The Use of Robotic Technology in Female Pelvic Floor Reconstruction by Jennifer T. Anger & Karyn S. Eilber

Author:Jennifer T. Anger & Karyn S. Eilber
Language: eng
Format: epub
Publisher: Springer International Publishing, Cham

Overall, there are significant benefits to patients who undergo minimally invasive surgeries compared to open techniques [14]. Patients have smaller incisions, less post-operative pain, and shorter hospital stays [15]. In the case of hysterectomy, these benefits are even more pronounced with the assistance of the operative robot [16]. In addition to improved recovery for patients, there are fewer complications , such as wound infections, bleeding requiring transfusion, deep vein thrombosis, nerve injury, and genitourinary and gastrointestinal tract injuries [17], many of which will require readmission and reoperation. Patients undergoing open abdominal hysterectomy have a threefold greater risk of mortality than those who undergo laparoscopic hysterectomy [18].

While generally associated with improved patient outcomes, there are complications unique to the use of power morcellation devices. Direct injuries to the bowel and large vessels, while uncommon, can occur. A review of the Manufacturer and User Facility Device Experience (MAUDE) database in 2014 revealed 66 reports of direct injuries, six of which were fatal [19]. These included injuries to the small and large bowel (31/66), large blood vessels (27/66), kidney (3/66), ureter (3/66), bladder (1/66), and diaphragm (1/66). Given the millions of procedures performed, these injury rates remain very low.

An additional concern with intracorporeal morcellation of any type is the development of parasitic fibroids or iatrogenic endometriosis , which can require repeat surgical treatment. Small chips or tissue fragments released from the specimen during morcellation can implant on the peritoneum and grow to cause symptoms such as pain, gastrointestinal or ureteral obstruction, or local organ dysfunction by exerting a mass effect [20, 21]. Even if asymptomatic, identification of an unknown abdominal mass frequently necessitates additional workup and surgical removal. The risk of such masses developing after uterine fibroid removal appears to increase significantly with the use of morcellation, with an overall incidence of 0.12–0.9% [22–24]. Exposure to gonadal steroid hormones increases this risk, with both premenopausal status and hormone replacement therapy promoting parasitic fibroid development and growth.

The most concerning of the complications attributed to morcellation, however, is the risk that an unrecognized malignancy could be spread in the abdomen and pelvis, leading to poor oncologic outcomes. This is the focus of the FDA safety warning and the main target of activism opposing the use of power morcellation. “If laparoscopic power morcellation is performed in women with unsuspected uterine sarcoma, there is a risk that the procedure will spread the cancerous tissue within the abdomen and pelvis, significantly worsening the patient’s long-term survival.” [3]

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