**2. Fundamental principles to consider**

Uterine fibroids, also known as fibroids or leiomyomas, are the most common benign tumors that appear in women of reproductive age. Depending on their location, number and size, the symptoms they produce vary in frequency and severity. There is scientific evidence that fibroids interfere with sperm migration, oocyte transport and embryo implantation due to endometrial inflammation or vascular alterations that they produce. Approximately 5 to 10% of infertile women have fibroids and their presence is the only abnormal factor found in up to 4% of them [1]. At present, in women of reproductive age with gestational desire and presence of fibroids, myomectomy is probably the treatment of choice.

Technology continues to evolve and expand conservative treatment options for women who desire fertility preservation. There are some techniques for this, such as: uterine artery embolization, high-frequency ultrasound guided by magnetic resonance imaging, and radiofrequency ablation. However, myomectomy remains the gold standard for women with infertility who suffer from uterine myomatosis and wish to become pregnant later [2].

The relationship between fibroids and fertility continues to be debated, especially with regard to intramural fibroids. It is generally accepted that submucosal fibroids decrease fertility and that subserous fibroids have little or no influence in this regard [3]. However, according to some reports, intramural fibroids that do not affect the cavity are also associated with unfavorable reproductive outcomes. Analysis of prospective and retrospective studies shows that intramural fibroids that do not distort the cavity have a significant adverse effect on live birth rates in women undergoing in vitro fertilization [4].

The impact of intramural fibroids that do not distort the endometrial cavity has been a point of constant controversy, especially when choosing the most appropriate therapeutic strategy, and as occurred in our study, intramural fibroids were the ones that were found more frequently in patients, without However, it is important to take into account the live birth rate and not only the postoperative pregnancy rate, since fibroids can be associated with an unfavorable obstetric outcome.

**123**

*Robotic Myomectomy: Until Achieving Reproductive Success, Step by Step*

A meta-analysis carried out by Sunkara and Rikhraj years later indicated that the presence of intramural fibroids that do not distort the cavity is associated with an adverse outcome in women undergoing treatment of In Vitro Fertilization (IVF), it is mentioned that the live newborn rate in patients with fibroids is 21% lower than

Those intramural fibroids that do not affect the cavity, the size of the same is still a point of debate, it is generally taken as a cut-off point for myomectomy those intrmaural fibroids that do not affect the cavity but are greater than or equal to 4 cm [5, 6]. As occurred in our group of patients, all intramural fibroids were at least 4 or more centimeters tall. In these cases, the route of choice for the surgical approach is

The surgical route of choice depends on two fundamental factors: the fibroid

Submucosal fibroids are treated hysteroscopically, while intramural and subserous fibroids can be treated laparoscopically, robotically, abdominally, or vaginally. Whenever possible, the route of choice should be through minimal access surgery, since there is a solid scientific basis in which it is shown that with the robotic laparoscopic, conventional laparoscopic or vaginal approach, there is less intraoperative blood loss, a lower rate of adhesions, less postoperative morbidity, and fewer days of hospitalization than with open myomectomy [7]. It should be noted that a recent study reported a faster return of patients to their work and/or daily activities after a

In this same sense, robotic myomectomy has shown that with a surgical team that operates frequently, it is superior to conventional laparoscopic myomectomy, even in the area of cost/benefit [9]. And it is that if you have a team made up of anesthesiologists, surgeons, nurses and doctors who regularly perform this type of robotic approach, efficiency, economy, shorter surgical times are achieved and the results are effective and at a reasonable cost. Even as Wu mentions, more studies are needed to determine which patients would benefit greatly from a robotic approach,

Takmaz et al. It compared symptom severity and health quality outcomes for women who underwent laparoscopic and robotic myomectomy. Finding that both laparoscopic and robotic myomectomy provides significant reductions in the severity of fibroid-associated symptoms and a significant improvement in quality of life 1 year after surgery. The rate of improvement was comparable for both procedures [11]. However despite the evidence that minimally invasive surgery is preferable to laparotomy, most myomectomies are still performed by laparotomy. Robotic surgery was introduced to eliminate or improve some of the difficulties associated with laparoscopic surgery. We know that a myomectomy is a surgery that requires suturing in several planes, in different directions and with different cancelations, where it was planned that the characteristics of a surgical robot that would help to carry out this work would be of great value. Robotic myomectomy has now been shown to be efficient and safe by a vast bibliography, its results are similar to laparoscopic surgery, although the robotic procedure is associated with a higher cost. The introduction of robotic surgery has expanded the indications for minimally invasive myomectomy to more complex cases that were previously performed using laparotomy. Despite everything, and as Lonnerfors points out, no randomized, prospective and controlled trials have been published that compare the different approaches to a myomectomy in order to make an analysis and from there derive the

There are two meta-analyzes that can be cited, the first by Lavazzo et al. The premise was to demonstrate that robot-assisted myomectomy was an equally safe and effective treatment option as laparoscopy and open surgery for uterine

itself, its location, its number, size and the experience of the surgical team.

