Feasibility and surgical outcomes of robotic myomectomy for large and multiple uterine fibroids- insights from a decade of experience at a single centre

Abstract

There is limited data on the safety and effectiveness of robotic-assisted myomectomy (RM) for large (≥ 8 cm) and multiple (≥ 5) fibroids. This study aims to assess the feasibility and perioperative outcomes of RM in these cases. A retrospective chart review was performed on 260 patients who underwent RM at a single institution between January 2013 and May 2024. Demographic information, primary symptoms, and operative outcomes were extracted from the patients' medical records. Large myomas were defined as those with a diameter of ≥ 8 cm, while multiple myomas were considered to be ≥ 5 fibroids. Data from 260 patients, with a mean age of 34.18 ± 5.55 years, were collected and analyzed. On average, 2.37 ± 0.31 fibroids were removed, with a mean weight of 294.0 ± 290.25 g. The average operative time was 144.6 ± 55.3 min, including a console time of 100.3 ± 47.13 min. The estimated blood loss (EBL) averaged 189.05 ± 296.65 mL, with 6.9% (18 patients) requiring transfusions. The mean hospital stay was 23.46 ± 6.42 h, with 87 patients staying more than 24 h. No conversions to laparotomy, reoperations, or major complications were reported. Patients with fibroids ≥ 8 cm experienced significantly higher EBL (p = 0.019), transfusion rates (p = 0.041), and longer hospital stays (p = 0.009). Although total operative time was not significantly affected by the number of fibroids, docking (p = 0.036) and console times (p < 0.001) were longer in patients with ≥ 5 fibroids. Additionally, blood transfusions were more frequently required in this group. Drawing on ten years of experience, this study highlights the feasibility and efficacy of RM in treating uterine myomas larger than 8 cm and in cases involving five or more fibroids.

Introduction

Uterine leiomyomas, commonly referred to as fibroids, represent one of the most prevalent benign gynecologic tumors, with an estimated incidence of up to 70% among women of reproductive age [1]. While many cases remain asymptomatic, approximately 30% of women experience significant symptoms such as abnormal uterine bleeding, iron-deficiency anemia, infertility, pelvic or back pain, and urinary or gastrointestinal disturbances that often necessitate medical or surgical intervention [2]. Myomectomy remains the surgical treatment of choice for women seeking to preserve fertility [3]. Although minimally invasive techniques are increasingly utilized, laparotomy remains the standard approach for myomectomy in more complex cases, such as those involving large or multiple fibroids [4]. Laparoscopic myomectomy (LM) for large fibroids (≥ 8 cm) is often challenging due to factors such as difficult enucleation, extended operative time, increased perioperative bleeding risk, and the potential need for conversion to laparotomy [5]. RM overcomes several technical limitations associated with conventional laparoscopy, offering distinct advantages such as reduced intraoperative blood loss, shorter hospital stays, improved access to deep-seated fibroids, and a lower rate of conversion to open surgery [6]. Saccardi et al. proposed that minimally invasive surgery should be reserved for patients with a dominant fibroid less than 8 cm in diameter and/or fewer than three fibroids, emphasizing the technical challenges associated with larger or multiple myomas [7]. However, other studies have shown that minimally invasive myomectomy remains safe, even for women with multiple and very large fibroids [8]. A meta-analysis by Sheng et al. found that RM offers significant advantages over LM, including reduced intraoperative bleeding, fewer blood transfusions, shorter hospital stays, lower reoperation rates, and fewer postoperative complications [9]. However, the meta-analysis did not specifically address the feasibility of RM for larger or more numerous fibroids. Due to the paucity of data regarding the safety and effectiveness of RM in complex cases, this study was conducted to assess its feasibility and perioperative outcomes in women with large (≥ 8 cm) and/or multiple (≥ 5) uterine fibroids.

