Pregnancy following robot-assisted laparoscopic myomectomy in women with deep intramural myomas

Robotic Single-Site Plus One-Port Myomectomy versus Robotic Single-Site Plus Two-Port Myomectomy: A Propensity Score Matching Analysis

PURPOSE

Robotic single-site plus one-port myomectomy (RSOM) was designed to reduce the number of incision sites for greater cosmetic satisfaction of patients while retaining the benefits of conventional robotic multi-site myomectomy (CRM). Robotic single-site plus two-port myomectomy (RSTM) eliminated one port relative to conventional CRM, and RSOM achieved the same advantage with respect to RSTM. This study aimed to compare RSOM with RSTM in terms of their respective methodologies and surgical outcomes.

MATERIALS AND METHODS

The medical records of 230 patients who had undergone RSOM and 146 patients who had undergone RSTM were reviewed. The groups' surgical outcomes were compared using propensity score matching (PSM) analysis.

RESULTS

In the total data, RSOM had a shorter operative time (135.1±57.4 min vs. 149.9±46.2 min, p=0.009) and a shorter hospital stay (5.2±0.5 days vs. 5.4±0.7 days, p=0.033) relative to RSTM. The PSM analysis showed that there were no statistically significant intergroup differences in the patients' baseline characteristics. Regarding the surgical outcomes, the RSOM group showed shorter operative time (129.2±49.3 min vs. 148.7±46.3 min, p=0.001) compared to the RSTM group.

CONCLUSION

Compared with RSTM, RSOM was associated with shorter operative time. Additionally, more detailed comparative and prospective studies are needed to evaluate RSOM relative to RSTM.

Multi-Port Robotic-Assisted Laparoscopic Myomectomy: A Systematic Review and Meta-Analysis of Comparative Clinical and Fertility Outcomes

BACKGROUND

Uterine fibroids are the most frequently diagnosed gynaecological tumours, and they often require surgical treatment (conventional laparoscopic myomectomy-CLM). The introduction and evolution of robotic-assisted laparoscopic myomectomy (RALM) in the early 2000s has expanded the range of minimally invasive options for the majority of cases. This study aims to compare RALM with CLM and abdominal myomectomy (AM).

METHODS AND MATERIALS

Fifty-three eligible studies adhered to the pre-established inclusion criteria and were subsequently evaluated for risk of bias and statistical heterogeneity.

RESULTS

The available comparative studies were compared using surgical outcomes, namely blood loss, complication rate, transfusion rate, operation duration, conversion to laparotomy, and length of hospitalisation. RALM was significantly superior to AM in all assessed parameters other than operation duration. RALM and CLM performed similarly in most parameters; however, RALM was associated with reduced intra-operative bleeding in patients with small fibroids and had lower rates of conversion to laparotomy, proving RALM as a safer overall approach.

CONCLUSION

The robotic approach for surgical treatment of uterine fibroids is a safe, effective, and viable approach, which is constantly being improved and may soon acquire widespread adoption and prove to be superior to CLM in certain patient subgroups.

Comparison of Clinical and Reproductive Outcomes between Adenomyomectomy and Myomectomy

STUDY OBJECTIVE

Women with adenomyosis may show a lower pregnancy rate and a higher miscarriage rate than healthy women. There is also a general agreement that leiomyomas, either submucosal or intramural, negatively affect fertility, when compared with women without myomas. Some of these women may benefit from adenomyomectomy, however this cytoreductive procedure is considered invasive and technically challenging especially in severe diffuse cases. The study aimed to compare the clinical and reproductive outcomes of patients who underwent adenomyomectomy with those of patients who underwent intramural myomectomy.

DESIGN

A retrospective study.

SETTING

Department of Obstetrics & Gynecology, Center of Gynecological Endoscopy and Minimally Invasive surgery, First Faculty of Medicine, General University Hospital in Prague.

PATIENTS

A total of 55 women who underwent surgical resection of uterine adenomyosis and 55 patients who underwent myomectomy for intramural uterine myomas were included in this study. All study participants wished to retain and possibly improve their reproductive potential.

