Myomectomy offers an alternative to hysterectomy for the treatment of uterine fibroids whether or not future fertility is an issue. While many women chose a uterine-sparing approach to maintain their fertility options, there still are many women who prefer myomectomy for reasons other than fertility preservation.
The procedure is an important one for gynecologic surgeons and their patients, as it conveys a high rate of symptom resolution: Eighty-one percent of women who undergo a myomectomy experience complete resolution of their symptoms (Fertil. Steril. 1981;36:433-45).
Robot-assisted laparoscopic myomectomy was first described in 2004 by Dr. Arnold P. Advincula and his colleagues (J. Am. Assoc. Gynecol. Laparosc. 2004;11:511-8).
Their report played a pivotal role in the Food and Drug Administration’s approval in 2005 for use of the da Vinci Surgical System (Intuitive Surgical, Sunnyvale, Calif.) for gynecologic surgical procedures.
By Dr. Michael C. Pitter
While myomectomy still is most commonly performed via laparotomy, a significant number of surgeons have adopted the robotic approach. According to data from Solucient, a health care information company managed by Thomson Reuters, approximately 4,000 robotic myomectomies were performed in the United States in 2010. This represents 10% of the approximately 40,000 myomectomies performed each year, a significant proportion considering that robotics had been introduced to gynecology only 5 years earlier.
Myomectomy is a suture-intensive procedure, and suturing by a conventional laparoscopic approach has proved to be extremely challenging. The robotic platform gives surgeons greater capability of successfully repairing deep hysterotomy defects and provides them with a more achievable minimally invasive option to offer patients.
Photo courtesy Dr. Michael C. Pitter
Figure 1. Below the endoscopic view of the fibroid uterus (top), MRI images are superimposed in the viewer of the surgeon's console. The upper left MRI image is a sagittal view of the pelvis and indicates the presence of fibroids (left to right) in the posterior fundal, submucosal, and posterior mid portion of the uterus. The upper right and and lower left images are axial views showing fibroids (top to bottom) in the anterior left, submucosal left mid portion, and posterior mid portion of the uterus.
Interestingly, utilization of the laparoscopic approach for hysterectomy also has increased with the introduction of robotics. Current statistics show that only 16% of all hysterectomy procedures performed in the United States are done via conventional laparoscopy (20 years, approximately, after the techniques were developed), while another 20% are now being performed with robot assistance. A new AAGL position statement saying that surgeons who offer hysterectomy should be able to perform either vaginal hysterectomy (the preferred approach) or laparoscopic hysterectomy (the second best approach) – or refer their patients to a surgeon who can (J. Minim. Invasive Gynecol. 2011;18:1-3) – is indicative of the growing belief that the benefits of minimally invasive surgery over open procedures should be considered where possible in aspects of gynecologic surgery.
At our institution, we saw a significant improvement in operative time after the first 20 cases of robotic-assisted myomectomy and hysterectomy. Our operative time went from a mean of 212 min. for cases 1-20 to a mean of 151 min. for cases 21-40 (Int. J. Med. Robot. 2008;4:114-20).
Others have reported similar findings on the learning curve for robotic-assisted gynecologic surgery: Another case series published several years ago, for instance, showed operative times for various surgical procedures for benign gynecologic problems stabilizing within 50 cases (J. Minim. Invasive Gynecol. 2008;15:589-94). In general, these data are indicative of a significantly shorter learning curve than seen with traditional laparoscopic surgery.
Incorporation of MRI
The main drawback to robotics always has been the absence of haptics or tactile feedback. This limitation has, however, spurred the development of creative techniques to compensate, including the use of real-time magnetic resonance imaging.
Photo courtesy Dr. Michael C. Pitter
Figure 2. Same as Figure 1, but with the relative size of the MRI images to the endoscopic view adjusted to the surgeon's needs at that point during the procedure. The surgeon can operate with the images mounted simultaneously in the viewer of the surgeon's console.
MRI images can now be incorporated in a real-time, 3-dimensional fashion into the surgeon’s console for use in mapping, detecting, locating, and enucleating myomas. All three views – axial, coronal, and sagittal – can be seen during the surgery. This enables the surgeon both to overcome the haptic limitations and to remove multiple fibroids. (See images 1 and 2.)
Certainly, the gynecologic surgeon employing this technique must be comfortable reading and interpreting MR images. The necessary comfort level can be achieved, on an individual basis, with time spent reviewing series of pelvic MR images with a radiologist.