Optimal surgical approaches to minimally invasive myomectomy for the fertility patient

Kathryn Coyne: Writing – original draft, Methodology, Investigation, Conceptualization. Zaraq Khan: Writing – review & editing, Supervision, Resources, Methodology, Conceptualization. Rebecca Flyckt: Writing – review & editing, Supervision, Methodology, Investigation, Conceptualization.

Complex fibroid burden in fertility-seeking patients remains one of the most technically demanding scenarios in minimally invasive reproductive surgery. In our experience, successful outcomes depend less on any single technique and more on a consistent, evidence-based approach that integrates preoperative medical optimization and detailed imaging, an experienced surgeon capable of using multiple techniques, and careful uterine reconstruction for preservation of function. The key clinical decisions we consider in this case include whether surgical management is indicated, which surgical approach will best accomplish complete fibroid removal while preserving uterine integrity, and how to reconstruct the uterus to optimize future fertility. Preoperative planning should be guided by presence of preoperative medical comorbidities, fibroid characteristics, symptom burden, and reproductive goals. In this case, the patient’s anemia, symptomatic fibroids with cavity distortion, and infertility make her an appropriate surgical candidate. Therefore, the primary clinical question is not whether to operate, but how to select the safest and most effective surgical approach that maximizes fibroid removal while preserving uterine integrity. The International Federation of Gynecology and Obstetrics (FIGO) classification system (types 0–8) enables standardized assessment of fibroid location and relationship to the endometrial cavity ( 1 ). In fertility-seeking patients, myomectomy is indicated primarily for FIGO types 0, 1, and 2 fibroids. The American Society for Reproductive Medicine advises that although removal is not recommended for myomas that do not distort the cavity to improve pregnancy outcomes, it is reasonable in certain circumstances. These scenarios include severe distortion of pelvic anatomy or when ovarian access is an issue for patients undergoing oocyte retrieval ( 2 ). In this patient, with a FIGO type 2–5 fibroid distorting the cavity alongside multiple intramural fibroids, myomectomy is indicated because of cavity distortion, in addition to evidence which supports removing type 3 myomas >2 cm and types 4, 5, or 6 myomas >4 cm ( 3 , 4 ). While pelvic ultrasonography is adequate for solitary lesions, MRI is the preferred imaging modality in patients with multiple, large, or deeply intramural fibroids, as it improves characterization of fibroid size, number, and depth, and proximity to the endometrial cavity. This imaging is particularly valuable when intramural or transmural fibroids predominate ( 1 , 5 ), when uterine volume exceeds 375 mL, or when >4 fibroids are present, given limited resolution with ultrasonography in these situations ( 6 ). For this patient, we would rely on MRI not only to confirm surgical candidacy but also to determine the anticipated number of hysterotomies, their depth, proximity to the cavity, and whether minimally invasive reconstruction is likely to be feasible. For patients with preoperative anemia and symptomatic fibroids, a comprehensive preoperative anemia management strategy should be used to optimize hemoglobin and reduce transfusion risk, which is associated with postoperative morbidity after myomectomy ( 7 ). Screening for iron deficiency and appropriate replacement, as well as consideration of gonadotropin-releasing hormone (GnRH) agonist therapy with add-back hormone therapy, ought to be considered for patients with preoperative anemia. Preoperative optimization of anemia with iron repletion and a target hemoglobin >13.0 g/dL should be considered when feasible ( 8 ). Preoperative GnRH agonist therapy reduces fibroid volume, improves hemoglobin, and decreases intraoperative blood loss and transfusion risk during myomectomy ( 9 , 10 ). In this patient with preoperative anemia, we would initiate iron repletion and consider a 2–3 month course of GnRH agonist with add-back to optimize hemoglobin to >13 g/dL and reduce fibroid volume before surgery. A hysteroscopic approach is performed for isolated FIGO type 0–1 (and select type 2) submucosal fibroids. For other FIGO type symptomatic fibroids, conventional laparoscopic and robot-assisted laparoscopic myomectomy often are appropriate as recommended by the American College of Obstetricians and Gynecologists ( 5 ). Selection between conventional laparoscopic and robot-assisted laparoscopic approaches depends on fibroid characteristics (type, size, number), surgeon training, equipment availability, and patient preference ( 5 ). Compared with conventional laparoscopy, robot-assisted myomectomy demonstrates unique advantages in complex cases, including reduced conversion rates to laparotomy (4.5-fold lower risk compared with conventional laparoscopy) and safety across a wide range of body mass indices ( 6 , 11 ). The robotic platform may help overcome variables limiting laparoscopic myomectomy, such as unfavorable myoma location ( 6 ). It is important to note that the laparoscopic