696
Fig. 1 Preparation of the right paravesical space for pelvic lymphadenectomy.
Journal of Minimally Invasive Gynecology, Vol 22, No 4, May/June 2015
without requiring the use of other robotic forceps. Indeed, during the robotic procedure, the use of multiple instruments is related to sensible cost augmentation. In our experience, during hysterectomy for benign indication, the use of only a robotic monopolar hook with a laparoscopic bipolar hook or scissors is adequate. In this setting, significant monetary savings for single procedure are possible. However, in patients needing comprehensive surgical staging, the use of robotic bipolar forceps appears useful and safe. In oncologic cases, complete single-site surgical staging with consequent minor surgical trauma justifies more spending with respect to R-SSH alone. The improvement in technology within the robotic industry and future clinical trials can extend the indications for single-site surgery in gynecology. Robotic single-site surgery seems to offer a possible solution to laparoscopic single-site complexities, even if the problem of roboticrelated cost still remains an ‘‘open question.’’
References
reported a significant reduction of console time in the group of patients treated with robotic bipolar instruments. The recent commercialization of bipolar forceps dedicated to the da Vinci single-site platform (Intuitive Surgical, Sunnyvale, CA) allowed clinicians to overcome the initially described surgical limitations. Nowadays, 2 types of bipolar instruments are available: Maryland bipolar forceps (MBF) and Joanne bipolar forceps (JPF). In our experience, total laparoscopic extrafascial hysterectomy and type 1 systematic pelvic lymphadenectomy can be successfully performed with the assistance of JBF and a monopolar hook in case of endometrial adenocarcinoma Federation Internationale de Gynecologie et d’Obstetrique stage IB-G2. The surgical procedure was successfully performed with a total operative time of 130 minutes, a console time of 95 minutes, and an estimated blood loss of 50 mL without surgical complications. The preparation of surgical spaces for lymphadenectomy was easy, and the number of lymph nodes removed was adequate and comparable with standard robotic surgery (27 removed nodes) (Fig. 1). Currently, in the literature, only 1 report described systematic pelvic lymphadenectomy during a robotic singlesite procedure using dedicated single-site MBF [6]. During single-site robotic hysterectomy, we prefer JBF over MBF because they provided excellent coagulation and better surgical grasping of the tissue was possible
Stefano Bogliolo, MD Valentina Musacchi, MD Chiara Cassani, MD Luciana Babilonti, MD Barbara Gardella, MD Arsenio Spinillo, MD Pavia, Italy
1. Escobar PF, Fader AN, Paraiso MF, et al. Robotic assisted laparoendoscopic single-site surgery in gynecology: initial report and technique. J Minim Invasive Gynecol. 2009;16:589–591. 2. Vizza E, Corrado G, Mancini E, et al. Robotic single-site hysterectomy in low risk endometrial cancer: a pilot study. Ann Surg Oncol. 2013;20: 2759–2764. 3. Scheib SA, Fader AN. Gynecologic robotic laparoendoscopic single-site surgery: prospective analysis of feasibility, safety, and technique. Am J Obstet Gynecol. 2015;212:179.e1–179.e8. 4. Bogliolo S, Mereu L, Cassani C, et al. Robotic single-site hysterectomy: two institutions’ preliminary experience. Int J Med Robot. 2014 Sep 18; http://dx.doi.org/10.1002/rcs.1613. 5. Sendag F, Akdemir A, Zeybek B, et al. Single-site robotic total hysterectomy: standardization of technique and surgical outcomes. J Minim Invasive Gynecol. 2014;21:689–694. 6. Tateo S, Nozza A, Del Pezzo C, Mereu L. Robotic single-site pelvic lymphadenectomy. Gynecol Oncol. 2014;134:631. http://dx.doi.org/10.1016/j.jmig.2015.01.006
Risk of Morcellation of Uterine Leiomyosarcomas in Laparoscopic Supracervical Hysterectomy and Laparoscopic Myomectomy, a Retrospective Trial Including 4791 Women To the Editor: We read on-line with great interest the paper ‘‘Risk of Morcellation of Uterine Leiomyosarcomas in Laparoscopic
Letters to the Editor
697
