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Kiss et al. Mini-invasive Surg 2021;5:55 https://dx.doi.org/10.20517/2574-1225.2021.70 Page 3 of 9

assisted and conventional laparoscopic myomectomy.

In a review study considering open or mini-invasive way of entrance in myoma enucleation, comparable
outcomes in estimated blood loss, complications, and duration of hospital stay were reached between
[11]
laparoscopy and robotic surgery . The operative time of robotic myomectomy was stated as longer, as in
previous studies. Demanding surgical skills for larger myomas and unfavorable localization and higher
economic burden were stated as additional limiting factors for robotic myomectomy. The authors cited an
older systematic review , in which short-term benefits such as blood loss, need of blood transfusion, and
[12]
hospitalization were significantly lower in robotic assisted myomectomy, while open surgery showed to be
preferable in operating time and costs. Gingold et al. reviewed the myoma management in conventional
[13]
vs. robotic assisted myomectomy. The outcomes of the reviewed studies show that robotic surgery was
preferred in more complex cases, in which easier maneuverability of the wristed robotic instruments and
three-dimensional visualization helped in better dissection, suturing, and application of hemostatic
techniques. Nevertheless, these findings tend to be biased by surgeons’ experience and inclination to select
more difficult cases for robotic surgery and should not be considered as outcome-based evidence to
prioritize robotic myomectomy.

When patients were questioned about their symptoms and health quality the morning before and one year
after laparoscopic and robotic myomectomy, both groups showed a significant reduction in symptoms and
improvement in quality of life without statistical difference between the two methods of surgery .
[14]

In the last few years, the dominant comparison studies are between multiport vs. single-site/single-port
robotic myomectomies. The consensus is that multiport myomectomy is preferred for larger myomas, while
single-site is feasible for selected patients with less complicated cases, and both methods are associated with
low rates of intra- and post-operative complications [15,16] . In a very recent review, no significant differences
were found in operating time, blood loss, and total complication rate .
[17]
OPERATING TIME
Generally, robot-assisted surgeries tend to be longer because of the necessary docking of the robotic arms
before the actual surgery begins. For myomectomies, the use of the wristed instruments should speed up the
suturing time, which, in comparison with laparoscopy, is a common obstacle even in experienced surgeons.
This hypothesis was disproved, when robotic myomectomies showed similar operating time with
laparoscopic ones regardless of the number of myomas removed . It seems that the difficulty of docking
[18]
and lack of tactile feedback during enucleation is compensated with easier and faster suturing in robotic
myomectomy.

In a very recent study, factors related to the total operative time were body mass index (BMI), number of
myomas, total myoma weight, location of dominant myoma, type of da Vinci robotic system (Xi vs. S),
intraoperative uterine cavity exposure, blood loss, and total hospitalization period . To the contrary, all of
[19]
the above-mentioned factors, except for the location of dominant myoma and type of robotic system, are
also associated with console time. Age, parity, previous surgeries, surgical indication, and size of the
dominant myoma were not associated with total operating time. In the analysis of 242 cases, the number of
myomas (5-9 vs. ≥10) and surgeon’s experience were the only two factors that were positively correlated
with operation time. Furthermore, the number of myomas and maximal myoma diameter were positively
[20]
correlated with estimated blood loss .