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Ikink ME, Voogt MJ, van den Bosch MAAJ, Nijenhuis RJ, Keserci B, Kim YS, Vincken KL, Bartels LW. Diffusion-weighted magnetic resonance imaging using different b-value combinations for the evaluation of treatment results after volumetric MR-guided high-intensity focused ultrasound ablation of uterine fibroids. Eur Radiol 2014; 24:2118-27. [PMID: 24962829 DOI: 10.1007/s00330-014-3274-y] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2013] [Revised: 05/20/2014] [Accepted: 06/03/2014] [Indexed: 01/11/2023]
Abstract
OBJECTIVES To assess the value of diffusion-weighted magnetic resonance imaging (DWI) and apparent diffusion coefficient (ADC) mapping using different b-value combinations for treatment evaluation after magnetic resonance-guided high-intensity focused ultrasound (MR-HIFU) of uterine fibroids. METHODS Fifty-six patients with 67 uterine fibroids were treated with volumetric MR-HIFU. Pre-treatment and post-treatment images were obtained using contrast-enhanced T1-weighted MRI (CE-T1WI) and DWI using b = 0, 200, 400, 600, 800 s/mm(2). ADC maps were generated using subsets of b-values to investigate the effects of tissue ablation on water diffusion and perfusion in fibroids treated with MR-HIFU. Four combinations of b-values were used: (1) all b-values; (2) b = 0, 200 s/mm(2); (3) b = 400, 600, 800 s/mm(2); and (4) b = 0, 800 s/mm(2). RESULTS Using the lowest b-values (0 and 200 s/mm(2)), the mean ADC value in the ablated tissue reduced significantly (p < 0.001) compared with baseline. Calculating the ADC value with the highest b-values (400, 600, 800 s/mm(2)), the ADC increased significantly (p < 0.001) post-treatment. ADC maps calculated with the lowest b-values resulted in the best visual agreement of non-perfused fibroid tissue detected on CE images. Other b-value combinations and normal myometrium showed no difference in ADC after MR-HIFU treatment. CONCLUSIONS A decrease in contrast agent uptake within the ablated region on CE-T1WI was correlated to a significantly decreased ADC when b = 0 and 200 s/mm(2) were used. KEY POINTS DWI could be useful for treatment evaluation after MR-HIFU of uterine fibroids. The ADC in fibroid tissue is influenced by the choice of b- values. Low b-values seem the best choice to emphasise perfusion effects after MR-HIFU.
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Affiliation(s)
- Marlijne E Ikink
- Department of Radiology, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands,
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Radosa MP, Owsianowski Z, Mothes A, Weisheit A, Vorwergk J, Asskaryar FA, Camara O, Bernardi TS, Runnebaum IB. Long-term risk of fibroid recurrence after laparoscopic myomectomy. Eur J Obstet Gynecol Reprod Biol 2014; 180:35-9. [PMID: 25016181 DOI: 10.1016/j.ejogrb.2014.05.029] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2013] [Revised: 02/09/2014] [Accepted: 05/23/2014] [Indexed: 10/25/2022]
Abstract
OBJECTIVE The use of laparoscopic myomectomy as a surgical treatment for uterine leiomyoma is associated with low intraoperative morbidity and short hospitalization. Limited data about the long-term outcome of this surgical approach are available. The aims of this study were to estimate the risk of uterine fibroid recurrence after laparoscopic myomectomy and to identify factors contributing to the rate of fibroid relapse. STUDY DESIGN Between 1996 and 2003, 331 patients underwent laparoscopic myomectomy to treat uterine leiomyoma in our hospital; 224 of these patients consented to participate in our 2009 follow-up survey. Clinical symptomatic uterine leiomyoma recurrence was defined as relapse. Recurrence rates at 24 and 60 months post-operatively were calculated for the study population. Fisher's exact tests were used to examine the impacts of factors previously linked to an increased risk of fibroid recurrence, including (1) patient age at the time of initial surgery, (2) pre-operative body mass index, (3) number and localization of uterine leiomyoma removed, and (4) pregnancy and (5) delivery after laparoscopic myomectomy on fibroid recurrence in our study cohort. RESULTS We observed 75 recurrences in 224 patients. The cumulative risk of recurrence was 4.9% at 24 months and 21.4% at 60 months post-operatively. An age of 30-40 years and the presence of more than one fibroid at the time of initial laparoscopic myomectomy were identified as factors significantly increasing the risk of symptomatic recurrence after laparoscopic myomectomy (31.25% and 38.71%, respectively; both p<0.01). CONCLUSION Patients with multiple uterine leiomyoma and those in the third decade of life should be counselled thoroughly about the risk of recurrence prior to laparoscopic myomectomy. The low observed recurrence rate in peri- and postmenopausal patients in our study may support the use of laparoscopic myomectomy as a uterus-preserving surgical alternative beyond the reproductive period.
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Affiliation(s)
- M P Radosa
- Department of Gynaecology and Obstetrics, Jena University Hospital, Friedrich-Schiller-University Jena, Bachstraße 18, 07743 Jena, Germany
| | - Z Owsianowski
- Department of Gynaecology and Obstetrics, Jena University Hospital, Friedrich-Schiller-University Jena, Bachstraße 18, 07743 Jena, Germany
| | - A Mothes
- Department of Gynaecology and Obstetrics, Jena University Hospital, Friedrich-Schiller-University Jena, Bachstraße 18, 07743 Jena, Germany
| | - A Weisheit
- Department of Gynaecology and Obstetrics, Jena University Hospital, Friedrich-Schiller-University Jena, Bachstraße 18, 07743 Jena, Germany
| | - J Vorwergk
- Department of Gynaecology and Obstetrics, Jena University Hospital, Friedrich-Schiller-University Jena, Bachstraße 18, 07743 Jena, Germany
| | - F A Asskaryar
- Department of Gynaecology and Obstetrics, Jena University Hospital, Friedrich-Schiller-University Jena, Bachstraße 18, 07743 Jena, Germany
| | - O Camara
- Department of Gynaecology and Obstetrics, Jena University Hospital, Friedrich-Schiller-University Jena, Bachstraße 18, 07743 Jena, Germany
| | - T S Bernardi
- Department of Gynaecology and Obstetrics, Jena University Hospital, Friedrich-Schiller-University Jena, Bachstraße 18, 07743 Jena, Germany
| | - I B Runnebaum
- Department of Gynaecology and Obstetrics, Jena University Hospital, Friedrich-Schiller-University Jena, Bachstraße 18, 07743 Jena, Germany.
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Siddiqui N, Nikolaidis P, Hammond N, Miller FH. Uterine artery embolization: pre- and post-procedural evaluation using magnetic resonance imaging. ACTA ACUST UNITED AC 2014; 38:1161-77. [PMID: 23471598 DOI: 10.1007/s00261-013-9990-y] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Magnetic resonance (MR) imaging has become the preferred method in assessing the uterus and pelvis prior to and following uterine artery embolization (UAE). The multiplanar imaging capabilities, increased spatial and contrast resolution, anatomic detail and assessment of fibroid viability that MR provides over ultrasound allows for accurate pre-treatment planning and post-treatment assessment. The purpose of this article is to demonstrate the use of MR in the selection of patients, anatomic evaluation and procedural planning before UAE, describe the use of MR in evaluating treatment response after UAE and illustrate the use of MR in identifying post-UAE complications. An understanding of these principles is essential in guiding appropriate therapy, determining treatment effectiveness and identifying associated complications before and after UAE.
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Affiliation(s)
- Nasir Siddiqui
- Department of Radiology, Feinberg School of Medicine, Northwestern University, 676 North St. Clair, Suite 800, Chicago, IL, 60611, USA
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Techniques to expand patient selection for MRI-guided high-intensity focused ultrasound ablation of uterine fibroids. AJR Am J Roentgenol 2014; 202:443-51. [PMID: 24450690 DOI: 10.2214/ajr.13.10753] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
OBJECTIVE MRI-guided high-intensity focused ultrasound (HIFU) ablation is increasingly adopted for treating symptomatic uterine fibroids. As a noninvasive therapy performed on an outpatient basis, it has been viewed by patients to have distinct advantages over other treatment options. However, its breadth of clinical application is still limited. To address this issue, various techniques have been implemented. CONCLUSION In this article, we discuss techniques that contribute to widening patient selection for MRI-guided HIFU therapy of uterine fibroids.
