Robot-assisted Laparoscopic Myomectomy Research Articles

A comparative retrospective analysis on robot-assisted laparoscopic surgery compared to conventional laparoscopy in case of myomectomy: experience in a third-level hospital of Southern Italy.

Uterine myomas are the most common gynecological disease in reproductive-aged women, present several symptoms, and require effective medical and/or surgical strategies. This study aimed to compare robotic-assisted laparoscopic myomectomy (RALM) with laparoscopic myomectomy (LM) in terms of operative times, intraoperative estimated blood loss, pre- and post-hemoglobin levels drop, and length of hospital stay. Data from 50 clinical records (25 RALM in Group A and 25 LM in Group B) of patients with uterine fibroids were collected from December 2022 to December 2023 at Gynecological Unit of DAI Materno-Infantile Federico II in Naples, Italy. Patients aged 30-49years with symptomatic fibroids were included. Data on peri-operative outcomes, including operative time for myomectomy (OTM), overall operative time (OOT), intraoperative estimated blood loss (EBL), pre- and post-operative hemoglobin levels, and length of hospital stay were analyzed. The OTM in the presence of > 5 myomas was 59 [52-65] vs 69min [61-96] (p < 0.001) for RALM and LM groups, respectively. Moreover, also in presence of ≤ 5 myomas, a difference was observed in the RALM group 48[43-55] compared to the LM group 53[50-61] min (p = 0.07). The OOT was also statistically significant for Group A compared to Group B (83[65-93] vs 72[56-110] min, p < 0.001). There were no significant differences between the two groups in terms of pre- and post-operative hemoglobin levels and EBL (p = 0.178). Group A demonstrated a notably shorter hospital stay 1.2 [1-2] days compared to Group B 2.9[3-3.75] days (p = 0.007). Our study suggests potential advantages of RALM over LM in terms of reduced operative times and shorter hospital stays. The standardized approach and extensive surgical experience likely contributed to the favorable outcomes of RALM.

Robotic-assisted laparoscopic versus abdominal and laparoscopic myomectomy: A systematic review and meta-analysis.

Myomectomy is the preferred treatment for women with uterine fibroids and fertility requirements. There are three modalities are used in clinical practice for myomectomy: abdominal myomectomy (AM), laparoscopic myomectomy (LM), and robot-assisted laparoscopic myomectomy (RLM). To compare the perioperative and postoperative outcomes of RLM, AM, and LM. We searched PubMed, Web of Science, Embase, and Clinical Trials for relevant literature published between January 2000 and January 2023. We included all studies reporting peri- and postoperative outcomes of myomectomy in patients with uterine myomas. Surgical treatments were classified as RLM, LM, or AM. Two or more authors selected studies independently, assessed risk of bias, and extracted data. We derived mean difference (MD) or odds ratio (OR) with 95% confidence intervals (CIs) for each outcome, subgrouping trials by the patient characteristics and myoma characteristics. We used the I2 statistic to quantify heterogeneity and the random-effects model for meta-analysis when appropriate. We used the funnel plot to assess the publication bias. A total of 32 studies with 6357 patients were included, of which 1982 women had undergone RLM. The operating time was significantly longer (MD = 43.58, 95% confidence interval [CI]: 25.22-61.93, P < 0.001), and the incidence of cesarean section after myomectomy was significantly lower (OR = 0.27, 95% CI: 0.10-0.78, P = 0.02) in RLM than in LM. Compared with AM, the operation time, blood loss, blood transfusion rate, complication rate, total cost, length of hospital stay, and pregnancy rate of patients with RLM were significantly different. The safety and effectiveness of RLM are superior to those of AM but inferior to those of LM.

Optimal energy use for robot-assisted laparoscopic myomectomy

Myomectomy is a surgical option for patients who wish to preserve fertility when removal of uterine fibroids is necessary. Robot-assisted laparoscopic surgery provides increased surgical dexterity during minimally invasive myomectomy (MIM) and permits greater accuracy with a layered closure of the uterine defect. However, uterine rupture following myomectomy has been reported more frequently with MIM than with laparotomy, including robot-assisted laparoscopic myomectomy (RALM). This article reviews the mechanisms of frequent uterine rupture following MIM and the optimal energy use during RALM.

