Arnold P. Advincula

Evaluating ureteral patency in the post-indigo carmine era: a randomized controlled trial

BACKGROUND: Many gynecologic, urologic, and pelvic reconstructive surgeries require accurate intraoperative evaluation of ureteral patency. OBJECTIVE: We performed a randomized controlled trial to compare surgeon satisfaction with 4 methods of evaluating ureteral patency during cystoscopy at the time of benign gynecologic or pelvic reconstructive surgery: oral phenazopyridine, intravenous sodium fluorescein, mannitol bladder distention, and normal saline bladder distention. STUDY DESIGN: We conducted an unblinded randomized controlled trial of the method used to evaluate ureteral patency during cystoscopy at time of benign gynecologic or pelvic reconstructive surgery. Subjects were randomized to receive 200 mg oral phenazopyridine, 25 mg intravenous sodium fluorescein, mannitol bladder distention, or normal saline bladder distention during cystoscopy. The primary outcome was surgeon satisfaction with the method, assessed via a 100‐mm visual analog scale with 0 indicating strong agreement and 100 indicating strong disagreement with the statement. Secondary outcomes included comparing visual analog scale responses about ease of each method and visualization of ureteral jets, bladder mucosa and urethra, and operative information, including time to surgeon confidence in the ureteral jets. Adverse events were evaluated for at least 6 weeks after the surgical procedure, and through the end of the study. All statistical analyses were based on the intent‐to‐treat principle, and comparisons were 2‐tailed. RESULTS: In all, 130 subjects were randomized to phenazopyridine (n = 33), sodium fluorescein (n = 32), mannitol (n = 32), or normal saline (n = 33). At randomization, patient characteristics were similar across groups. With regard to the primary outcome, mannitol was the method that physicians found most satisfactory on a visual analog scale. The median (range) scores for physicians assessing ureteral patency were 48 (0‐83), 20 (0‐82), 0 (0‐44), and 23 (3‐96) mm for phenazopyridine, sodium fluorescein, mannitol, and normal saline, respectively (P < .001). Surgery length, cystoscopy length, and time to surgeon confidence in visualization of ureteral jets were not different across the 4 randomized groups. During the 189‐day follow‐up, no differences in adverse events were seen among the groups, including urinary tract infections. CONCLUSION: The use of mannitol during cystoscopy to assess ureteral patency provided surgeons with the most overall satisfaction, ease of use, and superior visualization without affecting surgery or cystoscopy times. There were no differences in adverse events, including incidence of urinary tract infections.

The Essential Elements of a Robotic-Assisted Laparoscopic Hysterectomy

Robotic-assisted laparoscopic hysterectomies are being performed at higher rates since the da Vinci Surgical System (Intuitive Surgical, Inc, Sunnyvale, CA, USA) received US Food and Drug Administration approval in 2005 for gynecologic procedures. Despite the technological advancements over traditional laparoscopy, a discrepancy exists between what the literature states and what the benefits are as seen through the eyes of the end-user. There remains a significant learning curve in the adoption of safe and efficient robotic skills. The authors present important considerations when choosing to perform a robotic hysterectomy and a step-by-step technique. The literature on perioperative outcomes is also reviewed.

Robotics in Gynecology

Since the Food and Drug Administration (FDA) approval of the da Vinci Surgical System (Intuitive Surgical Inc., Sunnyvale, CA) in April 2005, robotic-assisted surgery has become popular among both gynecologic surgeons and their patients. Despite its widespread use, the role of robotic surgery in benign gynecology remains controversial. The available literature on this topic is lacking in quality, and the studies that have been conducted are mostly inconclusive. Nonetheless, a few key attributes of robotic surgery that are difficult to refute, even for the robot “nonsupporters,” include the fact that robotic surgery offers: (a) A more ergonomic option for the surgeon when compared to conventional laparoscopy (b) A less morbid surgical alternative when compared to abdominal surgery (c) The option of minimally invasive surgery for a broader patient pool

Robot-Assisted Laparoscopic Myomectomy (RALM)

In 2005, the Food and Drug Administration approved the da Vinci Surgical System (Intuitive Surgical, Sunnyvale, CA) for gynecologic surgery. Since its approval, robot-assisted surgery has become popular among both gynecologic surgeons and their patients. Robotic surgery was designed to overcome some of the challenges associated with conventional laparoscopy such as counterintuitive hand movements, two-dimensional visualization, and the limited range of motion encountered with the instruments (Rosero et al., Obstet Gynecol Surv 69: 18–19, 2014). It offers a more ergonomic environment for the surgeon when compared to conventional laparoscopy, is a less morbid surgical alternative when compared to abdominal surgery, and provides the option of minimally invasive surgery for a broader patient pool. Some limitations of robot-assisted laparoscopy include the absence of haptic (tactile) feedback and the cost, the latter of which is a point of major controversy and debate (Advincula and Song, Curr Opin Obstet Gynecol 19: 331–336, 2007).

Robot-assisted laparoscopy in benign gynecology: Advantageous device or controversial gimmick?

The growth of robot-assisted laparoscopic surgery has been exponential since its FDA approval for use in gynecologic surgery in the spring of 2005; however, controversy surrounding its use has been associated with this rise in utilization. Much of this discussion has pitted the conventional laparoscopist against the robotic surgeon particularly as it relates to issues such as operative time, costs, and the current scientific evidence. Although drawbacks exist in robotic technology, there are also clear and obvious advantages that are difficult to quantify in the scientific literature but evident to users. This chapter highlights the current state of affairs regarding the scientific literature with an evidence-based focus on the most commonly applied application - benign hysterectomy.