Preoperative Uterine Artery Embolization Research Articles

Does preoperative uterine artery embolization decrease blood loss during total abdominal hysterectomy for uterine fibroids?

Does preoperative uterine artery embolization decrease blood loss during total abdominal hysterectomy for uterine fibroids?

Predictors and Clinical Outcomes of Fibroid Expulsion After Uterine Artery Embolization.

To evaluate rates of fibroid expulsion after uterine artery embolization (UAE) and risk factors. Single-center retrospective study of UAEs for fibroids between 2016 and 2020. Preoperative UAE and patients with incomplete follow-up were excluded. Patients underwent MRI before and 3months after UAE and/or as indicated. Medical records were reviewed, and patient demographics, fibroid characteristics and clinical events were recorded. Fibroid expulsion included fibroid exposure to the endometrial cavity on MRI, and tissue loss/passage as observed clinically or on MRI. Symptoms were considered major if requiring additional clinic visits or treatment. Statistical tests included Chi-square, Fisher's exact test, and logistic regression models. One hundred ninety-nine women were included. Symptomatic fibroid expulsion occurred after 31 (16%) procedures: 16 minor and 15 major. Symptoms included vaginal discharge (n = 23), bleeding (n = 9), tissue passage (n = 9), cramping/pain (n = 3), and fever (n = 4). Fifteen women (8%) needed additional care, of whom 6 (3%) required invasive procedures (4 elective hysterectomies, 1 hysteroscopic resection, 1 transvaginal removal of passing tissue). The International Federation of Gynecology and Obstetrics (FIGO) classification was significantly associated with symptomatic fibroid expulsion (p = 0.001). Odds ratio for symptomatic expulsion and expulsion requiring additional care for FIGO 3-7 versus 0-2 fibroids was 0.32 (95% confidence interval, 0.14-0.71, p = 0.005) and 0.28 (95% confidence interval, 0.10-0.83, p = 0.02), respectively. Other factors were not consistently associated with expulsion. Fibroid expulsion after uterine artery embolization was more common than previously reported but mostly asymptomatic or minimally symptomatic. Women with FIGO ≤ 2 fibroids should be appropriately counseled regarding risk for expulsion.

Pre-operative uterine artery embolization before hysterectomy or myomectomy: a single-center review of 53 patients

PurposeTo assess outcomes of planned pre-operative uterine artery embolization (UAE) in patients with uterine fibroids at high risk for bleeding prior to hysterectomy or myomectomy. Materials & methodsA retrospective review of 53 consecutive patients who underwent planned UAE followed by surgery from 2004 to 2019 was performed in a subset of patients deemed high risk for bleeding by the referring surgeon due to bulky fibroids and/or adhesions. Characteristics of the largest fibroid, total number of fibroids, embolic agents, estimated blood loss (EBL), complications, and other factors were collected. Results53 patients (mean age = 41) had an elective UAE prior to a hysterectomy 24 (45%) or myomectomy 29 (55%). Median interval between UAE & surgery was 21.6 h (range 1.75 h-57 days).Of the myomectomies, 13 (45%) were open, 15 (52%) hysteroscopic and 1 laparoscopic. Mean number of fibroids/patient was 4.1 (SD 1.3), mean fibroid volume was 328 cm3 (range 11–741), and the mean fibroid diameter in longest dimension was 7.4 cm (range 3.2–15). Mean EBL was 90 (SD 99.5 mL). Three (10%) myomectomy patients required blood transfusion.All hysterectomies were via a laparotomy. Mean fibroid volume was 1699 cm3 (range 93–9099 cm3) with a mean maximum diameter of 16.2 cm (range 6.5–29.6) and an average of 2.4 (SD 1.7) fibroids. Mean EBL was 352 (SD 220 mL). Four (17%) hysterectomy patients required an intra- or post-operative blood transfusion.At a mean 1-year follow-up (range 1 month-14 years), 70% of UAE-myomectomy patients and 74% of UAE-hysterectomy patients reported symptom resolution. Three (6%) patients were readmitted: one for osteodiscitis, one wound dehiscence, and one for an infected retained fibroid after myomectomy. ConclusionPlanned pre-operative UAE resulted in intraoperative blood loss similar to “all-comer” myomectomy and hysterectomy patients in the literature. Further studies may elucidate which patients would be the best candidates for this staged treatment paradigm.

Perioperative Considerations for Hysterectomy in Second-Trimester Molar Pregnancy.