Efficacy and safety of robot-assisted laparoscopic myomectomy versus laparoscopic myomectomy: a systematic evaluation and meta-analysis

ObjectiveSystematic evaluation of the efficacy and safety of robotic-assisted laparoscopic myomectomy (RALM) versus laparoscopic myomectomy (LM).MethodsPubMed, Embase, The Cochrane Library, and Web of Science database were searched by computer to seek relevant literature in order to compare the efficacy and safety of RALM with that of LM from the establishment of the databases to January 2023, and Review Manager 5.4 software was utilized to perform a meta-analysis on the literature.ResultsA total of 15 retrospective clinical controlled studies were included. There exists a total of 45,702 patients, among 11,618 patients in the RALM group and the remaining 34,084 patients in the LM group. Meta-analysis results revealed that RALM was associated with lesser intraoperative bleeding (MD = − 32.03, 95%CI − 57.24 to − 6.83, P = 0.01), lower incidence of blood transfusions (OR = 0.86, 95%CI 0.77 to 0.97, P = 0.01), shorter postoperative hospital stay (MD = − 0.11, 95%CI − 0.21 to − 0.01, P = 0.03), fewer transitions to open stomach (OR = 0.82, 95%CI 0.73 to 0.92, P = 0.0006), and lower incidence of postoperative complications (OR = 0.58, 95%CI 0.40 to 0.86, P = 0.006) than LM, whereas LM is more advantageous in terms of operative time (MD = 38.61, 95%CI 19.36 to 57.86, P < 0.0001). There was no statistical difference between the two surgical methods in terms of maximum myoma diameter (MD = 0.26, 95%CI − 0.17 to 0.70, P = 0.24).ConclusionIn the aspects of intraoperative bleeding, lower incidence of blood transfusions, postoperative hospital stay, transit open stomach rate, and postoperative complications, RALM has a unique advantage than that of LM, while LM has advantages over RALM in terms of operative time.

Multi-Port Robotic-Assisted Laparoscopic Myomectomy: A Systematic Review and Meta-Analysis of Comparative Clinical and Fertility Outcomes.

Uterine fibroids are the most frequently diagnosed gynaecological tumours, and they often require surgical treatment (conventional laparoscopic myomectomy-CLM). The introduction and evolution of robotic-assisted laparoscopic myomectomy (RALM) in the early 2000s has expanded the range of minimally invasive options for the majority of cases. This study aims to compare RALM with CLM and abdominal myomectomy (AM). Fifty-three eligible studies adhered to the pre-established inclusion criteria and were subsequently evaluated for risk of bias and statistical heterogeneity. The available comparative studies were compared using surgical outcomes, namely blood loss, complication rate, transfusion rate, operation duration, conversion to laparotomy, and length of hospitalisation. RALM was significantly superior to AM in all assessed parameters other than operation duration. RALM and CLM performed similarly in most parameters; however, RALM was associated with reduced intra-operative bleeding in patients with small fibroids and had lower rates of conversion to laparotomy, proving RALM as a safer overall approach. The robotic approach for surgical treatment of uterine fibroids is a safe, effective, and viable approach, which is constantly being improved and may soon acquire widespread adoption and prove to be superior to CLM in certain patient subgroups.

Enhancing Myomectomies with 3D Uterine Modeling

<h3>Study Objective</h3> 3D modeling of uterine fibroids allows for preoperative surgical planning and patient education, as well as intraoperative fibroid identification. <h3>Design</h3> This video demonstrates utilization of 3D uterine modeling to assist a robotic assisted laparoscopic myomectomy. <h3>Setting</h3> Community Hospital. <h3>Patients or Participants</h3> 35-yo with pelvic pain and abnormal uterine bleeding - heavy menstrual bleeding, secondary to uterine fibroids <h3>Interventions</h3> robotic assisted laparoscopic myomectomy. <h3>Measurements and Main Results</h3> Successful myomectomy of >20 large bulky fibroids performed through minimally invasive technique. <h3>Conclusion</h3> 3D modeling assists in patient education and surgical planning. It helps to minimize number of incisions to remove fibroids, thus decreasing trauma to the myometrium and improving efficiency. It also helps intraoperatively with fibroid identification to ensure complete fibroid removal.

