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The aim of this study was to compare the short-term estimated hospital costs and charges for open, laparoscopic, and robot-assisted sacral colpopexy. The null hypothesis was that there would be no difference in costs and charges. Fifteen comparable cases were reviewed for demographics, surgical information, and estimated hospital charges and costs and then compared with analysis of variance. There were no differences in demographics and surgical variables among the three groups. For estimated hospital charges, minimally invasive sacral colpopexy was most expensive; open was the least expensive approach. The estimated direct costs were significantly higher for robot-assisted compared with open sacral colpopexy, but not different between robot-assisted and laparoscopic sacral colpopexy. Robot-assisted sacral colpopexy produces the highest estimated hospital charges and is more expensive than open sacral colpopexy. The least expensive surgical approach from the hospital costs perspective is open abdominal sacral colpopexy.

Background and Objectives: Fistulas inaccessible from the vagina may require abdominal repair; we sought to evaluate the robotic-assisted laparoscopic approach for this procedure., Methods: A 41-year-old nulliparous woman presented with urinary incontinence following an abdominal hysterectomy, and office evaluation identified a vesicovaginal fistula. After discussion with the patient regarding the surgical options, the robotic approach was chosen to facilitate precise dissection, fine visualization, and suturing. A stent was placed from the bladder into the vagina, and no intentional cystotomy was made. The bladder was dissected away from the anterior vaginal wall at the fistula site, and the defects were closed independently with interposition of a fatty epiploica from the sigmoid colon. Total operative time was approximately 4 hours, and robotic time was about 2.5 hours., Results: At 3 months after surgery, the patient had no recurrent symptoms., Conclusions: The robotic-assisted laparoscopic approach is a viable option for successful repair of a vesicovaginal fistula in a patient in whom a vaginal approach is not indicated.

Study Objective: To assess the safety of laparoscopic treatment of adnexal masses in the second trimester of pregnancy., Design: Retrospective chart review (Canadian Task Force classification II-3., Setting: Large tertiary care medical center., Patients: Eleven women., Intervention: Laparoscopic surgery., Measurements and Main Results: All masses were identified by ultrasound. The average gestational age at the time of surgery was 17 weeks, 4 days. In seven women the primary cannula was inserted in the left upper quadrant of the abdomen. Procedures were eight ovarian cystectomies, two oophorectomies, and one exploratory laparoscopy. Average operating time was 135 minutes (range 95-195 min). Average time exposed to carbon dioxide was 78 minutes (range 59-135 min). None of the masses was malignant. There were no fetal complications or malformations. No patients had preterm labor and all delivered at term., Conclusions: The increasing number of reported cases and our experience suggest that laparoscopic treatment of adnexal masses in the second trimester is safe and effective, but the surgeon must be skilled in advanced techniques of laparoscopic surgery.

Objective: To determine the safety and efficacy of primary left upper quadrant laparoscopic cannula insertion., Design: Retrospective review., Setting: Tertiary care medical center., Patient(s): Women undergoing laparoscopic surgery for gynecologic indications., Intervention(s): Left upper quadrant cannula insertion., Main Outcome Measure(s): Intraoperative complications., Result(s): Primary left upper quadrant cannula insertion was performed 58 times. There were no intraoperative complications. In one woman there was more pain at the LUQ site than at her other incisions. In 12 women (21%) adhesiolysis was performed before insertion of the umbilical cannula., Conclusion(s): Primary left upper quadrant cannula insertion is a safe and effective alternative to primary umbilical cannula insertion.

Objective: To compare laparoscopic, gross, and fluorescent assessment of laparoscopic pelvic injuries., Design: Experimental prospective study., Setting: Cleveland Clinic Foundation Animal Research Laboratory, Cleveland, Ohio., Animal(s): Nonpregnant adult female pigs., Intervention(s): Pelvic organs injured with laparoscopic energy sources were assessed laparoscopically, grossly, and with a fluorescent indicator and Wood's lamp., Main Outcome Measure(s): Three different measurements of each laparoscopic injury., Result(s): Assessment of injuries by laparoscopy did not differ significantly from gross assessment of injuries. In the segments of bowel and bladder that were injured with monopolar cautery, the Wood's lamp assessment of the injuries was significantly longer than the laparoscopic assessment of the injuries., Conclusion(s): Laparoscopic assessment of injured ureters, bowel, and bladder appear to be similar to gross assessment of these tissues. In tissue where the serosal surface is intact, the use of a fluorescent dye and a Wood's lamp provides a clear margin of the injured tissue.

Study Objective: To assess the outcome of laparoscopic repair of pelvic ureter injuries., Design: Retrospective case series (Canadian Task Force classification II-2)., Setting: Large urban tertiary care medical center., Patients: Four women who had pelvic ureter injuries and laparoscopic repair during laparoscopic gynecologic procedures., Intervention: Laparoscopic ureteroureterostomy., Measurements and Main Results: All injuries were identified immediately and repaired laparoscopically. No patient required repeat surgery. On assessment by physical examination, serum creatinine, and intravenous urogram, no patient had evidence of renal insufficiency. One woman had a narrowing at the site of ureteroureterostomy 6 weeks after repair; it was resolved on urogram 8 months after the injury., Conclusion: Laparoscopic ureteroureterostomy is feasible in some cases of ureteral injury. Experience with laparoscopic suturing is necessary to perform this procedure.

Objective: To compare the gross and histologic effects of bipolar and monopolar cautery, ultrasonic scalpel, and CO(2) laser on porcine ureter, bladder, and rectum., Design: Experimental prospective study., Setting: Cleveland Clinic Foundation Animal Research Laboratory, Cleveland, Ohio., Animal(s): Nonpregnant adult female pigs., Intervention(s): The rectum, bladder, and ureters of 12 female pigs were injured with four different laparoscopic energy sources., Main Outcome Measure(s): Gross measurements of injured tissue and histologic analysis of the depth of the tissue injury., Result(s): Gross assessment results were that monopolar injuries of the bowel and bladder were significantly longer than ultrasonic injuries (P<0.01). Injuries were generally manifest as coagulative denaturation of collagen bundles. This resulted in an eosinophilic homogenization of tissue. Nuclei were retained in the injured tissue, although in most cases they had a pyknotic, streamed appearance. The CO(2) laser caused no deep-tissue injury., Conclusion(s): Laparoscopic energy sources injure tissue differently. Monopolar cautery appears to have the most lateral spread of thermal energy. The CO(2) laser appears to cause the least deep-tissue injury.

Injury to the ureter is a possible complication of laparoscopic surgery. Traditionally, it is repaired by laparotomy. During laparoscopic surgery for bilateral ovarian remnants in a 29-year-old woman, the left ureter was transected. The ureter was repaired by primary end-to-end anastomosis by laparoscopy. The patient recovered uneventfully, and postoperative intravenous puelogram confirmed the repair to be intact.