Robotic surgery has opened new doors in treating uterine fibromas, allowing for less recovery time and preserving a woman’s ability to have children in the future.
Uterine fibromas are benign tumors that grow inside the muscular tissue of the uterus. More than 40 percent of women have them.
There are three types: uterine subserose fibroids, which develop in the external part of the uterus; intramural fibroids, which grow inside the uterus, making the organ feel larger than normal; and uterine submucosal fibroids, which develop just under the uterus walls.
“Each fibroid comes from a mutation in an individual cell and, like snowflakes, each one is unique and different. A woman with 10 fibromas has 10 different mutations,” says Dr. Stephen Zimberg, gynecologist obstetrician and co-director of the non-invasive gynecological surgery section of Cleveland Clinic Florida in Weston. “We see them in every type of patient, from age 19 up to their 60s.
“Something in these women’s systems allows them to grow, but we don’t know why, and that is the reason it hasn’t been possible to develop a vaccine or drug to prevent them or treat them.” Zimberg says.
Women who have not had children are more likely to have the tumors because “after giving birth, the uterus contracts and blood coagulates, which dissolves the small fibroids. That is why it is rare to find large fibroids in women who have had many children.”
“It happens in all races, in all countries. It’s a common and difficult problem,” he adds.
Dr. Rafael Pérez, gynecologist obstetrician and director of South Miami Hospital’s Fibroid Center, said fibromas may have no symptoms at first, but as they grow, they become bigger and women begin to feel them.
The tumors “increase blood flow and the size of the uterus can grow until reaching sizes comparable to a pregnant woman. Then we say that the patient has a distention comparable to a 12-week, 20-week pregnancy.”
Uterine fibroids can also cause incontinence, difficult menstrual cycles, infertility and spontaneous abortions. In many cases, if there are no serious symptoms, a doctor will choose to wait and monitor the tumors.
For many years the only option for treating women with serious symptoms was a hysterectomy, or the surgical removal of the uterus.
In 1931, Dr. Víctor Bonney developed a procedure to surgically remove the fibromas, preserving the cervix and the uterus. The procedure, named an abdominal myomectomy, is still considered as standard procedure in treating the tumors.
Abdominal myomectomy implies “making a downward incision in the abdomen or bikini style, depending on the size of the uterus, in order to later remove each one of the tumors and suture the area where they were located,” Zimberg says.
It is a tedious and demanding operation. “To remove an organ, or take out an ovary is relatively easy,” he says. “It’s much more difficult to fix something. To leave the organ intact or make it all new is much more difficult.”
The introduction of laparoscopic myomectomy in 1979 revolutionized these procedures, reducing recovery time and the likelihood of a hemorrhage during the procedure.
While a traditional operation requires two or three days of hospitalization and four to six weeks of recovery, the laparoscopic procedure — inserting a micro-camera and two surgical instruments through catheters — needs only a day of hospitalization and from one to four weeks of recovery.
But laparoscopic surgery is not recommended for all cases.
“If the fibroids are very large, there is not enough space for the instruments and the telescopic camera. Then you have to perform open surgery,” says Zimberg, who has authored a recent study published by the American College of Obstetricians and Gynecologists, comparing results of myomectomies performed in the traditional way with those performed by laparoscopy and robotic surgery.
“With laparoscopy we could only treat cases with a size equivalent up to a six-month pregnancy,” he said.
Pérez says that “it is very difficult to suture all the necessary stitches with laparoscopy, which prompted many doctors to avoid the procedure.”
The introduction of robotic surgery seeks to solve the most problematic areas of laparoscopy. The materials are introduced through the same three incisions made in laparoscopic surgery. Once inside the uterus, they are connected to a control panel inside the operating room.
“You put your hands inside the console and it is as if you had them inside the patient,” since the robot imitates all your movements and “you can see everything in three-dimension,” Zimberg explains.
“Robots have wrists and there is no other surgical instrument that would allow doing circles with your hands; you can even use them the same way you use your hands” to separate the tumors from the uterus and make the necessary sutures.
“You can suture beautiful stitches with the robot,” he adds.
The robots are particularly used with large fibromas, Pérez said. “Large fibromas are difficult. You need to be able to move the uterus sideways and the robot allows you to do it, making the procedure easier.”
The South Miami Hospital specialist also highlights that robotic surgery uses better instruments to cauterize in case of bleedings.
“Any procedure that allows the patients to go in and out of hospitals quickly, almost as an outpatient operation, is the way to go” because it dramatically diminishes the possibility of infections, he said.
“The disadvantage in this case falls on hospitals and doctors because this technology is expensive,” Pérez says. “As we continue to perform operations, technology becomes more accessible.”
Zimberg measures success by the speed with which his patients recover and the number of women who can have children after this type of surgery. “Robotic surgery allows us to take many more cases with better results, and that’s good news for our patients.”