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Giannini A, Cuccu I, D'Auge TG, De Angelis E, Laganà AS, Chiantera V, Caserta D, Vitale SG, Muzii L, D'Oria O, Perniola G, Bogani G, Di Donato V. The great debate: Surgical outcomes of laparoscopic versus laparotomic myomectomy. A meta-analysis to critically evaluate current evidence and look over the horizon. Eur J Obstet Gynecol Reprod Biol 2024; 297:50-58. [PMID: 38581885 DOI: 10.1016/j.ejogrb.2024.03.045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2024] [Revised: 03/28/2024] [Accepted: 03/31/2024] [Indexed: 04/08/2024]
Abstract
Myomectomy is one of the most common surgical procedure in the field of gynecology. However, the role of laparoscopic myomectomy is still debated for many factors, including surgical considerations, safety and fertility concerns, long-term outcomes, and cost-related issues. The aim of this study is to evaluate the surgical peri- and post-operative outcomes of laparoscopic and abdominal myomectomy. A systematic search for studies was performed up to June 2023 through MEDLINE, Pubmed, Embase. Studies reporting the comparison of surgical and obstetrical outcomes in laparoscopic versus laparotomic myomectomy were included for the following outcomes: time of surgery, estimated blood loss, decrease of postoperative hemoglobin, hospital stay, intra-operative complication rates, postoperative complications rates, postoperative analgesic use, postoperative pain at 24 h and pregnancy rate. The meta-analysis was performed using the Cochrane Review software. Fifty-six relevant articles were retrieved through the process of evidence acquisition. Eleven articles met inclusion criteria, for a total of 2,133 patients undergoing laparoscopic or laparotomic myomectomy. The estimated blood loss [standard mean differences (SMD) 0.72, IC 95 % 0.22 to 1.22], the hospital stays [SMD 3.12, IC 95 % 0.57 to 4.28], were significantly lower in laparoscopic than in open group. No statistically significant difference in intra-operative and post-operative complication rates, in pregnancy rate and others obstetrical outcomes between two surgical approaches were found. The findings of present metanalysis suggest that laparoscopic myomectomy offers multiple benefits, including reduced blood loss, shorter hospital stays, and less postoperative analgesic need, without a significant increase in complication rates and similar results in obstetrical outcomes when compared to abdominal myomectomy. However, the presence of few randomized studies on selected population may limit the generalizability of the findings to the entire population. Therefore, more well-designed studies or large population programdata to draw definitive conclusions are therefore warranted.
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Affiliation(s)
- Andrea Giannini
- Department of Medical and Surgical Sciences and Translational Medicine, PhD Course in "Translational Medicine and Oncology", Sapienza University, Viale dell'Università, 37, 00185 Rome, Italy; Gynecology Division, Department of Medical and Surgical Sciences and Translational Medicine, Sant'Andrea University Hospital, Sapienza University of Rome, Via di Grottarossa 1035, 00189 Rome, Italy; Unit of Gynecology, Sant'Andrea Hospital, Department of Surgical and Medical Sciences and Translational Medicine, Sapienza University of Rome, 00189 Rome, Italy
| | - Ilaria Cuccu
- Department of Maternal and Child Health and Urological Sciences, Sapienza University of Rome, Policlinico Umberto I, Viale del Policlinico 155, 00161 Rome, Italy.