INTERVENTIONS

Between 2004 and 2019, 110 women underwent laparoscopic or open uterus-sparing surgery for clinically significant uterine adenomyosis (group A) or myomas (group B), respectively.

MEASUREMENTS AND MAIN RESULTS

Two groups of women who underwent different fertility-saving procedures were compared. Although all women entering the study had declared their wish to conceive, only 28 patients in group A (group A1) and 24 women in group B (group B1) finally aimed toward pregnancy. The mean age and follow-up period was 35.0 years and 76.81 months, respectively, in group A and 34.8 years and 72.5 months, respectively, in group B. The pregnancy and delivery rates were 75.0% and 46.4%, respectively, in group A1 vs 96.0% and 70.8%, respectively, in group B1, with no significant differences between the 2 groups. The open surgical approach was significantly more frequently employed in group A (47.3% vs 16.4%; p <.01).

CONCLUSION

In this study, women who underwent surgery involving the uterine muscularity, including myomectomy or adenomyomectomy, had comparable reproductive outcomes, with no significant differences.

Fertility and Pregnancy Outcomes After Robotic-assisted Laparoscopic Myomectomy in a Canadian Cohort

STUDY OBJECTIVE

Myomectomy is the gold standard treatment for patients with symptomatic fibroids who desire fertility preservation. Given the relatively recent application of robotic surgery in the field of gynecology, there is only a small amount of data describing fertility outcomes after robotic-assisted laparoscopic myomectomy (RALM). The objective of this study was to determine the pregnancy rate in patients trying to conceive after RALM.

DESIGN

A single-center, retrospective case series.

SETTING

Department of Obstetrics and Gynecology, St. Michael's Hospital, Toronto, Ontario, Canada.

PATIENTS

All patients who underwent RALM between October 2008 and September 2015 and who consented to a telephone interview were included.

INTERVENTION

None. The primary outcome was pregnancy rate after RALM. Secondary outcomes included whether patients underwent fertility treatment, rate of live births after RALM, rate of spontaneous abortion mode of delivery in pregnancies following RALM, obstetric complications, and symptoms experienced postoperatively.

MEASUREMENTS AND MAIN RESULTS

A total of 123 patients underwent RALM between 2008 and 2015. Of them, 101 consented to be interviewed. Average age ± standard deviation was 34.4 ± 4.4 years. Average myoma size was 8.9 ± 2.2 cm. Of all myomas, 64 (63.4%) were intramural, 35 (34.7%) were subserosal, and 2 (2%) were submucosal according to preoperative imaging. The pregnancy rate after RALM was 42/60 (70.0%). Three additional patients became pregnant who were not trying to conceive. Of the 45 patients who became pregnant, 38 (84.4%) successfully delivered or were pregnant at the time of data collection.

CONCLUSION

The pregnancy rate after RALM was 70.0%, which is similar to that reported in previous studies. Future research should aim to conduct larger, prospective studies investigating fertility outcomes after RALM and should aim to identify variables that predict pregnancy.

Operative and Obstetric Outcomes after Single-port Laparoscopic Myomectomy: A Retrospective Single-center Analysis of 504 Cases

STUDY OBJECTIVE

To analyze the obstetric and operative outcomes of 504 cases of single-port laparoscopic myomectomy (SPLM).

DESIGN

Single-center retrospective study.

SETTING

A tertiary university hospital.

PATIENTS

A total of 502 patients (504 SPLM procedures) who underwent SPLM for symptom relief or growing myomas between October 2009 and April 2020.

INTERVENTIONS

Data on patient demographics, operative variables (estimated blood loss, hemoglobin decrease, operation time, perioperative complications, and postoperative hospital stay), and obstetric outcomes (the surgery-to-pregnancy interval and birth-related outcomes) were obtained from medical records and analyzed.

