Robotic Gynecologic Surgery...Clinical Expert Series Continuing medical education is available...

Clinical Expert Series

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Robotic Gynecologic SurgeryAnthony G. Visco, MD, and Arnold P. Advincula, MD

The objective of this article is to review the recent adoption, experience, and applications ofrobot-assisted laparoscopy in gynecologic surgery. The use of robotics in gynecologic surgery isincreasing in the United States. Robotic-assisted laparoscopic surgeries in gynecology includebenign hysterectomy, myomectomy, tubal reanastomoses, radical hysterectomy, lymph nodedissections, and sacrocolpopexies. The majority of the current literature includes case series ofvarious robotic surgeries. Recently, comparative retrospective and prospective studies havedemonstrated the feasibility of this particular type of surgery. Although individual studies vary,robot-assisted gynecologic surgery is often associated with longer operating room time butgenerally similar clinical outcomes, decreased blood loss, and shorter hospital stay. Robot-assisted gynecologic surgery will likely continue to develop as more gynecologic surgeons aretrained and more patients seek minimally invasive surgical options. Well-designed, prospectivestudies with well-defined clinical, long-term outcomes, including complications, cost, pain,return to normal activity, and quality of life, are needed to fully assess the value of this newtechnology.(Obstet Gynecol 2008;112:1369–84)

Occasionally, technologic advances profoundlychange a particular field and, therefore, themanagement of associated clinical conditions. Forinstance, the advent of tension-free vaginal slingsrevolutionized the surgical treatment of stress incon-tinence around the world.1 Similarly, the introductionof in vitro fertilization in 1978 forever changed the

management of infertility and allowed thousands ofotherwise infertile couples to conceive.2

Technical advancements have clearly broughtabout improvements to modern-day laparoscopy.These include high-intensity light sources, improvedhand instrumentation, and electrosurgical devices.Through the recent years, this technology has continuedto grow in the area of minimally invasive gynecologicsurgery and, in turn, affected how we address pathologyand perform traditional procedures. A prime example isthe evolution of hysterectomy from an abdominal ap-proach. Approximately 20 years ago, Harry Reich3

published the first case report of a laparoscopicallyassisted vaginal hysterectomy. Today we have the op-tion of total laparoscopic hysterectomy. Studies haveclearly shown that laparoscopic surgery allows fasterrecovery with shorter hospitalization, improved cosme-sis, decreased blood loss, and less postoperative pain.4,5

Despite the technologic advancements and proven ben-efits seen with hysterectomy, other complex procedures,such as the management of advanced endometriosis andprocedures that require extensive suturing such as myo-mectomy and sacrocolpopexy, are typically still man-aged by laparotomy.

See related editorial on page 1198.

From the Division of Urogynecology, Department of Obstetrics and Gynecology,Duke University Medical Center, Durham, North Carolina; and MinimallyInvasive Surgery Program, Department of Obstetrics and Gynecology, Universityof Michigan Medical Center, Ann Arbor, Michigan.

Corresponding author: Anthony G. Visco, MD, Associate Professor and Chief,Division of Urogynecology and Reconstructive Pelvic Surgery, Director ofGynecologic Robotic Surgery, Vice Chair for Gynecologic Surgical Services,Department of Obstetrics and Gynecology, Duke University Medical Center,Durham, NC 27710; e-mail: [email protected].

Financial DisclosureDr. Visco is a consultant for Intuitive Surgical (Sunnyvale, CA). Dr. AdvinculaIs a consultant for Intuitive Surgical, Gyrus/ACMI (Southborough, MA), andSurgRx (Redwood City, CA).

© 2008 by The American College of Obstetricians and Gynecologists. Publishedby Lippincott Williams & Wilkins.ISSN: 0029-7844/08

VOL. 112, NO. 6, DECEMBER 2008 OBSTETRICS & GYNECOLOGY 1369

One major obstacle to the more widespreadacceptance and application of minimally invasivesurgical techniques to gynecologic surgery has beenthe steep learning curve for surgeons and longeroperative times associated with many of these ad-vanced procedures. Other limitations encounteredwith conventional laparoscopy include counterintui-tive hand movements, two-dimensional visualization,and limited degrees of instrument motion within thebody as well as ergonomic difficulty and tremoramplification.6 Overall, it is unclear whether thedifficulty in training surgeons to feel comfortable withlaparoscopic surgery is due to residents or attendingshaving an inadequate volume of surgical cases tomaintain a comfort level with this technology andtranscend the learning curve or whether there areinherent limitations of laparoscopy that make gyne-cologic surgeons choose other routes of surgery.

In an attempt to overcome these obstacles, roboticshas been recently incorporated into the gynecologicarmamentarium. Robotic surgery carries with it thepotential to transform laparoscopic surgery by provid-ing, for the first time, instruments with distal ends thatmimic the intricate movements of the human handwhile at the same time providing the surgeon with ahigh-definition, three-dimensional view of the operativefield. As this technology grows and develops, the hope isthat further refinement and improvements will allow foreven more precise and even less invasive surgical op-tions beyond laparoscopy and the current forms ofsurgical robots. This article will review the history ofrobotics in medicine, its incorporation into gynecologicsurgery, and where the future lies.

MILITARY DEVELOPMENTThe use of robots in surgery has only come aboutwithin the past 25 years. The first application of arobot in surgery was in neurosurgery.7 The originalmodel, known as the PUMA 560 (Stäubli Corpora-tion, Duncan, SC), was used for neurosurgical stereo-tactic maneuvers under computed tomography (CT)guidance. Soon, orthopedic surgery was using a de-vice called ROBODOC (Curexo Technology Corpo-ration, Sacramento, CA) to aide in total hip replace-ments,8 and urology was performing transurethralresection of the prostate with a robot through guid-ance from a preoperatively constructed three-dimen-sional image.9 Common among these early robotswas the fact that they were developed to functionautonomously with a preoperative plan or in a super-visory role. This passive role would evolve into amore active one, with an immersive environment thatbecame known as robotic telepresence technology.

The concept of robotic telepresence technologywas born through the collaborative efforts of theStanford Research Institute, the Department of De-fense, and the National Aeronautics and Space Ad-ministration.10 Research was directed toward allowingmilitary surgeons to perform surgery on woundedsoldiers from a safe and remote location. As thetechnology further developed, research focused noton telesurgery but on using robotic surgery to furtherenhance laparoscopic and minimally invasive surgeryin civilian operating rooms. Such advances becamepossible due to improved vision systems, instrumentswith articulating distal ends, and improved ergonom-ics. Although robotic telepresence technology wasinitially created for cardiac surgery,11 it soon wasapplied to the fields of urology and gynecology.

INTRODUCTION OF ROBOTIC SURGERYOne of the early predecessors and first applications ofrobotic technology to the civilian operating room waswith a voice-activated robotic arm known as Aesop(Computer Motion Inc., Goleta, CA). The primaryrole of Aesop was to operate the camera during laparo-scopic surgery.12 This early device soon evolved intoZeus (Computer Motion Inc.), another predecessor tothe current platform of surgical robots. This systemcomprised three remotely controlled robotic arms thatwere attached to the surgical table and a workstationcalled a robotic console. This console possessed theinstrument controls, whereas three-dimensional visionwas obtained with the aide of special glasses. Therobotic arms operated the camera in a manner similar toAesop but also provided the surgeon with two operatingarms that possessed interchangeable “MicroWrist”(Computer Motion Inc.) instruments that had improveddexterity when compared with conventional laparo-scopic instruments. Most importantly, for the first time,the surgeon was moved away from the operating roomtable to a remote console.

