Interventions to reduce haemorrhage during myomectomy for fibroids

The impact of bilateral transient occlusion of uterine and utero-ovarian arteries on surgical blood loss during laparoscopic myomectomy: A systematic review and meta-analysis of randomized controlled trials

BACKGROUND

The primary perioperative concern during laparoscopic myomectomy is the risk of significant intraoperative blood loss, which can lead to hypovolemia, necessitate blood transfusion, and result in postoperative anemia. To address this issue, we conducted a systematic review and meta-analysis to assess the impact of temporarily clamping the uterine and utero-ovarian arteries on operative blood loss during laparoscopic myomectomy.

METHODS

We conducted a comprehensive search across various databases to identify eligible clinical trials from inception to May 2024, focusing on randomized controlled trials (RCTs). In the intervention group, temporary bilateral clamping of the uterine and utero-ovarian arteries was performed during laparoscopic myomectomy, while the control group underwent laparoscopic myomectomy without arterial clamping. A meta-analysis was carried out on the gathered data using Revman software. The primary outcomes examined were blood loss and change in hemoglobin, with secondary outcomes including operation time and length of hospital stay.

RESULTS

Three RCTs, involving a total of 275 patients, met our inclusion criteria. The intervention group showed significantly lower operative blood loss and a smaller reduction in hemoglobin compared to the control group. There was no notable difference in operation time between the two groups. Moreover, patients in the experimental group experienced a significantly shorter hospitalization duration than those in the control group.

CONCLUSIONS

The temporary bilateral occlusion of the uterine and utero-ovarian arteries is an effective method for reducing surgical blood loss, hemoglobin decline, and hospital stay duration during laparoscopic myomectomy. However, additional studies are needed to validate these findings.

Comparison of different types of single-port laparoscopic surgery in posterior uterine fibroid resection

This study aims to objectively assess the effect of three surgical approaches for posterior uterine fibroid resection: transumbilical laparoendoscopic single-site surgery (LESS), vaginal natural orifice transluminal endoscopic surgery (vNOTES) in prone position (vNOTES-P), and vNOTES in the lithotomy position (vNOTES-L). A retrospective analysis was conducted on data pertaining to all patients who underwent vNOTES and LESS for single posterior fibroids at our institution from January 2023 to July 2023. Patients were categorized into three groups based on the surgical approach: vNOTES-P group (n = 30), vNOTES-L group (n = 17), and LESS group (n = 32). Comparative analysis was performed on the demographic characteristics and perioperative outcomes among the three groups of patients. All 79 patients underwent surgery without the need for conversion to laparotomy. There were no statistically significant differences among the LESS group, vNOTES-P group, and vNOTES-L group in terms of operative time, intraoperative blood loss, and perioperative complication rates. In the vNOTES-L group, two patients required conversion to LESS during surgery. Patients had faster return of bowel function (less time to flatus) in the vNOTES group compared to the LESS group (P < 0.05). However, three cases of postoperative infection occurred in the vNOTES group, while none were reported in the LESS group. Compared to LESS, vNOTES demonstrates significant advantages in alleviating postoperative pain, shortening time to passage of flatus, speeding recovery and enhancing cosmetic outcomes. Particularly, vNOTES-P for posterior uterine fibroid resection, as an emerging surgical approach, offers certain advantages in facilitating surgical maneuverability and reducing operative time, rendering it more suitable for posterior uterine fibroid resection.

Effectiveness of the use of intravenous tranexamic acid and pericervical tourniquet in decreasing peri-operative blood loss following open abdominal myomectomy:A randomized controlled trial

Background

Uterine fibroid is the most common gynaecological tumour, with a prevalence of 20% to 50% of women over 30years.Abnormal uterine bleeding is one of the most common modes of presentation with menorrhagia. Open abdominal myomectomy is the most common treatment option in our environment. It is associated with a significant degree of blood loss, with consequent blood transfusion. Thus, the need for interventions to reduce blood loss during the procedure. This study assessed the effectiveness of intravenous tranexamic acid in reducing blood loss when used as an adjunct to peri-cervical tourniquet during open abdominal myomectomy.

Methodology

This study was conducted at Barau Dikko Teaching Hospital, Kaduna. It comprised thirty-six consenting patients scheduled for elective open abdominal myomectomy, randomly assigned to receive either intravenous tranexamic acid or placebo immediately after securing intravenous access in the theatre. All the patients had a peri-cervical tourniquet applied intraoperatively. The volume of intraoperative blood loss, blood transfusion rate and the total number of units transfused, haemodynamic changes associated with blood loss, and the complications associated with the use of tranexamic acid were evaluated during the first 72hours following the surgery.

Results

A total of thirty-six women who met the eligibility criteria were studied between June 2023 and December 2023. The mean age of the participants in the tranexamic acid group was 37.82 ± 5.89 years and 39.74 ± 5.17 years in the placebo group (p = 0.307). Most of the women 35 (97.2%) presented with symptoms of menorrhagia. Major blood loss > 1000 ml was recorded more among women in the placebo group than those who received tranexamic acid. There was a statistically significant reduction in the mean blood loss in the tranexamic acid group 947.65 ± 451.88 compared to 1320.53 ± 563.28. (p 0.037).There was an increase in the number of women who received a blood transfusion in the placebo group 7 (36.8%) compared to the tranexamic acid group 4 (23.5%) (p=0.387). Tranexamic acid resulted in a decrease in the risk of perioperative blood loss by 30%, RR 0.7 95% CI (2.19-2.59) and packed cell volume was significantly lower in the control group postoperatively (P value = .001). There was no significant side effect noticed in both groups.

Conclusion

Tranexamic acid reduces blood loss during and after myomectomy for patients with uterine fibroids and the need for blood transfusion is reduced in patients who had intravenous tranexamic acid as an adjunct to the application of a tourniquet.

Triple vs. single uterine tourniquet to reduce hemorrhage at myomectomy: a randomized trial

PURPOSE

This study aimed to compare the effect of triple uterine tourniquet and single tourniquet on intraoperative blood loss during open myomectomy.

METHODS

Women were randomized to undergo open myomectomy with a triple (n = 30) or single uterine tourniquet (n = 30). All symptomatic women aged 18-48 who had three or more myomas or at least one myoma greater than 8 cm if there were less than three myomas were eligible for the study. The primary outcome variable was the volume of intraoperative blood loss. The sample size was set to detect a 240 ml difference in blood loss with 80% power at α = 0.05, with an effect size of 0.8. The rate of transfusions, change in hemoglobin, volume of drains, operation time, tourniquet time, and perioperative complications were secondary outcomes.

RESULTS

We found no significant difference in intraoperative blood loss between triple and single uterine tourniquets (527 [102-2931]) ml vs. 508 [172-2764] ml, p = 0.238). Between the single and triple tourniquet groups, the median weight of myoma (379 [136-3850] vs. 330 [140-1636] g, p = 0.451) and median number (1 [1-18] vs. 2 (1-13), p = 0.214), total operation time (84 ± 31 min vs. 79 ± 27 min, p = 0.503), ischemia time (35 ± 21 min vs. 30 ± 14 min., p = 0.238), drain volume at 48th hour (196 ± 89)ml vs. 243 ± 148 ml, p = 0.144) and decrease in hemoglobin (2.3 ± 1.8 g/dl vs. 2.8 ± 1.4 g/dl, p = 0.437) were similar. Eight (27%) patients in the triple tourniquet group and 12 (40%) patients in the single tourniquet group were transfused (p = 0.273). One patient underwent hysterectomy 6-8 h after myomectomy in a single tourniquet group.

CONCLUSION

There was no clinically significant difference in intraoperative blood loss between triple and single uterine tourniquets during open myomectomy.

CLINICAL TRIAL REGISTRATION NUMBER AND DATE OF REGISTRATION

ClinicalTrials.gov ID: NCT02392585, 03/13/2015.

The Hangman's Tourniquet: A Safe and Practical Approach for Reducing Blood Loss During Uterine Myomectomy

STUDY OBJECTIVES

The application of a pericervical uterine artery tourniquet is a useful method of reducing intraoperative haemorrhage during abdominal myomectomy. However, the utilization of a single combined pericervical uterine artery and infundibulopelvic ligament tourniquet is a more effective and influential method of temporarily occluding the uterine vasculature to decrease intraoperative blood loss, reducing the requirement for blood products, the risk of conversion to hysterectomy, and patient morbidity and mortality during fertility-sparing leiomyoma surgery. Our objective of this retrospective review was to assess the effectiveness of the combined uterine artery and infundibulopelvic ligament tourniquet, which we coin as the "Hangman's uterine tourniquet", in reducing intraoperative blood loss during abdominal myomectomy, thereby reducing the need for blood products.

METHODS

This retrospective study included 39 patients diagnosed with symptomatic subserosal, intramural, and/or submucosal uterine leiomyoma (>3 cm) who underwent an abdominal myomectomy between January 2021 and December 2022.

RESULTS

Thirty-nine patients met the eligibility criteria for our study. The average patient age included in our study was 36 years. All myomectomies were completed with a mean intraoperative blood loss of 252.60 ml and the average number of fibroids removed was seven. The largest fibroid removed measured 27 x 20 cm in diameter while the most significant number of fibroids removed was 41. Moreover, the mean duration of the tourniquet application was 45.31 minutes, and the mean duration of operation was 80.44 minutes. Thirty-six patients (92.3%) had an estimated blood loss <500 ml. The number of fibroids removed was a statistically significant risk factor influencing estimated blood loss (p = 0.019). However, there was no statistical significance between estimated blood loss and the size of the largest fibroid removed (p = 0.178) nor estimated blood loss and a history of previous surgery (p = 0.412). The postoperative blood transfusion rate was 2.5% and no patients suffered grade III or higher surgical complications according to the Clavien-Dindo classification.

