a resurgence of interest in the supracervical approach to hysterectomy has occurred over the past 20 years .
early studies of supracervical hysterectomy ( sch ) demonstrated improved outcomes compared to total hysterectomy , particularly in sexual and urinary function , in addition to a diminished risk of vaginal prolapse .
although such claims did not stand up to subsequent scrutiny , sch persisted as many supported retaining the cervix as a way to facilitate the performance of laparoscopic hysterectomy and make it accessible to a wider population of surgeons .
these trends have created a cohort of post - hysterectomy patients at risk of persistent or recurrence of symptoms requiring a subsequent trachelectomy , defined as the surgical removal of the cervix from an intact uterus , or the excision of a retained surgical stump .
the preferred surgical approach should be based on the clinical indication , anatomic considerations , and the surgeon 's experience .
several large studies advocating for vaginal trachelectomy reported less morbidity and shorter hospital stay , compared with laparotomy . in cases of prolapse
, the vaginal approach may be preferred ; however , in patients with chronic pelvic pain or a history of endometriosis or adhesive disease , laparoscopy may offer an advantage in anatomic visualization and dissection . to date , few studies have described the surgical techniques and outcomes of laparoscopic trachelectomy .
this paucity of information may reflect a lack of widespread adoption of this approach , which could be due to its technical challenges .
robotic surgery may offer potential advantages in overcoming the challenges of traditional laparoscopy . a thorough literature search on robot - assisted laparoscopic trachelectomy ( rt ) after sch revealed only a single case report and a case series .
we , therefore , elected to review the surgical outcomes of patients in our health system who underwent rt after sch .
this study was a retrospective chart review of women who had rt after sch for benign indications from january 2009 through october 2014 .
information regarding patient demographics and medical , surgical , obstetric , and gynecologic history were collected .
the indications for sch , the mode of surgery , and the postoperative course were reviewed . in regard to the rt procedure , we gathered data regarding the indications for surgery , the preoperative imaging performed , and the time interval between sch and rt . any concomitant procedure at the time of the rt was documented .
patients in our series were referred to the division of minimally invasive gynecologic surgery for persistent symptoms after sch .
all had complex surgical history , including multiple laparotomies and severe endometriosis , pelvic adhesions or both .
therefore , robotic trachelectomy was offered as a safe and effective surgical approach that could treat all potential pathologies .
after the induction of general anesthesia , the patient was placed in a dorsal supine lithotomy position with the feet in allen stirrups ( allen universal , inc . , cleveland , oh , usa ) .
given the increased risk for adhesive disease in the areas of peritoneal access in such a group of patients , palmer 's point was chosen as the preferred technique for obtaining safe intraperitoneal entry and insufflation .
after confirmation of orogastric tube placement by the anesthesia team , a point in the midclavicular line 3 cm below the left subcostal margin was injected with 0.25% marcaine ( hospira inc , lake forest , il , usa ) and entered with a veress needle .
entry was confirmed with low pressure ( < 10 mm hg ) and tympani , with abdominal percussion in the right upper quadrant .
a 5-mm accessory trocar was inserted under direct visualization with a 5-mm , 0 laparoscope in the left upper quadrant .
a cervical manipulator was placed under direct vision after peritoneal access was gained . for that purpose
, we used a koh ring from the rumi manipulator ( cooper surgical inc , trumbull , ct , usa ) sutured to the cervix for stability then mobilized with a tenaculum , hulka tenaculum , or vulsellum clamp .
a 4-robotic arm approach was implemented to allow optimal retraction and independence for the console surgeon .
additional 8-mm ports were placed 10 cm to the lateral right and lateral left of this incision at a 15 angle caudad .
an additional right lower quadrant robotic 8-mm port site was placed 10 cm away from this right lower quadrant incision .
the monopolar scissor , bipolar fenestrated , or maryland grasper and prograsp ( intuitive surgical , inc , sunnyvale , ca , usa ) were used for dissection , energy , and retraction . a 5-mm trocar allowed for suction and additional retraction . the dissection proceeded by lysing any adhesions obscuring access to the pelvis .
bilateral ureterolysis was performed routinely to identify and lateralize the ureters , and on the left , this process often required mobilization of the rectosigmoid at the pelvic brim .
because the bladder was often scarred over the anterior aspect of the cervical stump , we performed retrograde filling of the bladder with irrigation fluid , to ascertain the dissection plane , and mobilized the bladder caudad by dissecting from a posterior  lateral to anterior  medial direction .
this allowed for identification of the bladder pillars and cervical branches of the uterine artery , which were then isolated , coapted with the bipolar instrument , and cut . at this stage of the dissection ,
the vesicocervical junction was usually quite clear , and both blunt and sharp dissection allowed the bladder to be displaced and an adequate width of vaginal fornix to be available for colpotomy and reapproximation .
