Robot-assisted laparoscopic myomectomy: current status.

Hysterectomy continues to remain the most common major gynecological surgery. Over time, various approaches to hysterectomy have developed, including open abdominal (TAH), vaginal (TVH), laparoscopic (TLH), robotic-assisted (RA-TLH), and the hybrid laparoscopic-assisted vaginal hysterectomy (LAVH). The trend over time has been to avoid open abdominal surgery and shift focus to minimally invasive approaches. In a 2004 position statement, the American Association of Gynecologic Laparoscopists (AAGL) stated that hysterectomies (for benign disease) should be approached vaginally or via minimally invasive techniques when possible. 7 Performance of robotic-assisted laparoscopic hysterectomy (RA-TLH) has become very frequent for benign disease despite the steep learning curve. Wright and colleagues assessed RA-TLH trends nationally and noted a 19-fold increase in the rates of RA-TLH over a 4-year period. 8 In addition, these authors noted that although the length of hospital stay was shortened and postoperative blood transfusion rate was reduced, the overall cost of RA-TLH was still higher than that of TLH. The operative time has also been noted to be longer with RA-TLH. A Cochrane review in 2014 also concluded that RA-TLH was comparable to TLH with respect to blood loss and safety, but there was a significant increase in the overall cost of surgery. 9 Resection of endometriosis is one of the most difficult laparoscopic surgeries. This is mainly due to the inherent nature of the disease, which results in significant scarring, distortion of the anatomy, loss of surgical planes, and immobility of pelvic organs. 10 Robotic assistance and better visualization are meant to enhance the resection outcomes of this complex surgery. Current data, however, does not support this statement. In a direct comparison of robotic-assisted laparoscopy with traditional laparoscopy, specifically for endometriosis, Nezhat et al found no significant differences in the amount of blood loss, conversion rate, complications, and duration of hospital stay between the two techniques. The only difference noted was longer average operative time associated with the robotic approach. 11 As the overall outcomes of surgery do not appear to differ between robotic-assisted and traditional laparoscopy, the greatest advantage is noted in the complexity of the cases achieved with robotic assistance. Resection of deep infiltrating endometriosis involving parts of the rectum, sigmoid colon, and extensive ureterolysis can all be achieved with the assistance of the robot system. 12 Studies have shown that with robotic assistance, these surgeries can be performed safely and effectively. In addition, Neme et al showed not only feasibility and safety of the robot system, but also reported subsequent fertility in 4 of 10 patients in these series. 12 Permanent female sterilization via fallopian tubal ligation remains a common method of contraception. Tubal reanastomosis has traditionally been performed by laparotomy with varying success in fertility and the risk for ectopic pregnancy. 13 Given the overall advantages in postoperative care, the laparoscopic technique for tubal reanastomosis has now developed into a viable option. The difficulty with the laparoscopic approach arises from the microsurgery technique and the need for precision and meticulousness, thus resulting in a steep learning curve. Since robotic assistance allows for greater control, visualization, and movement, studies have been performed to assess the feasibility and efficacy of robotic approaches for tubal reanastomosis. Rodgers et al compared the robotic approach with mini-laparotomy. 14 The operative time was again noted to be longer, and the costs were estimated to be higher with the robotic approach, but return to full function was significantly shorter compared to mini-laparotomy (1 week sooner). In addition, Patel et al compared robotic tubal reanastomosis to the laparotomy approach in their study. 15 The conclusion of this study was that while the operative time was longer with the robot, the mean hospital stay was significantly shorter (4 hours vs 35 hours), thus making the robotic approach feasible and comparable in terms of cost. Pregnancy rates were also similar with both techniques (28% vs 30%), with a mean time from sterilization to reversal being 8.5 years (robot: 8.1 years, open: 7.8 years, P =0.23). Uterine leiomyoma, also known as uterine fibroid, is the most common benign gynecologic neoplasm during the reproductive years with a large range of prevalence from 5.4% to 77%. 16 It is considered to be a benign overgrowth of the myometrium, which predominantly consists of smooth muscle cells and fibrous tissue, encased in a pseudocapsule rich in collagen. Different types of uterine fibroids include intracavitary, submucosal, intramural, subserosal, and pedunculated fibroids. Even though uterine fibroids may be asymptomatic, patients commonly report pelvic pain during or outside of menstrual cycles, excessive menstrual blood loss, pressure symptoms including urinary and bowel habit changes, and infertility. As a result, uterine fibroids are the most common indication for hysterectomy in the United States and have an enormous impact on the healthcare costs and quality of life. 16 , 17 Management options for fibroids include medical and surgical approaches. Medical therapies include non-hormonal therapies, such as non-steroidal anti-inflammatory drugs and tranexamic acid, and hormonal therapies, including oral contraceptive pills, gonadotropin (GnRH) analogs, progestin-impregnated intrauterine system, selective estrogen receptor modulators, antiprogestin drugs, selective progesterone receptor modulators, androgens, and aromatase inhibitors. 17 , 18 Non-hormonal therapies mainly serve to treat the symptoms of bleeding, and some of the hormonal therapies aim to temporarily decrease the size of the fibroids; however, these options may also be used as an adjunct to surgical therapy and for those who are approaching menopause and desiring to avoid surgical intervention. 17 – 19 Surgical approaches addressing uterine fibroids include uterine artery embolization, myomectomy, and hysterectomy. Uterine artery embolization appears to be effective for symptomatic relief; however, there are complications associated with this procedure including possible impaired fertility due to compromised ovarian blood supply and possible poor obstetrical outcomes including preterm labor. Approximately 15%–32% of these patients will require further surgical intervention within 2 years of the procedure, and 35% will end up with a hysterectomy in 10 years. 20 , 21 In patients attempting to conceive, it is typically recommended to consider removal of submucosal fibroids as they have a negative impact on fertility. Intramural uterine fibroids that distort the uterine cavity or larger intramural fibroids greater than 4 cm in size even without distorting the uterine cavity may also negatively affect fertility and therefore their removal should be considered. 22 , 23 Hysterectomy is the definitive surgical management for myomas; however, myomectomy should be considered prior to proceeding to hysterectomy, in order to decrease postoperative morbidity and also in the cases where fertility preservation is desired. 20

