Technique Of Myomectomy Research Articles

The Impact of Laparoscopic Myomectomy on Pregnancy Outcomes: A Systematic Review.

The objective of this systematic review is to investigate the impact of laparoscopic myomectomy techniques on pregnancy outcomes, with a specific focus on the correlation between the type of suture used during the procedure and the incidence of uterine rupture. Additionally, the study aims to examine how the localization and size of myomas, key factors in laparoscopic myomectomy, may influence fertility outcomes. extensive searches were conducted using MDPI, PubMed, Web of Science, and Cochrane Library databases from 2008 to November 2023. The study involved women of reproductive age diagnosed with fibroids who underwent surgical removal of fibroids using either laparotomy or laparoscopy. The evaluation of pregnancy outcomes focused on indicators such as live birth rates, miscarriage rates, stillbirth rates, premature delivery rates, and cases of uterine rupture. Quality assessment was systematically performed by employing the National Institutes of Health Study Quality Assessment Tools, with the subsequent formulation of clinical recommendations that were meticulously graded in accordance with the robustness of the underlying evidence. The pregnancy outcomes post-myoma treatment, as reflected in one of the presented tables, show a promising number of pregnancies and live births, but also indicate the potential risks of miscarriages and preterm births. The diversity in outcomes observed among various studies underscores the imperative for tailored patient care, as well as the necessity for additional research aimed at optimizing fertility and pregnancy outcomes following myoma treatment. This study offers insights into the criteria for patient selection and intraoperative methodologies specifically related to laparoscopic myomectomy. To enhance our understanding of the associations between fibroid characteristics (location, size) and reproductive outcomes, additional research is warranted, particularly through well-designed clinical trials.

Coaxial-Robotic Single-Site Myomectomy: Surgical Outcomes Compared with Robotic Single-Site Myomectomy by Propensity Score Matching Analysis.

The aim of this study was to introduce a coaxial-robotic single-site myomectomy (C-RSSM) technique to compensate for the shortcomings of robotic single-site myomectomy (RSSM) using semi-rigid instruments and to compare the surgical outcomes of C-RSSM and RSSM. The medical records of 13 consecutive women who had undergone C-RSSM and 131 consecutive women who had undergone RSSM were retrospectively reviewed. Patient characteristics and surgical outcomes after propensity score matching were evaluated and compared between the two groups. According to the propensity score matching results, the C-RSSM group had a lower estimated blood loss (75.0 vs. 210.5 mL, p = 0.001) and a shorter operating time (101.0 vs. 146.1 min, p = 0.008) relative to the RSSM group. In RSSM, there was one case of conversion to conventional laparoscopy and four cases of conversion to the multi-site robotic approach. There was no case of conversion from C-RSSM to conventional laparoscopy or the multi-site robotic approach. C-RSSM was found to be associated with shorter operative time and lower estimated blood loss. However, further prospective studies are needed to confirm these advantages.

Laparoscopic Myomectomy for a Large Incarcerated Posterior Myoma

<h3>Study Objective</h3> To demonstrate a technique for laparoscopic myomectomy with a large posterior fibroid and incarcerated uterus. <h3>Design</h3> We present a stepwise narrated demonstration of our technique for posterior myomectomy. <h3>Setting</h3> Referral Center in Upstate NY. <h3>Patients or Participants</h3> A 35-year-old with large posterior fibroid desiring fertility sparing treatment. <h3>Interventions</h3> Bilateral retroperitoneal dissections are performed, demonstrating both lateral and anterior approaches for isolation of uterine blood supply. Hemostatic control is achieved with the use of rectal misoprostol, intrauterine vasopressin and temporary occlusion of the uterine blood supply. A high hysterotomy is made and the fibroid is dissected away from the pseudocapsule, eventually allowing displacement of the uterus out of the posterior cul-de-sac with a vaginal hand as the dissection continues, demonstrating an approach to hysterotomy when the ideal location is inaccessible. On completion of the myomectomy, a uterine manipulator is placed, and excess serosa is trimmed. The myometrium is repaired with a 3-layer closure followed by a single layer on the uterine serosa. <h3>Measurements and Main Results</h3> Successful laparoscopic myomectomy for a 669-gram fibroid with estimated blood loss of 100ml and benign pathology. Patient discharged home postoperative day one. Normal appearing uterus on 3-month follow-up ultrasound. <h3>Conclusion</h3> Laparoscopic myomectomies can be safely performed on large posterior uterine fibroids even in the setting of an incarcerated uterus. The above techniques can improve hemostasis, access to the fibroid and repair of atypical hysterotomy.