CONCLUSION

This study showed that the utilization of a temporary intraoperative combined pericervical uterine artery and infundibulopelvic ligament tourniquet is an effective, practical, and economical approach to limiting intraoperative blood loss during abdominal myomectomy.

Tranexamic acid for percutaneous nephrolithotomy

BACKGROUND

Percutaneous nephrolithotomy (PCNL) is the gold standard for the treatment of large kidney stones but comes with an increased risk of bleeding compared to other treatments, such as ureteroscopy and shock wave lithotripsy. Tranexamic acid (TXA) is an antifibrinolytic agent that has been used to reduce bleeding complications in other settings.

OBJECTIVES

To assess the effects of TXA in individuals with kidney stones undergoing PCNL.

SEARCH METHODS

We performed a comprehensive literature search of the Cochrane Library, PubMed (including MEDLINE), Embase, Scopus, Global Index Medicus, trials registries, other sources of the grey literature, and conference proceedings. We applied no restrictions on the language of publication nor publication status. The latest search date was 11 May 2023.

SELECTION CRITERIA

We included randomized controlled trials (RCTs) that compared treatment with PCNL with administration of TXA to placebo (or no TXA) for patients ≥ 18 years old.

DATA COLLECTION AND ANALYSIS

Two review authors independently classified studies and abstracted data. Primary outcomes were: blood transfusion, stone-free rate (SFR), and thromboembolic events (TEEs). Secondary outcomes were: adverse events (AEs), secondary interventions, major surgical complications, minor surgical complications, unplanned hospitalizations or readmissions, and hospital length of stay (LOS). We performed statistical analyzes using a random-effects model. We rated the certainty of evidence (CoE) according to the GRADE approach using a minimally contextualized approach with predefined thresholds for minimally clinically important differences (MCIDs).

MAIN RESULTS

We analyzed 10 RCTs assessing the effect of systemic TXA in PCNL versus placebo (or no TXA) with 1883 randomized participants. Eight studies were published as full text. One was published in abstract proceedings, but it was separated into two separate studies for the purpose of our analyzes. Average stone surface area ranged 3.45 to 6.62 cm2. We also found a single RCT published in full text assessing the effects of topical TXA in PCNL versus placebo (or no TXA) with 400 randomized participants, the results of which are further described in the review. Here we focus only on the results of TXA used systemically. Blood transfusion - Based on a representative baseline risk of 5.7% for blood transfusions taken from a large presentative observational studies, systemic TXA may reduce blood transfusions (risk ratio (RR) 0.45, 95% confidence interval (CI) 0.27 to 0.76; I2 = 28%; 9 studies, 1353 participants; low CoE). We assumed an MCID of ≥ 2%. Based on 57 participants per 1000 with placebo (or no TXA) being transfused, this corresponds to 31 fewer (from 42 fewer to 14 fewer) participants being transfused per 1000. Stone-free rate - Based on a representative baseline risk of 75.7% for SFR, systemic TXA may increase SFRs (RR 1.11, 95% CI 0.98 to 1.27; I2 = 62%; 4 studies, 603 participants; low CoE). We assumed an MCID of ≥ 5%. Based on 757 participants per 1000 being stone free with placebo (or no TXA), this corresponds to 83 more (from 15 fewer to 204 more) stone-free participants per 1000. Thromboembolic events - There is probably no difference in TEEs (risk difference (RD) 0.00, 95% CI -0.01 to 0.01; I2 = 0%; 6 studies, 841 participants; moderate CoE). We assumed an MCID of ≥ 2%. Since there were no thromboembolic events in intervention and/or control groups in 5 out of6 studies, we opted to assess a risk difference with systemic TXA for this outcome. Adverse events - Systemic TXA may increase AEs (RR 5.22, 95% CI 0.52 to 52.72; I2 = 75%; 4 studies, 602 participants; low CoE). We assumed an MCID of ≥ 5%. Based on 23 participants per 1000 with placebo (or no TXA) having an adverse event, this corresponds to 98 more (from 11 fewer to 1000 more) participants with adverse events per 1000. Secondary interventions - Systemic TXA may have little to no effect on secondary interventions (RR 1.15, 95% CI 0.84 to 1.57; I2 = 0%; 2 studies, 319 participants; low CoE). We assumed an MCID of ≥ 5%. Based on 278 participants per 1000 with placebo (or no TXA) having a secondary intervention, this corresponds to 42 more (from 44 fewer to 158 more) participants with secondary interventions per 1000. Major surgical complications - Based on a representative baseline risk for major surgical complications of 4.1%, systemic TXA may reduce major surgical complications (RR 0.36, 95% CI 0.21 to 0.62; I2 = 0%; 5 studies, 733 participants; moderate CoE). We assumed an MCID of ≥ 2%. Based on 41 participants per 1000 with placebo (or no TXA) having a major surgical complication, this corresponds to 26 fewer (from 32 fewer to 16 fewer) participants with major surgical complications per 1000. Minor surgical complications - Systemic TXA may reduce minor surgical complications (RR 0.71, 95% CI 0.45 to 1.10; I2 = 76%; 5 studies, 733 participants; low CoE). We assumed an MCID of ≥ 5%. Based on 396 participants per 1000 with placebo (or no TXA) having a minor surgical complication, this corresponds to 115 fewer (from 218 fewer to 40 more) participants with minor surgical complications per 1000. Unplanned hospitalizations or readmissions - We are very uncertain how unplanned hospitalizations or readmissions are affected (RR 1.55, 95% CI 0.45 to 5.31; I2 = not applicable; 1 study, 189 participants; very low CoE). We assumed an MCID of ≥ 2%. Hospital length of stay - Systemic TXA may reduce hospital LOS (mean difference 0.52 days lower, 95% CI 0.93 lower to 0.11 lower; I2 = 98%; 7 studies, 1151 participants; low CoE). We assumed an MCID of ≥ 0.5 days.

AUTHORS' CONCLUSIONS

Based on 10 RCTs with substantial methodological limitations that lowered all CoE of effect, we found that systemic TXA in PCNL may reduce blood transfusions, major and minor surgical complications, and hospital LOS, as well as improve SFRs; however, it may increase AEs. We are uncertain about the effects of systemic TXA on other outcomes. Findings of this review should assist urologists and their patients in making informed decisions about the use of TXA in the setting of PCNL.

Minimizing blood loss in laparoscopic myomectomy with temporary occlusion of the hypogastric artery

Introduction

Uterine leiomyomas are common benign pelvic tumors. Currently, laparoscopic myomectomy (LM) is the preferred treatment option for women in the fertile age group with symptomatic myomas. The authors hypothesize that combining LM with a bilateral temporary occlusion of the hypogastric artery (TOHA) using vascular clips minimizes uterine blood flow during surgery and can significantly reduce surgery-associated blood loss.

Materials and methods

This single-center, prospective randomized study was conducted at the Department of Obstetrics and Gynecology, Municipal Emergency Clinical Hospital Timisoara, Romania. Patients aged between 18 and 49 who preferred laparoscopic myomectomy and wished to preserve fertility were included, provided they had intramural uterine leiomyomas larger than 4 cm in diameter that deformed the uterine cavity. The study analyzed data from 60 laparoscopic myomectomies performed by a single surgeon between January 2018 and December 2020. Patients were randomly assigned to either: "LM + TOHA" group (29 patients), and "LM" group (31 patients). The study's main objective was to evaluate the impact of TOHA on perioperative blood loss, expressed as mean differences in Hb (delta Hb).

Results

Delta Hb was statistically lower in the "LM + TOHA" group compared to "LM" group, with mean ± standard (min-max): 1.68 ± 0.67 (0.39-3.99) vs. 2.63 ± 1.06 (0.83-4.92) g/dL, respectively (p < 0.001). There was a statistically significant higher need for postoperative iron perfusion in the "LM" group, specifically 0 vs. 12 patients (p < 0.001), and lower postoperative anemia in "LM + TOHA" group (p < 0.001). Necessary artery clipping time was 10.62 ± 2.47 (7-15) minutes, with no significant impact on overall operative time: 110.2 ± 13.65 vs. 106.3 ± 16.48 (p = 0.21). There was no difference in the length of hospitalization or 12-month post-intervention fertility.

Discussion

Performing bilateral TOHA prior to laparoscopic myomectomy has proven to be a valuable technique in reducing surgery-associated blood loss, while minimizing complications during surgery, with no significant increase in the overall operative time.

Clinical trial registration

ISRCTN registry, (www.isrctn.com), identifier ISRCTN66897343.

Integrating Spatial Transcriptomics and Single-nucleus RNA Sequencing Reveals the Potential Therapeutic Strategies for Uterine Leiomyoma

Uterine leiomyoma is the most common gynecological tumor in reproductive women. Tumor-host interface is a complex ecosystem with intimate cell-cell communications and a critical scenario for tumor pathogenesis and progression. The pseudocapsule is the main tumor-host interface of uterine leiomyoma, but its cellular spatial disposition and gene expression are poorly explored. This study mapped the cellular architecture and corresponding gene profiles of the leiomyoma and its surrounding pseudocapsule by integrating spatial transcriptomics and single-nucleus RNA-sequencing at the first time. Here, we reported that estrogen receptor alpha and progesterone receptor mediated the occurrence and development of uterine leiomyoma and that estrogen receptor beta involved in the angiogenesis, which explained the effectiveness of hormonotherapy. Therapeutic targets including ERK1/ERK2 pathway and IGF1-IGF1R were found and might be applied for non-hormonal therapy of uterine leiomyoma. Furthermore, the injection of prostaglandin E2 was initially presented for bleeding control during myomectomy, injection site should be located at the junction between pseudocapsule and leiomyoma, and surrounding pseudocapsule should not be eliminated. Collectively, a single-cell and spatially resolved atlas of human uterine leiomyoma and its surrounding pseudocapsule was established. The results revealed potentially feasible strategies for hormonotherapy, non-hormonal targeted therapy and bleeding control during myomectomy.

