CLINICAL OBSTETRICS AND GYNECOLOGY

Volume 59, Number 1, 53–65

Copyright r 2016 Wolters Kluwer Health, Inc. All rights reserved.

The Role of
Hysteroscopic and
Robot-assisted
Laparoscopic
Myomectomy in the
Setting of Infertility
ERIN I. LEWIS, MD, and ANTONIO R. GARGIULO, MD
Department of Obstetrics, Gynecology and Reproductive Biology,
Center for Infertility and Reproductive Surgery, Brigham and
Women’s Hospital, Harvard Medical School, Boston, Massachusetts

Abstract: Fibroids, the most common gynecologic
condition in women of reproductive age, have tradi-
tionally been treated with hysterectomy. As more
women delay childbearing, myomectomy becomes an
essential component of the gynecologist’s armamenta-
rium. Minimally invasive approaches to myomectomy
have been shown to decrease morbidity and reduce
care-related costs, while improving reproductive out-
comes. Hysteroscopic myomectomy is a reproducible
and easily learned technique for the treatment of
submucosal fibroids. Robot-assisted laparoscopic my-
omectomy overcomes most of the technical challenges
of laparoscopic myomectomy for intramural and
subserosal fibroids. The combined adoption of these
technologies will allow more patients with fibroids to
benefit from a minimally invasive approach.
Correspondence: Antonio R. Gargiulo, MD, Brigham
and Women’s Hospital, Boston, MA. E-mail:
agargiulo@partners.org
A.R.G. is a consultant for Omniguide Inc. and Kawasaki
Robotics Inc. E.I.L. declares that there is nothing to
disclose.
Key words: fibroids, leiomyoma, minimally invasive
surgery, hysteroscopy, robotic-assisted surgery, infer-
tility, myomectomy
Introduction
Historically, the mainstay of surgical in-
tervention for treatment of symptomatic
uterine fibroids has been hysterectomy.
Myomectomy offers the chance for func-
tional uterine preservation and represents
the standard of care for women with
symptomatic fibroids who have not com-
pleted childbearing. Research indicates
that myomectomy is not associated with
increased perioperative morbidity com-
pared with hysterectomy; therefore, there
is no longer a reason to recommend
extirpative surgery when conservative sur-
gery could serve the patient best.1 Despite