route, with or without robotic assistance, shows increased recurrence risk in patients with >5 fibroids when compared with the abdominal route (odds ratio, 1.50) ( 5 ). Open myomectomy remains preferred for numerous fibroids or very large uteri ( 12 ). The threshold of when to use open techniques usually is dictated by a patient’s medical comorbidities, uterine size, fibroid characteristics, and most importantly, the surgeon’s skill and preference ( Table 1 ) ( 13 ). Although thresholds vary by surgeon experience and institutional resources, many surgeons consider open myomectomy when fibroid burden exceeds approximately 8 myomas >6 cm, dominant myoma size is >15 cm, or reconstruction is anticipated to be extensive. Referral to subspecialty care for a minimally invasive approach should be considered in scenarios with ≥5 myomas, ≥9 cm, or ≥500 g estimated weight. Table 1 Decision framework for surgical approach to myomectomy. Decision Clinical variable Favors this approach Notes References 1. Transcervical vs. Abdominal FIGO type relative to cavity Hysteroscopic: isolated type 0, 1, select type 2 (50% intramural) Complete resection less likely with increasing intramural extension 5 Abdominal: types 2–8 with significant intramural/subserosal component MIS or open routes 13 2. MIS vs. Open Fibroid number, size, uterine volume MIS: feasible for most cases; preferred when fibroid burden permits Faster recovery, lesspain, shorter hospitalization 5 Open: >8 myomas >6 cm, dominant myoma >15 cm, very large uterus Open preferred as MIS recurrence risk ↑ with >5 fibroids 5 , 13 3. Robot-assisted vs. conventional laparoscopy Fibroid location, depth, surgeon skill Robot-assisted: transmural/deep intramural, unfavorable location (low posterior wall lesions, cervical myomas etc.), elevated BMI, complex reconstruction May help overcome unfavorable myoma location; conventional laparoscopy has 4.5× higher conversion risk 12 , 6 Conventional laparoscopy: favorable location, equivalent surgeon proficiency, no robotic access No advantage of robotic over laparoscopic for operative time, blood loss, or hospital stay 5 , 12 4. Operate vs. refer Fibroid burden complexity Refer to reproductive surgeon or minimally invasive gynecologic surgeon: ≥5 myomas, ≥9 cm, ≥500 g, complex anatomy These thresholds associated with adverse outcomes benefiting from subspecialist skills 6 MIS, minimally invasive surgery. Decision framework for surgical approach to myomectomy. MIS, minimally invasive surgery. For this patient, we favor a robot-assisted laparoscopic approach over conventional laparoscopy. The FIGO type 2–5 transmural fibroid will require complex dissection and reconstruction, and the robotic platform offers a lower conversion risk while facilitating precise multilayer closure of the deep myometrial defect. Reduction of intraoperative blood loss is one of the central operative principles of myomectomy. A multimodal approach including dilute vasopressin injection (the investigators recommend 20 units in 100 mL of saline to reduce concerns related to cardiotoxicity), tranexamic acid administration, prostaglandin use, selective uterine vessel occlusion or temporary tourniquet use, and precise entry into the myoma pseudocapsule facilitates efficient enucleation while preserving surrounding myometrium ( 5 , 14 ). Consistent identification and maintenance of the correct tissue plane remain among the most important determinants of surgical efficiency and safety. Intraoperative ultrasound, laparoscopic ultrasound (LUS) and transvaginal ultrasound (TVS), significantly improves detection and enucleation of residual fibroids following removal of visible lesions, with LUS particularly useful for anterior wall and small intramural fibroids ( 15 ) ( Supplemental Video 1 , available on line). In practice, ultrasound guidance may improve localization, allow targeted serosal incisions (particularly when preoperative imaging suggests small or deeply situated lesions), and reduce the likelihood of residual fibroids ( 5 ). Comprehensive preoperative counseling should address the clinically important but often ambiguous distinction between residual fibroids, fibroid recurrence, and the need for future reintervention. The likelihood of residual fibroids increases with initial fibroid burden, and recurrence and reintervention remain important long-term considerations following myomectomy ( 5 , 15 ). Given this patient’s fibroid burden, we would use intraoperative ultrasound to maximize complete fibroid removal and reduce the risk of residual disease. Hysteroscopic myomectomy remains the preferred approach for FIGO type 0 and type 1 submucosal fibroids and select type 2 lesions, although complete resection in a single case becomes less likely with increasing intramural extension ( 16 , 17 ). With the increased prevalence of hysteroscopic morcellators, incomplete excision is becoming a more common challenge in the management of patients with type 2 myomas. The use of resectoscopic devices might be preferred for removal of type 2 myomas over nonresectoscopic devices (like the morcellator); however, the former requires advanced surgical skill and experience. It is imperative that an intracavitary myoma is removed in its entirety for optimal patient outcomes. After resecting the submucosal