The Management of Uterine Leiomyomas

Pregnancy-preserving Laparoendoscopic Single-site Surgery for Gynecologic Disease: A Case Series

STUDY OBJECTIVE

The study objective was to assess the feasibility of laparoendoscopic single-site surgery (LESS) for the management of nonobstetric, gynecologic disease processes in pregnant patients.

DESIGN

A retrospective case series of 13 pregnant women aged 21 to 42 years who underwent LESS for various gynecologic pathology. If able to be contacted, the patients were followed up until the delivery of the fetus.

SETTING

The surgeries were performed in a single institution between January 2015 and June 2019.

PATIENTS

The patients were selected if a laparoscopic intervention was indicated.

INTERVENTIONS

The cases included 6 ovarian cystectomies and 2 salpingo-oophorectomies for adnexal masses; 1 myomectomy for a degenerated myoma; 1 salpingectomy for a heterotopic pregnancy; 2 cerclage placements for recurrent pregnancy loss and cervical insufficiency; and 1 paratubal cystectomy. The patients underwent LESS through a 2.5-cm umbilical incision. The masses were exteriorized using a laparoscopic specimen retrieval bag, with the exception of 2 large adnexal masses, which were aspirated at the incision site, exteriorized after content drainage, and cystectomies performed extracorporeally. The fascial incision was repaired with a permanent suture.

MEASUREMENTS AND MAIN RESULTS

Various data were collected from patients, including age, surgical and obstetric history, gestational age at surgery, and ultrasonic imaging results. The outcomes measured were operative duration, intraoperative bleeding, postoperative symptoms, fetal monitoring before and after surgery, pathologic findings, conversions, intraoperative complications, and pregnancy outcomes. Eight cases were performed in the first trimester, 4 in the second trimester, and 1 in the third trimester, with the surgeries lasting between 45 minutes and 298 minutes. The blood loss ranged from 5 mL to 300 mL, and postoperative symptoms of mild pelvic or abdominal pain were reported. There were 2 conversions to traditional multiport laparoscopic surgery for the 2 cerclage cases, and there were no open surgery conversions or intraoperative complications. The fetal heart rate ranged between 130 beats per minute and 167 beats per minute postoperatively. Of the 9 patients who were able to be contacted for follow-up, all had successful deliveries. One patient was healthy at 31 weeks and 5 days without complication at the time of her last follow-up.

CONCLUSION

LESS may be performed by experienced surgeons on gravid patients in any trimester for adnexal masses, myomas, heterotopic pregnancy, and cervical incompetence. Future multiple-center studies may provide further evidence that LESS is a feasible and safe option for gynecologic surgery during pregnancy.

Benign leiomyoma with multiple metastases to vertebrae and calvarium: An index case with comprehensive review of endocrine targets

"Benign" metastatic leiomyomas (BML) are indolently growing metastatic tumors which mostly associate with uterine leiomyomas in women in reproductive ages. The reason to define these lesions as "benign" despite metastasis is their pathological features with low mitotic counts, lack of or minimal nuclear atypia, pseudocyst formation, and coagulative necrosis unlike leiomyosarcomas. Despite lack of pathological malignant features, they may cause significant morbidity and even mortality. Here, we describe a BML case with metastases to vertebrae and skull bones. Vertebral and skull metastases of BMLs were very rarely reported. In treatment of these tumors, hysterectomy and GnRH modifier treatments are widely employed. GnRH agonists act by desensitization and downregulation of the GnRH receptors, while GnRH antagonists act via the canonical competitive blockage. These treatments reduce FSH and LH levels, thereby reducing the systemic levels of sex steroids which stimulate leiomyoma growth. However, leiomyomas inherently harbor aromatase activity and synthesize their own estrogen; hence, treatment with systemic estrogen antagonists may provide better tumor control. Another important factor in BML pathogenesis is progesterone, and both progesterone receptor antagonists and high-dose progesterone receptor agonists may reduce BML growth. Following surgical treatment of the calvarial mass and radiotherapy of the vertebral metastatic foci, our BML case was successfully managed with hysterectomy and anastrozole treatment. Higher awareness of BML cases and their molecular endocrinological features in the neurosurgical community may pave to develop better strategies for treatment of these tumors causing high morbidity.

Vaginal leiomyoma: medical imaging and diagnosis in a resource low tertiary hospital: case report

Background

In the literature under review there are about 300 reported cases of vaginal leiomyomas with none from Cameroon. We report a case of vaginal leiomyoma and highlight the diagnostic challenges faced at the Douala Referral Hospital (DRH), Cameroon.

Case presentation

A 36-year-old G3P3002 sexually active Cameroonian married woman reported dysuria, dyspareunia, cessation of sexual intercourse and offensive smelling vaginal discharge for 6 months and a 3-year history of a vaginal tumour; she was misdiagnosed despite ultrasonography and magnetic resonance imaging (MRI) but was corrected by an experienced radiologist. She underwent first look laparoscopy, surgical excision of the tumour through the vagina and histopathology analysis that confirmed leiomyoma.

Conclusion

Posterior location of vaginal leiomyomas found in this case is a rare occurrence. The diagnosis is based on careful examination and preoperative imaging (ultrasonography and MRI). However, the definitive diagnosis is usually made intra-operatively. We combined laparoscopic exploration of the internal genital organs and per vaginal excision of the vaginal leiomyoma. Thus, we recommend frozen section biopsy to exclude leiomyosarcoma.

Ulipristal acetate for Japanese women with symptomatic uterine fibroids: A double-blind, randomized, phase II dose-finding study

PURPOSE

A multicenter, randomized, double-blind, placebo-controlled trial was conducted to evaluate the efficacy, safety, and appropriate dose of ulipristal acetate (UPA) in Japanese women with symptomatic uterine fibroids (UFs).

METHODS

A total of 121 premenopausal women with UFs were enrolled to receive either placebo, UPA-2.5 mg, UPA-5 mg, UPA-10 mg, or leuprorelin acetate (LEU), a reference drug, for 12 weeks. The primary end point was the rate of patients having achieved amenorrhea for 35 days at Week 12.

