Laparoscopic uterine artery bipolar coagulation plus myomectomy vs traditional laparoscopic myomectomy for "large" uterine fibroids: comparison of clinical efficacy

Use of a microsurgical vascular clip system for temporary bilateral occlusion of the four main uterine vessels for laparoscopic enucleation of very large intramural uterine fibroids

Objectives

The goal of this study was to examine the safety, feasibility, and effectiveness of the use of a microsurgical temporary vascular clip system to facilitate the laparoscopic enucleation of very large intramural uterine fibroids.

Methods

In this retrospective study, the surgical outcomes of 26 patients who underwent laparoscopic myomectomy with temporary uterine vessel clipping for very large (the largest measured diameter ≥ 9 cm) symptomatic intramural uterine fibroids in two tertiary referral hospitals between September 2017 and March 2020 were examined. Titan-made vascular clips (YASARGIL^® Aneurysm Clip System) were used to temporarily occlude the bilateral uterine arteries and utero-ovarian vessels. Main outcomes included operating time, blood loss, number of leiomyomas and weight, conversion rate, intra- and postoperative complication rates, and length of hospital stay.

Results

Twenty six patients were included. Dominant intramural uterine fibroid diameters were 9–22 cm. The general characteristics of the patients were similar. The mean surgery duration and intraoperative blood loss were 175.3 ± 32.7 (range 120–250) min and 241.1 ± 103 (range 100–450) ml, respectively. The median postoperative drop in hemoglobin was 0.89 ± 0.75 g/dL. No patient required blood transfusion. No procedure was converted to laparotomy. No major intra- or postoperative complication occurred.

Conclusions

Laparoscopic myomectomy for very large intramural uterine fibroids can be performed safely and effectively, with less intraoperative blood loss, using vascular clips for temporary clamping of the bilateral uterine vessels.

Factors influencing intraoperative blood loss and hemoglobin drop during laparoscopic myomectomy: a tailored approach is possible?

A retrospective study was conducted on patients subjected to laparoscopic myomectomy at our institution from January 2017 to December 2018 to identify predictive factors of blood loss. Two multiple regression models were run to predict intraoperative blood loss and haemoglobin drop. Predictors of an increased intraoperative blood loss and haemoglobin drop were the presence of three-four fibroids at ultrasound (+47 ml, p = .01; +0.58 g/dl, p = .05) and increased operative time (r = 0.57, p = .01; r = 0.01, p < .01), while predictors of a reduced intraoperative blood loss and haemoglobin drop were epinephrine injection (-50 ml, p < .01; -0.42 g/dl, p < .01), FIGO7 (-87 ml, p < .01; -0.85, p = .01), and FIGO6 (-35 ml, p < .01; -0.44, p = .02) fibroids at the ultrasound. Preoperative ultrasound evaluation is crucial in identifying patients at higher risk for blood loss, which could benefit from optimising haemoglobin values. The injection of diluted epinephrine could be proposed in selected high-risk patients. In the clinical practice, a tailored approach based on fibroids' ultrasonographic characteristics should be implemented to optimise preoperative Hb values and evaluate the use of diluted epinephrine in selected cases, reducing blood loss and the potential related complications.Impact statementWhat is already known on this subject? Laparoscopic myomectomy is the conservative surgical treatment of choice for symptomatic uterine fibroids. Still, it could represent a challenging procedure even for an experienced surgeon, with the risk of excessive blood loss, need of transfusions, prolonged operative time, and prolonged hospital stay. The knowledge of the predictive factors of blood loss is essential for patient preparation and surgical planning to reduce intraoperative and postoperative complications.What do the results of this study add? The results of the present study focus on the importance of presurgical evaluation to identify predictive factors of intraoperative blood loss and Hb drop such as the number of fibroids and the FIGO classification (at preoperative ultrasound), as well as intraoperative factors like operative time and the intramyometrial injection of diluted epinephrine.What are the implications of these findings for clinical practice and/or further research? A tailored approach based on the ultrasonographic characteristics of fibroids should be implemented to optimise preoperative haemoblobin levels.