Novel Technique for Performing a Minimally Invasive Myomectomy: Robotic vNOTES Myomectomy

<h3>Study Objective</h3> This video demonstrates robotic vaginal natural orifice transluminal endoscopic surgery (vNOTES) for myomectomy. <h3>Design</h3> There are various routes for myomectomy. The vaginal route is preferred for hysterectomy as it eliminates abdominal incisions and is associated with shorter hospital stays, operative time and recovery¹ and this can be assumed with myomectomy. However, visualization may be difficult with limited space. Robotic surgery offers enhanced visualization and precision. vNOTES myomectomy is previously described² however traditional laparoscopic instruments offer limited motion which makes suturing difficult. Robotic vNOTES is used for hysterectomy, sacrocolpopexy and endometriosis resection.^3,4,5,6 One study showed that for hysterectomy, there was no difference in operative time, admission length or postoperative pain between robotic and traditional vNOTES. This study proposed that robotic vNOTES was beneficial due to use of wristed instruments.³ Given advantages of vaginal and robotic surgery, the robotic vNOTES myomectomy technique was developed. <h3>Setting</h3> Academic hospital. Positioning was dorsal lithotomy, steep Trendelenburg. <h3>Patients or Participants</h3> A 28-year-old presented with pain and heavy periods. She had no significant history and had 3 prior vaginal deliveries. Imaging showed an 8cm posterior uterine fibroid and she desired fertility sparing, surgical management. <h3>Interventions</h3> A 3cm posterior colpotomy was made and an Alexis retractor with gel port was placed through the colpotomy. The Da Vinci robot was docked vaginally and myomectomy of an 8cm fibroid was performed. After the fibroid was detached, the myometrium was closed in layers. The robot was undocked and contained morcellation of the fibroid was performed using the ExCITE technique.⁷ The posterior colpotomy was closed. <h3>Measurements and Main Results</h3> The patient was discharged home same day with 100cc blood loss. <h3>Conclusion</h3> This video shows that robotic vNOTES is a feasible technique for myomectomy. It offers the benefits of minimally invasive vaginal surgery and the detail and precision of robotic surgery while maintaining quick post operative recovery and minimal blood loss.

7633 Laparoscopic Myomectomy: When and How?

<h3>Study Objective</h3> The objective of the video will be to review common fibroid symptoms, and diagnostic modalities that assist with surgical planning. A technique for laparoscopic myomectomy approach with the use of methylene blue will be reviewed. <h3>Design</h3> During this 6-minute video we will review fibroid symptoms including its effects on assisted reproductive technology. This video will review preoperative imaging and its assistance in surgical approach planning. Finally, it will focus on a 5-step surgical video tutorial of a laparoscopic myomectomy technique with methylene blue to assist with endometrial cavity identification. The presentation will end with concluding remarks. <h3>Setting</h3> Surgical management of fibroids. <h3>Patients or Participants</h3> Female's with symptomatic fibroids. <h3>Interventions</h3> Laparoscopic Myomectomy. <h3>Measurements and Main Results</h3> N/A. <h3>Conclusion</h3> Fibroids are a common female problem. Surgical management of fibroids should be considered if symptomatic i.e., pelvic pain, heavy vaginal bleeding or infertility issues secondary to endometrial cavity deforming fibroids. Usage of methylene blue throughout the laparoscopic myomectomy assists with assessing cavity integrity and decreasing the risk of intrauterine adhesions.

