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Page 2 of 9 Kiss et al. Mini-invasive Surg 2021;5:55 https://dx.doi.org/10.20517/2574-1225.2021.70

[1]
affects up to 70% of women until reaching menopause . Risk factors include ethnicity, parity, early
[2]
menarche, late menopause, family history, obesity, and hypertension . While the presence of myomas are
rarely life threatening, they are associated with symptoms affecting quality of life such as abnormal bleeding,
[3]
pelvic pain, and urinary tract problems . In addition, myomas might also be linked with adverse pregnancy
outcomes such as infertility, preterm birth, or postpartum hemorrhage . Diagnosis is made based on pelvic
[4]
bimanual examination, ultrasonography, magnetic resonance imaging, or hysteroscopy. According to the
localization of the lesion (submucosal, intramural, or subserous), myomas are further defined by the
International Federation of Gynecology and Obstetrics (FIGO) subclassification system to better describe
their relation to the uterus and help select the appropriate therapeutical approach alongside other factors
such as size, number of lesions, reproductive plans, surgeons’ skill, etc. . Almost one third of women with
[5]
myomas seek medical help and request treatment. The current medical strategies offer surgical
interventions (myomectomy, hysterectomy, and occlusion of uterine arteries) or their alternatives (uterine
artery embolization, high-frequency magnetic resonance-guided focused ultrasound, and ultrasound-guided
radiofrequency ablation). Selective progesterone receptor modulators such as ulipristal acetate can be used
as a preoperative option or as a pharmacological therapy to reduce symptomatology as an alternative to
surgical treatment .
[6,7]

Myomectomy is a standard fertility sparing surgical method and should be considered for women with
fibroid related symptoms who do not desire hysterectomy. While open surgery (laparotomy) is thought to
be reserved for large and numerous myomas, mini-invasive methods as laparoscopy and robot-assisted
surgery have evolved in the hands of experienced surgeons to also deal with these more complex cases. As
the tendency of robot-assisted surgeries is growing, many authors share their experience or comparisons
with other surgical methods. In our center, we specialize on all surgical modalities, although in the majority
of cases preferring mini-invasive methods. While hysterectomy is still our leading procedure on a robotic
system, in the past years, the number of robotic myomectomies is rapidly growing, mostly for complex
cases. Our goal when writing this article was to research the current literature to support our shift from
laparoscopic to robotic myomectomies. Articles indexed with “robotic myomectomy, robot-assisted
myomectomy” and published from 2016 to October 2021 were retrieved from PubMed and reviewed for
relevancy. Our article presents the reader up-to-date consolidated information concerning the quickly
evolving technique of robotic myomectomy.

COMPARISON STUDIES
Robotic myomectomy is favorable in less complications, blood loss and hospital stay compared to open
surgery, while it is becoming a preferred modality in more complex cases to conventional laparoscopy.

The meta-analysis conducted by Wang et al. including 20 studies (2852 patients) compared robotic,
[8]
laparoscopic, and open myomectomy. The results show that robotic myomectomy is associated with fewer
complications and lower blood loss than the other modalities. It also showed lower conversion rate and less
bleeding than laparoscopic myomectomy and lower postoperative pain score than open surgery. In a
retrospective study by Ranes et al. , longer operation time is stated as the biggest drawback in comparison
[9]
with open surgery, which could outweigh shorter hospital stay. A mean operative time difference of 84 min
(95%CI: 60.41-109.29) in favor of open myomectomy against robotic assisted was observed in a meta-
analysis by Iavazzo et al. . On the other hand, robotic assisted myomectomy showed superiority in lower
[10]
blood loss [92.78 mL/operation (95%CI: 47.26-138.29)], need for transfusion (981 patients; OR = 0.20;
95%CI: 0.09-0.43), total complications (1101 patients; OR = 0.31; 95%CI: 0.11-0.87), and length of hospital
stay [1.84 days/patient (95%CI: 1.40-2.29)]. No significant difference was found in operating time, estimated
blood loss, need for transfusion, number of complications, and length of hospital stay between robotic