Robotic Hysterectomy in Renal Recipient Lady with Very Large Fibroid Uterus

Introduction

Since the advent of the da Vinci Surgical System, robotic surgery has made major advances in all surgical arenas. It has major advantages in reducing morbidity, including infections, blood loss, and the need for narcotics. We present a case of robotic hysterectomy, which was challenging due to the location of the transplanted kidney, adhesions, and space constraints for placement of ports. Planning was done with the involvement of nephrology, urology, and anaesthesia teams, resulting in good surgical outcomes.

Case report

We present the case of a 44-year-old woman with a history of one previous normal vaginal delivery who presented to the outpatient department (OPD) with complaints of heavy menstrual bleeding and abdominal pain for the past few months. Her ultrasonography (USG) revealed a very large fibroid of about 10cm and she had come for further management of the same. She had a history of renal transplant (mother was the donor) in 2015, performed via open surgery for chronic renal disease. She was currently on immunosuppressants and anti-hypertensive medications. There was presence of arteriovenous (AV) fistula in her right arm due to a history of dialysis.

Currently, her menstrual cycles lasted 7-10 days with very heavy flow and passage of clots. She had one vaginal delivery 12 years back which was uneventful. Further investigations revealed a haemoglobin level of 10 g/dL and a serum creatinine level of 0.89 mg/dL, with other findings within normal limits. Her USG showed a large heterogenous fibroid of about 9.5x9.6cm, abutting the endometrial cavity and displacing it anteriorly. The endometrial cavity was distorted, and posterior endometrial interface was indistinct. The cervix was bulky, and both ovaries were obscured. The transplanted kidney was seen in the right iliac fossa.

Magnetic resonance imaging (MRI) pelvis was done, which revealed a large fibroid of about 89x92x89mm in the posterior wall, with cystic changes. The transplanted kidney was seen in the right iliac fossa, with mild hilar fat proliferation. On examination, a large abdominal scar was noted, extending from the right lumbar region to the mons pubis. The uterus, enlarged by the fibroid, was palpable above the umbilicus. Thorough counselling was done regarding these findings and the need for further definitive surgical management. A decision was taken for multidisciplinary approach involving urologist, nephrologist, and anaesthesia team.

A minimally invasive surgical approach was planned, considering the patient’s immunosuppressant therapy, to minimise the risk of wound-related complications and infection. Robotic-assisted surgery was chosen for its added advantages of precision, reduced complications, and lower likelihood of conversion to open surgery.

All necessary consents were sought and fitness for surgery was obtained. Her Pap test was done and was reported normal.

Robotic surgery was the preferred mode here due to the surgical challenges in this case:

1. Previous surgery-related adhesions (history of open transplant surgery with a large abdominal scar.)
2. Presence of transplanted kidney and altered ureter course in the right iliac fossa.
3. Very large myoma occupying the entire pelvis, extending up to the umbilicus.
4. Port placement issues due to space constraints.
5. Retrieval of large specimen.
6. Presence of AV fistula in right arm, limiting access to intravenous fluids and medications.
7. On immunosuppressants, making the patient prone to infections and anaemia, thus necessitating avoidance of open surgery and minimising the need for blood transfusions.

Once prepared for surgery in the operation theatre, port placement was done above the umbilicus, 7-8cm apart, using one endoscopy port, three other arm ports, and one infracostal port for instrument access. The instruments used included a 30-degree endoscope, bipolar forceps, Maryland curved scissors, and ProGrasp forceps.

Intraoperatively

The uterus was enlarged diffusely with a large myoma with vascularity, occupying the entire pelvis. The transplanted kidney was identified in the right iliac fossa, along with the neoureter and its course. Hysterectomy proceeded meticulously and bleeding was controlled effectively with use of robotic instruments and care was taken to safeguard the ureter and the kidney (the transplanted kidney was in the extraperitoneal portion in the right iliac fossa).

Once hysterectomy was done, the next concern was the retrieval of the large specimen. The uterus was bisected, and a myomectomy was done to facilitate removal of the uterus and myoma enbloc (without the use of morcellation) through the vagina, and no extension of the abdominal incision.

After retrieval of specimen, thorough pelvis wash was given, and the vault was closed using V-Loc 3-0 with robotic instruments. The patient tolerated the surgery very well, and her urine output was clear and adequate at the end of her surgery. Both the ovaries were normal and conserved.

She was observed carefully in the post-operative period along with the nephrology and urology teams, received good antibiotic cover, and ambulated early. Medications during the post-operative period included cefoperazone and sulbactam, prednisolone 10 mg, amlodipine 2.5 mg, metoprolol 50 mg, and sustained-release prazosin 5 mg.

Her blood pressure was well controlled with medications. She was discharged on Day 3 with oral medications and called for a follow up in the OPD in 7 days.

Her final dressing was done on Day 8 in the OPD. The histopathological biopsy revealed a uterine leiomyoma without atypia or mitosis. All her robotic port sites were well healed, and her complete blood count (CBC), and kidney function tests (KFT) were in the normal range.

Discussion

Significant advances in surgical techniques, along with induction and maintenance immunosuppression regimens, have improved allograft outcomes. Nonetheless, infections remain a leading cause of complications after kidney transplant. Other causes of morbidity include hypertension (75%-85% recipients), hyperlipidaemia (60%), cardiovascular disease (15%-23%), diabetes mellitus (16%-20%), and osteoporosis (60%).1

The Food and Drug Administration (FDA) approved the da Vinci Surgical System in 2005 for gynaecological surgery, based on preliminary evidence of safety and efficacy from their early experience with myomectomy and hysterectomy at the University of Michigan.2 It has been rapidly adopted and it has already assumed an important position at various centres where this is available. The system comprises three components: a surgeon's console, a patient-side cart with four robotic arms, and a high-definition three-dimensional (3D) vision system. Robotic surgery offers an edge in more complex surgeries. The conversion rate to open surgery is lesser with robotic assistance compared to laparoscopy

The EndoWrist movement of robotic instruments allows better and precise suturing than conventional straight-stick laparoscopy. Most publications emphasise that the main benefit of precise and articulated movements while using robotic arms comes in handy for adhesiolysis, when surgeons encounter dense adhesions or need to manipulate large uteri during hysterectomy. Our patient was selected for robotic hysterectomy for various reasons as discussed above, the main factor being her renal transplant status.

Patients in the robotics cohort typically experience a shorter hospital stay and reduced estimated blood loss. These patients also benefit from indirect cost savings compared to non-robotic approaches.³

Most authors report a significantly diminished incidence in laparotomy conversions and complications in robotic-assisted surgery.4,5,6

Studies that evaluated narcotic usage have found that the robotic procedures required fewer units of narcotics. Robotics represents the future of gynaecological surgery, offering distinct advantages over conventional surgical techniques.