CLINICAL OBSTETRICS AND GYNECOLOGY / VOLUME 59 / NUMBER 1 / MARCH 2016

www.clinicalobgyn.com | 53
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54 Lewis and Gargiulo
this evidence, the 2007 Nationwide Inpa-
tient Sample database (the most recent
available data) indicates that only 30,000
myomectomies were performed compared
with the approximately 600,000 hysterec-
tomies carried out yearly.2 One can safely
extrapolate that an American gynecologist
performs only 1 myomectomy for every 20
hysterectomies. In other words, many
gynecologists will become relatively un-
familiar with this operation within few
years of being in practice, which in turn will
negatively impact the overall adoption of
the technique, perpetuating a vicious cycle
favoring extirpative over conservative
surgery.
Current gynecologic practice has been
slow to adopt the myomectomy over
hysterectomy for treatment of fibroids,
but this anachronistic view may change
in the future as more women delay child-
bearing and desire uterine preservation.
UtilizingtheNationwideInpatientSample
database from 2007 with population esti-
mates, all leiomyoma-related hospitaliza-
tions are predicted to increase due to
changing demographics and an increase
in the female population by 2050. The
number of leiomyoma-related hysterecto-
mies is projected to increase by 20%,
whereas the number of myomectomies is
expectedtoincreaseby30%.2 Womenwith
leiomyoma have been found to incur 2.6
times the cost of total health care and 6.6
times the cost of inpatient care compared
with women without leiomyoma. The
prolonged inpatient stay and recovery
from abdominal fibroid surgery makeup
the majority of these costs.2 Given these
estimates, gynecologists as a whole, are
obligated to hone their skills to engender
safe and cost-efficient methods to treat
fibroids. Minimally invasive fibroid re-
moval offers the chance at decreased
inpatient hospital stay to bring down costs,
and has shown to be teachable and repro-
ducible for the general gynecologist.
In the last 20 years minimally invasive
techniques for myomectomy have gained
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traction especially among academic cen-
ters specializing in fibroid treatment. Hys-
teroscopyasaconceptdatesbacktothelate
1890s, but in the last few decades techno-
logic advances have revolutionized hys-
teroscopic myomectomy (HM), making it
easily accessible to gynecologists.3 Lapa-
roscopy also has a long and distinguished
history in gynecologic surgery. However,
laparoscopic myomectomy (LM) has yet
to gain wideutilization amonggynecologic
surgeons. A Canadian survey in 2010
found that only 3.9% of gynecologic
specialists performed >50% of their my-
omectomies laparoscopically.4 Given the
objective technical challenges imposed by
LM, gynecologists have looked at robot-
assisted laparoscopy as a means to estab-
lish minimally invasive techniques that
could be more reliably adopted by a higher
number of operators. Advincula et al5
developed robot-assisted laparoscopic
myomectomy (RALM) before the FDA
approval of the da Vinci Surgical System
for gynecologic surgery in 2005. In the
subsequent years, nascent gynecologic ro-
botic surgeons have demonstrated the
safety and effectiveness of RALM in the
treatment of fibroids.6–12
Minimally invasive techniques allow
careful dissection of tissues, causing mini-
mal damage, while still removing the en-
tirety of fibroid tumors. In fact, the risk of
uterine rupture after minimally invasive
myomectomy seems tobelessthanabdomi-
nal myomectomy (AM),0%to 1.1% versus
0% to 4%, respectively.13,14 Given the
benefits of minimally invasive myomec-
tomy for future pregnancies and the docu-
mented decreased perioperative morbidity,
modern gynecologists have the responsibil-
ity to incorporate these techniques in their
practice.15 We summarize here the novel
indications for minimally invasive myo-
mectomy within the field of infertility,
specifically focusing on HM and RALM,
as they have demonstrated to be the most
accessible and reproducible forms of min-
imally invasive myomectomy surgery.
 Hysteroscopic and RALM 55

FIGURE 1. FIGO classification of uterine fibroids. Submucosal: type 0 (peduculated), type 1

(Z50% intracavitary), type 2 (r50% intracavitary). Intramural: type 3 (contacts endometrium),
type 4 (intramural), type 5 (subserosal, Z50% intramural), type 6 (subserosal, r50% intramural).
Subserosal: type 7 (subserosal pedunculated).

Indications with hysteroscopic fibroid removal will

Indications for undergoing surgical inter-
vention for leiomyomas has traditionally
centered on symptom relief for abnormal
uterine bleeding, anemia, and pelvic pres-
sure and pain.16 More recently, attention
has been drawn to the role of myomectomy
toenhance fecundityin the infertile patient.
Surgical intervention with the goal of
improving success rates of fertility treat-
ment cycles has focused on submucosal
fibroids that distort the endometrial cavity
(either International Federation of Obstet-
rics and Gynecology (FIGO) type 0: pe-
dunculated intracavitary; type 1: <50%
intramural; type 2: Z50% intramural)
(Fig. 1).17 Clinical evidence pointing to a
deleterious effect of submucosal myomata
on implantation and pregnancy abound. A
systemic literature review and meta-analy-
sis in 2009 found that fibroids with a
submucosal component led to decreased
clinical pregnancy and implantation rates
compared with infertile control subjects.18
A2015CochraneReviewcouldnot exclude
the clinical benefit of hysteroscopic remov-
al of uterine fibroids for infertility, with
evidence suggesting that 39% of women
have a successful fertility outcome, com-
pared with 21% of women without fibroid
removal.19 There is no specific scientific
literature looking at the impact of FIGO
type 3 myomata (those abutting, but not
entering, the endometrial cavity). Basic
clinical prudence would suggest that those
tumors may indeed have a very similar
effect on implantation and early gestation
as the classic submucosal ones, and may in
fact be classified as submucosal in many
cases notusing the newFIGOclassification
(FIGO type 3 ultimately represents the
deepest type of submucosal myoma).17
For intramural and subserosal fibroids
that completely elude contact with the
endometrium (FIGO types 4 to 7), the
evidence that surgical intervention can
improve fertility is more nebulous.20 A
2009 systematic review of published stud-
ies found that intramural leiomyomas that
did not distort the cavity significantly
lowered pregnancy and live birth rates,
but when the data included only prospec-
tive studies only implantation rate and not
livebirthratewasaffected.18 Furthermore,
a 2010 meta-analysis of 19 observational