7911 Laparoscopic Intraligamentous Broad Ligament Leiomyoma Myomectomy and Closure

<h3>Study Objective</h3> To demonstrate a unique and rare case of a broad ligament leiomyoma and the techniques involved in the laparoscopic myomectomy. Emphasis on safe intraoperative management along with decreased blood loss <h3>Design</h3> A step-by-step explanation of the surgery using video (instructive video). <h3>Setting</h3> A university hospital based on Detroit, Michigan; Wayne State University/ Detroit Medical Center <h3>Patients or Participants</h3> 39-year-old G0 presenting for laparoscopic myomectomy due to AUB-L. Patient had generalized pelvic pain and pressure with limited pelvic exam likely due to intraligamentous broad ligament fibroid. <h3>Interventions</h3> Laparoscopic myomectomy with careful dissection, avoiding essential surrounding structures. <h3>Measurements and Main Results</h3> Successful removal of 7 leiomyomas, including an approximate 12 cm broad ligament fibroid. After removal of the broad ligament fibroid there a complete opening defect was closed with 0 V-loc. Technique involved closing the round ligament to the serosa on the anterior and posterior aspects of the uterus. The abdomen was carefully inspected after extraction, no injuries noted, good hemostasis confirmed. <h3>Conclusion</h3> Laparoscopic myomectomy removal offers effective surgical intervention. Due to limited data on laparoscopic technique, the rarity and symptomatic consequences of intraligamentous broad ligament leiomyomas – this case report aims to highlight the significance of skilled laparoscopic myomectomy techniques for overall lifestyle improvement in our patient.

New insights into the neural network of the nongravid uterus.

The human uterus is exposed to epigenetic factors during maturation, which might influence its neural network. The mesh muscle is formed from the circular muscle during development and maturation, and it coordinates the longitudinal and circular muscle function. The uterus has an autonomous neural network with contractility and propagation patterns that determine its reproductive potential and health during pregnancy and delivery. Emerging knowledge on the uterine neural network and mesh muscle ultrastructure contributes to new ideas and solutions on the role of intrauterine pressure and distending fluid intravasation during hysteroscopy, and even allows for improving the operative techniques of myomectomy, adenoma cytoreductive surgery and metroplasty. Good health and well-being start from the in utero stage of life. Prenatal and antenatal care are of paramount importance to minimize the risks of malnutrition and pollutants, and foster a healthy uterus. Research regarding the neural network, function and contractility of the nongravid uterus is a new chapter in gynecology that provides significant information for a better understanding and early diagnosis and treatment of uterine pathologies and early pregnancy support.

Robotic vaginal natural orifice transluminal endoscopic myomectomy

Robotic vaginal natural orifice transluminal endoscopic myomectomy

A survey on robotic-assisted laparoscopic myomectomy technique among high-volume gynecologic robotic surgeons in Korea

Objective: This study aimed to investigate the of robotic-assisted laparoscopic myomectomy (RALM) techniques among Korean gynecologic robotic surgeons with heavy robotic gynecologic caseloads.Methods: We conducted this online survey consisting of 11 questions regarding various aspects of RALM, such as the type of da Vinci system, number of skin incisions, trocar ports, robotic instruments, and suture materials, with a focus on multiport RALM. Twenty-one board-certified robotic gynecologic surgeons from 16 university-based tertiary medical centers responded.Results: The da Vinci Xi was the most commonly installed system at the respondents’ affiliated hospitals. In terms of instruments, monopolar curved scissors, fenestrated bipolar forceps, and mega suture needle driver were the most used. The most commonly used suture materials for serosal and myometrial layer closure were barbed suture materials, and the endometrial layer was most commonly closed with multifilament delayed absorbable suture material. Continuous running and baseball suture techniques were most frequently used for serosal layer closure.Conclusion: This is the first study investigating RALM surgical methods among Korean gynecologic robotic surgeon with heavy caseloads, and the findings can be of a great benefit to beginners as well as experts in the field of robotic surgery.

