Seyeon Won

Objectives: This study aimed to compare the impact of robotic (RO) versus laparoscopic single-site ovarian cystectomy (LO) on ovarian reserve, as measured by changes in anti-Müllerian hormone (AMH) levels. Methods: A total of 43 women undergoing LO and 40 women undergoing RO for mature cystic teratoma were included. The baseline characteristics and surgical outcomes were scrutinized. AMH levels were evaluated preoperatively and at 3 months after surgery. Results: BMI (body mass index) was higher in the LO group (23.1 ± 3.6 cm vs. 21.7 ± 2.1 kg/m², p = 0.03) than in the RO group. Otherwise, there were no statistically significant differences in patient characteristics. The LO group showed a shorter operative time (70.0 ± 24.0 vs. 86.5 ± 26.7 min, p = 0.002) than the RO group., However, multiple linear regression analysis revealed that BMI was independently associated with increased operative time (p = 0.001), while the surgical method was not a significant predictor (p = 0.725). There were no significant differences in the rate of decline in AMH level between the LO and RO groups (13.3 ± 21.2 vs. 4.64 ± 34.1%, p = 0.167). There were intergroup differences in the hemostasis method: in the LO group, bipolar coagulation was performed for 27 (62.8%) patients, and sutures were performed for 16 (37.2%) patients; in the RO group, bipolar coagulation was performed for 5 (12.5%) patients, and sutures were performed for 33 (82.5%) patients, while in the case of 2 (5.0%) patients, hemostasis was not performed (p < 0.001). However, note that in our logistic regression analysis, the hemostasis method was excluded as an independent factor affecting AMH. Conclusions: There appear to be no significant advantages of RO over LO in terms of ovarian reserve preservation.

Background: ArtiSential, a class of innovative laparoscopic instrument, has been developed to overcome the limitations of conventional laparoscopic surgery by enabling free, 360°‐unrestricted movement of the wrist joint, as in robotic surgery. Objective: The aim of the present study was to describe the initial experiences with these devices in myomectomy and to report the surgical outcomes. Methods: A total of 77 women undergoing laparoscopic or robotic myomectomy between January 2021 and June 2022 were included in this multicenter prospective study. The ArtiSential instruments used by the surgeons were those chosen according to their respective preferences. The baseline characteristics, surgical outcomes, trocar placement options, and operator survey results were scrutinized. Results: The mean age of the patients was 39.9 ± 6.3, and the mean body mass index (BMI, calculated as weight in kilograms divided by the square of height in meters) was 22.4 ± 3.4 kg/m ² ; 46.8% of the patients underwent robotic surgery, while 53.2% underwent laparoscopic surgery. The number of removed myomas was 3.3 ± 3.0, the size of the largest myoma was 7.1 ± 2.3 cm, and the operative time was 130.0 ± 54.0 min. No transfusions or laparotomy conversions were required. Other than one case of ileus, there were no postoperative complications. In most cases, the instruments were inserted through the umbilicus trocar, and the fenestrated forceps, needle holder, and bipolar fenestrated forceps, in that order, were frequently employed. According to a surgeon survey, 29.9% moderately or strongly agreed that the ArtiSential devices utilized were more convenient than conventional laparoscopic instruments, while only 9.7% moderately or strongly agreed that they were more convenient than robotic instruments. Conclusions: Myomectomy as performed with an ArtiSential instrument seems to be feasible and safe. Further studies are necessary in order to comparatively assess the outcomes and potential benefits of ArtiSential, robotic, and conventional laparoscopic myomectomy.

Choi SH, et al. Yonsei Med J. 2024 May;65:e27. https://doi.org/10.3349/ymj.2023.0434

Choi SH, et al. Yonsei Med J. 2023 Mar;64(3):204-212. https://doi.org/10.3349/ymj.2022.0278

Background: There is still concern regarding postoperative adhesion formation and adverse effects on pregnancy outcomes caused by barbed suture (BS) after myomectomy. The aim of this study was to compare the postoperative adhesion and pregnancy outcomes between conventional suture (CS) and BS after minimally invasive myomectomy (MIM) by robotic myomectomy (RM) or laparoscopic myomectomy (LM). Methods: The medical records of 94 women who had undergone MIM with CS and 97 who had undergone MIM with BS and achieved pregnancy were reviewed. Postoperative adhesion was evaluated following cesarean section. Results: The number of removed myomas was greater (5.3 ± 4.6 vs. 3.5 ± 3.1, p = 0.001) and the size of the largest myoma was larger (7.0 ± 2.2 vs. 5.8 ± 2.7 cm, p = 0.001) in the BS group relative to the CS group. A total of 98.9% of patients in the CS group and 45.4% in the BS group had undergone LM (p < 0.001), while the others underwent RM. There was no significant difference in the presence of postoperative adhesion at cesarean section between the BS and CS groups (45.5 vs. 43.7%, p = 0.095). Additionally, there were no intergroup differences in pregnancy complications such as preterm labor, placenta previa, accrete or abruption. Note also that in our logistic regression analysis, the suture type (BS or CS) was excluded from the independent risk factors regarding postoperative adhesion formation. Conclusions: Our data indicated that the incidence of postoperative adhesion after MIM with BS was similar when compared with CS. Also it seems that the suture type does not have a significant effect on pregnancy outcomes.