Early studies reported on its successful applica-tion to tubal reanastomosis. Falcone13 evaluatedpregnancy rates in 10 patients with previous tuballigations who underwent laparoscopic tubal reanas-tomosis using the identical technique used at lapa-rotomy. A postoperative tubal patency rate of 89%was demonstrated in 17 of the 19 tubes anasto-mosed, with a pregnancy rate of 50% at one year.There were no complications or ectopic pregnan-cies. Comparability to traditional gynecologic tech-niques was demonstrated.

Today there is only one U.S. Food and DrugAdministration–approved device for surgical robot-ics. This current robotic platform is known as the

1370 Visco and Advincula Robotic Gynecologic Surgery OBSTETRICS & GYNECOLOGY

daVinci surgical system (Intuitive Surgical, Sunny-vale, CA; Fig. 1). The key technologic advancementsseen with earlier predecessors are not only incorpo-rated into today’s platform but are further refined.

BASIC SETUPA basic surgical robotic system is composed of threeparts: a patient-side robot, a vision cart, and the roboticmaster console (Fig. 1). The robotic surgeon operatesfrom the remote master console using a combination ofhand controls and foot pedals (Fig. 2). One foot pedalcontrols the camera movement (right/left, up/down,in/out) and horizontal orientation, while a nearby pedalcontrols the focus. Another pedal provides a clutchingmechanism that allows for repositioning of hand con-trols and provides the instruments a range of motionbeyond the physical confines of the console. Another setof pedals controls both monopolar and bipolar energysources. The patient-side cart is wheeled in between thepatient’s legs, and the robotic arms are attached tostainless steel robotic trocars through a process termed“docking.” The hand controls operate either the cameraor up to two robotic instruments at one time. There areup to three operative robotic arms, with the option toswap control among any two of the three operativearms. While operating the robotic operative instru-ments, the surgeon is capable of manipulating, reposi-tioning, grasping, retracting, cutting, dissecting, coagu-lating, and suturing. The robotic master console alsoprovides the surgeon with three-dimensional imagingthrough a stereoscopic viewer. Despite all of thesetechnologic advancements that make the surgeon nearlyautonomous, a bedside assistant is still required for allrobot-assisted cases. Their responsibility is mainly in-strument exchanges, suction and irrigation, suture intro-duction and retrieval, and additional retraction.

ADVANTAGESRobotic surgery offers several advantages over lapa-roscopy: a three-dimensional vision system, wristedinstrumentation, and ergonomic positioning for thesurgeon while performing surgical procedures. Theonly currently available surgical robot employs twomagnifying, wide-angle cameras that when alignedprovide three-dimensional vision to the console sur-geon with an available high-definition vision system.This enhanced visualization gives the gynecologicsurgeon an improved ability to identify tissue planes,blood vessels, and nerves while performing the surgi-cal procedure. Decreased blood loss has been re-ported in comparative studies.14,15

The gynecologic laparoscopic surgeon performsprocedures in a confined space, the female pelvis. Thelimited degrees of freedom associated with a standardlaparoscopic instrument compared with the humanhand can significantly limit dexterity and a surgeon’sability to complete particular tasks, such as difficultdissections, lymph node removal, and intracorporealknot tying. Wristed instrumentation allows the gyne-cologic surgeon to obtain the exact instrument angleavailable at laparotomy. This also eliminates thefulcrum effect that is present with laparoscopy, wheresurgeons need to move their hand in the oppositedirection to the intended location of the distal instru-ment tip (eg, toward the patient’s left if they want theinstrument moved to the patient’s right). With roboticsurgery, the movements are natural, and surgeonsmove their hands in whichever direction they wantthe instruments to move. The “wristed” instrumenta-tion affords greater dexterity and provides sevendegrees of freedom, similar to the human hand. Threedegrees are provided by the robotic arms attached tothe abdominal wall trocars (insertion, pitch, yaw), andfour degrees result from the “wristed” instruments(pitch, yaw, roll, and grip). The terms pitch, roll, andyaw are the three characteristics that describe therotations in three dimensions around the roboticinstrument’s coordinate system origin, the center ofmass. Pitch is the rotation around the lateral ortransverse axis. The yaw is rotation about the verticalaxis, and the roll is rotation around the longitudinalaxis. The improved dexterity and control allow forfiner, more delicate, tremor-free manipulation, dissec-tion, removal, or reconstruction of tissue.

Fatigue and physical discomfort can become lim-itations during any surgical procedure. During lapa-roscopy, surgeons are often contorted to successfullycomplete the surgical procedure because they need to

Fig. 1. Da Vinci robot system. Copyright Intuitive Surgical,Inc. Reproduced with permission.Visco. Robotic Gynecologic Surgery. Obstet Gynecol 2008.

VOL. 112, NO. 6, DECEMBER 2008 Visco and Advincula Robotic Gynecologic Surgery 1371

reach over the patient’s abdomen to manipulate thehand controls on the laparoscopic instruments. Withrobotic surgery, the surgeon sits comfortably at thesurgical console from the vantage point of standing at

the patient’s head and manipulates the hand controlsand foot pedals while in an ergonomic position. Thismay serve to reduce fatigue and discomfort duringcomplex surgical procedures.

Fig. 2. A. Typical operating room setup for four-arm robotic system. Copyright Intuitive Surgical, Inc. Reproduced withpermission. B. daVinci robotic console. C. Foot pedals of robotic console. D. daVinci S robotic instrument arm. CopyrightIntuitive Surgical, Inc. Reproduced with permission. E. SutureCut needle driver. Copyright Intuitive Surgical, Inc.Reproduced with permission.Visco. Robotic Gynecologic Surgery. Obstet Gynecol 2008.


TELESTRATIONThe current version of the daVinci robotic surgicalsystem, the daVinci S (with or without high definition)allows for telestration. This allows the instructingsurgeon to write on a touch screen with a finger or anelectronic pen that is visible to both the consolesurgeon and the bedside staff. This feature allows theinstructor to help guide the dissection, supervisewhich direction a particular robotic instrument shouldbe moved, assist with suture tying, and outline vitalstructures to be avoided. It is important to confirmthat proper target alignment of the cameras has beenperformed to allow the exact location that is high-lighted to be appreciated by the console surgeon.

TilePro (Intuitive Surgical, Inc., Sunnyvale, CA)is a feature that allows for image and video input tothe console. This can be viewed by the consolesurgeon for instructional purposes during the earlyphase of the learning curve or for input of radiologicdata from ultrasonography, computed tomography,or magnetic resonance imaging.

DISADVANTAGESThe main disadvantages of robotic surgery acrossapplications are the cost, the large size of the robotand console, limited availability within some healthsystems, lack of tactile feedback or haptics, and theneed to train residents, attending surgeons and oper-ating room personnel on the use of this technology.The costs associated with robotic surgery include thecost of the unit that can range from 1.4–1.6 milliondollars, annual maintenance fees, and the cost ofinstrumentation that has limited (10) patient uses.Health systems need to perform a return on invest-ment analysis. Given the substantial fixed costs asso-ciated with the purchase, high robotic surgical volumeis required to improve this calculation. Additionalcosts that need to be considered include the time andcost of training surgeons and operating room person-nel, the potential cost of reduced productivity duringa surgeon’s learning curve, and increased operativetime associated with operating room setup as well asthe assembly and disassembly of the robotic systemduring the early phase of the adoption. There isevidence that with experience, operative time canbecome shorter than with laparoscopy.15

The bedside assistant(s) may experience difficultymanipulating laparoscopic instruments through anassistant port and controlling a uterine or vaginalmanipulator. This job is made more challenging forthe assistant because the robotic arms are movingover the patient at the same time. Although robotic

instrument exchange can become quite efficient, com-pared with laparoscopy it still requires attachment ofthe robotic instruments to the instrument arms beforeinsertion.