671 Etiopatogenic aspects of pelvic organs prolapse in women, modern surgical correction

The abstract discusses risk factors for pelvic organ prolapse, such as uterine leiomyoma and levels of hormones in reproductive aged women. The study was aimed to assess the risk factors for the pelvic organ prolapse occurrence and identify significant risk factors in women of reproductive age that affect further fertility. This is retrospective study in which clinical and laboratory data of 120 cases of reproductive aged women were reviewed. Group A maintained women with pelvic organ prolapses, according to the POP-Q classification, and group B was undergoing routine examination. Presence of uterine leiomyoma during USG examination and levels of hormones in blood samples were tested. According to the obtained data, uterine leiomyoma occurs significantly more often (p <0.05) in patients of group A, in comparison with group B. Also noteworthy is the decrease in the level of sex hormones in 88% of women in group A, while in group B it is reduced only in 95%. The results of the study clearly demonstrate the relevance of uterine leiomyoma in combination with pelvic organ prolapse. Also, an important role is played the level of sex hormones decrease, which manifests as skin and vaginal mucosa dryness, decreased libido and dissatisfaction sexual life. Based on retrospective observations, was determined that isolated removal of fibroids does not guarantee the absence of prolapse progression, and therefore there is a need to develop a myomectomy technique with simultaneous correction of pelvic organ prolapse and hormone replacement therapy.

Laparoscopic myomectomy: A retrospective analysis of 432 cases

Overview: Laparoscopic myomectomy has become increasingly popular in Sri Lanka due to its favorable long term outcome. Purpose of this study is to evaluate not only laparoscopic myomectomy technique but also operative time, blood loss depending on site, size and number of fibroid. Method: In this retrospective study we have analyzed data from 432 women who had undergone laparoscopic myomectomy at Colombo South Teaching Hospital, Sri Lanka during the period from 2011 January to 2021 January. Data were collected from patient database, hospital records and histopathology data base. Data were collected according to demographical details including age, BMI, parity and past surgical histories, myoma details including size, type, site and number, intraoperative details and postoperative data. Results: Mean age of patients undergone laparoscopic myomectomy are 35.5 years (SD 6.083) Majority of the population (67%) were nulliparous. Indication wise 192 patients (44.4%) had pressure symptoms,137 patients (31.7%) presented with heavy menstrual bleeding and 103 patients (23.8%) had subfertility history. Regarding fibroids characteristics, single fibroid found in 168 patients (38.9%), fibroids between 2-4 found in 199 patients (46.1%) and fibroids 5-10 found in 65 patients (15%). Considering the location of fibroid, 192 patients (44.4%) had anterior wall, posterior wall in 125 (28.9%), fundal in 87 (20.1%), broad ligament in 21 (4.1%) and other locations in 7 patients (1.6%). Regard to type of the fibroids intramural fibroids identified in 196 patients (45.4%), sub serosal in 136 (31.5%), submucosal in 75 (17.4%) and pedunculated in 22 patients (5.1%). Mean blood loss was 159.4 +/- 68.03 ml while mean operative time was 124 +/- 49.6 minutes. But those differs with number and size and site of the fibroids. Mean blood loss and operative time increased when fibroids number and size increased. Mean operative time is 92.23 minute for fibroid size less than 8cm vs 178.9 minute for fibroid more than 12cm. Mean blood loss is 115.25ml for fibroid less than 8cm vs 238.27ml for fibroid size more than 12cm. Mean operative time for single fibroid is 90.8 minute vs 179.5 minute for fibroids 5-10. Mean operative time and blood loss are increased with posterior wall and broad ligament fibroids. However, it is not statistically significant (P Value 0.006 and 0.008 respectively). Prolonged operative time did not impact on surgical outcomes in terms of hospital stay and blood transfusion. Conclusion: In experienced and expert hand, laparoscopic myomectomy is a safe procedure with good surgical outcomes and low complication rate. Operative time and blood loss are mainly associated with the size of largest fibroid and number of fibroids. Open myomectomy may be of benefit for number of fibroids &gt; 10 when considering completeness of surgery. Hand morcellation through suprapubic port is a safe and effective method of specimen retrieval in laparoscopic myomectomy.

