Research www. AJOG.

org

GENERAL GYNECOLOGY
Comparison of robotic and laparoscopic myomectomy
Carrie E. Bedient, MD; Javier F. Magrina, MD; Brie N. Noble, BS; Rosanne M. Kho, MD

OBJECTIVE: To compare surgical outcomes of patients with symptom-
atic leiomyomas after robot-assisted (“robotic”) or laparoscopic
myomectomy.
STUDY DESIGN: Retrospective chart review of 81 patients undergoing
robotic (n ⫽ 40) or laparoscopic (n ⫽ 41) myomectomy. Data included
fibroid characteristics (number, weight, location, and pathologic find-
ings), operating time, blood loss, complications, and postoperative hos-
pitalization length.
RESULTS: Patients undergoing laparoscopy had a significantly larger
mean uterine size, larger mean size of the largest fibroid, and greater
number of fibroids. When adjusted for uterine size and fibroid size and
number, no significant differences were noted between robotic vs lapa-
roscopic groups for mean operating time (141 vs 166 minutes), mean
blood loss (100 vs 250 mL), intraoperative or postoperative complica-
tions (2% vs 20% and 11% vs 17%, respectively), hospital stay more
than 2 days (12% vs 23%), readmissions, or symptom resolution.
CONCLUSION: Short-term surgical outcomes were similar after robotic
and laparoscopic myomectomy; long-term outcomes were not
assessed.
Key words: laparoscopy, myomectomy, robot-assisted surgery

Cite this article as: Bedient CE, Magrina JF, Noble BN, et al. Comparison of robotic and laparoscopic myomectomy. Am J Obstet Gynecol 2009;201:566.e1-5.

T he primary surgical techniques used

in myomectomy are open surgery,
laparoscopic surgery, and, recently, ro-
bot-assisted (“robotic”) surgery. The po-
tential complication of greatest concern
after myomectomy is uterine rupture
during a subsequent pregnancy because
of weakening of the myometrium; this
usually is attributed to poor closure of
the uterine incisions1 or to excessive use
of diathermy during tissue dissection.2
The risk of this complication might in-
From the Divisions of Gynecologic
Oncology (Drs Bedient and Magrina) and
Biostatistics (Ms Noble) and the Department
of Obstetrics and Gynecology (Dr Kho),
Mayo Clinic, Scottsdale, AZ.
Received Dec. 1, 2008; accepted May 26,
2009.
Reprints: Javier F. Magrina, MD, Division of
Gynecologic Oncology, Mayo Clinic, 13400
East Shea Blvd., Scottsdale, AZ 85259.
jmagrina@mayo.edu.
Dr Bedient is now with the Department of
Obstetrics and Gynecology, MetroHealth
System, Cleveland, OH.
Conflict of interest: Drs Magrina and Kho have
received a speaking honorarium from Intuitive
Surgical, Inc. (Sunnyvale, CA). The other
authors have no conflict of interest to declare.
0002-9378/$36.00
© 2009 Mosby, Inc. All rights reserved.
doi: 10.1016/j.ajog.2009.05.049
See Journal Club, page 625
crease after open myomectomy,3-5 but it
is a rare occurrence under any circum-
stance (⬍1%).6
Laparotomy was the approach origi-
nally used to treat myomectomy because
it allowed easy access to the uterus for the
removal of large fibroids; however, it re-
quires a large incision and, compared
with laparoscopic surgery, is associated
with longer hospitalization, consider-
ably higher levels of postoperative anal-
gesia, and increased morbidity.7 Laparo-
scopic myomectomy is not without
disadvantages; it is associated with diffi-
culties resulting from not maintaining
hemostasis, inadequately suturing uter-
ine incisions, and incomplete tissue ex-
cision.8 Furthermore, increased blood
loss and operating times initially were
observed after laparoscopic myomec-
tomy when compared with laparotomy.2
Robotic technology has improved per-
formance during laboratory drills when
compared with laparoscopy.9 Robotic
techniques may have some advantages
over laparoscopy for patients undergo-
ing simple10 and radical hysterectomy.11
However, although robotic myomec-
tomy recently was reported as being pre-
ferred to laparotomy,8 it was not pre-
ferred to laparoscopy.12
The optimal surgical treatment for
myomas remains debatable because of
the limitations of minimally invasive
techniques and the disadvantages of lap-
arotomy. We undertook this study to
evaluate outcomes of patients who un-
derwent robotic myomectomy and to
compare those findings with outcomes
of patients who underwent laparoscopic
myomectomy.
M ATERIALS AND M ETHODS
We conducted a retrospective chart re-
view that included all patients with be-
nign leiomyomata who underwent myo-
mectomy by laparoscopic or robotic
surgery from Feb. 1, 2000, through
March 31, 2008. The study protocol was
approved by the Mayo Clinic Institu-
tional Review Board. Robotic surgery
was performed using the da Vinci or da
Vinci S system (Intuitive Surgical, Inc.,
Sunnyvale, CA). Patients were excluded
if they had another major operation con-
currently or were undergoing myomec-
tomy by any other route or through an
open incision. Patient eligibility was not
affected by leiomyomata size and num-
ber, symptoms, or surgical history. The
laparoscopic group included all eligible
patients, and subjects were not matched
with respect to specific characteristics of
patients in the robotic group. Before
March 1, 2004, minimally invasive sur-
gery primarily was performed laparo-
scopically. Otherwise, selection of pa-
tients for laparoscopy or robotic surgery
depended solely on the availability of the
da Vinci system to the surgeon.