| | - Tullio Golia D'Auge
- Department of Maternal and Child Health and Urological Sciences, Sapienza University of Rome, Policlinico Umberto I, Viale del Policlinico 155, 00161 Rome, Italy
| | - Emanuele De Angelis
- Department of Maternal and Child Health and Urological Sciences, Sapienza University of Rome, Policlinico Umberto I, Viale del Policlinico 155, 00161 Rome, Italy
| | - Antonio Simone Laganà
- Unit of Obstetrics and Gynecology, "Paolo Giaccone" Hospital, Via Giordano Alfonso, 3, 90127 Palermo, Italy; Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties (PROMISE), University of Palermo, Piazza delle Cliniche, 2, 90127 Palermo, Italy
| | - Vito Chiantera
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties (PROMISE), University of Palermo, Piazza delle Cliniche, 2, 90127 Palermo, Italy; Unit of Gynecologic Oncology, National Cancer Institute - IRCCS - Fondazione "G. Pascale", Via Mariano Semmola, 53, 80131 Naples, Italy
| | - Donatella Caserta
- Gynecology Division, Department of Medical and Surgical Sciences and Translational Medicine, Sant'Andrea University Hospital, Sapienza University of Rome, Via di Grottarossa 1035, 00189 Rome, Italy
| | - Salvatore Giovanni Vitale
- Division of Gynecology and Obstetrics, Department of Surgical Sciences, University of Cagliari, Via Università 40, 09124 Cagliari, Italy
| | - Ludovico Muzii
- Department of Maternal and Child Health and Urological Sciences, Sapienza University of Rome, Policlinico Umberto I, Viale del Policlinico 155, 00161 Rome, Italy
| | - Ottavia D'Oria
- Department of Medical and Surgical Sciences and Translational Medicine, PhD Course in "Translational Medicine and Oncology", Sapienza University, Viale dell'Università, 37, 00185 Rome, Italy; Department of Woman's and Child's Health, Obstetrics and Gynecological Unit, San Camillo-Forlanini Hospital, Circonvallazione Gianicolense, 87, 00152 Rome, Italy
| | - Giorgia Perniola
- Department of Maternal and Child Health and Urological Sciences, Sapienza University of Rome, Policlinico Umberto I, Viale del Policlinico 155, 00161 Rome, Italy
| | - Giorgio Bogani
- Department of Gynaecologic Oncology, IRCCS National Cancer Institute, Via Giacomo Venezian 1, 20133 Milan, Italy
| | - Violante Di Donato
- Department of Maternal and Child Health and Urological Sciences, Sapienza University of Rome, Policlinico Umberto I, Viale del Policlinico 155, 00161 Rome, Italy
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Capezzuoli T, Aslan B, Vannuccini S, Orlandi G, La Torre F, Sorbi F, Fambrini M, Petraglia F. Recurrence of Uterine Fibroids After Conservative Surgery or Radiological Procedures: a Narrative Review. Reprod Sci 2024; 31:1171-1178. [PMID: 38110820 DOI: 10.1007/s43032-023-01418-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Accepted: 11/29/2023] [Indexed: 12/20/2023]
Abstract
The present narrative review aims to discuss the available data on the incidence and the risk factors of uterine fibroids (UFs) recurrence after different types of conservative surgical or radiologic procedures in women wishing to preserve their uterus. UFs are the most common benign tumors in women all over the world. Clinical presentation, including abnormal uterine bleeding (AUB), pelvic pain, bulky symptoms, and infertility affect patients' quality of life, and a large variety of conservative treatments are available especially for those with desire of pregnancy. Fertility sparing surgery, by either laparoscopy, hysteroscopy or laparotomy, or radiological interventions (uterine artery embolization, high-intensity focused ultrasound or magnetic resonance-guided focused ultrasound), are the most common therapeutic approaches. However, the genetic or acquired predisposition to UFs remain despite the treatments, and the recurrences are frequently described in a large percentage of patients. The most relevant risk factors for recurrence of UFs are young age at the first surgery, incomplete fibroid resection, the presence of multiple lesions, an enlarged uterus, and the coexistence with other pelvic diseases. The discussion on the possible medical strategy to reduce the recurrence is an open field of clinical investigation, in particular by using hormonal drugs.