Uterine fibroid vascularization: from morphological evidence to clinical implications

Uterine fibroids are the most common cause of solid pelvic tumours, occurring in 20-30% of fertile women and presenting clinical complications that seriously affect women's health. They commonly cause severe symptoms, such as heavy, prolonged menstrual bleeding and anaemia. The study of microscopic and macroscopic vascular aspects of uterine fibroids is important for understanding the clinical manifestations of uterine fibroids, for predicting the effectiveness of alternative treatments to surgery, i.e. uterine artery embolization, for improving surgery outcomes and for carrying out a differential diagnosis with other benign conditions, e.g. adenomyosis, or malignancy, e.g. leiomyosarcoma, and to develop new therapeutic approaches. In this review, current knowledge of how the vascular network and angiogenesis are implied in the formation of uterine fibroids and in the pathogenesis of related symptoms is explored, and evidence on the role of ultrasound in evaluating fibroid vascularization is summarized. This review combines anatomical, morphological and biomolecular information related to angiogenic mechanisms with diagnostic and clinical information, highlighting the various interconnections. Uterine and fibroid vascularization need further investigation to gain a deeper understanding of the pathogenetic elements that lead to the formation of uterine fibroids and their clinical manifestations.

Comparison of Laparoscopic Myomectomy with and without Uterine Artery Occlusion in Treatment of Symptomatic Multiple Myomas

Objective

Uterine artery occlusion (UAO) is a minimally invasive approach often used to treat symptomatic uterine myomas. This study aimed to compare the clinical effects of laparoscopic UAO (LUAO) in combination with laparoscopic myomectomy (LM) with LM alone to treat symptomatic multiple uterine myomas.

Methods

This was a prospective observational study. In total, 122 patients with symptomatic multiple uterine myomas underwent LUAO + LM or LM alone between April 2015 and October 2017. The surgical procedure time, blood loss, highest postoperative temperature, hospital length of stay, number of removed myomas, surgical complications, and recurrence rate of the two groups were compared.

Results

Mean blood loss was significantly lower in the LUAO + LM group compared with the LM group (177.97 ± 104.09 mL vs 258.10 ± 119.55 mL, p < 0.05). No significant difference in surgical procedure time, hospital length of stay, highest postoperative temperature, and surgical complications was found between the LUAO + LM group and LM group. The number of removed myomas was considerably higher in the LUAO + LM group than in the LM group (4[4–7] vs 3[3–5], p < 0.05). The recurrence rate in the LUAO + LM group was considerably lower than that in the LM group (6.2% vs 25.9%).

Conclusion

LUAO in combination with LM was associated with higher surgical quality and lower recurrence of myomas compared with LM alone. LUAO in combination with LM is recommended for women with symptomatic multiple uterine myomas who wish to retain their uteruses.

Combination of conservative treatment and temporary bilateral laparoscopic uterine artery clipping with hysteroscopic transcervical resection for cervical pregnancy: A retrospective study

INTRODUCTION

We investigated whether temporary bilateral laparoscopic uterine artery clipping with hysteroscopic transcervical resection (LUA clipping-TCR) is an effective minimally invasive treatment for the management of cervical pregnancy.

MATERIALS AND METHODS

This study is a retrospective clinical case series conducted at Teine Keijinkai Hospital from January 2014 to June 2019. Nine cervical pregnancies among 164 ectopic pregnancies were retrospectively examined. The intervention involved performing LUA clipping-TCR on villous tissue. Information on patient characteristics, clinical data, and surgical details was collected from medical records and surgical videos.

RESULTS

The mean (range) age of the patients was 33 years (29-41 years); and mean gestational sac diameter, 12.8 mm (5-24 mm). Five patients had a history of intrauterine procedures. Three patients had a positive fetal heartbeat. The mean (range) preoperative serum hCG level (mIU/mL), surgical time (min), uterine artery blocking time (min), and amount of surgical blood loss (ml) were 14,040 (2880-41,367), 82 (62-120), 42 (21-68), and 57 (10-200), respectively. The mean decrease in serum hCG level (second postoperative day) and duration until resumption of menstruation were 79.7 % (70-86.7 %) and 46 days (35-80 days), respectively. The hospitalization period was 2-3 days, with no evidence of persistent ectopic pregnancy. Live birth was achieved in four cases.

DISCUSSION

Our results confirm previous findings and provide new evidence that LUA clipping-TCR is effective for cervical pregnancy management and fertility preservation, respectively. Future large-scale prospective studies to compare different cervical pregnancy management methods are required.

