Fertility-Sparing Gynaecological Surgery and Its Limits

Fertility-sparing gynaecological surgery treats conditions such as fibroids, adenomyosis, ovarian cysts and prolapse while keeping the uterus and protecting the remaining eggs. In the practice of Dr. Deepika Aggarwal, Chief-Laparoscopic Gynae & Robotic Surgery, Artemis Hospitals, Gurugram, India, that means a hormonal coil before any operation for adenomyosis, combined robotic and hysteroscopic myomectomy for a complex fibroid case, and uterus-sparing robotic prolapse repair for young women.

Heavy bleeding and fibroids are often thought of as problems of later life, with hysterectomy as the eventual answer. Dr. Aggarwal's practice starts from a different premise. These conditions also affect young women, and when they do, preserving fertility becomes the paramount goal of treatment. The question is then not whether the uterus can be removed safely, but whether it can be kept, and what combination of medical treatment and surgery makes that possible.

Her answers vary by condition. For prolapse, she chooses between vaginal, laparoscopic and robotic routes according to the patient's age, her wishes about her ovaries and the state of her ligaments. In early cancer the logic reverses: the priority is restraint about which patients go on the robot at all.

Mirena for adenomyosis: treatment before surgery

In young women with heavy, painful periods and adenomyosis, Dr. Aggarwal tries medical treatment before surgery, and one of the options she uses is the Mirena coil. She describes adenomyosis as technically endometriosis of the uterus. In adenomyosis, tissue like the lining of the womb grows within the muscular wall of the uterus.

During the masterclass she discussed a young woman whose case she had recently reviewed. The patient had heavy, very painful periods and was taking a range of hormonal medicines. On review, she also had an element of adenomyosis.

How the Mirena coil works

Mirena is a T-shaped hormonal device, similar in form to the copper T that some countries use for contraception. It is placed inside the uterus, where it releases hormone locally. The hormone thins the lining of the womb, so the woman bleeds less, and it also counteracts adenomyosis.

How the Mirena coil is inserted

Insertion is a simple procedure. It can sometimes be performed in the outpatient department. For a woman who is not sexually active, insertion in clinic may be painful, and Dr. Aggarwal then performs it as a short procedure under sedation, taking about five minutes.

Mirena success rate and how long it lasts

Dr. Aggarwal puts the success rate of the Mirena coil in adenomyosis at 80 to 85%, with results usually expected within three to four months. If the coil works, it can stay in place for five years and then be replaced. If the woman wants to start a family within those five years, it can be removed easily by any gynaecologist anywhere in the world, so the treatment does not tie her to the clinic that inserted it.

Why not continue with tablets or injections

The alternative is hormones given orally or by intramuscular injection. Dr. Aggarwal's judgement is that these cause more side effects. She considers them acceptable as an interim measure for a few months, but not as long-term treatment. Because the Mirena releases its hormone locally, inside the uterus, she concluded that it was the best proposition for the patient she reviewed.

Fertility-sparing surgery for fibroids: myomectomy instead of hysterectomy

Dr. Aggarwal performs robotic myomectomy, the removal of fibroids with the uterus left in place, including removal of multiple fibroids, for women who want to keep their uterus. One of her recent cases shows how far that commitment can be taken. Typical fees are listed on the myomectomy cost page.

A fibroid obstructing the vagina: combined robotic and hysteroscopic myomectomy

A woman in her early thirties came to Artemis after a month of abdominal pain and very heavy bleeding. She had two large fibroids. One of them, a 7 cm fibroid, was at the cervix and was prolapsing into the vagina, causing complete obstruction. Dr. Aggarwal describes it as a technically very challenging case. The patient had been told that her uterus would have to be removed, and she had been refused minimally invasive surgery.

At her age, hysterectomy was not an acceptable option. Dr. Aggarwal treated the two fibroids by two different routes in one strategy:

• Robotic myomectomy to remove the fibroid that lay higher in the uterus, operating from above.
• Hysteroscopic myomectomy to remove the cervical fibroid that was coming through into the vagina, working from below under hysteroscopic vision, through a thin camera (a hysteroscope) passed through the cervix.

The patient went home the day after surgery. She has stayed in touch with Dr. Aggarwal, who expects to hear news of a pregnancy soon.

The case carries a broader lesson. A fibroid that distorts the cervix and fills the vagina looks, at first sight, like an indication for hysterectomy. Dividing the problem by location, and choosing the best access route for each fibroid, turned it into a fertility-preserving operation with a next-day discharge.

How long to wait before pregnancy after myomectomy

Dr. Aggarwal advises that women can usually plan a pregnancy three months after this kind of surgery. Advice on the interval varies with the depth of the myomectomy, and many surgeons recommend waiting three to six months.