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Affiliation(s)
- Tommaso Capezzuoli
- Department of Experimental, Clinical and Biomedical Sciences, University of Florence, Careggi University Hospital, Viale Morgagni 44, 50134, Florence, Italy
| | - Batuhan Aslan
- Department of Obstetrics and Gynecology, Ankara University School of Medicine, Ankara, Turkey
| | - Silvia Vannuccini
- Department of Experimental, Clinical and Biomedical Sciences, University of Florence, Careggi University Hospital, Viale Morgagni 44, 50134, Florence, Italy
| | - Gretha Orlandi
- Department of Experimental, Clinical and Biomedical Sciences, University of Florence, Careggi University Hospital, Viale Morgagni 44, 50134, Florence, Italy
| | - Francesco La Torre
- Department of Experimental, Clinical and Biomedical Sciences, University of Florence, Careggi University Hospital, Viale Morgagni 44, 50134, Florence, Italy
| | - Flavia Sorbi
- Department of Experimental, Clinical and Biomedical Sciences, University of Florence, Careggi University Hospital, Viale Morgagni 44, 50134, Florence, Italy
| | - Massimiliano Fambrini
- Department of Experimental, Clinical and Biomedical Sciences, University of Florence, Careggi University Hospital, Viale Morgagni 44, 50134, Florence, Italy
| | - Felice Petraglia
- Department of Experimental, Clinical and Biomedical Sciences, University of Florence, Careggi University Hospital, Viale Morgagni 44, 50134, Florence, Italy.
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Cianci S, Gulino FA, Palmara V, La Verde M, Ronsini C, Romeo P, Occhipinti S, Incognito GG, Capozzi VA, Restaino S, Vizzielli G, Palumbo M. Exploring Surgical Strategies for Uterine Fibroid Treatment: A Comprehensive Review of Literature on Open and Minimally Invasive Approaches. MEDICINA (KAUNAS, LITHUANIA) 2023; 60:64. [PMID: 38256325 PMCID: PMC10820219 DOI: 10.3390/medicina60010064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/25/2023] [Revised: 12/19/2023] [Accepted: 12/27/2023] [Indexed: 01/24/2024]
Abstract
Background and Objectives: Uterine myomas represent one of the most prevalent pathologies affecting the female population. These benign neoplasms originate from the smooth muscular cells of the uterus, and they can be either single or multiple. Often associated with debilitating symptoms such as pelvic heaviness, pain, constipation, and urinary dysfunctions, the surgical management of myomectomy exhibits considerable variability. This diversity in approaches is influenced by factors such as the number and size of myomas, the patient's age, and overall clinical conditions. This study aims to elucidate and compare the advantages and disadvantages of different surgical approaches, specifically endoscopic procedures versus open surgery, providing valuable insights for clinical decision making. Materials and Methods: A comprehensive bibliographic search spanning from 2013 to 2023 was systematically conducted across databases including Medline, Embase, the Cochrane Database of Systematic Reviews, and ClinicalTrials.gov. The search utilized keywords such as "myomectomy laparoscopic and open", "myomectomy open and minimally invasive", "myomectomy open and laparoscopic", and "myomectomy open vs. laparoscopic." The research methodology, along with predetermined inclusion and exclusion criteria, was established prior to the search, ensuring a systematic and rigorous approach. Subsequently, data analysis was carried out. Results: Following the study selection process, 25 articles met the eligibility criteria for inclusion in this analysis. The average numbers of myomas were 3.7 (ranging from 1 to 13.7) and 5.4 (ranging from 1 to 13.5) for the minimally invasive surgery and open surgery groups, respectively. In terms of myoma size, the total averages across studies were 7 cm (ranging from 4.8 to 14) for the minimally invasive group and 8 cm (ranging from 3.9 to 11.2) for the open surgery group. The average pregnancy and delivery rates were 29.7% (ranging from 1.8 to 100) for the minimally invasive group and 28.5% (ranging from 1.8 to 100) for the open surgery group. Regarding complications, the average rate was 14.2% (ranging from 0 to 50) for the endoscopic group and 22.3% (ranging from 0 to 60.3) for the laparotomic group. Conclusions: In conclusion, a critical factor influencing the choice of surgical approach is primarily the size and quantity of fibroids. The mini-laparotomic approach emerges as a viable alternative to endoscopy, demonstrating favorable surgical outcomes and aesthetic results. Interestingly, the type of surgical procedure appears to have no significant impact on the pregnancy rate.
