Tips and tricks for robotic management of diffuse adenomyosis

OBJECTIVE: To demonstrate a step-by-step approach in two cases of diffuse adenomyosis using different surgical techniques depending on the disease's extent. The video also highlights surgical tips to minimize blood loss and maximize the excision of the adenomyotic disease. DESIGN: Description of technique and narrated surgical video footage. SUBJECTS: The patients included in this video gave consent for the publication of the video and posting of the video online, including social media, the journal website, scientific literature websites (e.g., PubMed, ScienceDirect, and Scopus), and other applicable sites. FIRST CASE: A 38-year-old nulligravid patient with a history of chronic pelvic pain, dysmenorrhea, and infertility for 2 years had previously undergone two unsuccessful in vitro fertilization (IVF) cycles. During her first IVF cycle, five embryos were produced; one embryo was transferred, and the remaining embryos were frozen. In the second attempt, one frozen embryo was transferred after endometrial preparation as per protocol. However, both cycles were unsuccessful, resulting in implantation failure. Preoperative magnetic resonance imaging revealed diffuse adenomyosis in the posterior wall of the uterus, measuring 8.7 × 6.0 cm, with a thickened junctional zone (>12 mm). SECOND CASE: A 36-year-old G2P1 patient with a history of cesarean section and secondary infertility had two IVF cycles: the first resulted in early pregnancy loss at 6 weeks, and in the second cycle, she was premedicated with gonadotropin-releasing hormone for 3 months; however, it was unsuccessful. Preoperative magnetic resonance imaging identified diffuse adenomyosis involving both the anterior and posterior uterine walls, with a thickened junctional zone (>12 mm). EXPOSURE: In the first case, a classic excisional technique was performed to remove the adenomyosis from the posterior uterine wall. In the second case, a double flap approach was used to excise adenomyosis from both the anterior and posterior uterine walls. Intracavitary diluted indocyanine green dye was used to maximize the precise excision of adenomyosis tissue while maintaining an adequate myometrial residual around the cavity. MAIN OUTCOME MEASURES: Robotic-assisted excision of adenomyosis tissue while sparing adequate myometrium and reconstructing uterine walls. RESULTS: Both procedures were completed without complications, and patients were discharged on the same day of surgery. Patients were seen at 6 weeks for postoperative follow-up with no complaints. The plan is to obtain imaging before resuming IVF treatment. Patients were advised to wait 6 months after surgery before attempting conception to allow for recovery. CONCLUSION: Uterus-sparing surgical techniques for diffuse adenomyosis are advisable in selected cases where medical management and/or repeated IVF cycles fail. Preoperative imaging is crucial for precisely mapping the disease and applying the appropriate surgical technique. Different techniques have been proposed using an open or a minimally invasive approach. The use of a robotic platform, in conjunction with indocyanine green dye, can facilitate these surgical techniques and potentially improve outcomes.