When hysterectomy is the right answer

Not every fibroid case is managed this way. Where multiple large fibroids have enlarged the uterus and preserving it is not the aim, Dr. Aggarwal performs a robotic hysterectomy; the complete guide to minimally invasive surgery in gynaecology describes one such case.

Endometrioma surgery and endometriosis: protecting the ovaries

The precision of the robot matters most in operations where any bleeding has a cost beyond the operation itself, and ovarian and endometriosis surgery in young women are the clearest examples.

Endometriomas in young women who want to conceive

Endometriomas are ovarian cysts formed by endometriosis, and in young women who want to conceive Dr. Aggarwal removes them by ovarian cystectomy. Because cystectomy itself can reduce ovarian reserve (the number of eggs remaining in the ovaries), ESHRE guidance advises counselling women about that risk and does not recommend surgery for endometriomas solely to improve the chance of pregnancy with IVF. Dr. Aggarwal's aim in these operations is to avoid any bleeding, because bleeding can damage the remaining eggs and follicles. The fine dissection the robot allows is the edge she relies on in these cases. Complex cysts, such as dermoid cysts and large mucinous cysts, are also removed robotically.

Endometriosis that binds the pelvic organs together

In endometriosis, the bowel, bladder and ureter can be stuck together. Absolutely fine dissection is needed to separate them without causing complications, and this is where Dr. Aggarwal finds robotic precision especially valuable. The robot's imaging can also be used to visualise the ureter and avoid injuring it, as described in how the da Vinci robot works in gynaecological surgery.

Uterine prolapse surgery: vaginal, laparoscopic or robotic?

Dr. Aggarwal chooses the route for prolapse surgery by the patient's age, whether her ovaries are to be removed and the state of her ligaments. Her approach is a good illustration of her view that the robot is one tool among several, chosen when it adds value.

When vaginal surgery is enough

Uterine prolapse can be managed vaginally, and often easily. With a third-degree prolapse, there is no real need for a robotic hysterectomy: the operation can be done from below.

When the ovaries also need to come out

The calculation changes if the woman also wants her ovaries removed. Reaching the ovaries vaginally is challenging, and bleeding can occur. For these women Dr. Aggarwal recommends a robotic or laparoscopic hysterectomy with removal of the ovaries. A uterine manipulator, an instrument passed through the vagina to move the uterus, pushes the uterus in, the surgery is performed from above, and the uterus is then removed from below.

Vault suspension: preventing recurrence from above

Women with uterine prolapse, usually after the age of 60 or 70, tend to have lax ligaments. To prevent the prolapse from recurring, the vault, the top of the vagina, needs to be suspended. Traditionally this was done vaginally as a sacrospinous fixation. Dr. Aggarwal, who performed the procedure herself, remembers it as a very bloody technique after which patients had pain for weeks. Sacrospinous fixation remains a standard vaginal option for vault prolapse, offered alongside sacrocolpopexy in NICE guidance. With the robot, the vault suspension can be performed from above. Whether a woman needs it depends on the state of her ligaments.

Sacrohysteropexy: uterus-sparing prolapse repair for women who want more children

For young women with prolapse who do not want their uterus removed because they plan more children, Dr. Aggarwal performs a uterus-sparing operation robotically, known as sacrohysteropexy. The uterus is lifted and fixed to the sacrum inside the pelvis with the help of a mesh, correcting the prolapse while preserving the uterus. Guidance generally advises women who plan further pregnancies to consider delaying prolapse surgery, because pregnancy and birth can cause the prolapse to recur. Her answer to a question on robotic prolapse surgery is on the masterclass Live Discussion page.

Which early gynaecological cancers suit robotic surgery?

In Dr. Aggarwal's practice, robotic cancer surgery is usually for Stage 1 disease, in two groups: Stage 1 endometrial cancer (cancer of the lining of the uterus) and very early Stage 1 cervical cancer. In gynaecological oncology, robotic surgery is a question of selection before it is a question of technique. She operates on early cancers of the uterus, tubes, ovaries and cervix together with the oncology team at Artemis, and her first principle is restrictive: not every malignant case can be done robotically.

For cervical cancer, the 2018 LACC trial found lower survival after minimally invasive radical hysterectomy than after open surgery, and ESGO and NCCN guidelines now recommend open surgery as the standard approach, with minimally invasive surgery considered only for selected small, low-risk tumours.

Ovarian cancer is the main exception and the main challenge. If the ovarian mass is large, she does not operate robotically.

Within those limits, the robotic operations in her oncology practice include hysterectomy for malignant disease, lymphadenectomy (removal of lymph nodes), removal of the omentum (the fatty apron of tissue inside the abdomen), and removal of the tubes and ovaries.

Cancer operations are also where Dr. Aggarwal makes most use of the robotic vessel sealer, described with the rest of the instrument set in the article on the da Vinci system.