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Affiliation(s)
- Stefano Cianci
- Unit of Gynecology and Obstetrics, Department of Human Pathology of Adult and Childhood “G. Barresi”, University of Messina, 98122 Messina, Italy; (F.A.G.); (V.P.); (P.R.)
| | - Ferdinando Antonio Gulino
- Unit of Gynecology and Obstetrics, Department of Human Pathology of Adult and Childhood “G. Barresi”, University of Messina, 98122 Messina, Italy; (F.A.G.); (V.P.); (P.R.)
| | - Vittorio Palmara
- Unit of Gynecology and Obstetrics, Department of Human Pathology of Adult and Childhood “G. Barresi”, University of Messina, 98122 Messina, Italy; (F.A.G.); (V.P.); (P.R.)
| | - Marco La Verde
- Department of Woman, Child and General and Specialized Surgery, University of Campania “Luigi Vanvitelli”, 80138 Naples, Italy; (M.L.V.); (C.R.)
| | - Carlo Ronsini
- Department of Woman, Child and General and Specialized Surgery, University of Campania “Luigi Vanvitelli”, 80138 Naples, Italy; (M.L.V.); (C.R.)
| | - Paola Romeo
- Unit of Gynecology and Obstetrics, Department of Human Pathology of Adult and Childhood “G. Barresi”, University of Messina, 98122 Messina, Italy; (F.A.G.); (V.P.); (P.R.)
| | - Sara Occhipinti
- Department of General Surgery and Medical Surgical Specialties, University of Catania, 95124 Catania, Italy; (S.O.); (G.G.I.); (M.P.)
| | - Giosuè Giordano Incognito
- Department of General Surgery and Medical Surgical Specialties, University of Catania, 95124 Catania, Italy; (S.O.); (G.G.I.); (M.P.)
| | - Vito Andrea Capozzi
- Department of Obstetrics and Gynecology, University of Parma, 43125 Parma, Italy;
| | - Stefano Restaino
- Clinic of Obstetrics and Gynecology, “Santa Maria della Misericordia” University Hospital, Azienda Sanitaria Universitaria Friuli Centrale, 33100 Udine, Italy; (S.R.); (G.V.)
| | - Giuseppe Vizzielli
- Clinic of Obstetrics and Gynecology, “Santa Maria della Misericordia” University Hospital, Azienda Sanitaria Universitaria Friuli Centrale, 33100 Udine, Italy; (S.R.); (G.V.)
- Department of Medicine, University of Udine, 33100 Udine, Italy
| | - Marco Palumbo
- Department of General Surgery and Medical Surgical Specialties, University of Catania, 95124 Catania, Italy; (S.O.); (G.G.I.); (M.P.)