Supracervical Hysterectomy and Laparoscopic Myomectomy, a Retrospective Trial Including 4791 Women’’ by Lieng et al [1]. The authors conclude that ‘‘the incidence of uterine LMS in the population of women referred for anticipated benign fibroids was 0.0054’’ (26 out of 4791 women). However, we are concerned that this sentence misstates the data presented in the paper. Of the 26 women with LMS, 6 were diagnosed by endometrial biopsy before the surgical treatment and 14 were treated by open hysterectomy and bilateral salpingooophorectomy owing to ‘‘clinical preoperative suspicion of a malignant condition.’’ And, as the authors state, only ‘‘6 women with uterine LMS were treated according to anticipated benign fibroids.’’ This is an important distinction; if 6 women with LMS were diagnosed before surgery and 14 other women had a clinical suspicion of a malignant condition, then these 20 women were not considered to have benign fibroids before surgery. Consequently, only the remaining 6 women with LMS were considered to have benign fibroids preoperatively. Thus, the incidence should be stated as 6 unsuspected LMS cases out of 4771 women thought to have benign fibroids preoperatively, equal to 1 of 795, or 0.001. Owing to the current important discussions about the risk of LMS, we feel that the authors’ conclusion should be clarified. William Parker, MD Elizabeth Pritts, MD David Olive, MD Santa Monica, CA
tively, the woman is referred to a special oncologic unit for treatment. From our point of view, a leiomyosarcoma detected at our department in a woman admitted for treatment of fibroids is unanticipated by definition. Thus, according to the objective of our study, we calculated the incidence of leiomyosarcomas by dividing the number of new cases of leiomyosarcomas (n 5 26) within the total population of women referred for surgical treatment of anticipated fibroids (n 5 4791). We believe that this is the correct way to calculate the incidence of unanticipated leiomyosarcomas in this setting. Despite the relatively high occurrence of leiomyosarcomas in our population, we demonstrate that 76.9% of women with unanticipated leiomyosarcomas were treated according to the protocol of malignancy. In our opinion, this indicates that the majority of leiomyosarcomas can be suspected preoperatively during thorough preoperative selection. At our gynecology department, laparoscopic supracervical hysterectomy and laparoscopic myomectomy are offered as primary treatment options for fibroids. Both procedures are performed with the use of power morcellation. We believe that the rate of unintended morcellation of leiomyosarcomas in our trial (0.0002) justifies this approach in selected women with fibroids. Marit Lieng, MD, PhD Espen Berner, MD Bjoern Busund, MD Oslo, Norway http://dx.doi.org/10.1016/j.jmig.2015.01.016
Reference 1. Lieng M, Berner E, Busund B. Risk of morcellation of uterine leiomyosacomas in laparoscopic supracervical hysterectomy and laparoscopic myomectomy, a retrospective trial including 4791 women. J Minim Invasive Gynecol. 2014;22:410–414.
Robotic Single-Site Surgery in Management of Obese Patients With Early-Stage Endometrial Cancer
http://dx.doi.org/10.1016/j.jmig.2015.01.015
Reply To the Editor: We thank our distinguished colleagues for their interest in our paper. In their letter, Parker, Pritts, and Olive suggest a different calculation of the incidence of leiomyosarcomas. In general, the term ‘‘unanticipated’’ is relative, and consequently, the definition of when and under which circumstances a medical condition is ‘‘unanticipated’’ may allow room for discussion. The main objective of our trial was to calculate the incidence of uterine leiomyosarcomas in women admitted to our department for surgical treatment of uterine fibroids. This is clearly stated in our paper. In our general gynecology unit, we treat mainly benign conditions. When a leiomyosarcoma is diagnosed preopera-
To the Editor: Obesity (body mass index [BMI] R30 kg/m2) represents a clinical and social problem with serious consequences for public health policy worldwide. In Europe, obesity involves a large pproportion of the population, with prevalence in women ranging from 6% to 20%; in the United States, approximately one-third of women are obese [1–3]. Several technical difficulties and sequelae complicate surgery in obese patients. Moreover, numerous obesityrelated comorbidities, such as cardiovascular, metabolic, and respiratory diseases, are responsible for the anesthesiologic limitations to surgery [3,4]. Minimally invasive surgery has numerous advantages over standard abdominal surgery in obese patients as well. Indeed, laparoscopy is able to ameliorate surgical vision, reduce tissue trauma, and decrease postsurgical infection. The more rapid mobilization after laparoscopy can reduce the risk of thromboembolism in this subsets of high-risk patients [4–6].