Materials and methods

This retrospective analysis utilized prospectively collected data from 260 patients who underwent RM by an experienced surgeon at a single institution between January 2013 and May 2024. The study was conducted following approval from the Institutional Ethics Committee and following the ethical guidelines of the most recent version of the Helsinki Declaration, as well as relevant good clinical practice standards. Demographic information, including age, BMI, parity, and a history of previous abdominal or pelvic surgeries, was gathered from the admission records. Primary symptoms associated with myomas were also documented. Operative outcomes, such as operative time, fibroid count and size, total weight of removed myomas, EBL, any concomitant surgeries, pelvic adhesions, length of hospital stay, pain levels, and the necessity for extended intravenous (IV) analgesia, were extracted from the patients' medical records. The operative time was calculated from the initial skin incision to the completion of skin closure. Console time was measured from the beginning to the end of the surgeon’s involvement, excluding morcellation time. Myoma size was assessed preoperatively using magnetic resonance imaging (MRI) or transvaginal sonography. Large myomas were defined as those with a diameter of ≥ 8 cm, and numerous myomas were defined as ≥ 5 fibroids.

Operative technique

Magnetic resonance imaging (MRI) was employed for preoperative surgical planning, allowing the surgical team to accurately determine the number and location of fibroids and thereby optimize the placement of the hysterotomy incision. All procedures were performed under general anesthesia with the patient in the Trendelenburg position. In each case, a Rumi uterine manipulator system with an Advincula Arch (Cooper Surgical, USA) and a suitably sized Rumi tip was utilized to aid in uterine positioning and exposure. Pneumatic stirrups were employed to position the patients' legs. A 12 mm midline port was inserted for the camera using standard laparoscopic technique, accompanied by two additional 8 mm robotic ports on either side. A 5 mm assistant port was placed on the left for suction and irrigation. The surgical procedure was conducted using the da Vinci Si or Xi robotic system (Intuitive Surgical Inc., USA). The size and location of the fibroids were carefully assessed intraoperatively. To minimize intraoperative blood loss, diluted vasopressin (20 units in 200 mL of saline) was injected into the pseudo-capsule surrounding the myoma. Monopolar scissors were used to create a uterine incision, and the fibroid was meticulously enucleated from the surrounding myometrium. In cases involving multiple fibroids, the enucleated myomas were either threaded together or placed in a containment bag to prevent intraperitoneal displacement. The resulting myometrial defect was closed in 3–4 layers using 1–0 V-Loc sutures (Covidien, USA). All resected fibroids were placed in a containment bag and retrieved via cold-knife morcellation. For this, the umbilical incision was extended to 2 cm and protected with a Surgi Sleeve wound retractor (Covidien, USA). The fibroids were retrieved through the extended umbilical incision by grasping them and making an inverted ‘C’-shaped incision over each, allowing for their sequential extraction in strips.

Outcomes measured

The primary outcomes evaluated were estimated blood loss (EBL), need for blood transfusion, total operative time, console time, and postoperative complications, including the requirement for intravenous (IV) analgesia and hospital stay exceeding one day. These outcomes were compared between two subgroups: patients with fibroids ≥ 8 cm versus < 8 cm, and those with more than five fibroids versus five or fewer. The surgical complications analyzed in this study included conversion to laparotomy, EBL greater than 500 mL, requirement for blood transfusion, injury to pelvic organs, and acute urinary retention. Postoperative outcomes monitored included pain scores, need for prolonged IV analgesia, nausea, hospital stays > 2 days, abnormal wound healing, and any subsequent exploratory laparotomies. Patients were discharged within 24 h following an uncomplicated postoperative recovery and were seen in the outpatient clinic seven days post-surgery to assess recovery and wound healing.

Statistical analysis

Data were compiled using Microsoft Excel and analyzed with SPSS software (Version 16.0; IBM Corp., Armonk, NY). Descriptive statistics were used to summarize the distribution of both categorical and continuous variables. Categorical variables were summarized as frequencies (n) and percentages (%), whereas continuous variables were presented as means with corresponding standard deviations (mean ± SD). Group comparisons were conducted using independent-samples t-tests for continuous variables and chi-square tests for categorical data. Statistical significance was defined as a p-value less than 0.05.