566.e1 American Journal of Obstetrics & Gynecology DECEMBER 2009

www.AJOG.org General Gynecology Research

Data were retrieved from electronic

TABLE 1 medical records. Abstracted information
Patient and fibroid characteristics included age, body mass index, present-
Characteristic Robotic Laparoscopic P value ing symptoms, surgical history, fibroid
Age, y .40 characteristics (number, weight, loca-
.....................................................................................................................................................................................................................................
No. of patients 41 40 tion, and pathologic characteristics), op-
.....................................................................................................................................................................................................................................
erating time, blood loss (calculated by
Mean (SD) 43 (12) 40.9 (6.6)
..................................................................................................................................................................................................................................... subtracting irrigation volume from the
Median 39 39.5 total volume of fluid suctioned), compli-
.....................................................................................................................................................................................................................................
Range 22–81 29.7–56.4 cations (intraoperative and up to 6
..............................................................................................................................................................................................................................................
Body mass index, kg/m 2
.65 weeks’ postoperative), and length of hos-
.....................................................................................................................................................................................................................................
pitalization. Docking and console times
No. of patients 39 39
..................................................................................................................................................................................................................................... also were noted for robotic procedures.
Mean (SD) 24.7 (5.0) 25.3 (5.4) For continuous measures, statistical
.....................................................................................................................................................................................................................................
Median 23.0 24.0 significance was calculated by using a
.....................................................................................................................................................................................................................................
Range 17.0–38.0 16.0–39.0 2-sample t test. Dichotomous measures
..............................................................................................................................................................................................................................................
were compared by using the ␹2 test. If the
Uterus size, cm ⬍ .001
..................................................................................................................................................................................................................................... minimum expected cell count was less
No. of patients 30 34 than 5, the Fisher exact test was used for
.....................................................................................................................................................................................................................................
Mean (SD) 9.4 (3.1) 13.8 (5.1) the comparisons instead of the ␹2 test.
.....................................................................................................................................................................................................................................
Median 9.0 14.0 Adjusted comparisons were evaluated by
.....................................................................................................................................................................................................................................
using a general linear model with terms
Range 5.0–18.0 7.0–26.0
.............................................................................................................................................................................................................................................. for surgery type, uterine size, size of the
Incisions, n .003 largest fibroid, and number of uterine fi-
.....................................................................................................................................................................................................................................
No. of patients 41 38 broids. P values less than .05 were con-
.....................................................................................................................................................................................................................................
Mean (SD) 1.05 (0.74) 1.7 (1.2) sidered statistically significant. Because
.....................................................................................................................................................................................................................................
the study was exploratory, the primary
Median 1.00 1.5
..................................................................................................................................................................................................................................... outcomes were the only planned com-
Range 0.00–3.00 0.0–6.0 parisons; any other comparisons were
..............................................................................................................................................................................................................................................
Fibroids purely observational, and no adjust-
.....................................................................................................................................................................................................................................
Size of largest, cm .003 ments were made for multiplicity. All
...........................................................................................................................................................................................................................
computations were performed by using
No. of patients 39 39
........................................................................................................................................................................................................................... SAS software version 9 (SAS Institute,
Mean (SD) 4.7 (3.5) 7.0 (3.1) Inc., Cary, NC).