Second-trimester complete molar pregnancies are rare. Due to a later presentation, means to reduce surgical and long-term morbidity from hemorrhage, hyperthyroidism, and gestational trophoblastic neoplasia risk should be considered. A 48-year-old woman presented at 17 6/7 weeks of gestation with vaginal bleeding, with a human chorionic gonadotropin (hCG) level of 483,906 milli-international units/mL, biochemical hyperthyroidism, and ultrasonographic suspicion for complete molar pregnancy. The patient received preoperative uterine artery embolization and antithyroid medication before undergoing total abdominal hysterectomy. Her thyroid function and hCG level normalized by 1 week and 69 days postoperatively, respectively. Uterine artery embolization and hysterectomy may reduce surgical blood loss and lower the risk of malignancy for patients at high risk for gestational trophoblastic neoplasia. Preoperative treatment of hyperthyroidism with gestational trophoblastic disease can reduce morbidity from thyrotoxicosis.

Validation of uterine artery embolization before surgical laparoscopic myomenucleation compared to single surgical laparoscopic myomenucleation for the treatment of large fibroids and uterus myomatosus.

To determine the efficacy of preoperative uterine artery embolization (uterine artery embolization; UAE) prior to elective laparoscopic fibroid removal compared to single laparoscopic fibroid removal in women with large uterine fibroids and women with uterus myomatosus. A total of 202 women with symptomatic uterine fibroids who were scheduled for elective fibroid enucleation were included in this retrospective, monocentric, non-randomized study. Two procedures were compared: women who received percutaneous UAE 24 h prior to elective laparoscopic fibroid eviction for large uterine fibroids (>6 cm) and uterus myomatosus. And women who received laparoscopic fibroid enucleation alone for large uterine fibroids and uterus myomatosus. Outcome parameters for effectiveness were the hospital stay, the operating time and the intraoperative blood loss. Women who underwent preoperative percutaneous embolization of the uterine arteries, both for large fibroids and uterus myomatosus, had significantly less blood loss, shorter hospital stays, and shorter operating times. Especially women with large uterine fibroids and women with uterus myomatosus after having children can benefit from the combination therapy of preoperative percutaneous uterine embolization with subsequent laparoscopic myoma enucleation.

Hysteroscopic Removal of Residual Cesarean Scar Pregnancy

<h3>Study Objective</h3> Cesarean scar pregnancy (CSP) is a rare type of ectopic pregnancy which may be managed by various medical and surgical options. We present a case series of patients managed by combined medical and hysteroscopic surgical approach. <h3>Design</h3> Retrospective review of CSP cases managed by combined methotrexate and hysteroscopy. <h3>Setting</h3> University affiliated department of Obstetrics and Gynecology. <h3>Patients or Participants</h3> 5 patients with a viable 6 weeks CSP. <h3>Interventions</h3> Administration of methotrexate (local and systemic intramuscular), with or without uterine artery embolization, followed by hysteroscopic removal of the residual pregnancy mass. <h3>Measurements and Main Results</h3> The residual CSP mass was successfully removed in 4 out of 5 cases by hysteroscopy, while one patient required a robotic assisted resection and repair of the cesarean scar due to persistent CSP. Pre-operative uterine artery embolization was performed in 2 cases for the prevention of excessive bleeding. No intra- or post-operative complications occurred. The post-operative sono-hysterography showed a residual myometrial thickness >4 mm in all cases. <h3>Conclusion</h3> Combined medical and hysteroscopic removal of viable CSP is safe and allows for fertility preservation.