Fig. 1 Preparation of the right paravesical space for pelvic lymphadenectomy.
Journal of Minimally Invasive Gynecology, Vol 22, No 4, May/June 2015
without requiring the use of other robotic forceps. Indeed, during the robotic procedure, the use of multiple instruments is related to sensible cost augmentation. In our experience, during hysterectomy for benign indication, the use of only a robotic monopolar hook with a laparoscopic bipolar hook or scissors is adequate. In this setting, significant monetary savings for single procedure are possible. However, in patients needing comprehensive surgical staging, the use of robotic bipolar forceps appears useful and safe. In oncologic cases, complete single-site surgical staging with consequent minor surgical trauma justifies more spending with respect to R-SSH alone. The improvement in technology within the robotic industry and future clinical trials can extend the indications for single-site surgery in gynecology. Robotic single-site surgery seems to offer a possible solution to laparoscopic single-site complexities, even if the problem of roboticrelated cost still remains an ‘‘open question.’’
References
reported a significant reduction of console time in the group of patients treated with robotic bipolar instruments. The recent commercialization of bipolar forceps dedicated to the da Vinci single-site platform (Intuitive Surgical, Sunnyvale, CA) allowed clinicians to overcome the initially described surgical limitations. Nowadays, 2 types of bipolar instruments are available: Maryland bipolar forceps (MBF) and Joanne bipolar forceps (JPF). In our experience, total laparoscopic extrafascial hysterectomy and type 1 systematic pelvic lymphadenectomy can be successfully performed with the assistance of JBF and a monopolar hook in case of endometrial adenocarcinoma Federation Internationale de Gynecologie et d’Obstetrique stage IB-G2. The surgical procedure was successfully performed with a total operative time of 130 minutes, a console time of 95 minutes, and an estimated blood loss of 50 mL without surgical complications. The preparation of surgical spaces for lymphadenectomy was easy, and the number of lymph nodes removed was adequate and comparable with standard robotic surgery (27 removed nodes) (Fig. 1). Currently, in the literature, only 1 report described systematic pelvic lymphadenectomy during a robotic singlesite procedure using dedicated single-site MBF [6]. During single-site robotic hysterectomy, we prefer JBF over MBF because they provided excellent coagulation and better surgical grasping of the tissue was possible
Stefano Bogliolo, MD Valentina Musacchi, MD Chiara Cassani, MD Luciana Babilonti, MD Barbara Gardella, MD Arsenio Spinillo, MD Pavia, Italy
1. Escobar PF, Fader AN, Paraiso MF, et al. Robotic assisted laparoendoscopic single-site surgery in gynecology: initial report and technique. J Minim Invasive Gynecol. 2009;16:589–591. 2. Vizza E, Corrado G, Mancini E, et al. Robotic single-site hysterectomy in low risk endometrial cancer: a pilot study. Ann Surg Oncol. 2013;20: 2759–2764. 3. Scheib SA, Fader AN. Gynecologic robotic laparoendoscopic single-site surgery: prospective analysis of feasibility, safety, and technique. Am J Obstet Gynecol. 2015;212:179.e1–179.e8. 4. Bogliolo S, Mereu L, Cassani C, et al. Robotic single-site hysterectomy: two institutions’ preliminary experience. Int J Med Robot. 2014 Sep 18; http://dx.doi.org/10.1002/rcs.1613. 5. Sendag F, Akdemir A, Zeybek B, et al. Single-site robotic total hysterectomy: standardization of technique and surgical outcomes. J Minim Invasive Gynecol. 2014;21:689–694. 6. Tateo S, Nozza A, Del Pezzo C, Mereu L. Robotic single-site pelvic lymphadenectomy. Gynecol Oncol. 2014;134:631. http://dx.doi.org/10.1016/j.jmig.2015.01.006
Risk of Morcellation of Uterine Leiomyosarcomas in Laparoscopic Supracervical Hysterectomy and Laparoscopic Myomectomy, a Retrospective Trial Including 4791 Women To the Editor: We read on-line with great interest the paper ‘‘Risk of Morcellation of Uterine Leiomyosarcomas in Laparoscopic
Letters to the Editor
697