Making Use of the Tools in the Toolkit: Combined Transcervical Radiofrequency Ablation and Hysteroscopic Myomectomy

<h3>Study Objective</h3> To highlight and describe the combined use of radiofrequency ablation and hysteroscopic myomectomy to address symptomatic uterine fibroids. <h3>Design</h3> Video presentation. <h3>Setting</h3> Academic tertiary care center. <h3>Patients or Participants</h3> This is a 41-year-old patient G2P1011 patient with a history of abnormal uterine bleeding and uterine fibroids. Her past surgical history was significant for an exploratory laparotomy for an ectopic pregnancy, a robotic-assisted laparoscopic myomectomy, as well as a 2-staged hysteroscopic myomectomy. <h3>Interventions</h3> Preoperative pelvic ultrasound showed an enlarged uterus with a 4.1 × 3.7 × 5.2 cm FIGO type 1 fibroid extending from the left uterine fundus into the endometrial cavity. The patient opted for a combined procedure of transcervical radiofrequency ablation and hysteroscopic myomectomy to maximize her chances of success; given her prior failed treatments. <h3>Measurements and Main Results</h3> The radiofrequency ablation portion of the case was completed first; with three overlapping zones of ablation completed on the fibroids. The submucosal component of the fibroid was then resected using the resectoscope. The patient tolerated the procedures very well, no complications were encountered. She was discharged on the same day of her procedure with non-opioid analgesics. <h3>Conclusion</h3> Uterine preserving, concomitant use of multi-modality surgery can be considered for patients presenting with symptomatic uterine, including those with significant intramural and submucosal components. Combining minimally invasive tools such as radiofrequency ablation and hysteroscopic myomectomy can offer patients safe and effective alternatives in management of recurrent and recalcitrant leiomyomas.

Effect and safety of diluted vasopressin injection on bleeding during robot-assisted laparoscopic myomectomy: a protocol for a randomised controlled pilot trial

IntroductionEven though the injection of diluted vasopressin into the uterus is expected to reduce intraoperative bleeding with decreased adverse effects during robot-assisted laparoscopic myomectomy (RALM), there is a lack of...

Is robot-assisted laparoscopic myomectomy superior to laparoscopic myomectomy?

Background: To determine whether RLM (Robot-assisted Laparoscopic Myomectomy) or LM (Laparoscopic Myomectomy) provides better surgical and post-operative outcomes for patients willing to have minimally invasive myomectomy. Methods: In this retrospective cohort (Class II-2) analysis, all patients who underwent RLM and LM by a single expertise surgical team from January 1st, 2018 to March 31st, 2020 were identified. The patients’ characteristics, operative data, and post-operative outcomes were collected and statistically analyzed. Results: A total of 118 patients with an indication of myomectomy were included, 39 of whom underwent RLM, while 79 underwent LM. There were no significant differences among the groups in demographic characteristics (p &gt; 0.05). RLM was associated with lower estimated blood loss (55.00 ± 39.11 mL vs. 110.80 ± 74.72 mL, respectively, p &lt; 0.001) and larger myoma size (6.92 ± 1.88 cm vs. 6.00 ± 2.07 cm, p &lt; 0.001) compared with LM. No significant differences were noted between the groups for other parameters (p &gt; 0.05). Conclusions: Although RLM was associated with significantly less blood loss, this difference did not entail clinical implications. In general, both methods demonstrated similar clinical outcomes. For cost effectiveness, LM appears to outperform RLM, particularly in experienced hands.

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.