Validation of uterine artery embolization before surgical laparoscopic myomenucleation compared to single surgical laparoscopic myomenucleation for the treatment of large fibroids and uterus myomatosus

Aim

To determine the efficacy of preoperative uterine artery embolization (uterine artery embolization; UAE) prior to elective laparoscopic fibroid removal compared to single laparoscopic fibroid removal in women with large uterine fibroids and women with uterus myomatosus.

Material and methods

A total of 202 women with symptomatic uterine fibroids who were scheduled for elective fibroid enucleation were included in this retrospective, monocentric, non-randomized study. Two procedures were compared: women who received percutaneous UAE 24 h prior to elective laparoscopic fibroid eviction for large uterine fibroids (>6 cm) and uterus myomatosus. And women who received laparoscopic fibroid enucleation alone for large uterine fibroids and uterus myomatosus. Outcome parameters for effectiveness were the hospital stay, the operating time and the intraoperative blood loss.

Results

Women who underwent preoperative percutaneous embolization of the uterine arteries, both for large fibroids and uterus myomatosus, had significantly less blood loss, shorter hospital stays, and shorter operating times.

Conclusions

Especially women with large uterine fibroids and women with uterus myomatosus after having children can benefit from the combination therapy of preoperative percutaneous uterine embolization with subsequent laparoscopic myoma enucleation.

Laparoscopic myomectomy - The importance of surgical techniques

Laparoscopy is a routine procedure for benign gynecological tumors. Although the laparoscopic approach for myomas is a common procedure, it can be challenging. To improve outcomes, research regarding port access, suture type, morcellation, and complication management remains ongoing. Myomectomy is the main surgical option for patients seeking uterus-sparing procedures to maintain future fertility. The laparoscopic technique is the most important in these cases, given that possible complications can impact fertility and pregnancy outcomes. Herein, we reviewed and collated the available data regarding different suture techniques, including advantages, difficulties, and possible long-term impacts.

The use of sealing hemostat patch (HEMOPATCH®) in laparotomic myomectomy: a prospective case-control study

PURPOSE

Uterine myomas are the most common gynecological disease. In these cases, a myomectomy is performed traditionally laparotomically. However, alternatives have been widely used, including laparoscopic, endoscopic, and robotic surgery. During these techniques, diffuse parenchymatous bleeding remains one of the main intraoperative and postoperative complications and sometimes requires unplanned hysterectomies. Recently, hemostatic agents and sealants have been used to prevent excessive blood loss during surgical repair.

METHODS

We propose a prospective case-control study on the use of a sealing hemostat patch (HEMOPATCH^®) on uterine sutures in laparotomic myomectomy. In the period between July 2016 and April 2017, 46 patients with symptomatic uterine fibromatosis underwent surgery. They were divided into two groups of 23 patients, with different treatments in the hemostatic phase of oozing bleeding. HEMOPATCH^® is applied in group A, and spray electrocoagulation is applied in group B.

RESULTS

In group A, we achieve faster hemostasis (p < 0.05), than in group B. We report a significantly lower C-reactive protein value on the second and third days after surgery for group A compared to group B.

CONCLUSIONS

HEMOPATCH^®, during laparotomic myomectomy, is a valid alternative solution for obtaining rapid hemostasis and consequently intraoperative and postoperative bleeding. Furthermore, we suggest that a lower inflammatory peritoneal state is probably correlated with the barrier effect of the patch on the suture.

Utilization and cost of cell salvage in minimally invasive myomectomy

OBJECTIVE

To assess the utilization and cost of intraoperative cell salvage (ICS) in minimally invasive myomectomy.

STUDY DESIGN

Retrospective cohort study of patients who underwent minimally invasive myomectomy at a quaternary care academic hospital. Patients were classified into: ICS setup vs no ICS setup, ICS setup with reinfusion vs ICS setup without reinfusion.

RESULTS

Of 382 patients who underwent minimally invasive myomectomy, 67 (17.5 %) had ICS setup, 30 (44.8 %) of those patients reinfused. Median volume of reinfusion per patient was 300 mL (range 125-1000 mL). Patients who ultimately underwent ICS reinfusion, compared to those with ICS setup only, had significantly larger mean maximum fibroid size (9.8 cm vs 8.0 cm, p = 0.02), higher median total specimen weight (367 vs 304 g, p = 0.03), higher median estimated blood loss (575 vs 300 mL, p < 0.0001), longer mean operative time (261 vs 215 min, p = 0.04). No perioperative complications were associated with ICS. Higher costs are associated with universal use or complete lack of ICS; lowest cost is associated with ICS setup only for those ultimately reinfused.

CONCLUSION

ICS might reduce requirements for allogeneic blood transfusions in patients undergoing minimally invasive myomectomy, and may contribute to cost savings. Uterine and maximum fibroid sizes are possible preoperative indicators for patients who require cell salvage reinfusion.

Ascorbic Acid for Prevention of Intraoperative Blood Loss and Related Complications During Myomectomy: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

Leiomyomas are inherently well-vascularized neoplasms; thus, they are very vulnerable to bleeding-associated complications during myomectomy. Ascorbic acid has well-established functions in tissue healing and the prevention of bleeding tendencies. Several randomized controlled trials (RCTs) have explored the antihemorrhagic utility of ascorbic acid administration during myomectomy. This research aimed to systematically and meta-analytically summarize the clinical antihemorrhagic efficacy of ascorbic acid (i.e., the intervention arm) versus placebo/no treatment (i.e., the control arm) during myomectomy. We electronically searched six sources, i.e., PubMed, Scopus, Web of Science, Cochrane Central Register of Controlled Trials, and Google Scholar. Our search was from inception until October 2022. We used the Cochrane Risk of Bias Scale (version 2) to assess the quality of the included studies. We summarized the effect sizes as the mean difference (MD) or risk ratio (RR) with a 95% confidence interval (CI) in a fixed-effects or random-effects model. Overall, three RCTs met the inclusion criteria, comprising a total of 193 patients: 99 patients were allocated to the ascorbic acid arm, whereas 94 patients were allocated to the control arm. The overall study quality was "low" and "some concerns" risk of bias in two and one RCT(s), respectively. There was no significant difference between the ascorbic acid and control arms regarding the mean intraoperative blood loss (n=2 RCTs, MD = -190.29 ml, 95% CI [-626.62, 246.05], p=0.39) and mean change in hemoglobin level (n=3 RCTs, MD = -0.26 mg/dl, 95% CI [-0.56, 0.04], p=0.09), respectively. Conversely, the ascorbic acid arm had statistically significant reductions in the mean operative time (n=3 RCTs, MD = -24.10 min, 95% CI [-30.67, -17.53], p<0.001) and the rate of blood transfusion (n=3 RCTs, RR=0.36, 95% CI [0.15, 0.87], p=0.02) compared with the control arm. No serious adverse events related to ascorbic acid were identified. In conclusion, ascorbic acid administration was associated with several beneficial effects, including reductions in mean operative time and rate of blood transfusion, but without affecting the mean intraoperative blood loss and mean change in hemoglobin level. In view of the limitations of the present meta-analysis, the use of ascorbic acid as an antihemorrhagic additive among patients undergoing myomectomy is not strongly recommended.

The Appropriate Criteria in Patients Selection for Myomectomy in the Era of Minimally Invasive Surgery: A Case Report

Background

Myoma is the most common benign monoclonal neoplasm of the uterus with increased frequency during reproductive years of women.

Case Presentation

A twenty two year old female presented with abdomen lump, dysmenorrhoea, and heavy menstrual bleeding. Multiple myomas were diagnosed based on clinical and radiological findings. Abdominal myomectomy was performed and 75 myomas were enucleated followed by reconstruction of uterus. The second case was a 28 year old married woman presented with heavy menstrual bleeding and dysmenorrhoea. Ultrasound reported single posterior wall myoma of 8×6.3×5.8 cm in size. Laparoscopic myomectomy was performed. At follow-up visit, both cases were completely free of any symptoms.

Conclusion

Myomectomy is a feasible and safe option and a uterine preserving surgery even in the presence of multiple myomas. Setting appropriate criteria in selecting patients for abdominal myomectomy rather than MIS is essential to avoid conversion and associated morbidity.

Prophylactic tranexamic acid during myomectomy: A systematic review and meta-analysis of randomized controlled trials

OBJECTIVE

To conduct a systematic review and meta-analysis of randomized controlled trials on the clinical efficacy and safety of prophylactic tranexamic acid (TXA) versus control (normal saline/no treatment) during myomectomy.

METHODS

Six databases were screened from inception until 21-February-2022. The eligible studies were assessed for risk of bias. The outcomes were summarized as mean difference (MD) and risk ratio (RR) with 95% confidence intervals (CI) in a random-effects model.

RESULTS

Seven studies, comprising eight arms and 571 patients (TXA = 304 patients, control = 267 patients) were analyzed. The included studies had an overall low risk of bias. The mean intraoperative blood loss (MD = -224.34 ml, 95% CI [-303.06, -145.61], p < 0.001), mean postoperative blood loss, and mean total blood loss were significantly reduced in favor of the prophylactic TXA group. Additionally, the mean postoperative hemoglobin (MD = 0.4 mg/dl, 95% CI [0.11, 0.68], p = 0.006) and mean postoperative hematocrit levels were significantly higher in favor of the prophylactic TXA group. While the mean hospital stay was significantly reduced in favor of the prophylactic TXA group (MD = -0.39 d, 95% [-0.74, -0.04], p = 0.03), there was no significant difference between both groups regarding the mean operation time and rate of blood transfusion. None of the participants in both groups developed any incidence of thromboembolic events. The rate of nausea was significantly higher in disfavor of the prophylactic TXA group (RR = 2.68, 95% CI [1.11, 6.43], p = 0.03).

CONCLUSION

Among patients undergoing myomectomy, prophylactic TXA was largely safe and linked to substantial reductions in perioperative blood loss and related morbidities.

