Is robot-assisted laparoscopic myomectomy limited in multiple myomas?: a feasibility for ten or more myomas

Robotic-assisted laparoscopic versus abdominal and laparoscopic myomectomy: A systematic review and meta-analysis

BACKGROUND

Myomectomy is the preferred treatment for women with uterine fibroids and fertility requirements. There are three modalities are used in clinical practice for myomectomy: abdominal myomectomy (AM), laparoscopic myomectomy (LM), and robot-assisted laparoscopic myomectomy (RLM).

OBJECTIVES

To compare the perioperative and postoperative outcomes of RLM, AM, and LM.

SEARCH STRATEGY

We searched PubMed, Web of Science, Embase, and Clinical Trials for relevant literature published between January 2000 and January 2023.

SELECTION CRITERIA

We included all studies reporting peri- and postoperative outcomes of myomectomy in patients with uterine myomas. Surgical treatments were classified as RLM, LM, or AM.

DATA COLLECTION AND ANALYSIS

Two or more authors selected studies independently, assessed risk of bias, and extracted data. We derived mean difference (MD) or odds ratio (OR) with 95% confidence intervals (CIs) for each outcome, subgrouping trials by the patient characteristics and myoma characteristics. We used the I2 statistic to quantify heterogeneity and the random-effects model for meta-analysis when appropriate. We used the funnel plot to assess the publication bias.

MAIN RESULTS

A total of 32 studies with 6357 patients were included, of which 1982 women had undergone RLM. The operating time was significantly longer (MD = 43.58, 95% confidence interval [CI]: 25.22-61.93, P < 0.001), and the incidence of cesarean section after myomectomy was significantly lower (OR = 0.27, 95% CI: 0.10-0.78, P = 0.02) in RLM than in LM. Compared with AM, the operation time, blood loss, blood transfusion rate, complication rate, total cost, length of hospital stay, and pregnancy rate of patients with RLM were significantly different.

CONCLUSIONS

The safety and effectiveness of RLM are superior to those of AM but inferior to those of LM.

Exploring Surgical Strategies for Uterine Fibroid Treatment: A Comprehensive Review of Literature on Open and Minimally Invasive Approaches

Background and Objectives: Uterine myomas represent one of the most prevalent pathologies affecting the female population. These benign neoplasms originate from the smooth muscular cells of the uterus, and they can be either single or multiple. Often associated with debilitating symptoms such as pelvic heaviness, pain, constipation, and urinary dysfunctions, the surgical management of myomectomy exhibits considerable variability. This diversity in approaches is influenced by factors such as the number and size of myomas, the patient's age, and overall clinical conditions. This study aims to elucidate and compare the advantages and disadvantages of different surgical approaches, specifically endoscopic procedures versus open surgery, providing valuable insights for clinical decision making. Materials and Methods: A comprehensive bibliographic search spanning from 2013 to 2023 was systematically conducted across databases including Medline, Embase, the Cochrane Database of Systematic Reviews, and ClinicalTrials.gov. The search utilized keywords such as "myomectomy laparoscopic and open", "myomectomy open and minimally invasive", "myomectomy open and laparoscopic", and "myomectomy open vs. laparoscopic." The research methodology, along with predetermined inclusion and exclusion criteria, was established prior to the search, ensuring a systematic and rigorous approach. Subsequently, data analysis was carried out. Results: Following the study selection process, 25 articles met the eligibility criteria for inclusion in this analysis. The average numbers of myomas were 3.7 (ranging from 1 to 13.7) and 5.4 (ranging from 1 to 13.5) for the minimally invasive surgery and open surgery groups, respectively. In terms of myoma size, the total averages across studies were 7 cm (ranging from 4.8 to 14) for the minimally invasive group and 8 cm (ranging from 3.9 to 11.2) for the open surgery group. The average pregnancy and delivery rates were 29.7% (ranging from 1.8 to 100) for the minimally invasive group and 28.5% (ranging from 1.8 to 100) for the open surgery group. Regarding complications, the average rate was 14.2% (ranging from 0 to 50) for the endoscopic group and 22.3% (ranging from 0 to 60.3) for the laparotomic group. Conclusions: In conclusion, a critical factor influencing the choice of surgical approach is primarily the size and quantity of fibroids. The mini-laparotomic approach emerges as a viable alternative to endoscopy, demonstrating favorable surgical outcomes and aesthetic results. Interestingly, the type of surgical procedure appears to have no significant impact on the pregnancy rate.

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 surgical and obstetric outcomes in women with uterine leiomyomas after laparoscopic vs. abdominal myomectomy: A single-center cohort study

Our aim was to study the advantages, complications and obstetrical outcomes of laparoscopic myomectomy (LM) compared with abdominal myomectomy (AM). We conducted a retrospective cohort study at La Paz University Hospital that included LMs and AMs performed between 2012 and 2018, analyzing 254 myomectomies (142 AMs [55.7%] and 112 LMs [43.9%]). The mean number of fibroids was 1.8 ± 1.5 and 3 ± 2.9 for the LM and AM groups, respectively (p < 0.006). The mean size of the largest myoma was 7.6 cm ± 2.7 cm and 10.2 cm ± 5.4 cm for the LM and AM groups, respectively (p < 0.001). LMs were associated with longer surgical times (p < 0.001) and shorter hospitalizations (p = 0.001). There were no significant differences in the intraoperative and postoperative complication rates (p = 0.075 and p = 0.285 for LM and AM, respectively). The subsequent pregnancy rate was higher for the LM group (30.8% vs. 16.8%, p = 0.009), with a vaginal delivery rate of 69% and no cases of uterine rupture.