The use of the robot was first reported in gynecological surgery in 2000 by Falcone et al. 1 Robotic-assisted surgeries in gynecology have since expanded to include hysterectomy, myomectomy, salpingo-oophorectomy, resection of endometriosis, tubal reanastomosis, and more specialized surgeries, such as sacrocolpopexy and lymphadenectomy. 2 Robotic surgery has been readily accepted in gynecological oncology surgery education. A survey in 2010 showed that 95% of gynecologic oncology fellowship programs use the robot for surgical procedures and 94% of graduating fellows planned to perform robotic surgery in their future careers. 3 Compared to laparotomy, robotic-assisted surgery offers many of the same postoperative advantages as traditional minimally invasive laparoscopy. These advantages include excellent cosmesis from smaller incisions, minimal blood loss, lower infection rates, less postoperative pain, and shorter length of hospital stay. 4 Advantages of robotic surgery over conventional laparoscopy mainly lie in the engineering of the robot system that allows for greater wrist mobility, thus allowing the surgeon to execute more complex tasks, such as delicate tissue dissection and intracorporeal knot tying. 5 , 6

Robotic myomectomy is overall associated with many desirable outcomes compared to other types of myomectomy, especially abdominal myomectomy. A significant advantage of the robot technology is the opportunity to perform a minimally invasive surgery for myomectomy in patients who would have otherwise required a traditional laparotomy procedure for myomectomy. 47 This advantage is due to the fact that the robot offers the surgeon the ability to apply open surgical techniques in a minimally invasive fashion. As previously mentioned and also from our center’s experience, robotic myomectomy has been associated with decreased blood loss and length of hospital stay in comparison with other surgical techniques, albeit with an increased operative time and surgical costs. 41 From a reproductive standpoint, studies have shown advantageous reproductive outcomes and high pregnancy rates in patients who have undergone robotic myomectomy. 65 – 68 The robot is capable of providing the surgeon with dexterity, thereby achieving a more gentle tissue dissection and handling, which can favor reproductive outcomes. Some of the other benefits to the use of the surgical robot in gynecological surgery include the three-dimensional image of the operative field provided by the surgical console, the ease of suturing, improved and precise suture handling, the ability of the robotic endoscopic instruments to mimic the dexterity of the human hand to provide a greater range of motion and depth perception to increase surgical precision, and the motion scaling which eliminates tremor. The autonomous control over both camera and the instruments decreases surgical fatigue in contrast to complex laparoscopic and laparotomy cases, which may require the surgeon to contort his or her body in various positions for a long period of time. 69 Robotic myomectomy also provides improved cosmetic results and is associated with improvements in postoperative pain outcomes as mentioned previously. Long-term end points of robotic myomectomy including recurrence of myomas, quality of life outcomes, and obstetric outcomes are lacking and require additional data. These data will be important for determining the ultimate value and efficacy of robotic procedures.