Results

Between January 2013 and May 2024, RM was performed on a total of 260 patients. Of these, 99 had fibroids smaller than 8 cm, while 161 had fibroids ≥ 8 cm. Regarding the number of fibroids, 236 patients had fewer than five, and 24 had five or more fibroids. A total of 614 myomas were excised, with 201 located in the fundal position, 169 in the anterior position, 181 in the posterior position, 36 in the lateral position, 17 in the anterior cervical location, and 10 in the posterior cervical location. In terms of classification, 317 myomas (51.6%) were intramural, 251 (40.9%) were subserosal, and 46 (7.5%) were submucosal (FIGO 0–2). The average number of fibroids removed per patient was 2.37 ± 0.31 (95% CI: 2.333–2.407), while the mean weight of the excised fibroids was 365.7 ± 289.3 g, with a median weight of 300 g. The largest fibroid excised weighed 1500 g. The mean diameter of the excised myomas was 8.67 ± 3.29 cm (95% CI: 8.275–9.075 cm), with the largest measuring 21 cm. Notably, 25 patients presented with fibroids exceeding 15 cm in diameter. The average operative time was 144.6 ± 55.3 min, and the mean console time was 100.3 ± 47.13 min. The median operative duration was 140 min, ranging from 40 to 360 min. EBL averaged 189.05 ± 296.65 mL, with a median of 100 mL and a range of 10–1000 mL. Blood transfusions were administered to 18 patients (6.9%), either intraoperatively or during the postoperative period; of these, 12 received a single unit of packed red blood cells (PRBC), while the remaining six required two units. The mean hospital stay was 23.46 ± 6.42 h, with 87 patients staying more than 24 h. Two patients had extended stays of 63 h due to excessive blood loss and transfusions. The uterine cavity was breached in 40 patients, with the myoma bed closed in four layers for those with endometrial cavity breaches and in three layers for those with an intact endometrial cavity. No instances of laparotomy conversion, reoperation, organ injury, thromboembolic events, bowel obstruction, or sepsis were observed among the patients (Table 1).

Table 1.

Descriptive characteristics and operative outcomes of the study population (N = 260)

Variable
Age, mean ± SD, year	34.18 ± 5.55
BMI, mean ± SD, kg/m2	27.17 ± 4.29
Size of the myomas removed, cm
Mean ± SD	8.67 ± 3.29
< 8, n (%)	99 (38.1)
≥ 8, n (%)	161 (61.9)
Number of the myomas removed
Mean ± SD	2.37 ± 0.31
< 5, n (%)	236 (90.8)
≥ 5, n (%)	24 (9.2)
Position of myomas, n (%)
Fundal	201 (32.7)
Anterior	169 (27.5)
Posterior	181 (29.5)
Lateral	36 (5.9)
Anterior cervical	17 (2.8)
Posterior cervical	10 (1.6)
Classification, n (%)
Intramural	317 (51.6)
Subserosal	251 (40.9)
Submucosal	46 (7.5)
Weight of fibroids removed, grams
Mean ± SD	294.0 ± 290.25
< 300	127 (48.8)
300–599	89 (34.2)
600–899	23 (8.8)
900–1199	17 (6.5)
1200–1499	2 (0.8)
> 1500	2 (0.8)
Weight of fibroids removed, median (range), grams	300 (20–1500)
Total operative time, mean ± SD, min	144.6 ± 55.3
Total operative time, median (range), min	140 (40–360)
Docking time, mean ± SD, min	8.23 ± 6.61
Console time, mean ± SD, min	100.3 ± 47.13
EBL, mean ± SD, mL	189.05 ± 296.65
EBL, median (range), mL	100 (10–1000)
Blood transfusion, n (%)	18 (6.9)
Length of hospital stay, hours
Mean ± SD	23.46 ± 6.42
> 24 h, n (%)	87 (33.5)
IV analgesics time, mean ± SD, min	16.96 ± 14.67
Uterine cavity breach, n (%)	40 (15.4)

A comparison of demographic characteristics and operative outcomes based on fibroid size (< 8 cm vs. ≥ 8 cm) is provided in Table 2. The mean age and BMI were comparable between the two groups. However, patients with fibroids measuring ≥ 8 cm had significantly higher EBL (140.99 ± 133.23 vs. 107.83 ± 91.14 mL, p = 0.019) and were more likely to require blood transfusions (p = 0.041). While the total operative time was similar between groups, console time was significantly longer in the ≥ 8 cm group (p < 0.001). The need for IV analgesia did not differ between the groups, but patients with larger fibroids (≥ 8 cm group) were significantly more likely to have a hospital stay longer than two days (p = 0.009).

Table 2.