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56 Lewis and Gargiulo
studies found a decrease in live birth and
clinical pregnancy rates in those patients
with noncavity distorting fibroids.21 Un-
fortunately thedata arelargely mixed,with
a recent prospective study, including 119
cases and matched controls, demonstrat-
ing fibroids<5 cmthatwere notencroach-
ing on the endometrial cavity did not affect
clinical outcomes.22 Finally, a recent retro-
spective cohort studyfound that noncavity
distorting fibroids >2.85 cm impaired de-
livery outcomes.23 Conclusive evidence
arguing for myomectomy for intramural
fibroids to improve fertility is still lacking.
The uncertainty regarding intramural fib-
roids and infertility continues because
many of the studies addressing this issue
are underpowered, largely retrospective,
and investigation of the uterine cavity,
whether it is by hysteroscope or imaging,
varies from study to study. In the repro-
ductive age patient desiring pregnancy,
given evidence demonstrating adverse de-
livery outcomes from intramural fibroids
>5 cm such as an increased risk of prema-
turity, fetal malpresentation, and labor
dystocia, it might be prudent to remove
those fibroids that are symptomatic, re-
gardless of whether they encroach on the
endometrial cavity.24,25
The patient selection for myomectomy
procedures has certainly expanded to in-
clude those patients struggling with infer-
tility, with more and more concrete
evidence demonstrating improvement in
clinical outcomes especially for submu-
cosal fibroids. Along with new indications
to perform myomectomy,is the refinement
of minimally invasive techniques to re-
move fibroids. Here we describe the ad-
vantages and limitations of hysteroscopic
and robotic myomectomy in the patient
struggling with fertility.
HM
Removal of intracavitary fibroids (FIGO
types 0,1,and2)canoftenbeaccomplished
by hysteroscopy, in which the viewing and
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operating in the endometrial cavity is
performed by a transcervical approach
with a telescope and continuous flow of
distension fluid throughout the uterine
cavity. Since 1976, when the first case series
of successful hysteroscopic removal of
intracavitary fibroids were reported, re-
finements in optic and fiberoptic technol-
ogy and inventions of new surgical
instruments have improved visual resolu-
tion and surgical techniques.3 Hystero-
scopy is a now a safe and commonplace
procedure for removal of submucosal
fibroids. In addition, some hysteroscopic
procedures can be performed in the office,
andmostcanbecompletedinanoutpatient
surgery setting.26
Before performing any myomectomy,
proper patient selection is critical to ensure
safety and feasibility of the procedure. In
particular, in the case of HM it is necessary
to gain accurate information regarding the
thickness of the myometrium between the
intramural portion of the submucous fib-
roid and the uterine serosa. If such my-
ometrial thickness is minimal (<5 mm),
the myoma in question is comparable with
a FIGO type 2 to 5, spanning the entire
thickness of the organ from mucosa to
serosa. In this case, the surgeon runs the
risk of causing a uterine perforation, and
another minimally invasive technique
should be used.27 Furthermore, certain
locations of submucosal fibroid removal
may be close to the cornual region of the
uterus, and HM may ablate or occlude the
tubal ostia.27 The imaging modalities of
transvaginal ultrasound (TVUS), saline
sonohysterogram (SSH), and magnetic
resonance imaging (MRI) can be utilized
to ‘‘map’’ fibroids before surgery. TVUS is
the most widely used first-line pelvic imag-
ing modality, but has its limitations: in our
experience it is best utilized when assessing
small uteri, with 4 or fewer fibroids. In
addition, ultrasound is operator depend-
ent: that is to say that for a surgeon to really
understand the myoma location within the
uterus, she or he must perform the
 Hysteroscopic and RALM 57