a posterior colpotomy was performed after the dissection . in cases of an obliterated posterior cul - de - sac , proceeding with entry into the rectovaginal space
subsequently , a lateral - to - medial direction of dissection across the uterosacral ligaments successfully opened the denonvilliers ' fascia of the rectovaginal space , where fat identified the anterior aspect of the rectum .
we used an eea sizer ( medtronic , minneapolis , mn , usa ) to identify the rectum and to place light counterattraction posteriorly against the posterior deflection of the colpotomizer ring .
the colpotomy was performed with focused energy delivered via a monopolar instrument , the cervix was retrieved transvaginally , and a 10-mm trocar embedded in an inflatable pneumo occluder balloon was placed in the vagina for delivery of suture .
the vaginal cuff was closed with running 2 - 0 barbed sutures in a 2-layered closure fashion .
reduced pressure visualization confirmed hemostasis , and routine cystoscopy after administration of indigo carmine assessed ureteral patency and bladder integrity .
patients in our series were referred to the division of minimally invasive gynecologic surgery for persistent symptoms after sch . all had complex surgical history , including multiple laparotomies and severe endometriosis , pelvic adhesions or both .
therefore , robotic trachelectomy was offered as a safe and effective surgical approach that could treat all potential pathologies .
after the induction of general anesthesia , the patient was placed in a dorsal supine lithotomy position with the feet in allen stirrups ( allen universal , inc . , cleveland , oh , usa ) .
given the increased risk for adhesive disease in the areas of peritoneal access in such a group of patients , palmer 's point was chosen as the preferred technique for obtaining safe intraperitoneal entry and insufflation .
after confirmation of orogastric tube placement by the anesthesia team , a point in the midclavicular line 3 cm below the left subcostal margin was injected with 0.25% marcaine ( hospira inc , lake forest , il , usa ) and entered with a veress needle .
entry was confirmed with low pressure ( < 10 mm hg ) and tympani , with abdominal percussion in the right upper quadrant .
a 5-mm accessory trocar was inserted under direct visualization with a 5-mm , 0 laparoscope in the left upper quadrant .
a cervical manipulator was placed under direct vision after peritoneal access was gained . for that purpose
, we used a koh ring from the rumi manipulator ( cooper surgical inc , trumbull , ct , usa ) sutured to the cervix for stability then mobilized with a tenaculum , hulka tenaculum , or vulsellum clamp .
a 4-robotic arm approach was implemented to allow optimal retraction and independence for the console surgeon .
additional 8-mm ports were placed 10 cm to the lateral right and lateral left of this incision at a 15 angle caudad .
an additional right lower quadrant robotic 8-mm port site was placed 10 cm away from this right lower quadrant incision .
the monopolar scissor , bipolar fenestrated , or maryland grasper and prograsp ( intuitive surgical , inc , sunnyvale , ca , usa ) were used for dissection , energy , and retraction . a 5-mm trocar allowed for suction and additional retraction . the dissection proceeded by lysing any adhesions obscuring access to the pelvis .
bilateral ureterolysis was performed routinely to identify and lateralize the ureters , and on the left , this process often required mobilization of the rectosigmoid at the pelvic brim .
because the bladder was often scarred over the anterior aspect of the cervical stump , we performed retrograde filling of the bladder with irrigation fluid , to ascertain the dissection plane , and mobilized the bladder caudad by dissecting from a posterior  lateral to anterior  medial direction .
this allowed for identification of the bladder pillars and cervical branches of the uterine artery , which were then isolated , coapted with the bipolar instrument , and cut . at this stage of the dissection ,
the vesicocervical junction was usually quite clear , and both blunt and sharp dissection allowed the bladder to be displaced and an adequate width of vaginal fornix to be available for colpotomy and reapproximation .
a posterior colpotomy was performed after the dissection . in cases of an obliterated posterior cul - de - sac , proceeding with entry into the rectovaginal space
subsequently , a lateral - to - medial direction of dissection across the uterosacral ligaments successfully opened the denonvilliers ' fascia of the rectovaginal space , where fat identified the anterior aspect of the rectum .
we used an eea sizer ( medtronic , minneapolis , mn , usa ) to identify the rectum and to place light counterattraction posteriorly against the posterior deflection of the colpotomizer ring .
the colpotomy was performed with focused energy delivered via a monopolar instrument , the cervix was retrieved transvaginally , and a 10-mm trocar embedded in an inflatable pneumo occluder balloon was placed in the vagina for delivery of suture .
the vaginal cuff was closed with running 2 - 0 barbed sutures in a 2-layered closure fashion .