Background: Robotic single-site plus two port myomectomy (RSTM) was designed to reduce the number of incision sites while retaining the advantage of conventional robotic multi-port myomectomy (CRM). This study aimed to explicate RSTM and compare surgical outcomes between it and CRM. Methods: The medical records of 146 patients who had undergone RSTM and 173 who had undergone CRM were reviewed. The surgical outcomes between them were compared by propensity score matching (PSM) analysis. Results: The PSM analysis showed no statistically significant inter-group differences in patient characteristics. With regard to surgical outcomes, the RSTM group enjoyed shorter operative time (148.30 ± 44.8 vs. 162.3 ± 47.4 min, p = 0.011), less hemoglobin decrement (1.8 ± 0.9 vs. 2.3 ± 1.0 g/dL, p < 0.001), and shorter duration of hospital stay (5.4 ± 0.7 vs. 5.8 ± 0.7 days, p < 0.001). Conclusions: RSTM was associated with shorter operative time relative to CRM. Further prospective studies are needed in order to more fully investigate the advantages of RSTM.

Kim SJ, et al. Yonsei Med J. 2022 May;63(5):446-451. https://doi.org/10.3349/ymj.2022.63.5.446

Endometrial cancer (EC) in young women tends to be early-stage and low-grade; therefore, such cases have good prognoses. Fertility-sparing treatment with progestin is a potential alternative to definitive treatment (i.e., total hysterectomy, bilateral salpingo-oophorectomy, pelvic washing, and/or lymphadenectomy) for selected patients. However, no evidence-based consensus or guidelines yet exist, and this topic is subject to much debate. Generally, the ideal candidates for fertility-sparing treatment have been suggested to be young women with grade 1 endometrioid adenocarcinoma confined to the endometrium. Magnetic resonance imaging should be performed to rule out myometrial invasion and extrauterine disease before initiating fertility-sparing treatment. Although various fertility-sparing treatment methods exist, including the levonorgestrel-intrauterine system, metformin, gonadotropin-releasing hormone agonists, photodynamic therapy, and hysteroscopic resection, the most common method is high-dose oral progestin (medroxyprogesterone acetate at 500–600 mg daily or megestrol acetate at 160 mg daily). During treatment, re-evaluation of the endometrium with dilation and curettage at 3 months is recommended. Although no consensus exists regarding the ideal duration of maintenance treatment after achieving regression, it is reasonable to consider maintaining the progestin therapy until pregnancy with individualization. According to the literature, the ovarian stimulation drugs used for fertility treatments appear safe. Hysterectomy should be performed after childbearing, and hysterectomy without oophorectomy can also be considered for young women. The available evidence suggests that fertility-sparing treatment is effective and does not appear to worsen the prognosis. If an eligible patient strongly desires fertility despite the risk of recurrence, the clinician should consider fertility-sparing treatment with close follow-up.

Background: We hypothesized that the total operative time of robot myomectomy (RM) is shorter than that of laparoscopic myomectomy (LM) in cases where numerous myomas are removed, due to the faster suturing time of the robotic system. To verify this, we compared the surgical outcomes of RM vs LM for the number of myomas removed.Methods: The medical records of 144 women underwent LM and 121 women underwent RM by a single surgeon were reviewed.Results: The operative time did not statistically differ between the groups, even when the number of removed myomas was more than 12 (200.6 ± 48.2 vs 196.0 ± 48.4 minutes, P = .791). Note that in our logistic regression analysis, the operation type was excluded from the independent risk factors prolonging operative time.Conclusion: RM showed a similar operative time relative to LM regardless of the number of myomas removed (numerous or not).

Background: To introduce a hybrid robotic single‐site myomectomy (H‐RSSM) technique that includes laparoscopic single‐site myoma excision followed by robotic single‐site suture and compare its surgical outcomes with those of conventional robotic single‐site myomectomy (RSSM) using the da Vinci Si surgical system.Methods: Medical records of 89 consecutive women who underwent H‐RSSM and 131 consecutive women who underwent RSSM were retrospectively reviewed. Patients characteristics and surgical outcomes were evaluated and compared between two groups.Results: The H‐RSSM group had a significantly reduced operation time (98.7 ± 31.7 vs 141.4 ± 54.4 min, P < .001) and lower estimated blood loss (131.5 ± 78.1 vs 212.3 ± 189.8 mL, P < .001). Peritoneal adhesions were reported significantly more in the H‐RSSM group than in the RSSM group (27.0% vs 9.2%, P < .001).Conclusion: H‐RSSM was found to be associated with reduced operative time and lower estimated blood loss. However, further prospective studies are needed to clarify these advantages.