Single-Site Robotic Myomectomy without Accessory Instrument Compared with Two-Port Laparoscopic Myomectomy: A Propensity Score Matching Analysis

Abstract

Objectives: Despite the advantages of robotic technology, single stie robotic myomectomy without an accessory instrument (SSRM) is limited by a restricted range of motion, weaker suturing of a thick myometrium, and non-articulating instruments. We present our novel gradual turning out method (GTOM) of SSRM and our assessment of its feasibility and safety by comparing its perioperative outcomes with those of two-port laparoscopic myomectomy (LM). Design: Retrospective cohort case control study. Methods: This study included consecutive 46 patients who underwent SSRM for intramural myomas larger than 7 cm, from 2016 to 2019. Subsequently, 46 patients who underwent LM were selected by 1:1 propensity score matching by controlling for age, body mass index, myoma number, myoma diameter, and the presence of sexual intercourse. The perioperative outcomes of the two groups were compared using a Mann-Whitney U test and Fisher’s exact test. The effect of covariates on operation time was analyzed using univariable and multivariable linear regression. Results: SSRM was performed successfully with GTOM for myomas of up to 14 cm in the longest diameter, without conversion to laparotomy and intraoperative injuries. No differences between the groups were found in length of hospital stay, estimated blood loss, hemoglobin level decrease, transfusion rate, and postoperative pain, but operative time was significantly longer in the SSRM group than in the LM group (P < 0.001). Larger myomas, location of the lower segment, and the operation method of SSRM were significantly associated with a longer operation time. Whereas operation time for myomas located at the anterior wall, singleton myomas, and myomas <10 cm was significantly longer in the SSRM group than in the LM group, that for myomas at the posterior or lateral side of the uterus, multiple myomas, and myomas ≥10 cm did not differ significantly between the groups, indicating the advantage of SSRM for difficult myomectomy. Limitations: Retrospective nature of the study and limitation to a single-center study. Conclusions: Despite the lack of an accessory instrument, SSRM using the GOTM was feasible and safe as it yielded similar perioperative outcomes to those of LM.

Overcoming the limitations of single-site robotic myomectomy via the gradual turning out method without an accessory port, and a know-how

“…SSRM was shown to have comparative surgical outcomes in terms of estimated blood loss, hospital stay, and perioperative complications to traditional MRM [9,13]. Additionally, compared with LM, SSRM yields similar perioperative outcomes, including length of hospital stay, estimated blood loss, decrease in the hemoglobin level, transfusion rate, and postoperative pain [15]. However, operative time was significantly longer in SSRM for myomas located at the anterior wall, singleton myomas, and myomas less than 10 cm, compared with LM.…”

“…Although SSRM is still in the initial learning curve, recent reports showed its feasibility [9][10][11][12][13][14][15]. SSRM was shown to have comparative surgical outcomes in terms of estimated blood loss, hospital stay, and perioperative complications to traditional MRM [9,13].…”

“…A 2.0-2.5 cm vertical midline incision through the center of the umbilicus was made with an open Hasson approach [15,18]. The peritoneum was opened with Kelly forceps through the natural defect at the umbilical center.…”

“…Fenestrated bipolar forceps and a monopolar hook were inserted. An intravenous line extension was inserted for evacuation of surgical smoke [15], which worked better than we thought it would. This line could be used for suction and irrigation by switching the three-way valve.…”

“…Here we describe the novel gradual turning out method (GTOM) for performing an SSRM, which is safe and feasible [15]. An accessory port or a longer incision is not required in GTOM, which yields better cosmetic results.…”