8407 Interstitial Ectopic Pregnancy: A Case Series with Practical Tips for Surgical Management

<h3>Study Objective</h3> To review current treatment options for interstitial ectopic pregnancy (IP), with a focus on surgical treatments. To review outcomes of three surgically managed cases of IP. To demonstrate practical tips for success in laparoscopic management of IP. <h3>Design</h3> A case series presenting three cases of surgically managed IP with guided explanation of surgical intervention using video. <h3>Setting</h3> Academic affiliated community hospital. <h3>Patients or Participants</h3> The 3 cases of IP evaluated and treated over the past year were included in the study. <h3>Interventions</h3> Two patients underwent laparoscopic cornual resection of IP and one patient underwent emergent abdominal repair of ruptured IP. <h3>Measurements and Main Results</h3> Estimated blood loss (EBL) for laparoscopic management of 6-week IP with preoperative uterine artery embolization (UAE) was 20ml; length of post operative length of stay (LOS) was 1 day. EBL for 13-week IP without embolization was 50 ml, post op LOS was 0 days. EBL for ruptured IP repaired via open approach was 1000ml including hemoperitoneum, post operative LOS was 2 days. Beta hCG was trended once per week post operatively for all patients. Both patients undergoing laparoscopic resection had negative HCG by week 4. The patient with ruptured IP had negative hCG by week 8; however, she did not complete testing between week 5-7; at 4 weeks her hCG was 17. <h3>Conclusion</h3> IP is sometimes a difficult diagnosis to make; a high index of suspicion is necessary. Laparoscopic surgery for IP is achievable using similar techniques as laparoscopic myomectomy for limiting perioperative blood loss and repair of the myometrial defect; Ultrasonic scalpel, vasopressin, delayed absorbable barbed suture. IP can often be treated laparoscopically, however laparotomy may be necessary in unstable patients with advanced gestation. Further investigation is necessary to determine the best practice for surgical management of IP.

Management of Cesarean Scar Pregnancy Via Laparoscopic and Transcervical Approaches

<h3>Study Objective</h3> To detail novel management of sequelae of pre-operative uterine artery embolization in the setting of a cesarean scar pregnancy in a patient undergoing laparoscopic uterine wedge resection. <h3>Design</h3> A video case report with follow up at 2- and 6-weeks post-procedure. <h3>Setting</h3> An operative suite at a tertiary care center. <h3>Patients or Participants</h3> A 30-year-old woman with cesarean scar pregnancy in the setting of one prior cesarean section who underwent uterine artery embolization. Following embolization, she developed significant clot in the uterus, consistent with placental abruption, which was unable to be evacuated with uterine wedge resection alone. <h3>Interventions</h3> Uterine artery embolization followed by laparoscopic uterine wedge resection of a cesarean scar pregnancy with hysteroscopy and dilation and aspiration under direct laparoscopic visualization. <h3>Measurements and Main Results</h3> Approximately 100cc of additional products of conception and clot was evacuated from this patient by using a secondary method of uterine evacuation (dilation and aspiration). <h3>Conclusion</h3> Use of both laparoscopic and transcervical resection of cesarean scar ectopic pregnancy resulted in increased evacuation of products of conception. Further study is warranted to determine if this results in overall decreased blood loss in patients.

Successful pregnancy after presurgical uterine artery embolization in the management of a very large cervical myoma: A case report

Although fibroids are the most common benign tumors of the uterus in women of reproductive age, cervical fibroids are rarely seen. Since cervical fibroids are located deep in the pelvis, the incidence of complications in surgery is high. Among these complications bleeding is the most common, due to poor access to myoma, difficulty in suturing and repair, and distortion of vital neighboring structures. Each case should be managed individually to minimize bleeding. To decrease bleeding in patients who wish to retain their fertility, intraoperative interventions include vasoconstrictors such as vasopressin and adrenaline, uterotonics such as oxytocin, misoprostol or ergometrines, uterine artery clamping, internal iliac artery balloon occlusion catheters, and tourniquets; preoperative interventions include gonadotropin releasing-hormone analogues and uterine artery embolization. We present a case of a 40-year-old woman who had a large cervical myoma and a desire for future fertility. To overcome technical difficulties and reduce intraoperative bleeding during myomectomy, presurgical uterine artery embolization was performed. The patient conceived spontaneously after the operation and a healthy baby was delivered by cesarean section.

Preoperative Uterine Artery Embolization in Women Undergoing Uterus-Preserving Myomectomy for Extensive Fibroid Disease: A Retrospective Analysis

