Robotic Surgery for Fibroids: Myomectomy or Hysterectomy

Robotic surgery for fibroids removes the fibroids while preserving the uterus (robotic myomectomy), or removes the uterus itself (robotic hysterectomy), through small incisions. Dr. Deepika Aggarwal, Chief-Laparoscopic Gynae & Robotic Surgery, Artemis Hospitals, Gurugram, India, regards a uterus with multiple fibroids as one of the clearest indications for the robot, because removing several fibroids and rebuilding the uterus is long, bloody and demanding work by laparoscopy.

Fibroids and the two operations that treat them

Fibroids, also called leiomyomas or myomas, are non-cancerous growths of the smooth muscle of the uterus. They are very common, and many cause no symptoms. When they do need surgery, the choice lies between two operations:

• Myomectomy removes the fibroids and leaves the uterus in place, so the woman can still become pregnant. It is the operation for women who want to keep their fertility or their uterus.
• Hysterectomy removes the uterus. It ends the problem permanently, and it ends the possibility of pregnancy.

Both can be performed open, laparoscopically or robotically. The overview of what the robot adds across benign gynaecology is in the complete guide to the role of robotics in benign gynaecology; this article covers how Dr. Aggarwal applies it to fibroids.

Robotic surgery for multiple fibroids

A myomectomy for several fibroids has three stages, and Dr. Aggarwal walks through them to explain why the robot changes the calculation:

1. Enucleation. Each fibroid, which she describes as a roughly spherical ball, is shelled out of the wall of the uterus.
2. Reconstruction. The defects left in the uterine muscle are repaired, restoring the wall of the uterus.
3. Extraction. The fibroids are morcellated, that is, cut into smaller pieces so they can be removed through small incisions.

Consider a woman with three fibroids measuring 6, 4 and 2 cm. Done laparoscopically, that operation can take Dr. Aggarwal four to five hours. With the robot, it takes perhaps a couple of hours. The shorter operation reduces the risk of anaesthesia, reduces blood loss and shortens the hospital stay.

Morcellation needs one safeguard. Regulators and specialist societies advise that uncontained power morcellation can spread an unsuspected uterine sarcoma (a rare cancer that can resemble a fibroid), which is why careful preoperative assessment, and morcellation within a containment bag where appropriate, are now standard considerations.

Multiple fibroids in women of African descent

The question has particular weight for the doctors who attended the masterclass. Dr. Aggarwal noted that Afro-Caribbean women are very prone to fibroids and usually have multiple fibroids, and in her view they benefit more from robotic than from laparoscopic surgery. Epidemiological studies consistently show that fibroids are more common in Black women, appear at a younger age, and are more often multiple and larger than in white women.

Inside a robotic myomectomy

The recording Dr. Aggarwal showed of a robotic myomectomy illustrates each of these stages. The patient was a woman in her late thirties with multiple fibroids who wanted children, so preserving the uterus was the whole purpose of the operation. Three aims guided it: minimal bleeding, removal of the fibroids, and a reconstruction strong enough for her to carry a pregnancy to term.

Cutting and controlling bleeding at once. Dr. Aggarwal cuts with scissors in one robotic arm while holding and coagulating with a bipolar instrument in another, so bleeding is controlled as she goes. The largest fibroid in this case measured around 7 to 8 cm, and the dissection proceeded with very little blood loss.

Not losing fibroids. Small fibroids are easy to lose inside the abdomen. She removes the smaller ones as she encounters them, and where there are several she suspends the fibroids already removed so that they do not slip away among the loops of bowel.

Suturing the uterus. Suturing is where robotics most clearly outperforms laparoscopy, in her assessment. Three-dimensional vision and the wristed instruments let the surgeon place sutures accurately and give the repaired uterine wall good tensile strength. For a young woman planning a pregnancy, the integrity of the uterus after robotic suturing is, in her experience, far better than after laparoscopic surgery. That is the reason she advises women in this group to think seriously about the robotic route.

Fertility-sparing surgery beyond fibroids, including combined robotic and hysteroscopic myomectomy and the management of adenomyosis, is covered in Dr. Aggarwal's later masterclass on fertility-sparing gynaecological surgery and its limits.

Myomectomy or hysterectomy: how the decision is made

Robotic surgery has not removed the case for hysterectomy in women with fibroids. A doctor from Cameroon asked in the Live Discussion whether it had, and Dr. Aggarwal's answer was no. The decision still depends on the woman's age and her wish for future fertility, and sometimes hysterectomy remains the better offer.

Her reasoning centres on recurrence. Some women have, in addition to the main fibroids, very small, peanut-sized fibroids scattered through the uterus. These cannot all be removed at operation; the surgeon removes those larger than about 1 to 2 cm. The small ones that remain can grow, and fibroids can recur. For a perimenopausal woman of around 48 who has completed her family and has multiple fibroids, removing the uterus is therefore often the better choice than preserving it.

The decision is the patient's. Dr. Aggarwal takes each woman through the advantages and disadvantages of both operations, and the woman makes the final call. In summary:

• A young woman who wants children: myomectomy, with a strong case for the robot because of the quality of the uterine repair.
• A woman near the menopause who has completed her family and has multiple fibroids: either operation is reasonable, and hysterectomy avoids the risk of fibroids returning.

Typical fees for fibroid surgery are on the myomectomy cost page.

Fibroid size: when robotic, laparoscopic or open surgery is appropriate

The size of the uterus is the first practical filter. Gynaecologists describe an enlarged uterus by the stage of pregnancy it resembles, so an 18 week size uterus is as large as the uterus at 18 weeks of pregnancy; at around 20 weeks the top of the uterus reaches the level of the umbilicus.

Dr. Aggarwal sets two thresholds:

• Open surgery when the fibroids are massive, extending 4 to 5 cm above the umbilicus. There is then no space to insert the camera or to manoeuvre the instruments, and the case is straightforwardly an open one.
• Robotic surgery when the uterus is around 18 to 20 weeks' size. At that size laparoscopy becomes tricky, and the robot allows the surgeon to proceed with confidence.

A large fibroid that other centres would not operate on laparoscopically

One of Dr. Aggarwal's patients, a woman in her early fifties, had a 10 cm fibroid and had spent two to three months visiting different centres, each of which declined to remove it laparoscopically. For a fibroid or uterus of that size, a laparoscopic surgeon sometimes has to warn the patient of a 5% risk of conversion to open surgery. Dr. Aggarwal was confident that with the robot she would not need to open the abdomen. She performed a robotic hysterectomy, the patient needed no blood transfusion, and she went home after one day.

In her practice, about 90% of patients go home one day after robotic removal of the uterus or of fibroids, compared with at least two to three days after the laparoscopic operation and three to five days after open surgery.

When to refer fibroids for robotic surgery

For doctors managing women with fibroids, Dr. Aggarwal's criteria translate into a short set of referral signals:

• Multiple fibroids in a woman who wants to preserve fertility.
• A uterus of around 18 to 20 weeks' size, where local laparoscopic surgeons are not confident or expect to convert.
• Severe endometriosis (tissue similar to the lining of the uterus growing outside it), with the bowel, uterus and ovaries stuck together.
• A body mass index (BMI) above 30, where a shorter anaesthetic is safer.

Where the local team is not confident, or feels the patient may need to be opened, those are the cases she suggests sending to a robotic centre. Her full guidance on choosing between open, laparoscopic and robotic surgery, the complication rates she reported and the cost difference are in robotic vs laparoscopic surgery in benign gynaecology.