Histerectomía total en patología ginecológica benigna. Estudio comparativo entre dos técnicas quirúrgicas mínimamente invasivas: laparoscopia convencional versus laparoscopia con asistencia robótica

La primera histerectomía laparoscópica fue realizada en 1988 por Reich, en ella todos los pasos quirúrgicos eran similares a la técnica abdominal con la extracción del útero por vía vaginal. Permitía una recuperación rápida, así como un menor traumatismo del peritoneo, y una herida quirúrgica más pequeña (1). Muchos estudios han demostrado que la histerectomía por laparoscopia conduce a una disminución de la morbilidad perioperatoria, la estancia hospitalaria y a un más rápido retorno a las actividades habituales de las pacientes en comparación con la histerectomía abdominal (2, 3), ventajas a las que se suma las de la técnica en sí y que incluyen: la visión del cirujano próxima al tejido y magnificación del campo operatorio; el despegamiento de planos de disección favorecido por la distensión de los tejidos por el neumoperitoneo y escasa pérdida sanguínea por la acción hemostática vascular del mismo, superior a la presión venosa de pequeños capilares. Estos estudios también han mostrado que las tasas de complicaciones no son mayores para la cirugía laparoscópica si se realiza en centros con experiencia (4). Por estas razones, la histerectomía por laparoscopia debería ser considerada el procedimiento estándar para la histerectomía total, siempre que la patología que motive la intervención lo haga técnicamente posible. A pesar de estos resultados prometedores, el porcentaje de histerectomías por laparoscopia es decepcionalmente bajo en comparación con la cirugía laparotómica, y como resultado, la histerectomía abdominal sigue siendo el enfoque más común en casi todos los países del mundo (5). El principal problema de la técnica laparoscópica es la pérdida de visión tridimensional con un cambio en el concepto del espacio y las distancias, la dificultad de coordinación de dos o tres cirujanos con un solo ojo, las dificultades de suturar y anudar¿, lo que hacen necesario una amplia formación de los cirujanos y el equipo quirúrgico, siendo éstas las principales razones para no hacer de la histerectomía laparoscópica la vía de abordaje estándar (6, 7). Para superar estos inconvenientes y permitir que más pacientes puedan beneficiarse de un procedimiento menos invasivo, la cirugía robótica es una posible solución. El sistema quirúrgico de telemanipulación Da Vinci® es un robot que hace posible realizar intervenciones quirúrgicas mínimamente invasivas, aprobado por la Administración de Alimentos y Medicamentos de los Estados Unidos (US FDA) (8) para su uso en población adulta y pediátrica en cirugía laparoscópica en los siguientes procedimientos:- cirugía laparoscópica general - colecistectomía - funduplicatura de Nissen - prostatectomía radical - cirugía no cardiovascular torácica general - reparación de la válvula mitral - bypass quirúrgico de arteria coronaria durante revascularización cardíaca - histerectomía y miomectomía (9), abril 2005 - cirugía pediátrica. El dispositivo robótico Da Vinci® se ha empleado en casi todos los procedimientos ginecológicos tales como histerectomía, miomectomía, histerectomía radical con linfadenectomía pélvica y paraaórtica, anastomosis tubárica (10, 11) y está ocupando actualmente una de las principales áreas de desarrollo dentro de la disciplina quirúrgica. Este sistema está sustituyendo rápidamente a muchos procedimientos de cirugía oncológica. La mayoría de las series de casos en oncología ginecológica demuestran que los procedimientos son reproducibles y al menos comparables en viabilidad y en resultados con la cirugía laparoscópica. Sin embargo, en relación a los procedimientos quirúrgicos por patología benigna ginecológica, son pocos los estudios que comparen la cirugía laparoscópica con asistencia robótica y la cirugía laparoscópica mediante la técnica convencional. El reciente crecimiento de las técnicas de telemanipulación robótica conlleva, a su vez, un aumento del interés tanto por parte de los gestores sanitarios como de los cirujanos. Sin embargo, como ha sido mencionado, no se han realizado suficientes estudios que aporten una evidencia sólida en una tecnología tan prometedora como ésta y con un desarrollo tecnológico tan rápido. Por esta razón, se hace necesario estudios de resultados en salud que permitan la generación de dicha evidencia. Igualmente, se hace especialmente relevante la evaluación de los aspectos relacionados con la seguridad y la definición de los procedimientos que más se beneficiarían de su aplicación. Por ello, y con motivo de la disponibilidad en nuestro centro hospitalario del equipo de telemanipulación quirúrgico Da Vinci®, se ha propuesto la realización de un estudio para dar respuesta a la siguiente pregunta de investigación: ¿es el sistema de telemanipulación robótica Da Vinci® una alternativa eficaz y segura a la cirugía realizada con técnicas quirúrgicas laparoscópicas convencionales en la histerectomía total para el tratamiento de patología ginecológica benigna?Peer Reviewe

Ovarian Sertoli–Leydig cell tumours: How typical is their typical presentation?