RESULTS

The rates for amenorrhea were 4.5%, 60.0%, 72.7%, 88.0%, and 76.2% in the placebo, UPA-2.5 mg, UPA-5 mg, UPA-10 mg, and LEU groups, respectively. The median times to amenorrhea were 20.0, 5.0, 5.0, and 23.0 days for treatment with UPA-2.5 mg, UPA-5 mg, UPA-10 mg, and LEU, respectively. A significant dose-response of UPA for the rate of amenorrhea was observed. The overall incidence rates of adverse events were 45.8% in the placebo group, 56.5%-80.0% in the UPA groups, and 100.0% in the LEU group. There were no notable safety issues with UPA.

CONCLUSIONS

Ulipristal acetate was effective and well tolerated in Japanese women with UFs. The recommended dose of UPA is considered to be 10 mg.

Two-port myomectomy using bag-contained manual morcellation: A comparison with three-port myomectomy using power morcellation

OBJECTIVES

To evaluate the feasibility and safety of two-port myomectomy using bag-contained manual morcellation compared to three-port myomectomy using power morcellation.

MATERIAL AND METHODS

A retrospective chart review was conducted for 428 cases of either two-port or three-port laparoscopic myomectomy performed by single operator in the university hospital between January 2011 and December 2016.

RESULTS

The cohorts of three-port myomectomy with power morcellation was consisted of two hundred and forty-eight patients. One hundred and eighty patients underwent two-port myomectomy with manual morcellation in contained bag. Two-port group showed shorter hospital stay (5.16 ± 1.39 d vs. 4.83 ± 1.19 d, p = 0.001), less estimated blood loss (61.8 ± 58.2 mL vs. 50.2 ± 52.4 mL, p = 0.001), and higher hemoglobin level at postoperative day 1 (10.7 ± 1.17 g/dL vs. 11.0 ± 1.14 g/dL, p = 0.028) with statistical significance. Morcellation time (25.8 ± 9.30 min vs. 18.9 ± 10.11 min, p = 0.001) and total operative time (82.4 ± 30.19 min vs. 76.4 ± 25.47 min, p = 0.047) were also significantly shorter in two-port group. There were no identified spillages of fibroids, ruptures of specimen bag during manual morcellation in two-port myomectomy. In both groups, there were no cases of leiomyosarcoma diagnosed postoperatively.

CONCLUSION

Two-port laparoscopic myomectomy with bag-contained manual morcellation is a feasible and safe alternative for three-port with power morcellation. Its surgical outcomes were shown to be superior to conventional laparoscopic myomectomy according to our study but further evaluation in near future is needed.

Pregnancy Outcomes Following Ulipristal Acetate for Uterine Fibroids: A Systematic Review

OBJECTIVE

To determine pregnancy and fetal outcomes following treatment with ulipristal acetate (UPA) for symptomatic uterine fibroids.

METHODS

We conducted a systematic review and case series. We searched MEDLINE, EMBASE, PubMed, Web of Science, and Cochrane Register from inception to February 2017. From January 2014 to July 2017, we carried out a multi-centre retrospective chart review. All human studies that reported at least one pregnancy following UPA treatment were included. The case series included patients who conceived during/following UPA treatment. Titles and abstracts were screened for eligibility by two independent reviewers, and full texts were evaluated for inclusion and study quality. Data from the systematic review and case series were synthesized and reported separately.

RESULTS

Seven studies were included (six case reports, one retrospective series) and contributed 24 post-UPA pregnancies (19 live births, six spontaneous abortions [SA]). The case series contributed 47 post-UPA pregnancies (31 live births, 13 SA, 1 fetal death, 2 terminations, 1 ongoing). In total, 71 pregnancies were evaluated (44 underwent myomectomy post-UPA; 27 without interval surgery). Five pregnancies occurred during UPA use (10-36 days of exposure) and resulted in three live births, one SA, and one termination. Five women who did not undergo interval myomectomy experienced delivery complications related to their fibroid.

CONCLUSIONS

This is the first systematic review and largest reported case series evaluating pregnancy outcomes following UPA treatment for uterine fibroids. UPA alone, or in conjunction with surgery, can permit conception and favorable pregnancy outcomes.

Laparoscopic myomectomy after or without pre-treatment with ulipristal acetate

INTRODUCTION

The aim was to compare the surgical experience and the clinical results of laparoscopic myomectomy (LM) with or without pre-treatment with ulipristal acetate (UPA).

MATERIAL AND METHODS

Fifty-four women who underwent LM for intramural myomas and were pre-treated with three months of UPA were matched with 54 patients with the same procedure but no hormonal pre-treatment. All operations were performed by one team. The technical features of the procedures were reviewed and evaluated by two other laparoscopists, unaware of the eventual use of UPA. The clinical, histological, and reproductive outcomes of each patient were assessed and the results of both groups were compared.

RESULTS

The groups did not significantly differ in operation time, intra-operative blood loss, drop in hemoglobin concentration, number of complications, pregnancy rate, and delivery rate. Women pre-treated with UPA had significantly longer hospital stays, higher numbers of histologically abnormal leiomyomas, and higher rates of fibroids peri-procedurally assessed as soft and disintegrating. The other four technical parameters of LM were comparable in both groups.

CONCLUSIONS

The surgeons performing LM in women pre-treated with UPA should be aware of the abnormal texture of enucleated myomas. Nevertheless, this does not negatively affect the other surgical and clinical outcomes of these patients.

Successful Myomectomy in the Second Trimester of Pregnancy

The prevalence of uterine myomas during pregnancy is estimated to be small. However, a significant fraction of these could lead to pregnancy complications. Myomectomy is rarely performed during pregnancy because of fear of miscarriage and the risk of uncontrolled hemorrhage necessitating hysterectomy. This article reports on a case of myomectomy of subserous leiomyoma that was causing septic necrosis, leukocytosis, rise of inflammatory markers (erythrocyte sedimentation rate and C-reactive protein), and pressure symptom on the liver. Myomectomy was performed at 20 weeks of gestation. The pregnancy continued with no further problems, and at 39 weeks and 1 day of gestation, vaginal delivery resulted in a healthy baby. It is postulated that when myomectomy is performed in carefully selected patients, it prevents sepsis due to myoma torsion and necrosis and also protects surrounding organs against damage.