portion of a type 2 myoma, briefly lowering intracavitary pressure and reinserting the hysteroscope at the end of the case can facilitate extrusion of the intramural component to allow complete resection. The laparoscopic approach to myomectomy is technically challenging and surgeon experience remains critical ( 18 ). Intraoperative decision-making must remain flexible and conversion to laparotomy should be viewed as a judicious choice rather than a failure when visualization, hemostasis, or uterine reconstruction cannot be achieved adequately. In our experience, decisions to convert should be made as early in the case as possible as time under anesthesia is an important factor. Meticulous uterine reconstruction is essential in patients desiring future pregnancy. Multilayer closure with careful obliteration of dead space while excluding endometrium restores uterine strength, hemostasis, and anatomic integrity, reducing long-term complications ( 4 , 16 , 19 ). For this patient, multilayer closure excluding endometrium is particularly critical because her FIGO type 2–5 fibroid will likely require deep myometrial dissection with cavity proximity, and endometrial incorporation predisposes to niches (isthmoceles), adenomyosis, and accreta spectrum disorders ( 19 ). For this patient, we would perform a refined three-layer closure. We deliberately exclude the endometrium from the first layer, restore myometrial bulk with the second layer, and reapproximate the serosa with the third layer to maximize uterine integrity for future pregnancy( 19 ) ( Supplemental Video 2 , available online). Although the rationale for multilayer closure is well-established, no randomized trials have directly compared pregnancy outcomes between multilayer and single-layer techniques in the minimally invasive surgery setting, and the recommendation reflects expert consensus rather than trial-level evidence. Barbed sutures demonstrate equivalent reproductive outcomes to conventional sutures while offering potential operative advantages ( 20 , 21 ). Barbed sutures significantly reduce operative time and blood loss during minimally invasive myomectomy ( 22 , 23 ). Pregnancy-related complications occur at comparable rates regardless of suture type, and importantly the risk of uterine rupture regardless of technique is <1% ( 20 , 24 ). Closure technique should be individualized on the basis of the depth and location of each defect. For this patient, we would use barbed sutures for multilayer closure because they improve operative efficiency without compromising reproductive safety. Contained morcellation techniques should be used to limit tissue. Although the risk of unexpected leiomyosarcoma is very low, preoperative assessment of clinical risk factors and MRI findings may help identify patients who warrant additional evaluation ( 25 , 26 ). For this patient, I would perform manual morcellation within a containment system, although selection of extraction method should reflect fibroid characteristics, institutional resources, and surgeon expertise. In cases with high fibroid burden, we use a systematic “tag-and-track” strategy, which further supports complete tissue extraction ( Supplemental Video 3 , available online). Because this patient is actively pursuing pregnancy, we would not recommend radiofrequency ablation, magnetic resonance-guided focused ultrasound, or uterine artery embolization. Although these procedures may improve symptoms, myomectomy remains my preferred fertility-preserving intervention ( 27 , 28 , 29 ). Multidisciplinary collaboration among reproductive and/or minimally invasive gynecologic surgeons, radiologists, and anesthesiologists is valuable particularly in complex cases where fertility preservation is a central priority. At the time of myomectomy, we routinely evaluate tubal anatomy and patency with bilateral chromopertubation and address concurrent pathology, such as endometriosis, so that fertility planning can be individualized. Given the adhesiogenic nature of myomectomy, we also recommend second-look hysteroscopy after hysteroscopic myomectomy and after nonhysteroscopic myomectomy when the cavity is entered or in close proximity. We favor meticulous hemostasis and consideration of adhesion barriers during open and laparoscopic myomectomy. Younger age, lower fibroid burden, and longer follow-up are associated with improved fertility outcomes after myomectomy ( 24 ). Depending on the patient age as well as the location, number, and depth of hysterotomies, a duration of 3–6 months of uterine healing is recommended before attempting conception. For this 34-year-old patient with two years of infertility, there must be a balance between adequate healing and age-related fertility decline, and a complete fertility evaluation and assisted reproduction should be considered if natural conception does not occur within a defined window after healing. At the completion of surgery, we discuss future delivery planning with every patient and document whether cesarean delivery is recommended on the basis of the number, depth, and location of hysterotomies. Available reproductive outcome data after myomectomy generally are reassuring, although long-term prospective data specifically evaluating uterine scar integrity remain limited ( 20 , 21 , 24 ).