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Is myomectomy in women aged 45 years and older an effective option? Eur J Obstet Gynecol Reprod Biol 2014; 177:57-60. [PMID: 24768231 DOI: 10.1016/j.ejogrb.2014.04.006] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2013] [Revised: 04/02/2014] [Accepted: 04/08/2014] [Indexed: 12/30/2022]
Abstract
OBJECTIVES The aim of this study was to evaluate the recurrence and reoperation rate after myomectomy in women aged 45 years and older, who want to preserve their uterus. STUDY DESIGN We performed a retrospective review of women aged ≥45 years that underwent myomectomy between January 2000 and December 2010. The inclusion criteria were premenopausal status, myomectomy through abdominal or laparoscopic surgery, and at least 12 months interval from surgery. The clinical outcomes, including symptomatic change, recurrence of myoma on transvaginal ultrasonography (TVS), and reoperation data were collected and analyzed. RESULTS A total 92 patients were included in this study. The median age of the patient was 47 years (range 45-53 years), and the median follow-up duration was 30.5 months (range 12-95 months). On follow-up TVS, the recurrence of myoma was detected in 20 of 82 (24.4%) patients. Ten (10.9%) patients were not subjected to follow-up TVS. However, during their pelvic examination, the uterus was normal size, and all the 10 patients experienced symptomatic improvement and none of them needed additional surgical management. Using the Kaplan-Meier method, the cumulative recurrence rate at 36 months after myomectomy was calculated as 17.1%. Three patients underwent hysterectomy during the follow-up periods, and only one underwent hysterectomy due to myoma. The overall reoperation rate after myomectomy in this age group was 3.3%, and the reoperation for myoma rate was only 1.1%. CONCLUSION Considering the natural regression of myoma after menopause, myomectomy might be an effective option for women aged 45 years and older, who want to preserve their uterus.
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Brito LG, Ferriani RA, Candido-dos-Reis FJ, Nogueira AA. Using a search-volume tool (Google Trends) to assess global interest for uterine fibroids. Arch Gynecol Obstet 2014; 289:1163-4. [DOI: 10.1007/s00404-014-3207-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2014] [Accepted: 02/28/2014] [Indexed: 10/25/2022]
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Brito LGO, Panobianco MS, Sabino-de-Freitas MM, Barbosa HDF, de Azevedo GD, Brito LMO, Candido-Dos-Reis FJ. Uterine leiomyoma: understanding the impact of symptoms on womens' lives. Reprod Health 2014; 11:10. [PMID: 24476380 PMCID: PMC3909443 DOI: 10.1186/1742-4755-11-10] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2013] [Accepted: 01/24/2014] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Most women report negative experience about the symptoms of uterine leiomyoma (UL) in their lives, such as abnormal uterine bleeding and pelvic pain. Many studies have been conducted about efficacy of UL treatment, but little research has been performed about womens health related quality of life (HRQL). METHODS This is a semi-structured, descriptive, observational, qualitative study that was performed during eight months. Focus group (FG) interviews were performed with women attending at a tertiary hospital in Brazil, who were consecutively included in the study. Seventy women with symptomatic UL were recruited to this study. FG duration was one hour with mediators with 5-6 women at each group. Collected data from discussions was processed according to thematic analysis and stored at a qualitative software. RESULTS Women were negatively influenced by the presence of symptomatic UL. The major themes that were noticed during analysis were: beliefs and attitudes towards UL; limitation to social and professional activities; sensation of fear/unfairness/discouragement towards the symptoms and adverse effects during treatment with GnRH analogs. CONCLUSIONS Symptomatic UL has a negative impact on womens HRQL. Health providers should consider such impact when counseling women on their treatment options, since it may have an important influence in these patients' decision-making process. While current pharmacological treatments may improve disease specific outcomes, such as bleeding intensity and tumor volume, they fail on actually improving quality of life.
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Affiliation(s)
- Luiz Gustavo Oliveira Brito
- Department of Gynecology and Obstetrics, Ribeirão Preto School of Medicine, University of São Paulo, Avenida Bandeirantes, 3900, 8th floor, Monte Alegre, Ribeirão Preto, SP, Brazil.
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Benaglia L, Cardellicchio L, Filippi F, Paffoni A, Vercellini P, Somigliana E, Fedele L. The rapid growth of fibroids during early pregnancy. PLoS One 2014; 9:e85933. [PMID: 24465797 PMCID: PMC3896432 DOI: 10.1371/journal.pone.0085933] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2013] [Accepted: 12/03/2013] [Indexed: 11/30/2022] Open
Abstract
Several studies aimed to disentangle whether pregnancy influences the growth of uterine fibroids but results were inconsistent. In this study, we speculated that fibroid enlargement during pregnancy may not be linear and we hypothesized that this phenomenon may mainly occur during initial pregnancy. To test this hypothesis, we set up a prospective cohort study of women with fibroids undergoing IVF. Cases were women achieving a viable pregnancy. Controls were the subsequent women with fibroids but failing to become pregnant. Twenty-five cases and 25 controls were recruited. The total number of fibroids in the two groups was 46 and 41, respectively. The mean ± SD diameter of the fibroids was 17±10 and 20±11 mm, respectively (p = 0.18). A statistically significant enlargement emerged exclusively in pregnant women. The median (Interquartile Range) modification of the diameter of the lesions in cases and controls was +34% (+6%/+65%) and +2% (−6%/+12%), respectively (p<0.001). The median (Interquartile Range) modification of the volume of the lesions was +140% (+23%/+357%) and 0% (−18%/+37%), respectively (p<0.001). In pregnant women, we failed to document any significant correlation between the magnitude of the growth and ovarian responsiveness to hyper-stimulation, suggesting that steroids hormones are not the unique factors involved. In conclusion, fibroids undergo a rapid and remarkable growth during initial pregnancy. Reasons behind this phenomenon remain to be clarified. The early rise in steroids hormones during early pregnancy may not be sufficient to explain the process. Other pregnancy-related hormones and proteins may play also key roles.
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Affiliation(s)
- Laura Benaglia
- Obstet-Gynecol Dept, Fondazione Ca’ Granda, Ospedale Maggiore Policlinico, Milan, Italy
- * E-mail:
| | - Lucia Cardellicchio
- Obstet-Gynecol Dept, Fondazione Ca’ Granda, Ospedale Maggiore Policlinico, Milan, Italy
- Università degli Studi di Milano, Milan, Italy
| | - Francesca Filippi
- Obstet-Gynecol Dept, Fondazione Ca’ Granda, Ospedale Maggiore Policlinico, Milan, Italy
- Università degli Studi di Milano, Milan, Italy
| | - Alessio Paffoni
- Obstet-Gynecol Dept, Fondazione Ca’ Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | - Paolo Vercellini
- Obstet-Gynecol Dept, Fondazione Ca’ Granda, Ospedale Maggiore Policlinico, Milan, Italy
- Università degli Studi di Milano, Milan, Italy
| | - Edgardo Somigliana
- Obstet-Gynecol Dept, Fondazione Ca’ Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | - Luigi Fedele
- Obstet-Gynecol Dept, Fondazione Ca’ Granda, Ospedale Maggiore Policlinico, Milan, Italy
- Università degli Studi di Milano, Milan, Italy
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Segars JH, Parrott EC, Nagel JD, Guo XC, Gao X, Birnbaum LS, Pinn VW, Dixon D. Proceedings from the Third National Institutes of Health International Congress on Advances in Uterine Leiomyoma Research: comprehensive review, conference summary and future recommendations. Hum Reprod Update 2014; 20:309-33. [PMID: 24401287 DOI: 10.1093/humupd/dmt058] [Citation(s) in RCA: 113] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Uterine fibroids are the most common gynecologic tumors in women of reproductive age yet the etiology and pathogenesis of these lesions remain poorly understood. Age, African ancestry, nulliparity and obesity have been identified as predisposing factors for uterine fibroids. Symptomatic tumors can cause excessive uterine bleeding, bladder dysfunction and pelvic pain, as well as associated reproductive disorders such as infertility, miscarriage and other adverse pregnancy outcomes. Currently, there are limited noninvasive therapies for fibroids and no early intervention or prevention strategies are readily available. This review summarizes the advances in basic, applied and translational uterine fibroid research, in addition to current and proposed approaches to clinical management as presented at the 'Advances in Uterine Leiomyoma Research: 3rd NIH International Congress'. Congress recommendations and a review of the fibroid literature are also reported. METHODS This review is a report of meeting proceedings, the resulting recommendations and a literature review of the subject. RESULTS The research data presented highlights the complexity of uterine fibroids and the convergence of ethnicity, race, genetics, epigenetics and environmental factors, including lifestyle and possible socioeconomic parameters on disease manifestation. The data presented suggest it is likely that the majority of women with uterine fibroids will have normal pregnancy outcomes; however, additional research is warranted. As an alternative to surgery, an effective long-term medical treatment for uterine fibroids should reduce heavy uterine bleeding and fibroid/uterine volume without excessive side effects. This goal has not been achieved and current treatments reduce symptoms only temporarily; however, a multi-disciplined approach to understanding the molecular origins and pathogenesis of uterine fibroids, as presented in this report, makes our quest for identifying novel targets for noninvasive, possibly nonsystemic and effective long-term treatment very promising. CONCLUSIONS The Congress facilitated the exchange of scientific information among members of the uterine leiomyoma research and health-care communities. While advances in research have deepened our knowledge of the pathobiology of fibroids, their etiology still remains incompletely understood. Further needs exist for determination of risk factors and initiation of preventive measures for fibroids, in addition to continued development of new medical and minimally invasive options for treatment.