Objectives: The aim of this study was to determine if a long versus short interval between preoperative uterine artery embolization (PUAE) and subsequent myomectomy impact perioperative blood loss and the complication rate in cases of enlarged multi-fibroid uterus. Design: In cases of an enlarged multi-fibroid uterus, operative myomectomy can lead to heavy blood loss and consequently increases the risk for transfusion and hysterectomy. PUAE can possibly contribute to a reduction of these risks. Our study was designed to determine if a long versus short interval between PUAE and subsequent surgery impacts perioperative blood loss and complication rate. Participants and Methods: PUAE was performed 24 h before the planned myoma enucleation in 21 patients between January 2011 and March 2016 (group 1) or 19 days before the operation in 23 patients from March 2016 to May 2018 (group 2). A comparison was made to a historical sample of 57 patients with large myomas (>10 cm) without PUAE (group 3). Perioperative blood loss, need for postoperative blood transfusion, and postoperative complications were recorded. Subjective improvement of myoma-related symptoms was assessed for each group by a questionnaire. Results: PUAE was carried out successfully without complications in all patients. Conversion to hysterectomy was not needed in any of the PUAE patients but was necessary in one of the control patients. In the three groups’ comparison, there was a significant lower risk for high blood loss (≥500 mL) in group 1 and a lower but not significant lower risk in group 2 compared to group 3 without an embolization preoperatively. Also, a significant lower risk for postoperative blood transfusion for group 1 (OR 0.02; 0.001–0.328; p = 0.01) and 2 (OR 0.02; 0.001–0.277; p = 0.01) compared to group 3 was observed. The postoperative complication risk was lower in group 2 (model 1: OR 0.12; 0.016–0.848; p = 0.03; model 2 OR 0.07; 0.009–0.588; p = 0.01) compared to group 3. In the context of the postoperative questionnaire, 10 of 11 patients in group 1, 12 of 12 patients in group 2, and 31 of 36 patients from the control group reported an improvement of their complaints. Conclusion: PUAE is beneficial for uterus-preserving removal of myomas from patients with a substantially enlarged uterus. There is a significant reduction of high blood loss (≥500 mL), need for postoperative blood transfusion, and postoperative complications in patients with extensive fibroid disease after PUAE compared to no intervention before myoma enucleation.

Laparoscopic Management of Cesarean Scar Pregnancy

<h3>Study Objective</h3> To present a case and surgical video of a laparoscopic excision of a cesarean scar pregnancy at 12 weeks and review the literature regarding cesarean scar pregnancy management. <h3>Design</h3> Case report and surgical video. <h3>Setting</h3> Tertiary care hospital. <h3>Patients or Participants</h3> One patient. <h3>Interventions</h3> 23 y/o G5P0131 at 7 weeks 1 day with history of obesity and a 31-week low transverse cesarean delivery presented for initial prenatal care to an outside OB. Cesarean scar pregnancy diagnosis was not recognized until patient presented for a nucal translucency to maternal fetal medicine at 11 weeks and 3 days where suspicion for scar pregnancy was raised. Patient was referred to our institution where cesarean scar pregnancy was confirmed at 11 weeks and 6 days and laparoscopic excision was recommended, as it was felt that pregnancy was too large and advanced in gestational age for medical management to be successful. Patient underwent uterine artery embolization and fetal intra-cardiac KCl injection the day prior to procedure to prevent hemorrhage during surgery, then patient underwent laparoscopic excision of cesarean scar pregnancy. <h3>Measurements and Main Results</h3> Laparoscopic excision of cesarean scar pregnancy was completed successfully with no intra or post-operative complications. Surgical techniques are reviewed in the surgical video. Patient had a good surgical recovery. <h3>Conclusion</h3> Laparoscopic excision of a cesarean scar pregnancy can be accomplished successfully with good outcomes when preventative measures to achieve good hemostasis such as pre-operative uterine artery embolization and fetal intra-cardiac KCl injection are used.

Laparoscopic Cervical Myomectomy with PRE-Operative Uterine Artery Embolization and Concomitant Abdominal Cerclage: A Case Report

Laparoscopic Cervical Myomectomy with PRE-Operative Uterine Artery Embolization and Concomitant Abdominal Cerclage: A Case Report

3:36 PM Abstract No. 169 Preoperative uterine artery embolization before hysterectomy or myomectomy: a case series

3:36 PM Abstract No. 169 Preoperative uterine artery embolization before hysterectomy or myomectomy: a case series

Temporary uterine artery occlusion with a Nelaton catheter reduces bleeding during laparoscopic myomectomy for cervical fibroids

Laparoscopic myomectomy (LM) is currently widely used as surgical treatment for uterine fibroids; however, it may be technically challenging in some patients with cervical fibroids in whom laparotomy needs to be performed. Reportedly, preoperative uterine artery embolization and intraoperative cutting and ligation of the uterine artery reduce intraoperative bleeding during myomectomies. Notably, maintaining maximal uterine blood flow is necessary in patients who desire fertility preservation; unfortunately, currently, no such method is available.