Comparison of demographic characteristics and operative outcomes based on the size of the myomas removed (< 8 cm vs. ≥ 8 cm)

Variable	< 8 cm	≥ 8 cm	p-value
Age, mean ± SD, year	35.31 ± 5.88	33.5 ± 5.12	0.15
BMI, mean ± SD, kg/m2	27.44 ± 4.36	27.00 ± 4.02	0.23
EBL, mean ± SD, mL	107.83 ± 91.14	140.99 ± 133.23	0.019*
Total operative time, mean ± SD, min	130.86 ± 53.28	154.39 ± 54.54	0.768
Docking time, mean ± SD, min	8.94 ± 7.61	7.8 ± 5.9	0.009*
Console time, mean ± SD, min	82.91 ± 43.98	104.98 ± 46.86	< 0.001*
IV analgesics time, mean ± SD, min	17.73 ± 15.23	16.5 ± 14.35	0.89
Blood transfusion, n (%)	3 (3.0)	15 (9.3)	0.041*
Length of hospital stay > 2 days, n (%)	24 (24.2)	63 (39.1)	0.009*

^*Significant value

Table 3 presents a comparison of demographic characteristics and operative outcomes based on the number of fibroids removed (< 5 vs. ≥ 5). Both groups had comparable mean age (34.01 ± 5.42 vs. 35.38 ± 5.67 years) and BMI (27.16 ± 4.26 vs. 27.41 ± 4.44 kg/m²). Although patients with ≥ 5 fibroids had a higher mean EBL (149.65 ± 137.41 mL vs. 127.03 ± 112.02 mL), the difference was not statistically significant. Similarly, total operative time did not differ significantly between the groups. However, patients with ≥ 5 fibroids had significantly longer docking time (p = 0.036) and console time (p < 0.001), likely due to the increased complexity of suturing multiple myoma beds. The use of IV analgesics was similar in both groups. Blood transfusions were more commonly required in the ≥ 5 myoma group, possibly due to higher blood loss, which also contributed to significantly longer hospital stays in this group.

Table 3.

Comparison of demographic characteristics and operative outcomes based on the number of myomas removed (< 5 vs. ≥ 5 myomas)

Variable	< 5 myomas	≥ 5 myomas	p-value
Age, mean ± SD, year	34.01 ± 5.42	35.38 ± 5.67	0.475
BMI, mean ± SD, kg/m2	27.16 ± 4.26	27.41 ± 4.44	0.716
EBL, mean ± SD, mL	127.03 ± 112.02	149.65 ± 137.41	0.095
Total operative time, mean ± SD, min	138.93 ± 52.91	188.88 ± 46.27	0.416
Docking time, mean ± SD, min	8.07 ± 6.25	10.04 ± 9.64	0.036*
Console time, mean ± SD, min	121.76 ± 44.49	184.51 ± 51.56	< 0.001*
IV analgesics time, mean ± SD, min	16.46 ± 14.30	20.85 ± 17.54	0.71
Blood transfusion, n (%)	14 (5.9)	4 (17.4)	0.197
Length of hospital stay > 2 days, n (%)	71 (30.1)	16 (69.6)	0.058

^*Significant value

Discussion

This study presents a comprehensive evaluation of the feasibility and surgical outcomes of RM in managing large and multiple uterine fibroids, based on a decade of clinical experience. A review of 260 cases of RM performed between 2013 and 2024 revealed that perioperative outcomes were significantly affected by both the size and the number of fibroids. Notably, RM has demonstrated both safety and efficacy in managing cases involving larger fibroids (≥ 8 cm) or multiple myomas (≥ 5), which have historically been treated through open surgery. The robotic system’s advanced capabilities, including enhanced instrument dexterity, three-dimensional visualization, and wristed tools, enabled precise fibroid excision and meticulous multilayer myometrial repair. While concerns have been raised about longer operative times with RM, our institutional data suggest that surgical efficiency improves significantly over time as surgeons gain experience and optimize workflows. Compared to conventional laparoscopic or open myomectomy, RM offered clear technical advantages and was especially beneficial in managing complex cases with a heavy fibroid burden. What sets our study apart is the extensive timeframe and large sample size, along with a patient population characterized by a higher average number and size of fibroids than typically reported in the literature [10].

