Design: Surgical Video

Setting: Tertiary-care operating room

Patients or Participants: 61 yo G2P2002 who presented with complaints of stress urinary incontinence and a 14 cm cervical fibroid with right hydronephrosis.

Interventions: The video demonstrates robotic assisted total laparoscopic hysterectomy with bilateral salpingo-oophorectomy.

Measurements and Main Results: Cervical uterine myoma are the rarest of all uterine fibroids with an incidence of 0.6%. Risks of performing minimally invasive hysterectomy for cervical fibroids are mainly associated with injuries to the bladder or ureters due to altered anatomy and intraoperative hemorrhage. We used several techniques to assist us while performing this hysterectomy in a minimally invasive fashion. First, was preoperative stenting of ureters with cystourethroscopy. ICG was injected into the right ureteral stent for visualization during Firefly mode. Second, advanced knowledge of the pelvic anatomy was used to enter the retroperitoneal space in order to identify the blood supply at the infundibulopelvic ligament and the uterine artery. Third, careful dissection with the robotic monopolar scissors and bipolar was used to separate the cervical fibroid from the bladder flap. Next, the uterine manipulator was removed and a Lucite vaginal dilator was used for creation of the colpotomy. Lastly, a 17-cm Alexis contained extraction system was used for contained uterine morcellation for specimen removal. Pathology revealed benign leiomyoma and reported no malignancy in uterus, cervix and bilateral fallopian tubes.

Conclusion: Our robotic assisted approach demonstrates the possibilities and advantages of minimally invasive hysterectomy in patients with anatomically challenging leiomyomas.