[Edaily Reporter NA EUN-KYUNG ] Pain and surgical costs aren’t the only reasons women delay treatment for uterine fibroids. Some patients avoid visiting the hospital altogether after being told they’ll need to have their uterus removed. Dr. Lee Hong-joong, director of Yonsei Sarangmoa Women’s Hospital, who has focused on uterus-preserving surgeries, frequently encounters such patients in his clinic. Dr. Lee said he wants to inform them that there are ways to treat fibroids while preserving the uterus.

Dr. Lee told Palm Daily during a meeting on the 27th of last month at Yonsei Sarangmoa Women’s Hospital in Guro-gu, Seoul, “Many patients come to our hospital looking for ways to treat uterine fibroids while preserving their uterus—they don’t want a hysterectomy, but they find it difficult to endure the discomfort.”

According to the Health Insurance Review and Assessment Service, the number of patients treated for uterine fibroids in South Korea rose by 10.3 percent, from 589,902 in 2021 to 650,830 last year. Dr. Lee believes that, in addition to expanded screening, social changes such as later marriage and a decline in childbirth rates have also contributed to the increase in uterine fibroid patients. This is because women who have given birth tend to have a lower risk of developing uterine fibroids than those who have not. In some cases, existing fibroids shrink as the uterus returns to its original size after childbirth.

Treatment Delayed Due to Fears of Hysterectomy… Missing the Optimal Window for Pregnancy

Yonsei Sarangmoa Women’s Hospital is a women’s hospital that opened in 2007 and has provided both obstetric and gynecological care. The hospital specializes in uterine-preserving treatments, and Director Lee has extensive surgical experience, having performed a total of 2,000 gynecological robotic surgeries from April 2022 through October of this year. Conditions treated include giant and multiple uterine fibroids, adenomyosis, and ovarian cysts.

Dr. Lee explained, “Nine out of every ten patients who visit our hospital have uterine fibroids,” adding, “Among them, there are many patients with giant fibroids—measuring 10 cm or more in diameter—or multiple fibroids who are seeking treatment methods that preserve the uterus.” Some patients delayed treatment out of fear of a hysterectomy, even while suffering from symptoms such as heavy menstrual bleeding, anemia, pain, and pressure on surrounding organs.

One patient he cited as a particularly regrettable case was a 45-year-old woman who wanted to become pregnant. She had been advised to undergo a hysterectomy several years earlier but kept postponing her hospital visit until it was too late. In Dr. Lee’s opinion, it was possible to preserve her uterus, but given her age, pregnancy would not be easy. Dr. Lee said, “There are patients who want to become pregnant but waste time believing that a hysterectomy is the only treatment option before finally coming to see us. I can’t help but feel a sense of regret, wondering what might have happened if she had explored other options sooner.”

Conversely, the most rewarding moments are when he meets patients who have experienced healthy pregnancies and childbirth following fibroid surgery. Dr. Lee explained, “Since our hospital also handles deliveries, I can personally monitor patients from fibroid removal through pregnancy and childbirth,” adding, “Just a few days ago, we had a case where a patient gave birth after having her fibroids removed.”

While uterine-preserving surgery does not guarantee pregnancy, treatment to remove the fibroids can be helpful when they interfere with conception. Dr. Lee explained that unless there is discomfort, it is not necessary to perform surgery simply because fibroids are present; instead, the treatment method is determined by considering symptoms, the characteristics of the lesions, and pregnancy plans.

In particular, large or multiple fibroids can be difficult to access via conventional laparoscopic surgery, making robotic surgery a particularly advantageous option. Dr. Lee also admitted that, initially, he felt apprehensive about performing robotic surgery on fibroids larger than 10 cm. However, as he gained experience, he expanded the scope of robotic applications to include more complex procedures. “When performing robotic fibroid surgery, I consult thoroughly with the patient to determine the treatment plan,” he said. “Now, I use the robot even for fibroids as large as 15 cm or cases involving 30 fibroids.”

In this process, the Da Vinci system plays a key role in suturing. After removing the fibroids, the surgeon must control bleeding at the site and reconstruct the uterine wall. The larger the lesions and the more widespread they are, the more complex the suturing becomes in terms of both scope and direction. Dr. Lee explained, “While a hysterectomy involves relatively fixed areas to cut and suture, fibroids can be located in the front, back, and sides, so each excision site must be sutured individually,” adding, “Only by meticulously suturing the sites where the fibroids were removed can the shape of the uterus be properly restored.”

The da Vinci system, including the “da Vinci X” by Intuitive Surgical used by Dr. Lee, is a robot-assisted surgical system in which the surgeon controls articulated surgical instruments from a console while viewing magnified, high-definition 3D images. A key feature is that the surgeon’s hand movements are transmitted almost exactly to the instruments, and the instruments—which move like a wrist—allow for precise adjustment of the suture needle’s angle and direction even within the narrow pelvic cavity.

