Successful Pregnancy after Extensive Robotic Adenomyosis Surgery Using the Double-Flap Technique and Intrauterine Indocyanine Green

Abstract

Study Objective

To evaluate the feasibility and outcomes of extensive robotic adenomyomectomy using the double-flap technique combined with intrauterine indocyanine green (ICG) for fertility preservation in patients with diffuse adenomyosis.

Design

Retrospective case report with longitudinal follow-up after extensive diffuse adenomyosis resection by robotics.

Setting

Procedures were performed in a high-volume tertiary referral center with the patient in dorsal lithotomy position using the Da Vinci robotic system. Three 8 mm robotic arms and one auxiliary 5 mm trocar were utilized. Ergonomics favored precise dissection and layered suturing.

Patients or Participants

A 41-year-old nulligravid patient with severe diffuse adenomyosis and a history of failed IVF cycles. The reproductive endocrinologist (RE) recommended fertility-preserving robotic surgery in an attempt to improve the chances of implantation of the patient’s remaining two frozen embryos

Interventions

Robotic adenomyomectomy with uterine vessels tourniquet, intraoperative vasopressin injection, intrauterine ICG to delineate infiltration depth, and the double-flap technique for uterine wall reconstruction.

Measurements and Primary Results

ICG fluorescence allowed to identify less infiltrated (green-intense) from more diseased myometrium. Adenomyotic tissue was resected while preserving a 1 cm margin of healthy myometrium internally and externally. The uterine cavity and the myometrium were reconstructed in multiple layers using barbed sutures. MRI and hysteroscopy at 1 year confirmed uterine integrity and normal anatomy. Embryo transfer resulted in a pregnancy, delivered via C-section at 32 weeks. There were no intraoperative or postoperative complications, and the patient remains asymptomatic.

Conclusion

Robotic double-flap adenomyomectomy with intrauterine ICG evaluation appears to be a safe and feasible fertility-preserving approach in selected patients with diffuse adenomyosis. Further studies with larger cohorts are needed to validate these findings and assess long-term reproductive outcomes.