Another current limitation of robotic surgery isthe lack of haptics, or tactile feedback. While this isinitially noted to be a limitation for novice roboticsurgeons, most quickly adapt and obtain heightenedvisual feedback from the magnified, three-dimen-sional vision system. If there are particular structuresthat the surgeon desires to palpate, they can do solaparoscopically before docking the robot or ask thebedside assistant to palpate and confirm the location,such as palpation of a cervicovaginal colpotomy ringduring a hysterectomy or the sacral promontoryduring a sacrocolpopexy.

Moving the robot to the operating table anddocking or attaching the robotic arms to the trocars isoften cited as a major disadvantage requiring signifi-cant time. With practice and training, this can beperformed efficiently but does require time that is notnecessary with laparoscopy. Docking time has beenshown to decrease with experience to an average ofless than 5 minutes.16 Once docked, the robotic armsare attached and fixed to specialized trocars. Becausethe operating table and the robot do not communicateand are therefore not synchronized, once the roboticunit is docked, the patient bed cannot be moved inany direction, including Trendelenburg; otherwise,the trocar depth can become incorrectly positionedand abdominal wall as well as visceral trauma couldoccur. Increased operative time associated with somerobotic surgeries may have associated side effects,including anesthetic complications. Prospective stud-ies with large sample sizes will also be necessary tofully assess for differences of rare outcomes such asdeep vein thrombosis, dependent edema, and subcu-taneous emphysema.

Finally, given the size of both the robotic unit andconsole, operating room size becomes a major con-sideration. Depending on current operating room sizeand availability, relocation to a larger operating roommay be necessary. Many of these disadvantages couldbe improved with further development and techno-logic refinement.

Future research is imperative to address the ques-tions of cost-effectiveness, effect on resident training,and whether this technology is best made available toall surgeons or to a limited number of surgeons withhigh surgical volume who develop particular roboticexpertise and are able to maintain proficiency withthis evolving technology. Well-designed randomizedtrials comparing various routes of surgery with clini-


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cally meaningful long-term outcomes are needed.These outcomes include effect on quality of life andpatient satisfaction associated with hysterectomy, re-currence, and survival rates for oncology procedures,future fertility rates and pregnancy outcomes associ-ated with tubal reanastomosis or myomectomy, andreoperation rates for urinary incontinence or recur-rent pelvic organ prolapse for sacrocolpopexy.

INTRODUCTION OF ROBOTIC SURGERYIn 2005, U.S. Food and Drug Administration ap-proval was granted for the use of the daVinci surgicalsystem in gynecologic surgery. Since that time, thistechnology has been applied to a number of differentconditions, with the development of several roboticprocedures. Robotic hysterectomy with or without bilat-eral salpingo-oophorectomy, myomectomy, tubal reanas-tomoses, pelvic and paraaortic lymph node dissection,and sacrocolpopexy can all be performed robotically.These procedures can also be accomplished laparoscopi-cally, but there has been limited adoption of laparoscopyfor these procedures. It is yet to be determined if theadoption curve for gynecologists will be similar to that ofurologists. Robotic prostatectomy, first performed in theUnited States in 2000, has become a standard approachfor this surgical procedure.

General GynecologyHysterectomyHysterectomy, the most common major gynecologicsurgery, can be performed a number of ways: vagi-nally, laparoscopically, and abdominally.17 A system-atic evidence-based review that included 27 random-ized controlled trials comparing vaginal, laparoscopic,and abdominal hysterectomy concluded that laparo-scopic hysterectomy was preferred over abdominal hys-terectomy.18 Patients undergoing laparoscopic surgeryhad a quicker return to normal activities, shorter lengthof hospital stay, and lower mean estimated blood loss. Ahigher rate of bladder and ureteral injury were observedin the laparoscopic hysterectomy group (odds ratio 2.695%, confidence interval [CI] 1.2–5.6).

Technologic advances introduced over the pasttwo decades, such as improved optics, more powerfullight sources, and safer electrosurgical generators,have facilitated the transformation of hysterectomyfrom the abdominal approach to the laparoscopic-assisted vaginal hysterectomy and eventually the lapa-roscopic supracervical and total laparoscopic hyster-ectomy.19–21 Although a definite trend towardlaparoscopic hysterectomy has been seen since the1990s, hysterectomy performed with laparotomy re-

mains the most common route.17 It is important torecognize that although laparoscopic hysterectomy isavailable and performed easily in many situations, thedata from a cross-sectional analysis of national dis-charge data using the 2003 National Inpatient Sampleshowed that the minority of surgeons use this mini-mally invasive option. Our study found that of the538,722 hysterectomies performed for benign disease,66.1% were performed abdominally, 21.8% were per-formed vaginally, and only 11.8% were performedlaparoscopically.17 We concluded that despite ashorter hospital stay, vaginal and laparoscopic hyster-ectomies remain far less common than abdominalhysterectomy for benign disease.

One explanation for this slow acceptance is thelearning curve with conventional laparoscopy and itsassociated complications. Another has often beenadvanced pathology, such as large uteri or pelvicadhesions, which affect the surgical anatomy field.This in turn is affected by the surgeon’s skill level andthe technical limitations of conventional laparoscopicinstruments. Contributing to this trend is a decreasingnumber of gynecologic residents who complete resi-dency with adequate numbers of total vaginal hysterec-tomies to provide them with the skills and confidence toperform this surgery independently upon graduation.

Dunn et al22 analyzed whether a concerted effortto increase the number of vaginal hysterectomiesperformed in a residency training program could beaccomplished without an increase in intraoperative orpostoperative complications. During a period of 3years, the rate of vaginal hysterectomy increased from37% to 60% compared with the previous 3-yearperiod. It is yet to be determined whether such aconcerted effort will be made across the country. Thecurrent state of residency education in vaginal hyster-ectomy provides significant challenges to maintaininga cohort of gynecologists with the skills and confi-dence to perform this minimally invasive procedure.Given the morbidity and recovery associated withlaparotomy incisions, the evaluation of alternatives,including laparoscopic hysterectomy and robotic hys-terectomy, is prudent. This, of course, can be donewhile also working to increase the percentage ofhysterectomies performed vaginally.23

Robotics has been looked upon as a possible wayto facilitate the trend toward a less invasive hysterec-tomy. In the gynecologic literature, several authorshave evaluated robot-assisted laparoscopic hysterec-tomy and patient outcomes. Diaz-Arrastia and col-leagues24 in 2002 reported one of the earliest experi-ences with robot-assisted laparoscopic hysterectomy.This series included 16 patients ranging in age from


27 to 77 years. Operative times ranged from 270 to600 minutes, and blood loss ranged between 50 mLand 1,500 mL, with an average loss of 300 mL. Theaverage hospital stay was 2 days, with a range of 1 to3 days. Although their approach was labeled a lapa-roscopic hysterectomy, all cases in that series wereType IIB according to the American Association ofGynecologic Laparoscopists (AAGL) classificationsystem for laparoscopic hysterectomy, meaning thatthe posterior culdotomy and ligation of the cardinaland uterosacral ligament complexes were performedvaginally to complete the hysterectomy.25

Beste et al26 described their initial hysterectomyexperience with 10 robot-assisted AAGL Type IVEcases. The AAGL Type IVE hysterectomy is definedas totally laparoscopic removal of the uterus andcervix, including vaginal cuff closure. They foundtheir operative results were similar to those of con-ventional laparoscopic hysterectomy.