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Affiliation(s)
- James H Segars
- Program in Reproductive and Adult Endocrinology, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health (NIH), Department of Health and Human Services (DHHS), Bethesda, MD 20892, USA
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Vaginal mifepristone for the treatment of symptomatic uterine leiomyomata: an open-label study. Fertil Steril 2013; 101:496-500. [PMID: 24220703 DOI: 10.1016/j.fertnstert.2013.10.015] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2013] [Revised: 10/05/2013] [Accepted: 10/08/2013] [Indexed: 11/20/2022]
Abstract
OBJECTIVE To evaluate the efficacy and safety of 3 months of vaginal mifepristone treatment on leiomyoma volume and related symptoms. DESIGN Prospective, open-label, two tertiary centers, phase II clinical trial. SETTING Two tertiary medical centers in Israel. PATIENT(S) Thirty-three enrolled women, ages 30-53 years, diagnosed with symptomatic uterine fibroids. INTERVENTION(S) Patients received 10 mg mifepristone vaginally daily for 3 months. MAIN OUTCOME MEASURE(S) Reduction in uterine leiomyoma volume. Improvement in symptoms related to uterine fibroids was assessed with the use of the "Uterine Fibroid Symptoms Quality of Life Questionnaire" (UFS-QoL). The number of bleeding days, safety, and tolerability were secondary measures. RESULT(S) Mifepristone treatment significantly reduced leiomyoma volume from 135.3 ± 22.9 cc at enrollment to 101.2 ± 22.4 cc after 3 months of treatment. The UFS-QoL Score significantly decreased from 20.7 ± 0.7 at enrollment to 14.0 ± 0.8 after 3 months of treatment. The number of bleeding days significantly decreased by 3.5 days. Endometrial biopsies showed no evidence of endometrial hyperplasia or cellular atypia. There were no major side effects during the course of the study, and treatment was well tolerated. CONCLUSION(S) Vaginal mifepristone may offer an effective treatment option for women with symptomatic uterine leiomyoma and can improve the patients' quality of life. CLINICAL TRIAL REGISTRATION NUMBER NCT00881140.
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Gobern JM, Rosemeyer CJ, Barter JF, Steren AJ. Comparison of robotic, laparoscopic, and abdominal myomectomy in a community hospital. JSLS 2013; 17:116-20. [PMID: 23743382 PMCID: PMC3662728 DOI: 10.4293/108680812x13517013317473] [Citation(s) in RCA: 51] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Laparoscopic and robotic-assisted laparoscopic myomectomies demonstrated shorter hospital stays, less blood loss, and fewer transfusions than abdominal myomectomies. Robotic myomectomy offers a minimally invasive alternative for management of symptomatic myoma in a community hospital setting. Background and Objectives: To evaluate the operative outcomes between robotic, laparoscopic, and abdominal myomectomies performed by a private gynecologic oncology practice in a suburban community hospital. Methods: The medical records of 322 consecutive robotic, laparoscopic, and abdominal myomectomies performed from January 2007 through December 2009 were reviewed. The outcomes were collected from a retrospective review of patient medical records. Results: Records for 14/322 (4.3%) patients were incomplete. Complete data were available for 308 patients, including 169 (54.9%) abdominal, 73 (23.7%) laparoscopic, and 66 (21.4%) robotic-assisted laparoscopic myomectomies. Patients were similar in age, body mass index, parity, and previous abdominopelvic surgery. Median operative time for robotic surgery (140 min) was significantly longer (P<.005) compared to laparoscopic (70 min) and abdominal (72 min) myomectomies. Robotic and laparoscopic myomectomies had significantly less estimated blood loss and hospital stay compared to abdominal myomectomies. There was no significant difference in complications or in the median size of the largest myoma removed between the different modalities. However, the median aggregate weight of myomas removed abdominally (200g; range, 1.4 to 2682) was significantly larger than that seen laparoscopically (115g; range, 1 to 602) and robotically (129g; range 9.4 to 935). Postoperative transfusion was significantly less frequent in robotic myomectomies compared to laparoscopic and abdominal myomectomies. Conclusion: While robotic-assisted laparoscopic myomectomies had longer operative times, laparoscopic and robotic-assisted laparoscopic myomectomies demonstrated shorter hospital stays, less blood loss, and fewer transfusions than abdominal myomectomies. Robotic myomectomy offers a minimally invasive alternative for management of symptomatic myoma in a community hospital setting.
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Affiliation(s)
- Joseph M Gobern
- Department of Obstetrics and Gynecology, Walter Reed National Military Medical Center, Bethesda, MD 20889, USA.
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Mid-term clinical efficacy of a volumetric magnetic resonance-guided high-intensity focused ultrasound technique for treatment of symptomatic uterine fibroids. Eur Radiol 2013; 23:3054-61. [PMID: 23793518 DOI: 10.1007/s00330-013-2915-x] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2013] [Revised: 04/25/2013] [Accepted: 05/04/2013] [Indexed: 10/26/2022]
Abstract
OBJECTIVE To assess the mid-term efficacy of magnetic resonance-guided high-intensity focused ultrasound (MR-HIFU) using a volumetric ablation technique for treating uterine fibroids. METHODS Forty-six premenopausal women with 58 symptomatic uterine fibroids were prospectively included for MR-HIFU. After treatment, CE-MRI allowed measurement of the non-perfused volume (NPV) ratio, defined as the non-enhancing part of the fibroid divided by fibroid volume. Clinical symptoms and fibroid size on T2W-MRI were quantified at 3 and 6 months' follow-up. The primary endpoint was a clinically relevant improvement in the transformed Symptom Severity Score (tSSS) of the Uterine Fibroid Symptom and Quality of Life questionnaire, defined as a 10-point reduction. RESULTS Volumetric ablation resulted in a mean NPV ratio of 0.40 ± 0.22, with a mean NPV of 141 ± 135 cm(3). Mean fibroid volume was 353 ± 269 cm(3) at baseline, which decreased to 271 ± 225 cm(3) at 6 months (P < 0.001), corresponding to a mean volume reduction of 29 % ± 20 %. Clinical follow-up showed that 54 % (25/46) of the patients reported a more than 10-point reduction in the tSSS. Mean tSSS improved from 50.9 ± 18.4 at baseline to 34.7 ± 20.2 after 6 months (P < 0.001). CONCLUSION Volumetric MR-HIFU is effective for patients with symptomatic uterine fibroids. At 6 months, significant symptom improvement was observed in 54 % of patients. KEY POINTS • Volumetric MR-guided high-intensity focused ultrasound is a novel ablation technique for leiomyomatosis. • We prospectively evaluated the outcome of volumetric MR-HIFU ablation for symptomatic fibroids. • This study showed that volumetric MR-HIFU results in an effective treatment. • A randomised controlled trial would set this technique in an appropriate context.
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Guo XC, Segars JH. The impact and management of fibroids for fertility: an evidence-based approach. Obstet Gynecol Clin North Am 2013. [PMID: 23182558 DOI: 10.1016/j.ogc.2012.09.005] [Citation(s) in RCA: 75] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Fibroids affect 35% to 77% of reproductive-age women. When selecting a treatment plan for symptomatic fibroids, the fibroid location, size, and number must be considered. Myomectomy remains the preferred method for women with fibroid-related infertility who wish to have children or maintain fertility. Currently available medical therapies reduce symptoms in the short term but may involve side effects when used long term. Initial fertility studies are encouraging but trials are needed. Recent medical advances have led to minimally invasive approaches for women with fibroid disease, but there is a strong demand for additional treatment options.
