Antonio R Gargiulo

• Doctor of Medicine
• Managing Director at Brigham and Women's Hospital

Background Fibroids are non-cancerous uterine growths that can cause symptoms impacting quality of life. The breadth of treatment options allows for patient-centered preference. While conversation aids are known to facilitate shared decision making, the implementation of these aids for uterine fibroids treatments is limited. We aimed to develop two...

(Abstracted from Am J Obstet Gynecol 2023;229(3):275.e1–275.e17) Symptomatic uterine fibroids (UFs) are benign tumors diagnosed in approximately 30% of American women by the age of 50 years. Symptomatic UFs can significantly affect quality of life (QoL) and have a wide range of symptoms and severity, including pelvic pressure, dyspareunia, sexual d...

Background: Few studies have directly compared different surgical procedures for uterine fibroids with respect to long-term health-related quality of life outcomes and symptom improvement. Objective: We examined differences in change from baseline to 1, 2 or 3-year follow-up in health-related quality of life and symptom severity among patients w...

Objective: To compare 12-month post-treatment health-related quality of life (HR-QoL) and symptom severity (SS) changes among patients with symptomatic uterine fibroids (SUF) not seeking fertility and undergo a hysterectomy, abdominal myomectomy (AM), or uterine artery embolization (UAE). Materials and Methods: The Comparing Options for Management:...

Purpose of Review Evaluation and management of uterine fibroids is an ever evolving area of medicine, impacting a large percentage of the female population. We present contemporary trends in evidence-based practice and research. Recent Findings Point of care intraoperative ultrasound may improve surgical ability to detect and remove small myomas,...

Objective To determine the incidence and risk factors for intrauterine adhesions (IUA) following minimally invasive, open and hysteroscopic myomectomy. Design Retrospective cohort study Setting University-affiliated fertility center Patients Patients 18 and older undergoing robotic-assisted or conventional laparoscopic minimally invasive myomect...

Robotic myomectomy is one the oldest robotic operations: it has been safely performed in the United States for over twenty years. This technique transcends the inherent challenges of laparoscopic microsurgery, thereby raising the threshold for open myomectomy. Ultimately, robotic assistance allows most myomectomies to be performed in a minimally in...

Study Objective To determine the incidence & risk factors for intrauterine adhesions (IUA) following myomectomy. Design Retrospective cohort. Setting Academic practice. Patients or Participants 158 women undergoing robotic (RM), laparoscopic (LM), abdominal (AM) or hysteroscopic (HM) myomectomy between 2007-2017 with post-procedure hysteroscopy...

Minimizing the number of port incisions during minimally invasive surgery is associated with improved outcomes and patient satisfaction. We designed this work to study the perioperative outcomes of robotic single-site myomectomy (RSSM) in comparison to robotic multiport myomectomy (RMM) in a certain subset of patients. The design of the study is a...

Our article endeavors to be both a review of the recent past and a preview of the future of reproductive surgery. By reflecting on the rate of technological advancement over the past decade, we attempt to predict the trajectory of the next. We also delve into the changing nature and practical challenges of the practice of gynecologic surgery for th...

INTRODUCTION To compare adhesions at cesarean delivery following open vs laparoscopic myomectomy. METHODS In this retrospective cohort study, patients with an abdominal myomectomy were compared to those having conventional or robot-assisted laparoscopic myomectomy with regard to dense adhesions at the time of cesarean delivery. Logistic regression...

Despite irrefutable evidence of the superiority of minimally invasive myomectomy over open abdominal myomectomy, laparoscopic myomectomy has an unacceptably low adoption in most countries. Robotic myomectomy is a proven solution to this unsustainable status quo. Introduced in 2004, this operation has a long safety record, allows the performance of...

Cambridge Core - Surgery - Reproductive Surgery - edited by Jeffrey M. Goldberg

Following the birth of the first child from a transplanted uterus in Gothenburg, Sweden, in 2014, other centers worldwide have produced scientific reports of successful uterus transplantation, as well as more recent media reports of successful births. The American Society for Reproductive Medicine recognizes uterus transplantation as the first succ...

Study objective: To compare the number of days required to return to daily activities following laparoscopic hysterectomy with two tissue extraction methods: manual morcellation via colpotomy or minilaparotomy. Secondary outcomes include additional measures of patient recovery, perioperative outcomes, containment bag integrity and tissue spillage....