How to differentiate uterine leiomyosarcoma from leiomyoma with imaging

Uterine leiomyomas, the most frequent benign myomatous tumors of the uterus, often cannot be distinguished from malignant uterine leiomyosarcomas using clinical criteria. Furthermore, imaging differentiation between both entities is frequently challenging due to their potential overlapping features. Because a suspected leiomyoma is often managed conservatively or with minimally invasive treatments, the misdiagnosis of leiomyosarcoma for a benign leiomyoma could potentially result in significant treatment delays, therefore increasing morbidity and mortality. In this review, we provide an overview of the differences between leiomyoma and leiomyosarcoma, mainly focusing on imaging characteristics, but also briefly touching upon their demographic, histopathological and clinical differences. The main indications and limitations of available cross-sectional imaging techniques are discussed, including ultrasound, computed tomography, magnetic resonance imaging (MRI) and positron emission tomography/computed tomography. A particular emphasis is placed on the review of specific MRI features that may allow distinction between leiomyomas and leiomyosarcomas according to the most recent evidence in the literature. The potential contribution of texture analysis is also discussed. In order to help guide-imaging diagnosis, we provide an MRI-based diagnostic algorithm which takes into account morphological and functional features, both individually and in combination, in an attempt to optimize radiologic differentiation of leiomyomas from leiomyosarcomas.

Clinical characteristics of patients with leiomyoma who undergo surgery after high intensity focused ultrasound (HIFU)

Objective

We evaluated the clinical characteristics of patients who underwent surgery after high intensity focused ultrasound (HIFU) to treat uterine leiomyoma.

Methods

From June 2016 to September 2017, patients at our hospital who underwent HIFU to treat uterine leiomyoma prior to surgery were enrolled. All patients underwent pelvic magnetic resonance imaging (MRI) before and after HIFU. If 6 months had passed since the last pelvic MRI was performed, imaging was performed again before the operation.

Results

A total of 12 patients were analyzed. The median age was 45 (range, 28–51) years. The median body mass index was 24.9 (range, 18.1–29.2) kg/m². The median size of the leiomyoma was 10.1 (range, 7.8–14.0) cm before HIFU, which changed to 8.75 (range, 5.9–14.8) cm after HIFU. The median size increased to 9.1 (range, 5.9–18.0) cm before the operation. Surgery was planned for several reasons, including an increase in the leiomyoma size (n=6), persistent symptoms (n=4), and newly developed lesion (n=2). The median interval between HIFU and surgery was 7 (range, 3–32) months. Ten of the 12 patients underwent laparoscopic surgery, while the others underwent laparotomy; 6 patients also underwent laparoscopic myomectomy, and 4 underwent hysterectomy. Histopathologic findings showed infarction-type necrosis surrounded by granulation tissue with the infiltration of lymphocytes and macrophages in all patients.

Conclusion

Treatment of leiomyoma with operative procedures should be considered in selected patients with tumor size greater than 10 cm, multiple tumors, and persistent symptoms after HIFU treatment.

Minimally Invasive Myomectomy: An Overview on the Surgical Approaches and a Comparison with Mini-Laparotomy

Uterine fibroids (UFs) are the most common benign solid tumors of the female genital tract manageable by surgical of pharmacological approach. When the medical management is ineffective or surgery is primarily requested, several surgical approaches can be used. Among these, minimally invasive surgery might be preferred. Myomectomy is the standard surgical treatment when fertility sparing is claimed. It can be performed via laparoscopy, robotic surgery and hysteroscopy and the choice depend on UFs features and surgeon's skill. Alongside these minimally invasive options, mini-laparotomy has been proposed as a less invasive surgical approach comparable to the well-established minimally invasive options. The aim of this review is to describe the most recent advances in minimally invasive techniques to perform myomectomy, comparing them with mini-laparotomy approach.

The Expression of MBD6 Is Associated with Tumor Size in Uterine Leiomyomas

Background: Uterine leiomyoma (UL) is the most common benign smooth muscle tumor of the uterus in reproductive women. Prior studies indicated that methyl-CpG-binding domain proteins (MBDs) may be involved in the pathogenesis of UL. Materials and Methods: In this study, UL tissues and paired adjacent myometrium were collected from a total of 51 patients. The expression of MBD mRNAs and their cognate proteins were analyzed via quantitative polymerase chain reaction assays and western blotting, respectively. The relationships between the MBD expression levels and the patients' clinicopathologic variables were assessed using Student's t test, nonparametric tests, or Pearson χ² methods. Results: Our results show that both the mRNA and protein levels of MBD2 were significantly decreased in ULs compared to the adjacent myometrium. In addition, MBD6 protein expression was also decreased significantly in UL samples when compared to the adjacent myometrium. There was, however, no significant difference on the mRNA expression of MBD6 between these two groups. Neither the mRNA nor the protein levels of the other MBD members (MBD1, MBD3, MBD4, MBD5, and MeCP2) showed any significant differences between ULs and the adjacent myometria. The decreased expression of the MBD6 protein was correlated with the tumor size of ULs. Conclusions: These results suggest that the dysregulated expression of MBD2 and MBD6 in ULs may play a role in their development; however, a larger sample size together with cellular functional assays should be carried out to further elucidate the precise role of MBD6 in ULs.

Health-related quality of life in pregnancy with uterine fibroid: a cross-sectional study in China

Background

Uterine fibroids (UFs) are the most common benign tumors in women. They are likely to cause numerous clinical symptoms, such as pain, menorrhagia, and other obstetric complications in pregnant women. This study aimed to determine the health-related quality of life (HRQoL) during pregnancy with uterine fibroids (UF), thus providing a utility-based case value in pregnant women with UF and understanding of whether HRQoL is associated with clinical outcomes in pregnant women with UFs.