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Cañete ML, Hernandez A, Romero V, Lobo I, Alcazar JL. Nuevo paradigma en la cirugía del mioma: reparación uterina. CLINICA E INVESTIGACION EN GINECOLOGIA Y OBSTETRICIA 2023. [DOI: 10.1016/j.gine.2023.100859] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/08/2023]
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Sanchez Diaz E, Rendon Pereira GJ, Pareja R, Palacios Rodriguez OG, Serna Ortíz CA, Huertas Duran CP. Recurrent leiomyomatosis peritonealis disseminata. Int J Gynecol Cancer 2023; 33:827-832. [PMID: 37127328 DOI: 10.1136/ijgc-2023-004409] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/03/2023] Open
Affiliation(s)
| | | | - Rene Pareja
- Gynecologic Oncology, Clinica ASTORGA and Instituto Nacional de Cancerología, Medellín and Bogotá, Colombia
| | | | - Carlos Andres Serna Ortíz
- CES University CES Clinic, Medellin, Colombia
- Pathology Department, Clinica Las Américas AUNA, Medellín, Colombia
| | - Claudia Patricia Huertas Duran
- Radiology, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
- Department of Radiology, Clinica Las Américas AUNA, Medellín, Colombia
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Simko S, Dallas K, Molina AL, Siedhoff MT, Wright KN, Anger JT, Truong MD. Rates of Complications and Reoperation after Myomectomy-the Impact of Surgical Approach: A Statewide Population-based Cohort Study from 2005-2018. J Minim Invasive Gynecol 2022; 29:1157-1164. [PMID: 35781056 DOI: 10.1016/j.jmig.2022.06.021] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2022] [Revised: 06/23/2022] [Accepted: 06/25/2022] [Indexed: 12/30/2022]
Abstract
STUDY OBJECTIVE To assess rates of and factors associated with complications and reoperation after myomectomy. DESIGN Population-based cohort study. SETTING All non-Veterans Affairs facilities in the state of California from January 1, 2005, to December 31, 2018. PARTICIPANTS Women undergoing abdominal or laparoscopic myomectomy for myoma disease were identified from the Office of Statewide Health Planning and Development datasets using appropriate International Classification of Diseases, Ninth and Tenth Revision and Current Procedural Terminology codes. INTERVENTIONS Demographics, surgery facility type, facility surgical volume, and surgical approach were identified. Primary outcomes included complications occurring within 60 days of surgery and reoperations for myomas. Patients were followed up for over an average of 7.3 years. Univariate and multivariable associations were explored between the above factors and rates of complications and reoperation. All odds ratios (ORs) are adjusted ORs. MEASUREMENTS AND MAIN RESULTS Of the 66 012 patients undergoing myomectomy, 5265 had at least one complication (8.0%). Advanced age, black, Asian race, MediCal and Medicare payor status, academic facility, and medical comorbidities were associated with increased odds of a complication. Minimally invasive myomectomy (MIM) was associated with decreased complications compared with abdominal myomectomy (AM) (OR, 0.29; 95% confidence interval [CI], 0.25-0.33; p <.001). Overall, 17 377 patients (26.3%) underwent reoperation. Medicare and MediCal payor status and medical comorbidities were associated with increased odds of a repeat surgery. Reoperation rates were higher in the MIM group over the entire study period (OR, 2.33; 95% CI, 1.95-2.79; p <.001). However, the odds of reoperation after MIM decreased each year (OR, 0.93; 95% CI 0.92-0.95; p <.001), with the odds of reoperation after AM surpassing MIM in 2015. CONCLUSION This study identifies outcome disparities in the surgical management of myomas and describes important differences in the rates of complications and reoperations, which can be used to counsel patients on surgical approach. These findings suggest that MIM can be considered a lasting and safe approach in properly selected patients.
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Affiliation(s)
- Sarah Simko
- Department of Obstetrics and Gynecology, Adventist Health White Memorial Medical Center (Dr. Simko), University of California San Diego, Los Angeles, California.