MEASUREMENTS AND MAIN RESULTS

The mean age of the patients was 40.6 ± 6.6 years. The patients had had an average of 2.3 ± 2.2 myomas removed; the largest myoma size was 6.8 ± 2.4 cm. The mean operation time, postoperative hemoglobin decrease, and postoperative hospital stay duration were 112.9 ± 45.3 minutes, 1.7 ± 1.1 g/dL, and 2.2 ± 1.4 days, respectively. The overall rate of postoperative complications was 7.7% (39/504), and the common complications were transfusions (16/504, 3.1%) or wound problems (15/504, 3.0%). Conversion to multiport or open myomectomy was required in 0.8% of the cases (4/504). A total of 376 women were of child-bearing age, and 56 attempted to become pregnant after surgery. The mean interval from surgery to pregnancy was 15.6 ± 12.2 months. The obstetric outcomes were pregnancy (42/56, 75.0%), live birth (39/56, 69.6%), and miscarriage (2/56, 3.6%). One pregnant woman was lost to follow-up. The 39 live births predominantly involved full-term delivery (36/39, 92.3%), mostly through cesarean section (36/39, 92.3%). No postpartum complications were reported. The 2 most common obstetric complications were preterm labor (7.6%) and gestational diabetes (5.1%).

CONCLUSION

SPLM seems to be an effective procedure with good operative and postoperative obstetric outcomes for women with myomas who require surgery and may wish to subsequently become pregnant.

Time to conceive after myomectomy: should we advise a minimum time interval? A systematic review

The optimal time interval between myomectomy and pregnancy is unclear and no specific guidelines exist. The aim of this review was to study the time interval from myomectomy to pregnancy and the occurrence of uterine rupture after myomectomy. Randomized controlled trials, cohort studies and retrospective studies were used to assess the primary objective, and case reports, cases series or letters to the editor for the secondary objective. Only articles reporting myomectomy performed via the vaginal route, laparotomy, laparoscopy or robot-assisted surgery were selected for inclusion. Among 3852 women who wanted to become pregnant after the surgery, 2889 became pregnant, accounting for 3000 pregnancies (77.9%) and 2097 live births (54.4%). Mean time between myomectomy and pregnancy was estimated at 17.6 months (SD 9.2) for 2451 pregnant women. Among 1016 women, a third were advised to delay attempting to conceive for between 3 and 6 months and another third for between 6 and 12 months. A total of 70 spontaneous uterine ruptures with a mean gestational age of 31 weeks at occurrence were identified. No linear relationship was found between gestational age at the event and time interval from myomectomy to conception (P = 0.706). There are insufficient data to advise a minimal time interval between myomectomy and conception.

Robotic Management of Fibroids: Discussion of Use, Criteria and Advantages

Fibroids are the most common benign tumors affecting fertility and quality of life. Different methods either definitive or fertility sparing are used for their management by using open, laparoscopic and robotic techniques. This is a narrative review presenting the role and the advantages of robotic surgery in fibroids (myomectomies or hysterectomies). Such a management is effective, safe and feasible in hands of well-trained teams even for multiple, large or deep located fibroids.

Fertility and obstetrical outcomes after robot-assisted laparoscopic myomectomy

OBJECTIVE

To evaluate fertility after robot-assisted laparoscopic myomectomy (RALM) in terms of pregnancy rates, and obstetrical outcomes.

PATIENTS

This is a retrospective cohort of RALM performed for symptomatic leiomyomas among women who want to conceive. Medical data were retrospectively reviewed. An office hysteroscopy was prescribed 3 months after the surgery.

RESULTS

Fifty-three patients were included. The mean number of myomas was 2 ± 1.5 with a mean size of 69 ± 17.7 mm. A breach of the cavity was noticed in 15.1% of the cases. Two cases of intrauterine adhesions were diagnosed and treated during the post-operative office hysteroscopy (5.7%). Clinical pregnancy rates were 52.8% with a live birth rate of 41.5% in patients desiring pregnancy. A caesarean section was performed in 17 cases (70.8%). No case of uterine rupture was reported.

