Uterine-preserving Robotic Resection of a Challenging Submucosal Myoma under Ultrasound Guidance

To demonstrate the surgical technique and clinical utility of an ultrasound-guided robotic approach for the resection of a large, complex submucosal myoma in a patient desiring future fertility.

The Uterine Myoma Center at a university tertiary referral hospital.

A 33-year-old nulliparous woman (G1P0) with a history of midtrimester pregnancy loss at 15 + 6 weeks owing to a massive myoma. Preoperative magnetic resonance imaging revealed multiple lesions, including a few small subserosal myomas, a 3.5 cm fundal intramural myoma (International Federation of Gynecology and Obstetrics type 4), and an 8.4 cm intracavitary lesion (International Federation of Gynecology and Obstetrics type 2-5 hybrid) causing marked cavitary distension.

Although operative hysteroscopy is the conventional gold standard for submucosal myomas [1,2], its feasibility is often limited by large tumor size, deep intramural extension, or severe degeneration. In this case, preoperative magnetic resonance imaging clearly demonstrated that the 8.4 cm hybrid-type myoma completely obliterated the endometrial cavity with profound anatomic distortion. To optimize the surgical workspace and minimize interim menorrhagia, preoperative gonadotropin-releasing hormone agonist therapy was administered [3]. Consequently, an abdominal robotic platform was chosen over a hysteroscopic approach to simultaneously address these complex, coexisting myomas and ensure precise multilayered reconstruction [4]. We initiated the procedure by resecting the fundal intramural myoma under real-time transvaginal ultrasound guidance. Instead of a specialized robotic probe, a standard ultrasound feed operated by a bedside assistant was integrated via the da Vinci TilePro function, providing high-resolution, real-time imaging without sacrificing a robotic arm. After this initial enucleation, saline-distended intraoperative hysterosonography was performed [5]. Crucially, sonography revealed the remaining friable submucosal component situated immediately beneath the initial incision bed. Using the robotic cold-cut technique to minimize thermal injury, the intracavitary mass was meticulously enucleated. Before enucleation, diluted vasopressin (10 IU in 100 mL of normal saline) was injected into the myometrium after meticulous aspiration to prevent accidental intravascular administration. A focal 1 cm endometrial defect was repaired with 3-0 Vicryl. The myometrial defect was reconstructed in 3 layers, and specimen extraction was safely performed via contained power morcellation. Postoperatively, a pediatric Foley catheter was maintained inside the cavity, and oral estradiol valerate (2 mg twice daily) was administered for 1 month.

For challenging submucosal myomas where hysteroscopic resection may be incomplete or high-risk, an ultrasound-guided robotic platform allows for precise enucleation and robust reconstruction. This approach ensures complete preservation of endometrial integrity, optimizing reproductive outcomes for patients seeking uterine preservation. VIDEO ABSTRACT.