Recently, Fiorentino and colleagues published aseries of AAGL Type IVE hysterectomy.27 Eighteenof 20 women presenting with benign gynecologicconditions underwent a successful robot-assisted totallaparoscopic hysterectomy. Two patients were con-verted to laparotomy with subsequent abdominalhysterectomy because of poor visualization duringrobot-assisted surgery. Reynolds and Advincula28 re-ported their initial series of 16 consecutive patientswho underwent either an AAGL Type IVE or TypeIII laparoscopic supracervical hysterectomy. In con-trast to the Type IVE, the Type III laparoscopicsupracervical hysterectomy is defined as a totallylaparoscopic supracervical procedure with removal ofthe uterine corpus, including division of the uterinearteries. The mean uterine weight was 131.5 g with arange of 30–327 g. There were no conversions tolaparotomy in this series. Specifically, they noted theadvantage of robotic technology in the patient withscarred or obliterated surgical planes, because 13 ofthe 16 patients had prior pelvic surgery and requiredintraoperative management of pelvic adhesions tocomplete the hysterectomy. This same advantage wasalso described by Advincula and Reynolds29 in arobotic series of six patients undergoing successfulhysterectomy who had a scarred or obliterated ante-rior cul-de-sac as a result of prior cesarean deliveries.

Despite significant advantages seen with the ro-botic approach for hysterectomy, Nezhat et al30 re-cently described disadvantages with their very earlyrobotic experience. They found the absence of haptic(tactile) feedback, bulkiness of the system, lack ofvaginal access, and costs to be limiting factors; how-

ever, their experience included only three robotichysterectomies.

Kho et al16 at the Mayo Clinic, Scottsdale, publishedthe largest series to date. Ninety-one patients undergo-ing robotic hysterectomy were evaluated. Those requir-ing lymphadenectomy were excluded. A wide range ofpathology, including ovarian neoplasms, abnormal uter-ine bleeding, and moderate-to-severe endometriosis,was addressed. The average uterine weight was 135.5grams. The mean operative time was 127.8 minutes,with an estimated blood loss of only 78.6 mL andhospital stay of 1.4 days. There were no conversions toconventional laparoscopy or laparotomy and no blad-der or ureteral injuries occurred.

The only comparative study to date of robotichysterectomy to conventional laparoscopy is byPayne and Dauterive15 in 2008. Their experienceinvolved a retrospective review of their last 200consecutive hysterectomy cases completed beforeand after implementation of a robotics program.There were no statistically significant differences inpatient characteristics or uterine weights between thetwo groups. The rate of intraoperative conversions tolaparotomy was two-fold higher in the laparoscopiccohort of 100 patients as compared with the roboticcohort (9% compared with 4%). The mean blood losswas also significantly reduced in the robotic cohort.However, the incidence of adverse events was similarin the two groups.

OncologyA natural progression of robotic technology in gyne-cology has been to the area of oncology. In 2005, thefirst feasibility studies in both Europe and the UnitedStates were published. The first, by Marchal et al31

evaluated 12 malignant cases (five endometrial ade-nocarcinomas and seven cervical carcinomas). Themean number of pelvic lymph nodes removed was 11(range 4–21). No port-site metastasis or recurrenceswere found with a mean follow-up of 10 months(range 2–23). A second study involved seven patients(four endometrial, two ovarian, and one fallopiantube cancer).32 The median lymph node count was 15(range 4–29). Both early experiences clearly demon-strated the feasibility of applying robotic assistance tolaparoscopic cancer staging without an increase incomplication rates or compromise to surgical tech-nique. Since these early reports, several other caseseries confirming feasibility have been published(Table 1).33,34

Magrina et al14 published the first comparativestudy of robotic radical hysterectomy. This studyevaluated all three approaches: laparotomy, conven-


tional laparoscopic, and robotic. There were no sta-tistically significant differences between the threegroups with respect to mean age, body mass index, orlymph node count. However, the authors did findsignificantly less estimated blood loss and shorterlength of stay associated with the robotic approach. Inparticular, operative times were comparable to opensurgery and better than conventional laparoscopy.There were also no conversions or intraoperativecomplications in the robotic group.14

Similarly, Boggess et al35 published a study com-paring robot-assisted, conventional laparoscopic andopen hysterectomy with staging for endometrial can-cer. They found the highest lymph node yields withthe robotic approach. Robotic hysterectomy withstaging was associated with significantly longer oper-ative times compared with open hysterectomy, butshorter operative times when compared with laparos-copy. Conversion rates for robotic and laparoscopicgroups were similar. Boggess et al36 later published acomparative study of robotic-assisted radical hyster-ectomy with pelvic lymph node dissection comparedwith open radical hysterectomy. The robotic cohortwas associated with higher lymph node retrieval,shorter operative time, lower estimated blood loss,and shorter length of stay. Ultimately, 5-year survivalrates will need to be evaluated to truly assess the effectof robotics on gynecologic cancer staging.

Reproductive SurgeryMyomectomyThe ability to manage leiomyomas endoscopically isone of the major advances in minimally invasivegynecologic surgery. Despite the fact that two pro-spective trials have shown postoperative morbidity tobe less and recovery faster with laparoscopic myo-mectomy, the majority of cases are still performedusing laparotomy.4,38

Because the various steps of myomectomy can bedifficult with conventional laparoscopy, many con-cerns exist. In particular, the ability to enucleateleiomyomas and perform a multilayer closure re-quires advanced laparoscopic skills. Although preg-nancy rates after myomectomy managed endoscopi-cally are similar to those after laparotomy, a majorworry continues to be the risk of uterine rupture. Also,the risk of recurrence seems to be higher after lapa-roscopic myomectomy compared with laparotomy.These factors and the associated learning curve maycontribute to the fact that abdominal myomectomyremains the standard approach.39,40 In a mannersimilar to hysterectomy, robotics may facilitate the

incorporation of a less invasive approach to thesurgical management of leiomyomas. Figure 3 showsrobot-assisted laparoscopic myomectomy and myo-metrial suturing after myomectomy.

In a series of 35 cases of robot-assisted laparoscopicmyomectomy from Advincula et al41 the mean�standarddeviation myoma weight was 223.2�244.1 g (95% CI135.8–310.6). The mean number of myomas removedwas 1.6 (range 1–5), and the mean diameter was 7.9�3.5cm (95% CI 6.6–9.1). The average estimated blood losswas 169�198.7 mL (95% CI 99.1–238.4). No bloodtransfusions were necessary. The mean operating timewas 230.8�83 minutes (95% CI 201.6–260.0). Medianlength of stay for these patients was 1 day. Their conver-sion rate to laparotomy was 8.6% (two cases), because ofan absence of haptic (tactile) feedback, which madeenucleation of the leiomyomas difficult.

In 2007, Advincula et al42 published a retrospec-tive case-matched analysis of robot-assisted laparo-scopic myomectomy compared with abdominal myo-

Fig. 3. A. Myomectomy. B. Myometrial suturing aftermyomectomy.Visco. Robotic Gynecologic Surgery. Obstet Gynecol 2008.


mectomy. Although costs and operative times werehigher in the robotic cohort, patients had significantlyless blood loss and did not require blood transfusions.Complication rates were higher in the laparotomygroup. Length of stay was significantly reduced in therobotic cohort (mean 1.5 days compared with 3.6days).

Nezhat43 compared 15 robot-assisted laparo-scopic myomectomies to a matched sample of 35patients undergoing conventional laparoscopic myo-mectomy. The groups were matched by age, bodymass index, parity, previous abdominopelvic surgery,and size, number, and location of the myomas. Theyfound that the mean surgical time for the roboticmyomectomy was longer: 234 minutes (range 140–455) compared with 203 minutes (range 95–330) forlaparoscopic myomectomy. The authors found thatthe blood loss, length of stay, and postoperativecomplications were not significantly different. Re-cently, Senapati and Advincula44 described their sur-gical technique with robot-assisted laparoscopic myo-mectomy as a means to overcome the difficultiesencountered with hysterotomy, including enucle-ation, repair, and extraction, that adheres to theprinciples of open surgery.