Objective: To determine whether reproductive endocrinologists and minimally invasive surgeons support uterine transplantation as a treatment option for absolute uterine factor infertility (AUFI). Design: Cross-sectional study (Canadian Task Force Classification II-2) SETTING: Web-based survey. Patients(s): Physician members of the American Soc...

Objective: Our objective was to evaluate opinions and attitudes of the general public regarding uterine transplantation (UTx) in the United States (U.S.). Design: Cross-sectional study (Canadian Task Force Classification II-2) SETTING: Web-based survey. Patients(s): Nationally representative sample of adult U.S. residents by age and gender. I...

The patient is a 30-year-old healthy nulligravid patient diagnosed with an 8 centimeter (cm) intramural fibroid (FIGO type 3–5) [1].

Study objective To examine whether a robotic surgical platform can complement the fine motor skills of the non-dominant hand, compensating for the innate difference in dexterity between the surgeon's hands, thereby conferring virtual ambidexterity. Design Crossover intervention study. Design classification Level II-1 evidence. Setting Centers fo...

Robotic technology applied to laparoscopy augments the armamentarium of the reproductive specialist. Uterine leiomyomas, adenomyosis, endometriosis, adnexal masses, sterilization reversal, and fertility preservation techniques can all be addressed with a robotic surgery skill set. Additionally, new approaches with single site and natural orifice su...

Objective: To report a diagnosis of hereditary leiomyomatosis and renal cell cancer (HLRCC) syndrome following initial presentation with multiple cutaneous lesions. Design: Case report. Design classification: N/A. Setting: Academic tertiary care center. Patient(s): 27-year-old nulligravid woman who presented with multiple red-brown lesions on her s...

We report our experience with coaxial robot-assisted laparoendoscopic single-site (RA-LESS) myomectomy, including a detailed description of the technique and outcomes from our first 21 cases. This was a retrospective cohort study carried out at the reproductive endocrinology and gynecologic oncology divisions at two academic medical centers. RA-LES...

Purpose of Review We aim to provide insight on the treatment of fibroids in the infertile patient. Specifically, we discuss which fibroids, based on size and location within the uterine wall, have the most impact on fertility outcomes. In addition, we demonstrate which methods are best for treatment of fibroids in the infertile patient, focusing on...

(Abstracted from BJOG 2016; doi: 10.1111/1471-0528.14179) Leiomyomata are found in up to 80% of uteri examined at hysterectomy; symptoms are present in 20% to 50% of women. The preferred surgical procedure when uterine conservation is desired is myomectomy; when feasible, the laparoscopic approach is preferred.

Rupture of the gravid uterus is a rare obstetrical emergency that is immediately and simultaneously life threatening to both mother and fetus. An infrequent occurrence during labor and at the end of a pregnancy, this complication is even more infrequent during the first 20 weeks of gestation (Fig. 11.1). Although the overall rate of uterine rupture...

Objective: To determine if higher-volume, fixed-dose administration of vasopressin further reduces blood loss at the time of minimally invasive myomectomy. Design: Randomised multicentre clinical trial. Setting: Tertiary-care academic centres in the USA. Population: Women undergoing conventional laparoscopic or robot-assisted laparoscopic my...

Background: Autoimmune progesterone dermatitis is a poorly recognized syndrome associated with a hypersensitivity to progestogens. Symptoms present heterogeneously, which may complicate diagnosis. Management has generally centered on symptomatic control with medication. Recently, an increasing number of cases have been reported with in vitro ferti...

Even in the context of the expansion of assisted reproductive technologies (ART), reproductive surgery continues to fulfill its deserved place in the arsenal of fertility treatments. Rather than being competitive, these two avenues of treatment can optimize fertility care when utilized as an adjunct to one another. Surgical indications and techniqu...

Background Conventional single-incision laparoscopic surgery has been successfully employed for treatment of ovarian endometriomas. However, this technique presents surgeons with formidable ergonomic challenges, that make its widespread adoption unlikely. Robotic assistance in single-incision laparoscopic surgery provides adequate instrument triang...

Fibroids, the most common gynecologic condition in women of reproductive age, have traditionally been treated with hysterectomy. As more women delay childbearing, myomectomy becomes an essential component of the gynecologist's armamentarium. Minimally invasive approaches to myomectomy have been shown to decrease morbidity and reduce care-related co...

