Study Objective: To compare the postoperative outcomes and the overall expenses between conventional laparoscopy and robotic surgery, in a series of consecutive patients managed for only severe endometriosis in our institute. Design: A cohort comparative study. Setting: Center of Excellence in Multidisciplinary Endometriosis Care. Patients: A total of 175 symptomatic patients undergoing surgery for only severe endometriosis from March 2021 to August 2022. Interventions: We treated patients with endometriosis involving the digestive tract such as rectum, sigmoid colon, and ileocecal junction by rectal shaving, discoid resection, or segmental resection (141 surgeries) with or without bladder (23 surgeries), sacral plexus (19 surgeries), and diaphragm involvements (14 surgeries). Measurements and Main Results: Postoperative outcomes were evaluated in terms of total surgical time (total surgical room occupancy time and total operating time), hospitalization period, postoperative complications, rehospitalization, and second surgical procedures. A statistically higher total surgical room occupancy (203 minutes vs 151 minutes) and operating time (150 minutes vs 105 minutes) were observed in the robotic group (p = .001). No differences in terms of mean hospital stay (p = .06), postoperative complications (p = .91), rehospitalization (p = .48), and secondary surgical treatment (p = .78) were identified. Concerning the cost analysis only for disposable supply, the cost of colorectal resection was totaled at 2604 euros for the laparoscopic conventional approach vs 2957 euros for the robotic approach (+352.6 euros, +14%). The cost of rectal disc excision was 1527 euros for the laparoscopic conventional approach vs 1905.85 euros (+378 euros, +25%). Conclusions: Our study confirms the feasibility of the robotic approach for the treatment of severe endometriosis, with however a higher cost of robotic approach. Next studies should identify specific indications for robotic surgery, where technical advantages provided by the technology are followed by objective improvement of patients' outcomes. (c) 2023 AAGL. All rights reserved.

OBJECTIVE:To compare robotic-assisted laparoscopy (RAL) and laparoscopy (LPS) for intraoperative and postoperative outcomes, and functional results after a 6-month follow-up period among patients having undergone excision of deep endometriosis (DE) involving the sacral plexus (SP) and sciatic nerve (SN). METHODS:A retrospective analysis of 100 patients included in our prospective database, who underwent surgical eradication of DE involving the SP and SN at our tertiary referral centre between September 2018 and June 2023. Patients were managed by LPS (n = 71) until 2021, and subsequently by RAL (n = 29). RESULTS:Baseline symptoms and distribution of DE lesions were comparable in the two groups. Nerve dissection, nerve shaving, and intra-nerve dissection were performed in 55 (77.5%), 14 (19.7%), and 2 (5.6%) patients in the LPS group, respectively. Nerve dissection and nerve shaving were performed and in 24 (82.8%) and 5 (17.2%) patients in the RAL group, while no cases of intra-nerve dissection were observed (P = 0.434). Mean operative times were 183.71 ± 85.32 min and 177.41 ± 77.19 min, respectively (P = 0.734). There were no reported cases of conversion to open surgery. Intraoperative and early postoperative complications were comparable between the two groups. At 6 months follow up, we observed a significant reduction in sciatic pain in both the LPS group (39.1% vs 15.6%, P < 0.001) and RAL group (37.5% vs 25%, P = 0.001), with no differences in terms of outcomes (P = 0.1). CONCLUSION:Both LPS and RAL result in significant long-term relief of symptoms associated with SP and SN endometriosis. Although surgeons found that RAL improved the quality of excision of these specific DE localizations, our study did not reveal significant advantages in terms of its outcomes.

STUDY OBJECTIVE:To assess the feasibility, effectiveness, and safety of the robotic surgical approach in the treatment of severe diaphragmatic endometriosis (DE). DESIGN:Retrospective single-center study using data prospectively recorded in the Franco-European Multidisciplinary Institute of Endometriosis database and the National Observatory for Endometriosis database. SETTING:Tertiary referral center. Endometriosis care center. PATIENTS:Sixty consecutive patients undergoing robotic excision of severe DE from January 2020 to July 2023. INTERVENTIONS:Robotic excision of severe DE. MEASUREMENT AND MAIN RESULTS:Categorical and continuous variables were evaluated and compared using descriptive statistics. A p value of <.05 was considered statistically significant. Full-thickness diaphragmatic resection was performed in 76.7% of patients (46 of 60) and partial diaphragmatic muscle resection in 10% of cases (6 of 60). Peritoneal stripping technique was performed in 60% of patients (36 of 60), divided as follows: as the only technique in the case of extensive superficial diaphragmatic involvement in 13.3% of cases (8 of 60), in addition to full-thickness or partial diaphragmatic resection in the case of concomitant multiple foci in 46.7% of patients (28 of 60). Median operative time was 79.6 minutes with no statistically significative difference related to the surgeon performing surgery (p >.05). Intraoperative and postoperative complications occurred in 1.7% (1 of 60) and 6.6% of cases (4 of 60), respectively. Diaphragmatic hernia (Clavien-Dindo 3b) was the most common postoperative complication and required surgical repair in all cases. Median hospital stay was 24 hours. The rate of patients with complete recovery from DE symptoms has gradually increased during follow-up, reaching 89% after 12 months from surgery. CONCLUSION:In this case series, robotic treatment of severe DE in expert hands was feasible, effective, and safe.