FIGURE 2. Hysteroscopic myomectomy techniques. A, Cold loop enucleation of the intramural

portion of a fibroid (image courtesy of Mazzon et al32). B, Bipolar resection of a type 1 submucosal
fibroid using hysteroscopic loop and normal saline distending medium.

ultrasound: images stored by the radiol-
ogist are intended to document and sup-
port the reported findings, but cannot be
reinterpreted.16 SSH are useful in assessing
FIGO types 0, 1, and 2 fibroids given their
ability to delineate the inner uterine cavity.
MRI, however, has been proven to be the
most sensitive in detecting fibroids, and
particularly submucosal fibroids. In a
recent study comparing different imaging
modalities, TVUS, SSH, and even hystero-
scopy demonstrated inferior diagnostic
ability compared with MRI that demon-
strated 100% sensitive and 91% specific in
detecting submucosal myomas.28 MRI is
also more reproducible compared with
TVUS, which has demonstrated substan-
tial disparity among observers.29 Doppler
and 3D ultrasound are newer imaging
modalities that have shown success in
differentiating between adenomyosis and
leiomyomas, and delineating vascular pat-
terns around fibroids.30,31 Further studies
are needed to validate the usefulness of 3D
ultrasound and Doppler in preoperative
imaging. MRI currently allows the most
accurate mapping of the fibroids and can
potentially help decrease operative times
and errors given its superior detection or
location of fibroids. Last, but certainly not
least, MRI can avoid the performance of
unnecessary surgery, thanks to its high
sensitivity and specificity for adenomyosis
(a condition with rare conservative surgical
indications).
There are several methods to resect
submucosal fibroids hysteroscopically: (1)
monopolar resection using loop resection
with an electrolyte-free distending media
(sorbitol 5%, sorbitol 3% with mannitol
0.5%,orglycine1.5%);(2)bipolarresection
using loop resection with normal saline
distending media; and (3) traditional me-
chanical methods, with scissors or hystero-
scopicmorcellation,usingnormalsalinefor
distending media (Fig. 2).16
Techniques utilizing an electrical loop
arebyfarthemostcommonlyperformedat
this time. When using monopolar resec-
tion, the patient is grounded (connected to
a return electrode), and a nonconducting
solution must be used to distend the uterine
cavity. The sequelae of intravasation of
hypoosmotic solution include blood elec-
trolyte disturbances such as hyponatre-
mia, which in extreme cases can cause
pulmonary and cerebral edema.33 Intra-
vasation is strongly related to operating
time and location of the fibroid: fibroids
with deeper intramural extension and