Evidence-Based Management of Uterine Fibroids With Botanical Drugs-A Review

Uterine fibroids (UFs) are a common benign gynecological tumor that affect the majority of women over their lifetime. Several pharmacological agents are available to reduce the size of fibroids and ameliorate the symptoms of UF. However, these drugs are expensive and are usually associated with profound side effects. Thus, botanical drugs are gaining attention in this era due to their cost effectiveness with a comparable and more potent therapeutic efficacy while demonstrating lesser adverse effects. The objective of this review is to summarize the available information on the mechanism of various botanical drugs and polyherbal formulations with anti-uterine fibroid activity. A systematic search was performed on botanical drugs with anti-uterine fibroid activity using several search engines, which include PubMed, Google Scholar, and Science Direct. Based on the literatures identified, a total of five botanical drugs and three polyherbal formulations were included and discussed in this review, which yields useful information regarding the mechanism of different botanical drugs and polyherbal formulations in exerting anti-uterine fibroid activity for its potential use as an alternative treatment choice for uterine fibroids.

Can the application of a temporary uterine tourniquet during an abdominal myomectomy reduce bleeding?

Objective

Uterine fibroids are common, benign uterine tumours. The three most common surgical treatment approaches for uterine fibroids are laparoscopic, robotic and abdominal myomectomies. Bleeding is a risk with all three approaches. The present study compared post-operative and pregnancy outcomes in patients with bilateral uterine artery occlusion who underwent an abdominal myomectomy, with or without a temporary uterine tourniquet.

Material and Methods

This retrospective study included patients with intra-mural fibroids (≥5 cm) who underwent an abdominal myomectomy. The patients were divided into two groups according to the use or non-use of a temporary uterine tourniquet. Post-operative and pregnancy outcomes in the tourniquet use and non-use groups were compared. The association of the number of uterine fibroids removed (≤3 vs >3) with laboratory parameters was also evaluated.

Results

A total of 84 patients were included, divided into use (n=36) and non-use (n=48) of the temporary tourniquet. There was a statistically significant difference between the groups with >3 myomas removed and with a uterine tourniquet applied and not applied in terms of reduction in hemoglobin and hematocrit, transfusion amounts, operation times and lengths of hospitalization in favour of the uterine tourniquet use group (p=0.019, p=0.023, p=0.012, p=0.044 and p=0.036, respectively). Bilateral uterine arterial occlusion using a temporary uterine tourniquet had no negative effects on pregnancy outcomes.

Conclusion

A temporary uterine tourniquet may be an effective method for reducing the amount of perioperative bleeding in patients with multiple, large-sized myomas located close to vascular structures.

Uterine artery embolisation versus myomectomy for premenopausal women with uterine fibroids wishing to avoid hysterectomy: the FEMME RCT

BACKGROUND

Uterine fibroids are the most common tumour in women of reproductive age and are associated with heavy menstrual bleeding, abdominal discomfort, subfertility and reduced quality of life. For women wishing to retain their uterus and who do not respond to medical treatment, myomectomy and uterine artery embolisation are therapeutic options.

OBJECTIVES

We examined the clinical effectiveness and cost-effectiveness of uterine artery embolisation compared with myomectomy in the treatment of symptomatic fibroids.

DESIGN

A multicentre, open, randomised trial with a parallel economic evaluation.

SETTING

Twenty-nine UK hospitals.

PARTICIPANTS

Premenopausal women who had symptomatic uterine fibroids amenable to myomectomy or uterine artery embolisation were recruited. Women were excluded if they had significant adenomyosis, any malignancy or pelvic inflammatory disease or if they had already had a previous open myomectomy or uterine artery embolisation.

INTERVENTIONS

Participants were randomised to myomectomy or embolisation in a 1 : 1 ratio using a minimisation algorithm. Myomectomy could be open abdominal, laparoscopic or hysteroscopic. Embolisation of the uterine arteries was performed under fluoroscopic guidance.

MAIN OUTCOME MEASURES

The primary outcome was the Uterine Fibroid Symptom Quality of Life questionnaire (with scores ranging from 0 to 100 and a higher score indicating better quality of life) at 2 years, adjusted for baseline score. The economic evaluation estimated quality-adjusted life-years (derived from EuroQol-5 Dimensions, three-level version, and costs from the NHS perspective).

RESULTS

A total of 254 women were randomised - 127 to myomectomy (105 underwent myomectomy) and 127 to uterine artery embolisation (98 underwent embolisation). Information on the primary outcome at 2 years was available for 81% (n = 206) of women. Primary outcome scores at 2 years were 84.6 (standard deviation 21.5) in the myomectomy group and 80.0 (standard deviation 22.0) in the uterine artery embolisation group (intention-to-treat complete-case analysis mean adjusted difference 8.0, 95% confidence interval 1.8 to 14.1, p = 0.01; mean adjusted difference using multiple imputation for missing responses 6.5, 95% confidence interval 1.1 to 11.9). The mean difference in the primary outcome at the 4-year follow-up time point was 5.0 (95% CI -1.4 to 11.5; p = 0.13) in favour of myomectomy. Perioperative and postoperative complications from all initial procedures occurred in similar percentages of women in both groups (29% in the myomectomy group vs. 24% in the UAE group). Twelve women in the uterine embolisation group and six women in the myomectomy group reported pregnancies over 4 years, resulting in seven and five live births, respectively (hazard ratio 0.48, 95% confidence interval 0.18 to 1.28). Over a 2-year time horizon, uterine artery embolisation was associated with higher costs than myomectomy (mean cost £7958, 95% confidence interval £6304 to £9612, vs. mean cost £7314, 95% confidence interval £5854 to £8773), but with fewer quality-adjusted life-years gained (0.74, 95% confidence interval 0.70 to 0.78, vs. 0.83, 95% confidence interval 0.79 to 0.87). The differences in costs (difference £645, 95% confidence interval -£1381 to £2580) and quality-adjusted life-years (difference -0.09, 95% confidence interval -0.11 to -0.04) were small. Similar results were observed over the 4-year time horizon. At a threshold of willingness to pay for a gain of 1 QALY of £20,000, the probability of myomectomy being cost-effective is 98% at 2 years and 96% at 4 years.

LIMITATIONS

There were a substantial number of women who were not recruited because of their preference for a particular treatment option.

CONCLUSIONS

Among women with symptomatic uterine fibroids, myomectomy resulted in greater improvement in quality of life than did uterine artery embolisation. The differences in costs and quality-adjusted life-years are very small. Future research should involve women who are desiring pregnancy.

TRIAL REGISTRATION

This trial is registered as ISRCTN70772394.

FUNDING

This study was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme, and will be published in full in Health Technology Assessment; Vol. 26, No. 22. See the NIHR Journals Library website for further project information.

Research on myoma in Northeastern Romania and socio-medical outcomes

Myomas are the most common benign uterine tumors in women of childbearing age, with an incidence of up to 77% and a major impact on women's health. The aim of our study was to provide information concerning the incidence and prevalence of myomas in the patients admitted to a tertiary referral center in Northeastern Romania. This retrospective study conducted at the Iasi 'Cuza Voda' University Hospital of Obstetrics and Gynecology (Romania) included 11,538 patients, representing all patients admitted to the gynecology department between January 2013 and December 2019. During the study interval, the number of hysterectomies (total and for myomas) had increased. The rate of laparoscopic surgery showed a small decrease (31.3% from 34%), classic therapy showed a decrease by more than 10% and the hysteroscopy rate was tripled. There are few studies in the literature that have established with accuracy the incidence of myomas. In the present study, the prevalence of hysterectomy for myomas was 54.42%. Our results are in agreement with the data in the literature, namely that 40-60% of all performed hysterectomies are for myomas. The vast majority of admissions for myomas involve a surgical procedure most commonly hysterectomy.

Evolution of laparoscopic myomectomy and description of two hemostatic techniques in a large teaching gynecological center

OBJECTIVE

To provide a description of laparoscopic myomectomy and the two hemostatic techniques performed over the last 11 years in a single reference center for gynecology and obstetrics and to evaluate the factors associated with favorable surgical outcomes.

STUDY DESIGN

We retrospectively analyzed 625 who underwent laparoscopic myomectomy from January 2009 to December 2019.

RESULTS

Of 625 patients, 437 (69.8%) were symptomatic. The most common symptoms were heavy uterine bleeding (33.2%). 188 patients (30.1%) were asymptomatic but were operated in 77 cases (12.3%) for rapid fibroid growth, 32 (5.1%) for uterine cavity distortion and, in 45 cases (8.6%), the myomectomy was indicated during a surgery for other medical reason due to its accessibility. In 173 cases (27.9%) intramyometrial adrenaline was injected and in 246 cases (39.7%) a temporary blockage of the uterus blood supply was performed. Only 35 (5.6%) patients presented complications, of which, 14 (40%) were hemorrhagic. These hemorrhagic complications were more frequent when intramyometrial adrenaline was used (5,8%) than after the temporary clipping of the uterine arteries and infundibulopelvic ligaments (0,8%; p < 0,001). In the multivariate logistic regression model, the only factor statistically associated with favorable surgical outcome was the use of temporary clipping of the uterine arteries at their origin and infundibulopelvic ligaments as hemostatic technique during the surgery.

CONCLUSION

Laparoscopic myomectomy was generally safe with a high level of favorable outcomes. The temporary clipping of uterine arteries and infundibulopelvic ligaments presented fewer intraoperative bleedings compared with injecting intramyometrial adrenaline.