A high-risk case: early endometrial cancer and sarcoidosis

The case Dr. Aggarwal presented from her oncology practice involved a woman in her mid-seventies with cancer of the uterus. She presented it to show the level of complexity robotic surgery can now handle. The cancer itself was early. What made the case challenging was the patient's lungs.

The diagnosis before surgery. The patient had already undergone hysteroscopy and D&C (dilatation and curettage, in which tissue is taken from the lining of the uterus), so the type of cancer was known before she reached the operating theatre: endometrial cancer, Grade 1, which the team assessed as Stage 1. Endometrial cancer is formally staged at surgery, on the removed specimen. The team judged that the cancer had not spread and expected surgery to be curative. The standard operation for Stage 1 endometrial cancer is a total hysterectomy with removal of both tubes and ovaries, with assessment of the lymph nodes where indicated; the more extensive radical hysterectomy is reserved mainly for cervical cancer.

The complication: sarcoidosis. The patient had sarcoidosis, an inflammatory disease that most often affects the lungs and can reduce lung capacity. She was otherwise well. Despite her age and her lung disease she was not bed-bound, and her lung function was good.

The difficulty lay in the position the operation requires. In robotic and laparoscopic pelvic surgery, the patient lies with the head down and the legs raised, at an angle of 30 degrees (the steep Trendelenburg position). That position puts more pressure on the lungs. A patient with sarcoidosis may manage well lying flat and struggle in this position. As Dr. Aggarwal put it, the challenge of sarcoidosis lay less with her as the surgeon than with the anaesthetist.

Why robotic surgery was still the right choice. The multispecialty team concluded that the patient would benefit from robotic surgery despite this challenge, for three reasons:

1. Shorter operating time. In Dr. Aggarwal's experience, the precision of the robot allows the surgery to be done faster than by laparoscopy. Comparative studies more often report similar or longer operating times for robotic than for laparoscopic hysterectomy.
2. Less bleeding, a priority in a frail woman of her age.
3. Faster recovery and mobilisation. The operation is performed through three or four small incisions (robotic port incisions are typically about 8 to 12 mm), so the patient recovers and mobilises sooner. In frail women of her age, the risk of deep vein thrombosis after surgery is very high, which makes early mobilisation especially important.

On balance, the team decided to give her the benefits of robotic surgery.

How anaesthesia was adapted. Robotic gynaecological surgery is performed under general anaesthesia, and the abdomen is inflated with carbon dioxide, typically at a pressure of 12 to 15 mmHg. With the anaesthetist, Dr. Aggarwal's team kept the insufflation pressure at a bare minimum of 8 mmHg, well below that usual range. To protect her lung function further, Dr. Aggarwal undocked the robot every 20 minutes to make sure her lungs were working well.

The outcome. The operation was completed with minimal blood loss. Even at her age, and after cancer surgery of this kind, the patient was discharged within 48 hours.

The case shows what makes robotic cancer surgery safe in a high-risk patient. The surgical decision was straightforward because the disease was early. The risk lay in the anaesthetic, and it was managed by an operating team prepared to work at low pressure and to pause the operation at fixed intervals for the patient's lungs.

Adjuvant therapy after surgery: who needs further treatment

Removing an early cancer is not always the end of treatment. Dr. Aggarwal's practice is that the specimen goes for histopathology (examination of the tissue under the microscope) and for additional marker testing, and that decisions on further treatment are taken collectively. Current guidelines for endometrial cancer recommend molecular classification of the tumour (POLE mutation, mismatch repair status and p53 status), because it refines the risk of recurrence and the choice of adjuvant therapy, the treatment given after surgery.

Artemis holds a dedicated multidisciplinary meeting once a week. The specialists around the table range from PET-CT to the chemotherapy and radiation teams, together with Dr. Aggarwal as the operating surgeon and her own team.

Depending on the results of the tests on the specimen, some patients need chemotherapy or radiotherapy after surgery. This can apply even to Stage 1 cancers. The purpose is to prevent recurrence: Dr. Aggarwal's view is that the team has to consider the long-term recurrence rate, even after the cancer has been cured surgically. Not all patients need adjuvant treatment.

When to refer for robotic gynaecological cancer surgery

For a doctor considering referral for robotic cancer surgery, Dr. Aggarwal's approach suggests three practical questions.

1. Is the cancer early enough? Robotic surgery in her practice is for Stage 1 disease, principally endometrial cancer and very early cervical cancer. A large ovarian mass is outside that scope.
2. Is the diagnosis established? In the case above, a hysteroscopy and D&C had already confirmed the type and grade of the cancer before the operation was planned.
3. Can the patient tolerate the position and the gas? Age and lung disease are not automatic exclusions. They are reasons for close planning with the anaesthetic team, as the sarcoidosis case shows.