1493 Preoperative Uterine Artery Embolization Prior to the Surgical Management of Fibroids: An Institutional Case Series

Study Objective Uterine artery embolization (UAE) can be used as a preoperative adjunct for the surgical management of fibroids. Few, small studies have reported that preoperative UAE may reduce blood loss or facilitate a laparoscopic approach for myomectomies. We assessed outcomes at our institution with preoperative UAE prior to surgical management of fibroids from 7/1/2013 through 8/1/2018. Design Case series Setting Academic medical center Patients or Participants Patients who underwent preoperative UAE prior to surgical management of fibroids Interventions Preoperative UAE followed by myomectomy/hysterectomy Measurements and Main Results Eight patients underwent planned UAE immediately prior to surgery: 2 myomectomies and 6 hysterectomies. One myomectomy was laparoscopic; 22 week size uterus, 3 fibroids removed (largest 11 cm), specimen weight 903g, estimated blood loss (EBL) 300cc with intraop vasopressin use. The other myomectomy was abdominal; 22 week size uterus, 23 fibroids removed (largest 11 cm), specimen weight 1723g, EBL 500cc, with intraoperative vasopressin and misoprostol used. Of the hysterectomy cases, 3 were abdominal and 3 were laparoscopic. A notable open case was a supracervical hysterectomy of a 32 week size uterus; EBL 200cc, specimen weight 5150g. Among the laparoscopic hysterectomy cases, the mean uterine size was 19 weeks (range 17-21 weeks; mean specimen weight 1328g), average EBL 350cc (range minimal-500cc). There were no complications from the UAE and no perioperative surgical complications (conversion to laparotomy, blood transfusions, fever/infection, bleeding, reoperations). All minimally invasive cases were discharged on postoperative day 0. Conclusion Preoperative UAE for surgical management of fibroids appears to be a safe adjunct to myomectomy or hysterectomy with respect to control of EBL, reduced need for transfusions, and maintaining a laparoscopic approach (when applicable). Future larger studies, likely with pooled data from multiple sites, are needed to further evaluate the safety and efficacy of preoperative UAE in this setting.

The Enlarged Fibroid Uterus: Aberrant Arterial Supply via the Omental Artery.

Uterine artery embolization is considered a first-line therapy for symptomatic fibroids and is occasionally required to mitigate operative risk prior to total abdominal hysterectomy or myomectomy. We present a pictorial review of parasitized omental artery supply to the enlarged fibroid uterus in three patients undergoing preoperative uterine artery embolization. A detailed understanding of variant uterine blood supplies is crucial when performing fibroid embolization. Although omental artery supply to the fibroid uterus is an unusual finding, aortography to include mesenteric arteries may be necessary when anomalous blood supply to the enlarged fibroid uterus is suspected.

Analysis of presurgical uterine artery embolization (PUAE) for very large uterus myomatosus; patient's desire to preserve the uterus; case series and literature review.

Purpose of this paper to present results of a group of 21 consecutive patients who underwent uterine artery embolization (UAE) immediately before myomectomy. Surgical myomectomy can lead to a substantial blood loss in case of large or multiple tumors due to the hypervascularization of the tumors. This may lead to multiple blood transfusion or hysterectomy. In cases were the preservation of the uterus is demanded, pre-operative embolization could reduce the risk of substantial bleeding. Between January 2011 and March 2016, 21 patients underwent UAE 24 hours before myomectomy. All patients were asked by questionnaire about post-surgical follow-up, complications, the length of the scar, satisfaction and improvement of symptoms. Data of the operation and embolization were retrospectively assessed. UAE could be performed in all patients without complications. Mean diameter of the largest myoma was 12.7 ± 3.2 cm, primary preservation of the uterus succeeded in all cases. In none of the cases a perioperative blood transfusion was necessary. One patient underwent hysterectomy in another hospital after primary successful resection, one patient received transfusion of 2 bags of red blood cell concentrate during her stay in hospital.11 of 21 patients responded to the questionnaire. 10 of 11had subjective symptom improvement. Mean inability to work was 31 days, the mean self-measured length was 12 cm. 9 of 11 patients would recommend the procedure, one patient was in the second trimester of pregnancy. Preoperative uterine artery embolization facilitates a safe and uterus-preserving myomectomy in patients with very large or multiple fibroids. · Uterus-preserving myomectomy can be used in cases of large uteri or with multiple fibroids with low amount of blood loss.. · The combination of preoperative embolization and subsequent myomectomy may be a therapeutic option in cases of infertility due to a fibroid-induced uterine deformation.. · Good interdisciplinary cooperation is essential for sustainable results in this complex group of patients.. · Schnapauff D, Russ M, Kröncke T et al. Analysis of presurgical uterine artery embolization (PUAE) for very large uterus myomatosus; patient's desire to preserve the uterus; case series and literature review. Fortschr Röntgenstr 2018; 190: 616 - 622.