A Romanian study on the impact of glypressin in laparoscopic myomectomy

A major myomectomy-associated problem is excessive blood loss. The aim of the present study was to evaluate the effect of glypressin on blood loss during laparoscopic myomectomy (LM) in women with uterine myomas. A total of 188 women scheduled for LM for uterine myomas were divided into two groups. The one group of women (n=64) received a 5-ml intramyometrial injection of glypressin 0.2 mg/ml (glypressin group; group 1). The other group of women (n=124) (group 2) had an LM performed without any other method to reduce blood loss. The decrease in postoperative hemoglobin (Hb), hematocrit (Ht), morbidity and duration of hospital stay were assessed. The results revealed that Hb and Ht (as it was presumed) exhibited similar changes in our study. Statistically significant differences (P<0.05) were obtained between the two groups in terms of Hb and Ht; after LM both Hb and Ht were decreased. In conclusion, the impact of glypressin administration in hemorrhage control in uterine leiomyomas may establish new future perspectives, regarding its administration in gynecological hemorrhagic pathologies.

Is an abdominal cerclage indicated with a cervical myomectomy? A case report

INTRODUCTION

Cervical myomectomy can compromise cervical integrity and the risk of subsequent cervical incompetence is unclear. In this case report, the literature on cervical myomectomies is reviewed as well as that on the potential benefits of cervical cerclage.

CASE PRESENTATION

A 30-year-old woman, nulligravida, with a 12 cm cervical leiomyoma consulted for heavy menstrual bleeding and pelvic pain. After failure of multiple medical therapies, a laparoscopic cervical myomectomy was successfully performed after pre-operative uterine artery embolization using absorbable gelatin sponges to reduce surgical blood loss.

DISCUSSION

A concomitant laparoscopic cerclage was achieved in order to prevent cervical incompetence, given that the full thickness of the anterior cervix was penetrated during the myomectomy.

Reducing the risk of bleeding after myomectomy: is preemptive embolization a valuable tool?

PURPOSE

Abdominal myomectomy can be a challenging procedure, with elevated intraoperative blood loss and post-operative complications such as the need for blood transfusion and hemostasis with sometimes hysterectomy. Previous studies suggested that preemptive uterine artery embolization (PUAE) might reduce intraoperative blood loss.

MATERIALS AND METHODS

We reviewed all cases of abdominal myomectomy in our institution between January 2016 and June 2018. Out of 119 cases, 16 patients had PUAE and 103 did not. The objective of our study was to determine whereas PUAE reduced blood loss and post-operative complication rate.

RESULTS

In our study, there was no difference between the two groups in regard to average blood loss (128 vs 192 mL, OR 1,00 [0.99;1,01], p = 0,73), difference between pre- and post-operative hemoglobin level (- 1,15 g/dL vs - 1,32 g/dL, OR 0,91 [0.47;1,73], p = 0,79), and post-operative complications (need for transfusion, surgical revision, post-operative embolization, hysterectomy).

CONCLUSION

Our findings could not conclude that PUAE is effective in reducing intraoperative blood loss during abdominal myomectomy, but it should still be considered an option for patients with large or multiple myomas, with a specific situation or previously operated, who wish to preserve their uterus.

New Surgical Technique for Robotic Myomectomy: Continuous Locking Suture on Myoma (LSOM) Technique

Robot-assisted laparoscopic myomectomy (RALM) has broadened the indications even in complex myomas. However, the high cost of RALM remains the main disadvantage. Therefore, a surgical technique that can reduce the cost of RALM and still has the advantages of robotic surgery is required. We propose a "locking suture on myoma (LSOM)" technique and compared the operative and perioperative outcomes of patients who underwent RALM with or without the LSOM technique. We included 337 patients who underwent RALM with (n = 160) or without (n = 177) the LSOM technique between March 2019 and August 2020. The LSOM group had low parity and gravidity, with a low rate of Cesarean sections. Myoma type was not different between the groups; however, patients in the LSOM group had larger, heavier, and higher number of myomas, although fewer patients had multiple myomas and were discharged earlier. Total operating time, estimated blood loss, pre- and postoperative hemoglobin levels, transfusion rate, and postoperative fever were not different between the two groups. In conclusion, the LSOM technique may be a viable surgical option for myomas, as it can reduce the cost of RALM by obviating the need for robotic Tenaculum forceps.

A clinical audit of the patterns of presentations and complications of abdominal myomectomy at the University College Hospital, Ibadan, Nigeria

Abdominal myomectomy is a common modality of treatment for large and symptomatic uterine fibroids in women who wish to retain their fertility. Black women have higher rates and larger sizes of uterine fibroids. We aimed to determine the presentation patterns, peri-operative complications, and determinants of complications in patients who underwent abdominal myomectomy. This was a retrospective review of women who had abdominal myomectomy between July 2016 and June 2019. There were intra-operative complications and post-operative complications in 25% and 29.3% of patients respectively. There were higher odds for developing intra-operative complications among those who had general anaesthesia [OR = 3.514, 95%CI (1.951-6.331)], more than 10 fibroid nodules enucleated [OR = 4.917, 95%CI (2.600-9.298)], pre-operative Packed cell volume (PCV) < 30% [OR = 4.831, 95%CI (2.370-9.880)], presence of adhesions [OR = 2.680, 95%CI (1.510-4.730)], fibroids larger than 10 centimetres [OR = 1.98, 95%CI (1.13-3.49)], previous pelvic surgery [OR = 2.68, 95%CI (1.52-4.63)]. Post-operative complications were higher in those who had general anaesthesia or pre-existing medical conditions.IMPACT STATEMENTWhat is already known on this subject? Abdominal myomectomy is a major surgical procedure globally with a significant morbidity rate. Sufficient evidence relating to the determinants of peri-operative complications are lacking.What do the results of this study add? Our results highlight the factors associated with increased odds of developing complications following abdominal myomectomy.What are the implications of these findings for clinical practice and/or further research? Our study complements existing data on the peri-operative complications following abdominal myomectomy. It also reflects the possibility of mortality albeit a rarerity. A retrospective multivariate analysis like this, while classifying morbidities into intra-operative and post-operative complications, is required to start an audit cycle. Knowing these determinants will help improve patient optimisation for surgery, identify high risk women and enhance more directed counselling. The results from this pilot study will also be used to design a prospective study to be undertaken by the authors.

Evaluating efficacy of intravenous carbetocin in reducing blood loss during abdominal myomectomy: a randomized controlled trial

OBJECTIVE

To evaluate the efficacy of carbetocin versus placebo in decreasing intraoperative blood loss and the need for blood transfusion during abdominal myomectomy.

DESIGN

Randomized, double-blind, placebo-controlled trial.

SETTING

Tertiary university hospital from September 2019 to February 2020.

PATIENT(S)

A total of 138 women with symptomatic leiomyoma who were candidates for abdominal myomectomy (n = 69 in each group).

INTERVENTION(S)

We randomized the study participants in a 1:1 ratio to carbetocin and placebo groups. Intravenous 100 μg carbetocin or placebo was administered slowly after induction of anesthesia.

MAIN OUTCOME MEASURE(S)

Intraoperative blood loss, need for blood transfusion, postoperative hemoglobin, operative time, length of hospitalization, and drug side-effects.

RESULT(S)

The baseline characteristics were similar among all groups. Carbetocin had significantly lower intraoperative blood loss compared with placebo (mean difference 184 mL). Hemoglobin level 24 hours after surgery was significantly lower in the placebo group than in the carbetocin group (9.1 ± 0.8 vs. 10.3 ± 0.6 g/dL). Eight women in the carbetocin group needed blood transfusion compared with 17 in placebo group. Operative time, length of hospitalization, and side-effects were similar in both groups.

CONCLUSION(S)

A single preoperative intravenous dose of 100 μg carbetocin is a simple, practical, and effective method of decreasing intraoperative blood loss and the need for blood transfusion during abdominal myomectomy, with tolerable, few, nonsignificant side-effects.

CLINICAL TRIAL REGISTRATION NUMBER

NCT04083625.

Risk of vasopressin use: a case of acute pulmonary oedema, post intramyometrial infiltration of vasopressin in laparoscopic myomectomy

A 34-year-old patient underwent a laparoscopic myomectomy, complicated by a profound episode of bradycardia and hypotension following intramyometrial infiltration of vasopressin (20 IU), promptly corrected with intravenous ephedrine (6 mg) and glycopyrrolate (200 µg). At extubation, pink frothy fluid was noted in the endotracheal tube; she was visibly distressed, desaturated to 89% in air and was coughing up pink stained fluid. Acute pulmonary oedema secondary to vasopressin was suspected. A tight-fitting oxygen mask (100%) with positive end expiratory pressure was applied and intravenous furosemide (20 mg) and diamorphine (4 mg, 1 mg increments) were administered to facilitate diuresis and oxygenation. Chest X-ray confirmed acute pulmonary oedema. Arterial blood gas demonstrated type 2 respiratory failure. Over 12 hours, the oxygen was weaned to 1 L/min. She demonstrated excellent diuresis. Troponin and brain-natriuretic peptide were elevated, but echocardiogram was normal. The cardiology diagnosis was vasopressin-induced coronary vasospasm, precipitating acute pulmonary oedema. She was discharged home on day 5.

Comparison of Misoprostol and Mefenamic Acid on Reducing Menstrual Bleeding in Patients Suffering From Heavy Menstrual Bleeding

Objective: Heavy menstrual bleeding is one of the most frequent complaints of women. Various therapeutic approaches have been applied to treat this condition. In this study, we compared the efficacy of mefenamic acid and misoprostol in reducing menorrhagia. Materials and methods: This is a randomized clinical trial study performed on 60 patients with menorrhagia. They were divided into two equal groups and randomly received mefenamic acid or misoprostol. Cycle duration, bleeding volume (according to the pictorial blood assessment chart), hemoglobin, hematocrit, and pad count were recorded before and after treatment. Side effects of treatment regimens were recorded. Results: Blood loss volume per menstruation day in the mefenamic acid group was 118.40 ± 36.26 ml before treatment which decreased to 48.50 ± 24.71 ml after treatment (p = 0.262). Misoprostol reduced menstrual bleeding volume from 135.37 ± 34.85 ml per day to 49.40 ± 32.161 ml (p = 0.003). Mean duration of the menstrual period in patients receiveding mefenamic acid was 9.50 ± 3.27 days which decreased to 7.73 ± 2.14 days after treatment (p = 0.001). The similar change occurred in the misoprostol group and the mean duration of the menstrual period decreased from 7.70 ± 2.10 to 6.37 ± 2.29 days (p = 0.002). The number of pads used by patients in the mefenamic acid group before treatment was 23.20 ± 12.61 which was decreased to 14.33 ± 5.86 after treatment (p = 0.001). This alteration in misoprostol group was from 20.67 ± 6.12 to 15.53 ± 6.49 (p = 0.001). Conclusion: Misoprostol can significantly reduce menstrual bleeding.