Method

This study was conducted in a cross-sectional manner. This study was based on questionnaire surveys completed by sequential out- and in-patients and was conducted in a regional university hospital in Guangzhou, China. The EuroQoL five-dimension-five-level (EQ-5D-5 L) questionnaire was used, and demographic data were collected. An electronic record of the clinical outcomes of pregnant women with UF was retrieved from the hospital’s electronic medical record system. The association between UF and HRQoL was evaluated by ordered regression.

Results

Seven-hundred-sixty-seven pregnant women with a mean age (SD) of 32.7 (4.8) years completed 707 questionnaires. Overall, when comparing the UF with non-UF groups, we detected statistical differences in age, body mass index (BMI), gravidity and abortion times, partner’s smoking and alcoholic habits, advanced maternal age, and uterine scars (p <  0.05). Furthermore, pregnant women without UF scored significantly higher than those with UF on the EQ-5D value system (0.84 versus 0.79; p = 0.017). Moreover, pregnant women with UF suffered more health-related problems, especially with respect to self-care (odds ratio [OR] = 3.69, p <  0.01) and usual activity dimensions (OR = 2.11; p = 0.01).

Conclusion

We found that UF has a negative impact on the HRQoL of pregnant women with respect to self-care and usual activity dimensions. Also, the EQ-5D score was a better index than the EQ-VAS score for HRQoL when evaluating of the QoL of our population of pregnant women.

Different methylation levels in the KLF4, ATF3 and DLEC1 genes in the myometrium and in corpus uteri mesenchymal tumours as assessed by MS-HRM

Mesenchymal tumours of the corpus uteri comprise common benign lesions - leiomyomas and very rare malignant variants - sarcomas. It can be difficult to distinguish between the particular types of mesenchymal tumours pre-surgically. Primarily, leiomyomas and the very aggressive leiomyosarcomas can be easily misdiagnosed when using only imaging devices. Therefore, a reliable non-invasive marker for these tumour types would provide greater certitude for patients that the lesion remains benign. Our collection comprises 76 native leiomyomas, an equal number of healthy myometrium samples and 49 FFPE samples of various types of sarcomas. The methylation level was assessed by MS-HRM method and we observed differences in the methylation level between healthy, benign and (semi)malignant tissues in the KLF4 and DLEC1 genes. The mean methylation levels of leiomyomas compared to myometrium and leiomyosarcomas were 70.7% vs. 6.5% vs. 39.6 % (KLF4) and 66.1% vs. 14.08% vs. 37.5% (DLEC1). The ATF3 gene was differentially methylated in leiomyomatous and myometrial tissues with 98.1% compared to 76.6%. The AUC values of the predictive logistic regression model for discrimination between leiomyomas and leiomyosarcomas based on methylation levels were 0.7829 (KLF4) and 0.7719 (DLEC1). Finally, our results suggest that there should be distinct models for the methylation events in benign leiomyomas and sarcomas, and that the KLF4 and DLEC1 genes can be considered potential methylation biomarkers for uterine leiomyomas.

Huge Primary Parasitic Leiomyoma in a Postmenopausal Lady: A Rare Presentation

Although uterine myomas are the most common benign tumours of the female pelvis in the reproductive age group, they rarely grow in menopausal women. Parasitic fibroids without prior history of laparoscopic myomectomy are even a rarer presentation particularly in menopausal women. The case presented is a 58-year-old grand-multiparous, menopausal lady with progressive abdominal swelling of three-year duration. She had excision of a huge parasitic fibroid attached to omentum. She had partial omentectomy, total abdominal hysterectomy, and bilateral salpingo-oophorectomy. The parasitic fibroid mass weighed 5.2kg and histopathology confirmed leiomyoma uteri with cystic degeneration and lymph nodes with reactive lymphoid hyperplasia. She had uneventful postoperative recovery and follow-up has so far been uneventful.

Unusual presentation of parasitic leiomyoma; a tale of twists and turns

Uterine leiomyoma is the most common benign pelvic tumor of the myometrium, as the prevalence could be as high as 70%. Major risk factors include age between 40–60 years and African descent. It usually presents with abnormal uterine bleeding and/or pelvic pain or pressure. Extra-uterine cases of leiomyoma have been reported including Leiomyomatosis Peritonealis Disseminata (LPD), in which multiple nodules are found in the pelvis, peritoneum, or intestine. The term parasitic leiomyoma has been used in literature to describe a non-disseminating pattern . There is no clear explanation for pathogenesis; however, some reports linked it to previous uterine procedures. We are presenting here a case report of an unusual presentation of extra-uterine leiomyoma in a patient with a remote history of hysterectomy for uterine fibroids.

Adlay (Coix lachryma-jobi L. var. ma-yuen Stapf.) Hull Extract and Active Compounds Inhibit Proliferation of Primary Human Leiomyoma Cells and Protect against Sexual Hormone-Induced Mice Smooth Muscle Hyperproliferation

Uterine leiomyomas, also known as fibroids, are benign neoplasms of the uterus and have a high incidence rate in women of reproductive age. Hysterectomy or myomectomy is the initial treatment, but fibroids will recur if the patient is still exposed to similar risk factors. Therefore, developing new therapeutic strategies are urgently necessary. In this study, the anti-proliferation effects of each fraction of adlay seeds were evaluated in uterine leiomyomas, and we identified the potential phytochemical compounds. We found that the ethyl acetate fraction of adlay hull (AHE-ea) appeared to be highly efficient in the anti-proliferation of rat uterine leiomyoma ELT3 cells and primary human uterine leiomyoma (hUL) cells. The proliferation of primary human normal uterine smooth muscle (UtSMC) and normal uterine myometrial (hUM) cells were also suppressed by AHE-ea. Two phytosterols, stigmasterol and β-sitosterol, were identified from AHE-ea fraction. Mice treated with AHE-ea and stigmasterol alone demonstrated reduced diethylstilbestrol/medroxyprogesterone 17-acetate (DES/MPA)-induced uterine myometrial hyperplasia, which is the critical step for the development of leiomyoma. Taken together, our results suggest that the AHE-ea fraction could be considered as a natural plant-based medicine in the prevention or treatment of uterine leiomyoma growth.

