Image: CC/Nimur

Study author, Dr. Antonio Gargiulo, talks to 2 Minute Medicine. Center for Infertility and Reproductive surgery and Medical Director of the Department of Robotic Surgery, Brigham and Women’s Hospital*:

“While the numbers alone from this study only demonstrate non-inferiority, the fact that the study population had higher-risk pregnancies suggests that these same women may have fared worse if they had instead undergone a laparoscopic or open (abdominal) fertility-preserving myomectomy.

Further, the finding that robotic myomectomy has a roughly one in ten chances of presenting with adhesions at cesarean delivery has important clinical implications for surgeons and patients alike. The finding has relevance because the rate of pelvic adhesions reported in the literature for abdomonal myomectomy range between 60% and 90% and for laparoscopic myomectomy between 25% and 33%. Pelvic adhesions at cesarean section are associated with higher risk of surgical complications. Because a very high number of women undergoing myomectomy are committed to a cesarean birth, this study has great clinical relevance and patients should be aware of these findings when choosing the type of myomectomy they undergo.”

*Other authors include Michael Pitter, Leo Bonaventura, J. Stefano Lehman and principal investigator Serene Srouji

Key study points:

1. In women undergoing fertility-preserving robot-assisted laparoscopic myomectomy (RALM), there was a low rate (11.4%) of pelvic adhesions.

2. Despite higher rates of pregnancy risk factors (infertility, obesity, advanced maternal age, and multiple pregnancy) in this cohort, pregnancy outcomes in women after RALM were similar to those published for patients after traditional laparoscopic myomectomy.

Primer: Robot-assisted laparoscopy is a technique that has been under development since the 1980s to address limitations of conventional laparoscopy (such as sub-optimal ergonomics and two-dimensional visualization) (1). The application of robot-assisted laparoscopic techniques to various surgical procedures, mainly employed today in urology and gynecology, has been debated in the academic community and the lay press, with skeptics questioning the cost-effectiveness of these procedures and calling attention to the paucity of research demonstrating definitive improvements in patient outcomes (2).

Fibroids are benign tumors of uterine smooth muscle that can cause heavy menstrual bleeding and adversely impact fertility. This typically occurs when submucosal fibroids distort the uterine cavity, impairing implantation, though some argue that intramural fibroids with intra-cavitary components may also adversely impact implantation. The treatments for fibroids are medical or surgical, with definitive treatment being a hysterectomy. The mainstay of therapy for women with bulk symptoms, abnormal uterine bleeding, and impaired fertility is surgical. For women desiring fertility and/or uterine preservation, a minimally-invasive myomectomy is the treatment of choice. Studies have shown that, as compared to abdominal and/or laparoscopic myomectomy, RALM for treatment of symptomatic fibroids is associated with decreased blood loss, less need for post-operative pain medication, decreased risk of pelvic adhesions, and shorter hospital stays (3, 5). However, RALMs come at greater cost (4). Short-term outcomes have been shown to be equivalent or better in patients undergoing RALM (5). The question remains, however, whether longer-term reproductive outcomes (namely, fertility and pregnancy outcomes) are significantly better in robot-assisted as compared to laparoscopic or abdominal myomectomies.

The present work is the first study to characterize long-term pregnancy outcomes, a marker for post-surgical uterine functionality, in women desiring fertility preservation who undergo RALM.

Background reading:

1. Up-to-Date: Robot-Assisted Laparoscopy

2. NY TImes OpEd by Ezekial Emanuel: “In Medicine, Falling for Fake Innovation”

3. Surgical Outcomes in RALM vs Abd MMY

4.- Cost-effectiveness of abdominal, laparoscopic and robot-assisted myomectomy

5. Robot-assisted myomectomies: comparison of surgical outcomes and costs

This [retrospective cohort] study evaluated pregnancy outcomes from 872 women with fibroids who underwent RALM at three high-volume robotic surgery centers. The cohort consisted of women who desired minimally invasive fibroid treatment with uterine preservation. There were 127 pregnancies in the cohort after undergoing this procedure, over a five-year period.

Results showed that despite higher rates of infertility, obesity, advanced maternal age, and multiple pregnancy in this cohort of patients undergoing RALM, pregnancy outcomes were similar to those reported in the literature for patients after traditional laparoscopic myomectomy. The main pregnancy outcomes studied included rate of spontaneous abortions, ectopic pregnancies, and live births. One of the most striking findings of this study was the low rate of pelvic adhesions (11.4%) noted at the time of Cesarean delivery.

In sum: This study is the first to assess long-term pregnancy outcomes after RALM. Despite representing a higher-risk population, pregnancy outcomes in this cohort of women after RALM were similar to those previously published for patients after traditional laparoscopic myomectomy.

Click to read the study in the current issue of Human Reproduction

By [LH] and [DB]

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