Superior Hypogastric Plexus Nerve Block in Minimally Invasive Gynecology: A Randomized Controlled Trial

To assess the efficacy of a superior hypogastric plexus nerve block in reducing opioid requirements in the first 24 hours after minimally invasive gynecologic surgery. Patient-blinded randomized controlled trial. Single-center academic institution (Sydney Women's Endosurgery Centre). Two surgeons administering the blocks in their own surgeries. Patients undergoing either laparoscopic or robot-assisted laparoscopic hysterectomy or myomectomy for benign indications. Ropivacaine 10 mL (0.75%) infiltrated into the retroperitoneal space overlying the superior hypogastric plexus vs control of no block given at the completion of surgery. The primary outcome was the total opioid use in the first 24 hours after surgery, measured in morphine milligram equivalents (MME). Standardized fentanyl patient-controlled analgesia was given to all patients in the trial. The secondary outcome was pain measured on a visual analog scale (1 to 10) at 1, 2, 6, 12, and 24 hours after surgery. Fifty patients out of 56 approached for the study participated in, and completed, the study (89.2%). The patients were randomized over a 5-month period, March 2020 to July 2020. A total of 27 patients were randomized to receive a nerve block, and 23 were randomized to the control. There was a difference of -21.8 MME in the block group compared with the no-block group (95% confidence interval [CI], -38.2 to -5.5; p=.008). This correlated to a 38% reduction in opioid use in the block group. The mean opioid use in the patients in the block group was 33.1 MME (95% CI, 24.2-41.9) and in those in the no-block group 54.9 MME (95% CI, 40.7-69.1). For the block group, opioid use ranged from 1.0 to 76.5 MME, with an interquartile range of 37 (14-51). For the control group, the range was 7.5 to 113.5 MME, with a higher interquartile range of 60 (28-88). Pairwise comparisons of the mean pain scores over the 24 hours showed a lower pain score with a nerve block of 1.8 (95% CI, 1.5-2.1) compared with a no-block score of 2.6 (95% CI, 2.3-2.9) No adverse effects of local anesthetic toxicity, nerve injury, or bowel/vascular injury were noted in any patient. A superior hypogastric plexus nerve block is a simple technique for reducing postoperative opioid requirements and pain in the first 24 hours after minimally invasive gynecologic surgery.

Fertility and Pregnancy Outcomes After Robotic-assisted Laparoscopic Myomectomy in a Canadian Cohort

Myomectomy is the gold standard treatment for patients with symptomatic fibroids who desire fertility preservation. Given the relatively recent application of robotic surgery in the field of gynecology, there is only a small amount of data describing fertility outcomes after robotic-assisted laparoscopic myomectomy (RALM). The objective of this study was to determine the pregnancy rate in patients trying to conceive after RALM. A single-center, retrospective case series. Department of Obstetrics and Gynecology, St. Michael's Hospital, Toronto, Ontario, Canada. All patients who underwent RALM between October 2008 and September 2015 and who consented to a telephone interview were included. None. The primary outcome was pregnancy rate after RALM. Secondary outcomes included whether patients underwent fertility treatment, rate of live births after RALM, rate of spontaneous abortion mode of delivery in pregnancies following RALM, obstetric complications, and symptoms experienced postoperatively. A total of 123 patients underwent RALM between 2008 and 2015. Of them, 101 consented to be interviewed. Average age ± standard deviation was 34.4 ± 4.4 years. Average myoma size was 8.9 ± 2.2 cm. Of all myomas, 64 (63.4%) were intramural, 35 (34.7%) were subserosal, and 2 (2%) were submucosal according to preoperative imaging. The pregnancy rate after RALM was 42/60 (70.0%). Three additional patients became pregnant who were not trying to conceive. Of the 45 patients who became pregnant, 38 (84.4%) successfully delivered or were pregnant at the time of data collection. The pregnancy rate after RALM was 70.0%, which is similar to that reported in previous studies. Future research should aim to conduct larger, prospective studies investigating fertility outcomes after RALM and should aim to identify variables that predict pregnancy.

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.