...........................................................................................................................................................................................................................
Median 3.6 7.2
...........................................................................................................................................................................................................................
Range 0.2–14.4 1.3–13.5
.....................................................................................................................................................................................................................................
R ESULTS
Number ⬍ .001
........................................................................................................................................................................................................................... Eighty-one patients were included in the
No. of patients 41 40 study: 41 underwent laparoscopic myo-
...........................................................................................................................................................................................................................
Mean (SD) 2.7 (1.9) 6.5 (6.4) mectomy and 40 underwent robotic
...........................................................................................................................................................................................................................
Median 2.0 4.5 myomectomy. Patient and fibroid char-
...........................................................................................................................................................................................................................
acteristics are shown in Table 1. The use
Range 1.0–9.0 1.0–26.0
..................................................................................................................................................................................................................................... of prophylactic bulldog clamps and the
Weight, g .13 performance of a minilaparotomy for re-
...........................................................................................................................................................................................................................
No. of patients 19 32 moval of large fibroids by morcellation
...........................................................................................................................................................................................................................
Mean (SD) 210 (270) 350 (330) were similar for each group (P ⬎ .99 and
...........................................................................................................................................................................................................................
P ⫽ .08, respectively).
Median 120 260
........................................................................................................................................................................................................................... Surgical factors and outcomes are
Range 7–1076 10–1316 shown in Table 2. We suspected that
.....................................................................................................................................................................................................................................
Location within uterus, n (%) uterine size, fibroid size, and number of
...........................................................................................................................................................................................................................
Subserosal 25/38 (66%) 24/36 (67%) .94 fibroids could affect outcomes because
...........................................................................................................................................................................................................................
these values were higher for women in
Intramural 22/37 (59%) 26/36 (72%) .25
........................................................................................................................................................................................................................... the laparoscopic group. When adjusted
Submucosal 6/38 (16%) 13/38 (34%) .06 for uterine size, number of fibroids, and
...........................................................................................................................................................................................................................
Other 2/36 (6%) 7/37 (19%) .15 a size of the largest fibroid, no difference
.............................................................................................................................................................................................................................................. between groups was observed for mean
Bedient. Robotic vs laparoscopic myomectomy. Am J Obstet Gynecol 2009. (continued )

DECEMBER 2009 American Journal of Obstetrics & Gynecology 566.e2

Research General Gynecology www.AJOG.org

operating time (P ⫽ .61), mean blood

loss (P ⫽ .37), and length of hospital stay TABLE 1
(P ⫽ .81; Table 2). Patient and fibroid characteristics (continued)
Intraoperative complications are Characteristic Robotic Laparoscopic P value
shown in Table 3. Neither group had in- Location on uterus, n (%)
.....................................................................................................................................................................................................................................
traoperative complications attributable Anterior 24/38 (63) 31/38 (82) .07
to visceral injuries. Although no signifi- .....................................................................................................................................................................................................................................
Posterior 23/38 (61) 20/37 (54) .57
cant differences between groups were .....................................................................................................................................................................................................................................

noted for specific complications, the Broad ligament 4/38 (11) 4/37 (11) ⬎ .99 a
.....................................................................................................................................................................................................................................
overall complication rate was lower for Fundal 18/38 (47) 18/38 (47) ⬎ .99
.....................................................................................................................................................................................................................................
patients undergoing robotic surgery. Other 2/38 (5) 6/37 (16) .15 a

Two patients undergoing laparoscopic ..............................................................................................................................................................................................................................................

