UTERINE-PRESERVING ROBOTIC RESECTION OF A CHALLENGING SUBMUCOSAL FIBROID UNDER ULTRASOUND GUIDANCE.
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OBJECTIVE: 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. SETTING: The Uterine Myoma Center at a University Tertiary Referral Hospital. PARTICIPANT: A 33-year-old nulliparous woman (G1P0) with a history of mid-trimester pregnancy loss at 15+6 weeks due to a massive fibroid. Preoperative MRI revealed multiple lesions, including a few small subserosal fibroids, 3.5cm fundal intramural fibroid (FIGO Type 4) and an 8.4cm intracavitary lesion (FIGO Type 2-5 hybrid) causing marked cavitary distension. INTERVENTIONS: While operative hysteroscopy is the conventional gold standard for submucosal fibroids(1, 2), its feasibility is often limited by large tumor size, deep intramural extension, or severe degeneration. In this case, preoperative MRI clearly demonstrated that the 8.4cm hybrid type fibroid completely obliterated the endometrial cavity with profound anatomical distortion. To optimize the surgical workspace and interim menorrhagia, preoperative GnRH agonist therapy administered. (3) Consequently, an abdominal robotic platform was chosen over hysteroscopic approach to simultaneously address these complex, coexisting fibroids and ensure precise multi-layered reconstruction.(4) We initiated the procedure by resecting the fundal intramural fibroid 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. Following 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. Utilizing the robotic cold-cut technique to minimize thermal injury, the intracavitary mass was meticulously enucleated. Prior to enucleation, diluted vasopressin (10 IU in 100mL of normal saline) was injected into the myometrium following meticulous aspiration to prevent accidental intravascular administration. A focal 1cm endometrial defect was repaired with 3-0 Vicryl. The myometrial defect was reconstructed in three 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 (2mg twice daily) was administered for one month. CONCLUSION: 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.