Abdelazim and AbuFaza technique for temporary bilateral uterine occlusion to decrease the blood loss during myomectomy: Case reports

The standard treatment of symptomatic fibroids is hysterectomy for women completed their childbearing and myomectomy for women desire future fertility. Myomectomy associated with life-threatening bleeding and emergency blood transfusion. The two studied cases were unmarried presented with multiple fibroid uterus of 28 and 24 weeks' gestation. Both the studied women refused hysterectomy because of their fertility potential. Myomectomy was done with removal of two big myomas (10×12 cm and 7×8 cm), three moderate size myomas (5×5 cm, 4×4 cm and 3×4 cm) and four small size myomas for the first case and removal of one big myoma (8×6 cm), four small size myomas for the second case. The hemoglobin difference was 0.6 and 0.4 gms% for the first and the second case; respectively and no blood transfusion was required for them. This report represents the outcome of Abdelazim and AbuFaza technique for temporary bilateral uterine occlusion to decrease the blood loss during myomectomy.

Comparing perioperative vaginal misoprostol with intraoperative pericervical hemostatic tourniquet in reducing blood loss during abdominal myomectomy: A randomized controlled trial

Objective

To compare the effectiveness of perioperative vaginal misoprostol with intraoperative pericervical hemostatic tourniquet in reducing blood loss during abdominal myomectomy.

Material and Methods

A randomized controlled trial involving women with uterine leiomyoma who underwent abdominal myomectomy was conducted at a tertiary facility in Nigeria. Participants were recruited after they gave informed consent and randomized into group I (single dose 400 μg vaginal misoprostol one-hour before surgery) and group II (intraoperative pericervical hemostatic tourniquet). Eighty participants (40 in each group) were recruited. Uterine size was measured in centimeters above the pubic symphysis, and blood loss estimation involved direct volume measurement and gravimetric methods. The main outcome measures were intraoperative blood loss, blood transfusion, and recourse to hysterectomy. Ethical approval and trial registration were obtained; the data were analyzed using the SPSS software version 21.0; p<0.05 was considered significant.

Results

Participants in group I had higher mean intraoperative blood loss (931.89±602.13 vs 848.40±588.85 mL, p=0.532), intra-operative blood transfusion rates (60 vs 55%; p=0.651) and mean units of blood transfused (1.30±1.20 vs 1.20±1.30; p=0.722) compared with group II. The mean uterine size (19.50±6.93 vs 20.05±6.98 cm; p=0.725) and number of fibroid nodules (11.25±7.99 vs 11.45±8.22; p=0.912) were comparable. The change in post-operative hematocrit was 2.66±2.21% vs 3.24±2.85% (p=0.315) and post-operation blood transfusion was 2.5 vs 5% (p=0.556). There was no recourse to hysterectomy in either of the study groups. While adverse effects of misoprostol occurred in 5 (12.5%) participants of group I.

Conclusion

The effectiveness of perioperative vaginal misoprostol is comparable to intra-operative hemostatic pericervical tourniquet in reducing blood loss during abdominal myomectomy.

Oxytocin infusion reduces bleeding during abdominal myomectomies: a randomized controlled trial

PURPOSE

To evaluate the effectiveness of oxytocin infusion to reduce intraoperative bleeding during abdominal myomectomies.

METHODS

This randomized, parallel group, blinded study was conducted between October 2017 and May 2018. Patients undergoing abdominal myomectomies were randomized 1:1 either to the oxytocin group or to the control group (saline). In the oxytocin group, 10 IU oxytocin in 500 ml of saline at a rate of 120 ml/h was given during the course of the operation. The primary outcome of this study was to measure intraoperative blood loss between the study groups. Correlation and multiple regression analysis were performed to illustrate factors associated with intraoperative blood loss during the myomectomy.

RESULTS

The mean intraoperative blood loss during the surgery was 489.20 ± 239.72 ml in the oxytocin group and was 641.40 ± 288.21 ml in the control group. The hemoglobin decline was more evident in the control group than in the oxytocin group. Positive correlations were also observed between the intraoperative blood loss and number of fibroids removed during the surgery, largest fibroid removed and weight of fibroids removed. The use of oxytocin infusion during the myomectomy resulted in a reduction of bleeding in the regression model.

CONCLUSION

Intravenous oxytocin infusion is a safe and practical method to reduce intraoperative blood loss during the abdominal myomectomy.

Hemodynamic effects of intramyometrial epinephrine injection for blood loss reduction in laparoscopic myomectomy

PURPOSE

To evaluate changes in hemodynamic effects of intramyometrial epinephrine injection for blood loss reduction in laparoscopic myomectomy.

METHODS

A total of 185 women with symptomatic uterine fibroids who underwent laparoscopic myomectomy were enrolled in this study. Eighty-six women (study collective) received an intramyometrial injection of epinephrine and were compared to ninety-nine women (control collective) who underwent laparoscopic myomectomy without an intramyometrial epinephrine injection. Demographic parameters, change of hemodynamic parameters during surgery as well as hemoglobin drop after surgery were analyzed.

RESULTS

In the study collective maximum systolic blood pressure (p < 0.001), maximum increase of the systolic blood pressure within 5 min (p = 0.003), duration of hypertension (p = 0.012), maximal (p < 0.001) and mean heart rate (p = 0.005), maximal increase of heart rate within 5 min (p = 0.003) and difference of mean to maximal heart rate (p < 0.001) were higher compared to the control collective. There was no difference in pre- and postoperative hemoglobin levels in both collectives and no intraoperative clinically relevant complication occurred due to intramyometrial epinephrine injection.

CONCLUSION

The intramyometrial application of epinephrine seems to be safe but leads to significant alterations of hemodynamic parameters without a significant change in postoperative hemoglobin levels.

Modern Myoma Treatment in the Last 20 Years: A Review of the Literature

Myomas, also known as fibroids, are a specific characteristic of the human species. No other primates develop fibroids. At a cellular level, myomas are benign hyperplastic lesions of uterine smooth muscle cells. There are interesting theoretical concepts that link the development of myomas in humans with the highly specific process of childbirth from an upright position and the resulting need for greatly increased "expulsive" forces during labor. Myomas might be the price our species pays for our bipedal and highly intelligent existence. Myomas affect, with some variability, all ethnic groups and approximately 50% of all women during their lifetime. While some remain asymptomatic, myomas can cause significant and sometimes life-threatening uterine bleeding, pain, infertility, and, in extreme cases, ureteral obstruction and death. Traditionally, over 50% of all hysterectomies were performed for fibroids, leading to a significant healthcare burden. In this article, we review the developments of the past 20 years with regard to multiple new treatment strategies that have evolved during this time.

Preoperative medical therapy before surgery for uterine fibroids

BACKGROUND

Uterine fibroids occur in up to 40% of women aged over 35 years. Some are asymptomatic, but up to 50% cause symptoms that warrant therapy. Symptoms include anaemia caused by heavy menstrual bleeding, pelvic pain, dysmenorrhoea, infertility and low quality of life. Surgery is the first choice of treatment. In recent years, medical therapies have been used before surgery to improve intraoperative and postoperative outcomes. However, such therapies tend to be expensive.Fibroid growth is stimulated by oestrogen. Gonadotropin-hormone releasing analogues (GnRHa) induce a state of hypo-oestrogenism that shrinks fibroids , but has unacceptable side effects if used long-term. Other potential hormonal treatments, include progestins and selective progesterone-receptor modulators (SPRMs).This is an update of a Cochrane Review published in 2000 and 2001; the scope has been broadened to include all preoperative medical treatments.

OBJECTIVES

To assess the effectiveness and safety of medical treatments prior to surgery for uterine fibroids.

SEARCH METHODS

We searched the Cochrane Gynaecology and Fertility Group specialised register, CENTRAL, MEDLINE, Embase, PsycINFO and CINAHL in June 2017. We also searched trials registers (ClinicalTrials.com; WHO ICTRP), theses and dissertations and the grey literature, handsearched reference lists of retrieved articles and contacted pharmaceutical companies for additional trials.

SELECTION CRITERIA

We included randomised comparisons of medical therapy versus placebo, no treatment, or other medical therapy before surgery, myomectomy, hysterectomy or endometrial resection, for uterine fibroids.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by The Cochrane Collaboration.

