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Page 4 of 9 Kiss et al. Mini-invasive Surg 2021;5:55 https://dx.doi.org/10.20517/2574-1225.2021.70

[21]
Movilla et al. proposed a preoperative calculator to predict the total operative time of myomectomies.
Factors significantly associated with the length of surgery are age, diabetes mellitus, uterine volume, number
of myomas generally and those more than 3 cm, diameter of the dominant myoma, and surgeons’
experience. On the other hand, BMI, hypertension, previous surgeries, location, and classification of the
myomas do not affect the operative time.

The significantly reduced time of single-site procedure can be acquired by combining the advantages of the
laparoscopic enucleation and robotic assisted suturing called hybrid robotic single-site myomectomy [22,23] .

The operating time also depends on the experience of the surgeon and the OR team. Robotic
myomectomies have a steep learning curve, with the operating time significantly reducing after 10 cases .
[24]

LARGE/HEAVY/MULTIPLE MYOMAS
Several case studies show the enucleation of huge myomas (the biggest being 28 cm and 3.2 kg), while
pushing the limits of robotic assisted techniques [25,26] . These cases confirm the efficiency, reliability, and
safety of the robotic approach in well-selected cases regardless of the size of the fibroids. The major
advantages of robotic surgery in comparison to abdominal is shorter hospital stay with faster recovery and
less blood loss. Wristed instruments enabling a larger range of movements in a limited abdominal space
blocked by the enlarged uterus and easier suturing of extensive uterine defects after enucleation are the
assets of robotic surgery in contrast with laparoscopy resulting in lower conversion rate. A retrospective
study of Lee et al. compared robot-assisted myomectomies (RAM) with abdominal myomectomies (AM)
[27]
in myomas larger than 10 cm and heavier than 250 g. While the operating time was significantly longer in
RAM than AM (164 min vs. 108 min), hospital stays were shorter (2.68 RAM days vs. 4.13 AM days). Short-
term postoperative complications such as fever or bleeding were lower in RAM than AM (26% vs. 54%). In a
retrospective study, outcomes of robotic myomectomies of patients with large myomas (> 10 cm) were
compared with myomas < 10 cm operated by a single surgeon . While the largest myoma was 20 cm in
[28]
diameter, operation time was the only significant difference between the two groups (263.4 ± 83.7 min vs.
219.1 ± 75.7 min, P = 0.02). Another comparison study between myoma size (≥ 9 cm vs. < 9 cm) showed
significant increase in operation time (130 min vs. 92 min) and estimated blood loss (100 mL vs. 25 mL),
while no major adverse outcomes were reported in either group . Jansen et al. retrospectively studied
[29]
[30]
surgical approaches (abdominal, laparoscopic, or robotic) of myomectomies for extreme myoma burden
(total specimen weight 436 g or ≤ 7 myomas). While the perioperative outcomes (estimated blood loss,
blood transfusion, and complications) were similar in all modalities, mean operating time was the longest in
robotic surgery (239 min) and mean hospital stay in abdominal surgery (2.2 days). Based on the analyses,
the likelihood of complications increases in parallel with the myoma weight and number. The authors
suggested preferring abdominal or laparoscopic approach in cases with extreme myoma weight and
abdominal in cases of large number of myomas. On the other hand, Kim et al. compared 30 robotic vs. 13
[31]
open surgeries for the removal of ≥ 10 myomas. Operating times were longer in the robotic approach
(360 min vs. 180 min), while length of hospital stay was shorter (2.5 days vs. 3.5 days). Because there were
no conversions to laparotomy or any major complication, the authors suggested robotic approach to be an
[32]
alternative to open surgery in cases with more than 10 myomas. Lee et al. recommended multiport
robotic myomectomy with supraumbilical incisions in myomas larger than the umbilical level not only to
ensure better cosmetic effect, but also to eliminate instrument and trocar collisions in single-port systems in
a limited intrapelvic space.