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The Role of Robotics in Ovarian Transposition 135 acta inform med. 2013 jun; 21(2): 135-137 doi: 10.5455/aim.2013.21.4-6 Received: 15 february 2013 • Accepted: 02 April 2013 conflict of interest: none declared © AVICENA 2013 The Role of Robotics in Ovarian Transposition christos iavazzo,1 filippos m. darlas, 1 ioannis d. gkegkes,2 iaso maternity Hospital, athens, greece1 department of thoracic surgery, “kat” general Hospital, athens, greece2 corresponding author: christos iavazzo, md, msc, phd. address: 38, seizani str., nea ionia, athens, greece, 14231. tel: 00306948054119. e-mail: [email protected] professional paper irradiation. The principal surgical ways in the fied dealing with this technique. Robotic as- aBSTRaCT transposition of the ovaries is both through sisted ovarian transposition is presented and The preservation of ovarian function in young laparotomy and laparoscopy. Recently, the the possible advantages and disadvantages of patients after radical hysterectomy has an application of the robotic technology on this such a technique are discussed. important role at the post-oncologic man- method seems to be promising. We performed Key words: Ovarian transposition, neoplasms, agement and preserves life quality. Ovarian a literature search with terms related to ovarian function, preservation, laparoscopy, transposition is a technique in order to avoid robotic surgery and ovarian transposition in robotics, cervical cancer irreversible damage to the ovaries caused by Pubmed and Scopus. Two articles were identi- 1. introduction who necessitate pelvic radiation but of 2 which both were identified as eli- Cervical cancer frequently involves not oophorectomy. Other indications gible for inclusion in this review (5, young women who are at the peak of of ovarian transposition are pelvic 6). No additional studies were iden- their reproductive capacity. The sur- sarcomas, Hodgkin’s lymphomas, tified as eligible for inclusion in this gical treatment of such a malignancy and vaginal cancer. Traditionally, review through hand-searching bibli- usually consists of radical hysterec- ovarian transposition is performed ographies of relevant articles. tomy followed by radiotherapy (1). either with laparotomy or laparos- Technique – Surgical steps So, the risk of damage to the ovaries copy, while recently has also been Patient is positioned in a Tre- caused by radiotherapy is raised. For performed robotically (5, 6). delenburg position. The surgical this reason, ovarian transposition is The aim of this review is to present cart is positioned between the pa- suggested by main gynecological cen- the role of robotic surgery in the tient’s legs. Foley catheter is placed ters to preserve ovarian function either ovarian transposition technique by in the bladder and uterine manipu- for fertility sparing reasons or to avoid presenting the main advantages and lator could be used. A 10 mm trocar early menopause. The most important the possible disadvantages. is inserted in the midline 4 cm above advantage of this surgical treatment is the umbilicus under direct visualiza- 2. metHods the fact that such radiosensitive organs tion. The abdomen is fully insufflated such as the ovaries can be transposed We searched the literature using for insertion of additional trocars. out of the radiation field (2). the terms “robot” or “robotic” or The trocars are placed about 22 cm Ovarian transposition (oophoro- “telesurgery” in combination with from the pubic rami in order to be pexy or ovarian suspension) is the the terms “ovarian transposition”. easier to use the robotic instruments. collocation of the ovaries outside of Any study reporting data on the ro- An accessory trocar is placed at the pelvis for protection from pelvic ra- botic assisted ovarian transposition Palmer’s point in order to be used as diation. The most frequent locations was included in this review. Ab- a port for the fixation device and the for ovarian transposition are out of stracts in scientific conferences as suction. A Foley catheter was inserted the pelvis to the paracolic gutters bi- well as studies published in languages into the urinary bladder for contin- laterally, normally at