed and suffer in silence. Still others do not raise this issue because they mistakenly believe the only treatment option is surgical. It is incumbent on the provider to ask women about leakage.


Gynecology_Novak

Gynecology_Novak. Studies show that there is little relationship between the volume of urine lost and the distress that it causes a patient (10). The degree to which women are bothered by leakage is inﬂuenced by various factors, including cultural values and expectations regarding urinary continence and incontinence. If the leakage is distressing to the patient, evaluation and treatment should be offered. Incontinence can almost always be improved and frequently can be cured, often using relatively simple, nonsurgical interventions. Table 26.1 Classification and Definition of Lower Urinary Symptoms in Women I. Abnormal Storage Symptoms and Signs Incontinence (symptom) Any involuntary leakage of urine Stress urinary incontinence Involuntary leakage on effort or exertion, or on sneezing or coughing (symptom) Stress urinary incontinence Observation of involuntary leakage from the urethra, synchronous with exertion/effort, or sneezing (sign) or coughing


Gynecology_Novak

Gynecology_Novak. Stress urinary incontinence Observation of involuntary leakage from the urethra, synchronous with exertion/effort, or sneezing (sign) or coughing Urgency urinary Involuntary loss of urine associated with urgency incontinence (symptom) Mixed incontinence Involuntary loss of urine associated with urgency and also with effort or physical exertion or on sneezing or coughing Continuous urinary Continuous involuntary loss of urine incontinence Frequency Number of voids per day, from waking in the morning until falling asleep at night Increased daytime urinary Micturition occurs more frequently during waking hours than previously deemed normal by women frequency (traditionally defined as more than seven episodes) Nocturia Interruption of sleep one or more times because of the need to micturate (each void is preceded and followed by sleep) Nocturnal enuresis Involuntary loss of urine that occurs during sleep Urgency Sudden, compelling desire to pass urine, which is difficult to defer


Gynecology_Novak

Gynecology_Novak. Nocturnal enuresis Involuntary loss of urine that occurs during sleep Urgency Sudden, compelling desire to pass urine, which is difficult to defer Postural urinary Involuntary loss of urine associated with change of body position, for example, rising from a seated incontinence or lying position Insensible urinary Urinary incontinence where the women has been unaware of how it occurred incontinence Coital incontinence Involuntary loss of urine with coitus. This symptoms might be further divided into that occurring with penetration or intromission and that occurring at organism. Overactive bladder Urinary urgency, usually accompanied by frequency and nocturia, with or without urgency urinary syndrome (OAB) incontinence, in the absence of urinary tract infection or other obvious pathology II. Abnormal Sensory Symptoms


Gynecology_Novak

Gynecology_Novak. II. Abnormal Sensory Symptoms Increased bladder Desire to void during bladder filling occurs earlier or is more persistent from that previous sensation experienced (differs from urgency by the fact that micturition can be postpone despite the desire to void) From Haylen BT, de Ridder D, Freeman RM, et al. An International Urogynecological Association (IUGA)/International Continence Society (ICS) Joint Report on the terminology for female pelvic ﬂoor dysfunction. Neurourol Urodyn 2010;29:4–20, with permission. Types of Disorders


Gynecology_Novak

Gynecology_Novak. Types of Disorders Stress urinary incontinence occurs during periods of increased intra-abdominal pressure (e.g., sneezing, coughing, or exercise) when the intravesical pressure rises higher than the pressure that the urethral closure mechanism can withstand. Some advocate the term “activity-related incontinence” in some languages to avoid the confusion with psychological stress (8). Stress urinary incontinence is the most common form of urinary incontinence in women and is particularly common in younger women. Active women are more likely to notice symptoms of stress urinary incontinence. In a survey of 144 collegiate female varsity athletes, 27% reported stress incontinence while participating in their sport (11). The activities most likely to produce urinary loss were jumping, high-impact landings, and running.