A Case of Hemoperitoneum Due to Spontaneous Bleeding from a Uterine Leiomyoma

Patient: Female, 26

Final Diagnosis: Uterine leiomyoma

Symptoms: Abdomen distension • acute abdomen

Medication: —

Clinical Procedure: Exploratory laparotomy

Specialty: Obstetrics and Gynecology

Nonresective treatments for uterine fibroids: a systematic review of uterine and fibroid volume reductions

Patients are increasingly seeking uterus-preserving, minimally invasive treatments for symptomatic uterine fibroids. This has led to a greater use of nonresective treatments such as uterine artery embolization (UAE), focused ultrasound (FUS) and more recently, radiofrequency ablation (RFA) of fibroids. This systematic review, following PRISMA guidelines, examines the change in uterine and fibroid volumes associated with UAE, FUS, and RFA. Pubmed and MedlinePlus databases were searched from 1956 to 2016. The keywords used were 'radiofrequency ablation,' 'magnetic resonance guided focused ultrasound,' 'ultrasound guided focused ultrasound', 'uterine artery embolization,' 'uterine fibroid embolization,' and 'leiomyoma' or 'fibroid'. Publications with at least 20 patients were included. Data were collected and analyzed using Microsoft Excel^® (Microsoft Corporation, Redmond, WA) software. Eighty-one relevant papers were identified: 52 related to UAE, 11 to RFA, 17 to FUS, 1 compared UAE and FUS. We report the published uterine volume and fibroid volume changes seen in these studies at 1 to 36 months. The pooled fibroid volume reductions at six months seen with RFA were 70%, UAE 54% and FUS 32%. All three types of nonresective treatment result in fibroid volume reduction. However, fibroid volume reduction is most marked with RFA, with UAE resulting in the next most volume reduction. Additional larger cohort studies, including those that are randomized and/or comparative, would enable definitive conclusions. This is the first systematic review comparing uterine and fibroid volume reduction after RFA, UAE and MRgFUS.

Successful pregnancy after uterine artery embolization for uterine arterovenous malformation: a rare case report

Objective

This paper reports on a rare case of pregnancy after uterine artery embolization (UAE) for uterine arteriovenous malformation (AVM). Debate exists about persistence of fertility in women after UAE. Adverse effects of this technique can modify both uterine echostructure, inducing necrosis and infarction, endometrial atrophy and uterine artery rupture, and ovarian reserve, causing persistent amenorrhea. Ovarian reserve appears to be affected by UAE in pre-menopausal women. However, younger ovaries (according to biological ovarian age) exhibit a greater capacity for recovery after ovarian damage. Therefore, larger studies are needed for more conclusive results.

Case report

A 28-year-old woman was admitted to our department due to life-threatening uterine bleeding, resulting in tachycardia, pallor, and sweating. The patient came with a history of two spontaneous miscarriages. After sonography and computed tomography, AVMs were identified at uterine fundus and anterior wall.

Conclusion

The pathogenesis of infertility after UAE is not yet known. The peculiarity of this case was that, only few months later, the patient became pregnant and gave birth to a live fetus at 37 weeks with cesarean delivery.

A Patient Registry for the Management of Uterine Fibroids in Canada: Protocol for a Multicenter, Prospective, Noninterventional Study

BACKGROUND

Uterine fibroids are the most common benign tumor in women. Among those with fibroids, approximately 30% become symptomatic, with abnormal uterine bleeding, pelvic pain, and bulk symptoms. Despite the high prevalence of fibroids, little information is available regarding symptoms, treatment choices, and outcomes for patients.

OBJECTIVE

A Canada-wide patient registry was established to understand the real-world practice. This registry included patient presentation and treatment preferences, health care provider attitudes, and clinical outcomes in the management of symptomatic uterine fibroids.

METHODS

This study is a prospective, noninterventional, observational patient registry. It will include women diagnosed with uterine fibroids and being managed for symptoms. Participant inclusion criteria were (1) at least 18 years of age, (2) premenopausal with a confirmed diagnosis of uterine fibroids, and associated symptoms, and (3) initiating treatment (drug intervention, procedure intervention, or a combination of both) or watchful waiting. Patients (or legal representative) must understand the nature of the project and provide written informed consent before enrollment. Participant exclusion criteria were (1) they have known or suspected clinically significant pelvic pathology not associated with uterine fibroids, and (2) they are undergoing an emergency hysterectomy at the initial visit. Outcomes will be evaluated in the context of routine clinical practice.

RESULTS

Participant recruitment of this registry began in July 2015. This study currently has a total sample of 1500 patients.

CONCLUSIONS

This registry, a first in Canada, will accumulate evidence on the risks and benefits of watchful waiting, and medical and procedural interventions. It will contribute to enhancing access to treatment options for patients.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02580578; https://clinicaltrials.gov/ct2/show/NCT02580578 (Archived by WebCite at http://www.webcitation.org/6yax4Hpvr).

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR1-10.2196/10926.

Factors influencing the difficulty of laparoscopic myomectomy: the development of a surgical rating tool

Objective To obtain expert consensus on the patient and fibroid characteristics that affect the complexity of laparoscopic myomectomy (LM) and to use these factors to create a grading tool for objective evaluation of LM procedures. Study design Modified Delphi Methodology Study (Canadian Task Force III). Setting included a series of online surveys via SurveyMonkey (SurveyMonkey Inc., San Mateo, California, USA). Participants were Canadian minimally invasive gynecologic surgeons (MIGS) who perform LM. A list consisting of patient, uterine and procedural characteristics was disseminated to Canadian MIGS. Opportunity to include additional factors was provided. Consensus was predefined as Cronbach's α of ≥0.80. A second Delphi survey was then done to assign weight value for each item in the grading tool. Results Twenty-seven surgeons from across Canada participated. Most (23/27, 85%) were MIGS fellowship trained, and performed more than 6 LM per year (18/27, 66.7%). Consensus was achieved in the first round of the survey (Cronbach's α = 0.93). Sixteen of 27 factors met the criteria for inclusion (>80% respondents agreed or strongly agreed) and were included in the final rating tool. Factors that met the criteria for inclusion were grouped as patient factors (including body mass index), uterine factors (including number of fibroids, size of largest fibroid), and surgical factors (including ease of developing the cleavage plane). Conclusions Using the Delphi methodology to obtain expert consensus on the factors influencing the difficulty of LM, we have developed an objective grading tool to evaluate the degree of technical complexity of LM.