CONCLUSION

More than half of the patients became pregnant after RALM. A low rate of obstetrical complications was reported, with no uterine ruptures, highlighting the promise of this technique for infertile patients.

Robot-assisted myomectomy

Uterine fibroids are the most common tumors of the uterus and the female pelvis and are associated with substantial morbidity for several women. In women with a wish to preserve fertility, a myomectomy is the surgical procedure of choice when medical therapy is inadequate. Despite evidence that minimally invasive surgery is preferable to laparotomy, most myomectomies are still performed by laparotomy. Robotic surgery was introduced to overcome some of the difficulties associated with laparoscopic surgery. A myomectomy is a suture-intensive surgery where the properties of a surgical robot have been suggested to be of particular value. Robotic myomectomy is feasible and safe, with similar outcome to laparoscopic surgery, although a robotic procedure is associated with a higher cost. The introduction of robotic surgery has expanded the indications for minimally invasive myomectomy to more complex cases previously performed by laparotomy. Randomized trials comparing different approaches to myomectomy are yet to be published. More studies are needed to determine the patients in whom a robotic approach is most beneficial, both in terms of patient outcomes and cost efficiency.

Robotic-assisted laparoscopy in reproductive surgery: a contemporary review

Robotic surgery is a conceptual fusion of the conventional open surgery and the minimally invasive laparoscopic surgery. We reviewed the current role of robotic-assisted laparoscopy in the field of reproductive surgery by a literature search in PubMed database. We analyzed the reported advantages and limitations of the use of robotics in reproductive surgeries like myomectomy, tubal reanastomosis, endometriosis, ovarian tissue cryopreservation, and ovarian transposition. Overall, robotic assistance in reproductive surgery resulted in decreased blood loss, less post-operative pain, shorter hospital stay, and faster convalescence, whereas reproductive outcomes were similar to open/laparoscopic approaches. The main drawbacks of robotic surgery were higher cost and longer operating times. It is as safe and effective as the conventional laparoscopy and represents a reasonable alternate to abdominal approach. Procedures that are technically challenging with the conventional laparoscopy can be performed with robotic assistance. It has advantages of improved visualization and Endowrist™ movements allowing precise suturing. This helps to overcome the limitations of laparoscopy, especially in complicated procedures, and may shorten the steep learning curve in minimal invasive surgery. Randomized controlled trials looking at both short- and long-term outcomes are warranted to strengthen the role of robotic surgery in the field of reproductive surgery.

Robot-assisted laparoscopic myomectomy: current status

Robotic-assisted surgery has seen a rapid development and integration in the field of gynecology. Since the approval of the use of robot for gynecological surgery and considering its several advantages over conventional laparoscopy, it has been widely incorporated especially in the field of reproductive surgery. Uterine fibroids are the most common benign tumors of the female reproductive tract. Many reproductive-aged women with this condition demand uterine-sparing surgery to preserve their fertility. Myomectomy, the surgical excision of uterine fibroids, remains the only surgical management option for fibroids that entails preservation of fertility. In this review, we focus on the role of robotic-assisted laparoscopic myomectomy and its current status, in comparison with other alternative approaches for myomectomy, including open, hysteroscopic, and traditional laparoscopic techniques. Several different surgical techniques have been demonstrated for robotic myomectomy. This review endeavors to share and describe our surgical experience of using the standard laparoscopic equipment for robotic-assisted myomectomy, together with the da Vinci Robot system. For the ideal surgical candidate, robotic-assisted myomectomy is a safe minimally invasive surgical procedure that can be offered as an alternative to open surgery. The advantages of using the robot system compared to open myomectomy include a shorter length of hospital stay, less postoperative pain and analgesic use, faster return to normal activities, more rapid return of the bowel function, and enhanced cosmetic results due to smaller skin incision sizes. Some of the disadvantages of this technique include high costs of the robotic surgical system and equipment, the steep learning curve of this novel system, and prolonged operative and anesthesia times. Robotic technology is a novel and innovative minimally invasive approach with demonstrated feasibility in gynecological and reproductive surgery. This technology is expected to take the lead in gynecological surgery in the upcoming decade.