Solid scientific evidence indicates that minimally invasive myomectomy provides clinical advantages over its classic open counterpart, and should therefore represent the gold-standard for most patients. In spite of this, the adoption of laparoscopic myomectomy at over two decades from its introduction has been limited, due to the objective technica...

Background: Safe tissue removal is a challenge for minimally invasive procedures such as myomectomy, supracervical hysterectomy or total hysterectomy of a large uterine specimen. There is concern regarding disruption or dissemination of tissue during this process, which may be of particular significance in cases of undetected malignancy. Contained...

Objective: To report clinical cases of autoimmune progesterone (P) dermatitis, its relationship to IVF, and the potential for P desensitization to treat these cases to achieve viable pregnancies. Design: Clinical description. Setting: Institutional hospitalary practice. Allergy Division. Patient(s): Six patients from the Allergy Clinic consulting f...

To provide a step-by-step description of our published technique of single-site robot-assisted laparoscopic myomectomy with the goal of promoting its safe adoption. Surgical video tutorial. Institutional review board-approved study at university medical center. Ten women undergoing single-site robot-assisted laparoscopic myomectomy between November...

This study compared the odds of adverse obstetrical outcomes of pregnancies in women who conceived from IVF (n = 464) versus spontaneous conception (n = 1171) after stratification into three body mass index (BMI) groups: normal weight (18.5-24.9 kg/m(2)), overweight (25.0-29.9 kg/m(2)) and obese (>30 kg/m(2)). With increasing BMI, incidences of com...

To compare the effectiveness and safety of a flexible CO2 laser fiber to the ultrasonic scalpel when employed through a robotic surgical system. Retrospective cohort study. Level II-2 evidence SETTING: Reproductive surgery practice at an academic hospital. 236 women who had undergone robot-assisted laparoscopic myomectomy with either CO2 laser (n=8...

Objective. To examine success of robot-assisted laparoscopic myomectomy (RALM) measured by sustained symptom relief and fertility. Methods. This is a retrospective survey of 426 women who underwent RALM for fibroids, symptom relief, or infertility at three practice sites across the US. We examined rates of symptom recurrence and pregnancy and facto...

To report the first cases of robotic single-site (RSS) myomectomy with the use of the Da Vinci Si Surgical System with wristed semirigid instrumentation. Case series. University hospital. Four patients with symptomatic uterine fibroids desiring conservative minimally invasive surgical treatment. Four RSS myomectomies were performed with the Da Vinc...

To demonstrate 2 step-by-step techniques for contained morcellation of uterine tissue. Instructional video showing laparoscopic electromechanical morcellation within an endoscopic pouch, and alternatively, tissue extraction via ultra-minilaparotomy. Academic medical center. Women undergoing laparoscopic myomectomy or hysterectomy. For contained ele...

Radical improvements in laser technology mean that the time is ripe for a resurgence of this low-impact energy in laparoscopic gynecologic surgery. Flexible CO2 lasers are tools of proven safety that minimize thermal damage to irreplaceable reproductive tissues. They should be strongly considered in pelvic surgery, particularly in reproductive-age...

Trained fertility specialists possess a unique clinical perspective and an extensive medical and technological armamentarium to overcome reproductive dysfunction: it is their privilege and ethical duty to lead the field of reproductive surgery. However, modern reproductive surgery can no longer exist outside of the realm of advanced laparoscopy. Th...

Study objective: To evaluate risk of leakage and tissue dissemination associated with various contained tissue extraction (CTE) techniques. Design: In vitro study (Canadian Task Force classification: II-1). Setting: Academic hospital simulation laboratory. Intervention: Beef tongue specimens weighing 400 to 500 g were stained using 5 mL indi...

To compare the surgical precision of a flexible carbon dioxide (CO2) laser fiber to that of monopolar electrosurgery in porcine myometrium DESIGN: Experimental animal study DESIGN: Classification: Level II-1 evidence SETTING: University-affiliated animal laboratory SUBJECTS: Six live adult, nonpregnant female pigs INTERVENTIONS: Linear injury to th...