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Affiliation(s)
- Xiaoxiao Catherine Guo
- Program in Reproductive and Adult Endocrinology, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, 10 Center Drive, Building 10 CRC 1-3140, MSC 1109, Bethesda, MD 20892-1109, USA
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Bulman JC, Ascher SM, Spies JB. Current concepts in uterine fibroid embolization. Radiographics 2013; 32:1735-50. [PMID: 23065167 DOI: 10.1148/rg.326125514] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Uterine fibroid embolization (UFE) has become established as an accepted minimally invasive treatment for uterine fibroids and should be considered a treatment option for patients with symptomatic uterine fibroids. It is important for diagnostic radiologists to understand the procedure, since imaging is a key component in the evaluation and care of these patients. Both the interventional radiologist and the gynecologist must fully evaluate a patient before recommending UFE as a treatment for symptomatic fibroids. However, relatively few absolute contraindications exist (pregnancy, known or suspected gynecologic malignancy, and current uterine or adnexal infection). A thorough evaluation includes a medical history, menstrual history, physical examination, and discussion of fertility goals. In almost all cases, bilateral uterine artery catheterization and embolization are needed, since most uterine fibroids, whether single or multiple, receive blood supply from both uterine arteries. After UFE, patients can reasonably expect resolution of symptoms such as menorrhagia, pelvic pressure, and pelvic pain. Although infrequent, major adverse events can occur and include ovarian failure or amenorrhea, fibroid expulsion, and rarely venous thromboembolism. Hysterectomy remains the definitive and most common treatment for uterine fibroids, but less-invasive approaches such as UFE are becoming of greater interest to both patients and physicians.
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Affiliation(s)
- Julie C Bulman
- Department of Radiology, Georgetown University Hospital, 3800 Reservoir Rd NW, CG 201, Washington, DC 20007-2113, USA
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Yin H, Lo JH, Kim JY, Marsh EE, Kim JJ, Ghosh AK, Bulun S, Chakravarti D. Expression profiling of nuclear receptors identifies key roles of NR4A subfamily in uterine fibroids. Mol Endocrinol 2013; 27:726-40. [PMID: 23550059 DOI: 10.1210/me.2012-1305] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Uterine fibroids (UFs), also known as uterine leiomyomas, are benign, fibrotic smooth muscle tumors. Although the GnRH analog leuprolide acetate that suppresses gonadal steroid hormones is used as a treatment, it has significant side effects, thereby limiting its use. Availability of more effective therapy is limited because of a lack of understanding of molecular underpinnings of the disease. Although ovarian steroid hormones estrogen and progesterone and their receptors are clearly involved, the role of other nuclear receptors (NRs) in UFs is not well defined. We used quantitative real-time PCR to systematically profile the expression of 48 NRs and identified several NRs that were aberrantly expressed in UFs. Among others, expression of NR4A subfamily members including NGFIB (NR4A1), NURR1 (NR4A2), and NOR1 (NR4A3) were dramatically suppressed in leiomyoma compared with the matched myometrium. Restoration of expression of each of these NR4A members in the primary leiomyoma smooth muscle cells decreased cell proliferation. Importantly, NR4As regulate expressions of the profibrotic factors including TGFβ3 and SMAD3, and several collagens that are key components of the extracellular matrix. Finally, we identify NR4A members as targets of leuprolide acetate treatment. Together, our results implicate several NRs including the NR4A subfamily in leiomyoma etiology and identify NR4As as potential therapeutic targets for treating fibrotic diseases.
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Affiliation(s)
- Hanwei Yin
- Division of Reproductive Biology Research, Department of Obstetrics and Gynecology, Feinberg School of Medicine, Northwestern University, Chicago, IL 60611, USA
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Ibrahim R, Alhilli JA, Cooper TT, Dashkova I, Guy J, Gandhi A, Zaman M. Idiopathic thrombocytopenia with iron deficiency anemia. Clin Med Insights Blood Disord 2013; 6:1-5. [PMID: 25512714 PMCID: PMC4222302 DOI: 10.4137/cmbd.s11371] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
We report a rare case of anemia and thrombocytopenia as a result of uterine fibroid and adenomyosis, complicated by immune thrombocytopenic purpura (ITP). Symptoms were presented as menorrhagia and metrorrhagia in a 34-year-old African American woman, who was later treated with blood and platelet transfusion and iron therapy with steroids. Uterine fibroids are commonly found to cause hematologic disturbances such as anemia and reactive thrombocytosis and, less commonly, thrombocytopenia. Moreover, such hematologic disturbances are secondary to heavy and irregular uterine bleeding, which is typically presented. A previous uterine fibroid diagnosis was made and reconfirmed by pelvic and transvaginal ultrasound to exclude other locoregional pathologies. ITP was suggested by Coombs test and several other serologies, leading to confirmation via bone marrow biopsy. In a previous case study, we reported positive responses in hemotecrit and platelet count after the introduction of iron therapy to an iron-depleted middle-aged female presenting severe anemia and thrombocytopenia.1
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Affiliation(s)
- Ramy Ibrahim
- Brookdale University Hospital and Medical Center, Brooklyn, NY
| | | | - Tyler T Cooper
- Brookdale University Hospital and Medical Center, Brooklyn, NY
| | - Irina Dashkova
- Brookdale University Hospital and Medical Center, Brooklyn, NY
| | - Judah Guy
- Brookdale University Hospital and Medical Center, Brooklyn, NY
| | - Anjula Gandhi
- Brookdale University Hospital and Medical Center, Brooklyn, NY
| | - Mohammad Zaman
- Brookdale University Hospital and Medical Center, Brooklyn, NY
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Shokeir T, Shalaby H, Nabil H, Barakat R. Reducing blood loss at abdominal myomectomy with preoperative use of dinoprostone intravaginal suppository: a randomized placebo-controlled pilot study. Eur J Obstet Gynecol Reprod Biol 2013; 166:61-4. [DOI: 10.1016/j.ejogrb.2012.09.014] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2012] [Revised: 07/07/2012] [Accepted: 09/13/2012] [Indexed: 11/25/2022]
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Park MJ, Kim YS, Keserci B, Rhim H, Lim HK. Volumetric MR-guided high-intensity focused ultrasound ablation of uterine fibroids: treatment speed and factors influencing speed. Eur Radiol 2012; 23:943-50. [PMID: 23080072 DOI: 10.1007/s00330-012-2665-1] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2012] [Revised: 08/23/2012] [Accepted: 09/10/2012] [Indexed: 11/25/2022]
Abstract
OBJECTIVES To assess the treatment speed of volumetric magnetic resonance-guided high-intensity focused ultrasound (MR-HIFU) ablation of symptomatic uterine fibroids, with a focus on factors affecting treatment speed. METHODS We received Institutional Review Board approval, and informed consent was obtained from all participants. Among 109 patients referred, 43 women (39.4 %) (mean age, 43.7 years), with 112 fibroids passed the screening. We treated 53 symptomatic uterine fibroids (47.3 %, 53/112) (volume, 341.2 ± 256.5 ml) using volumetric MR-HIFU ablation. We assessed procedure times, non-perfused volume (NPV) and treatment speed (NPV/treatment time). We statistically analysed the factors affecting treatment speed using multiple logistic regression tests. RESULTS Technical success was achieved in 42 of 43 cases. MR room time (from entrance to exit) and treatment time (from first to last sonication) were 216.0 ± 40.6 min and 131.5 ± 55.9 min, respectively. Immediate NPV was 178.9 ± 147.3 ml, which was 57.4 ± 25.5 % of the fibroid volume. Treatment speed was 81.8 ± 48.0 ml/h. Multivariate analysis showed that a large fibroid volume (P < 0.001), a low signal intensity ratio of fibroid to skeletal muscle on T2-weighted images (P = 0.009) and timing after completion of the learning curve (P < 0.001) significantly increased treatment speed. CONCLUSION Volumetric MR-HIFU ablation can effectively treat symptomatic uterine fibroids. The treatment speed appeared to improve when treating large and/or dark fibroids as well as upon completion of the learning curve.
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Affiliation(s)
- Min Jung Park
- High-intensity Focused Ultrasound (HIFU) Center, Samsung Medical Center, Seoul, South Korea
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Tsiligiannis SE, Zaitseva M, Coombs PR, Shekleton P, Olshansky M, Hickey M, Vollenhoven B, Rogers PAW. Fibroid-associated heavy menstrual bleeding: correlation between clinical features, Doppler ultrasound assessment of vasculature, and tissue gene expression profiles. Reprod Sci 2012; 20:361-70. [PMID: 22995988 DOI: 10.1177/1933719112459233] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Despite the prevalence of uterine fibroids (Fs), few studies have investigated the links between clinical features and the cellular or molecular mechanisms that drive F growth and development. Such knowledge will ultimately help to differentiate symptomatic from asymptomatic Fs and could result in the development of more effective and individualized treatments. The aim of this study was to investigate the relationship between ultrasound appearance, blood flow, and angiogenic gene expression in F, perifibroid (PM), and distant myometrial (DM) tissues. We hypothesized that angiogenic gene expression would be increased in tissues and participants that showed increased blood flow by Doppler ultrasound. The study was performed using Doppler ultrasound to measure blood flow prior to hysterectomy, with subsequent tissue samples from the F, PM, and DM being investigated for angiogenic gene expression. Overall, PM blood flow (measured as peak systolic velocity [PSV]) was higher than F blood flow, although significant heterogeneity was seen in vascularity and blood flow between different Fs and their surrounding myometrium. We did not find any correlation between PSV and any other clinical or molecular parameter in this study. We identified 19 angiogenesis pathway-related genes with significant differences in expression between F and DM, and 2 genes, matrix metalloproteinase 9 (MMP9) and Neuropilin 2 (NRP2), that were significantly different between F and PM. These results are consistent with subtle differences between PM and DM. Understanding the differences between symptomatic versus asymptomatic Fs may eventually lead to more effective treatments that directly target the source of heavy menstrual bleeding.