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58 Lewis and Gargiulo
vascularity carry greater risk.34 The more
modern bipolar resectoscopes avoid the
need for hypoosmolar distension media;
therefore, allowing the use of higher vol-
umes of distension fluid. However, bipolar
resectoscopy may create more gas bubbles
that hamper visualization and can rarely
cause gas emboli.35
To minimize risks of intravascular ab-
sorption of distending media it is highly
recommended to operate with an auto-
mated fluid management system, and to
utilize the lowest fluid pressure that is able
to achieve optimal visualization (60 to
80 mm Hg). Decisions regarding maxi-
mum fluid absorption are provider de-
pendent and the age and comorbidities of
the patient need to be taken into consid-
eration when managing fluid deficits. The
American Association of Gynecologic
Laparoscopists recommends that in eld-
erly patients and others with cardiac co-
morbidities, a maximum fluid deficit of
750 mL is recommended. For young,
healthy patients the maximum fluid deficit
for hypotonic solutions is 1000 mL, where-
as the maximum fluid deficit for isotonic
solutions is 2500 mL.36 Steps can also be
taken to decrease fluid absorption, such as
injecting dilute vasopressin in the cervix
before cervical dilation and hysteroscopic
resection of fibroids. Two well-designed
randomized trials have demonstrated that
the injection of dilute vasopressin in the
cervix before the start of the case results in a
significant decrease in fluid absorp-
tion.37,38 HM can be a safe procedure if
careful preoperative evaluation, intrao-
perative monitoring, and preventative
techniques are undertaken to decrease
fluid absorption.
When dealing with small submucosal
myomata, particularly in infertility pa-
tients, it might be ideal to perform HM
withoutelectrosurgery.Conventionalcold
instruments (such as scissors, grasping
forceps, and biopsy forceps) avoid thermal
damage to the endometrium and myome-
trium. Cold resection might be particularly
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helpful in patients with opposing submu-
cosal myomas, given that up to 78% of
patients with this anatomy are found to
have intrauterine adhesions at second-
look hysteroscopy.39 One retrospective
study of 806 HMs found that cold loop
resection of submucosal myomas was safe
andeffectiveandassociatedwithonlya4%
rate of intrauterine adhesions on second-
look hysteroscopy.32 Meanwhile after
resection with monopolor energy, intra-
uterine adhesion rate has been described in
the literature to be up to 30% to 40%.40 An
assortment of rigid, semirigid and flexible
instruments have been developed to help
incise a myoma around its border at the
normal myometrium to promote expul-
sion and avoid healthy endometrial dam-
age, further aiding the patient struggling
with fertility3 (Fig. 2A).
Even though hysteroscopy involves the
learning of delicate surgical techniques, it
clearly does not present a steep learning
curve. In a retrospective analysis of 5000
outpatient hysteroscopic procedures, most
procedures were successfully completed by
those surgeons with low experience (<50
hysteroscopies per operator), and 92.2% of
the procedures were completed by opera-
tors having performed <20 procedures.41
At the same time, there are limits to the size
of myoma amenable to safe hysteroscopic
resection, with most experts citing 5 cm as
the accepted upper limit.16 Furthermore, as
for any surgery, case throughput matters:
surgeons performing more hysteroscopic
procedures have demonstrated shorter op-
erating times and were able to remove more
fibroidtissuepersurgery.42 Asthesizeofthe
myoma increases, a 2-step procedure can be
considered: patients should be counseled
about this prospectively, to set realistic
expectations.16
Use of Gonadotropin releasing hor-
mone (GnRH) analogs has been shown
to preoperatively shrink myomas, which
potentially allows for more feasible hys-
teroscopic resection.43 Two randomized
controlled studies used GnRH analogs