Demographically, the average age and BMI of the study population were comparable to those observed in previous research, suggesting a representative patient cohort [11]. Our findings also showed lower mean operative times and blood loss, with hospital stays comparable to previously published data [6]. Furthermore, our findings are consistent with those of a comprehensive pooled analysis of 15 retrospective studies involving over 11,000 patients, which concluded that RM is associated with significantly reduced intraoperative blood loss, lower transfusion rates, shorter hospital stays, fewer conversions to open surgery, and a decreased incidence of postoperative complications compared to LM [9]. Reported ranges for RM in that review included operative times of 118.52 ± 43.59 to 210 ± 94.8 min, blood loss between 100 ± 120.4 and 206.54 ± 360.17 mL, and hospital stays from 0.8 ± 0.9 to 4.6 ± 0.8 days, figures closely mirrored by our patient outcomes.

Impact of fibroid size on surgical outcomes

Our analysis indicates that patients with fibroids measuring ≥ 8 cm experienced significantly greater EBL compared to those with smaller fibroids. The mean EBL in this group was 140.99 ± 133.23 mL, versus 107.83 ± 91.14 mL for patients with fibroids < 8 cm (p = 0.019). This observation is consistent with prior studies linking larger fibroid size to increased vascularity and surgical complexity, which often contribute to higher intraoperative blood loss. For instance, Baba et al. (2018) reported a positive correlation between fibroid size and blood loss during LM, identifying 7.27 cm as the MRI-derived threshold for predicting hemorrhage > 300 mL [12]. Although Bedient et al. (2009) reported no significant difference in EBL between the two surgical approaches after adjusting for uterine and fibroid characteristics [13], our study identified a significantly higher transfusion rate among patients with fibroids ≥ 8 cm compared to those with smaller fibroids (9.3% vs. 3%; p = 0.041). This suggests that, in our cohort, larger fibroid size not only increased blood loss but also had clinical implications requiring transfusion. Supporting this, Gigg et al. (2024) reported a median fibroid size of 8.8 cm with a median perioperative blood loss of 536.3 mL, surpassing intraoperative estimates and emphasizing the bleeding risk in such cases [14]. Despite these challenges, RM appears to offer advantages in minimizing blood loss. Wang et al. (2018) found that RALM led to significantly lower EBL and fewer transfusions compared to abdominal myomectomy [15]. Similarly, Tsakos et al. (2023) reported reduced intraoperative bleeding in RM relative to LM, especially in cases involving smaller fibroids [16]. While a higher risk of bleeding is generally associated with larger fibroids, current literature does not conclusively show increased transfusion rates in RM for this subgroup, making our findings a notable contribution. Moreover, we observed significantly longer console times in patients with larger fibroids (104.98 vs. 82.91 min; p < 0.05), reflecting the additional surgical time required for these more complex procedures. Balfoussia et al. (2019) also reported a significant positive correlation between fibroid size and operative duration (p < 0.001) [17], reinforcing the notion that larger myomas contribute to longer surgical times. In contrast, Bedient et al. (2009) found no significant difference in operative times between RM and LM after adjusting for fibroid characteristics, suggesting that the robotic approach does not inherently prolong surgery when case complexity is accounted for [13]. Supporting this, another study demonstrated that patients with fibroids > 10 cm had significantly greater myoma weights (p < 0.001) and experienced longer operative times (p = 0.02). Although EBL was higher in the larger myoma group, the difference did not reach statistical significance (p = 0.06) [10]. To manage prolonged operative times, hybrid surgical strategies have been proposed. These include combining laparoscopic enucleation with robotic-assisted suturing and using unidirectional barbed sutures to expedite uterine closure [18]. Collectively, these findings reinforce the feasibility of RM for large fibroids, offering operative times on par with laparoscopy while potentially mitigating intraoperative blood loss.

Patients with larger fibroids experienced significantly longer hospital stays, with 39.1% remaining hospitalized for more than 24 h, compared to 24.2% in the smaller fibroid group (p = 0.009). This pattern indicates that larger fibroid size may be associated with increased intraoperative complexity as well as prolonged postoperative recovery, potentially driven by factors such as elevated blood loss, a greater likelihood of transfusion, and a heightened risk of perioperative complications. Although Aendekerk et al. (2019) reported longer hospital stays for patients undergoing LM compared to RM, they did not specifically examine the impact of fibroid size [11]. Their study also highlighted that larger fibroids were more commonly treated via laparotomy rather than minimally invasive methods. In contrast, Felemban (2020) reported favorable outcomes following RM even in cases involving large fibroids, with the largest measuring 20 × 17 cm, and noted a relatively short postoperative hospital stay averaging 3 days [19]. These findings support the notion that, despite the challenges posed by large fibroids, robotic-assisted surgery can effectively limit postoperative hospitalization through improved surgical precision and reduced complication rates.