SD, standard deviation.
myomectomy had conversion to lapa- a
Fisher exact test.
rotomy. For 1 patient, open myomec- Bedient. Robotic vs laparoscopic myomectomy. Am J Obstet Gynecol 2009.
tomy was considered a safer approach
because of severe dextrorotation of the
uterus, the extent of which was not C OMMENT and the objective benefits they confer to
known before the procedure. For the sec- Before the latest technologies are em- patients must be investigated thor-
ond patient, a granulosa cell tumor of the braced wholeheartedly, the true merit of oughly. Robotic technology appears to
ovary was discovered. She underwent new equipment in the operating room have advantages that are specific to the
open hysterectomy, bilateral salpingo-
oophorectomy, and cancer staging. TABLE 2
Postoperative complications are Surgical factors and outcomes for patients undergoing
shown in Table 3. No major differences robotics vs traditional laparoscopic myomectomy
were noted between groups for the type Adjusted
and number of postoperative complica- Characteristic Robotic Laparoscopic P value P valuea
tions. Of the 3 patients who required Operating time, min .06 .61
hospital readmission, 1 was from the .....................................................................................................................................................................................................................................
No. of patients 41 40
laparoscopic group. She was readmitted .....................................................................................................................................................................................................................................

on the eighth postoperative day because Mean (SD) 141 (53) 166 (64)
.....................................................................................................................................................................................................................................
of pain and fever caused by a pelvic he- Median 129 163
.....................................................................................................................................................................................................................................
matoma and again on postoperative day Range 50–277 68–315
38 for repair of a posterior uterine wall ..............................................................................................................................................................................................................................................
Console time, min NA — —
dehiscence. She had undergone 2 previ- .....................................................................................................................................................................................................................................

ous uterine artery embolizations else- No. of patients 31

.....................................................................................................................................................................................................................................
where. One patient in the robotic surgery Mean (SD) 69 (39)
.....................................................................................................................................................................................................................................
group was readmitted for fever attribut- Median 60
able to a urinary tract infection, and her .....................................................................................................................................................................................................................................
Range 18–207
symptoms resolved quickly. Another pa- ..............................................................................................................................................................................................................................................

tient underwent outpatient robotic re- Docking time, min NA — —

.....................................................................................................................................................................................................................................
moval of a single fibroid (8.2 cm, 273 g) No. of patients 32
.....................................................................................................................................................................................................................................
through an anterior transverse uterine Mean (SD) 3.6 (2.2)
incision. She was readmitted 6 days later .....................................................................................................................................................................................................................................
Median 3.0
because of an ileal perforation, likely at- .....................................................................................................................................................................................................................................

tributable to an electrical injury sus- Range 1–9

..............................................................................................................................................................................................................................................
tained during surgery. A temporary il- Blood loss, mL .02 .37
.....................................................................................................................................................................................................................................
eostomy was performed. During the No. of patients 41 39
subsequent ileostomy reversal, no pelvic .....................................................................................................................................................................................................................................
Mean (SD) 100 (130) 250 (390)
adhesions were noted, and the uterine .....................................................................................................................................................................................................................................

incision was well healed. Median 75 100

.....................................................................................................................................................................................................................................
Symptom resolution was difficult to Range 25–800 10–2000
..............................................................................................................................................................................................................................................
evaluate because of the limited number Hospital stay ⬎2 d, n (%) 5/41 (12%) 9/40 (23%) .22 .81
of patients who received follow-up care ..............................................................................................................................................................................................................................................
NA, not applicable; SD, standard deviation.
at our institution. However, no major a
Adjusted for uterine size, number of fibroids, and size of largest fibroid.
differences were noted between the 2 ap- Bedient. Robotic vs laparoscopic myomectomy. Am J Obstet Gynecol 2009.
proaches (Table 4).