before HM, with 1 study giving goserelin:
3.6 mg intramuscular (IM) injection
monthly  12 weeks, and the other giving
triptorelin: 3.75 mg IM injection month-
ly  8 weeks. Both studies found no differ-
enceincompleteresectionorneedforrepeat
operation between treatment and placebo
groups, but both found reduced operating
time and decreased hysteroscopic fluid
resorption in patients that had received
GnRH analogs.44,45 Selective progesterone
receptor modulators (SPRM) have also
been studied before fibroid removal sur-
gery. A randomized controlled trial in 2012
compared patients taking ulipristal acetate
(a SPRM): oral 5 mg daily  13 weeks
versus placebo, and found that patients in
the treatment arm had reduction in the
size of their fibroids and decreased vaginal
bleeding preoperatively.46 Most recently,
a nonrandomized comparative pilot
study evaluated triptorelin, letrozole (an
aromatase inhibitor), and ulipristal acetate
treatment before hysteroscopy, and found
that the GnRH analog and aromatase
inhibitor decreased operating times and
fluid absorption, but the SPRM did not.47
Further studies are needed to validate these
findings before making specific pharmaco-
logic treatments a routine therapy before
hysteroscopy.
There is no doubt that hysteroscopic
removal of submucosal fibroids has revo-
lutionized the practice of myomectomy.
With more evidence accumulating regard-
ing submucosal fibroid removal and im-
provementinfertility,thistechniquecanbe
used by the general gynecologist before
more advanced infertility treatments to
improve fecundity. At the same time, care-
ful patient selection and preoperative eval-
uation is necessary to ensure the feasibility
and safety of the procedure.
RALM
RALM, remains the most radically
novel (and most controversial) surgical
method for removal of leiomyomas at 10
Copyright r 2016 Wolters Kluwer Health, Inc. All rights reserved.
Hysteroscopic and RALM 59
years of its introduction.This laparoscopic
technique, based on a sophisticated tele-
operator, rather than a true autonomous
robot, represents a reliable minimally in-
vasive surgery option for the majority of
those fibroids deemed inoperable by hys-
teroscopy and for which conventional
laparoscopy is consideredtechnically chal-
lenging by the operator (Fig. 3). In other
words, it should be clearly stated at the
beginning of this section that the merit of
RALM is that it constitutes the minimally
invasive alternative to open myomectomy
in those cases that cannot be adequately
and consistently addressed with conven-
tional minimally invasive surgery. This
technique is to be considered complemen-
tary to the conventional techniques de-
scribed above, and should be used to
promote the overarching goal of limiting
the use of open myomectomy (with its
significantly higher morbidity load). Ulti-
mately,thereis only1typeofmyomectomy
technique (for those myomata that cannot
be reached hysteroscopically): it involves
intracapsular tumor enucleation with re-
pair in layers without exposed sutures.
Every properly trained gynecologist can
consistently perform this technique
through an open abdominal wall; a few
very skilled laparoscopic surgeons can
consistently perform it without robotic
assistance; many more trained laparo-
scopic surgeons, however, will find that
robotic assistance is a valuable contribu-
tion to their practices, in that it drastically
reduces the need to resort to open myo-
mectomy. Our reproductive surgery divi-
sion includes 2 surgeons that have adopted
RALM as a complementary tool since
2006. Aside from securing an intraoper-
ative open surgery conversion rate of just
about 0.1% (a single conversion was
reported in over 650 consecutive cases to
date), we have reduced the need for AM to
<5% of our patients. This was achieved by
raising the open surgery threshold through
RALM (A. Gargiulo, personal oral com-
munication, data presented at the 44th
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60 Lewis and Gargiulo

FIGURE 3. Robot-assisted laparoscopic myomectomy technique. A, Fibroid enucleation. B,

Demonstration of unentered endometrial cavity after fibroid enucleation. C, Closure of hyster-
otomy. D, Repaired uterus.

Global Congress of the American Associ- to 7 cm transverse suprapubic incision).49

ation of Gynecologic Laparoscopists, Las
Vegas, 2015).
Onecannotdiscussthebenefitsofrobotic
technique for myomectomy, without first
recounting the advances made by conven-
tional LM, which have paved the way for its
robotic counterpart. LM has proven to be a
successfulandfeasibleprocedureforaselect
group of patients. Specifically, less compli-
cations have been noted when <3 fibroids
are removed, or if the size of the dominant
fibroid is <5 cm.48 A meta-analysis of 6
randomized controls trials comparing LM
with AM found that the minimally invasive
approach was associated with shorter hos-
pital stay, reduction in blood loss and
postoperative pain, and faster recovery.15
At the same time, LM has also been
associated with longer operating times
and increased surgical difficulty when com-
pared with minilaparotomy (defined as a 4
Despite its demonstrated benefits, LM has
yet to be widely adopted given its required
technical complexity.4
As discussed above, RALM is poised to
improve upon the advances made by LM
and to make this minimally invasive sur-
gery more accessible to gynecologists. The
learning curve for robotic surgery is rela-
tively rapid, with a gynecologic surgeon
needing to perform just over 50 cases to
reach a stable operative time.50 Robotic
surgery, by virtue of the fact that it is
performed through a computerized con-
sole, is also particularly prone to being
simulated. Evidence indicates that it is
simulation itself that may determine the
future of this technique, by shortening the
learning curve to previously unthinkable
levels and, therefore, eliminating the ‘‘nec-
essary evil’’ of surgeons refining their skills
on live patients. A fundamental study