The Effectiveness of Tranexamic Acid at Reducing Blood Loss and Transfusion Requirement for Women Undergoing Myomectomy: A Systematic Review and Meta-analysis

BACKGROUND

The surgical removal of fibroids can be associated with excessive blood loss requiring transfusion.

OBJECTIVE

This review sought to determine the effectiveness of tranexamic acid (TA) in reducing perioperative blood loss in women undergoing myomectomy.

METHODS

Electronic bibliographic databases were searched from inception until June 3, 2017. The review included RCTs of women of reproductive age with uterine fibroids who were undergoing myomectomy and who received TA or a comparator. Two independent reviewers extracted relevant data, and meta-analysis was performed.

RESULTS

Three studies included women undergoing abdominal myomectomy. TA significantly reduced intraoperative blood loss by a mean difference of 213.1 mL (95% CI -242.4 to -183.7) and postoperative blood loss by a mean difference of 56.3 mL (95% CI -67.8 to -44.8) compared with control arms. However, no significant differences were seen in blood transfusion requirement (relative risk 0.58; 95% CI 0.33-1.00). In one study for women undergoing hysteroscopic myomectomy, TA was not associated with improved outcomes in transfusion requirement and resulted in reduced postoperative hemoglobin levels compared with oxytocin.

CONCLUSION

Among women undergoing abdominal myomectomy, TA is effective at reducing perioperative blood loss compared with no treatment or placebo. For women undergoing hysteroscopic myomectomy, TA compared with oxytocin is not associated with improved outcomes in transfusion requirement and resulted in reduced postoperative hemoglobin levels.

Use of pre-operative imaging for symptomatic uterine myomas during pregnancy: a case report and a systematic literature review

PURPOSE

Uterine fibroids (UFs) occur in 10% of pregnancies and may lead to severe maternal-fetal complications, mainly depending on UFs characteristics and the distance to the uterine cavity (UC). When symptomatic, UFs are managed medically. Nevertheless, in about 2% of cases, surgery becomes necessary. Entry into the UC should be avoided during myomectomy. Consequentially, pre-operative assessment of this risk could be beneficial. Ultrasonography (US) represents the gold standard for UFs assessment; however, scarce evidence has been produced to assess the role of magnetic resonance imaging (MRI). The aim of the present study was to summarize current evidence about the pre-operative use of imaging techniques for UFs during pregnancy.

METHODS

A systematic research of the literature was conducted in Scopus, PubMed/MEDLINE, ScienceDirect and the Cochrane Library, including case reports and case series. A case report was also discussed. We collected data regarding patients, imaging assessment, UFs characteristics, surgical information, timing and modality of delivery.

RESULTS

According to our search strategy, 66 articles were selected and 210 patients were included. US assessment was reported in 36 (17%) cases. MRI was reported in 10 (4.7%) cases. Only in one case, MRI was used to measure the distance between UFs and UC.

CONCLUSION

US allows an adequate pre-operative evaluation of anterior, submucosal or pedunculated symptomatic UFs in pregnancy. However, compared to US, MRI may provide a more accurate evaluation of multiple, large, intramural or posterior UFs and could measure the distance between UFs and UC more accurately.

Five-year clinical outcomes of uterine artery embolization for symptomatic leiomyomas: An analysis of risk factors for reintervention

OBJECTIVES

The objective of this study is to investigate the five-year reintervention rate of uterine artery embolization (UAE) for symptomatic leiomyomas and to identify potential predictive factors of reintervention.

METHODS

From March 2011 to February 2012, 92 consecutive women (mean age 41.9 years, range 28-55 years) underwent bilateral UAE. Contrast-enhanced magnetic resonance imaging (MRI) was performed at three-month follow-up. After annual follow-up, a survey on clinical outcome and reintervention incidences was performed at five-year follow-up. Potential predictive factors of reintervention were evaluated.

RESULTS

Of the 67 patients, menorrhagia and/or bulk-related symptoms were resolved after UAE in all but one patient (98.5%). At median follow-up of 60 months (range, 5-60 months), reintervention rate was 10.4%, with seven reintervention cases (five myomectomy and two hysterectomy cases). Complete (100%) or near complete (90-99%) infarction rate of the dominant leiomyoma was 96.4% (54 of 56). Independent factors of reintervention on multivariate logistics regression analysis included near complete or partial (<90%) infarction of the dominant leiomyoma (odds ratio [OR] 22.238; 95% confidence interval [CI] 2.405-205.620; p = 0.006), as well as the presence of non-dominant viable leiomyomas (OR 12.134; 95% CI 1.213-121.409; p = 0.034).

CONCLUSION

UAE provides excellent and sustained symptom improvement of symptomatic leiomyomas with a low reintervention rate at five-year follow-up. In addition to near complete or partial infarction of the dominant leiomyoma on follow-up MRI, the presence of viable non-dominant leiomyomas indicates a higher risk of reintervention.

Long-term outcome of MR-guided focused ultrasound treatment and laparoscopic myomectomy for symptomatic uterine fibroid tumors

BACKGROUND

Fibroid tumors are the most common benign tumors in women of reproductive age. Treatment is usually indicated for those who are symptomatic, with different techniques being used.

OBJECTIVE

The purpose of this study was to compare the long-term outcome of laparoscopic myomectomy with magnetic resonance-guided focused ultrasound for symptomatic uterine fibroid tumors.

STUDY DESIGN

A cohort study was conducted on all patients with symptomatic uterine fibroid tumors who were admitted to a single tertiary care center and treated operatively with laparoscopic myomectomy or treated conservatively with magnetic resonance-guided focused ultrasound from January 2012 until January 2017. Assessment for further interventions and sustained fibroid-associated symptoms was performed, with the use of the Uterine Fibroid Symptom and Quality of Life symptom severity score.