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Affiliation(s)
- Sophia E Tsiligiannis
- Department of Obstetrics and Gynaecology, Centre for Women's Health Research, Monash University, Clayton, Victoria, Australia
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71
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Sarici OO, Avsar AF, Tan S, Ersoy R. The biorhythm mechanism of myoma uteri. BIOL RHYTHM RES 2012. [DOI: 10.1080/09291016.2011.593846] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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72
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Kasai M, Ichimura T, Kawamura N, Sumikura T, Matsuda M, Asano C, Sumi T, Ishiko O. Prediction of the shrinking rate of uterine leiomyoma nodules using needle biopsy specimens. Fertil Steril 2012; 98:440-3. [DOI: 10.1016/j.fertnstert.2012.05.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2011] [Revised: 05/07/2012] [Accepted: 05/18/2012] [Indexed: 11/24/2022]
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Zimmermann A, Bernuit D, Gerlinger C, Schaefers M, Geppert K. Prevalence, symptoms and management of uterine fibroids: an international internet-based survey of 21,746 women. BMC WOMENS HEALTH 2012; 12:6. [PMID: 22448610 PMCID: PMC3342149 DOI: 10.1186/1472-6874-12-6] [Citation(s) in RCA: 259] [Impact Index Per Article: 21.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/12/2011] [Accepted: 03/26/2012] [Indexed: 11/26/2022]
Abstract
Background In 2009 the Uterine Bleeding and Pain Women's Research Study (UBP-WRS) was conducted interviewing 21,479 women across 8 countries in order to gain patient-based prevalence data on uterine pain and bleeding indications and investigate uterine symptoms and women's treatment experiences. This article shows relevant results of the study for the indication uterine fibroids providing data on self-reported prevalence, symptomatology and management of uterine fibroids. Methods 2,500 women (USA: 4,500 women) in each country (Brazil, Canada, France, Germany, Italy, South Korea, the UK, the USA) completed an online survey. Women included were in their reproductive age (age group 15-49 years; USA: 18-49 years) and had ever experienced menstrual bleedings. Quotas were applied for age, region, level of education and household income of respondents. Variables have been analyzed descriptively and exploratory statistical tests have been performed. Results The self-reported prevalence of uterine fibroids ranged from 4.5% (UK) to 9.8% (Italy), reaching 9.4% (UK) to 17.8% (Italy) in the age group of 40-49 years. Women with a diagnosis of uterine fibroids reported significantly more often about bleeding symptoms than women without a diagnosis: heavy bleedings (59.8% vs. 37.4%), prolonged bleedings (37.3% vs. 15.6%), bleeding between periods (33.3% vs. 13.5%), frequent periods (28.4% vs. 15.2%), irregular and predictable periods (36.3% vs. 23.9%). Furthermore women with diagnosed uterine fibroids reported significantly more often about the following pain symptoms: pressure on the bladder (32.6% vs. 15.0%), chronic pelvic pain (14.5% vs. 2.9%), painful sexual intercourse (23.5% vs. 9.1%) and pain occurring mid-cycle, after and during menstrual bleeding (31.3%, 16.7%, 59.7%, vs. 17.1%, 6.4%, 52.0%). 53.7% of women reported that their symptoms had a negative impact on their life in the last 12 month, influencing their sexual life (42.9%), performance at work (27.7%) and relationship & family (27.2%). Conclusions Uterine fibroid is a common concern in women at fertile age causing multiple bleeding and pain symptoms which can have a negative impact on different aspects in women's life.
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Affiliation(s)
- Anne Zimmermann
- Charité - Universitätsmedizin Berlin, Berlin School of Public Health, Seestraße 73, Berlin 13347, Germany.
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Eke AC, Chawla M, Bridges N, Ezebialu I. Progestogen only versus combined oral contraceptive pills for fibroid related heavy menstrual bleeding. Hippokratia 2012. [DOI: 10.1002/14651858.cd009737] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Affiliation(s)
- Ahizechukwu C Eke
- Harvard School of Public Health (HSPH); Department of Health Policy and Management, Masters in Public Health (MPH); 677 Huntington Avenue Boston Massachusetts USA 02115
| | - Manupreet Chawla
- Harvard University School of Public Health; Quantitative Methods Concentration, Masters in Public Health (MPH) Program; 677 Huntington Avenue Boston Massachusetts USA 02115
| | - Naima Bridges
- Harvard School of Public Health; Global Health and Population; 677 Huntington Avenue Boston USA
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Nair S, Al-Hendy A. Adipocytes enhance the proliferation of human leiomyoma cells via TNF-α proinflammatory cytokine. Reprod Sci 2012; 18:1186-92. [PMID: 22096007 DOI: 10.1177/1933719111408111] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVE Obesity is a well-documented risk factor for uterine leiomyoma with a major impact on women health and health care system of the nation. Obesity is associated with increased secretion of adipokines that significantly influence growth and proliferation of tumor stroma and malignant cells. Adipokines, such as tumor necrosis factor α (TNF-α), are produced in the adipose tissue with concomitant expression in other organs and tissues. Increased and sustained cytokine production is associated with alterations in cell growth and differentiation. We, therefore, explored the influence of human adipocytes (SW872 cells)-mediated biological humoral factors on human uterine leiomyoma (HuLM) cells. METHODS We measured cell proliferation and expression of cell-proliferating proteins (proliferating cell nuclear antigen [PCNA], cyclin D1, and B-cell lymphoma 2 [BCL-2]) in human leiomyoma cells cocultured with SW872 cells. SW872-conditioned media was neutralized for TNF-α and proliferation of HuLM cells was observed along with antiapoptotic marker, BCL-2, using Western immunoblot. RESULTS We found that both SW872-conditioned media and coculture with SW872 cells increased HuLM cell proliferation significantly (P < .05). We determined that this effect was associated with the upregulation of specific markers for proliferation, such as PCNA, cyclin D1, and BCL-2 (P < .05). Furthermore, the addition of neutralizing antibodies, anti-TNF-α, to SW872-conditioned media reversed the proliferation of leiomyoma cells and induced apoptosis as indicated by the reduced expression of antiapoptotic marker BCL-2. CONCLUSIONS SW872 cells secrete TNF-α, which is associated with a proliferative gene profile in HuLM cells and may play a role in initiation and/or progression of uterine leiomyoma.
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Affiliation(s)
- Sangeeta Nair
- Department of Obstetrics and Gynecology, Center for Women's Health Research, Meharry Medical College, Nashville, TN 37208, USA
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Isono W, Wada-Hiraike O, Osuga Y, Yano T, Taketani Y. Diameter of dominant leiomyoma is a possible determinant to predict coexistent endometriosis. Eur J Obstet Gynecol Reprod Biol 2012; 162:87-90. [PMID: 22377227 DOI: 10.1016/j.ejogrb.2012.01.018] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2011] [Revised: 12/26/2011] [Accepted: 01/30/2012] [Indexed: 10/28/2022]
Abstract
OBJECTIVE To identify the frequency and assess risk factors for unexpected discovery of peritoneal endometriotic implants in patients who underwent myomectomy or hysterectomy for symptomatic uterine leiomyomas. STUDY DESIGN We retrospectively collected medical records of 829 patients with symptomatic leiomyomas in The University of Tokyo Hospital. All the patients underwent abdominal or laparoscopic surgeries between January 2001 and December 2010 and the presence or absence of endometriosis during surgery was analyzed. Possible determinant to predict coexistent endometriosis was statistically investigated. RESULTS In total, 105 leiomyoma cases (12.7% in 829 patients) were diagnosed with endometriosis. Patients with small dominant leiomyomas were significantly complicated by peritoneal endometriotic implants (small leiomyomas were classified as < 8 cm). The patients with both diagnoses were more likely to be infertile and at age 39 years or younger than those with leiomyoma alone. CONCLUSIONS Women undergoing myomectomy or hysterectomy with both endometriosis and leiomyomas have several different clinical features compared with women with only leiomyomas. The size of largest leiomyoma may provide an important clue for coexistent endometriosis. Women with substantial infertility despite a smaller leiomyomas burden may be more likely to have a surgical indication for concomitant endometriosis.
