Reproductive outcomes following robotic-assisted laparoscopic myomectomy (RALM)

Abstract

Uterine myomas are the most common type of benign tumor in women of reproductive age and are commonly associated with menorrhagia, dysmenorrhea, dyspareunia, and urinary symptoms. Uterine fibroids have been also linked to infertility and pregnancy loss. Women wishing to preserve or restore their fertility are best treated by myomectomy. Robotic-assisted laparoscopic myomectomy is one of the latest technological applications of minimally invasive surgery. Limited data exist regarding the feasibility of robotic-assisted laparoscopic myomectomy (RALM) in terms of pregnancy and surgical outcomes, and more studies are needed. The goal of this study is to assess reproductive outcomes following RALM in a private practice setting. The study was performed in the form of a retrospective chart review. Female patients 22-44 years old diagnosed with intramural myoma were eligible for inclusion. Presence of a myoma was a necessary but not necessarily the presenting symptom. All patients underwent RALM between January 2006 and May 2009 under the care of one surgeon at two clinical sites. Patients were selected postsurgically via chart review based on inclusion parameters outlined above. Median values for pregnancy rate, number of myomas, diameter of largest myoma, surgery duration, and blood loss were calculated and used for subsequent statistical analysis. Clinically useful markers for pregnancy outcomes evaluation following RALM were identified. Thirty patients were enrolled, of whom 16 were interested in conception due to infertility. A pregnancy rate of 75 % was recorded. Among those who conceived, eight patients (67 %) reported natural conception within 6 months of unprotected intercourse, while four patients (33 %) utilized assisted reproductive technologies to conceive. One patient (8 %) miscarried. Two patients (17 %) experienced premature delivery, at 28 and 32 weeks, respectively. All deliveries were performed via Cesarean section. No surgical complications were reported following RALM. There were no cases of scar dehiscence or rupture. The median number of myomas in those who delivered was estimated at 1.0 compared with 3.5 in those unable to conceive (p < 0.05). In addition, median age was 34 compared with 42.5 years, respectively (p < 0.05). This retrospective study assessed pregnancy outcomes following RALM. Our pregnancy rate of 75 % combined with a low incidence of complications contributes to the limited pool of data available on this topic, and supports the need for a multicenter trial to further evaluate effectiveness and safety of RALM in terms of pregnancy outcomes.

Fertility and Symptom Relief following Robot-Assisted Laparoscopic Myomectomy

“…The difference may reflect the larger proportion of women in this study who were actively trying to conceive. Our conception rate after three years among women actively trying to conceive (67%) is on par with the rates from studies discussed above, 68%–78% [ 7 – 9 ]. Average time to pregnancy in our study was 10.6 months, comparable to the median time of 10 months observed by Lonnerfors and Persson [ 8 ].…”

“…In the study by Lonnerfors and Persson [ 8 ], 15 out of 22 (68.2%) women who actively wanted to achieve pregnancy were successful after removal of deep intramural myomas by RALM. Tusheva et al [ 9 ] reported a success rate of 75% in 16 RALM patients desiring pregnancy. We have previously reported on pregnancies following RALM in a large, multicenter study [ 10 ] and found an overall conception rate of 12.3%, similar to the rate of 13% shown by Cela et al [ 7 ].…”

“…We found that, in addition to longer time since surgery and an active desire to conceive (group 3 women), achieving pregnancy was associated with younger age, prior conception success, Caucasian race, and remaining symptom-free. Other RALM [ 8 , 9 ] and LM [ 12 , 15 , 24 , 25 ] studies have reported a negative association between pregnancy and increasing age and a positive association between prior pregnancy and future conception success [ 1 ]. The positive effect of Caucasian race may be related to a lower risk of myoma regrowth without symptom recurrence (controlled for in logistic analysis).…”

“…However, long-term outcomes following RALM, in particular symptom recurrence and pregnancy rates, have received little attention thus far. Fertility following RALM has been reported only in a few small case series [ 7 – 9 ]. Pitter et al [ 10 ] studied outcomes of pregnant women following RALM in a large patient series but made no reference to women who did not achieve pregnancy.…”

Minimally Invasive Gynecological Surgery

“…While safety and reproductive benefi ts of laparoscopic myomectomy compared to the open abdominal approach have been established in literature Seracchioli et al 2000 ;Palomba et al 2007 ), limited data is available about the robotic myomectomy. Another retrospective cohort study reported the pregnancy rate of 75 % among 16 patients attempting conception following robotic myomectomy procedure with no reported complications, including entry to the uterine cavity (Tusheva et al 2013 ). The authors reported 18 pregnancies resulting in 3 miscarriages, 2 terminated pregnancies, 10 successful term deliveries, and 3 ongoing pregnancies.…”