The field of robotic surgery has made significant advancements over the last decade, and its application has become increasingly common in gynecological surgery. Gynecological procedures were reported to be comprisinĝ60% of the total robotic surgeries performed in 2013. 70 As the robot technology continues to grow, it is expected that additional revisions, technological advancements, and rapidly expanding modifications will be made to this system. Some of these potential future directions include the use of smaller robotic equipment, applying measures to decrease the set up and surgical time needed for the robot, including assisted docking, introducing single incision surgeries, and the ability to perform telesurgery using the robot system. These potential directions can provide the field of robotic surgery with an array of opportunities for clinical investigation. Additional prospective research studies are required to provide further information regarding long-term end points after robotic surgery and the cost effectiveness of this surgical technique.

The da Vinci system is not without its own limitations. Some of the major limitations include surgical system and specialized equipment costs, the need for personnel training, the learning curve associated with learning a new surgical technique, and extended operative time. There is also a lack of tactile feedback during the procedure, which may lead to breakage of suture or applying excessive traction on the myoma resulting in breaching and compromising the endometrial cavity, which is an undesirable outcome. Port placement in robotic surgery is another limitation as the ports are larger than the typical conventional laparoscopic ports and they are placed higher on the abdomen. This higher port placement will make possible conversion of robotic to laparoscopic myomectomy more challenging if needed. The use of the robot system is also limited due to its size. Any position changing requires undocking and re-docking the robot which will result in even more added surgical time. 62 These aspects can all have a great impact on the cost-effectiveness of robotic surgery.

The principles of postoperative management after a robotic myomectomy are similar to those of a laparoscopic myomectomy. Early mobilization and pain control are the essential goals. Patient can be discharged later on the day of or the following day after surgery. Depending on the extent of the surgical procedure, disruption of the uterine myometrium, and entry into the endometrial cavity, the surgeon should have a conversation with the patient regarding obstetrics recommendations and potential need for future cesarean section. These recommendations should also be documented in the operative report by the surgeon for future review by the obstetrician. The potential increased risk of uterine rupture should also be discussed.

Robotic-assisted myomectomy is a commonly performed reproductive surgery. As previously mentioned, in order to be able to determine the most appropriate route for surgical management of uterine leiomyoma, having the principle knowledge of anatomic factors is essential. Some of these key factors include myoma size, extent, number, location, and proximity to the uterine cavity. 45 Selection of the appropriate patients who would be ideal surgical candidates for robotic myomectomy is an important initial step in surgical planning for uterine fibroids. Choosing the robotic approach versus other surgical routes for myomectomy should therefore be individualized and based on the appropriate patient selection, as previously discussed. Individual’s medical and surgical histories are also factors that should be considered. Other principles that must be taken into consideration prior to choosing a surgical approach for myomectomy include surgeon’s level of training and experience, and the availability and costs of surgical equipment. In general, the most suitable candidates for robotic approach are those with subserosal, intramural, fundal, or pedunculated fibroids. 45 Some women may not be considered as appropriate candidates for robotic myomectomy. These include patients with an enlarged uterus >16 weeks in size, those with more than a total of five myomas present in the uterus, and those with uterine fibroids located in anatomically challenging locations, such as those adjacent to the broad ligament, cervix, uterine cornua, or uterine blood vessels. Robotic myomectomy may also not be suitable when there is a single uterine fibroid present, which is >15 cm in size. 40 , 46 Additionally, fibroids abutting the endometrial cavity or fibroids with a submucousal component may not be ideal for the robotic approach. Removal of these fibroids can be more challenging and associated with a higher rate of entering the endometrial cavity. Closure of the cavity defect may be more complicated with the use of the robot given the lack of tactile feedback. 47 It is important to note that robotic myomectomy may be attempted in these cases, as long as the patient is made aware that conversion to open surgery can be anticipated at a higher rate. The general conversion rate of a robotic-assisted myomectomy to laparotomy is ~11.3%. 48 This rate is similar to that of conversion in laparoscopic myomectomy. The conversion rate may also vary based on the surgeon’s experience and patient selection. The maximum size and number of uterine fibroids that are safely amenable to robotic-assisted laparoscopic myomectomy must therefore be individualized to each surgeon based on their expertise, training, and their level of comfort. Once the surgical technique has been selected as robotic-assisted myomectomy, the same preoperative preparation will be implemented as in open, laparoscopic, and hysteroscopic approaches. If the surgical candidate is anemic, pretreatment with a GnRH-releasing hormone agonist should be considered to address anemia and also to help reduce the uterine or fibroid volume. 49 In our practice, we also consider obtaining preoperative magnetic resonance imaging (MRI) for all myomectomy candidates, in order to delineate the uterine dimensions and the number, size, and the exact location of the uterine fibroids. MRI can also help in differentiating uterine fibroids from adenomyosis with a high specificity for diagnosis of adenomyosis. 50 A preoperative diagnosis of adenomyosis is of extreme importance, as it can affect the entire surgical approach. In our practice, MRI is therefore also obtained in the cases of suspected adenomyosis or when the diagnosis is unclear.