*DOI: http://dx.doi.org/10.5772/intechopen.97880*

preferably by minimally invasive surgery.

myomectomy for minimally invasive surgery [8].

best recommendations based on the evidence [12].

both in terms of patient outcomes and cost-effectiveness [10].

in women without fibroids [3, 4].

### *Robotic Myomectomy: Until Achieving Reproductive Success, Step by Step DOI: http://dx.doi.org/10.5772/intechopen.97880*

*Latest Developments in Medical Robotics Systems*

Vision in third dimension (3D) High visual definition on the console

on the learning curve of each.

Movements of the forceps similar to those of the doctor's hand Better ergonomic position during surgery that avoids fatigue.

maintain the skill looking for the safety of the patient at all times.

of fibroids, myomectomy is probably the treatment of choice.

**2. Fundamental principles to consider**

and wish to become pregnant later [2].

women undergoing in vitro fertilization [4].

Surgeons who practice robotic surgery in benign gynecological conditions agree that in some cases, blood loss and transfusions are reduced, the time of hospital stay and of reintegration to daily activities is less, although commonly in the first cases of each surgeon surgical time may be longer than laparoscopic surgery depending

There are different opinions regarding the advantages and disadvantages that robotic surgery offers vs. laparoscopic surgery in benign gynecological conditions, which is why the advantages of this system and/or surgical approach should be known as in any other type of surgery, as well as the potential risks inherent in all surgery and notify the patient through an informed consent before the intervention. As in any other surgical technique, it is important that the surgeon is trained and certified in accordance with the guidelines that each hospital institution indicates for the practice of robotic surgery and is constantly updated through the tools provided by robotic surgery to ensure the correct use of this technology and always

Uterine fibroids, also known as fibroids or leiomyomas, are the most common benign tumors that appear in women of reproductive age. Depending on their location, number and size, the symptoms they produce vary in frequency and severity. There is scientific evidence that fibroids interfere with sperm migration, oocyte transport and embryo implantation due to endometrial inflammation or vascular alterations that they produce. Approximately 5 to 10% of infertile women have fibroids and their presence is the only abnormal factor found in up to 4% of them [1]. At present, in women of reproductive age with gestational desire and presence

Technology continues to evolve and expand conservative treatment options for women who desire fertility preservation. There are some techniques for this, such as: uterine artery embolization, high-frequency ultrasound guided by magnetic resonance imaging, and radiofrequency ablation. However, myomectomy remains the gold standard for women with infertility who suffer from uterine myomatosis

The relationship between fibroids and fertility continues to be debated, especially with regard to intramural fibroids. It is generally accepted that submucosal fibroids decrease fertility and that subserous fibroids have little or no influence in this regard [3]. However, according to some reports, intramural fibroids that do not affect the cavity are also associated with unfavorable reproductive outcomes. Analysis of prospective and retrospective studies shows that intramural fibroids that do not distort the cavity have a significant adverse effect on live birth rates in

The impact of intramural fibroids that do not distort the endometrial cavity has been a point of constant controversy, especially when choosing the most appropriate therapeutic strategy, and as occurred in our study, intramural fibroids were the ones that were found more frequently in patients, without However, it is important to take into account the live birth rate and not only the postoperative pregnancy rate, since fibroids can be associated with an unfavorable obstetric outcome.

**122**

A meta-analysis carried out by Sunkara and Rikhraj years later indicated that the presence of intramural fibroids that do not distort the cavity is associated with an adverse outcome in women undergoing treatment of In Vitro Fertilization (IVF), it is mentioned that the live newborn rate in patients with fibroids is 21% lower than in women without fibroids [3, 4].

Those intramural fibroids that do not affect the cavity, the size of the same is still a point of debate, it is generally taken as a cut-off point for myomectomy those intrmaural fibroids that do not affect the cavity but are greater than or equal to 4 cm [5, 6]. As occurred in our group of patients, all intramural fibroids were at least 4 or more centimeters tall. In these cases, the route of choice for the surgical approach is preferably by minimally invasive surgery.