Tubal ReanastomosisThe ability to leverage the advantages of an advancedvision system along with the microsurgical precisionof articulating endoscopic instruments is exemplifiedin gynecologic surgery with tubal reanastomosis. Al-though much is written by Falcone and colleagues13,45

on their early work with the Zeus Surgical System,very little has been published as it pertains to today’splatform of surgical robotics. In 2000, Degueldre etal46 reported their feasibility study on eight patientswith prior laparoscopic tubal sterilization who re-quested tubal reanastomosis. Sixteen tubes were suc-cessfully reanastomosed. The mean time that therobotic system was in use was 140 minutes, and meansurgical time was 52 minutes per tube. Five of theeight patients underwent a hysterosalpingogram anddemonstrated at least unilateral patency, with twopregnancies reported within 4 months after surgery.The authors noted the absence of tactile feedback tobe a disadvantage, but overall found that the operat-ing time compared favorably with the time requiredto perform open microsurgery.46 Similar operatingtimes were noted in a second study that evaluated 28patients.47

Dharia et al48 prospectively compared robotic toopen microsurgical tubal anastomosis in women witha history of bilateral tubal ligation who desired rever-

sal. They found that robotic tubal anastomosis wasassociated with significantly longer operative time(201 minutes compared with 155 minutes with open)but significantly shorter hospital length of stay (4hours compared with 34.7 hours with open) and fasterreturn to normal activities of daily living (11.1 dayscompared with 28.1 days with open). Pregnancy rateswere comparable between groups (62.5% comparedwith 50% with open), yet the robotic group had ahigher number of ectopic pregnancies (four comparedwith one with open). The cost per delivery was similarbetween robotic anastomosis ($92,488) and opentubal anastomosis ($92,206).

Most recently, Rodgers et al49 published a retro-spective case–control study of tubal anastomosis byrobotics compared with outpatient minilaparotomy.Twenty-six cases were performed with the robot, and 41cases were performed by outpatient minilaparotomy.Although there were no conversions to laparotomy inthe robotic group, the authors found significantly pro-longed surgical and anesthesia times with the robotictechnique. The robotic approach was associated withhigher costs but a more rapid return to normal activity.

UrogynecologySacrocolpopexyImproved access to health care, advances in medi-cine, and healthier lifestyles have contributed to theincreased life expectancy observed over the pastcentury. The life expectancy at age 65 years increasedfrom 12 years in 1900 to 20 years in 2004. The lifeexpectancy of a female born in 2004 is 80 years.50 Asthe size of the aging population grows, it is expectedthat we will see similar increases in the prevalence ofconditions associated with age, such as pelvic organprolapse. Abdominal sacrocolpopexy has a high long-term success rate of 93–99% but has traditionally beenprimarily performed through a laparotomy incision(Fig. 4).51 Vaginal reconstructive surgical options,such as sacrospinous ligament fixation, uterosacralligament suspension, and vaginally placed mesh pro-cedures, are alternative treatments but have differenteffectiveness levels and are associated with differentrisks of complication.52–55

Maher et al56 performed a systematic evidencereview that included three randomized controlledtrials and found that abdominal sacrocolpopexy wasbetter than vaginal sacrospinous fixation in terms of alower rate of recurrent vault prolapse (relative risk[RR] 0.23, 95% CI 0.07–0.77) and less dyspareunia(RR 0.39, 95% CI 0.18–0.86), but the trend toward alower reoperation rate for prolapse after abdominal


sacrocolpopexy was not statistically significant (RR 0.46,95% CI 0.19–1.11). However, compared with sacrocol-popexy performed through a laparotomy, the vaginalsacrospinous fixation was associated with shorter oper-ating room time, less cost, and earlier return to activitiesof daily living. The data were too few to evaluate otherclinical outcomes and adverse events.

Laparoscopic sacrocolpopexy is possible buttechnically challenging due to the technical difficul-ties with dissection of both the presacral space andrectovaginal septum, mesh positioning, suturing, andextracorporeal knot tying. It is for these reasons thatthis technique, while available for more than a de-cade, has not gained wide popularity. The few datathat are available indicate that a laparoscopic sacro-colpopexy is associated with lower blood loss andshorter hospital stay but longer operating room time.

Agarwala et al57 reported a series of 74 patients withstage II–IV prolapse who underwent a laparoscopicsacrocolpopexy52 or cervicopexy23 with polypropylene

mesh (Prolene, Ethicon, Inc., Johnson and Johnson,Somerville, NJ). Patients had a median age of 63 years(range 48–76 years) and median BMI of 35 (range24–41). The median estimated blood loss was less than25 mL (range 25–150 mL), and median length ofhospital stay was 1 day (range 1–2 days). Two subjects(3%) required conversion, one to laparotomy due todense rectosigmoid adhesions requiring a partial sig-moid resection because of postdissection trauma to thesigmoid. Another surgery was completed as a vaginalprocedure because of finding a prior polyethyleneterephthalate (Mersilene, Ethicon, Inc.) mesh that wasdensely adherent to the pelvic contents. Fifty-two pa-tients underwent a concurrent sling for urinary inconti-nence. Patients had a subjective and objective cure of97% and 100%, respectively. No mesh erosions werenoted with a median follow-up of 24 months (range9–36 months).57

Paraiso et al5 compared 56 laparoscopic with 61abdominal sacrocolpopexies in a retrospective cohort

Fig. 4. A. Normal anatomy. Copy-right Intuitive Surgical, Inc. Repro-duced with permission. B. Uterineprolapse. Copyright Intuitive Surgi-cal, Inc. Reproduced with permis-sion. C. Vaginal vault prolapse.Copyright Intuitive Surgical, Inc. Re-produced with permission. D. Pelvisafter sacrocolpopexy. Copyright Intu-itive Surgical, Inc. Reproduced withpermission.Visco. Robotic Gynecologic Surgery.Obstet Gynecol 2008.


study. The patients were followed for 13.5�12.1months in the laparoscopic group and 15.7�18.1months in the open group. Mean operating time wassignificantly greater in the laparoscopic cohort(269�65 minutes) compared with the open group(218�60 minutes; P�.001). However, estimatedblood loss (172�166 mL compared with 234�149mL; P�.04) and hospital stay (1.8�1.0 days com-pared with 4.0�1.8 days; P�.001) were significantlyless in the laparoscopic group than in the open group.Complication and reoperation rates were similar.

Robotic SacrocolpopexyRobotic sacrocolpopexy has been developed over thepast few years (Fig. 5). Elliott et al58 reported long-term outcomes in 30 patients who underwent robotic-assisted sacrocolpopexy for posthysterectomy vaginalvault prolapse. They performed the presacral dissec-tion laparoscopically and the suturing robotically.Recurrent grade 3 rectocele developed in one patientand recurrent vaginal vault prolapse in another. Twopatients experienced mesh erosion. All patients re-ported satisfaction with the procedure. The meanoperative time was 3.1 hour (range 2.2–4.8 hours). Allbut one patient left on postoperative day 1.