Gynecology_Novak

Gynecology_Novak. Stress incontinence is an interesting “disease” as the same symptoms have varying effects on different women. This condition is best considered in a biobehavioral model that examines the interaction of three variables: (i) the biologic strength of the urethral sphincteric mechanism, (ii) the level of physical stress placed on the closure mechanism, and (iii) the woman’s expectations about urinary control. This model explains the enormous variation that exists among the symptoms, the degree of demonstrable leakage, and a patient’s response to her stress incontinence. Modification of any one of these factors may inﬂuence the patient’s clinical status; for example, many patients give up certain physical activities (e.g., running, dancing, aerobics) when they experience stress incontinence. Limiting their activities may eliminate the incontinence problem, but it does so at a certain cost to their quality of life. Other women learn to cope with stress incontinence by adopting new body


Gynecology_Novak

Gynecology_Novak. Limiting their activities may eliminate the incontinence problem, but it does so at a certain cost to their quality of life. Other women learn to cope with stress incontinence by adopting new body postures during physical activities that prevent them from leaking or by strengthening their pelvic muscles to compensate for increased exertion. Other women may be profoundly relieved to find out that the small amount of leakage they experience from time to time is not abnormal. In any case, the interaction of these three biopsychosocial factors opens up a variety of strategies for the management of stress incontinence. Surgical intervention is only one strategy, and it addresses only the biologic competence of the sphincteric mechanism rather than either of the other factors that interact to produce the clinical problem.


Gynecology_Novak

Gynecology_Novak. Although stress incontinence is the most common type of urinary continence in all women, urgency incontinence is the most common form of incontinence in older women (12). Urgency urinary incontinence is the involuntary leakage of urine accompanied by or immediately preceded by urgency. The new joint report from the International Urogynecological Association and International Continence Society recommended this symptom be called urgency urinary incontinence to differentiate between the normal urge experienced when the bladder is full from the abnormal response that may require treatment. This is a symptom-based diagnosis; the cause may or may not be detrusor overactivity, based on urodynamic observation characterized by involuntary detrusor contractions during the filling phase.


Gynecology_Novak

Gynecology_Novak. This is a symptom-based diagnosis; the cause may or may not be detrusor overactivity, based on urodynamic observation characterized by involuntary detrusor contractions during the filling phase. Women may have other related problems such as urgency, nocturia, and increased daytime frequency. The definition of nocturia is quantifiable: The woman wakes one or more times a night to void (8). Increased daytime frequency occurs when the patient considers that she voids too often. The term pollakisuria is used to describe this condition in many countries.


Gynecology_Novak

Gynecology_Novak. Urgency is the sudden compelling desire to pass urine that is difficult to defer. Most women have experienced these symptoms during times of voluntary delays in voiding or increased ﬂuid intake. However, urinary urgency implies more than just the feeling that all normal women have if they voluntarily delay voiding beyond a reasonable time (8). When a woman presents for treatment, she generally reports an intrusive, bothersome, persistent need to urinate that takes her attention away from other activities. Increased daytime frequency is often brought up as an issue when a woman experiences a change in her own voiding pattern.


Gynecology_Novak

Gynecology_Novak. There is very little information about what is “normal” in terms of voiding frequency. Overactive bladder (OAB) is frequently defined in studies of pharmacologic agents as more than eight voids per 24 hours, a definition that was based on the 95th percentile of voids in a small sample of Scandinavian women (13). Data from a broader sample of women in the United States suggest that the median number of voids per day is eight, and 95% of so-called normal women void 12 or fewer times per day (14). Overactive detrusor function is defined as a urodynamic diagnosis characterized by involuntary detrusor contractions during the filling phase, which may be spontaneous or provoked. It is divided into neurogenic detrusor overactivity, resulting from a relevant neurologic condition and idiopathic detrusor overactivity, when there is no clear cause (15).


Gynecology_Novak

Gynecology_Novak. The term overactive bladder syndrome is defined as urinary urgency, usually accompanied by frequency and nocturia, with or without urgency urinary incontinence, in the absence of urinary tract infection or other obvious pathology (8). It is often referred to as OAB-dry when women with these symptoms do not leak urine, and OAB-wet when it is accompanied by incontinence. It is important to note that a woman with severe urgency and a sense of impending leakage who remains dry may have the exact same bladder pathology as one with severe urgency and concomitant leakage. A woman with a strong urethral sphincteric mechanism may be able to avoid leakage during uninhibited bladder contractions, and although one with a strong sphincter may remain dry, she still may be disturbed by the urgency and impending sense of leakage.


Gynecology_Novak

Gynecology_Novak. Mixed Incontinence As implied by the name, women with mixed incontinence have symptoms of both stress and urge urinary incontinence. Younger women are more likely to have stress incontinence alone, whereas in older women mixed and urge incontinence predominate. In a review of 15 population-based studies of women of all ages with urinary incontinence, a median of 49% (range 24% to 75%) had stress urinary incontinence, 21% (range 7% to 49%) had urge urinary incontinence, and 29% (range 11% to 61%) had mixed urinary incontinence (16).


