Preserving Fertility with Minimally Invasive Myomectomy

3D illustration of surgical robot on white background

Uterine fibroids are highly prevalent in women over 35. As more women delay childbearing, techniques to remove uterine fibroids (leiomyomas) while also preserving fertility are of increasing importance.

At Brigham and Women’s Hospital’s Center for Infertility and Reproductive Surgery (CIRS), reproductive endocrinologist and surgeon Antonio R. Gargiulo, MD, champions minimally invasive myomectomy – and particularly robot-assisted surgery – for women with symptomatic fibroids who still wish to bear children or otherwise preserve the uterus and for women experiencing reproductive difficulties directly related to the presence of fibroids.

“Myomectomy was once a classic open procedure, typically associated with a high risk of complications. By embracing advanced hysteroscopic access and robot-assisted laparoscopic access, we have relegated the use of open myomectomy to a small minority of our cases and have made myomectomy a very safe day-surgery operation,” said Dr. Gargiulo, medical director of robotic surgery at Brigham Health, whose team was the first in New England to perform robot-assisted laparoscopic myomectomy (RALM) to treat fibroids.

Over the past year, fewer than 1 in 5 of the 155 abdominal myomectomies performed by the hospital’s minimally invasive gynecologists and reproductive endocrinology specialists required open surgery.

For intracavity fibroids that are reachable through natural orifice surgery, hysteroscopic excision is performed. For fibroids that are deep within the uterine wall, minimally invasive options include laparoscopic surgery, with or without robotic assistance.

Advantages of all minimally invasive techniques (all performed in day surgery protocol) include significantly lower morbidity and shorter recovery time as compared to open myomectomy. Minimally invasive techniques also allow more precise dissection of tissue, causing minimal damage to irreplaceable reproductive tissues and therefore greater fertility-sparing capability, even for women with large and numerous fibroids, Dr. Gargiulo added.

Given the generally low adoption of conventional laparoscopic myomectomy, he expects RALM to be the option of choice for informed women as it becomes more available, both within and beyond childbearing years.

The Unexpected Ease of Robotic Laparoscopic Myomectomy

Despite evidence of clinical superiority and lower cost to society of minimally invasive myomectomy, open surgery has remained a first choice for many surgeons outside of highly specialized reproductive surgery centers. Conventional laparoscopic myomectomy, while beneficial to patients, can be difficult to master, due to the need for rapid suturing to address the continuous blood loss that occurs when the uterus is cut to remove each tumor. Even experienced laparoscopic surgeons, when challenged with such time constraints, have difficulty adapting to the monocular vision and the ergonomic challenges of laparoscopic surgery (which works on the principle of the fulcrum, with hand movements being inverted to the direction imparted to the instruments).

Robotic surgery has the potential to change the equation. While RALM requires capital investment and special training, the procedure itself is easier to master than traditional laparoscopic surgery, said Dr. Gargiulo.

Since robot-assisted surgery was approved for gynecologic surgery in 2005, Dr. Gargiulo and colleagues at CIRS have performed more than 1,500 robot-assisted procedures, including myomectomies, complex tubal and ovarian microsurgery and excision of pelvic endometriosis.

The FDA-approved da Vinci® Surgical System that is used in multiple departments at Brigham and Women’s Hospital consists of a dual surgeon’s console equipped with a control panel and a hi-definition monitor and a patient side-cart that is outfitted with slender robotic arms (including one equipped with a high definition 3-D magnification camera) and is attended by another surgeon and a nurse. The wristed capabilities of the robotic arms (and of the miniaturized robotic instruments) provide the dexterity and broad range of movements needed to carry out laparoscopic microsurgery of the same quality allowed by open surgery.

The Brigham’s division of reproductive endocrinology typically trains four or five fellows in robotic surgery over each three-year span.

While RALM builds upon many advances of conventional laparoscopic myomectomy, the robotic technique is far more accessible to gynecologists, Dr. Gargiulo said, noting that the intuitive movements and stereoscopic vision of robot-assisted myomectomy make it much easier to master than conventional laparoscopic surgery.

At Brigham and Women’s, trainees learn and perfect their robotic technique at the STRATUS Center for Medical Simulation. Before operating on a patient, new users are required to pass validated simulation testing that has been shown to bring novices to the level of credentialed robotic surgeons. Gargiulo called robotic surgery “revolutionary” for this reason.

“It completely decouples the achievement of perfect technique from direct patient care,” he said. “When trainees learn a technique on the simulator, they are technically perfect when they perform the surgery on their first patient. Surgery becomes a matter of strategy and understanding of the pathology at hand, rather than an exercise in laparoscopic dexterity.”

Continuing to expand the capabilities of robotic technology, Dr. Gargiulo and colleagues recently described the novel technique of robotic single-site myomectomy (performed completely through a single incision in the umbilicus) and found it comparable in outcome to its multi-port counterpart. Although the technique is safe and has been replicated in other centers, its current applicability is limited. “We’ve done proof of principle,” Dr. Gargiulo said, “but we’re waiting for better technology.”

Myomectomy Instead of Hysterectomy for Perimenopausal Women?

While myomectomy is generally performed for fertility preservation, women who have completed childbearing and wish to preserve the uterus also are candidates for minimally invasive myomectomy for removal of fibroids instead of hysterectomy, Dr. Gargiulo said. Advantages of myomectomy over hysterectomy include: lower chance of hemorrhage and infection; no post-operative urinary incontinence; no loss of libido or other sexual disfunction; virtually no occurrence of urinary tract injury, rectal injury or vaginal cuff dehiscence; and no loss of ovarian function (which has been described even for ovary-sparing hysterectomy).

“Myomectomy has no increased complication over hysterectomy,” said Dr. Gargiulo, who refutes the notion that hysterectomy for benign fibroids in the post reproductive years is justified by the risk of recurrence after myomectomy. “Recurrence is an issue in women of reproductive age, but in women who are approaching menopause, estrogen-dependent tumors rarely will have time to grow back. The closer the patient is to menopause the more one should allow her to avoid the many perioperative complications of a hysterectomy, and have a myomectomy even past reproductive age, if that is her choice.”

Because fibroids generally shrink after menopause, he currently does not advocate post-menopausal myomectomy.