Supracervical Hysterectomy and Laparoscopic Myomectomy, a Retrospective Trial Including 4791 Women’’ by Lieng et al [1]. The authors conclude that ‘‘the incidence of uterine LMS in the population of women referred for anticipated benign fibroids was 0.0054’’ (26 out of 4791 women). However, we are concerned that this sentence misstates the data presented in the paper. Of the 26 women with LMS, 6 were diagnosed by endometrial biopsy before the surgical treatment and 14 were treated by open hysterectomy and bilateral salpingooophorectomy owing to ‘‘clinical preoperative suspicion of a malignant condition.’’ And, as the authors state, only ‘‘6 women with uterine LMS were treated according to anticipated benign fibroids.’’ This is an important distinction; if 6 women with LMS were diagnosed before surgery and 14 other women had a clinical suspicion of a malignant condition, then these 20 women were not considered to have benign fibroids before surgery. Consequently, only the remaining 6 women with LMS were considered to have benign fibroids preoperatively. Thus, the incidence should be stated as 6 unsuspected LMS cases out of 4771 women thought to have benign fibroids preoperatively, equal to 1 of 795, or 0.001. Owing to the current important discussions about the risk of LMS, we feel that the authors’ conclusion should be clarified. William Parker, MD Elizabeth Pritts, MD David Olive, MD Santa Monica, CA
tively, the woman is referred to a special oncologic unit for treatment. From our point of view, a leiomyosarcoma detected at our department in a woman admitted for treatment of fibroids is unanticipated by definition. Thus, according to the objective of our study, we calculated the incidence of leiomyosarcomas by dividing the number of new cases of leiomyosarcomas (n 5 26) within the total population of women referred for surgical treatment of anticipated fibroids (n 5 4791). We believe that this is the correct way to calculate the incidence of unanticipated leiomyosarcomas in this setting. Despite the relatively high occurrence of leiomyosarcomas in our population, we demonstrate that 76.9% of women with unanticipated leiomyosarcomas were treated according to the protocol of malignancy. In our opinion, this indicates that the majority of leiomyosarcomas can be suspected preoperatively during thorough preoperative selection. At our gynecology department, laparoscopic supracervical hysterectomy and laparoscopic myomectomy are offered as primary treatment options for fibroids. Both procedures are performed with the use of power morcellation. We believe that the rate of unintended morcellation of leiomyosarcomas in our trial (0.0002) justifies this approach in selected women with fibroids. Marit Lieng, MD, PhD Espen Berner, MD Bjoern Busund, MD Oslo, Norway http://dx.doi.org/10.1016/j.jmig.2015.01.016
Reference 1. Lieng M, Berner E, Busund B. Risk of morcellation of uterine leiomyosacomas in laparoscopic supracervical hysterectomy and laparoscopic myomectomy, a retrospective trial including 4791 women. J Minim Invasive Gynecol. 2014;22:410–414.
Robotic Single-Site Surgery in Management of Obese Patients With Early-Stage Endometrial Cancer
http://dx.doi.org/10.1016/j.jmig.2015.01.015
Reply To the Editor: We thank our distinguished colleagues for their interest in our paper. In their letter, Parker, Pritts, and Olive suggest a different calculation of the incidence of leiomyosarcomas. In general, the term ‘‘unanticipated’’ is relative, and consequently, the definition of when and under which circumstances a medical condition is ‘‘unanticipated’’ may allow room for discussion. The main objective of our trial was to calculate the incidence of uterine leiomyosarcomas in women admitted to our department for surgical treatment of uterine fibroids. This is clearly stated in our paper. In our general gynecology unit, we treat mainly benign conditions. When a leiomyosarcoma is diagnosed preopera-
To the Editor: Obesity (body mass index [BMI] R30 kg/m2) represents a clinical and social problem with serious consequences for public health policy worldwide. In Europe, obesity involves a large pproportion of the population, with prevalence in women ranging from 6% to 20%; in the United States, approximately one-third of women are obese [1–3]. Several technical difficulties and sequelae complicate surgery in obese patients. Moreover, numerous obesityrelated comorbidities, such as cardiovascular, metabolic, and respiratory diseases, are responsible for the anesthesiologic limitations to surgery [3,4]. Minimally invasive surgery has numerous advantages over standard abdominal surgery in obese patients as well. Indeed, laparoscopy is able to ameliorate surgical vision, reduce tissue trauma, and decrease postsurgical infection. The more rapid mobilization after laparoscopy can reduce the risk of thromboembolism in this subsets of high-risk patients [4–6].