reduced pressure visualization confirmed hemostasis , and routine cystoscopy after administration of indigo carmine assessed ureteral patency and bladder integrity .
sch was most commonly performed for pelvic pain ( 8/11 , 73% ) and abnormal uterine bleeding ( 7/11 , 64% ) .
laparoscopic and abdominal schs were performed in 55% and 45% of cases , respectively , with a median uterine weight of 367 g ( 441500 g ) . in 10 of 11 cases
, the symptoms leading to rt were the same as those experienced prior to sch . in 1 of the cases
, the sch was complicated by a pelvic abscess and a vesicovaginal fistula ( vvf ) necessitating a trachelectomy 1 month after the surgery .
demographic and clinical characteristics of prior sch sch , supracervical hysterectomy ; sd , standard deviation . the median interval time from sch to seeking medical help for the persistence or recurrence of symptoms was 6 months ( 2 weeks to 26 months ) and to rt , it was 27 months ( 157 months ) .
interval pelvic imaging , pelvic ultrasound followed by pelvic magnetic resonance imaging , demonstrated residual uterine tissue , an ovarian remnant mass , and a pelvic mass / hematosalpinx in 3 of the 11 patients .
concomitant procedures , mostly adnexal , were performed in 8 of 11 cases ( 73% ) ( table 2 ) .
ureteral stents were placed bilaterally in 2 cases : one was a case of vvf that occurred 2 weeks after sch , and in the other case , the stents were placed in the presence of extensive pelvic adhesions because of a history of multiple laparotomies and severe endometriosis .
the average estimated blood loss during rt was 81 ml ( range , 10200 ) .
demographic and clinical characteristics of robotic trachelectomy rt , robotic trachelectomy ; sch , supracervical hysterectomy ; sd , standard deviation .
one patient had a posterior bladder wall defect secondary to thermal injury sustained during trachelectomy for severe endometriosis .
she presented with postoperative abdominal pain , fever , and urinary symptoms , and work - up demonstrated the posterior bladder wall defect .
two weeks after robotic repair , she presented with a vvf and underwent successful robotic repair . in a second case , dissection of fibrotic tissue surrounding the left distal ureter caused a superficial adventitial laceration , necessitating ureteral stent placement for 6 weeks .
the median postoperative length of stay after rt was 1 d. final pathology showed endometriosis in 3 cases , cervicitis in another 3 , and a normal cervix in the remaining 5 cases .
pathology results did not support the presence of suspected residual uterine tissue or ovarian remnant mass demonstrated by imaging studies .
six patients reported complete resolution of symptoms after surgery , and the remaining 5 patients reported a significant improvement of their symptoms after a follow - up of 12 to 72 months .
our study demonstrates that trachelectomy can be considered a definitive therapy for patients with persistent pelvic pain and vaginal bleeding after sch .
although trachelectomy can be a challenging surgery , our experience suggests that the robotic approach may be a dependable means of achieving safe and reproducible outcomes .
a growing interest in sch in the 1990s led to a significant increase in the rate of patients who underwent this procedure .
laparoscopic sch is considered to be technically less challenging with a lower risk of bladder and ureteral injury , shorter operative time , and lower blood loss , compared with laparoscopic total hysterectomy .
early studies reported that sch is associated with improved urinary function , pelvic support , and sexual function , though subsequent studies cast doubt on these presumed advantages .
moreover , the current climate of concern regarding the risk of the occurrence of occult leiomyosarcoma after mechanical morcellation of uterine tissue may shift the pendulum away from sch .
nevertheless , sch remains an option for patients and physicians ; therefore , the issue of persistent post - hysterectomy symptoms associated with retained cervix will continue to present clinical challenges .
the range of the time interval from sch to trachelectomy is very wide , based on the published literature .
persistent symptoms after sch , such as pelvic pain , vaginal bleeding , and dyspareunia , may call for early intervention , whereas evolving symptoms , such as pelvic relaxation , may be encountered many years later , during the postmenopausal period .
hilger et al . showed that the average time between sch and trachelectomy for patients with prolapse was 31.1 years as compared to 20.7 years for other indications .
reported pelvic prolapse as the most common indication for trachelectomy , with a mean time interval of 30 years between surgeries . in our series , most patients suffered from persistent symptoms after sch , and the median interval between procedures was 27 months .
our results are comparable to those of okaro et al . and tam et al . who reported a mean interval time of 14 and 48 months , respectively
the decision regarding the surgical approach to trachelectomy should be based on the underlying disease .
okaro and colleagues reported that in all cases where trachelectomy was performed because of persistent symptoms , mainly pelvic pain and vaginal bleeding , the surgical approach was either laparoscopic ( 87.5% ) or abdominal ( 12.5% ) .