RESULTS

One hundred fifty-four women met the inclusion criteria. Complete follow-up evaluation was achieved for 64 women who underwent laparoscopic myomectomy and for 68 women who were treated by magnetic resonance-guided focused ultrasound. Follow-up time was similar for the 2 groups (median, 31 months [interquartile range, 17-51 months] vs 36 months [interquartile range, 24-41]; P=.95). The rate of additional interventions was 5 (7.8%) and 9 (13.2%), respectively (P=0.312). Similarly, the Uterine Fibroid Symptom and Quality of Life symptom severity score questionnaire score at follow-up interviews revealed comparable median scores of 17 (interquartile range, 12-21) vs 17 (interquartile range, 13-22) for laparoscopic myomectomy and magnetic resonance-guided focused ultrasound, respectively (P=.439). Analysis of each of the symptoms separately (bleeding, changes in menstruation, abdominal pain, bladder activity, nocturia, fatigue) did not change these findings, nor did a multivariate analysis.

CONCLUSION

Satisfaction with long-term outcome and rate of reinterventions after magnetic resonance-guided focused ultrasound treatment or laparoscopic myomectomy for uterine fibroid tumors was comparable. Further larger randomized trials are needed to confirm these findings.

Reintervention Rates After Myomectomy, Endometrial Ablation, and Uterine Artery Embolization for Patients with Uterine Fibroids

Background: Women with uterine fibroids (UF) may undergo less invasive procedures than hysterectomy, including myomectomy, endometrial ablation (EA), and uterine artery embolization (UAE); however, long-term need for reintervention is not well characterized. We estimated reintervention rates for 5 years and identified predictors of reintervention.

Materials and Methods: A longitudinal retrospective cohort study was conducted in women in MarketScan^® Commercial Claims and Encounters (Truven Health Analytics) aged 18–49 years with UF diagnosis before myomectomy, EA, or UAE from 2008 to 2014. Patients were categorized by initial procedure (index date) and required to have ≥12 months of continuous coverage before and after. Kaplan–Meier analyses and Cox proportional hazard models were used to estimate survival without reintervention and hazard of reintervention for 5 years.

Results: The study included 35,631 women with myomectomy (n = 13,804: 8,018 abdominal, 941 hysteroscopic, and 4,845 laparoscopic), EA (n = 17,198), and UAE (n = 4,629). Myomectomy had the lowest 12-month reintervention rate (4.2%), followed by UAE (7.0%), then EA (12.4%; both p < 0.001 relative of myomectomy). Estimates of 5-year reintervention rates were 19% for myomectomy (17%, 28%, and 20% for abdominal, hysteroscopic, and laparoscopic, respectively), 33% for EA, and 24% for UAE. EA and UAE had adjusted hazard ratios of 2.63 (95% confidence interval [CI], 2.44–2.83) and 1.56 (95% CI, 1.42–1.72). Prior anemia, bleeding, pelvic inflammatory disease, and abdominal and pelvic pain increased the hazard of reintervention.

Conclusion: Reintervention rate estimates ranged from 17% to 33% for 5 years after myomectomy, EA, and UAE for patients with UF. Risk of requiring reintervention should be considered during treatment selection.

Alternatives to excisional therapy: a clinical review of our current options to conservatively manage symptomatic leiomyomas

PURPOSE OF REVIEW

This article provides a clinical review of the alternatives to traditional excisional surgical therapies for uterine leiomyomas, such as myomectomy or hysterectomy.

RECENT FINDINGS

In this review, currently available hormonal medications will be briefly discussed. Then, nonhormonal medical therapy will be addressed with respect to mechanism of action, safety, and efficacy. Finally, the risk-benefit profile of nonexcisional procedures for management of leiomyomas will be addressed.

SUMMARY

This provides an update on the information available for more conservative options for symptomatic leiomyoma management.

Unplanned hysterectomy following myomectomy at a tertiary institution: A case series and review of the literature

Introduction:

Myomectomy is the gold standard uterine-sparing treatment for fibroids. However, the procedure is often complicated by blood loss. In rare cases, haemorrhage may be so severe that a conversion to hysterectomy is warranted. The aim of our study was to investigate the rates of and the clinical reasoning behind unplanned hysterectomies following attempted myomectomies at our institution.

Methods:

All patients who underwent an open or laparoscopic myomectomy at the Royal Women’s Hospital were identified using a gynaecology unit database, maintained from January 2004 to December 2013. Records for patients whose surgeries were unexpectedly converted to a hysterectomy were examined. A review of the literature was also performed, investigating the rates of unplanned hysterectomies following myomectomies.

Results:

Of the 1501 myomectomies performed, six resulted in an unplanned hysterectomy; an incidence rate of 0.4%. Fibroids were either intramural or pedunculated with the median number of tumours per patient being 2.5 (interquartile range: 1–6). The largest tumour for each patient varied significantly from 4.0 × 3.2 cm to 29.0 × 25.0 cm. In all cases, despite being strongly advised to have a planned hysterectomy, patients insisted on having a myomectomy. Two patients underwent conversion to hysterectomy intraoperatively while the remainder required a return to theatre. Difficulty achieving intraoperative haemostasis (n = 2), and the development of postoperative bleeding and coagulopathy (n = 4) were reasons cited for proceeding to hysterectomy.

Conclusion:

The rate of conversion from myomectomy to hysterectomy at our institution was low at 0.4%. In all cases, the reason for conversion was difficulty with haemostasis, despite infrequent use of haemostatic agents, and coagulopathy.