Effect and safety of diluted vasopressin injection on bleeding during robot-assisted laparoscopic myomectomy: a protocol for a randomised controlled pilot trial

INTRODUCTION

Even though the injection of diluted vasopressin into the uterus is expected to reduce intraoperative bleeding with decreased adverse effects during robot-assisted laparoscopic myomectomy (RALM), there is a lack of relevant trials to show its effect and safety. Thus, this study was designed to compare the effect and safety of vasopressin injection on bleedings based on dilution levels of vasopressin with constant volumes during RALM.

METHODS AND ANALYSIS

This is a randomised controlled pilot trial, where a total of 39 patients will be randomly divided into three experimental groups in a 1:1:1 ratio. All patients will be classified into the three groups based on the dilution level of vasopressin: group 1-a solution prepared by mixing 20 units of vasopressin with 100 mL of normal saline to make a total of 100 mL; group 2-a solution prepared by mixing 20 units of vasopressin with 200 mL of normal saline to make a total of 100 mL and group 3-a solution prepared by mixing 20 units of vasopressin with 400 mL of normal saline to make a total of 100 mL. During RALM, we will inject diluted vasopressin at different concentrations with a total of 100 mL. As the primary endpoint, estimated blood loss would be compared. As secondary endpoints, we will check the level of haemoglobin and haematocrit, operation time, amount of transfusion, and the period of hospitalisation. In addition, we will check other complications related to vasopressin injection.

ETHICS AND DISSEMINATION

This pilot study has been approved by the Institutional Review Board of the Seoul National University Hospital (No. H-2011-107-1174). All potential subjects will be provided written informed consent. The results of this study will be published in peer-reviewed journals and be presented at academic conferences.

TRIAL REGISTRATION NUMBERS

NCT04874246 and CKCT0006225.

Clinical experience of robotic myomectomy for fertility preservation using preoperative magnetic resonance imaging predictor

Objective

This study aimed to demonstrate the use of preoperative magnetic resonance imaging (MRI) findings to select the optimal surgical technique between single-site (SS) and multi-site (MS) robotic myomectomy based on clinical experience, for the preservation of fertility.

Methods

Ninety-eight patients who underwent SS or MS robotic myomectomy using the da Vinci^® Si system after undergoing MRI were evaluated retrospectively. The correlation between preoperative MRI findings and the intraoperative or postoperative findings during robotic myomectomy for the preservation of fertility was analyzed. The reproductive outcome was investigated when the patient wished to conceive.

Results

The mean age of the patients was 35.68±5.04 years and 80 patients (81.6%) were nulliparous. The total diameter of myomas on MRI was 106.75±54.52 mm. The number of resected myomas was 4.31±4.39 (range, 1–27), and the total weight of resected myomas was 293.11±281.13 (range, 30–1,260) g. Myomas with high signal intensity on MRI required less time for resection. MS robotic myomectomy was performed for an increased number and total diameter of a myoma or a deep-seated myoma. Postoperatively, all patients resumed normal menstruation. Of the 15 patients who wished to conceive, 12 (80%) conceived successfully. Of these, uterine dehiscence occurred in 1 patient and 10 patients underwent an uneventful cesarean section.

Conclusion

SS or MS robotic myomectomy can be recommended for patients who wish to conserve fertility. However, the optimal surgical technique should be selected based on preoperative MRI findings to predict an effective surgical process and the successful preservation of fertility.

The effects and costs of laparoscopic versus abdominal myomectomy in patients with uterine fibroids: a systematic review and meta-analysis

BACKGROUND

Abdominal myomectomy (AM) and laparoscopic myomectomy (LM) are commonly see surgery for the uterine fibroids, several randomized controlled trials (RCTs) have compared the role of AM and LM, the results remained inconsistent. Therefore, we attempted this meta-analysis to analyze the role of LM versus AM in patients with uterine fibroids.

METHODS

We searched PubMed et al. databases from inception date to July 31, 2019 for RCTs that compared LM versus AM in patients with uterine fibroids. Two authors independently screened the studies and extracted data from the published articles. Summary odd ratios(OR) or mean differences(MD) with 95% confidence intervals(CI) were calculated for each outcome by means of fixed- or random-effects model.

RESULTS

Twelve RCTs with a total of 1783 patients were identified, with 887 patients for and 897 patients for AM. Compared with AM, LM could significantly decrease the blood loss (OR = - 29.78, 95% CI -57.62- - 0.95), shorten the duration of postoperative ileus (OR = - 10.91, 95% CI -18.72- - 3.11), reduce the length of hospital stay (OR = - 1.57, 95% CI -2.05- - 1.08), but LM was associated with longer duration of operation (OR = 16.10, 95% CI 6.52-25.67) and higher medical cost (OR = 17.61, 95% CI 7.34-27.88).

CONCLUSIONS

LM seems to be a better choice for patients with uterine fibroids, more related studies are needed to identify the role of LM and AM for the treatment of uterine fibroids.