[The endometriosis combined treatment results of the Department of Gynecology and Minimally Invasive Therapy, Na Homolce Hospital, Prague in six years period 2001--2007]

OBJECTIVE

The endometriosis combined treatment optimisation on the basis of own results.

DESIGN

The retrospective clinical study. DEPARTMENT: Department of Gynecology and Minimally Invasive Therapy, Na Homolce Hospital Prague.

METHODS

The retrospective analysis of the endometriosis treatment results on the basis of subjective severity and the inspection laparoscopy objective determination including work-up and imaging examinations.

RESULTS

Out of 586 patients, who underwent endometriosis combined (surgical and medicamentous) treatment, there were 91% of patients with no subjective severity with normal inspection laparoscopy determination in area of lesser pelvis.

CONCLUSION

91% of treatment success entitles us to consider that our method of the endometriosis treatment is an option for future. We plan a long term monitoring of patients after restore to health within a period of years and percentage of pregnancy success, which we monitored alongside patients with the deep-infiltrating endometriosis.

[Da vinci robotic surgery in gynaecological oncology: a critical interim appraisal]

OBJECTIVE

Benefit evaluation of robot-assisted surgery in gynecological oncology. The parameters observed were feasibility, safety, overal surgery length and economic aspects.

DESIGN

Prospective study analysing our experience in 10 patients operated due to gynaecological malignancy, adnexal tumors or planned for the procedure used as a part of extensive oncological surgery.

SETTINGS

Department of Gynecology and Minimally Invasive Surgery Na Homolce Hospital, Prague.

METHODS

The surgeries were performed with Da Vinci robotic system (Intuitive Surgical, inc., USA) including surgeon's console with stereoscopic viewer with hand and foot controls. The second component of the system was In Site vision system with 3D 12 mm endoscope. The third part comprised of 3 telerobotic arms with Endowrist instruments. From 2/2006 to 9/2006 10 patients were operated upon. 2 patients with early invasive cervical cancer, 2 patients with cervical cancer in situ (CIS), 3 patients with complex ovarian tumors, 2 patients with symptomatic atypical endometrial glandular hyperplasia and 1 patient underwent necessary gynecological surgery as a part of oncological treatment of breast cancer. The range of surgery included Total robotic hysterectomy, Robot-assisted vaginal hysterectomy with adnexectomy and frozen section, Robot-assisted radical vaginal trachelectomy with pelvic lymphadenectomy and unilateral adnexectomy with frozen section. The average age of patients was 52 years (range 32-58 years). 30% of patients had a previous laparotomy in their history.

RESULTS

All procedures were finished with robot-assisted system. In 2 patients a temporary conversion to laparoscopy was made. In 3 patients a technical fault of the robotic system was noticed. This was corrected during the surgery. The overal surgery time was significantly longer (29 hours for robot-assisted versus 12 hours for laparoscopy). This represented operation time increase of 59% in comparison to identical laparoscopic procedures in our department in 2006. This was caused by lengthy assembly and disassembly time of the robotic system. No patients experienced any peroperative or postoperative comlications. The costs in our setting were approximately 10 times higher in comparison to laparoscopy.

CONCLUSION

Our preliminary experience shows that Robot-assisted surgery is comparable to the standard laparoscopic procedure in terms of feasibility and outcome, but costs are considerably higher owing to longer operating time and the use of more expensive instruments. A major limitation is the lack of a large operation field. The enormous costs and the lack of appropriate instruments can be a major problem in the further expansion of robotic surgery. The use of robotic system in gynecologic oncologic surgery and in abdominal surgery in general offers, at this stage, no relevant benefit and thus is not justified. Clinical data demonstrating improved outcomes are so far lacking for robotic surgical application within the abdomen.

[Laparoscopic therapy of symptomatic splenic implants in the minor pelvis]

OBJECTIVE

The radical laparoscopic treatment of the aforementioned pathology has made it possible to eliminate recurrent pelvic pain of the 24 years old patient.

SUBJECT

Case report.

METHODS AND RESULTS

24 year old, nulligravid patient, had primary laparoscopy in 1998 because of chronic pelvic pain. Histology has confirmed both, the infiltrative endometriosis and the pelvic splenosis. While the endometriosis has been radically excised, splenic implants have been, in accordance with the current opinions in the literature, left in situ. Only their biopsy has been done. Due to recurrent pelvic pain after 15 months and the growth of the splenical implants, the second look laparoscopy was performed with the radical excision of these foci.

CONCLUSION

The patient, 4 months after the intervention is asymptomatic. At variance with most of the literature, we assume that the pelvic splenosis in contrast to the abdominal is in many cases symptomatic. It causes especially pelvic pain and dyspareunia in connection with the contingent implant growth. In such cases the radical excision is indicated, where the laparoscopy is the chosen method. Authors are discussing the differentiational diagnosis of this syndrome especially concerning endometriosis, peritoneal carcinomatosis, accessory spleen and the manifestation of the lymphoma.