| | - Kai Dallas
- Division of Urology, Department of Surgery, City of Hope Medical Center (Dr. Dallas), University of California San Diego, Los Angeles, California
| | - Andrea L Molina
- Department of Obstetrics and Gynecology, Cedars-Sinai Medical Center (Drs. Molina, Siedhoff, Wright, and Truong), University of California San Diego, Los Angeles, California
| | - Matthew T Siedhoff
- Department of Obstetrics and Gynecology, Cedars-Sinai Medical Center (Drs. Molina, Siedhoff, Wright, and Truong), University of California San Diego, Los Angeles, California
| | - Kelly N Wright
- Department of Obstetrics and Gynecology, Cedars-Sinai Medical Center (Drs. Molina, Siedhoff, Wright, and Truong), University of California San Diego, Los Angeles, California
| | - Jennifer T Anger
- Division of Urology, Department of Surgery, University of California San Diego (Dr. Anger), Los Angeles, California
| | - Mireille D Truong
- Department of Obstetrics and Gynecology, Cedars-Sinai Medical Center (Drs. Molina, Siedhoff, Wright, and Truong), University of California San Diego, Los Angeles, California
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Current Trends in the Evaluation and Management of Uterine Fibroids. CURRENT OBSTETRICS AND GYNECOLOGY REPORTS 2022. [DOI: 10.1007/s13669-022-00331-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Jonsdottir G, Beermann M, Lundgren Cronsioe A, Hasselrot K, Kopp Kallner H. Ultrasound guided microwave ablation compared to uterine artery embolization treatment for uterine fibroids - a randomized controlled trial. Int J Hyperthermia 2022; 39:341-347. [PMID: 35134317 DOI: 10.1080/02656736.2022.2034991] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
OBJECTIVE To evaluate the efficacy, feasibility and acceptability of microwave ablation (MWA) compared to uterine artery embolization (UAE) as treatment for uterine fibroids. METHOD A randomized controlled superiority trial, including premenopausal women 30-55 years, with symptomatic uterine fibroids without any single fibroid exceeding mean diameter of eight centimeters. Patients were randomized to receive microwave ablation, performed abdominally or vaginally, or to uterine artery embolization. The primary outcome was volume difference of the three largest fibroids at 6 months post treatment evaluated by magnetic resonance imaging (MRI) by a blinded radiologist analyzed by Mann-Whitney U-test. Secondary outcomes included symptom severity score (SSS), health related quality of life (HR-QoL), amount of menstrual bleeding, postoperative pain, length of hospitalization, need for additional treatment, adverse events and if patients would recommend the treatment to a friend. RESULTS Patients were recruited from 30 January 2017 to 12 September 2019, with a total of 17 patients treated in each group from May 2017 to December 2019. Superiority of MWA could not be established. The volume reduction was 41.8% (Interquartile range, IQR, 14-63) in the MWA group compared to 62.2% (IQR 34.9-80.1) in the UAE group (p = 0.29). Effects on symptoms, HR-QoL and acceptability did not differ between groups. Days of hospitalization and sick leave were significantly fewer in the MWA group (p < 0.001 and p = 0.001). CONCLUSIONS Although superiority of MWA could not be established, it is a promising technique for treating uterine fibroids. It was well tolerated and associated with lower use of health care resources. Trial registration: NCT02942537, www.clincialtrials.gov.
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Affiliation(s)
- Gudny Jonsdottir
- Department of Obstetrics and Gynecology, Danderyd Hospital, Stockholm, Sweden.,Department of Clinical Sciences at, Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden
| | - Marie Beermann
- Department of Clinical Sciences at, Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden.,Department of Radiology, Danderyd Hospital, Stockholm, Sweden
| | | | - Klara Hasselrot
- Department of Obstetrics and Gynecology, Danderyd Hospital, Stockholm, Sweden.,Department of Clinical Sciences at, Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden
| | - Helena Kopp Kallner
- Department of Obstetrics and Gynecology, Danderyd Hospital, Stockholm, Sweden.,Department of Clinical Sciences at, Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden
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Abstract
Uterine leiomyomas (fibroids) are the most common solid and symptomatic neoplasm in women. They are the leading indication for hysterectomy (1, 2), which is a definitive and effective surgical treatment for leiomyoma. However, many patients benefit from and seek out management options other than hysterectomy because they desire future childbearing or wish to retain their uterus. The purpose of this Practice Bulletin is to provide updated evidence-based recommendations for the medical, procedural, and surgical management of symptomatic leiomyomas. Discussion of the use of morcellation in the surgical management of leiomyomas is beyond the scope of this document and is addressed in a separate American College of Obstetricians and Gynecologists (ACOG) publication (3).
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