Early detection and aggressive chemotherapy/radiotherapy treatments have improved the long-term survival rates for many young women with various types of cancer. As a consequence of these cytotoxic treatments, their reproductive future can be either short lived or eradicated. For young single women with cancer, oocyte cryopreservation offers the best potential option for achieving a future pregnancy using their own gametes. Unfortunately, the urgent need to commence cytotoxic treatment often does not permit adequate time for cryopreservation of mature oocytes. Conversely, cryopreservation of ovarian tissue eliminates the delay necessary to obtain mature oocytes, but the subsequent potential for establishing pregnancy is currently unknown. Although ovarian tissue cryopreservation is an attractive alternative and frequently used for patients with these conditions, little has been published on the efficacy of various protocols. Cryopreservation of ovarian tissue is more complex than that of gametes or embryos, requiring preservation of multiple cell types, which may vary in volume and water permeability.

Uterine anomalies are a relatively common congenital abnormality, with uterine septum being the most common (Table 8.1.1). This is even truer in patients with recurrent pregnancy loss, in whom rates of uterine abnormalities may approach 15% to 27%. Historically, the uterine septum has been approached via laparotomy through either a Tompkins or Jones procedure. These successful but highly morbid procedures required laparotomy, significant hospital stays, and subsequent cesarean delivery and had a high risk of adhesion formation. More recently, this surgery has been supplanted by hysteroscopic or other minimally invasive methodologies for treatment. This section focuses on the embryologic development of the genital tract that may lead to mullerian abnormalities, discusses the work-up of patients before treatment, evaluates the appropriate candidates for surgical procedures, and discusses the technical aspects of the procedure itself, postoperative recommendations, and results of various modalities of treatment. In addition, complications specific to these procedures are reviewed.

EMBRYOLOGY

It is unclear what the exact rate of mullerian abnormalities is in the general population as there have been no good cross-sectional studies of normal patients. It is believed that the incidence is in the range of 1% to 6%, and there are numerous variations. The American Fertility Society (now the American Society for Reproductive Medicine) has published a classification system to standardize the nomenclature among surgeons (Tables 8.1.1, 8.1.2).

The development of surgical robotics is a dynamic process, a constant interplay between clinical need and technologic capability. As both of these factors are constantly changing, it is unlikely that the form the surgical robot takes today will be the form it takes in 20 years. In many aspects, the technology has progressed beyond perceived clinical need. This has created a novel challenge for the surgeon — to determine whether a technologic innovation with apparent benefit has meaningful clinical application. This process has defined the in corporation of robotic technologies into many surgical disciplines, including gynecologic, cardiothoracic, urologic, abdominal, and pediatric surgeries. In whatever way this interplay of technology and clinical need progresses, surgeons are left with the task of guiding its impact on patient care.

The term robot is a misnomer when describing this surgical device. Derived from the Czech robota meaning “drudgery,” this term implies autonomous function, which most surgical robots do not have. Instead, they are better described as computerassisted telemanipulators, implying that they are subject to human control. The complexity of surgical procedures does not currently allow for devices that work entirely autonomously. Nevertheless, the term robot has added a flare of futurism to the endeavor and has been the one most commonly used in the literature.

Uterine leiomyomas are monoclonal smooth muscle tumors. Early research on isoform analysis of glucose-6-phosphate dehydrogenase in the smooth muscle cells of uterine leiomyomas pointed to the monoclonal nature of this tumor. Each leiomyoma lesion in the uterus may have a distinct isoform and are presumed to arise independently. Cytogenetic abnormalities of several chromosomes have been identified within these smooth muscle tumors with normal karyotype in the adjacent non-tumorous regions. These cytogenetic mutations have been identified in about 40% of uterine leiomyomas. Some of the mutations involve genes involved in cellular growth regulation. Correlation between the genotype of the leiomyomas and the phenotype has not led to conclusive observations.

Gross morphology

Uterine leiomyomas are usually well-circumscribed tumors. They can occur in any part of the uterus, including the cervix. They may also occur in the round ligaments. Generally they are divided into subserosal, intramural, and submucosal. The subserosal and submucosal uterine leiomyomas can become pedunculated. The submucosal uterine leiomyomas can protrude into the uterine cavity or become pedunculated, and protrude through the cervix. Uterine leiomyomas can become separated from the uterus, and can be found in different areas such as the retroperitoneal space between the leaves of the broad ligament of the uterus.