The use of robotics in gynecology and reproductive medicine

Abstract

Over the last several years, there has been a significant development in the utilization of robotics in gynecology and reproductive medicine. Robotic surgery offers several technical advantages over conventional laparoscopy, including stable and highly magnified 3D vision, enhanced hand-eye coordination, a surgeon-controlled field, optimized ergonomics, motion scaling, and physiological tremor filtering. Women’s Health has solicited and published articles as part of a special collection aiming to focus on the current progress of robotics in gynecology and reproductive medicine. In this interesting and innovative issue, three articles were published: one editorial and two retrospective studies.

Plain Language Summary

Robotics in Gynecology and Reproduction

During the last years there has been an increase in the application of robotics in surgery. Robotic surgery is used widely in all types of gynecological operation. It ensures better outcomes, quicker recovery and minimal complications in difficult operations requiring surgical dexterity. However it has some disadvantages, these are the operational costs and the necessity for surgical training. The expansion of robotic surgery has decreased the costs and has led to the establishment of training fellowships.

Over the last several years, there has been a significant development in the utilization of robotics in gynecology and reproductive medicine. Robotic surgery offers several technical advantages over conventional laparoscopy, including stable and highly magnified 3D vision, enhanced hand-eye coordination, a surgeon-controlled field, optimized ergonomics, motion scaling, and physiological tremor filtering. ¹ Women’s Health has solicited and published articles as part of a special collection aiming to focus on the current progress of robotics in gynecology and reproductive medicine. In this interesting and innovative issue, three articles were published: one editorial ² and two retrospective studies.^3,4

Fertility preservation is a major concern in patients with autoimmune diseases, especially in women with ulcerative colitis. Martins and Sousa ² in an editorial highlighted the potential benefits of robotic-assisted surgery (RAS) for fertility preservation in patients undergoing total proctocolectomy with ileal pouch-anal anastomosis (IPAA) for ulcerative colitis. It was emphasized that RAS enhances the visualization of the pelvis, it offers improved dissection of the tissues; pelvic fibrosis, adhesion formation, and tubal occlusion are reduced.

The authors concluded that no study has evaluated the effects of RAS on reducing infertility rates after IPAA. However, the potential benefits seem quite reasonable. More studies with a similar design and methodology are necessary to reach safer conclusions regarding the fertility outcomes.

The Hugo™ RAS system is a modular and portable robotic surgical platform developed by Medtronic. It is designed to enhance minimally invasive surgery by providing surgeons with greater dexterity, precision, and control. The system features an open console, a system tower, and four independently extendable arm carts. ³ Anagani et al. ⁴ performed a real-world single-center study of 20 patients treated for various gynecological conditions. ⁴ In total, n = 18 patients underwent hysterectomy, uterine mass excision n = 1 patient, and myomectomy n = 1 patient. The authors evaluated several surgical parameters and reported that, based on their initial experience, the Hugo RAS system provides favorable results for gynecological patients, with benefits including efficient docking time, short surgery duration, minimal blood loss, a short hospital stay, few postoperative complications, and low pain perception. The authors concluded that further studies with larger sample sizes, comparing the Hugo RAS system with other RAS systems and traditional laparoscopic procedures in the gynecological domain, are needed. We should underline that the use of RAS systems in robotic surgery has decreased the costs over the last years in comparison with the Da Vinci systems. The three main limitations of this study were as follows: First, it was conducted in a single center; second, it had a small population of patients (n = 20), and third, it lacked a comparison group.

The Dexter Robotic System™ (Distalmotion SA, Epalinges, Switzerland) is an open robotic platform that allows the integration and easy switching between the laparoscopic and robotic interfaces. Imboden et al. ⁵ performed hysterectomies on 24 patients with the Dexter robot–assisted hysterectomies for indications like endometrial cancer, endometriosis, and uterine fibroids. For all patients, a hysterectomy was performed in addition to other procedures such as radical lymphadenectomy or deep-infiltrating endometriosis surgery that was mostly performed by conventional laparoscopy. The authors used the Clavien-Dindo classification for complications. ⁶

The authors reported that Clavien-Dindo grade III postoperative complications were observed in four patients; these were the following: three vaginal dome infections and one umbilical (camera arm) trocar hernia. It should be highlighted that there were no intraoperative complications, and no operation was converted to laparotomy among the enrolled patients. It was pointed out that the rate of vaginal dome infections in their study was 12.5%, which was higher than the rate reported in the systematic review by Uccella et al., ⁷ which found up to 7.5% for both benign and malignant indications for conventional laparoscopic hysterectomy. It was also higher than the reported rate of up to 5.2% in robotic hysterectomies for malignant indications. ⁵

The authors reported that important limitations of their study were the small cohort of patients (n = 24) and the retrospective design as well.

Application of newer, more developed robotic systems in everyday clinical practice would minimize the hospital stay, and decrease the rate of complications and postoperative pain. The main challenges of future progression are the operational costs and the training of health professionals. Robotic training centers should be launched worldwide and be accessible to physicians from developed and developing countries.

The continuous technological evolution in medicine initiates novel systems in RAS. Systems like Hugo RAS and Dexter may see wider use in the coming years. We should underline the need for the establishment of future studies with observational or randomized design that will compare laparoscopic versus robotic newer systems. Future studies should also analyze the cost-effectiveness of robotic surgery and provide standardization of the training curricula. Studies with long-term outcomes should be designed. Further research is needed to develop and establish newer robotic surgical techniques and technologies.