The surgical route of choice depends on two fundamental factors: the fibroid itself, its location, its number, size and the experience of the surgical team. Submucosal fibroids are treated hysteroscopically, while intramural and subserous fibroids can be treated laparoscopically, robotically, abdominally, or vaginally. Whenever possible, the route of choice should be through minimal access surgery, since there is a solid scientific basis in which it is shown that with the robotic laparoscopic, conventional laparoscopic or vaginal approach, there is less intraoperative blood loss, a lower rate of adhesions, less postoperative morbidity, and fewer days of hospitalization than with open myomectomy [7]. It should be noted that a recent study reported a faster return of patients to their work and/or daily activities after a myomectomy for minimally invasive surgery [8].

In this same sense, robotic myomectomy has shown that with a surgical team that operates frequently, it is superior to conventional laparoscopic myomectomy, even in the area of cost/benefit [9]. And it is that if you have a team made up of anesthesiologists, surgeons, nurses and doctors who regularly perform this type of robotic approach, efficiency, economy, shorter surgical times are achieved and the results are effective and at a reasonable cost. Even as Wu mentions, more studies are needed to determine which patients would benefit greatly from a robotic approach, both in terms of patient outcomes and cost-effectiveness [10].

Takmaz et al. It compared symptom severity and health quality outcomes for women who underwent laparoscopic and robotic myomectomy. Finding that both laparoscopic and robotic myomectomy provides significant reductions in the severity of fibroid-associated symptoms and a significant improvement in quality of life 1 year after surgery. The rate of improvement was comparable for both procedures [11].

However despite the evidence that minimally invasive surgery is preferable to laparotomy, most myomectomies are still performed by laparotomy. Robotic surgery was introduced to eliminate or improve some of the difficulties associated with laparoscopic surgery. We know that a myomectomy is a surgery that requires suturing in several planes, in different directions and with different cancelations, where it was planned that the characteristics of a surgical robot that would help to carry out this work would be of great value. Robotic myomectomy has now been shown to be efficient and safe by a vast bibliography, its results are similar to laparoscopic surgery, although the robotic procedure is associated with a higher cost. The introduction of robotic surgery has expanded the indications for minimally invasive myomectomy to more complex cases that were previously performed using laparotomy. Despite everything, and as Lonnerfors points out, no randomized, prospective and controlled trials have been published that compare the different approaches to a myomectomy in order to make an analysis and from there derive the best recommendations based on the evidence [12].

There are two meta-analyzes that can be cited, the first by Lavazzo et al. The premise was to demonstrate that robot-assisted myomectomy was an equally safe and effective treatment option as laparoscopy and open surgery for uterine

myomatosis. It was found that regarding the comparison between the robotic and laparoscopic technique, no significant differences were found between both types of surgery. Concluding that the minimally invasive approach has the advantage of less blood loss, less need for transfusion and shorter hospital stay. Suggesting that long-term outcomes required clarification, including pain control, fertility, and postoperative pregnancy rates, as well as possible recurrence rates [13].

Two years later, Wang et al. They carried out a new meta-analysis on our subject and concluded that compared to the laparoscopic and abdominal approaches, robotic surgery is significantly associated with: lower indices of complications, lower conversion rate of the procedure and less operative bleeding [14].

The results in functional terms after performing a myomectomy by any approach is to achieve the birth of a healthy baby. In Mexico, the first successful report on a robotassisted myomectomy was made by our surgical team [14]. However, in this area there are not such drastic conclusions about the approach in favor of one or another technique according to the superiority of its reproductive results and the absence of randomized studies that compare the different surgical approaches in this regard. However Jayakumaran in a comparative analysis of the role of robot-assisted laparoscopy in the field of reproductive surgery the reported advantages and limitations of the use of robotics in reproductive surgeries such as myomectomy, among others. He found that robotic assistance in reproductive surgery presented decreased blood loss, less postoperative pain, a shorter hospital stay, and a faster convalescence, while reproductive outcomes were similar in the other approaches. He likewise found that robotic surgery was as safe and effective as conventional laparoscopy, representing a totally reasonable alternative to the abdominal approach. He suggesting that procedures that are technically challenging with the Conventional laparoscopy could be performed with robotic assistance due to its advantages of better visualization and Endowrist™ movements (similar to the wrist of the human hand) that allow for precise suturing. This helps to overcome the limitations of laparoscopy, especially in complicated procedures, and can shorten the learning curve of minimally invasive surgery. Thus justifying the controlled and randomized studies that compare the short and long-term results to strengthen the role of robotic surgery in the field of reproductive surgery [15].

Regarding efficiency with good results, fundamental characteristics in surgical procedures, there is the question that up to what number of fibroids would it be possible to remove by minimally invasive surgery?(16), particularly in robotic surgery. Kim et al. They demonstrated that it is feasible to perform a robotic myomectomy in patients with up to 20 fibroids, preserving efficiency and good postoperative results, being even a faster procedure than the open myomectomy with which it was compared in the study [16, 17].