Comparison of Long-Term Fertility and Bleeding Outcomes after Robotic-Assisted, Laparoscopic, and Abdominal Myomectomy

Background/Aims. To compare long-term fertility and bleeding outcomes of women who underwent robotic-assisted, laparoscopic, and abdominal myomectomy at our institution over a 15-year period. Methods. This was a retrospective cohort study of myomectomy patients 18-39 years old that had surgery between January 1995 and December 2009 at our institution. Long-term follow-up on fertility and bleeding outcomes was collected from the patient directly. The uterine fibroid symptom and quality of life survey was also administered to assess current bleeding patterns. Baseline characteristics were compared across groups. Univariable comparisons of fertility and bleeding outcomes based on surgical approach were made using analysis of variance, Kruskal-Wallis analysis of ranks, and Chi-square tests as appropriate. Results. 134/374 (36%) subjects agreed to participate in the study. 81 subjects underwent an open procedure versus 28 and 25 subjects in the laparoscopic and robotic groups, respectively. Median follow-up after surgery was 8 years. 50% of patients desired pregnancy following surgery and, of those, 60% achieved spontaneous pregnancy; the spontaneous pregnancy rate did not differ between groups. Additionally, UFS-QOL scores and/or subscores did not differ between groups. Conclusion. There is no significant difference in long-term bleeding or fertility outcomes in robotic-assisted, laparoscopic, or abdominal myomectomy.

Robot-assisted laparoscopic myomectomy for deep intramural myomas

BACKGROUND

To evaluate the efficacy of robot-assisted laparoscopic myomectomy for deep intramural myomas.

METHODS

We have conducted a retrospective study for 170 patients who underwent robot-assisted laparoscopic myomectomy by a single operator of tertiary university hospital.

RESULTS

There were 100 cases of robot-assisted laparoscopic myomectomy for deep intramural myomas. The patients had 3.8±3.5 myomas on average, and the mean size of the largest myoma of each patient was 7.5±2.1 centimeters in diameter. Mean operative time was 276.4±97.1 minutes, and mean console time was 146.0±62.7 minutes. Thirty two patients had surgeries for other gynecologic conditions such as pelvic endometriosis or endometrial polyps along with myomectomy at the same time. All the patients recovered without any major complication. After the surgery, nine(75.0 %) of the 12 women pursuing a pregnancy became pregnant.

CONCLUSION

Robot-assisted laparoscopic myomectomy for deep intramural myomas could be a minimal invasive surgical option for women who wish preserve fertility. Copyright © 2016 John Wiley & Sons, Ltd.

Myomectomy by Robotically Assisted Laparoscopic Surgery: Results at Foch Hospital, Paris

We reported an observational, retrospective chart review of 36 women who underwent robotic myomectomy at the Department of Obstetrics and Gynecology, Foch Hospital. Short- and long-term results were analyzed. We compared our results with literature data. Potential advantages and limits of robotic surgery in myomectomy are discussed.

Fertility and Symptom Relief following Robot-Assisted Laparoscopic Myomectomy

Objective. To examine success of robot-assisted laparoscopic myomectomy (RALM) measured by sustained symptom relief and fertility. Methods. This is a retrospective survey of 426 women who underwent RALM for fibroids, symptom relief, or infertility at three practice sites across the US. We examined rates of symptom recurrence and pregnancy and factors associated with these outcomes. Results. Overall, 70% of women reported being symptom-free, with 62.9% free of symptoms after three years. At >3 years, 66.7% of women who underwent surgery to treat infertility and 80% who were also symptom-free reported achieving pregnancy. Factors independently associated with symptom recurrence included greater time after surgery, preoperative dyspareunia, multiple fibroid surgeries, smoking after surgery, and preexisting diabetes. Factors positively correlated with achieving pregnancy included desiring pregnancy, prior pregnancy, greater time since surgery, and Caucasian race. Factors negatively correlated with pregnancy were advanced age and symptom recurrence. Conclusions. This paper, the first to examine symptom recurrence after RALM, demonstrates both short- and long-term effectiveness in providing symptom relief. Furthermore, RALM may have the potential to improve the chance of conception, even in a population at high risk of subfertility, with greater benefits among those who remain symptom-free. These findings require prospective validation.

