Robotic-assisted uterine transposition followed by anatomic pelvic repositioning for a patient with intramural fibroids and rectal cancer.

OBJECTIVE: To report the first described case of robotic-assisted utero-ovarian transposition followed by anatomic repositioning in the pelvis and cervico-vaginal anastomosis in a woman with uterine fibroids, which was performed for fertility preservation in the context of pelvic radiation for rectal cancer.

DESIGN: Description of technique and live-action narrated surgical footage showing uterine transposition and repositioning.

SUBJECT(S): 36 year-old woman with a new diagnosis of cT3N2M0 rectal adenocarcinoma, planned for neoadjuvant chemotherapy and pelvic radiation, who desired fertility preservation permissive of future pregnancy. Transvaginal ultrasound revealed a 5-cm posterior leiomyoma and normal endometrial cavity. The patient elected for utero-ovarian transposition prior to chemoradiation. The patient included in this video gave consent for publication and posting of the video online including social media, the journal website, scientific literature websites and other applicable sites. Per institutional guidelines, IRB review was not required.

INTERVENTIONS: Robotic-assisted utero-ovarian transposition was performed in an inpatient setting two weeks following ovarian stimulation and oocyte retrieval. She was given GnRH agonist for menstrual suppression after oocyte retrieval. The uterus and adnexa were transposed en bloc to the upper abdomen, with perfusion via retroflected infundibulopelvic ligaments. Intravenous indocyanine green (ICG) was administered intraoperatively to visualize uterine perfusion. Three weeks postoperatively, the patient underwent surgical management of small bowel obstruction, which was successfully managed with laparoscopic adhesiolysis. The patient subsequently completed chemoradiation, and had complete response of rectal tumor. She therefore elected for surveillance. Seven months following transposition, and two months following completion of treatment, the patient underwent uncomplicated robotic-assisted utero-ovarian anatomic repositioning in the pelvis with cervico-vaginal anastomosis. Chromopertubation confirmed tubal patency.

MAIN OUTCOME MEASURES: Restoration of normal pelvic anatomy, resumption of reproductive physiology RESULTS: At her 4-month postoperative visit, the cervix and vagina were normal in appearance. The patient reported return of spontaneous menses and sexual activity without complication.

CONCLUSION: This case is unique due to the presence of bulky intramural uterine fibroids. The described technique may be useful for select cancer patients, who desire to carry a pregnancy following pelvic radiation for cancer treatment, and demonstrates that patients considering utero-ovarian transposition need not be excluded solely based on presence of uterine fibroids.