Impact of number of fibroids on surgical outcomes

In assessing the impact of fibroid number on surgical outcomes, patients with ≥ 5 fibroids demonstrated a higher mean EBL compared to those with fewer fibroids (149.65 mL vs. 127.03 mL), although the difference was not statistically significant (p = 0.095). Similarly, the blood transfusion rate was elevated in the ≥ 5 fibroid group (17.4% vs. 5.9%), but this difference also did not achieve statistical significance (p = 0.197). These trends suggest that while the number of fibroids may contribute to increased blood loss, the size of individual fibroids likely plays a more dominant role in determining the need for transfusion, particularly as patients with multiple fibroids in our cohort also tended to have larger fibroids. Leaf et al. (2024) found that the removal of ten or more fibroids during minimally invasive myomectomy, including robotic-assisted procedures, was associated with significantly higher EBL compared to cases involving fewer fibroids (470 mL vs. 246 mL; p < 0.001) [20]. Despite this, other perioperative metrics such as transfusion requirements, conversion rates to open surgery, complication incidence, and duration of hospitalization remained comparable across both groups, suggesting that RM remains a viable option even in complex cases with numerous fibroids. In the present study, while the overall operative duration for patients with ≥ 5 fibroids was longer, the difference did not reach statistical significance (p = 0.416). In contrast, console time was significantly extended in this group (184.51 min vs. 121.76 min; p < 0.001), indicating the added technical challenges involved in managing multiple fibroids. This observation is in line with the findings of Kang et al. (2016), who noted prolonged surgical times in cases involving higher fibroid counts during robotic procedures [21]. In contrast, a study by Won et al. (2020) reported no significant difference in operative time between RM and LM in cases involving more than 12 fibroids, indicating that both techniques are similarly efficient in managing a high fibroid burden [22]. Taken together, current evidence suggests that fibroid size, rather than number, plays a more decisive role in determining perioperative outcomes such as blood loss and duration of hospitalization. Recognizing this distinction is crucial for surgical planning and setting appropriate expectations during preoperative counselling in complex cases. However, the findings of our study must be interpreted with caution due to its retrospective design and single-center setting, which may limit the broader applicability of the results. Furthermore, the completeness of data was occasionally compromised due to missing clinical records. The extended study duration of 11 years also encompasses the surgeon’s learning curve, which may have influenced early outcomes. Additionally, we did not evaluate long-term follow-up parameters such as fibroid recurrence or postoperative fertility rates, which are important considerations in this patient population.

Conclusion

Drawing on a decade of institutional experience, our study underscores the feasibility and efficacy of RM in managing complex cases involving uterine myomas ≥ 8 cm and/or ≥ 5 fibroids. RM proved to be a safe approach, with low complication rates and only a modest, statistically insignificant increase in operative time in cases with multiple fibroids. While larger fibroids were associated with a slightly prolonged hospital stay, this was not clinically prohibitive. Among the perioperative variables analysed, fibroid size emerged as the most significant predictor of intraoperative blood loss and postoperative hospital stay, underscoring its critical role in surgical planning and risk assessment for RM.

Author contributions

All authors were involved in data collection and analysis and reviewed multiple drafts of the manuscript. Feedback from each author was incorporated into the final version.

Funding

Apart from article processing charges and submission-related assistance, the authors received no financial support, including funding or grants, to prepare this manuscript.

Data availability

No datasets were generated or analysed during the current study.

Declarations

Conflict of interest

The authors declare no competing interests.

Ethical approval

The approval for this study was obtained from the Institutional Ethics Committee under letter number AHJ-C-S-018/09–24, dated October 5, 2024.

Consent to participation

As this retrospective study used de-identified data with no direct participant contact, the IRB/IEC granted a waiver of informed consent. All study procedures adhered to the ethical standards of the participating institution and the principles outlined in the Declaration of Helsinki.