STUDY OBJECTIVE:To assess the duration needed for regaining normal bladder voiding function in patients with postoperative bladder dysfunction requiring intermittent self-catheterization after deep endometriosis surgery and identify risk factors that might affect the recovery process. DESIGN:Retrospective study based on data recorded in a large prospective database. SETTING:Endometriosis referral center. PATIENTS:From September 2018 to June 2022, 1900 patients underwent excision of deep endometriosis in our center; 61 patients were discharged with recommendation for intermittent self-catheterization and were thus included in the study. INTERVENTIONS:Intermittent self-catheterization after endometriosis surgery. MEASUREMENTS AND MAIN RESULTS:A total of 43 patients (70.5%) stopped self-catheterization during the follow-up period. Median follow-up was 25 weeks (range, 7-223 wk). Surgery was performed laparoscopically in 48 patients (78.7%) and robotically in 13 (21.3%); 47 patients (77%) had nodules involving the digestive tract, 11 (18%) had urinary tract involvement, 29 had parametrial nodules (47.5%), and 13 (21.3%) had sacral plexus involvement. The probability of bladder voiding function recovery and arrest of self-catheterization was 24.5%, 54%, 59%, 72%, and 77% at 4, 8, 12, 52, and 78 weeks, respectively. Cox's multivariate model identified preoperative bladder dysfunction as the only statistically significant independent predictor for arrest of self-catheterization (hazard ratio, 0.36; 95% confidence interval, 0.15-0.83). CONCLUSION:Patients requiring intermittent self-catheterization for bladder dysfunction after deep endometriosis excision may spontaneously recover bladder function in 77% of cases. Symptoms suggesting preoperative bladder voiding dysfunction should be reviewed before planning surgery, and patients should be informed of the higher postoperative risk of long-term bladder voiding dysfunction.

Objective: To evaluate the rate and risk factors for anastomosis leakage in patients undergoing colorectal resection with low anastomosis for rectal endometriosis and rectal adenocarcinoma. Methods: A retrospective cohort study evaluating prospectively collected data was conducted. Patients undergoing colorectal resection for rectal endometriosis and rectal adenocarcinoma with low anastomosis (<7 cm from the anal verge [AV]) from September 2018 to January 2023 were included in the analysis. The main outcome was the rate of anastomosis leakage. A multivariate logistic regression was conducted to evaluate risk factors for anastomosis leakage in both groups. Results: A total of 159 patients underwent colorectal resection with low anastomosis due to rectal endometriosis (n = 99) and rectal adenocarcinoma (n = 60). Patients with endometriosis were significantly younger than those with adenocarcinoma (35.7 +/- 5.1 vs 63.7 +/- 12.6; P = 0.001). The leakage rate was similar between the endometriosis (n = 12, 12.1%) and adenocarcinoma (n = 9, 15.0%) patients (P = 0.621). The anastomosis height less than 5 cm from the AV (adjusted odds ratio [aOR] 12.12, 95% confidence interval [CI] 2.24-23.54) was significantly associated with the anastomosis leakage. Protective stoma was associated with the decrease of the leakage risk (aOR 0.12, 95% CI 0.01-0.72). The type of disease (rectal endometriosis or adenocarcinoma) was not associated with the anastomosis leakage (aOR 2.87, 95% CI 0.34-21.23). Conclusions: Despite the different pathogenesis, the risk of anastomotic leakage was found to be similar between patients with low rectal endometriosis and those with rectal adenocarcinoma. These results must be considered by the gynecologist and colorectal surgeon to deliver proper information before rectal surgery for endometriosis.

STUDY OBJECTIVE:Surgical excision of large deep endometriosis nodules infiltrating the bladder may be challenging, particularly when the nodule limits are close to the trigone and ureteral orifice. Bladder nodules have classically been approached abdominally. However, combining a cystoscopic with an abdominal approach may help to better identify the mucosal borders of the lesion to ensure complete excision without unnecessary resection of healthy bladder. This study aimed to compare classical excision of large bladder nodules by abdominal route with a combined cystoscopic-abdominal approach. DESIGN:Retrospective comparative study on data prospectively recorded in a database. Patients were managed from September 2009 to June 2022. SETTING:Two tertiary referral endometriosis centers. PATIENTS:A total of 175 patients with deep endometriosis infiltrating the bladder more than 2 cm undergoing surgical excision of bladder nodules. INTERVENTIONS:Excision of bladder nodules by either abdominal or combined cystoscopic-abdominal approaches. MEASUREMENTS AND MAIN RESULTS:A total of 141 women (80.6%) were managed by abdominal route and 34 women (19.4%) underwent a combined cystoscopic-abdominal approach. In 99.4% of patients, the approach was minimally invasive. Patients with nodules requiring the combined approach had a lower American Fertility Society revised score and endometriosis stage and less associated digestive tract nodules, but larger bladder nodules. They were less frequently associated with colorectal resection and preventive stoma. Operative time was comparable. The rate of early postoperative complications was comparable (8.8% vs 22%), as were the rates of ureteral fistula (2.2% vs 2.9%), bladder fistula (2.2% vs 0), and vesicovaginal fistula (0.7% vs 2.9%). CONCLUSION:In our opinion, the combined cystoscopic-abdominal approach is useful in patients with large bladder nodules with limits close to the trigone and ureteral orifice. These large deep bladder nodules seemed paradoxically associated to less nodules on the digestive tract, resulting in an overall comparable total operative time and complication rate.