Robotic Myomectomy: Five Modifications in Our Practice.

We discuss five technical modifications made over 8 years in the technique of robotic myomectomy at our institution. Universal preoperative MRI was the first modification. Precise hysterotomy incisions were planned by accurate myoma mapping. The second modification was to reduce the number of ports. We performed surgery with one 12-mm-port for the camera and one 8-mm-port on either side of the patient for scissors and fenestrated bipolar forceps. Third modification was to reduce the number of robotic instruments by using laparoscopic myoma screw instead of robotic tenaculum during enucleation and discard the use of a second needle driver and prograsp forceps. So instead of six instruments in classical technique, we now use only three instruments thus reducing the cost of instruments by 40-50%. The fourth modification was to use a single 30 or 45cm barbed suture. A single long suture efficiently managed by wristed needle driver of robot was sufficient in most cases for hysterotomy closure. This reduces the time needed for multiple needle pass and cost due to reduced number of sutures used. The fifth modification was to not use the electro mechanical morcellator and commercially available bags. We do cold knife morcellation in indigenous plastic bags. Over a period of eight years, we have made robotic myomectomy efficient and reduced the cost of instruments by 40-50% as compared to the classical technique. This has enabled wider adoption of robotic myomectomy at our institution thus reducing open myomectomy in all types of myomas.

Comparison of transendometrial myomectomy versus conventional myomectomy in cesarean section

ObjectiveTo compare the surgical results of transendometrial myomectomy (TEM) and conventional myomectomy (CM) procedures for fibroid in cesarean section. Material and methodsThis retrospective study was conducted with computer-based medical records of patients who underwent myomectomy during cesarean section between January 2013 and March 2019. During the study period, 41 patients underwent transendometrial myomectomy, and 52 patients with had conventional myomectomy. In all patients included in the study, myoma was single, intramural, and localized in the anterior of the uterus. ResultsThe total duration of surgery was shorter in the TEM group than in the CM group (50,5 ± 10 min vs 63,6 ± 15,2, p = 0,001). There was no difference in terms of length of hospital stay, procedure-related hemoglobin difference, blood transfusion requirement and postoperative fever (respectively, p = 0,65, p = 0,81, p = 0,33 and p = 0,9). Patients who underwent TEM (0.58 ± 0.61) had significantly lower adhesion scores in their subsequent pregnancy compared to patients who underwent CM (1,76 ± 1,1) (p = 0,001). ConclusionTransendometrial myomectomy technique seems to be more advantageous in selected patients compared to the conventional technique due to the shorter operation time.

50 Vascular bulldog clamps for robotic myomectomy

The objective of this video is to illustrate how to incorporate the use of vascular bulldog clamps for reducing blood loss during robotic-assisted laparoscopic myomectomy. This video provides technical details on the use of robotic bulldog clamps and shows their placement and removal during a robotic myomectomy case. For experienced surgeons comfortable with retroperitoneal dissection, the use of vascular bulldog clamps may be easily incorporated into surgical technique for robotic myomectomy.