Comparison of uterine fibroids' growth pattern during pregnancy according to fetal sex: an observational study

BACKGROUND

To investigate the effect of fetal sex on fibroids' growth during pregnancy according to the hCG serum levels METHODS: Observational study conducted from January 2007 to December 2016 on women with ultrasound identification of uterine fibroids who had a pregnancy within 1 year from diagnosis. The fibroids diameter was determined during the pre-pregnancy ultrasound, early first trimester (5-7 weeks), late first trimester (11-13 weeks), second trimester (19-21 weeks), and third trimester (31-33 weeks). The diameter growth was calculated in each interval between two ultrasounds. The hCG serum levels were determined both in early and late first trimester. The correlation between hCG levels and fibroid diameter was evaluated. Obstetric outcomes collected were gestational weeks at birth and the rate of cesarean section. Neonatal outcomes were birthweight and Apgar score at 1 min.

RESULTS

Eighty-seven of the included women had a male fetus, and 70 had a female fetus. A progressive increase of fibroid diameter was observed from pre-pregnancy to second trimester for both fetal sexes. In third trimester, the mean ± SD fibroid diameter of female fetuses showed a slowdown, while the mean ± SD fibroid diameter of male fetuses continued to grow. Women carrying a female fetus presented a higher fibroid diameter in early first trimester (33.5 ± 13.3 mm vs 27.4 ± 11.0 mm, p < 0.01), late first trimester (40.2 ± 13.9 mm vs 34.6 ± 11.7 mm, p < 0.01), and second trimester (40.5 ± 14.9 mm vs 34.7 ± 10.3 mm, p < 0.01). The hCG serum levels resulted higher in women with a female fetus: 61406 (50554-71760) mU/ml vs 46016 (37160-56744) mU/ml (p < 0.01). A positive correlation between hCG levels and fibroid diameter was found both for male and female fetuses (male r = 0.77, 95% CI 0.71-0.82, p < 0.01 and female r = 0.82, 95% CI 0.76-0.86, p < 0.01).

CONCLUSION

Women with female fetus seem to have a higher growth of fibroids up to second trimester of pregnancy. This process may be mediated by the higher serum hCG levels found in women expecting a female fetus.

Bilateral uterine artery coagulation in laparoscopic hysterectomy for benign disease in uteri more than 1000 g

AIM

We aimed to evaluate the efficacy of bipolar uterine artery coagulation in laparoscopic hysterectomy for uteri larger than 1000 g.

METHODS

Data from 674 patients who underwent laparoscopic hysterectomy were retrospectively analyzed. Among those, 75 patients with uteri weighing more than 1000 g were included. The clinical and surgical outcomes of patients with large uteri were compared according to bipolar uterine artery coagulation performance status.

RESULTS

The mean difference in intraoperative blood loss between the groups of patients with uterine artery occlusion and without uterine artery occlusion was statistically significant (89.26 ± 65.52 vs 227.94 ± 124.65 mL; P < 0.001). The hemoglobin decrease was also significantly lower in the patients with uterine artery occlusion (0.46 ± 0.23 vs 1.21 ± 0.79 g/dL; P < 0.001).

CONCLUSION

When performing laparoscopic hysterectomy of uteri weighing over 1000 g, the occlusion of the bilateral uterine arteries at the point of exit from the internal iliac arteries using bipolar coagulation at the beginning of the operation reduces intraoperative hemorrhage and hemoglobin decrease.

The association between childbirth, breastfeeding, and uterine fibroids: an observational study

The aim of this study was to investigate the effect of childbirth and breastfeeding on uterine fibroids and to identify the factors associated with size variations. This was a monocenter observational study carried on women with a sonographic diagnosis of uterine fibroids from January 2007 to December 2016, with no indication for immediate treatment, and who became pregnant within one year from diagnosis. All patients were re-evaluated six months after delivery. Fibroid diameters were compared between pre-pregnancy period, first, second, third trimester and post-delivery. The rate of "regressed" (growth of diameter <-40%), "unchanged" (growth of diameter between -40% and +40%) or "increased" (growth of diameter >+40%) fibroids at the post-delivery evaluation with respect to the pre-pregnancy state was calculated. One-hundred fifty-seven women were included in the final analysis. At the post-delivery ultrasound, a significant reduction of the fibroid diameter with respect to all previous examinations was observed, and there was no evidence of 67 (37.2%) fibroids. Ongoing breastfeeding was positively associated with an "unchanged" or "regressed" fibroid diameter (adOR 3.23, 95%CI: 1.35-7.70, p < 0.01). Smaller pre-gravidic fibroids were more likely to return to pre-pregnancy dimensions or to regress, with a cut-off of 32 mm for lactating women and of 26 mm for non-lactating women. In conclusion, fibroids seem to return to pre-pregnancy dimensions or to regress in the post-partum period. This process may be sustained by uterine involution and hormonal variations, with an additional role of breastfeeding.