least 3 cm above other than English, German, French, uous drainage during the entire pro- the upper border of the radiation Italian and Spanish were excluded cedure. Then the robot is docked. field or laterally within the pelvis, from this review. We identified two Use of EndoWrist Maryland® bipolar in the lower paracolic gutters, ante- articles dealing with robotic ovarian grasper and EndoWrist Cadiere® for- rior to the psoas muscles (3). It was transposition. ceps are suggested. After explora- described for first time in the late fif- tion of the abdominal cavity, lateral 3. results ties (4). This procedure is performed peritoneal is opened along ovarian at patients with diagnosed malignan- The searches performed in vessels. After opening lateral aspect, cies most commonly cervical cancer PubMed and Scopus generated a total tubes and ovarian ligaments are cut. aCTa inFOrM MeD. 2013 Jun; 21(2): 135-137 / prOFeSSiOnal paper 136 The Role of Robotics in Ovarian Transposition Peritoneum between ovarian vessels new location of the ovaries was later- are only two case reports regarding and ureters is cut. Peritoneum lat- ally and anteriorly to the level of the the use of robotic technology on eral is cut while release of caecum is anterosuperior iliac spines. Although ovarian transposition. The first case performed maintaining the angle of the patient had received a large dose refers on a woman, in her early thir- ovarian vessels. In every dissection, of pelvic irradiation in combination ties, who had undergone a radical hys- ureters are clearly identified. The with intrathecal brachytherapy, the terectomy and bilateral pelvic lymph- ovary is sutured into the paracolic menstrual cycles of the patient were adenectomy for a Stage I-B1 cervical gutter and peritoneum of subhepatic never interrupted (14). squamous cell carcinoma.6 The trans- area. Clips are attached at the lower The transposed ovaries could be position of the ovaries was performed limit of the ovaries in order to recog- allocated to a variety of anatomic in second time after the radical hys- nize and maintain ovaries outside the sites, from the base of round liga- terectomy. The histopathologic anal- radiation field, postoperatively. ment to the low pole of kidneys (15). ysis of the enlarged lymph nodes pre- The pelvic brim is the lowest limit sented no evidence of metastatic dis- 4. discussion where the ovaries should be trans- ease. The second case was presented It is known that the incidence of posed. In order to avoid the return by Al-Badawi study, the robotic-as- ovarian metastasis in cases with cer- of the ovaries into the pelvic cavity, sisted ovarian transposition was per- vical cancer is rather rare (0.5% in the transposed ovaries should be su- formed in a 39-year-old woman with squamous cancer and 1.3% in adeno- tured firmly to the peritoneum. In stage II-B cervical cancer and without carcinomas) (7, 8). For this reason, addition, the transposition above the presence of extra-uterine disease ovarian transposition could be a this level could be achieved without (5). The operating time ranged from safe option in the management of any difficulty, being careful not to 50-170 minutes, however it should be young women with cervical cancer. separate the fallopian tubes from its noticed that in the case of 170 min- Ovarian transposition represent an uterine origin (15). Preserving the in- utes, 108 minutes were necessary for efficient procedure for preserving tegrity of the fallopian tubes permit adhesiolysis. So it should be assumed ovarian function in patients treated the possibility of spontaneous con- that the operating time is around an by a combination of surgical and ra- ception. In contrary to fallopian tube, hour with the time to be decreasing diation therapy. Patients <40 years of the ovarian ligament is not stretch- when the learning curve will in- age with a small invasive cervical car- able. To facilitate mobilization of the crease. In both studies, the blood cinoma (<3 cm), who are treated by ovaries, the ovarian ligament should loss was minimum and the patients initial surgery, are candidates for this be divided (16). were hospitalized for a night while procedure (9). In these selected pa- During the