Robot-assisted laparoscopic myomectomy for FIGO type II sub-mucosal leiomyoma without endometrial injury for a patient with history of miscarriage

To introduce a technique for robot-assisted laparoscopic myomectomy for FIGO type II sub-mucosal leiomyoma with >50% myometrial extension, without endometrial injury. A narrated video demonstration of our technique has been provided. Our patient was a 35-year-old, gravida 1, para 0 woman with secondary infertility. She had been married for three years. She complained of heavy menstrual bleeding and severe dysmenorrhea with a pain score of 10 on visual analogue scale (VAS). Surgery was done after thorough counseling and an informed consent was obtained. Institutional Review Board number: KC17OESI0375, approval date: 21.09.2018. Several steps can be taken to help prevent endometrial injury, and these include: (1) proper preoperative imaging to plan surgery; (2) use of intraoperative ultrasound to determine best location of incision; (3) use of a “cold cut” technique with monopolar curved scissors without energy to avoid obscuring the border between the leiomyoma and the endometrium; (4) careful millimeter by millimeter dissection; (5) use of diluted indigo carmine to aid delineation of the endometrial cavity during dissection. The patient had a normal post-operative course. On follow-up her VAS pain score was 0. Transvaginal ultrasound repeated four months postoperatively showed normalization of uterine anatomy and endometrial contour. Robot-assisted laparoscopic myomectomy may be an option to preserve fertility and minimize endometrial injury. This surgical method allows complete removal of large sub-mucosal leiomyomas in one session with exact suturing.

New Surgical Technique for Robotic Myomectomy: Continuous Locking Suture on Myoma (LSOM) Technique.

Robot-assisted laparoscopic myomectomy (RALM) has broadened the indications even in complex myomas. However, the high cost of RALM remains the main disadvantage. Therefore, a surgical technique that can reduce the cost of RALM and still has the advantages of robotic surgery is required. We propose a “locking suture on myoma (LSOM)” technique and compared the operative and perioperative outcomes of patients who underwent RALM with or without the LSOM technique. We included 337 patients who underwent RALM with (n = 160) or without (n = 177) the LSOM technique between March 2019 and August 2020. The LSOM group had low parity and gravidity, with a low rate of Cesarean sections. Myoma type was not different between the groups; however, patients in the LSOM group had larger, heavier, and higher number of myomas, although fewer patients had multiple myomas and were discharged earlier. Total operating time, estimated blood loss, pre- and postoperative hemoglobin levels, transfusion rate, and postoperative fever were not different between the two groups. In conclusion, the LSOM technique may be a viable surgical option for myomas, as it can reduce the cost of RALM by obviating the need for robotic Tenaculum forceps.

The Emerging Role of Robotic Single-site Approach for Myomectomy: A Systematic Review of the Literature

Objective. To review the existing studies on single-site robotic myomectomy and test the safety and feasibility of this innovative minimally invasive technique. Data Sources. PubMed, Scopus, Google Scholar (from their inception to October 2019), as well as Clinicaltrials.gov databases up to April 2020. Methods of Study Selection. Clinical trials (prospective or retrospective) that reported the outcomes of single-site robotic myomectomy, with a sample of at least 20 patients were considered eligible for the review. Results. The present review was performed in accordance with the guidelines for Systematic Reviews and Meta-Analyses (PRISMA). Four (4) studies met the inclusion criteria, and a total of 267 patients were included with a mean age from 37.1 to 39.1years and BMI from 21.6 to 29.4kg/m2. The mean operative time ranged from 131.4 to 154.2min, the mean docking time from 5.1 to 5.45min, and the mean blood loss from 57.9 to 182.62ml. No intraoperative complications were observed, and a conversion rate of 3.8% was reported by a sole study. The overall postoperative complication rate was estimated at 2.2%, and the mean hospital stay ranged from 0.57 to 4.7days. No significant differences were detected when single-site robotic myomectomy was compared to the multiport technique concerning operative time, blood loss, and total complication rate. Conclusion. Our findings support the safety of single-site robotic myomectomy and its equivalency with the multiport technique on the most studied outcomes. Further studies are needed to conclude on the optimal minimally invasive technique for myomectomy.