Selective progesterone receptor modulators for fertility preservation in women with symptomatic uterine fibroids

Uterine fibroids (UFs, AKA leiomyoma) are the most important benign neoplastic threat to women's health, with costs up to hundreds of billions of health care dollars worldwide. Uterine fibroids caused morbidities exert a tremendous health toll, impacting the quality of life of women of all ethnicities, especially women of color. Clinical presentations include heavy vaginal bleeding, pelvic pain, bulk symptoms, subfertility, and obstetric complications. Current management strategies heavily lean toward surgical procedures; nonetheless, the choice of treatment is generally subject to patient's age and her desire to preserve future fertility. Women with UF who desire to maintain future fertility potential face a dilemma because of the limited treatment choices that are currently available to help them achieve that goal. Recently, ulipristal acetate the first of the promising family of oral selective progesterone receptor modulators has been approved for UF treatment in Europe, Canada, and several other countries and is under review for possible approval in the USA. In this review article, we discuss recent advances in the management options against UF with a bend toward oral effective long-term treatment alternatives who are particularly suited for those seeking to preserve their future fertility potential. We also explore the transformative concept of primary and secondary UF prevention using these new anti-UF agents. We envision a remarkable shift in the management of UF in future years from surgical/invasive treatment to orally administrated options; clearly, this potential shift will require additional intense clinical research.

Selective Progesterone Receptor Modulators for the Medical Treatment of Uterine Fibroids with a Focus on Ulipristal Acetate

Uterine fibroids are the most frequent benign tumours in women of child-bearing age. Their symptoms are diverse and the quality of life of the women affected can be significantly impaired. While treatment to date has been primarily by means of surgical intervention, selective progesterone receptor modulators (SPRMs) open up new medication-based treatment options. EMA's Pharmacovigilance Risk Assessment Committee (PRAC) has recently completed its review of ESMYA® (ulipristal acetate, 5 mg), following reports of serious liver injury, including liver failure leading to transplantation in postmarketing settings. We will provide some information on the PRAC's recommendations to minimize this risk. Nevertheless, the effectiveness and safety of the SPRM ulipristal acetate (UPA), both with regard to preoperative administration and with regard to an intermittent administration as long-term treatment for patients with symptomatic uterine fibroids, have been shown in several clinical studies (PEARL I-IV).

The past, present, and future of selective progesterone receptor modulators in the management of uterine fibroids

Uterine fibroids are common in women of reproductive age and can have a significant impact on quality of life and fertility. Although a number of international obstetrics/gynecology societies have issued evidence-based clinical practice guidelines for the management of symptomatic uterine fibroids, many of these guidelines do not yet reflect the most recent clinical evidence and approved indication for one of the key medical management options: the selective progesterone receptor modulator class. This article aims to share the clinical experience gained with selective progesterone receptor modulators in Europe and Canada by reviewing the historical development of selective progesterone receptor modulators, current best practices for selective progesterone receptor modulator use based on available data, and potential future uses for selective progesterone receptor modulators in uterine fibroids and other gynecologic conditions.

Changes in Hysterectomy Route and Adnexal Removal for Benign Disease in Australia 2001-2015: A National Population-Based Study

Objective

Hysterectomy rates have fallen over recent years and there remains debate whether salpingectomy should be performed to reduce the lifetime risk of ovarian cancer. We examined trends in adnexal removal and route of hysterectomy in Australia between 2001 and 2015.

Methods

Data were obtained from the national procedural dataset for hysterectomy approach (vaginal, VH; abdominal, AH; and, laparoscopic, LH) and rates of adnexal removal, as well as endometrial ablation. The total female population in two age groups (“younger age group,” 35 to 54 years, and “older age group,” 55 to 74 years) was obtained from the Australian Bureau of Statistics.

Results

The rate of hysterectomy fell in both younger (61.7 versus 45.2/10000/year, p < 0.005) and older (38.8 versus 33.2/10000/year, p < 0.005) age groups. In both age groups there were significant decreases in the incidence rates for VH (by 53% in the younger age group and 29% in the older age group) and AH (by 53% and 55%, respectively). The rates of LH increased by 153% in the younger age group and 307% in the older age group. Overall, the proportion of hysterectomies involving adnexal removal increased (31% versus 65% in the younger age group, p < 0.005; 44% versus 58% in the older age group, p < 0.005). The increase occurred almost entirely after 2011.

Conclusion

Hysterectomy is becoming less common, and both vaginal and abdominal hysterectomy are being replaced by laparoscopic hysterectomy. Removal of the adnexae is now more common in younger women.

[The molecular mechanisms and morphological manifestations of leiomyoma reduction induced by selective progesterone receptor modulators]

AIM

to investigate the molecular mechanisms and morphological substrate of reduced uterine leiomyoma in patients receiving the selective progesterone receptor modulator (SPRM) ulipristal acetate for 3 months, by estimating the immunohistochemical expression of the markers steroid receptor coactivator 1 (SRC-1), nuclear receptor corepressor 1 (NCoR-1), ER, PgR, Ki-67, p16, TGF-β, and VEGF in tumor tissue.

SUBJECTS AND METHODS

The investigation enrolled 75 women with uterine leiomyoma, menorrhagias, and anemia. Group 1 included 40 patients who were treated with ulipristal for 3 months, followed by laparoscopic myomectomy. Group 2 consisted of 35 patients who underwent surgery without previous preparation. The intra- and postoperative parameters and molecular and morphological changes in the myomatous nodules were comparatively analyzed in both groups.

RESULTS

After 3 months of therapy initiation, menorrhagia completely ceased, myomatous nodules decreased in size (p<0.05), hemoglobin levels were elevated (p<0.01), and total intraoperative blood loss and operative time decreased in all the patients in Group 1. The morphological substrate of partial leiomyoma reduction was leiomyocyte apoptosis and dystrophy, tumor stroma sclerosis and hyalinosis with diminished Ki-67 expression and elevated p16 in the smooth muscle cells, trophic nodular tissue disorders exhibited by vascular wall sclerosis and lower VEGF and TGF-β expression, and leiomyocyte hormonal reception dysregulation that made itself evident through the reduced expression of SRC-1 with the unchanged expression of PR and ER and the maintained level of NCoR-1.

CONCLUSION

The molecular mechanisms of tumor reduction involved the reduced Ki-67 expression and elevated p16, lower VEGF and TGF-β, diminished SRC-1 expression with the maintained level of PR, ER, and NCoR-1. Overall, this is suggestive of enhanced apoptosis and reduced leiomyoma proliferation and angiogenesis induced by SPRM and indicative of the expediency of using ulipristal acetate as a preoperative agent for organ-sparing surgery in reproductive-aged patients with uterine myoma, menorrhagias, and anemia.