MAIN RESULTS

We included a total of 38 RCTs (3623 women); 19 studies compared GnRHa to no pretreatment (n = 19), placebo (n = 8), other medical pretreatments (progestin, SPRMs, selective oestrogen receptor modulators (SERMs), dopamine agonists, oestrogen receptor antagonists) (n = 7), and four compared SPRMs with placebo. Most results provided low-quality evidence due to limitations in study design (poor reporting of randomisation procedures, lack of blinding), imprecision and inconsistency. GnRHa versus no treatment or placebo GnRHa treatments were associated with reductions in both uterine (MD -175 mL, 95% CI -219.0 to -131.7; 13 studies; 858 participants; I² = 67%; low-quality evidence) and fibroid volume (heterogeneous studies, MD 5.7 mL to 155.4 mL), and increased preoperative haemoglobin (MD 0.88 g/dL, 95% CI 0.7 to 1.1; 10 studies; 834 participants; I² = 0%; moderate-quality evidence), at the expense of a greater likelihood of adverse events, particularly hot flushes (OR 7.68, 95% CI 4.6 to 13.0; 6 studies; 877 participants; I² = 46%; moderate-quality evidence).Duration of hysterectomy surgery was reduced among women who received GnRHa treatment (-9.59 minutes, 95% CI 15.9 to -3.28; 6 studies; 617 participants; I² = 57%; low-quality evidence) and there was less blood loss (heterogeneous studies, MD 25 mL to 148 mL), fewer blood transfusions (OR 0.54, 95% CI 0.3 to 1.0; 6 studies; 601 participants; I² = 0%; moderate-quality evidence), and fewer postoperative complications (OR 0.54, 95% CI 0.3 to 0.9; 7 studies; 772 participants; I² = 28%; low-quality evidence).GnRHa appeared to reduce intraoperative blood loss during myomectomy (MD 22 mL to 157 mL). There was no clear evidence of a difference among groups for other primary outcomes after myomectomy: duration of surgery (studies too heterogeneous for pooling), blood transfusions (OR 0.85, 95% CI 0.3 to 2.8; 4 studies; 121 participants; I² = 0%; low-quality evidence) or postoperative complications (OR 1.07, 95% CI 0.43 to 2.64; I² = 0%; 5 studies; 190 participants; low-quality evidence). No suitable data were available for analysis of preoperative bleeding. GnRHa versus other medical therapies GnRHa was associated with a greater reduction in uterine volume (-47% with GnRHa compared to -20% and -22% with 5 mg and 10 mg ulipristal acetate) but was more likely to cause hot flushes (OR 12.3, 95% CI 4.04 to 37.48; 5 studies; 183 participants; I² = 61%; low-quality evidence) compared with ulipristal acetate. There was no clear evidence of a difference in bleeding reduction (ulipristal acetate 5 mg: OR 0.71, 95% CI 0.3 to 1.7; 1 study; 199 participants; moderate-quality evidence; ulipristal acetate 10 mg: OR 0.39, 95% CI 0.1 to 1.1; 1 study; 203 participants; moderate-quality evidence) or haemoglobin levels (MD -0.2, 95% CI -0.6 to 0.2; 188 participants; moderate-quality evidence).There was no clear evidence of a difference in fibroid volume between GnRHa and cabergoline (MD 12.71 mL, 95% CI -5.9 to 31.3; 2 studies; 110 participants; I² = 0%; low-quality evidence).The included studies did not report usable data for any other primary outcomes. SPRMs versus placebo SPRMs (mifepristone, CDB-2914, ulipristal acetate and asoprisnil) were associated with greater reductions in uterine or fibroid volume than placebo (studies too heterogeneous to pool) and increased preoperative haemoglobin levels (MD 0.93 g/dL, 0.5 to 1.4; 2 studies; 173 participants; I² = 0%; high-quality evidence). Ulipristal acetate and asoprisnil were also associated with greater reductions in bleeding before surgery (ulipristal acetate 5 mg: OR 41.41, 95% CI 15.3 to 112.4; 1 study; 143 participants; low-quality evidence; ulipristal acetate 10 mg: OR 78.83, 95% CI 24.0 to 258.7; 1 study; 146 participants; low-quality evidence; asoprisnil: MD -166.9 mL; 95% CI -277.6 to -56.2; 1 study; 22 participants; low-quality evidence). There was no evidence of differences in preoperative complications. No other primary outcomes were measured.

AUTHORS' CONCLUSIONS

A rationale for the use of preoperative medical therapy before surgery for fibroids is to make surgery easier. There is clear evidence that preoperative GnRHa reduces uterine and fibroid volume, and increases preoperative haemoglobin levels, although GnRHa increases the incidence of hot flushes. During hysterectomy, blood loss, operation time and complication rates were also reduced. Evidence suggests that ulipristal acetate may offer similar advantages (reduced fibroid volume and fibroid-related bleeding and increased haemoglobin levels) although replication of these studies is advised before firm conclusions can be made. Future research should focus on cost-effectiveness and distinguish between groups of women with fibroids who would most benefit.

Pushing the boundaries of laparoscopic myomectomy: a comparative analysis of peri-operative outcomes in 323 women undergoing laparoscopic myomectomy in a tertiary referral centre

Background

The aim of this study was to analyse the demographic data and peri-operative outcomes of women undergoing a laparoscopic myomectomy and assess what factors, if any, precluded using the laparoscopic approach.

Methods

A single surgeon observational study of 323 patients undergoing a laparoscopic myomectomy was undertaken. Data was collected prospectively over a 12-year period and analysed using SPSS. Surgical outcomes included operating time, estimated blood loss, conversion to laparotomy, intraoperative and postoperative complications and duration of inpatient stay.

Results

A total of 323 patients underwent a laparoscopic myomectomy over the 12-year period. The majority of fibroids removed were intramural (49%) and subserosal (33%). The mean size of fibroids removed was 7.66 ± 2.83 (7.34–7.99) cm, and the mean number was 4 ± 3.62 (3.6–4.39), with the greatest being 22 removed from a single patient. Average blood loss was 279.14 ± 221.10 (254.59–303.69) ml with mean duration of surgery and inpatient stay recorded as 112.92 ± 43.21 (107.94–117.91) min and 1.88 ± 0.95 (1.77–1.99) days, respectively. No major intraoperative complications were noted, and the conversion to laparotomy rate was 0.62%. All histology following morcellation was benign. Over the 12-year period despite increasingly large and more numerous fibroids being tackled, increasing experience resulted in a simultaneous reduction in overall blood loss, operating time and duration of inpatient stay.

Conclusions

Laparoscopic myomectomy is a safe and efficacious procedure that should be considered the gold standard surgical treatment option for fibroids. With experience, the procedure can be undertaken with minimal complications, a low risk of conversion to laparotomy and early discharge from hospital, even in cases of large and multiple fibroids that historically would have required the open approach. This allows even the most complex of cases to now benefit for the advantages of the minimal access approach.

Robot-assisted laparoscopic myomectomy: current status

Robotic-assisted surgery has seen a rapid development and integration in the field of gynecology. Since the approval of the use of robot for gynecological surgery and considering its several advantages over conventional laparoscopy, it has been widely incorporated especially in the field of reproductive surgery. Uterine fibroids are the most common benign tumors of the female reproductive tract. Many reproductive-aged women with this condition demand uterine-sparing surgery to preserve their fertility. Myomectomy, the surgical excision of uterine fibroids, remains the only surgical management option for fibroids that entails preservation of fertility. In this review, we focus on the role of robotic-assisted laparoscopic myomectomy and its current status, in comparison with other alternative approaches for myomectomy, including open, hysteroscopic, and traditional laparoscopic techniques. Several different surgical techniques have been demonstrated for robotic myomectomy. This review endeavors to share and describe our surgical experience of using the standard laparoscopic equipment for robotic-assisted myomectomy, together with the da Vinci Robot system. For the ideal surgical candidate, robotic-assisted myomectomy is a safe minimally invasive surgical procedure that can be offered as an alternative to open surgery. The advantages of using the robot system compared to open myomectomy include a shorter length of hospital stay, less postoperative pain and analgesic use, faster return to normal activities, more rapid return of the bowel function, and enhanced cosmetic results due to smaller skin incision sizes. Some of the disadvantages of this technique include high costs of the robotic surgical system and equipment, the steep learning curve of this novel system, and prolonged operative and anesthesia times. Robotic technology is a novel and innovative minimally invasive approach with demonstrated feasibility in gynecological and reproductive surgery. This technology is expected to take the lead in gynecological surgery in the upcoming decade.

Assessment of Blood Loss in Abdominal Myomectomy by Intramyometrial Vasopressin Administration Versus Conventional Tourniquet Application

INTRODUCTION

Myomectomy is an invasive surgical procedure. It can be associated with intraoperative and postoperative complications like excessive haemorrhage. There are various methods to control haemorrhage like pharmacological and as well as mechanical methods.

AIM

This study was taken to compare intraoperative blood loss following abdominal myomectomy after receiving intramyometrial vasopressin or tourniquet application and to estimate postoperative reduction in haemoglobin & haematocrit values.

MATERIALS AND METHODS

The study was a randomised single blinded parallel group study. Total 48 patients were included in this study according to inclusion and exclusion criteria. All patients were divided into two groups i.e. 'T' and 'V' group, 24 in each group. 'T' group received conventional tourniquet application and 'V' group received intramyometrial vasopressin administration. The analyses in this study were both sided and p<0.05 was considered significant statistically. The Software used were Statistica version 6 (Tulsa, Oklahoma: Stat Soft Inc., 2001) and Graph Pad Prism version 5 (San Diego, California: Graph Pad Software Inc., 2007).

RESULTS

The blood loss in the tourniquet group was significantly higher (p=<0.001). Postoperative haemoglobin and haematocrit were lower in tourniquet group than vasopressin group. There was significant fall in haemoglobin and haematocrit in postoperative period in both group (p=<0.001) but it was more in tourniquet group. Total five patients (three in tourniquet group and two in vasopressin group) had received one unit whole blood transfusion.

CONCLUSION

Intramyometrial vasopressin injection during myomectomy operation more effectively decreases the blood loss, need for blood transfusion and it causes less reduction in haemoglobin and haematocrit. Thereby it seems to be an effective method without having any risk of ischemic damage to the uterus.

Effect of intravenous ascorbic acid infusion on blood loss during laparoscopic myomectomy: a randomized, double-blind, placebo-controlled trial

OBJECTIVE

Most interventions aimed at reducing bleeding during myomectomy lack sufficient evidence regarding their effectiveness. Recently, it was reported that intraoperative ascorbic acid administration effectively reduced blood loss during abdominal myomectomy. Therefore, this study aimed to investigate whether intravenous ascorbic acid infusion would affect intraoperative blood loss in women undergoing laparoscopic myomectomy.