vaginal trachelectomy was the preferred surgical approach when the leading indication for intervention was pelvic organ prolapse evolving after sch . in our case series
, most patients underwent rt due to persistent symptoms , including pelvic pain and vaginal bleeding , which may be suggestive of endometriosis as the leading cause of patients ' complaints .
when removal of the cervical stump is secondary to endometriosis , adhesions , or pelvic mass , the vaginal approach may present significant technical challenges , whereas a laparoscopic surgery may facilitate the procedure and optimize patient outcomes .
specifically , laparoscopy is associated with reduced morbidity , smaller incisions , less pain , shorter recovery time , and shorter hospital stay , compared with laparotomy . in 1996 , nezhat et al .
was the first to publish a series of 6 laparoscopic trachelectomies for persistent pelvic pain and endometriosis after sch .
however , laparoscopic trachelectomy , as reflected in the paucity of studies in the literature , has not been widely adopted by gynecologic surgeons , perhaps because of the technical challenges of laparoscopy , including 2-dimensional view , the fulcrum effect across abdominal wall access , and paradoxical movement , which may limit dexterity in more difficult dissections , such as trachelectomy .
the robotic platform provides a 3-dimensional view , improved ergonomics , and intuitive motion and may help overcome these technical challenges of traditional laparoscopy . in their series of laparoscopic trachelectomy , nezhat and colleagues reported a mean operative time of 225 minutes and a mean blood loss of 100 ml .
hilger et al . evaluated the surgical outcomes of 310 patients after abdominal or vaginal trachelectomy and observed a mean estimated blood loss of 606 and 193 ml , respectively .
our study presents favorable results : the mean and median operative times for rt were 218 and 186 min , respectively , and estimated blood loss was 81 ml .
obtaining previous operative and pathology reports may play a pivotal role in regard to both counseling the patient and predicting the need for other surgical consultants , unique instrumentation , and alternative modes of peritoneal access .
the presence of dense pelvic adhesions may necessitate ureteral stenting , as stated by nezhat et al . as they reported stenting in 50% of cases . in our series , we performed ureterolysis in all cases , whereas placement of ureteral stents was implemented in 2 cases .
we are aware of several limitations that are inherent in the retrospective nature of this study .
specifically , the number of cases presented is small , and hence , the generalization of our recommendations is limited .
moreover , the results may be skewed by our selection criteria for the robotic approach . finally , no other approach to trachelectomy
our study shows that trachelectomy can be considered a definitive therapy for patients with unrelieved symptoms after sch .
trachelectomy is a potentially challenging surgery ; however , our experience suggests that the robotic approach is a valuable means of achieving safe and reproducible outcomes .
 background and objectives : a renewed interest in the supra cervical approach to hysterectomy has created a cohort of patients with a retained cervix at risk of persistent symptoms requiring a subsequent trachelectomy . 
 the objective of this study was to evaluate the efficacy of robotic trachelectomy after a previous supracervical hysterectomy.methods:this is a retrospective chart review of women who had robotic trachelectomy after supracervical hysterectomy for benign gynecologic disease from january 2009 through october 2014.results:eleven patients underwent robotic trachelectomy for benign conditions during the observed period . 
 prior supracervical hysterectomy had been performed for pelvic pain ( 8/11 , 73% ) , abnormal uterine bleeding ( 7/11 , 64% ) , and dysmenorrhea ( 5/11 , 45% ) . in 10 of 11 patients 
 , the symptoms leading to robotic trachelectomy were the same as those leading to supracervical hysterectomy . 
 the time from hysterectomy to recurrence of symptoms ranged from 0.5 to 26 months ( median , 6 ) , whereas the time interval from previous surgery to robotic trachelectomy ranged from 1 to 57 months ( median , 26 ) . 
 mean age and body mass index at robotic trachelectomy were 42  5.4 years and 32  6.1 kg / m2 . 
 mean length of surgery was 218  88 minutes ( range , 100405 ) . 
 there was 1 major postoperative complication involving bladder perforation and subsequent vesicovaginal fistula ( vvf ) . 
 endometriosis was seen in 27% of pathologic specimens and cervicitis in another 27% ; 45% showed normal tissue histology . in 6 ( 55% ) cases , symptoms leading to trachelectomy 
 resolved completely after surgery , and the other 5 ( 45% ) patients reported a significant improvement.conclusions:although trachelectomy can be a challenging surgery , our experience suggests that the robotic approach may be a valuable means of achieving safe and reproducible outcomes . 
INTRODUCTION
MATERIALS AND METHODS
Description of Surgical Technique
RESULTS
DISCUSSION
CONCLUSION