566.e3 American Journal of Obstetrics & Gynecology DECEMBER 2009

www.AJOG.org General Gynecology Research
going robotic procedures had conver-
TABLE 3 sion to laparotomy, and they had
Intraoperative and postoperative complicationsa significantly fewer uterine incisions
Complications Robotic Laparoscopic P valueb when compared with the laparoscopy
Intraoperative complications 1/41 (2%) 8/40 (20%) .01 group, despite similar location and type
.....................................................................................................................................................................................................................................
Bleeding 1 6 c of uterine fibroids. This probably reflects
.....................................................................................................................................................................................................................................
the advantages of the robotic technology,
Conversion to laparotomy 0 2
.............................................................................................................................................................................................................................................. particularly instrument articulation.
d
Postoperative complications 4/36 (11%) 6/35 (17%) .45 The amount of time needed to extract
.....................................................................................................................................................................................................................................
Pneumonia 1 0 fibroids from the abdominal cavity was
.....................................................................................................................................................................................................................................
Atelectasis 0 2 not measured directly; however, we esti-
.....................................................................................................................................................................................................................................
mated that approximately 25.6 minutes
Blood transfusion 2 2
..................................................................................................................................................................................................................................... were required. Time to extract fibroids
Wound infection 2 2 was calculated as follows:
.....................................................................................................................................................................................................................................
Bowel injury 1 0
..................................................................................................................................................................................................................................... Time to extract fibroids from abdominal
Pelvic abscess 1 0
..............................................................................................................................................................................................................................................
cavity ⫽ total operating time ⫺ (console
Hospital readmission 2/41 (5%) 1/40 (3%) ⬎ .99 time ⫹ docking time) ⫺ (trocar setup ⫹
..............................................................................................................................................................................................................................................
a
Data are shown as no. (%) of patients (or no. of patients); b Fisher exact test; c Three patients required a blood transfusion; closure times from prior study)
d
Pneumonia, wound infection, bowel injury, and pelvic abscess occurred in a single patient.
Bedient. Robotic vs laparoscopic myomectomy. Am J Obstet Gynecol 2009.
where total operating time was defined
as the time elapsed between the initial
incision and the final closure of skin.
performance of myomectomy because of complications for patients in the robotic Console and docking times are shown in
the challenges inherent in traditional surgery group. However, when patient Table 2. We assumed a trocar setup and
laparoscopy. These challenges include groups were adjusted for uterine size, closure time of 39 minutes because a re-
the difficulties associated with the use of size of the largest fibroid, and number of cent study from our institution11 re-
rigid instruments for fibroid removal fibroids, no significant differences were ported a mean trocar setup and closure
through the appropriate pseudocapsule noted for operating time, blood loss, time of 39 minutes for robotic radical
plane and difficulty providing a strong, blood transfusions, length of hospital hysterectomy; presumably, differences
layered closure for uterine incisions. stay, and intraoperative and postopera- in trocar setup and closure times were
Moreover, robotic techniques were de- tive complications. The type and loca- minimal between the 2 studies.
signed specifically to remedy some of the tion of fibroids, use of prophylactic bull- When compared with patients under-
hurdles of traditional laparoscopy such dog clamps (preemptively placed on the going open myomectomy, patients un-
as counterintuitive hand movements, uterine arteries before the myotomy in- dergoing robotic surgery had a signifi-
tremor, 2-dimensional imaging, and the cision to decrease the amount of intra- cant increase in operating time and cost
prolonged standing position of the operative bleeding), and a minilapa- but had less blood loss, shorter duration
surgeon. rotomy incision (for the expeditious of hospitalization, and fewer postopera-
Significant findings from the current morcellation of large fibroids) were sim- tive complications.8 Robotic myomec-
study included fewer intraoperative ilar for both groups. No patients under- tomy provided patient advantages simi-
lar to those observed with laparoscopy.8
TABLE 4 A retrospective comparison of 15 pa-
Symptom resolution after myomectomya tients undergoing robotic myomectomy
Symptoms Robotic Laparoscopic and 35 matched patients undergoing
laparoscopic myomectomy showed sig-
Any 22/26 (85%) 25/30 (83%)
.............................................................................................................................................................................................................................................. nificantly increased operating time and
Infertility 1 1 overall cost for patients undergoing ro-
..............................................................................................................................................................................................................................................
Bloating 1 5 botic surgery, whereas no differences
..............................................................................................................................................................................................................................................
Urinary frequency 2 6 were observed regarding blood loss,
..............................................................................................................................................................................................................................................
length of hospitalization, or complica-
Pelvic pain 13 16
.............................................................................................................................................................................................................................................. tions.12 The authors concluded that ro-
Pelvic pressure 3 8 botic technology did not provide advan-
..............................................................................................................................................................................................................................................
Bleeding 9 13 tages over a laparoscopic approach, but
..............................................................................................................................................................................................................................................
Other 1 0 their experience with laparoscopy was
..............................................................................................................................................................................................................................................
a far greater.
Data are shown as no. (%) of patients (or no. of patients).
Bedient. Robotic vs laparoscopic myomectomy. Am J Obstet Gynecol 2009.
We believe that robotic surgery im-
proved fibroid enucleation and layered