STUDY DESIGN

A randomized, double-blind, parallel-group, placebo-controlled trial including 50 women undergoing laparoscopic myomectomy was conducted. Women with ≤4 myomas, ≤9cm in maximum diameter were eligible. The study:control group ratio was 1:1. Starting 30minutes before anesthesia, 2g of ascorbic acid or a placebo were administered for 2hours intraoperatively. Intraoperative blood loss, the primary endpoint, was calculated as the difference between the volume of fluids acquired from suction and that used for irrigation of the abdominal cavity during surgery using constant values.

RESULTS

Among the 50 randomized women, 1 and 3 in the study and control groups, respectively, were excluded due to withdrawal of consent, cancelation of surgery, or non-measurement of the primary endpoint. The baseline and operative characteristics were similar between the study and control groups, as was the intraoperative blood loss (193±204mL vs. 159±193mL, P=0.52). In addition, the operating time (95±29min vs. 110±52min; P=0.50) and decrease in hemoglobin level after surgery (1.9±1.31g/dL vs. 1.4±1.4g/dL; P=0.24) were similar between the study and control groups.

CONCLUSIONS

Intravenous ascorbic acid infusion did not reduce intraoperative blood loss in women undergoing laparoscopic myomectomy.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov, www.clinicaltrials.gov, NCT01715597.

Comparison of the Perioperative Outcomes of a Vessel Sealing Instrument-Assisted Technique with a Conventional Technique in Abdominal Myomectomy

INTRODUCTION

In gynaecologic practice, LigaSure Precise(TM) is generally used in endoscopic and open surgeries, such as hysterectomy, adnexectomy, and cancer surgery. However, there is no case report or main research article where LigaSure Precise(TM) has been used for myomectomy. We want to compare a technique using a vessel sealing instrument with a conventional technique in abdominal myomectomy.

MATERIALS AND METHODS

Fifty-five women who underwent abdominal myomectomy were divided two groups: (1) a vessel sealing instrument-assisted technique (24 patients); and (2) a conventional technique (31 patients) between January 2011 and December 2014 at the Department of Gynaecology and Obstetrics, Gulhane Military Medical Academy, Ankara, Turkey. The data for the operation times, the occurrence of perioperative complications, the hospitalization times, and changes in haemaglobin and haematocrit levels for the two techniques were collected and compared.

RESULTS

The mean operation time was 48 minutes for the vessel sealing instrument-assisted technique and 54 minutes for the conventional technique. No statistically significant differences were determined for haemoglobin and haematocrit changes, hospital stay and perioperative complications.

CONCLUSION

We did not find any difference in the occurrence of complications, changes in haemoglobin or haematocrit levels, or hospital stay. The vessel sealing instrument-assisted technique is feasible and effective in reducing operation times.

Effectiveness of tranexamic acid in reducing blood loss during cytoreductive surgery for advanced ovarian cancer

BACKGROUND

Ovarian cancer is the third most common gynaecological cancer worldwide, with an age-standardised incidence rate of 6.1 per 10,000 women. Standard therapy for advanced epithelial ovarian cancer (EOC) includes a combination of cytoreductive surgery and platinum-based chemotherapy. Cytoreductive surgery aims to remove as much of the visible tumour as possible. As extensive intraperitoneal metastases are typical of advanced EOC, cytoreductive surgery is usually an extensive procedure with the risk of excessive bleeding. Tranexamic acid given perioperatively is effective in reducing blood loss and allogeneic blood transfusion requirements in a variety of surgical settings. Therefore, tranexamic acid seems to be a promising agent for minimising blood loss and the need for blood transfusion among women with advanced EOC undergoing cytoreductive surgery.

OBJECTIVES

To assess the effects of tranexamic acid for reducing blood loss associated with cytoreductive surgery in women with advanced EOC (stage III to IV).

SEARCH METHODS

We searched the Cochrane Gynaecological, Neuro-oncology and Orphan Cancers Trial Register, the Cochrane Central Register of Controlled Trials (CENTRAL) (Issue 5, 2015), MEDLINE, EMBASE and conference proceedings to May 2015. We also checked registers of clinical trials, citation lists of included studies, key textbooks and previous systematic reviews for potentially relevant studies.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) comparing tranexamic acid given during surgery versus placebo or no treatment, in adult women diagnosed with advanced EOC.

DATA COLLECTION AND ANALYSIS

Two review authors (CK, AS) independently selected potentially relevant trials, extracted data, assessed risk of bias, compared results and resolved disagreements by discussion.

MAIN RESULTS

We found only one study that met our inclusion criteria. This was a randomised double blind, placebo-controlled multicentre study conducted to evaluate the effectiveness of a single dose of intravenous tranexamic acid (15 mg/kg body weight) versus placebo, given immediately before surgery for reducing blood loss and the need for red blood cell transfusion. The mean total estimated blood loss was 668.34 mL and 916.93 mL for participants assigned to tranexamic acid and placebo groups, respectively. The mean difference (MD) of total estimated blood loss between the groups did not show a clinically important effect (MD - 248.59 mL; 95% confidence interval (CI) - 550.9 to 53.79; one study, 100 participants; moderate quality evidence). The mean number of transfused units of blood components was not different between the two groups (low quality evidence). There were no noted differences in the incidence of reoperation, readmission or thromboembolic events (very low quality evidence). We considered the methodology of the included study to be at low risk of selection, detection, and reporting biases. However, we were concerned about an imbalance of some baseline characteristics between the groups, and as there was no protocol for blood transfusion, the rate of blood transfusion may vary depending on the practice of each participating hospital.

AUTHORS' CONCLUSIONS

Currently, there is insufficient evidence to recommend the routine use of tranexamic acid for reducing blood loss in women undergoing cytoreductive surgery for advanced EOC, as only limited data are available from a single, low quality RCT at low overall risk of bias.

Intravenous tranexamic acid as an adjunct haemostat to ornipressin during open myomectomy. A randomized double blind placebo controlled trial

Background

Myomectomy is a surgical technique used for removal of uterine fibroids and historically hysterectomy has represented the mainstay of treatment. The options of conservative surgical approaches mainly aim at retention of fertility but have to be balanced against potential risks such as haemorrhage; blood loss at myomectomy still remains troublesome with use of various pharmacologic agents yielding inconclusive results. This trial aimed to explore the benefit of combining ornipressin and tranexamic acid during open myomectomy.

Study design

A randomized double blind placebo controlled trial.

Methods

Women who satisfied eligibility criteria were enrolled into the study and randomized into one of two groups. The experimental group received 1 g of tranexamic acid diluted to 50 ml of saline administered at 100 ml per hour at cutting time (knife to skin). The control group received placebo diluted to 50 ml of saline administered at 100 ml per hour at cutting time. Both groups had five international units ornipressin diluted in 60 ml of saline administered during surgery. The primary outcome (blood loss) was assessed by determining the weight difference of dry and soaked swabs using a digital weighing scale by converting this to volume (ml). Operating time was noted from the time of uterine incision to the time of uterine closure. The need for transfusion was determined by anaesthetists’ assessment of acceptable blood loss and clinical assessment of vital signs. Post-operative stay was calculated from the time of extubation to 8 am on the day of discharge.

Results

A total of thirty-four patients were randomized to two groups; 17 received ornipressin only and 17 received tranexamic acid and ornipressin. There was no difference in blood loss between the groups with a median blood loss in the ornipressin (n = 17) and ornipressin plus tranexamic acid arms of 398 ml (IQR: 251–630) ml and 251 ml (IQR: 158–501) ml respectively P = 0.361.

Conclusions

Ornipressin administered along with tranexamic acid is not beneficial for blood loss reduction at open myomectomy. In settings such as ours where myomata are prevalent and severe anaemia rampant, blood donation and judicious use of scarce blood resources is key. Efforts to optimize preoperative haemoglobin levels and blood auto-donation seem the most promising options in pre-operative preparation prior to myomectomy.

Clinical Trials Registration Number: PACTR201203000369163

Assessment of carboprost tromethamine for reducing hemorrhage in laparoscopic intramural myomectomy

The aim of the present study was to evaluate the effect of carboprost tromethamine on blood loss during laparoscopic myomectomy (LM) in females. Ninety women, who were scheduled for LM due to symptomatic uterine myomas, were randomly divided into three groups. Twenty-four women were intramyometrially injected with 12 IU diluted vasopressin (vasopressin group), 30 cases received a deep intramuscular injection of 250 µg carboprost tromethamine 30 min prior to myomectomy (carboprost group), and 36 cases received an intramuscular injection of 250 µg carboprost tromethamine followed by a 20 IU oxytocin intravenous infusion at a rate of 120 mU/min during the procedure (carboprost plus oxytocin group). The procedure time, amount of hemorrhage, postoperative reduction in hemoglobin levels, adverse effects, bowel deflation time and time of postoperative hospital stay were compared. The procedure time, amount of hemorrhage and postoperative reduction in hemoglobin levels were not significantly different between the carboprost group and the vasopressin group (P>0.05). In the carboprost plus oxytocin group, the procedure time, amount of hemorrhage and postoperative reduction in hemoglobin levels were 24.3±2.6 min, 51.1±8.4 ml and 6.9±1.5 g/l, respectively, which were significantly less than those in the vasopressin and carboprost groups (all P<0.05). In the carboprost and carboprost plus oxytocin groups, the incidence of mild uterine contraction pain was significantly higher than in the vasopressin group (χ2=12.913, P=0.002). The incidences of other side-effects were not significantly different among the three groups. The times for bowel deflation and postoperative hospital stay were marginally increased in both the carboprost and carboprost plus oxytocin groups, compared with the vasopressin group, although no significant differences were found among the three groups (P>0.05). Deep intramuscular injections of carboprost tromethamine prior to performing myomectomy could be an effective approach for reducing blood loss from intramural LM, in particular when combined with oxytocin intravenous infusion.