Fertility and Pregnancy Outcome after Myoma Enucleation by Minilaparotomy under Microsurgical Conditions in Pronounced Uterus Myomatosus

Introduction: Besides the typical complaints and symptoms, myomas can cause sterility, infertility and complications during pregnancy. Laparoscopic interventions reach their limits with regard to organ preservation and the simultaneous desire to have children in the removal of multiple and larger intramural myoma nodes. The aim of this study is to examine fertility status and pregnancy outcome after myoma removal by minilaparotomy (skin incision maximal 8 cm) in women with pronounced uterus myomatosus. Materials and Methods: This retrospective study makes use of the data from 160 patients with an average age of 34.6 years. Factors analysed include number, size and localisation of the myomas, complaints due to the myoma, pre- and postoperative gravidity, mode of delivery, and complications of birth. Results: Indications for organ-sparing myoma enucleation were the desire to have children (72.5 %), bleeding disorders (60 %) and pressure discomfort (36.5 %). On average 4.95 (SD ± 0.41), maximally 46 myomas were removed. The largest myoma had a diameter of 6.64 cm (SD ± 2.74). 82.5 % of the patients had transmural myomas, in 17.5 % the uterine cavity was inadvertently opened. On average the operating time was 163 minutes (SD ± 45.47), the blood loss 1.59 g/dL (SD ± 0.955). 60.3 % of the patients with the desire to have children became pregnant postoperatively. 75.3 % of the pregnancies were on average carried through to the 38th week (28.4 % vaginal deliveries, 71.6 % Caesarean sections). In the postoperative period there was one case of uterine rupture in the vicinity of a previous scar. Discussion: By means of the microsurgical "mini-laparotomy" even extensive myomatous uterine changes can, in the majority of cases, be operated in an organ-sparing manner with retention of the ability to conceive and to carry a pregnancy through to maturity of the infant. The risk for a postoperative uterine rupture in a subsequent pregnancy and during delivery is minimal.

Comparison of the initial surgical experience with robotic and laparoscopic myomectomy

OBJECTIVE

To compare the initial surgical outcomes of robotic and laparoscopic myomectomy in patients with symptomatic uterine myomas.

STUDY DESIGN

Retrospective chart review of 86 patients undergoing robotic (RM) (n = 43) or laparoscopic (LM) (n = 43) myomectomy. Data included fibroid characteristics (number, weight, location) layers of uterine reconstruction, operating time, blood loss, complications, and postoperative hospital stay.

RESULTS

No significant differences were noted between RM and LM for fibroid number and weight and mean operating time, although the number of patients receiving at least a double-layer uterine reconstruction was higher in RM than LM. Blood loss was higher after LM, while no differences resulted in hospital stay.

CONCLUSION

RM may have some additional advantages compared with LM in terms of bleeding and uterine suturing without compromising operation duration, at least when surgeons were at the beginning of their experience of endoscopic treatment of symptomatic uterine myomas.

Fertility and endocrine outcome after robot-assisted laparoscopic myomectomy (RALM)

INTRODUCTION

Laparoscopic myomectomy has recently gained wide acceptance but this procedure remains technically highly demanding and concerns have been raised about the increased blood loss and an higher risk of postoperative uterine rupture of the pregnant uterus.

OBJECTIVE

The aim of the present study is to evaluate the fertility and endocrine outcome in women underwent robot-assisted laparoscopic myomectomy (RALM).

METHODS

Data from 48 RALM performed in our department between the years 2007 and 2011 have been collected. Conception rate, abortion rate, incidence of feto-maternal morbidity or severe pregnancy and labor-related complications were reported; FSH and AMH levels and ultrasound valuation of AFC has been made before and 6 months after operation. Number of cesarean sections and vaginal deliveries were described.

