Page 20 - WJOLS - Laparoscopic Journal

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website to identify the papers on robotic surgery, laparos­ forceps or vacuum assistance. Premature preterm rup­
copic surgery, robot­assisted laparoscopic myomectomy, ture of membranes occurred in seven women. A large
conventional laparoscopic myomectomy, pregnancy proportion of babies were preterm deliveries (up to
outcomes following robot­assisted laparoscopic myomec­ 35 weeks of gestational age) with 2 at, 28 weeks, 1 at 28 to
tomy. Forty­three articles were referred from all sources. 32 weeks and 13 from 33 up to 35 weeks. One pregnancy
Twelve articles were chosen based on following criteria: resulted in uterine rupture and fetal demise and another
• Contemporary articles, in uterine dehiscence. Abnormal placentation included
• Published in journals with high impact factor and one occurrence of placenta accreta and one of placenta
ranked best in scientific journal ratings, previa. The placenta accreta did not occur at the site of
• High sample size. the hysterotomy incision for the robotic myomectomy.
The results were tabulated and compared by multi­ Peri­uterine adhesions were observed in 11% of women
variate model using Statistical Package for Social Sciences who delivered by cesarean section. Malpresentation of
(SPSS) software. the fetus occurred in 10% of births. Estimated blood loss
during delivery was 700 to 900 ml. There were five cases
RESULTS of postpartum hemorrhage, two of them requiring blood
During these studies, 872 women underwent robotic myo­ transfusions. One of the patients requiring transfusion
mectomy. One hundred seven subsequently conceived was the patient with a documented uterine rupture.
resulting in 127 pregnancies and 92 deliveries through The remaining patients had unremarkable postpartum
2011 to 2013. One hundred eight RALM were performed courses. Birth weight was 2800 to 3100 gm. Apgar scores
in the 107 women who later conceived. Over 50% of at 1 and 5 minutes were 8 and 9, respectively. Analysis
patients were nulligravid and 88.5% were nulliparous. of the relationship between myomectomy characteris­
About 10% had undergone a previous myomectomy or tics (number of myomas, myoma size, myoma weight,
a prior cesarean delivery. Thirty­three percent had prior location, entry into the endometrial cavity and multiple
gynecologic procedures (e.g. laparoscopy and dilatation myomectomies) and preterm delivery risk indicated a
and curettage). Operative time for the daVinci robotic significantly higher number of myomas removed among
procedure averaged just under 3 hours. Estimated blood women who later had preterm deliveries. Anterior loca­
loss was generally low, but three women received blood tion (of the largest incision) compared with all other
transfusions. The uterine size and the myoma size sites also was associated with higher preterm delivery
(greatest dimension) were 12.3 + 3.1 and 7.5 + 3.0 cm, rates. Neither patient age nor the characteristics of the
respectively. The myoma weight was 191.7 + 144.8 gm. myomas were significantly associated with spontaneous
The number of myomas removed were 3.9 + 3.2 with the abortion or time to conception following myomectomy.
largest number being 14. The most common locations Table 1 summarizes the published medical literature on
of the largest incision were the anterior portion of the pregnancy outcomes after laparoscopic myomectomy
uterus, posterior aspect and fundal region. Entry of the identified through various searches.
myoma into the endometrial cavity occurred in 20% of
myomectomies. None of the robotic surgeries resulted DISCUSSION
in a conversion to laparotomy. A total of 127 pregnan­ Women in these series had obstetrical outcomes that were
cies occurred in the 107 women including seven twin comparable with parameters described in the literature
and two triplet pregnancies. The majority of concep­ following laparoscopic myomectomy. This is especially
tions were spontaneous. The remainder originated from reassuring given that the women in this group were
assisted reproduction techniques (ART), with IVF being generally of advanced maternal age and overweight,
the most common. and had a high prevalence of infertility and multiple
The time to conception was 12 to 18 months. Spon­ births, all factors that are associated with pregnancy
taneous abortions up to 20 weeks occurred in 19% of complications. 4,9,13,42 Furthermore, findings at the time
pregnancies with very few after 14 weeks of gestation. of cesarean section revealed a very low rate of pelvic
Patient age was unrelated to this outcome. In addition, adhesion formation (11%), providing additional evidence
there were two ectopic pregnancies. Women became to support this minimally invasive approach for treat­
hypertensive in 12% of pregnancies. About two­thirds of ment of uterine fibroids. Major adverse outcomes were
the women delivered at age 35 years or older with only uncommon. However, one case of uterine rupture was
three women over the age of 43. The gestational age at reported in this series with a resultant rate of 1.1%. This
delivery was 35 to 37 weeks. The majority delivered by uterine rupture occurred in a patient who conceived
cesarean section; 5% delivered vaginally. None required 18 weeks after myomectomy and had no history of prior
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