Uterine myoma is the most common benign tumors of the uterus and may be presented 20–40% of women at reproductive age [1]. The myomas can be asymptomatic. However, they often cause abnormal uterine bleeding, pelvic pain, compression symptom, or even infertility [1,2]. Instead of hysterectomy, myomectomy can be one option for symptomatic women who wish to preserve their childbearing capabilities [3,4]. Along with advances and improvements in surgical devices and instruments, an increasing number of gynecologists have chosen minimally invasive procedures as the solution to treat myoma [5].

Because of small incision wound and cosmetics advantage, laparoscopic myomectomy (LM) has been confirmed in the management of uterine myoma [6,7]. However, it is very “unfriendly” for surgeons because of many disadvantages such as keeping stand for a long time, unable to relying on, or swaying visual field by first-assistant [8,9]. Since the approval by the US Food and Drug Administration (FDA) in April 2005, robotic surgeries using the da Vinci Surgical System (Intuitive Surgical Inc., Sunnyvale, CA, USA) have been applied widely in many surgical fields including urology, orthopedics, general surgery, cardiothoracic surgery, and gynecology [10]. The three-dimensional vision system and the wrist-like structure of EndoWrist instruments (Intuitive Surgical Inc.) recapitulating the motion of the surgeon’s hand make precise procedures easier than in conventional laparoscopy, which allows robotic surgery to overcome some of the shortcomings and limitations of traditional laparoscopy [11]. We had also successfully undergone robotic surgery in many complicated gynecologic diseases in Taiwan [12].

A few case series comparing robotic hysterectomy with laparoscopic hysterectomy have been reported. Sarlos et al. [13] reported a randomized control trial for robotic hysterectomy and laparoscopic hysterectomy with 100 patients. Paraiso et al. [14] analyzed 62 cases of robotic hysterectomy and laparoscopic hysterectomy. Both the aforementioned groups reported that the robotic procedure was associated with longer operating times. Overall conversion to open surgery was not noted. In one case, laparoscopic hysterectomy was converted to laparotomy owing to bleeding and pneumoperitoneum failure. With respect to myomectomy, only two retrospective studies have analyzed the advantages of robotic myomectomy (RM). Bedient et al. [5] reported a chart review of 81 patients with RM; Nezhat et al. [15] reported on 15 cases of RM and 35 cases of LM. Bedient et al. [5] reported that the short-term surgical outcomes were similar between RM and LM. Conversion to an open approach was not noted in the RM group; however, two cases of conversion were reported in the LM group [5]. Nezhat et al. [15] claimed the RM required a significant prolonged surgical time over LM. They concluded that RM did not offer any substantial when performed by skilled laparoscopic surgeons. However, there are some limitations of these two retrospective studies. In addition to the small number of cases and non-prospective study design, the severity of each myoma assessed was not clear. The authors did not provide detailed information about the myoma location or about the cervical or broad ligament type. Selection bias is apparent and commonly noted in clinical practice. The selection of RM or conventional LM for the management of uterine leiomyomas is a dilemma for gynecologic surgeons to date. Thus, a controlled trial is needed to clarify RM’s role, especially the open conversion rate.

The authors are accountable for all work aspects in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. The Institutional Review Board of TMU approved this project (N202003111).

We introduce the study design and flowchart to compare robotic and laparoscopic myomectomy. This observation cohort project is on the way and the results will be analyzed in future.

Since the FDA approved the robotic platform in the gynecological field in 2005, it has been a mature surgical technique for gynecological diseases. There is still an issue of learning curves in robotic surgery, although the platform is more user-friendly than laparoscopic surgery. Woelk et al. [18] found that operative time decreased significantly from 3.5 to 2.7 hours during 3 years of robotic hysterectomy. The proportion of patients with a stay longer than 1 day significantly decreased from 49.2% to 14.7%. Chen et al. [19] reported a steep decrease in docking time and console time in the robotic single-site hysterectomy group given chronological change. Although no study has addressed RM’s learning curve, we assume it is similar to robotic hysterectomy [20]. Therefore, we assumed 24 cases within 1 year could master the technique needed for RM.

Myoma is heterogeneous in size, location, and FIGO type. These characteristics consist of complexity and directly influence the operation outcome. Thus, myomectomy surgery is individualized and difficult to standardize [21]. There is no score yet that is clinically helpful for risk stratification of minimally invasive myomectomy. Thus, we try to develop a risk stratification score, like the prediction of the adherent placenta in placenta previa [22], which will help the patient selection of RM, LM, or OM.

The initial trial was proposed for the collaborative effort of the ASGR members. Through this cooperation, ASGRS will strengthen the network and contribute to women’s health.