In contrast, in conventional laparoscopic surgery, the surgeon must use a long instrument—30 to 40 cm in length—to grasp a curved suture needle, adjust its angle, and then suture the tissue. It requires considerable practice and experience for a surgeon to become proficient in the technique of suturing in multiple directions within a confined space.

He explained, “In laparoscopic surgery, when suturing, the surgeon must use long forceps to push the needle in the desired direction and then rotate it to pull it out—but simply grasping and pushing the needle is difficult in itself. However, the Da Vinci system’s articulated instruments allow for flexible execution of these movements,” adding, “The advantage is that surgeons can move as freely as in open surgery while keeping the incision as small as in laparoscopic surgery.”

Comparative studies have also confirmed differences in hospital stay and surgery duration. A 2018 meta-analysis analyzing 20 studies involving 2,852 patients found that while robot-assisted myomectomy took approximately 1 hour and 25 minutes longer than open surgery, the hospital stay was, on average, 1.74 days shorter. A 2023 meta-analysis comparing it to standard laparoscopic surgery also found that while the procedure took about 39 minutes longer, there was less blood loss and fewer complications. The hospital stay was also shorter by an average of 0.11 days, or about 2 hours and 40 minutes.

Intuitive Instrument Control, Experience-Driven Surgical Decision-Making

The Da Vinci X is a model designed to reduce the burden of adoption by utilizing the same surgeon’s console as the Da Vinci Xi, as well as the same vision cart—which processes surgical images and displays them to the medical team—while sharing key surgical instrument technologies. It allows the camera, surgical instruments, and energy devices for incision and hemostasis to be integrated and used as a single system.

After experiencing the benefits of robotic surgery firsthand while using the da Vinci system, Director Lee introduced a surgical robot from another company about three months ago. Having used various systems, he cited the Da Vinci’s integration and its ability to naturally replicate hand movements as key strengths. “It’s crucial how organically the camera—which acts as the eyes—and the surgical instruments—which act as the hands—are connected and how naturally they execute the desired movements,” he said. “The Da Vinci gave me the impression that each element of the system is seamlessly integrated, much like Apple products.”

The purchase price, maintenance costs, and consumables for surgical robots are significant hurdles that primary and secondary care facilities must overcome when adopting such technology. As a hospital administrator, Director Lee also weighed the financial burden. However, he judged that the system would see high utilization given the large number of existing patients with uterine fibroids, and he decided to adopt it because he wanted to perform surgeries himself using the Da Vinci system—a device whose advantages he had heard about from fellow medical professionals.

“I concluded that introducing the Da Vinci system would allow us to treat existing patients more effectively and also treat patients for whom surgery had previously been difficult,” he recalled. “The fact that Intuitive Surgical provides systematic training not only for doctors but for the entire care team—including nurses who participate in the surgeries—also played a positive role in our decision to adopt the system.”

In addition to robotic surgery, the hospital provides care to aid patients’ postoperative recovery. This includes shortening the fasting period and resuming meals based on the patient’s condition, as well as removing urinary catheters early and encouraging early ambulation. The hospital’s 24-hour operation system, which also handles childbirth, serves as the foundation for responding to postoperative complications such as bleeding or fever.

Director Lee stated, “Uterine fibroid surgery requires not only the surgeon’s experience but also the support of the hospital’s overall preparation and care,” adding, “As both the surgeon and the director, my goal is to monitor the recovery process necessary for the patient and minimize their discomfort, rather than rushing them out of the hospital.”

Of course, even though the robot assists with manipulation, it does not make surgical decisions on the surgeon’s behalf. Decisions regarding where to make an incision, how to remove the fibroids, and how to suture the uterine wall depend on the surgeon’s experience. Director Lee emphasized, “While the robotic-assisted surgical system is intuitive to operate, making it relatively easy to learn how to use the instruments, one must distinguish between becoming familiar with instrument manipulation and having surgical experience.” He added, “Even for the same type of fibroid, the approach varies depending on its location, size, and number. Ultimately, the surgeon must decide where to make the incision and how to suture, and as experience accumulates, the capabilities of the robot-assisted surgical system can be utilized more effectively,” he emphasized.

His focus on uterine preservation is not because he considers hysterectomy to be the wrong treatment. While a hysterectomy eliminates the possibility of fibroid recurrence, it also makes future pregnancy impossible, and depending on the patient, it can lead to a sense of loss and psychological distress associated with losing an organ. On the other hand, myomectomy preserves the uterus, but new fibroids may develop, or the remaining fibroids may grow. Director Lee believes that not only the medical pros and cons of treatment but also how the patient perceives her own body and the treatment outcomes are important.

“Every patient’s health condition, living environment, and expectations for life after treatment are different. If I determine that treatment is possible while preserving the uterus, I want to fully explain the possibilities and the pros and cons, and help the patient make their own choice with a full understanding. My approach to patient care is not just about treating the disease, but also about considering what kind of life the patient wants to live after treatment.”