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utilizing a commercially available robotic
simulator found that novice robotic sur-
geons, who had trained on the simulator
until they matched the level of exercise
performancepreviouslysetbyexpertusers,
were able to approachthe speedand finesse
of these expert surgeons in their first live
surgery.51 Lim et al52 compared operative
times between laparoscopic and robotic
hysterectomy and found a significant de-
crease in operative time in chronological
order of surgeries for robotic surgery,
whereas there was no change with laparo-
scopicsurgery,suggestingthatthelearning
curve for robotic surgery was indeed much
shorter. Although initially, RALMs have
showntoincurlongeroperatingtimes,they
have also allowed many surgeons over-
come the technical and ergonomic chal-
lenges of laparoscopic surgery.7–11
Given that any type of myomectomy can
beabloodysurgery,stepsshouldbetakento
minimize intraoperative blood loss before
proceeding with RALM. Since 2000,
GnRH analog treatment before under-
going AM or hysterectomy surgery has
been utilized to reduce uterine size and
volume to minimize blood loss, vertical
abdominal incisions, and postoperative
complications.43 No trials looking at the
effect of pretreatment with GnRH analogs
in RALM exist. However, data from LM
research demonstrate that the benefits of
GnRH analogs translate to the minimally
invasive arena. Chang et al53 found that
leuprolide acetate (3.75 mg IM) injection
every 4 weeks for 3 months before LM in
patients with single myomas Z10 cm (or 2
myomas >5 cm) was associated with de-
creased intraoperative blood loss, operat-
ing times, formation of pelvic hematomas,
and need for postoperative blood trans-
fusions. Other systematic reviews did not
find operating time to be decreased after
leuprolide acetate pretreatment; however,
those studies were focusing on patients with
smaller sized myomas.54 The benefit of
GnRH analog treatment might be best
realized in those myomas initially deemed
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Hysteroscopic and RALM 61
inoperable by laparoscopic approach, that
arethenabletodecreaseinsizesubstantially
to allow a minimally invasive operation.
Pretreatment with misoprostol, a pros-
taglandin derivative, known to reduce
blood flow to the uterus, has demonstrated
decreased intraoperative blood loss in
open myomectomies.55,56 Given that this
is a low-risk medication without any re-
ported serious side effects, we have intro-
duced this practice for our RALM
procedures to add further safeguard to
the procedure. Given the novelty of the
RALM approach, further studies are
needed to validate pretreatment medica-
tions and their role in reduction of blood
loss in robotic gynecologic procedures.
There is no doubt that robotic RALM
has proven to be an acceptable and safe
alternative to LM in the last 10 years, with
similar outcomes to those achieved by LM
over AM.6,12 Specifically, robotic sur-
geons can overcome the challenges of
laparoscopic myoma dissection and sutur-
ing in multiple layers.16 RALM, with its
synergism of many technological innova-
tions (compensation for the multiple-ful-
crum or single-fulcrum effect, regained
stereoscopic view, and use of the surgeon’s
wrist for pitch and yaw) also allows greater
application of microsurgery principles.
These techniques allow for more gentle
tissue handling, improved hemostasis,
continuous irrigation, and a smaller oper-
ative field, which have all been shown to
greatly reduce postoperative adhesion for-
mation.57,58 Although it has been touted
that LM results in less intra-abdominal
adhesions than AM, the data are not
conclusive. Future studies evaluating ad-
hesion formation after RALM are needed
to validate this hypothesis. There are no
second-look studies of pelvic and abdomi-
nal adhesions after RALM. The closest
extrapolation of the adhesiogenic power of
this technique can be made from observa-
tions derived from a large retrospective
analysis of women who underwent RALM
and subsequently delivered by cesarean
