VIDEOS Uterus transplantation: robotic surgeon perspective Hubert Fornalik, M.D. and Nicole Fornalik, P.A.-C. Goshen Center for Cancer Care, Goshen, Indiana Objective: To study the safety and feasibility of robotic dissection of deep pelvic vessels as applied to the robotic harvesting of a uterus from live transplant donor. Design: Surgical video. Setting: Gynecologic oncology practice of a tertiary community cancer center. Patient(s): Two patients undergoing robotic nerve-sparing radical hysterectomy for International Federation of Gynecology and Obstetrics (FIGO) stage Ib1 cervical cancer. Intervention(s): Application of robotic platform to precise dissection of internal iliac artery and vein, their branches, including the su- perﬁcial and deep uterine artery and vein. The robotic technique for deep pelvic dissection in gynecologic oncology demonstrated here provides superior outcomes compared with the open technique. In our settings, a typical robotic nerve-sparing radical hysterectomy takes 3 hours from completion of the pelvic lymphadenectomy to the moment when the patient leaves the operating room. Main Outcome Measure(s): Safety and adequacy of robotic dissection of deep pelvic vessels. The procedure's modiﬁcation to the cur- rent technique demonstrated improved transplant blood supply and outﬂow. Demonstration of modiﬁcation to current technique, that has potential to improve transplant blood supply and outﬂow. Result(s): Using the robotic technique for nerve-sparing radical hysterectomy, the pelvic vessels can be dissected with superior precision, hemostasis, efﬁciency, and clinical outcomes. Due to its difﬁculty, nerve-sparing radical hysterectomy is not even performed via a laparotomy approach in the United States. Robotic dissection allows for better exposure of the pelvic vessels, which may allow for harvesting intact uterine vessels with internal iliac artery and vein patches, thus facilitating wider vascular anastomosis and superior blood supply and outﬂow of the transplant. Conclusion(s): Uterine harvesting from a live donor is currently being performed via a laparotomy technique, resulting in long pro- cedures associated with signiﬁcant morbidity. Based on our gynecologic oncology experience, a robotic approach to deep pelvic dissec- tion is superior to laparotomy. Robotic nerve-sparing radical hysterectomy is a difﬁcult procedure that requires knowledge of deep pelvic vessels' anatomy, precise dissection techniques, and repetition. Robotic harvesting of the uterus for transplantation from a live donor may provide better results in terms of transplant survival and donor outcomes. This type of procedure should be attempted by a robotic team that has experience in working with deep and large pelvic vessels. (Fertil Steril 2018;109:365. 2017 by American Society for Reproductive Medicine.) Use your smartphone to scan this QR code Key Words: Internal iliac patch, nerve sparing radical hysterectomy, robotic deep pelvic and connect to the dissection, robotic uterus harvesting, uterus transplantation video for this article now.* Discuss: You can discuss this article with its authors and other readers at https://www. fertstertdialog.com/users/16110-fertility-and-sterility/posts/21354-24449 * Download a free QR code scanner by searching for “QR scanner” in your smartphone’s app store or app marketplace. vations and lessons learned from early setbacks 5. Shazly SA, Murad MH, Dowdy SC, Gostout BS, AVAILABLE ON YOUTUBE to technical success. Am J Tranplant 2017;17: Famuyide AO. Robotic radical hysterectomy in https://youtu.be/vlkS4z0l0HY 2901–10. early stage cervical cancer: a systematic review 3. Fujii S, Takakura K, Matsumura N, Higuchi T, and meta-analysis. Gynecol Oncol 2015;138: Yura S, Mandai M, et al. Precise anatomy of 457–71. SUGGESTED READING the vesico-uterine ligament for radical hysterec- 6. Fornalik H, Brooks H, Moore ES, Flanders N, € € 1. Brannstrom M. Uterus transplantation and tomy. Gynecol Oncol 2007;104:186–91. Callahan MJ, Sutton GP. Hand-assisted robotic beyond. J Mater Sci Mater Med 2017;28:70. 4. Magrina JF, Kho R, Magtibay PM. Robotic surgery for staging of ovarian cancer and uter- 2. Testa G, Koon EC, Johannesson L, McKenna GJ, radical hysterectomy: technical aspects. Gynecol ine cancers with high risk of peritoneal spread. Anthony T, Klintmalm GB, et al. Living donor Oncol 2009;113:28–31. Int J Gynecol Cancer 2015;25:1488–93. uterus transplantation: a single center’s obser- Received June 2, 2017; accepted October 31, 2017; published online December 13, 2017. H.F. has nothing to disclose. N.F. has nothing to disclose. Reprint requests: Hubert Fornalik, M.D., Goshen Center for Cancer Care, 200 High Park Avenue, Goshen, Indiana 46527 (E-mail: firstname.lastname@example.org). Fertility and Sterility® Vol. 109, No. 2, February 2018 0015-0282/$36.00 Copyright ©2017 American Society for Reproductive Medicine, Published by Elsevier Inc. https://doi.org/10.1016/j.fertnstert.2017.10.038 VOL. 109 NO. 2 / FEBRUARY 2018 365
Fertility and Sterility – Elsevier
Published: Feb 1, 2018
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