STUDY OBJECTIVE:To evaluate 2 cases of uterine transplant surgery that used utero-ovarian veins as outflow channels, internal iliac arteries for perfusion, and the organ harvest surgery performed laparoscopically.DESIGN:Case study (Canadian Task Force Classification III).SETTING:An urban, private, tertiary care hospital.PATIENTS:Two patients, ages 30 and 24years, diagnosed with absolute uterine factor infertility secondary to Mayer-Rokitansky-Küster-Hauser syndrome underwent related living donor uterine transplants; donors were their mothers with normal menses.INTERVENTIONS:Retrieval of organs through minilaparotomy and laparoscopic harvest of donor internal iliac arteries and ovarian veins.MEASUREMENTS AND MAIN RESULTS:Anastomosis was completed with bilateral donor internal iliac arteries to recipient internal iliac arteries in an end-to-end manner and with bilateral donor ovarian veins to recipient external iliac veins in an end-to-side manner. The lengths of utero-ovarian veins of both donors were 11 and 11cm on both sides; the lengths of the internal iliac arteries of both donors were 10 and 7.5cm on the left side and 10 and 6cm on the right side. The operative times for harvest surgery, bench surgery and transplant surgery were 2:40 and 3:20 hours, 34:32 and 33:30 min and 4:00 and 4:30 hours respectively for recipients 1 and 2. Daily postoperative uterine Doppler was completed through day 8 and then every other day and showed good intrauterine blood flow (i.e., low resistance arcuate vessel flow; resistance index < .5). Cervical biopsies on postoperative days 7 and 14 showed no evidence of rejection in either recipient. Both recipients started menstruating within 2 months of surgery.CONCLUSION:By using ovarian veins as outflow channels, the challenges involved in dissection along the internal iliac vein are avoided, and harvesting the donor internal iliac artery reduces the tension on vascular anastomosis. The selection of vessels to be harvested could make the technique reproducible, although larger studies are warranted to confirm results.

STUDY OBJECTIVE:To report the first ever laparoscopic-assisted live donor uterus retrieval in 2 patients for uterus transplant.DESIGN:Case study (Canadian Task Force classification III).SETTING:Galaxy CARE Laparoscopy Institute, Pune, India.PATIENTS:Two patients with absolute uterine factor infertility with their mothers as donors.INTERVENTIONS:In vitro fertilization and uterine transplant.MEASUREMENTS AND MAIN RESULTS:A 12-member team was formed, and approval for transplant was obtained from the institutional review board. Pretransplant, in vitro fertilization for both patients was done. Two consecutive uterine transplants were done on 2 successive days. Vessels were harvested laparoscopically in both donors. Uterus and harvested vessels were retrieved by a small abdominal incision to prevent injury and infection. The uterus was transplanted in the recipients by end to side anastomosis of the harvested vessels to external iliac vessels, followed by anchoring of supports of the donor uterus to those of the recipients. Surgical intra- and postoperative parameters, postoperative investigations, and follow-up data of 6 months were measured. Operative time for laparoscopic donor surgery was 4 hours. Bench surgery took 45 minutes. Recipient surgery time was 4 hours. There were no intraoperative or immediate postoperative complications. Both the recipients started menstruating after 34 days and 48 days, respectively, and have had 6 cycles of menses at regular intervals. Uterine artery Doppler showed good flow in both patients. Hysteroscopy-guided cervical biopsies were used as a method of surveillance of graft rejection after uterine transplant. Office hysteroscopy was done after 2 months in both patients, and hysteroscopy-guided endometrial and cervical biopsies were taken. Minimal slough was seen on the endometrium in the patient with Mayer-Rokitansky-Küster-Hauser syndrome, which was removed. Repeat hysteroscopy after 10 days showed a healthy endometrium.CONCLUSIONS:Laparoscopic-assisted uterus donor retrieval is feasible and affords all the advantages of a minimally invasive technique, thereby reducing the morbidity of the procedure. It helps in better dissection of the vessels, shortens the operative time, and helps to minimize tissue handling of the harvested uterus and vessels.