How Robotic Surgery Is Changing Treatment for Gynecologic Conditions (podcast)

Dr. Garg: Fibroid tumors can cause pelvic pain in some cases depending on where they are and how large they are. For the most part, they are not cancerous. Occasionally, they can be. Any time we do surgery, there is an analysis done on all the tissue. But in general, fibroids are usually benign tumors. But pain and bleeding are some of the major symptoms that we see.

Dr. Gafori: Fibroids that grow in the lining of the uterus can cause problems with fertility and sometimes they need to be removed before someone tries to get pregnant.

Dr. Garg: A myomectomy is when you just remove the fibroid tumor. When we treat fibroids, some people require a hysterectomy to remove the entire uterus, but for people who don't want to have extensive surgery or who want to be able to get pregnant, then we try to do the least amount of surgery possible, which is just to remove that tumor.

Dr. Gafori: There are hysteroscopic myomectomies, which are done through the vagina and the fibroid is removed through the vagina.

There are open surgeries, which are big, extensive surgeries, where we make big incisions [in the abdomen] and those are typically reserved for patients who have many, many very large fibroids. There are laparoscopic myomectomies and robot-assisted laparoscopic myomectomies.

Dr. Garg: Yes, up to half the time, it can return. It is a very, very common thing. So we choose that surgery wisely, especially if they want to get pregnant later. Fibroids are a little bit more concerning if it grows post menopause.

Dr. Gafori: Fibroid tumors are typically hormone dependent. In menopause, your hormone levels go down so it’s a bit more uncommon to have that. For women over age 60 who have new fibroids, [we are concerned because that could possibly represent] a sarcoma, which is a cancerous growth.

Dr. Garg: The only true permanent cure is a hysterectomy. By removing the entire uterus, there is nowhere a fibroid could possibly grow back again.

Dr. Gafori: Unfortunately there isn’t a real reliable method to do that other than pathology, where the pathologist takes the tissue through a biopsy and looks at it under a microscope. We do start with an ultrasound, and sometimes we’ll refer patients for an MRI if we have some suspicion of something. But typically it’s at time of surgery that the full diagnosis is made.

Dr. Garg: Pelvic prolapse happens when the muscle and the ligaments that support any part of the pelvic organs — whether it’s the bladder, the uterus, vaginal tissue — get weaker over time and start sagging and literally pushing into the vagina and even protruding outward. This can cause pain, pressure and urinary problems.

Pelvic organ prolapse is more common post menopause and more common in people who’ve had multiple childbirths.

Dr. Garg: Laparoscopic surgery was kind of the first major advancement for minimally invasive surgery. What it involves is that rather than a big open incision across the stomach, [the surgeon makes] three or four smaller incisions, each less than an inch big. That surgery is an excellent surgery. It’s still something we still frequently use. But it does have its limitations in terms of how much range of motion you have and how much instrumentation you have available.

Robotic surgery is a bit of a misnomer that kind of implies the surgery is being done by some sort of machine. The actual robot is a large machine that holds all those laparoscopic instruments for us, and we still control all of them. But it allows us a lot more dexterity and a lot more options for the types of surgeries we can do than we could do with only laparoscopic surgery before. Like in laparoscopy, it’s still the two or three little holes, but with those robotic instruments, there are more options and they have a lot more articulation and a lot more range of movement. And when we look inside the [robotic surgery] camera it’s a 3D high-definition visual field compared to a regular two-dimensional screen that is used in laparoscopy. Having that 3D visualization has been such a huge difference for hand-eye coordination.

Dr. Gafori: In robotic surgery, the instruments have 360 degrees of rotation. The computer translates our movements into smaller, more precise movements with the robot. The small incisions help in terms of recovery for patients. Instead of having a large incision, they have these little incisions. They can even go home the day of the surgery, which is amazing. And they can return to work much earlier.

Dr. Garg: With open surgery, most patients will stay in the hospital for up to three to four days for a routine recovery. For [robotic] surgeries, most of our patients go home the same day.

With open surgery, their return to work can be as long as four to eight, even 12 weeks. With robotic surgery, I've had patients go back as soon as the first week after surgery and most patients within two or three weeks.

Dr. Garg: The risks are essentially the same as any surgery we do. Every surgery has those inherent risks — bleeding, infection, all sorts of other complications. And those aren’t necessarily different with the robot. In fact, studies show a lot lower complications with robotic surgery when it’s in the hands of highly skilled surgeons compared to open surgery.

Dr. Gafori: Some of the surgeries can actually be almost bloodless, which is incredible.

Dr. Garg: Recovery is really where that maximum benefit is.

Dr. Gafori: Any type of prolonged abnormal bleeding is something that you need to see us for. Excessively painful periods, bleeding in between periods, those are typically things we would like to see you for. Any type of post-menopausal bleeding is considered something that needs an evaluation.

Dr. Garg: I would say, especially for pain or bleeding or cramping or anything like that, anything that lasts for more than one period or more than one cycle, it’s generally worth at least checking to see if there is something else going on.

In terms of urinary issues, I would say the second you have experienced anything, it’s an issue worth looking into. It is one of the most under-reported things that we deal with.

Dr. Gafori: Most patients probably could be a candidate. Patients who might not want to have this kind of surgery are those who have medical problems that would make it difficult for them to be positioned in the way that we need them to be positioned.

Dr. Garg: There are certain conditions where a more extensive surgery needs to be done — if the uterus is very, very large, if someone has had a lot of previous surgeries. But in general, there is not an overall set rule for who can get it and who can’t. It really comes down to that individual evaluation.

Dr. Gafori: We try to reserve the robotic surgeries for patients who have a little bit more complicated situations. A normal tubal ligation or a small cyst that needs to be removed, we typically just do it laparoscopically.