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Affiliation(s)
- Wataru Isono
- Department of Obstetrics and Gynecology, Graduate School of Medicine, The University of Tokyo, 7-3-1, Hongo, Bunkyo-ku, Tokyo 113-8655, Japan
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Angioli R, Plotti F, Ricciardi R, Terranova C, Zullo MA, Damiani P, Montera R, Guzzo F, Scaletta G, Muzii L. The use of novel hemostatic sealant (Tisseel) in laparoscopic myomectomy: a case-control study. Surg Endosc 2012; 26:2046-53. [PMID: 22302534 DOI: 10.1007/s00464-012-2154-2] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2011] [Accepted: 12/20/2011] [Indexed: 12/31/2022]
Abstract
BACKGROUND This is the first case-control study on the use of a fibrin sealant (Tisseel) on uterine suture during laparoscopic myomectomy (LM), with the primary endpoint to evaluate the intraoperative bleeding and postoperative blood loss. In addition, we evaluated the time required to achieve hemostasis using Tisseel and how much it can influence operative time. METHODS From December 2009 to January 2011, consecutive patients older than 18 years with symptomatic isolate intramural myoma with maximal diameter B6 cm and ≥ 4 cm and with a sonographically diagnosed free myometrium margin ≥ 0.5 cm were included in the study. We selected from our institute's database a group of consecutive patients with homogeneous features of the study group, who underwent laparoscopic myomectomy without Tisseel application. RESULTS Fifteen women with symptomatic myoma were enrolled in the study (group A). Regarding the control group (group B), we selected a homogenous group of 15 patients with the same preoperative characteristics of the study group. Mean operative time was 47.7 min and 62.1 min, for groups A and B respectively (p < 0.05). Mean time required to achieve complete haemostasis was 195.5 s in group A and 361.8 in control group B (p < 0.0001). Mean estimated blood loss was 111.3 mL and 230 mL in groups A and B, respectively (p < 0.05). Mean hemoglobin decrease was 1.36 g/dL and 2.04 g/dL in groups A and B, respectively (p < 0.05). CONCLUSIONS The use of Tisseel during LM may represent a valid alternative solution for obtaining hemostasis, reducing intra- and postoperative bleeding. Furthermore, it may help the surgeon to obtain a rapid healing of the injured surfaces, probably reducing the use of electrocoagulationand traumatisms.
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Affiliation(s)
- Roberto Angioli
- Department of Obstetrics and Gynecology, Campus Bio Medico University of Rome, Via Álvaro del Portillo, 200-00128 Rome, Italy.
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Hirschelmann A, De Wilde RL. Plastic and reconstructive uterus operations by minimally invasive surgery? A review on myomectomy. GMS INTERDISCIPLINARY PLASTIC AND RECONSTRUCTIVE SURGERY DGPW 2012; 1:Doc09. [PMID: 26504693 PMCID: PMC4582479 DOI: 10.3205/iprs000009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND Plastic and reconstructive uterus operations are performed in congenital uterine anomalies or benign uterine conditions. Congenital uterine anomalies are relatively rare diseases with various approaches for surgical treatment. Therefore, to address the question of the usefulness of a minimally invasive approach in plastic uterus operations, the most common uterine condition which requires reconstructive surgery, namely myomectomy, is discussed. METHOD Searches were conducted in PubMed and The Cochrane Library to identify relevant literature. FINDINGS Compared with myomectomy by laparotomy and minilaparotomy, laparoscopic myomectomy is associated with improved short-term outcomes. Laparoscopy is further associated with less adhesion formation. Pregnancy rates after myomectomy in symptomatic patients might be higher after laparoscopy than after laparotomy. Although uterine ruptures following laparoscopic myomectomy are described in the literature, it seems to be a rare event. Concerning the recurrence, there is evidence that rates are similar after laparoscopy and laparotomy. CONCLUSION Myomectomy by laparoscopy has several advantages over abdominal myomectomy (by conventional laparotomy and minilaparotomy) and should be the standard procedure. Despite the advantages of laparoscopy, abdominal myomectomy is still a frequently performed procedure. Lack of training in advanced laparoscopic procedures hampers the wide-spread use of laparoscopic myomectomy. Due to the advantages of laparoscopic surgery, efforts should be made to implement this procedure into daily practice. To provide the best care, physicians should offer patients the opportunity of a laparoscopic treatment of myomas.
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Affiliation(s)
- Anja Hirschelmann
- Pius-Hospital Oldenburg, Klinik für Frauenheilkunde, Geburtshilfe und Gynäkologische Onkologie, Oldenburg, Germany
| | - Rudy Leon De Wilde
- Pius-Hospital Oldenburg, Klinik für Frauenheilkunde, Geburtshilfe und Gynäkologische Onkologie, Oldenburg, Germany
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Parker WH. The utility of MRI for the surgical treatment of women with uterine fibroid tumors. Am J Obstet Gynecol 2012; 206:31-6. [PMID: 21982615 DOI: 10.1016/j.ajog.2011.08.021] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2011] [Revised: 06/07/2011] [Accepted: 08/16/2011] [Indexed: 12/23/2022]
Abstract
Determination of the reasonable treatment options and the appropriate clinical treatment of women with uterine fibroid tumors often depends on the ability of imaging modalities to accurately detect and localize fibroid tumors. Magnetic resonance imaging (MRI) gives the most complete evaluation (sizes, positions, number) of submucous, intramural, and subserosal myomas and is the most sensitive modality for the detection of small fibroid tumors. MRI allows the evaluation of fibroid tumor proximity to the bladder, rectum, and endometrial cavity, helps define what can be expected at surgery, and may help the gynecologist avoid missing fibroid tumors during surgery. MRI can also make the diagnosis of adenomyosis reliably and may be able to identify uterine sarcoma when present.
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Affiliation(s)
- William H Parker
- Department of Obstetrics and Gynecology, UCLA School of Medicine, Los Angeles, CA 90401-2831, USA.
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Goldman KN, Hirshfeld-Cytron JE, Pavone ME, Thomas AP, Vogelzang RL, Milad MP. Uterine artery embolization immediately preceding laparoscopic myomectomy. Int J Gynaecol Obstet 2011; 116:105-8. [PMID: 22098788 DOI: 10.1016/j.ijgo.2011.08.022] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2011] [Revised: 08/30/2011] [Accepted: 10/17/2011] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To determine whether performing uterine artery embolization (UAE) immediately before laparoscopic myomectomy can facilitate a minimally invasive surgical approach for larger uterine fibroids. METHODS In a retrospective case-control study, laparoscopic myomectomy with and without preoperative UAE was examined. Data were analyzed from 26 laparoscopic myomectomies performed by a single surgeon at Northwestern University Feinberg School of Medicine between 2004 and 2010. Controls were matched for age, calendar year, surgeon, and number of fibroids removed. Surgical outcomes included preoperative clinical uterine size, operative time, operative blood loss, and postoperative myoma specimen weight. Data were analyzed via 2-tailed Student t test. RESULTS Twelve women underwent laparoscopic myomectomy within 169 ± 16minutes (mean ± SEM) of preoperative UAE. Fourteen control patients underwent laparoscopic myomectomy alone. The UAE group had a greater mean preoperative clinical uterine size (19.7 versus 12.4 weeks, P<0.001) and a greater mean myoma specimen weight measured postoperatively (595.3 versus 153.6 grams, P<0.05). There were no significant differences in operative time or blood loss, and there were no intra-operative complications. CONCLUSION UAE performed immediately before laparoscopic myomectomy facilitated minimally invasive surgery for larger uteri and larger uterine myomas, with no differences in operative time or blood loss.
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Affiliation(s)
- Kara N Goldman
- Department of Obstetrics and Gynecology, Division of Reproductive Endocrinology and Infertility, Northwestern University Feinberg School of Medicine, Chicago, IL 60611, USA
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Malvasi A, Tinelli A, Rahimi S, D’Agnese G, Rotoni C, Dell’Edera D, Tsin DA, Cavallotti C. A three-dimensional morphological reconstruction of uterine leiomyoma pseudocapsule vasculature by the Allen-Cahn mathematical model. Biomed Pharmacother 2011; 65:359-63. [DOI: 10.1016/j.biopha.2011.04.018] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2010] [Accepted: 04/07/2011] [Indexed: 11/30/2022] Open
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LÖNNERFORS CELINE, PERSSON JAN. Pregnancy following robot-assisted laparoscopic myomectomy in women with deep intramural myomas. Acta Obstet Gynecol Scand 2011; 90:972-7. [DOI: 10.1111/j.1600-0412.2011.01207.x] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Abstract
Uterine fibroids are an important problem for women of reproductive age. Although hysterectomy has been the traditional treatment for fibroids, many women are interested in a less invasive therapy. Magnetic resonance-guided focused ultrasound (MRgFUS) is a new technique for treating a variety of solid tumors. It has been tested and approved by the U.S. Food & Drug Administration (FDA) for the treatment of uterine fibroids. The procedure is completely noninvasive. It is performed as an outpatient procedure and the patient can resume her normal activities the day following the procedure. Techniques of treatment of uterine fibroids are still being refined, but significant progress has been made in understanding some of the challenges for this new technology. Some fibroids are more responsive to the focused ultrasound; some fibroids are more resistant. Not all women are candidates for this procedure. Absolute contraindications include bowel that is in the path of the ultrasound beam, or surgical scars in the beam pathway. The procedure of MRgFUS is feasible, safe and becoming increasingly popular. Questions still remain particularly the use of this technique for patients desiring fertility, and what will be the long-term results.