Ovarian Sertoli–Leydig cell tumours (OSLCT) are rare and typically present with androgenic manifestations in women of the 2nd–3rd decade. Out of 228 diagnoses of ovarian sex cord-stromal tumours recorded at an academic institution during a 14-year period, eight women were surgically treated for OSLCT. Patient mean age was 54.8 years (range 19–81), five women being in the postmenopausal stage (62.5%). Only one woman presented with androgenic manifestations (12.5%), four with abnormal/postmenopausal uterine bleeding (50%), and three with abdominal pain (37.5%). Fertility sparing or radical surgery was performed depending on patient age and stage of disease. The only patient with an advanced disease (FIGO stage IV) was referred to palliative care postoperatively. The other seven were at FIGO stage I. Five of them were free from disease at a mean follow-up of 67 months, while the remaining two were lost at follow-up. The youngest woman of the series, treated with fertility-preserving unilateral salpingo-oophorectomy at the age of 19, had two spontaneous pregnancies and deliveries of healthy babies during a 10-year follow-up period. In conclusion, our single institution 14-year experience demonstrates that the diagnosis of OSLCT is particularly challenging since many patients are older than expected and lack androgenic manifestations.Impact statement • What is already known on this subjectOvarian Sertoli–Leydig cell tumours (OSLCT) are rare and are thought to typically present with androgenic manifestations in women of the 2nd–3rd decade. • What the results of this study addOur single institution 14-year experience shows that a high proportion of women with ovarian Sertoli–Leydig cell tumours may not present with androgenic manifestations, and many of them also are in the postmenopausal stage. Most patients have a good prognosis and fertility-preserving surgery in younger women can lead to spontaneous pregnancies and deliveries of healthy children after treatment. • What are the implications of these findings for clinical practice and/or further researchThe diagnosis of OSLCT is particularly challenging and therefore not reached before surgery in most of the cases. However, while hysterectomy with bilateral salpingo-oophorectomy and surgical staging are recommended for women with higher stage or no fertility wish, fertility-sparing surgery should be considered in younger women with early disease. Therefore, further research should focus on non-invasive diagnosis possibly by means of laboratory or imaging techniques

Healthcare and Indirect Cost of the Laparoscopic vs. Vaginal Approach in Benign Hysterectomy.

The aim of this study was to analyze indirect costs of vaginal and laparoscopic routes for hysterectomy to determine whether this makes a difference in total costs when considering route for surgery. A five-year observational retrospective cohort study was conducted in an academic tertiary care center. A total of 517 patients scheduled for total laparoscopic hysterectomy (n = 137) and vaginal hysterectomy (n = 380) for benign conditions between January 1, 2008 and December 31, 2012 meeting inclusion criteria were reviewed. Indirect costs were higher in the vaginal hysterectomy group compared to the laparoscopic hysterectomy group (mean cost €3,239.86 vs. €1,371.58; cost increase of €1,868.28; p  Among women undergoing hysterectomy for benign disease, laparoscopic hysterectomy appears to be superior to vaginal hysterectomy when indirect costs are analyzed in a five-year temporal horizon. Laparoscopic hysterectomy is a good alternative to vaginal hysterectomy when technically feasible as both present comparable advantages. The surgical approach to hysterectomy should be decided in light of the relative benefits and hazards, which will depend on clinical circumstances and surgical expertise

Early implementation of protective measures defines surgical outcomes in the COVID-19 pandemic

Quick implementation of specific protocols and protective measures in a tertiary hospital in Spain allowed for the early diagnosis and optimal management of patients with SARS-CoV-2 infection and proper protection of staff and inpatients. From the COVID-19 outbreak in this country until the time of writing, 14 patients in our hospital underwent surgery with COVID-19, or COVID-19 developed postoperatively. Their postoperative outcomes did not differ from those in our routine clinical practice, with a 0% respiratory failure rate and a 7.14% mortality rate, in contrast with other published series. COVID-19 did not develop in any of the healthcare workers present in the operating room during these procedures or in those who cared for these patients on the ward

Long term COST-minimization analysis of robot-assisted hysterectomy versus conventional laparoscopic hysterectomy

[Background] The aim of this study is to carry out the economic evaluation, in term of a cost-minimization analysis that considers healthcare costs and indirect costs, of robot-assisted hysterectomy (RAH) compared with conventional laparoscopic hysterectomy (CLH) in female adults scheduled for total laparoscopic hysterectomy for benign conditions.[Methods] Cost-minimization analysis based on an analytic observational study of prospective cohorts with a five-year time horizon. Eligible participants were all female adults scheduled for total laparoscopic hysterectomy for benign conditions at tertiary hospital. The economic evaluation was conducted from a Spanish National Health Service and societal perspective, including healthcare costs and indirect costs. The costs are expressed in Euros from the year 2015.[Results] One hundred sixty nine patients were analyzed, 68 in the RAH group and 101 in the CLH group. Average cost for the RAH group was €8982.42 compared to €8015.14 for the CLH group (incremental cost €967.27; p = 0.054). Healthcare cost is the most important component of total cost and represents 86.4% for the RAH group and 82.3% for the CLH group. The difference of €1169 (p = 0.01) in the average healthcare cost is mainly due to the cost of purchasing and maintaining the equipment (difference of €1206.39 in favor of RAH; p < 0.005). With regard to indirect costs, for patients in the RAH group the costs associated with loss of productivity were lower (difference of €203.42; p = 0.17), while the cost of trips to the hospital was higher (difference of €1.98; p = 0.66) in respect to CLH.[Conclusions] Our findings reveal similar effectiveness between RAH and CLH, although CLH is the more efficient option from the point of view of an economic analysis based on cost-minimization.Peer reviewe