procedure, the ovaries neither immediate nor late complica- tients, the risk of ovarian metastasis is are mobilized and along with their tions are described. Furthermore, in considered low.9 The technique used vascular supply, are brought out of both studies, the transposed ovaries for ovarian transposition was first de- the pelvis to the paracolic gutters, presented with good blood supply scribed by Husseinzadeh et al (10). ideally at least 3 cm from the upper and with confirmed preservation of In the literature, there have been border of the radiation field. The pub- ovarian function by measuring post- described various methods of ovarian lished success rates present great vari- irradiation LH and FSH levels. transposition which are character- ation (16 to 90%) (17). Various factors, The DaVinci® robot offers the op- ized of advantages and disadvantages such as the vascular compromise of portunity of a key hole operation (Table). The practice of lateral ovarian the ovaries, the age of the patient, the which results to significantly less transposition seems to be more effec- radiation dose delivered and whether pain, less blood loss, better aesthetic tive than the collocation of the ova- ovaries are shielded during the pro- result, as well as shorter hospital stay ries behind uterus and protecting cedure, can influence the success of and shorter recovery time. More spe- them with a lead block (11). Another the procedure. Furthermore, chronic cifically, robotically assisted tech- option could be the exteriorization ovarian pain, infarction of the fallo- nology presents various advantages. of the ovaries under the skin through pian tubes, and formation of ovarian The articulated instruments of the an opening in the flank , but it is not cysts are some of the reported com- robot permit an extensive range of generally used and has been related plications following this procedure motion and decreases unintentional with the formation of ovarian cysts (18). Radiation therapy should take hand tremor (20). The 3-dimention (12). Heterotopic ovarian transplanta- place before ovarian transposition visibility of the abdominal cavity fa- tion is a more complicate procedure, performed in order to prevent return cilitates the complex surgical ma- where vascular anastomosis is per- of ovaries to former position (9). As nipulations which can be potentially formed and the ovary is implanted spontaneous pregnancy may be more performed with greater efficiency. In on the inner surface of the arm (13). difficult, the patient may possibly ne- addition, the surgeon has the possi- Furthermore, in the late nineties, cessitate in vitro fertilization other- bility to sit comfortably on the con- in a patient with rectal carcinoma, wise repositioning as the transposed sole and visualizes the various ana- without dissection of the caecum, the ovaries can migrate back to their tomic cavities with a great variety of ovarian ligament was transected and original position, with the purpose magnification. Moreover, in the lap- the ovaries were transposed without of conceive (19). aroscopy-assisted robotic surgery is cutting the fallopian tubes (14). The In the published literature, there important the proper position of the prOFeSSiOnal paper / aCTa inFOrM MeD. 2013 Jun; 21(2): 135-137 The Role of Robotics in Ovarian Transposition 137 references surgical cart in order to provide the Croom RD, 3rd. Oophoropexy and appropriate instrument alignment, 1. Rasool N, Rose PG. Fertility-pre- the management of Hodgkin’s dis- avoiding interference with the an- serving surgical procedures for pa- ease. A reevaluation of the risks and esthesiologic stuff. The bulky equip- tients with gynecologic malignan- benefits. Arch Surg. 1986; 121: 1083- ment used and increased costs of the cies. Clin Obstet Gynecol. 2010; 53: 1085. current technology are the main dis- 804-814. 12. Kovacev M. Exteriorization of ova- advantages of the robotic surgery (21), 2. Salakos N, Bakalianou K, Iavazzo C. ries under the skin of young wom- while the efficacy and operation’s et al. The role of ovarian transposi- en operated upon for cancer of the time are going to be improved as the tion in patients with early stage cer- cervix. Am J Obstet Gynecol. 