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Affiliation(s)
- Anne Roberts
- Department of Radiology, University of California, San Diego, and Veterans Administration Medical Center, San Diego, California
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Yoshida Y, Kiyono Y, Tsujikawa T, Kurokawa T, Okazawa H, Kotsuji F. Additional value of 16α-[18F]fluoro-17β-oestradiol PET for differential diagnosis between uterine sarcoma and leiomyoma in patients with positive or equivocal findings on [18F]fluorodeoxyglucose PET. Eur J Nucl Med Mol Imaging 2011; 38:1824-31. [DOI: 10.1007/s00259-011-1851-8] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2011] [Accepted: 05/20/2011] [Indexed: 11/30/2022]
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Abstract
An appropriately developed and functional reproductive tract is essential for the natural production of offspring. However, abnormal development or disease, either within or external to the reproductive tract, can cause considerable morbidity and mortality. This Review describes the normal function of each section of the female reproductive tract. Some of the major conditions and diseases that cause reproductive tract dysfunction in women of reproductive age are reviewed, with a focus on endocrine-related dysfunction. As the female reproductive tract is vital for the continuation of the human species, it is crucial to have an improved understanding of how the cells and tissues of this system interact under normal conditions and to define how hormonal and genetic abnormalities cause pathophysiologic derangement of reproduction.
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Affiliation(s)
- Angshumoy Roy
- Department of Pathology, Baylor College of Medicine, Houston, TX 77030, USA
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Bourdel N, Bonnefoy C, Jardon K, Da Ines D, Tognazza E, Rabischong B, Botchorisvili R, Pouly JL, Canis M, Mage G. Myomectomie hystéroscopique : récidive et enquête de satisfaction à court et long terme. ACTA ACUST UNITED AC 2011; 40:116-22. [DOI: 10.1016/j.jgyn.2011.01.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2010] [Revised: 01/06/2011] [Accepted: 01/11/2011] [Indexed: 10/18/2022]
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88
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Wei LH, Torng PL, Hsiao SM, Jeng YM, Chen MW, Chen CA. Histone deacetylase 6 regulates estrogen receptor alpha in uterine leiomyoma. Reprod Sci 2011; 18:755-62. [PMID: 21421902 DOI: 10.1177/1933719111398147] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Histone deacetylase 6 (HDAC) 6 is a regulatory factor in the endocrine traffic network that controls growth factor receptor stability. Histone deacetylase 6 expression and its pathogenic role in the uterine leiomyoma have not been studied. Here, we demonstrated that there was a consistent pattern of increasing HDAC6 and estrogen receptor (ER) α expression in leiomyoma samples. For all individual cases, expression of HDAC6 in the normal myometrium or leiomyoma positively correlated with ERα expression. The spearman's rho (ρ) was .53 (P = .008) between HDAC6 and ERα in normal myometrium and, more significantly, the spearman rho was .80 (P < .001) between HDAC6 and ERα in leiomyoma. In ELT-3 leiomyoma cells, silencing HDAC6 expression substantially reduced ERα expression, lowered estrogen response, and inhibited ELT-3 cell growth. Our results, taken together, are the first to provide experimental evidence suggesting that HDAC6 may be an essential molecular therapeutic target in controlling leiomyoma growth.
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Affiliation(s)
- Lin-Hung Wei
- Department of Oncology, National Taiwan University Hospital, Taipei, Taiwan
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89
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Barrier methods used to prevent pelvic adhesions in videolaparoscopy: experimental study in female rabbits. Surg Endosc 2011; 25:2637-42. [DOI: 10.1007/s00464-011-1617-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2010] [Accepted: 02/06/2011] [Indexed: 11/27/2022]
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90
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Lehtonen HJ. Hereditary leiomyomatosis and renal cell cancer: update on clinical and molecular characteristics. Fam Cancer 2011; 10:397-411. [PMID: 21404119 DOI: 10.1007/s10689-011-9428-z] [Citation(s) in RCA: 104] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Affiliation(s)
- Heli J Lehtonen
- Department of Medical Genetics, Genome-Scale Biology Research Program, Biomedicum Helsinki, Haartman Institute, University of Helsinki, Haartmaninkatu 8, P.O. Box 63, Helsinki 00290, Finland.
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91
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Leiomyomas in adolescents. Fertil Steril 2011; 95:2434.e15-7. [PMID: 21392748 DOI: 10.1016/j.fertnstert.2011.02.025] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2010] [Revised: 01/31/2011] [Accepted: 02/11/2011] [Indexed: 11/20/2022]
Abstract
OBJECTIVE To describe a rare finding of a large leiomyoma and recurrence in an adolescent. DESIGN Case report. SETTING Major academic medical center. PATIENT(S) A 14-year-old gravida 0 presented with a 16-cm pelvic mass that was found to be an anterior uterine leiomyoma. INTERVENTION(S) Exploratory laparotomy with resection of leiomyoma followed by robotic myomectomy when the mass recurred. MAIN OUTCOME MEASURE(S) The incidence, pathogenesis, fertility implications, and treatment options for leiomyomas in adolescents. RESULT(S) Leiomyomas are rare in adolescents. The mass was resected and recurred within 1 year. There are no prior cases of recurrence in an adolescent. CONCLUSION(S) Benign leiomyomas should be considered in adolescents presenting with uterine masses, as malignancies are even less common. Myomectomy is the procedure of choice to preserve fertility in this population.
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92
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De Vivo A, Mancuso A, Giacobbe A, Savasta LM, De Dominici R, Dugo N, Dugo C, Vaiarelli A. Uterine myomas during pregnancy: a longitudinal sonographic study. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2011; 37:361-365. [PMID: 20922776 DOI: 10.1002/uog.8826] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 08/24/2010] [Indexed: 05/29/2023]
Abstract
OBJECTIVE To evaluate volumetric changes of uterine myomas (fibroids) during pregnancy. METHODS This was an observational, longitudinal and prospective study of 38 consecutive Caucasian women with singleton pregnancies and a total of 42 uterine myomas, enrolled from a cohort of 1492 women who took part in our first-trimester Down syndrome screening program. Myoma volume was evaluated by ultrasound at 11-14, 20-22 and 32-34 weeks of gestation. RESULTS Mean myoma volume increased significantly throughout pregnancy. Taking a volumetric change of > 10% between gestational periods to be an increase in size, 71.4% of uterine myomas increased in size between the first and second gestational periods, while this percentage was slightly lower (66.6%) between the second and third periods. Logistic regression analysis revealed that greater maternal age was correlated with a reduction/no change in overall myoma size and multiparity was correlated with a decrease/no change between the first and second trimesters, while a higher prepregnancy maternal body mass index (BMI) was correlated with a volumetric increase between the first and second trimesters and a decrease/no change between the second and third trimesters. CONCLUSIONS Fibroids enlarge during pregnancy regardless of their initial size or local factors, and maternal age, prepregnancy BMI and parity are apparently correlated with these changes.
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Affiliation(s)
- A De Vivo
- Department of Gynecological, Obstetrical Sciences and Reproductive Medicine, University Hospital, Messina, Italy.