DECEMBER 2009 American Journal of Obstetrics & Gynecology 566.e4

Research General Gynecology
closure of the uterine incisions when
compared with laparoscopy, and it pro-
vided an unsurpassed level of surgeon
comfort. The lower number of uterine
incisions for patients in the robotic
group may provide a potential benefit
against uterine rupture during future
pregnancies. Whether improvements in
layered closure with robotic technology
result in a similar benefit remains
unproven.
Robotic surgery is associated with spe-
cific challenges. First, the reduced field of
movement limits its effectiveness for re-
moval of very large fibroids. At our institu-
tion, patients with large fibroids are se-
lected to undergo minilaparotomy, rather
than to use higher port placement; thus,
port placement is the same (standard) for
robotic and laparoscopic pelvic surgery.
Second, the torque of the robotic instru-
ments is not adequate for the countertrac-
tion (usually provided by the assistant) re-
quired for removal of large fibroids. Third,
hemostatic pressure cannot be applied to a
large bleeding area as it can be with lapa-
rotomy or minilaparotomy. We therefore
have limited performance of robotic and
laparoscopic myomectomy to select pa-
tients with symptomatic uterine fibroids,
particularly patients with small-to-me-
dium fibroids. For patients with very large
fibroids, bulldog clamps are applied bilat-
erally to the uterine arteries using robotics
to minimize bleeding before the myomec-
tomy is performed via minilaparotomy.
This study was limited by a small sample
size and the difference between groups
566.e5 American Journal of Obstetrics & Gynecology DECEMBER 2009
with regard to uterine size, size of the larg-
est fibroid, and number of fibroids re-
moved. However, after adjusting for these
factors, no difference in short-term surgi-
cal outcomes between the patient groups
was noted. Long-term outcomes such as
rates of pregnancy, uterine rupture, and
complications from adhesions could not
be assessed because of the small number of
patients attempting pregnancy and the
short duration of follow-up. Although
fewer postoperative complications oc-
curred in the group undergoing robotic
myomectomy, the difference was not sta-
tistically significant.
Both techniques provided similar res-
olution of symptoms for the small num-
ber of patients who had continued fol-
low-up care at our institution. A
prospective, randomized trial would be
optimal to clarify the definitive advan-
tages of robotic vs laparoscopic surgery,
as well as to determine long-term out-
comes for rates of pregnancy, uterine
rupture, and complications such as pain
and bowel obstruction that result from
adhesions. However, because of differ-
ences in fibroid location, size, and num-
ber, and the need to study outcomes of
patients treated by surgeons who are
equally competent in laparoscopic and
robotic myomectomy, this may be diffi-
cult to accomplish. f rotomy. Gynecol Oncol 2008;109:86-91.
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