1968; experience is growing. vical cancer - two case reports. Eur 101: 756-769. Our study has some limitations. J Gynaecol Oncol. 2008; 29: 280-281. 13. Leporrier M, von Theobald P, Rof- Someone could argue that there 3. Sella T, Mironov S, Hricak H. Imag- fe JL, Muller G. A new technique to might be more studies in which an ing of transposed ovaries in patients protect ovarian function before pel- ovarian transposition is performed in with cervical carcinoma. AJR Am J vic irradiation. Heterotopic ovarian the counter of case series presenting Roentgenol. 2005; 184: 1602-1610. autotransplantation. Cancer. 1987; robotic radical hysterectomy results. 4. McCall ML, Keaty EC, Thompson 60: 2201-2204. We included only a small number of JD. Conservation of ovarian tissue 14. Tulandi T, Al-Took S. Laparoscopic cases while the fact that the robotic as- in the treatment of carcinoma of ovarian suspension before irradia- sisted ovarian transposition is an on the cervix with radical surgery. Am tion. Fertil Steril. 1998; 70: 381-383. going technique makes our conclu- J Obstet Gynecol. 1958; 75: 590-600. 15. Bisharah M, Tulandi T. Laparoscop- sions premature. However, our review 5. Al-Badawi I, Al-Aker M, Tulandi T. ic preservation of ovarian function: depicts that the procedure can techni- Robotic-assisted ovarian transposi- an underused procedure. Am J Ob- cally be performed with the use of Da- tion before radiation. Surg Technol stet Gynecol. 2003; 188: 367-370. Vinci Robot. Moreover, it should be Int. 2010; 19: 141-143. 16. Covens AL, van der Putten HW, mentioned that our literature search 6. Molpus KL, Wedergren JS, Carlson Fyles AW, et al. Laparoscopic ovar- while extensive did not cover confer- MA. Robotically assisted endoscop- ian transposition. Eur J Gynaecol ence publications. However, the ex- ic ovarian transposition. JSLS. 2003; Oncol. 1996; 17: 177-182. isting learning curve of this novel 7: 59-62. 17. Bromer JG, Patrizio P. Preservation procedure is more difficult from lapa- 7. Aida H, Kodama S, Aoki Y. et al. The and postponement of female fertil- rotomy but easier to laparoscopy and study of ovarian metastasis in uter- ity. Placenta. 2008; 29 Suppl B: 200- for this reason the authors believe that ine cancer. Nihon Sanka Fujinka 205. more cases with robotic ovarian trans- Gakkai Zasshi. 1992; 44: 315-322. 18. Dursun P, Ayhan A, Yanik FB, Kus- position are going to be added in the 8. Nakanishi T, Wakai K, Ishikawa H, cu E. Ovarian transposition for the literature in the near future. et al. A comparison of ovarian me- preservation of ovarian function in tastasis between squamous cell car- young patients with cervical carci- 5. conclusion cinoma and adenocarcinoma of the noma. Eur J Gynaecol Oncol. 2009; Robotic assisted ovarian transposi- uterine cervix. Gynecol Oncol. 2001; 30: 13-15. tion seems to be a simple and efficient 82: 504-509. 19. Falcone T, Bedaiwy MA. Fertili- surgical method. It is beneficial not 9. Morice P, Juncker L, Rey A, El-Has- ty preservation and pregnancy out- only to prevent premature menopause san J, Haie-Meder C, Castaigne D. come after malignancy. Curr Opin but also for preservation of fertility. Ovarian transposition for patients Obstet Gynecol. 2005; 17: 21-26. The application of the robotic tech- with cervical carcinoma treated by 20. Advincula AP, Falcone T. Laparo- nology in ovarian transposition rep- radiosurgical combination. Fertil scopic robotic gynecologic surgery. resents an innovation that both the Steril. 2000; 74: 743-748. Obstet Gynecol Clin North Am. clinical utility and the cost effective- 10. Husseinzadeh N, van Aken ML, 2004; 31: 599-609, ix-x. ness of the method are yet to be clari- Aron B. Ovarian transposition in 21. Lowery WJ, Leath CA, 3rd, Robin- fied through larger studies. Further in- young patients with invasive cervi- son RD. Robotic surgery applica- vestigation is needed to be done both cal cancer receiving radiation ther- tions in the management of gyne- on the learning curve of the technique apy. Int J Gynecol Cancer. 1994; 4: cologic malignancies. J Surg Oncol. and on patients’ satisfaction as well. 61-65. 2012; 105: 481-487. 11. Gabriel DA, Bernard SA, Lambert J, aCTa inFOrM MeD. 2013 Jun; 21(2): 135-137 / prOFeSSiOnal paper