• In fertility-seeking patients with cavity-distorting fibroids (FIGO types 0–2), myomectomy is the primary surgical intervention to improve fertility; for noncavity-distorting intramural fibroids, the evidence for fertility benefit from removal is less clear, and surgery is driven by symptoms and fibroid size thresholds (types 3 >2 cm, types 4–6 >4 cm). • Robot-assisted myomectomy should be considered over conventional laparoscopy for transmural or deep intramural fibroids, given the 4.5-fold reduction in conversion to laparotomy, which is a particularly important consideration in fertility patients where minimizing adhesion formation is paramount. • OBGYN physicians in general practice should consider referral to a subspecialist (Reproductive Endocrinology and Infertility or Minimally Invasive Gynecologic Surgery) for patients with ≥5 fibroids, dominant fibroid ≥9 cm, or estimated fibroid weight ≥500 g. • Multilayer uterine closure excluding endometrium is critical after transmural myomectomy to reduce the risk of niches, iatrogenic adenomyosis, and accreta spectrum disorders in subsequent pregnancies. • Preoperative anemia optimization (target hemoglobin >13 g/dL) with iron repletion and consideration of GnRH agonist therapy reduces intraoperative blood loss and transfusion risk, facilitating a safer minimally invasive surgery approach. In fertility-seeking patients with cavity-distorting fibroids (FIGO types 0–2), myomectomy is the primary surgical intervention to improve fertility; for noncavity-distorting intramural fibroids, the evidence for fertility benefit from removal is less clear, and surgery is driven by symptoms and fibroid size thresholds (types 3 >2 cm, types 4–6 >4 cm). Robot-assisted myomectomy should be considered over conventional laparoscopy for transmural or deep intramural fibroids, given the 4.5-fold reduction in conversion to laparotomy, which is a particularly important consideration in fertility patients where minimizing adhesion formation is paramount. OBGYN physicians in general practice should consider referral to a subspecialist (Reproductive Endocrinology and Infertility or Minimally Invasive Gynecologic Surgery) for patients with ≥5 fibroids, dominant fibroid ≥9 cm, or estimated fibroid weight ≥500 g. Multilayer uterine closure excluding endometrium is critical after transmural myomectomy to reduce the risk of niches, iatrogenic adenomyosis, and accreta spectrum disorders in subsequent pregnancies. Preoperative anemia optimization (target hemoglobin >13 g/dL) with iron repletion and consideration of GnRH agonist therapy reduces intraoperative blood loss and transfusion risk, facilitating a safer minimally invasive surgery approach.

Minimally invasive myomectomy is a technically demanding but effective fertility-sparing intervention for reproductive-aged patients with complex fibroid disease. Careful preoperative planning, disciplined intraoperative execution, and meticulous uterine reconstruction are central to optimizing outcomes while preserving uterine integrity ( Table 2 ). Although emerging technologies continue to expand treatment options, myomectomy remains the standard surgical approach for patients desiring future pregnancy. Ongoing investigation is needed to refine best practices and clarify long-term reproductive outcomes in this evolving field ( 30 , 31 ). Table 2 Surgical planning considerations for minimally invasive myomectomy in fertility-seeking patients Domain Key considerations Clinical implications Preoperative imaging MRI for fibroid number, size, FIGO type, depth, and cavity distortion Improves surgical planning and patient counseling Preoperative assessment of anemia Optimization of preoperative anemia Decreases postoperative morbidity Patient selection Fibroid burden, uterine size, location, surgeon expertise, fertility goals Guides feasibility of MIS approach Intraoperative blood loss reduction Vasopressin, misoprostol, tranexamic acid, vessel occlusion, tourniquet Reduces transfusion risk and morbidity Fibroid localization Intraoperative ultrasound, tag-and-track strategy Minimizes retained fibroids Uterine closure Multilayer closure, dead space obliteration, barbed sutures Preserves uterine integrity Adhesion prevention Meticulous hemostasis and adhesions barriers over hysterotomy Reduces risk of inherent adhesiogenesis Tissue extraction Contained morcellation techniques Maintains MIS benefits while limiting dissemination Surgical planning considerations for minimally invasive myomectomy in fertility-seeking patients

K.C. has nothing to disclose. Z.K. has nothing to disclose. R.F. has nothing to disclose.