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62 Lewis and Gargiulo
section: the intra-abdominal adhesion rate
was only 11.4%. Even with the limitation
of the positive selection bias, this is a
remarkably low rate of adhesion for any
myomectomy operation.59
RALM and LM have demonstrated
safety and efficacy in carrying a pregnancy
to term. When looking at the risk of uterine
rupture during pregnancy, LM has been
associated with 0.0% to 0.25% risk of
rupture, with the specific use of electro-
surgery (bipolar and monopolar), a predis-
posing risk factor.60 In a recent multicenter
study the rate of uterine rupture after
RALM showed similar results with a
1.1% rupture rate. The only rupture re-
corded was associated with the use of
electrosurgeryonthemyometrium,whereas
norupturesoccurredinthegroupofpatients
where the ultrasonic scalpel was used for
hysterotomy.59 Endocrinologic evaluation
(day 3 follicle stimulating hormone of
menstrual cycle and anti-mullerian hor-
mone levels) of young women undergoing
RALM have shownpreservationof ovarian
reserve 6 months after surgery.61 The largest
retrospective study of pregnancy outcomes
after RALM in 872 women, found that
observed miscarriage rate (19%) was in the
range of those reported after LM.59 Higher
preterm delivery rates were significantly
associated with greater number of myomas
removed and anterior location of the largest
incision.59 As more RALM are performed
we will be better able to generalize repro-
ductive outcomes after surgery.
Conclusions
We present here 2 minimally invasive
surgical options for fibroid treatment in
the patient struggling with infertility or
desiring future childbearing. The pendu-
lum has definitely swung in terms of what
constitutes acceptable surgical fibroid
treatment modalities. In a now comfort-
ably remote past, definitive treatment by
way of a hysterectomy would have been the
most common first-line option. Modern
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Copyright r 2016 Wolters Kluwer Health, Inc. All rights reserved.
treatment of uterine fibroids in women of
reproductive age (and select women be-
yond the reproductive years) is now not
only conservative, but minimally invasive
by default. Minimally invasive approaches
preserve fertility, while also minimizing
morbidity. HM represents the gold stand-
ard for the treatment of fibroids encroach-
ing on the endometrium (FIGO types 0, 1,
and 2). With careful patient selection,
knowledge of the properties of the distend-
ing media and equipment, and smart pre-
operative imaging, a general gynecologist
can develop the skill and finesse to perform
this procedure. RALM, on the other end,
represents a practical minimally invasive
option for deep submucosal, intramural,
hybrid, and subserosal fibroids (FIGO
types 2 to 7). RALM has a short learning
curve compared with conventional LM
and has demonstrated to be safe and
reproducible in select patients. These min-
imally invasive options are not an option
for all patients, especially those who
present with widely disseminated fibroid
disease, making a minimally invasive ap-
proach unfeasible. Fibroids are one of the
most common benign gynecologic disor-
ders, and will continue to be a large part of
gynecologic practice in the future. As
gynecologists we must continue to evolve
as a field, improve upon past treatments,
decrease morbidity, and follow the trajec-
tory of our patient’s wishes. In the last 20
years, the US population has seen a 150%
increase in first births in women aged 35 to
39 years and the birth rate for women aged
40to44yearsisatitshighestratesince1966,
and has steadily increased by 2% a year
since 2000.62 In the future, more gyneco-
logicpatientswillbewomenintheirlate30s
and early 40s, struggling with infertility
and leiomyoma disease, and we must be
able to offer the least invasive, least mor-
bid, and most beneficial treatments avail-
able. Such need will not be met by complex
elite surgeries mastered by a few, but by
well standardized surgeries with a true
potential for widespread adoption.

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