RESULTS

The average age of the patients was 35 years and median Body Mass Index was 23 kg/m(2) (range 18-35 kg/m(2)). Seven women (13%) became pregnant after RALM with eight pregnancies. One pregnancy is actually on going; there were six deliveries with caesarian section and one spontaneous delivery. No spontaneous abortions. No uterine ruptures occurred. No significant modification of ovarian function was found after myomectomy.

CONCLUSION

RALM seems to have a favorable impact on the reproductive outcome of young patients with no impact on the ovarian function.

Pregnancy outcomes following robot-assisted myomectomy

STUDY QUESTION

What are the characteristics of the pregnancy outcomes in women undergoing robot-assisted laparoscopic myomectomy (RALM) for symptomatic leiomyomata uteri?

SUMMARY ANSWER

Despite a high prevalence of women with advanced maternal age, obesity and multiple pregnancy in our cohort, the outcomes are comparable with those reported in the literature for laparoscopic myomectomy.

WHAT IS KNOWN ALREADY

Reproductive outcomes after traditional laparoscopic myomectomy are well documented. However, reproductive outcomes following robotic myomectomy are not well studied. This paper describes the pregnancy outcomes for a large cohort of women after robotic myomectomy.

STUDY DESIGN, SIZE, DURATION

This is a retrospective cohort of women who became pregnant after robot-assisted myomectomy at three centers. Of the 872 women who underwent robotic myomectomy during the period October 2005-November 2010, 107 subsequently conceived resulting in 127 pregnancies and 92 deliveries through 2011.

PARTICIPANTS/MATERIAL, SETTING, METHODS

Women of reproductive age with fibroids who wanted a minimally invasive treatment option and desired uterine preservation were recruited. We conducted a multicentre study with three centers, two in a private practice and one in an academic setting. Pregnancy outcomes and their relationship to myoma characteristics were analyzed.

MAIN RESULTS AND ROLE OF CHANCE

Mean ± SD age at myomectomy was 34.8 ± 4.5 years and 57.4% [95% confidence interval (CI) 48.0, 66.3] of women were overweight or obese. The mean number of myomas removed was 3.9 ± 3.2 with a mean size of 7.5 ± 3.0 cm and mean weight of 191.7 ± 144.8 g. Entry of the myoma into the endometrial cavity occurred in 20.6% (95% CI 15.0, 27.7) of patients. The mean time to conception was 12.9 ± 11.5 months. Assisted reproduction techniques were employed in 39.4% (95% CI 32.6, 46.7) of these women. Seven twin pregnancies and two triplet pregnancies occurred, for a multiple pregnancy birth rate of 9.8% (95% CI 5.0, 17.8). Spontaneous abortions occurred in 18.9% (95% CI 13.0, 26.6). Preterm delivery prior to 35 weeks of gestational age occurred in 17.4% (95% CI 10.9, 26.5). One uterine rupture (1.1%; 95% CI 0.3, 4.7) was documented. Pelvic adhesions were discovered in 11.4% (95% CI 7.0, 18.0) of patients delivered by Cesarean section. Higher preterm delivery rates were significantly associated with a greater number of myomas removed and anterior location of the largest incision (compared with all other sites) in logistic regression analyses (P = 0.01). None of the myoma characteristics were related to spontaneous abortion.

BIAS, CONFOUNDING AND OTHER REASONS FOR CAUTION

Given the retrospective nature of the data collection, some pregnancies may not have been captured. In addition, owing to the high prevalence of infertility patients in this cohort, the data cannot be used to counsel women who are undergoing RALM about fertility rates after surgery.

GENERALIZABILITY TO OTHER POPULATIONS

Prospective studies are needed to determine if the results shown in our cohort are generalizable to all women seeking a minimally invasive option for the conservative treatment of symptomatic fibroids with pregnancy as a desired outcome.

STUDY FUNDING/COMPETING INTEREST(S)

There was no funding source for this study.