Variables that prolong total operative time for robotic-assisted laparoscopic myomectomy: A 10-year tertiary hospital study in Korea

Study objectiveTo identify factors that prolong total operative time (TOT) in robotic-assisted laparoscopic myomectomy (RALM). DesignRetrospective cohort study. SettingTertiary university hospital. PatientsWomen who underwent RALM between April 2009 and May 2019 conducted by a single high-volume gynecologic surgeon. InterventionsPatients’ demographic data and intraoperative records were obtained. The association between the perioperative characteristics and TOT was analyzed. Measurements and main resultsA total of 584 cases met the inclusion criteria, with a mean TOT of 231.6 ± 86.7 min. The mean patient age was 36.3 ± 5.5 years, and the patients had a mean of 4.2 ± 4.0 myomas. The dominant myoma had a mean diameter of 7.6 ± 2.6 cm. The mean total weight of the extracted myomas removed was 202.2 ± 152.6 g.From multiple regression analysis, the following perioperative factors were intimately associated with the TOT: ① body mass index, ② the number of myomas, ③ weight of total myomas, ④ location of dominant myoma, ⑤ type of da Vinci robot system, ⑥ endometrial cavity opening during the operation, ⑦ intraoperative blood loss, and ⑧ patient hospitalization period. The number of myoma was most closely related to the TOT, with an R2 value of 0.330. All of the above factors with the exception of the type of robot system and location of dominant myoma were related to the console time. Age, parity, history of previous abdominal surgery, surgical indication, diameter, and FIGO classification were not associated with the TOT. ConclusionWith an accurate identification of the perioperative parameters above, we can improve the quality of RALM by counselling, selecting an appropriate patient selection, and preoperative planning.

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 Largest Uterine Leiomyoma Removed by Robotic-Assisted Laparoscopy in the Late Reproductive Age: A Case Report.

Uterine leiomyoma is a very common gynecological tumor in the reproductive years. Recent studies have shown that surgical treatment of uterine leiomyoma using robotic-assisted laparoscopic myomectomy (RALM) is associated with significantly fewer complications, lower estimated blood loss, fewer conversions, and less bleeding than conventional laparoscopic myomectomy. This study reports the case of a giant uterine leiomyoma treated using RALM. A 50-year-old woman was referred to our outpatient clinic with progressive abdominal distension. Ultrasonography and magnetic resonance imaging were performed and showed a markedly enlarged uterus containing a 28-cm uterine myoma. RALM confirmed the 28-cm subserosal myoma on the posterior wall of the uterus. The myoma was enucleated, and the myometrial and serosal defect was repaired with a continuous suture using barbed suture materials. The entire myoma was removed using an electric morcellator. The operation lasted for 190 minutes. The total weight of the removed myoma was 3,262 g, and uterine leiomyoma was pathologically diagnosed. There were no postoperative complications. Although the treatment of huge myomas using RALM is controversial and technically demanding, we successfully performed RALM in a patient with a large myoma. This case confirms the efficiency, reliability, and safety of a robotic-assisted laparoscopic approach for removing a huge myoma. In a well-selected case, RALM can be performed by experienced surgeons regardless of the size of fibroids.

A Novel Technique to Minimize Blood Loss in Robotic-Assisted Laparoscopic Myomectomy

Study Objective To evaluate the effect and feasibility of using bulldog clamps for temporary occlusion of bilateral uterine and utero-ovarian vessels on blood loss during robotic-assisted laparoscopic myomectomy. Design Retrospective chart review. Setting Academic tertiary care center. Patients or Participants A total of 15 consecutive patients, who underwent robotic-assisted laparoscopic myomectomy using bulldog clamps performed by single minimally invasive gynecologic surgeon, from 2018 to 2020. Interventions Patients were taken to the operating room for robotic-assisted laparoscopic myomectomy. Bilateral retroperitoneal dissection was performed with development of avascular spaces and ureterolysis. The uterine artery was skeletonized at its origin bilaterally and bulldog clamp was applied to each side, taking care to avoid ureteral and/or vascular injury. Furthermore, an avascular window was created in the mesosalpinx bilaterally and bulldog clamps were placed, occluding both left and right utero-ovarian vessels. Myomectomy was performed and once completed, all four clamps were removed allowing return of uterine blood flow. Measurements and Main Results Mean age and body mass index were 35.2 and 30.9 kg/m2, respectively. Most patients were black (53.3%). Mean myoma size and total myoma weight per patient were 6.6 cm and 106 g (standard deviation or SD = 82.7). Most leiomyomas were located in the fundus (41.4%). Mean estimated blood loss was 83 ml (range 20-200 ml). Mean operative time was 186 minutes. There were no intraoperative complications and all patients were discharged home on the same day of surgery. Conclusion Temporary bilateral uterine and utero-ovarian vessel occlusion using bulldog clamps can minimize blood loss during robotic-assisted laparoscopic myomectomy. Placement and removal of bulldog clamps for temporary uterine and utero-ovarian vessel occlusion are relatively easy and safe, compared to other methods of uterine artery ligation.