Laparoscopic management of uncommon benign uterine tumors: a systematic review

The objective of the study was to review the reported cases of uncommon benign uterine tumors managed by laparoscopy. Medline database was searched using predefined search terms linked to atypical leiomyomas, leiomyoma variants, laparoscopy and morcellation. Quality of articles was assessed using Joanna Briggs Institute (JBI) critical appraisal tool. Due to heterogeneity in reporting characteristics of the patients, radiological findings, macroscopic findings, histological characteristics and follow-up, we performed a narrative synthesis. We included 109 cases of leiomyoma variants managed by laparoscopy. This stands for an incidence of 2.5% out of all the included laparoscopic management of leiomyomas. These cases were approached as classic leiomyoma. Only after the final histological results that their uncommon aspect was diagnosed. Intra-operatively, the management was similar to that of leiomyoma, with either myomectomy or hysterectomy performed depending on each individual case. Follow-up of these cases was variable: one case (0.9%) recurred as peritoneal sarcoma after 5 years of follow-up. It is important for the gynecologist, radiologist and pathologist to be aware about leiomyoma variants trying to diagnose them preoperatively. Strict follow-up of these cases is mandatory, because of the risk of recurrence and the very low but possible risk of future sarcomas.

Combined Laparoscopic Uterine Artery Occlusion and Myomectomy versus Laparoscopic Myomectomy: A Direct-Comparison Meta-Analysis of Short- and Long-Term Outcomes in Women with Symptomatic Leiomyomas

OBJECTIVE

To ascertain the efficacy and safety of laparoscopic uterine artery occlusion (LUAO) during laparoscopic myomectomy (LM) on intra- and postoperative morbidity and to assess its impact on leiomyoma recurrence rates.

DATA SOURCES

MEDLINE, Scopus, Web of Science, and Cochrane Database were searched for relevant references from inception until December 2018, in line with PRISMA guidelines.

METHODS OF STUDY SELECTION

Two authors screened for study eligibility and extracted data. Randomized controlled trials (RCTs) and observational studies (OSs) comparing short- and long-term morbidity of LM with or without LUAO were included. The modified Jadad score and the methodologic index for nonrandomized studies were used to evaluate the quality of RCTs and OSs, respectively.

TABULATION, INTEGRATION, AND RESULTS

Twelve studies encompassing 750 LM and 873 LUAO-LM cases were included in the meta-analysis. The studies were of moderate quality. LUAO-LM appears to significantly decrease intraoperative blood loss, postoperative hemoglobin drop, and blood transfusion rate. A trend toward shorter hospital length of stay was demonstrated, whereas no significant difference in operation duration was observed. The combined procedure seemingly contributes to lower recurrence rate. No LUAO-related complications were reported. Moderate to high heterogeneity was observed for few outcomes.

CONCLUSION

This is the first meta-analysis to date to provide a convincing overview of efficacy and safety of LUAO-LM. Although a medium risk of bias warrants some caution with interpretation of the results, LUAO-LM seemingly improves intra- and postoperative outcomes in women with symptomatic leiomyomas.

Laparoscopic reversible occlusion of uterine arteries and cornuostomy for advanced interstitial pregnancy

During laparoscopic enucleation of an interstitial pregnancy, adequate hemostatic control is of paramount importance due to the high vascularization of the uterine cornus. However, no consensus or guidance exists regarding the optimal hemostatic technique. We report laparoscopic reversible uterine arteries occlusion as hemostatic technique during laparoscopic enucleation by cornuostomy of an interstitial pregnancy at advanced gestational age (46 × 40 mm gestational sac). Preliminary identification of the uterine arteries and bilateral reversible occlusion by Hem-o-Lok clips allowed bleeding control during surgery. The laparoscopic procedure was performed without complications and with limited blood loss. The reported case reinforces the feasibility of this minimally invasive technique in interstitial pregnancy.