Is Myomectomy during Caesarean Section a Safe Procedure? Prospective Cohort Study

Background: Benign uterine myoma is the commonest female tumor in the reproductive tract, and its incidence in pregnancy was estimated to be 2% to 5%. Traditionally, cesarean myomectomy was rejected as there is a liability of intrapartum and postpartum hemorrhage. The aim of this work is to investigate the significance of cesarean myomectomy together with early impact on the mother. Patients and methods: This study was conducted on 73 patients having different types and sizes of myoma during caesarean section delivery, the myomectomy was done by traditional technique but timing of myomectomy either pre or post delivery of the baby varied between different cases .Infusion of oxytocin during the operation and for 24 h later. Results: All women with uterine myoma were aging from 20- 38 years and had different parity. The participating women had myoma with different characteristics mostly from 5-10 cm. Also, the commonest types were intramural alone and sub-serous alone (76.8%). The commonest sites of fibroid were the uterine fundus and upper segment (80%).Intrapartum hemorrhage occurred in 10 cases that were overcome by ecbolics and bilateral uterine artery ligations with or without B-lynch technique. Five cases suffered from post operative fever that was overcome by antibiotics and antipyretics. The post partum hospital stay was 3 days in 63% of cases .Conclusion: caesarean myomectomy is a safe procedure but can be only done by experienced surgeon with some precautions.

Single Site Laparoscopic Myomectomy

Study Objective My objective in making this video is to share how we approach laparoscopic myomectomy in a patient with large uterine leiomyoma. Design Video presentation. Setting Hospital, operating room. Patients or Participants Laparoscopic myomectomy case was presented. Interventions Myomectomy. Measurements and Main Results N/A Conclusion I present a case of laparoscopic myomectomy, demonstrating myomectomy and suturing techniques, as well as leiomyoma morcellation through the umbilicus.

Concomitant Use of Laparoscopic Radiofrequency Ablation with Hysteroscopic Myomectomy for Large, Multi-Fibroid Uterus

Study Objective To discuss the combination of minimally invasive myomectomy techniques for large multi-fibroid uteri to ensure resolution of all associated symptoms. Design Case Study. Setting Suburban hospital, Michigan. Patients or Participants 37-year-old Caucasian G2P1011. Interventions 1. Hysteroscopic resectoscope of submucosal fibroid (TruClear) 2. Ultrasound guided laparoscopic radiofrequency ablation (Acessa system) of intramural, subserosal, and broad ligament fibroids Measurements and Main Results Patient presented with a longstanding history of a bulky, multi-fibroid uterus. Her symptoms included menorrhagia (resulting in anemia), lower abdominal pressure, cramping and back pain. Two prior gynecologists had recommended open hysterectomy given that she had completed childbearing, however she desired uterine conserving surgery. Physical exam revealed a BMI of 24 and a 20-week multi-fibroid uterus. Previous ultrasound noted a multi-fibroid uterus measuring 19 × 14.1 × 8.3 cm and pre-operative MRI demonstrated the largest intramural fibroid to measure 10.9 × 9.1 × 9.2 cm in the posterior lower uterine segment. A pedunculated submucosal (type 0) fibroid was also identified with significant distortion of the endometrial cavity. She elected to proceed with laparoscopic radiofrequency ablation with ultrasound guidance for the type 4-8 fibroids with concurrent mechanical resection of her submucous fibroid. The procedure was performed without complication and the total operative time was less than 2.5 hours. She was discharged from recovery in good condition. At 6-month follow-up, she noted significant reduction in pain, pressure and cramping, with almost complete resolution of menorrhagia. Conclusion Uterine sparing concomitant multi-modality surgery can be considered for patients presenting with large fibroids, including those with submucosal fibroids as a cause for their symptoms. Laparoscopic radiofrequency ablation combined with hysteroscopic resection, even for fibroids larger than 8 cm, can provide dramatic relief of menorrhagia, bulk and pain symptoms.