[Laparoscopic sterilization using the Filshie clip--a prospective study of 180 patients]

OBJECTIVE

In this prospective study from 1997-2000, authors have been analyzing preliminary results of 180 tubal sterilizations, which were performed by method of the laparoscopic application of Filshie clips.

DESIGN

Prospective study.

SETTING

Department of operative gynaecology and minimally invasive surgery, Hospital Na Homolce, Prague.

METHODS

The procedures were performed in accordance with the still valid Public Notice of the Czech Republic Ministry of Health n. 1/1972, section 5/1972. The mean age of the patients was 38.6 years, with each patient having 2.1 living children on average. During the intervention 42% of the patients either had IUD or were taking a hormonal contraceptive, while 29% of the patients had in their history a record of previous abdominal surgery.

RESULTS

The average duration of the operation (from the incision to the closure) was 14 min. There were no per- or postoperative complications and until the present we have no knowledge of failure. In the view of both the patient and the surgeon, this is the most acceptable procedure.

CONCLUSION

In accordance with the British (RCOG) and the Canadian Gynecological Society conclusions and also on the basis of many randomized studies and recommendations from WHO, we conclude that the laparoscopic approach with the mechanical tubal occlusion by means of the clip is the first choice method. Our previous experience and meta-analytic studies of the literature, demonstrate that from all accessible clip methods, the Filshie clip method is the most suitable as it has the lowest failure rate, the least occurrences of extrauterine gravidity (in a case of failure). Most importantly it is a simple, quick and easily taught method. Another potentially significant factor is the highest rate of successful reversibility.

[Role of total laparoscopic hysterectomy in genital reconstruction in transsexuals]

OBJECTIVE

Evaluation of the suitability of total laparoscopic hysterectomy as an adjunctive procedure in the female-to-male transsexual reassignment surgery. Surgical reassignment surgery in the transsexual is not a frequent procedure. The expertise of an gynaecologist in the treatment of the syndrome is necessary as well as the input of other specialists such as psychiatrists, psychologists, plastic and reconstructive surgeons and urologists. The gynaecological surgeon usually performs the hysterectomy and in some cases also colpectomy.

SUBJECT

Case report.

METHODS

The authors analyse their own surgical experience with the above mentioned syndrom in the patient in whom the surgical reconstruction took place in two phases. In the first phase the Total Laparoscopic Hysterectomy with Bilateral Salpingo Ophorectomy (TLH, BSO) was performed. Of note is that this procedure was chosen due to extremely narrow vaginal canal with no uterine descent. For the second phase of the surgery the patient was referred to the urological surgeon.

RESULTS

The duration of the surgery was 54 minutes, the blood loss was not measurable. We have not encountered any per- and postoperative complications and the patient was discharged after 48 hours.

CONCLUSION

We conclude that the TLH/BSO approach has enabled to us to preserve the vital structures needed for reconstruction of external genitalia, e.g. inferior epigastric vessels and rectus muscles were not disturbed. This approach is complex and has clear advantages in comparison to vaginal hysterectomy, laparoscopic assisted vaginal hysterectomy or even total abdominal hysterectomy. It does guarantee a smooth removal of both ovaries and it is not dependent on the size of the vagina or uterine descent.

Adrenalin versus terlipressin: blood loss and cardiovascular side-effects in the vaginal part of laparoscopically-assisted vaginal hysterectomy or vaginal hysterectomy

The purpose of the study was to compare blood loss and cardiovascular side-effects in the course of the vaginal part of laparoscopically-assisted vaginal hysterectomy (LAVH) or single vaginal hysterectomy (VH) [1]. Blood loss was evaluated in relation to local application of two haemostatic agents, e.g. adrenalin as a gold standard versus terlipressin. The investigation was designed as a prospective randomised study. A prospective group of 40 patients selected for LAVH or VH was randomised into two groups, e.g. 20 patients in each group. In both of these groups, the blindly selected haemostatic agent was applied locally immediately before circular colpotomy, the surgeon not being aware which agent was being used. Because of the claimed delayed effect of terlipressin a third group of another 20 patients was randomly selected. For comparison in this group terlipressin was locally already applied before the laparoscopic part of LAVH, e.g. 20-25 minutes before performing circular colpotomy. Thus, this particular group could not be made blind to the surgeon. The study confirmed a significantly superior haemostatic effect of adrenalin. On the other hand after the adrenalin application a higher frequency of hypertensive reactions and mild arrythmias were observed but without any clinical seguelae.

[Comparative prospective study of laparoscopic hysterectomy and abdominal hysterectomy]

Based on assembled findings, the authors assume that laparoscopically assisted vaginal hysterectomy is a real alternative of abdominal hysterectomy and extends the spectrum of indications to overcome contraindications of the vaginal approach in the treatment of benign diseases of organs of the lesser pelvis. In the investigated group of patients the advantages of the minimally invasive approach when evaluating convalescence parameters were confirmed. Introduction of LH had also a favourable impact on the interest in and extension of vaginal operations. It is essential to implement extensive prospective investigations which will evaluate objectively the contribution of endoscopic surgery and their effect on somatic, psychic, social and economic parameters.