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93
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Somigliana E, De Benedictis S, Vercellini P, Nicolosi AE, Benaglia L, Scarduelli C, Ragni G, Fedele L. Fibroids not encroaching the endometrial cavity and IVF success rate: a prospective study. Hum Reprod 2011; 26:834-9. [PMID: 21317415 DOI: 10.1093/humrep/der015] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND The impact of fibroids, not encroaching the endometrial cavity, have on the rate of success of IVF is still controversial. Recent meta-analyses suggest a detrimental effect of intramural lesions but not subserosal lesions. However, they also emphasize the need for further evidence. In order to elucidate this, we designed a prospective cohort study to compare the rate of success of IVF in women with and without fibroids. METHODS Exposed women were those with asymptomatic intramural or subserosal fibroids with a diameter below 50 mm and who were selected for IVF. Unexposed women were those free of fibroids, who were matched to cases by age and number of previous IVF cycles. All recruited patients underwent hystero-sonography to rule out intra-cavitary lesions. RESULTS There were 119 cases and 119 controls recruited. The number of clinical pregnancies in women with and without fibroids was 28 (24%) and 22 (19%), respectively (P= 0.43). The adjusted odds ratio (OR) for pregnancy in affected women was 1.38 [95% confidence interval (CI): 0.73-2.60]. The number of deliveries was 22 (18%) and 16 (13%), respectively (P= 0.38). The adjusted OR was 1.45 (95% CI: 0.71-2.94). Similar results emerged when focusing exclusively on women carrying intramural lesions (n= 80 couples). There was no significant relationship between clinical outcome and either the number or size of the fibroids. CONCLUSIONS In asymptomatic patients selected for IVF, small fibroids not encroaching the endometrial cavity did not impact on the rate of success of the procedure.
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Affiliation(s)
- Edgardo Somigliana
- Department of Obset/Gynecol-Fondazione Cà Granda, Ospedale Maggiore Policlinico, Via Commenda 12, 20122 Milano, Italy
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94
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Benaglia L, Somigliana E, de Benedictis S, Paffoni A, Scarduelli C, Fedele L, Ragni G. Hyperstimulation during IVF cycles does not modify dimensions of small subserosal and intramural leiomyomas. Fertil Steril 2011; 95:2489-91. [PMID: 21236423 DOI: 10.1016/j.fertnstert.2010.12.051] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2010] [Revised: 11/12/2010] [Accepted: 12/22/2010] [Indexed: 10/18/2022]
Abstract
To evaluate the influence of IVF on the dimension of leiomyomas, we selected 72 women with small intramural or subserosal leiomyomas and assessed the size of these lesions before and after the treatment cycle. The mean ± SD diameters of the tumors at these two time points were 20.5 ± 9.5 and 20.6 ± 10.2 mm, respectively, thus supporting the conclusion that IVF does not influence the growth of these lesions.
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Affiliation(s)
- Laura Benaglia
- Infertility Unit, Fondazione Ospedale Maggiore Policlinico Mangiagalli e Regina Elena, Milan, Italy.
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95
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96
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Balbinotto RP, Trindade MRM, Muller ALL, Nunes AG, Da Silva R, Meyer FS, Cerski CTS. Experimental model of the formation of pelvic adhesions by videolaparoscopic in female rabbits. Acta Cir Bras 2010; 25:34-6. [PMID: 20126885 DOI: 10.1590/s0102-86502010000100009] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2009] [Accepted: 11/18/2009] [Indexed: 11/21/2022] Open
Abstract
PURPOSE To verify the frequency of postsurgical pelvic adhesion formation in an experimental animal model using videolaparoscopy. METHODS Experimental study in a sample of 11 non-pregnant female rabbits, aged 5 to 7 months. After general anesthesia, access to the abdominal cavity was performed by an open puncture technique, with 10mm optics, placing two other 5 mm trochars under direct visualization, in the iliac fossae. Then a fragment of peritoneum was resected, followed by electrocauterization. In 21 days, the videolaparoscopy was repeated, and adhesion formation and score was looked at, with biopsies at the surgical site. RESULTS 54 % of adhesion formation was observed, and the median score of adhesions was 6 (minimum of 3 and maximum of 10), all of them found in the bladder and the anterior abdominal wall. CONCLUSION The method used presents a high frequency of intra-abdominal adhesion formation.
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97
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Ichigo S, Takagi H, Matsunami K, Suzuki N, Imai A. Beneficial effects of dienogest on uterine myoma volume: a retrospective controlled study comparing with gonadotropin-releasing hormone agonist. Arch Gynecol Obstet 2010; 284:667-70. [PMID: 21052701 DOI: 10.1007/s00404-010-1732-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2010] [Accepted: 10/14/2010] [Indexed: 11/26/2022]
Abstract
PURPOSE Uterine leiomyomas are the most common benign tumors of reproductive age women, but there is no effective medical therapy to data. Aim of this study was to examine and compare the efficacy of gonadotropin-releasing hormone agonist (GnRHa) versus dienogest in premenopausal women with uterine myoma. METHODS We retrospectively analyzed the medical records of 55 premenopausal patients with endometriosis, who received dienogest (2 mg daily) for 6 months regarding coexistence of uterine myoma between January 2008 and June 2010. To compare these data in a case-control study, we analyzed a matched control group of 12 patients treated with leuprolide acetate (1.88 mg monthly) for 6 months having uterine myoma. RESULTS Of the 55 patients treated with dienogest, six were associated with coexistent myoma node. Total myoma volume significantly decreased to 59.7 ± 7.0% of initial in dienogest group and 51.9 ± 5.5% in GnRHa group. Reduction rate in myoma volume was similar in both groups. CONCLUSION Uterine myoma volume was successfully reduced by use of dienogest. Consideration of GnRHa disadvantages may lead to short- or long-term management of women with myoma who are to be managed transiently, and who wish to avoid surgical intervention, especially perimenopausal women.
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Affiliation(s)
- Satoshi Ichigo
- Department of Obstetrics and Gynecology, Matsunami General Hospital, Gifu 501-6062, Japan
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98
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GnRH analogue treatment before hysteroscopic resection of submucous myomas: a prospective, randomized, multicenter study. Fertil Steril 2010; 94:1496-1499. [DOI: 10.1016/j.fertnstert.2009.05.070] [Citation(s) in RCA: 78] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2009] [Revised: 05/15/2009] [Accepted: 05/27/2009] [Indexed: 11/20/2022]
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99
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Marret H, Fauconnier A, Chabbert-Buffet N, Cravello L, Golfier F, Gondry J, Agostini A, Bazot M, Brailly-Tabard S, Brun JL, De Raucourt E, Gervaise A, Gompel A, Graesslin O, Huchon C, Lucot JP, Plu-Bureau G, Roman H, Fernandez H. Clinical practice guidelines on menorrhagia: management of abnormal uterine bleeding before menopause. Eur J Obstet Gynecol Reprod Biol 2010; 152:133-7. [PMID: 20688424 DOI: 10.1016/j.ejogrb.2010.07.016] [Citation(s) in RCA: 119] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2010] [Accepted: 07/02/2010] [Indexed: 02/04/2023]
Abstract
BACKGROUND Normal menstrual periods last 3-6 days and involve blood loss of up to 80ml. Menorrhagia is defined as menstrual periods lasting more than 7 days and/or involving blood loss greater than 80ml. The prevalence of abnormal uterine bleeding (AUB) is estimated at 11-13% in the general population and increases with age, reaching 24% in those aged 36-40 years. INVESTIGATION A blood count for red cells+platelets to test for anemia is recommended on a first-line basis for women consulting for AUB whose history and/or bleeding score justify it. A pregnancy test by an hCG assay should be ordered. A speculum examination and Pap smear, according to the French High Health Authority guidelines should be performed early on to rule out any cervical disease. Pelvic ultrasound, both abdominal (suprapubic) and transvaginal, is recommended as a first-line procedure for the etiological diagnosis of AUB. Hysteroscopy or hysterosonography can be suggested as a second-line procedure. MRI is not recommended as a first-line procedure. TREATMENT In idiopathic AUB, the first-line treatment is medical, with efficacy ranked as follows: levonorgestrel IUD, tranexamic acid, oral contraceptives, either estrogens and progestins or synthetic progestins only, 21 days a month, or NSAIDs. When hormone treatment is contraindicated or immediate pregnancy is desired, tranexamic acid is indicated. Iron must be included for patients with iron-deficiency anemia. For women who do not wish to become pregnant in the future and who have idiopathic AUB, the long-term efficacy of conservative surgical treatment is greater than that of oral medical treatment. Placement of a levonorgestrel IUD (or administration of tranexamic acid by default) is recommended for women with idiopathic AUB. If this fails, a conservative surgical technique must be proposed; the choices include second-generation endometrial ablation techniques (thermal balloon, microwave, radiofrequency), or, if necessary, first-generation techniques (endometrectomy, roller-ball). A first-line hysterectomy is not recommended in this context. Should a hysterectomy be selected for functional bleeding, it should be performed by the vaginal or laparoscopic routes.
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Affiliation(s)
- H Marret
- Centre Hospitalo-Universitaire de Tours, Hôpital Bretonneau, Service de Gynécologie, Tours 37044 cédex 1, France.
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100
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Kang JL, Wang DY, Wang XX, Yu J. Up-regulation of apoptosis by gonadotrophin-releasing hormone agonist in cultures of endometrial cells from women with symptomatic myomas. Hum Reprod 2010; 25:2270-5. [DOI: 10.1093/humrep/deq178] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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