Daneshgari et al59 published a series of 15patients with stage III–IV pelvic organ prolapsewho underwent robotic sacrocolpopexy or sacro-uteropexy. They experienced a 20% conversionrate (3 of 15), one to laparoscopy, one to open, andone to a transvaginal repair. The patients had amean age of 64 years (range 50 –79 years) and amean pelvic organ prolapse quantification system(POP-Q) stage of 3.1.3,4 Preoperatively, the mean

POP-Q values for the anterior vaginal wall (Aa, Ba),posterior vaginal wall (Ap, Bp), and apex (C) point were:Aa�–0.9, Ba��1.0, Ap�–1.0, Bp��1.3, C��2.1.Postoperatively, the mean POP-Q Stage was 0 andmean POP-Q measurements were Aa�–2.3, Ba�–2.3,Ap�–2.7, Bp�–2.7, C�–8.3. The mean estimatedblood loss during surgery was 81 mL (range 50–150mL) and the mean length of hospital stay was 2.4 days(range 1–7 days).

We performed a comparative study of 73 roboticsacrocolpopexies performed by a single surgeon(A.V.) compared with 105 open colpopexies per-formed by four urogynecologists (see p. 1201).60

These surgeries were performed for vaginal vaultprolapse and uterine prolapse. Robotic sacrocol-popexy was associated with similar improvement inPOP-Q “C” point (–9 compared with –8, P�.008)when compared with abdominal sacrocolpopexy andwas associated with less blood loss (103�96 mLcompared with 255�155 mL, P�.001), longer totaloperative time (328�55 minutes compared with225�61 minutes, P�.001), shorter length of stay(1.3�0.8 days compared with 2.7�1.4 days, P�.001),and a higher incidence of postoperative fever (4.1%compared with 0.0%, P�.04). There were no differ-ences in other secondary outcomes but limited powerto fully assess secondary outcomes.

We find dissection of the presacral space, posi-tioning of the mesh, and intracorporeal suturing to besignificant advantages to the robotic approach. Weconcluded, based on our initial experience, that ro-botic assisted sacrocolpopexy offers a reproducible,minimally invasive technique for vaginal vault anduterine prolapse with similar short-term durability

Fig. 5. A. Presacral dissection. B.Suturing during robotic sacrocol-popexy. Numbers represent roboticarm 1, 2, 3. C. Suturing mesh tosacrum.Visco. Robotic Gynecologic Surgery.Obstet Gynecol 2008.


compared with open sacrocolpopexies. Follow-upstudies are needed to assess factors such as long-termdurability, effect on quality of life, and postoperativesexual and urinary function.

TEACHING ROBOTIC SURGICAL SKILLSGiven the recent introduction of robotic assistance insurgery—particularly in gynecologic surgery—little isknown about how best to train robotic surgeons.There is a paucity of experienced robotic surgeons.Currently, the training involves practice with thesurgical robot in either a pig or human fresh tissuelaboratory environment to become familiar with thefunctions of the robot, the attachment of the roboticarms to the robotic trocars, and the overall functionsof the robotic console. Further training allows thesurgeon to learn how to perform simple maneuverssuch as grasping, cutting, and intracorporeal knottying, the last task being particularly difficult withconventional laparoscopy. In fact, the vast majority oflaparoscopic surgeons perform any knot tyingextracorporeally.

Our understanding of the method and process bywhich a surgeon becomes experienced and proficientat performing robot-assisted laparoscopy is limited.The belief is that robotic surgery will allow for a morerapid development of the necessary skills and allowfor a larger number of surgeons to attain those skillsand, therefore, provide minimally invasive surgicaloptions to a larger number of patients. One studycompared five novices (medical students) to fiveexpert laparoscopists in various operative skills usinga robotic surgical system. Before training, the time totask completion for the various inanimate steps cho-sen was significantly longer for the novices. However,the novices significantly improved their surgical effi-ciency after only 10 trials. Most interesting was thefinding that novice performance after this brief ro-botic training approached expert performance.61

Residents and fellows exposed to advanced lapa-roscopy and robotic surgery have several years tolearn and become proficient with the technology andthe surgical techniques. However, can the gynecolo-gist in practice, whether a generalist or subspecialist,obtain the necessary postgraduate training? Vlaovic etal62 studied the effect of an intensive 1-week open,traditional laparoscopic, and robotic surgery trainingprogram for postgraduate urologists. The mean age ofthe surgeons was 47 years. Using Objective StructuredAssessment of Technical Skill scoring, significant im-provements were observed after training with laparos-copy (58 compared with 52) and to an even greaterdegree with robotic surgery (114 compared with 95).

Learning CurveA paucity of data existed in the area of learning curvesfor gynecology until recently. Two studies have spe-cifically looked at learning curves. The first by Pitteret al63 compared blood loss and operative time in thefirst 20 cases of robotic hysterectomies and myomec-tomies with the second 20 cases. All surgeries wereperformed by a single surgeon. They found no signif-icant difference between groups in blood loss, with 86mL in the first group and 63 mL in the second group.However, mean total operative times were signifi-cantly shorter in the second group, with 212 min-utes for the first group compared with 151 minutesfor the second group. There were no conversions tolaparotomy.

A second study by Lenihan et al64 evaluated 113sequential patients over a 22-month period. Theyfound that the learning curve for various benignsurgical interventions stablized in regard to operativetimes after 50 cases. A similar learning curve wasdocumented for the OR team to be able to set up therobot for surgery in 30 minutes. This break point was20 cases.

Several other studies allude to learning curves. Amajor hurdle often encountered early in a surgeon’srobotic experience is “docking time,” or the attach-ment of the robotic device to the patient. This is oftenperceived as taking an inordinate amount of time.However, Kho et al16 published a mean docking timeof 2.95 minutes in 88 patients, with times decreasingfor subsequent groups of 10 patients. Even moresignificant are the findings by Payne and Dauterive,15

who noted improvements in mean operative timesbetween their first 25 cases compared with last 25cases in the robotic cohort (133.5 compared with 78.7minutes). Also, their mean operative time for laparo-scopic hysterectomy in the prerobotic cohort of 100cases was 92.4 minutes compared with 78.7 minutesin the last 25 robotic cases. After progressing throughthe learning curve, they were able to improve upontheir conventional laparoscopic times with the aide ofrobotics.

CredentialingWith the introduction of robotic surgery, hospitalsand departments have been challenged to establishcredentialing requirements for this advanced surgicaltechnique. There are no universally established cre-dentialing guidelines. We propose a set of guidelinesthat require as a prerequisite that the surgeon be fullycredentialed in laparoscopic surgery.


Basic System TrainingWe also recommend that the surgeon show evidenceof at least 8 hours of hands-on training in the use ofthe robotic surgical system. A significant portion ofthis training must include console time as the primarysurgeon performing surgical procedures on eitheranesthetized pigs or fresh cadavers. For surgeons whoare already familiar with the robotic surgical system,usually having completed a residency or fellowshipthat included training in robotic surgery or havingperformed robotic surgical procedures at anotherinstitution, demonstration of such experience is re-quired. We recommend that the requesting surgeondemonstrate proof of a minimum of 10 robotic surgi-cal procedures of the same type to waive the basicsystem training.

Preceptorship/ProctoringThe surgeon is required to perform a minimum of tworobotic surgical procedures of each type for whichprivileges are being requested in the presence of anexpert preceptor. Some institutions are using four asthe minimum number of proctored robotic surgeriesnecessary for independent robotic privileges. Theapplicant should also possess privileges to perform aprocedure by laparotomy before requesting such priv-ilages robotically. If the applicant is applying forrobotic privileges based on a previously documentedseries of a minimum of 10 cases either as part of anaccredited residency or fellowship program or basedon performance of such procedures at another insti-tution, the Division Chief or Chair of the appropriateSurgical Division or Department may, at his/herdiscretion, recommend waiving the requirement ofone or all of the proctored surgical roboticprocedures.