Although considerable progress has been made in the field of medically assisted reproduction, minimally invasive surgery remains of vital importance in optimizing and preserving fertility, as well as treating infertility. By definition, reproductive surgery employs microsurgical techniques with the objective of restoring natural fertility or enhanc...

Reproductive endocrinology and infertility subspecialists enjoy a unique perspective of their patients' reproductive endeavor as well as a deep understanding of the medical, technological, and surgical armamentarium to overcome infertility. As such, it is their privilege and their ethical duty to take full charge of the field of reproductive surger...

Study question Hysteroscopic metroplasty (HM) reported to improve pregnancy wastage associated with uterine septum. Different hysteroscopic approaches are possible and effectiveness, safety and advantages of one hysteroscopic technique to other are yet to be determined. Summary answer HM is shown to improve obstetric outcome in uterine septum pati...

This review discusses in detail robotic tubal reanastomosis as one of the classic reproductive surgery procedures. Other applications of robotics in adnexal surgery are also reviewed, including adult and pediatric adnexectomy, resection of endometriosis, benign ovarian mass resection, early ovarian cancer resection and staging, ovarian transpositio...

Current strategies for fertility preservation rely heavily on assisted reproductive technology and fertility-sparing surgery. Whether seeking to avert loss of fertility associated with excision of adnexal or uterine disease or to preempt gonadal failure resulting from chemotherapy or radiation, each woman is unique in her reproductive endeavor and...

STUDY QUESTION What are the characteristics of the pregnancy outcomes in women undergoing robot-assisted laparoscopic myomectomy (RALM) for symptomatic leiomyomata uteri?

To compare surgical outcomes of laparoscopic myomectomy and robot-assisted laparoscopic myomectomy. Retrospective cohort study of 115 consecutive laparoscopic myomectomy and 174 consecutive robot-assisted laparoscopic myomectomy performed at Brigham and Women's Hospital over a period of 31 months. Uterine incisions were closed in multiple layers (r...

Single-incision laparoscopic surgery for gynecologic applications has recently been described. Such an ultra-minimally invasive technique is attractive to patients and may have clinical advantages because of the reduced number of abdominal incisions. However, because of its extreme geometrical challenges and instrument crowding, single-incision lap...

We describe a novel surgical technique combining the use of a robotic surgical platform with a flexible CO2 laser in gynecologic surgery at a university-hospital-based reproductive medicine practice. Thirteen women with symptomatic uterine fibroids and/or adenomyosis, desiring uterine conservation, underwent robot-assisted laparoscopic myomectomy o...

Reproductive surgery employs microsurgical techniques to achieve preservation of natural fertility and enhancement of assisted reproductive technologies. The minimalist approach of this branch of gynecology has made it the natural trailblazer of laparoscopic surgery. Minimally invasive conservative treatment of uterine, tubal, ovarian, and peritone...

To report clinical cases of autoimmune progesterone (P) dermatitis, its relationship to IVF, and the potential for P desensitization to treat these cases to achieve viable pregnancies. Clinical description. Institutional hospitalary practice. Allergy Division. Six patients from the Allergy Clinic consulting for cyclic rashes or anaphylaxis related...

Minimally invasive gynecologic surgery is continuously pushing its limits by embracing ever more sophisticated technology. This is also true for reproductive surgery, arguably the birthplace of gynecologic endoscopy, where minimally invasive treatment of uterine, tubal, ovarian, and peritoneal pathology has long become the gold standard. This artic...

To investigate the efficacy of ultrasound-guided transabdominal follicular aspiration when the ovaries are not accessible transvaginally. Retrospective case-control study. University-hospital based in vitro fertilization (IVF) clinic. 69 women undergoing transabdominal follicular aspiration for oocyte retrieval, including 12 cases of mixed abdomina...

The primary surgical techniques used in myomectomy are open surgery, laparoscopic surgery, and, recently, robot-assisted ("robotic") surgery. The optimal surgical treatment of myomas is still a subject of debate because of the limitations of minimally invasive techniques and the disadvantages of laparotomy. In this article, the authors discuss the...

To determine whether peripheral blood mononuclear cell (PBMC) secretion of T-helper (Th)-1 type cytokines and Th-2 and Th-3 type cytokines in women undergoing in vitro fertilization-embryo transfer (IVF-ET) is associated with therapeutic failure and success, respectively. Cohort study. Academic medical center. One hundred one women undergoing IVF-E...