Durability of Laparoscopic Myomectomy

Study Objective To determine the time to re-intervention for fibroid symptoms following robotic or laparoscopic myomectomy by sub-specialty trained gynecologic surgeons. Design Retrospective cohort of patients who underwent robot-assisted and traditional laparoscopic myomectomy from 2005 through 2019 at tertiary care academic hospitals operating in Arizona, Florida, and Minnesota. Setting Three tertiary-care academic hospitals. Patients or Participants Electronic medical record database was surveyed using CPT codes for laparoscopic myomectomy yielding 592 charts, all of which were reviewed. After exclusion of those who underwent myomectomy for an indication other than symptoms attributable to uterine fibroids 451 patient charts remained for analysis. Interventions Any treatments targeting a symptom attributed to uterine fibroids following initial surgery were considered “retreatment.” Both medical and surgical managements were included. Measurements and Main Results Cumulative incidence curves were calculated for time to retreatment event and log-rank tests used to compare curves between: route of laparoscopic myomectomy, age group, BMI, race, parity, diagnosis group, FIGO grade, and myoma weight. Overall incidence of retreatment was 5.96% per year. Women less than 40 years of age were significantly more likely to require retreatment, 8.22% per year, compared to those older than 40, 4.18% per year (p=0.003). There were no significant differences between time to treat based on any other demographic. Thirteen percent of patients required retreatment and the majority (26, 44%) of these 59 patients underwent hysterectomy, followed by repeat myomectomy (13, 22%), and medical management (13, 22%). Conclusion The incidence of retreatment was found to be less than 6% per year for minimally invasive myomectomy, and only 13% of patients required some form of re-intervention demonstrating that minimally invasive myomectomy is a durable procedure for treatment of symptomatic fibroids. Further, the longevity of this treatment is greater in patients older than 40, as compared to their younger counterparts.

Gynecologic Pathology Presenting As Urologic Symptoms: A Lesson on Pelvic Nerves

Study Objective Patients with underlying gynecologic pathology often present with a combination of seemingly unrelated and non-specific complaints such as pelvic pain, urinary frequency, urgency, and gastrointestinal symptoms. Thus, patients are often misdiagnosed and mismanaged. A thorough understanding of pelvic nerve anatomy is important in properly diagnosing and treating these patients. Design N/A Setting N/A Patients or Participants This video will highlight two patient cases which demonstrate how gynecologic pathology can present as urologic symptoms secondary to disease involvement of certain pelvic nerves. The first patient is a 32 year old female who struggled with urinary frequency, urgency, nocturia, and pelvic pain; all of which were secondary to endometriotic implants overlying the hypogastric nerve. The second patient is a 31 year old female who also presented with urinary urgency, nocturia, and pelvic pain which was secondary to a large broad ligament fibroid impinging the hypogastric nerve and causing mass effect on her bladder. Interventions The first patient underwent robotic assisted laparoscopic excision of endometriotic tissue. The second patient underwent robotic assisted laparoscopic myomectomy. Measurements and Main Results Each of these patients had pathology either directly compressing the pelvic nerves or causing chemical irritation to the nerves. Postoperatively, after removal of endometrial implants resulting in decreased nerve irritation, the first patient's pain and urinary symptoms improved. Likewise, in the second patient, when the fibroid was removed the compression of the surrounding pelvic nerves and bladder were relieved and the patients, symptoms subsequently resolved. Conclusion Understanding pelvic nerve anatomy is important in properly diagnosing and managing patients who do not present with conventional gynecologic symptoms. It is important to remember that with structural and biochemical irritation of these nerves, gynecologic pathology can present as urologic or even gastrointestinal symptoms. Proper diagnosis saves the patient from unnecessary testing and ineffective treatments.