Gynecology_Novak

Gynecology_Novak. Functional incontinence is more common in elderly women and refers to incontinence that occurs because of factors unrelated to the physiologic voiding mechanism. A woman who cannot get to the bathroom quickly enough may often become incontinent. Functional incontinence can be related to such factors as decreased mobility, musculoskeletal pain, or poor vision. Factors leading to transient urinary incontinence are, as the name implies, medically reversible conditions. A useful mnemonic to help remember these factors is DIAPPERS (17,18) (Table 26.2). These factors argue strongly for the inclusion of a thorough medical evaluation as part of the workup of any patient with urinary incontinence. Table 26.2 Reversible Causes of Incontinence From Resnick NM, Yalla SV. Management of urinary incontinence in the elderly. N Engl J Med 1985;313: 800–805, with permission.


Gynecology_Novak

Gynecology_Novak. Table 26.2 Reversible Causes of Incontinence From Resnick NM, Yalla SV. Management of urinary incontinence in the elderly. N Engl J Med 1985;313: 800–805, with permission. to the outside (19). Such cases are diagnosed at birth. Before the advent of modern reconstructive surgery, these infants usually died very early in life from sepsis. Ectopic ureter, a subtle congenital anomaly causing extraurethral urine loss, generally is detected early in life, but occasionally may escape detection until adolescence or early adulthood (20). In infancy, an ectopic ureter should be suspected when a mother seeks care for her baby, whom she says is never dry. Normally, infants have periods of dryness interspersed with periods of wetness. Most commonly, the ectopic ureter drains into the vagina, but occasionally, it may drain into the urethra distal to the point of continence. This condition can be diagnosed by excretory urography.


Gynecology_Novak

Gynecology_Novak. A traumatic opening between the urinary tract and the outside is called a fistula. Vesicovaginal fistulas, located between the bladder and urethra, are most common, but fistulas may occur between the vagina, uterus, or bowel, and the urethra, ureter, or bladder. Worldwide, the most common cause of vesicovaginal fistulas is obstructed labor. This was true in the Western world 150 years ago, but advances in the provision of basic obstetric services and advanced obstetric intervention have virtually eliminated this problem in developed countries.


Gynecology_Novak

Gynecology_Novak. Obstructed labor can occur in rural areas where girls are married young (sometimes as early as 9 to 10 years of age) and where transportation is poor and access to medical services is limited. In such circumstances, pregnancy often occurs shortly after menstruation begins and before maternal skeletal growth is complete. When labor begins, cephalopelvic disproportion is common and little can be done to correct fetal malpresentations. Women may be in labor as long as 5 to 6 days without intervention, and if they survive, they usually give birth to a stillborn infant. In such cases, the soft tissues of the pelvis are crushed by constant pressure from the fetal head, leading to an ischemic vascular injury and subsequent tissue necrosis. When this tissue sloughs, a genitourinary or rectovaginal fistula develops. Many of these patients have complex or multiple fistulas, involving total destruction of the urethra and sloughing of the entire bladder base (Fig. 26.2). Obstetric fistulas are


Gynecology_Novak

Gynecology_Novak. fistula develops. Many of these patients have complex or multiple fistulas, involving total destruction of the urethra and sloughing of the entire bladder base (Fig. 26.2). Obstetric fistulas are frequently as large as 5 to 6 cm in diameter.


Gynecology_Novak

Gynecology_Novak. After such fistulas develop, the lives of these young women (most of whom are younger than 20 years of age) are ruined unless they can gain access to curative surgical services. The constant, uncontrolled dribble of urine makes them offensive to their husbands and family members and they are often ostracized from their families. Most of them eventually become destitute social outcasts—and yet these are otherwise healthy young women. The social and economic costs of this problem are enormous, yet the world medical community largely ignores it. The morbidity associated with obstetric fistulas remains, along with the related maternal mortality, one of the single most neglected issues in international women’s health care. Figure 26.2 Moderate-sized obstetric vesicovaginal fistula. A metal probe has been placed through the urethra and is clearly visible through the bladder base. (Copyright Worldwide Fistula Fund, used by permission.)


Gynecology_Novak

Gynecology_Novak. Figure 26.3 Posthysterectomy fistulas. Note three small fistulas in a row.