4:21 PM Abstract No. 311 Preoperative uterine artery embolization may reduce blood loss during hysterectomy for select uterine leiomyomata

To determine the effect of preoperative uterine artery embolization (UAE) on blood loss during hysterectomy. A retrospective query of internal databases selected patients who underwent UAE prior to hysterectomy from 2012-2016. Estimated blood loss (EBL) during hysterectomy, as documented by the gynecological surgeon, was compared between patients who received preoperative UAE and a control group of similarly sized uteri from a previously published study of women undergoing hysterectomy alone. An alternative method for measuring blood loss, as calculated using the Gross Equation, was also compared to EBL for study subjects as a secondary outcome. Data was stratified based on uterine weight. Unpaired Student’s t-test calculated the statistically significant relationships between blood loss in patients who received a preoperative UAE and those who underwent hysterectomy alone. 19 patients underwent UAE prior to hysterectomy. There was no significant difference in EBL between the control and the preoperative UAE cohort (427.7 ± 305.0 mL vs. 421.3 ± 400.3 mL; p = 0.929). When stratifying according to uterine weight, hysterectomy of intermediate and small uteri trended toward decreased blood loss when preceded by UAE with EBL of 464.3 ± 285.2 mL vs. 337.5 ± 47.9 mL (p = 0.381) and 387.6 ± 281.4 mL vs. 225.0 ± 311.3 mL (p = 0.137), respectively. There was significantly more blood loss on overall and sub-group analysis when blood loss was estimated using the Gross Equation rather than surgical documentation. Although logical and employed in clinical practice, there is little evidence to date supporting the use of prehysterectomy UAE to decrease blood loss during surgery. While this study is limited by sample size and does not show a significant decrease in EBL with preoperative UAE, it does suggest a benefit for patients with small and intermediate size uteri. Larger uteri may have a highly collateralized blood supply, decreasing the efficacy of embolization on intraoperative hemostasis. Further investigation with higher power and more robust measurements of blood loss should be conducted to more clearly elucidate the benefits of UAE prior to hysterectomy.

Preoperative Uterine Artery Embolization for Huge Prolapsed Pedunculated Submucosal Fibroid

Preoperative Uterine Artery Embolization for Huge Prolapsed Pedunculated Submucosal Fibroid

Robotic-Assisted Laparoscopic Treatment of Residual Ectopic Pregnancy in a Previous Cesarean Section Scar: A Case Report

Study ObjectiveTo describe a technique of robotic-assisted laparoscopy of residual cesarean scar pregnancy (CSP) and uterine defect repair. DesignVideo case report, with step-by-step explanation of the procedure (Canadian Task Force classification III) SettingCSP may be treated by different approaches including surgery and methotrexate. Successful methotrexate treatments avoid an emergency surgical treatment. In these cases a residual CSP often remains and should be removed in women who desire to conceive. CSP is often associated with a cesarean section scar defect called an isthmocele. In case of isthmocele with important defect and desire for pregnancy, laparoscopic repair may be proposed. Diagnosis and treatment of isthmocele is usually performed in a second time after a successful treatment of CSP. In this case, a surgical treatment including the removal of the residual CSP and treatment of the isthmocele may be proposed. InterventionIn this video we describe a technique for the surgical removal of residual CSP and isthmocele treatment by robotic-assisted laparoscopy. A 32-year-old patient developed a CSP treated by 2 in situ injections of methotrexate. A magnetic resonance imaging study performed 1 month after the last methotrexate injection revealed a persistent 4-cm residual CSP, associated with an isthmocele. Preoperative uterine artery embolization was performed to reduce intraoperative bleeding. After localization of the residual CSP on the left side, a temporary left uterine occlusion was performed. Residual CSP was totally removed. The residual defect and isthmocele were closed using delayed absorbable suture. ConclusionRobotic-assisted laparoscopic removal of residual CSP and isthmocele treatment is a feasible and safe procedure. This procedure may be proposed in patients presenting with this condition after a methotrexate treatment of CSP.