An expert preceptor is defined as a surgeon whohas current Robotic Surgical Privileges and has beenapproved as an expert preceptor by the Chair of theDepartment of the individual applying for privileges.Ideally, a preceptor will be from the same institutionand will have full privileges at that institution. Theability to sit at the console occasionally during the firstfew surgical procedures is a valuable educationalopportunity that is generally not possible when thepreceptor is chosen from another institution or state.Telestration, the ability to write on a touch screen andhave the markings visible at the console, is helpful butdoes not replace the educational guidance a “cosurgeon”training robotic console would afford. Such a “copilot”console is not currently commercially available.

Reappointment/Maintenance of PrivilegesWe contend that, similar to other surgical procedures,maintenance of competence requires performing pro-cedures on an ongoing basis. We recommend that atreappointment, the applicant must demonstrate main-tained competence of a set number of robotic proce-dures determined by the hospital or institutionalcredentialing committee. For surgeons who have per-formed less than the required number of roboticprocedures per year and who desire ongoing privi-leges, a plan by the applicant and Service Chief/Chairthat may include potential preceptorship would besubmitted for review by the institutional credentialingcommittee.

SUMMARYRobotic surgery has seen enormous growth over thepast decade in several fields, including gynecology.However, we are likely to see further improvementsas the technology continues to develop and furtherrefinements occur. It has been just more than adecade since robotic surgery was first introduced intothe operating room. Advances in robotic gynecologicsurgery are also likely to continue as more gyneco-logic surgeons are trained in this technique and morepatients seek minimally invasive surgical options.Well-designed, prospective studies with well-definedlong-term clinical outcomes, including complications,cost, pain, return to normal activity, and quality oflife, are needed to fully assess the value of this newtechnology.

REFERENCES1. Ward K, Hilton P, United Kingdom and Ireland Tension-free

Vaginal Tape Trial Group. Prospective multicentre random-ised trial of tension-free vaginal tape and colposuspension asprimary treatment for stress incontinence. BMJ 2002;325:67.

2. Steptoe PC, Edwards RG. Birth after the reimplantation of ahuman embryo. Lancet 1978;2:366.

3. Reich H, Decaprio J, McGlynn F. Laparoscopic hysterectomy.J Gynecol Surg 1989;5:213–7.

4. Mais V, Ajossa S, Guerriero S, Mascia M, Solla E, Melis GB.Laparoscopic versus abdominal myomectomy: a prospective,randomized trial to evaluate benefits in early outcome. Am JObstet Gynecol 1996;174:654–8.

5. Paraiso MF, Walters MD, Rackley RR, Melek S, Hugney C.Laparoscopic and abdominal sacral colpopexies: a compara-tive cohort study. Am J Obstet Gynecol 2005;192:1752–8.

6. Stylopoulos N, Rattner D. Robotics and ergonomics. Surg ClinNorth Am 2003;83:1321–37.

7. Kwoh YS, Hou J, Jonckheere EA, Hayati S. A robot withimproved absolute positioning accuracy for CT guided stereo-tactic brain surgery. IEEE Trans Biomed Eng 1988;35:153–60.

8. Mantwill F, Schulz AP, Faber A, Hollstein D, Kammal M, FayA, et al. Robotic systems in total hip arthroplasty—is the timeripe for a new approach? Int J Med Robot 2005;1:8–19.


9. Davies BL, Hibberd RD, Coptcoat MJ, Wickham JE. Asurgeon robot prostatectomy—a laboratory evaluation. J MedEng Technol 1989;13:273–7.

10. Satava RM. Robotic surgery: from past to future—a personaljourney. Surg Clin North Am 2003;83:1491–500, xii.

11. Diodato MD Jr, Damiano RJ Jr. Robotic cardiac surgery:overview. Surg Clin North Am 2003;83:1351–67, ix.

12. Mettler L, Ibrahim M, Jonat W. One year of experienceworking with the aid of a robotic assistant (the voice-controlledoptic holder AESOP) in gynaecological endoscopic surgery.Hum Reprod 1998;13:2748–50.

13. Falcone T, Goldberg JM, Margossian H, Stevens L. Robotic-assisted laparoscopic microsurgical tubal anastomosis: ahuman pilot study. Fertil Steril 2000;73:1040–2.

14. Magrina JF, Kho RM, Weaver AL, Montero RP, MagtibayPM. Robotic radical hysterectomy: comparison with laparos-copy and laparotomy. Gynecol Oncol 2008;109:86–91.

15. Payne TN, Dauterive FR. A comparison of total laparoscopichysterectomy to robotically assisted hysterectomy: surgicaloutcomes in a community practice. J Minim Invasive Gynecol2008;15:286–91.

16. Kho RM, Hilger WS, Hentz JG, Magtibay PM, Magrina JF.Robotic hysterectomy: technique and initial outcomes [pub-lished erratum appears in Am J Obstet Gynecol 2007;197:332].Am J Obstet Gynecol 2007; 197:113.e1–4.

17. Wu JM, Wechter ME, Geller EJ, Nguyen TV, Visco AG.Hysterectomy rates in the United States, 2003. Obstet Gynecol2007;110:1091–5.

18. Johnson N, Barlow D, Lethaby A, Tavender E, Curr L, GarryR. Methods of hysterectomy: systematic review and meta-analysis of randomised controlled trials. BMJ 2005;330:1478.

19. Reich H, McGlynn F, Wilkie W. Laparoscopic management ofstage I ovarian cancer. A case report. J Reprod Med 1990;35:601–4.

20. Donnez J, Nisolle M. Laparoscopic supracervical (subtotal)hysterectomy (LASH). J Gynecol Surg 1993;9:91–4.

21. Reich H, McGlynn F, Sekel L. Total laparoscopic hysterec-tomy. Gynaecol Endoscopy 1993;2:59–63.

22. Dunn TS, Weaver A, Wolf D, Goodard W. Vaginal hysterec-tomies performed in a residency program: can we increase thenumber? J Reprod Med 2006;51:83–6.

23. Brill AI. Hysterectomy in the 21st century: differentapproaches, different challenges. Clin Obstet Gynecol 2006;49:722–35.

24. Diaz-Arrastia C, Jurnalov C, Gomez G, Townsend C Jr.Laparoscopic hysterectomy using a computer-enhanced surgi-cal robot. Surg Endosc 2002;16:1271–3.

25. Olive DL, Parker WH, Cooper JM, Levine RL. The AAGLclassification system for laparoscopic hysterectomy. Classifica-tion committee of the American Association of GynecologicLaparoscopists. J Am Assoc Gynecol Laparosc 2000;7:9–15.

26. Beste TM, Nelson KH, Daucher JA. Total laparoscopic hys-terectomy utilizing a robotic surgical system. JSLS 2005;9:13–5.

27. Fiorentino RP, Zepeda MA, Goldstein BH, John CR, Retten-maier MA. Pilot study assessing robotic laparoscopic hysterec-tomy and patient outcomes. J Minim Invasive Gynecol 2006;13:60–3.

28. Reynolds RK, Advincula AP. Robot-assisted laparoscopic hys-terectomy: technique and initial experience. Am J Surg 2006;191:555–60.

29. Advincula AP, Reynolds RK. The use of robot-assisted lapa-roscopic hysterectomy in the patient with a scarred or obliter-ated anterior cul-de-sac. JSLS 2005;9:287–91.

30. Nezhat C, Saberi NS, Shahmohamady B, Nezhat F. Robotic-assisted laparoscopy in gynecological surgery. JSLS 2006;10:317–20.

31. Marchal F, Rauch P, Vandromme J, Laurent I, Lobontiu A,Ahcel B, et al. Telerobotic-assisted laparoscopic hysterectomyfor benign and oncologic pathologies: initial clinical experi-ence with 30 patients. Surg Endosc 2005;19:826–31.

