Robotic single-port platform for gynecologic surgery: indications, outcomes and challenges

Abstract

Dear Editors-In-Chief, With great deal of interest, we read the article entitled “The robotic single-port platform for gynecologic surgery” by Capozzi et al. that has been published to your journal [1]. The authors present a systematic review which included 27 articles. The studies were divided into 3 groups: group 1 (14 studies) including benign conditions, group 2 (8 studies) including malignant conditions, and group 3 (5 studies) including both benign and malignant conditions. The pooled analysis identified no significant differences between groups for BMI, operative time, estimated blood loss, and/or length of hospital stay. However, the analysis of complications and conversion rates revealed a higher complications rate in group 2 and higher general conversion rate in group 3 compared to the other groups. More specifically, the study revealed that patients with malignant disease had a higher complication rate than patients with benign disease (5.3% vs. 1.9%, respectively). It should be highlighted that one of the limitations of the systematic review is the fact that the studies could not clarify what was characterized as conversion in each individual study as some of them defined as conversion the addition of a single trocar, whereas others the transition from minimally-invasive to open surgery. The authors highlighted that to the best of their knowledge, this was the first analysis of the robotic single-port platform outcomes concerning the different gynecological indications in the literature. It is correct that it is the first meta-analysis performed in the field, however some years ago our team performed twice a systematic review and an update of it, respectively, analysing the role of singlesite port robotic-assisted hysterectomy [2, 3]. As our publications were not cited in the published manuscript, we would like to highlight them comparing their results with the excellent work of Capozzi et al. At the point, we would like to present the results of our previous studies published in the field [2, 3]. Our initial study [2] included six studies with 16 patients (10/16 treated for benign and 6/16 for malignant conditions) in total. Their age ranged from 34 to 70 years. The body mass index of the included patients ranged from 15.8 to 35.8 kg/m2. The operative time ranged from 105 to 311 min and the estimated blood loss from 10 to 750 ml, respectively. The weight of the removed uteri ranged from 40 to 310 g. None of the included patients presented any post-operative complications such as urinary infection, wound infection, ileus or hernia. There was the need of conversion to threeport robotic surgery due to severe pelvic adhesions in 1 out 16 patients. The hospital stay varied from 1 to 6 days. In that review, we proposed possible indications (e.g., low body mass index, good physical status of the patient, clear surgical history, young age) and contraindications (e.g., metastatic disease/ carcinomatosis, poor pulmonary function, extensive prior umbilical surgery, morbid obesity and uterus of large dimension) in the utilization of single site port robotic assisted hysterectomy. In our update of the review [3], 26 studies were analyzed among which five case reports. Five hundred and five patients underwent single port robotic hysterectomy with age ranging between 21 and 88 years and a BMI between 15.9 and 55 kg/m2 which can show that age and BMI are not limitations for such a technique. Compared to our previous review, we identified that the technique had been used in more elderly or obese patients. The operative time was ranging between 60 and 311 min. However, longer duration was found in cases which included lymph node dissection or challenging cases of endometriosis. When we excluded such cases, the duration of simple hysterectomy could range between 60 and less than 180 min. Furthermore, the blood loss was ranging between 7 and 300 ml similar with the multiple-port approach. The complication rate was 4.9% and * C. Iavazzo [email protected]