32. Reynolds RK, Burke WM, Advincula AP. Preliminary experi-ence with robot-assisted laparoscopic staging of gynecologicmalignancies. JSLS 2005;9:149–58.

33. Kim YT, Kim SW, Hyung WJ, Lee SJ, Nam EJ, Lee WJ.Robotic radical hysterectomy with pelvic lymphadenectomyfor cervical carcinoma: a pilot study. Gynecol Oncol 2008;108:312–6.

34. Veljovich DS, Paley PJ, Drescher CW, Everett EN, Shah C,Peters WA 3rd. Robotic surgery in gynecologic oncology:program initiation and outcomes after the first year withcomparison with laparotomy for endometrial cancer staging.Am J Obstet Gynecol 2008;198:679.e1–9.

35. Boggess J, Gehrig P, Cantrell L, Shafer A, Ridgway M, SkinnerE, et al. A comparative study of three surgical methods forhysterectomy with staging for endometrial cancer; robotic-assistance, laparoscopy, laparotomy. Am J Obstet Gynecol2008;199:360.e1–9.

36. Boggess J, Gehrig P, Cantrell L, Shafer A, Ridgway M, SkinnerE, et al. A case-control study of robot-assisted type III radicalhysterectomy with pelvic lymph node dissection compared toopen radical hysterectomy. Am J Obstet Gynecol 2008;199:357.e1–7.

37. Fanning J, Fenton B, Purohit M. Robotic radical hysterectomy.Am J Obstet Gynecol 2008;198:649.e1–4.

38. Doridot V, Dubuisson JB, Chapron C, Fauconnier A, Babaki-Fard K. Recurrence of leiomyomata after laparoscopic myo-mectomy. J Am Assoc Gynecol Laparosc 2001;8:495–500.

39. Advincula AP, Song A. The role of robotic surgery in gyne-cology. Curr Opin Obstet Gynecol 2007;19:331–6.

40. Manyonda I, Sinthamoney E, Belli AM. Controversies andchallenges in the modern management of uterine fibroids.BJOG 2004;111:95–102.

41. Advincula AP, Song A, Burke W, Reynolds RK. Preliminaryexperience with robot-assisted laparoscopic myomectomy.J Am Assoc Gynecol Laparosc 2004;11:511–8.

42. Advincula AP, Xu X, Goudeau S 4th, Ransom SB. Robot-assisted laparoscopic myomectomy versus abdominal myo-mectomy: a comparison of short-term surgical outcomes andimmediate costs. J Minim Invasive Gynecol 2007;14:698–705.

43. Nezhat C, Lavie O, Hsu S, Watson J, Barnett O, Lemyre M.Robotic-assisted laparoscopic myomectomy compared withstandard laparoscopic myomectomy-a retrospective matchedcontrol study. Fertil Steril 2008 Mar 28 [Epub ahead of print].

44. Senapati S, Advincula AP. Surgical techniques: robot-assistedlaparoscopic Myomectomy with the da Vinci surgical system.J Robotic Surg 2007;1:69–74.

45. Falcone T, Goldberg J, Garcia-Ruiz A, Margossian H, StevensL. Full robotic assistance for laparoscopic tubal anastomosis: acase report. J Laparoendosc Adv Surg Tech A 1999;9:107–13.

46. Degueldre M, Vandromme J, Huong PT, Cadiere GB. Roboti-cally assisted laparoscopic microsurgical tubal reanastomosis: afeasibility study. Fertil Steril 2000;74:1020–3.


47. Cadiere GB, Himpens J, Germay O, Izizaw R, Degueldre M,Vandromme J, et al. Feasibility of robotic laparoscopic sur-gery: 146 cases. World J Surg 2001;25:1467–77.

48. Dharia Patel SP, Steinkampf MP, Whitten SJ, Malizia BA.Robotic tubal anastomosis: surgical technique and cost effec-tiveness. Fertil Steril 2007 Dec 1 [Epub ahead of print].

49. Rodgers AK, Goldberg JM, Hammel JP, Falcone T. Tubalanastomosis by robotic compared with outpatient minilapa-rotomy. Obstet Gynecol 2007;109:1375–80.

50. Fried LP. Epidemiology of aging. Epidemiol Rev 2000;22:95–106.

51. Nygaard IE, McCreery R, Brubaker L, Connolly A, Cundiff G,Weber AM, et al. Abdominal sacrocolpopexy: a comprehen-sive review. Obstet Gynecol 2004;104:805–23.

52. Barber MD, Visco AG, Weidner AC, Amundsen CL, BumpRC. Bilateral uterosacral ligament vaginal vault suspensionwith site-specific endopelvic fascia defect repair for treat-ment of pelvic organ prolapse. Am J Obstet Gynecol2000;183:1402–10.

53. Benson JT, Lucente V, McClellan E. Vaginal versus abdomi-nal reconstructive surgery for the treatment of pelvic supportdefects: a prospective randomized study with long-term out-come evaluation. Am J Obstet Gynecol 1996;175:1418–21.

54. Maher CF, Qatawneh AM, Dwyer PL, Carey MP, CornishA, Schluter PJ. Abdominal sacral colpopexy or vaginalsacrospinous colpopexy for vaginal vault prolapse: a pro-spective randomized study. Am J Obstet Gynecol 2004;190:20–6.

55. Jia X, Glazener C, Mowatt G, Maclennan G, Bain C, FraserC, et al. Efficacy and safety of using mesh or grafts in surgeryfor anterior and/or posterior vaginal wall prolapse: system-atic review and meta-analysis. BJOG 2008;115:1350–61.

56. Maher C, Baessler K, Glazener CM, Adams EJ, Hagen S.Surgical management of pelvic organ prolapse in women. TheCochrane Database of Systematic Reviews 2007, Issue 3. Art.No.: CD004014. DOI: 10.1002/14651858.CD004014.

57. Agarwala N, Hasiak N, Shade M. Laparoscopic sacral col-popexy with Gynemesh as graft material–experience andresults. J Minim Invasive Gynecol 2007;14:577–83.

58. Elliott DS, Frank I, Dimarco DS, Chow GK. Gynecologic useof robotically assisted laparoscopy: Sacrocolpopexy for thetreatment of high-grade vaginal vault prolapse. Am J Surg2004;188:52S–6S

59. Daneshgari F, Kefer JC, Moore C, Kaouk J. Robotic abdomi-nal sacrocolpopexy/sacrouteropexy repair of advanced femalepelvic organ prolapse (POP): utilizing POP-quantification-based staging and outcomes. BJU Int 2007;100:875–9.

60. Geller J, Siddiqui N, Wu J, Visco AG. Short-term outcomes ofrobotic sacrocolpopexy compared with abdominal sacrocol-popexy Obstet Gynecol 2008;112:XXX–XX.

61. Judkins TN, Oleynikov D, Stergiou N. Objective evaluation ofexpert and novice performance during robotic surgical trainingtasks. Surg Endosc 2008 Apr 29 [Epub ahead of print].

62. Vlaovic PD, Sargent ER, Boker JR, Corica FA, Chou DS,Abdelshehid CS, et al. Immediate impact of an intensiveone-week laparoscopy training program on laparoscopic skillsamong postgraduate urologists. JSLS 2008;12:1–8.

63. Pitter MC, Anderson P, Blissett A, Pemberton N. Robotic-assisted gynaecological surgery-establishing training criteria;minimizing operative time and blood loss. Int J Med Robot2008;4:114–20.

64. Lenihan JP Jr, Kovanda C, Seshadri-Kreaden U. What is thelearning curve for robotic assisted gynecologic surgery? J MinimInvasive Gynecol 2008;15:589–94.


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