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Satorres E, Orive A, Ruiz C, Monleón J. [Uterine fibroid surgical treatment]. Med Clin (Barc) 2023; 161 Suppl 1:S22-S26. [PMID: 37923510 DOI: 10.1016/j.medcli.2023.07.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Revised: 07/07/2023] [Accepted: 07/08/2023] [Indexed: 11/07/2023]
Affiliation(s)
- Elena Satorres
- Servicio de Ginecología, Hospital Universitario y Politécnico La Fe, Valencia, España
| | - Alba Orive
- Servicio de Ginecología, Hospital Universitario y Politécnico La Fe, Valencia, España
| | - Carmen Ruiz
- Servicio de Ginecología, Hospital Universitario y Politécnico La Fe, Valencia, España
| | - Javier Monleón
- Servicio de Ginecología, Hospital Universitario y Politécnico La Fe, Valencia, España.
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Tal MG, Keidar R, Magnazi G, Henn O, Kim JH, Chudnoff SG, Stepp KJ. Pressure-Induced Fibroid Ischemia: First-In-Human Experience with a Novel Device for Laparoscopic Treatment of Symptomatic Uterine Fibroids. Reprod Sci 2023; 30:1366-1375. [PMID: 35941511 PMCID: PMC9360636 DOI: 10.1007/s43032-022-01033-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2022] [Accepted: 07/04/2022] [Indexed: 11/29/2022]
Abstract
The purpose of this study was to assess the feasibility of use of a novel uterine fibroid treatment device hypothesized to cause fibroid infarction by increasing intra-tumoral pressure. Between August 2019 and January 2020, 21 uterine fibroids were treated in 16 symptomatic pre-menopausal black women. Pelvic magnetic resonance imaging was performed before the procedure, a day after the procedure and at 1, 3, 6, and 12 months. The subjects were also followed for clinical outcomes and quality of life up to 12 months at a single investigational site. At 3 months, the mean reduction in the fibroid volume was 36.3% (P = .002). Incremental reduction in volume peaked at the end of the follow-up, at the 12-month mark (60.4%; P = .008). There were no procedures in which the users failed to perform laparoscopic pressure suturing of fibroids with the pressure-induced fibroid ischemia device. Improvement in the quality of life was evident in the Health-Related Quality of Life total, Energy/Mood, Control, and Sexual Function domains of the Uterine Fibroid Symptom and Quality of Life questionnaire at 3 months post-procedure. Unanticipated risks were not identified. Serious adverse events were not identified. The initial clinical assessment of the pressure-induced fibroid ischemia device supports feasibility of the approach and does not reveal serious safety concerns. Trial is currently being registered retrospectively (This was a feasibility study and therefore registration was not mandatory).
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Affiliation(s)
- Michael G Tal
- Division of Interventional Radiology, Hadassah Medical Center, Jerusalem, Israel.
| | - Ran Keidar
- Department of Obstetrics and Gynecology, E. Wolfson Medical Center, Holon, Israel
- Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | | | - Ohad Henn
- Empress Medical Ltd., Tel Aviv, Israel
| | - Jin Hee Kim
- Department of Obstetrics & Gynecology, Columbia University, New York, NY, USA
| | - Scott G Chudnoff
- Obstetrics and Gynecology, Maimonides Medical Center, New York, NY, USA
| | - Kevin J Stepp
- Atrium Health Women's Care Urogynecology and Pelvic Surgery, Atrium Health, Charlotte, NC, USA
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Matasariu DR, Ursache A, Himiniuc L, Toma B, Boiculese VL, Grigore M, Dumitrascu I. Research on myoma in Northeastern Romania and socio-medical outcomes. Exp Ther Med 2022; 23:30. [PMID: 34824638 PMCID: PMC8611495 DOI: 10.3892/etm.2021.10952] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2021] [Accepted: 09/07/2021] [Indexed: 11/13/2022] Open
Abstract
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.
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Affiliation(s)
- Daniela Roxana Matasariu
- Department of Obstetrics and Gynecology, ‘Grigore T. Popa’ University of Medicine and Pharmacy, 700115 Iasi, Romania
| | - Alexandra Ursache
- Department of Obstetrics and Gynecology, ‘Grigore T. Popa’ University of Medicine and Pharmacy, 700115 Iasi, Romania
| | - Loredana Himiniuc
- Department of Obstetrics and Gynecology, ‘Grigore T. Popa’ University of Medicine and Pharmacy, 700115 Iasi, Romania
| | - Bogdan Toma
- Department of Obstetrics and Gynecology, ‘Grigore T. Popa’ University of Medicine and Pharmacy, 700115 Iasi, Romania
| | - Vasile Lucian Boiculese
- Department of Preventive Medicine and Interdisciplinarity Medical Informatics and Biostatistics, ‘Grigore T. Popa’ University of Medicine and Pharmacy, 700115 Iasi, Romania
| | - Mihaela Grigore
- Department of Obstetrics and Gynecology, ‘Grigore T. Popa’ University of Medicine and Pharmacy, 700115 Iasi, Romania
- Department of Obstetrics and Gynecology, ‘Cuza Voda’ Obstetrics and Gynecology Clinical Hospital, 700038 Iasi, Romania
| | - Irina Dumitrascu
- Department of Obstetrics and Gynecology, ‘Grigore T. Popa’ University of Medicine and Pharmacy, 700115 Iasi, Romania
- Department of Obstetrics and Gynecology, ‘Cuza Voda’ Obstetrics and Gynecology Clinical Hospital, 700038 Iasi, Romania
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Lee SR, Lee ES, Lee YJ, Lee SW, Park JY, Kim DY, Kim SH, Kim YM, Suh DS, Kim YT. Robot-Assisted Laparoscopic Myomectomy versus Abdominal Myomectomy for Large Myomas Sized over 10 cm or Weighing 250 g. Yonsei Med J 2020; 61:1054-1059. [PMID: 33251780 PMCID: PMC7700878 DOI: 10.3349/ymj.2020.61.12.1054] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2020] [Revised: 10/22/2020] [Accepted: 10/29/2020] [Indexed: 12/27/2022] Open
Abstract
PURPOSE Here, we compared the operative and perioperative outcomes between robot-assisted laparoscopic myomectomy (RALM) and abdominal myomectomy (AM) in patients with large (>10 cm) or heavy myomas (>250 g). MATERIALS AND METHODS We included 278 patients who underwent multi-port RALM (n=126) or AM (n=151) for large or heavy myomas in a tertiary care hospital between April 2019 and June 2020. The t-test, chi-square, Bonferroni's test, and multiple linear regression were used. RESULTS No differences were observed in age, body mass index, parity, or history of pelvic surgery between the two groups. Myoma diameters were not different (10.8±2.52 cm vs. 11.2±3.0 cm, p=0.233), but myomas were lighter in the RALM group than in the AM group (444.6±283.14 g vs. 604.68±368.35 g, respectively, p=0.001). The RALM group had a higher proportion of subserosal myomas, fewer myomas, fewer large myomas over >3 cm, lighter myomas, and longer total operating time. However, the RALM group also had shorter hospital stay and fewer short-term complications. Estimated blood loss (EBL) was not different between the two groups. The number of removed myomas was the most significant factor (coefficient=10.89, p<0.0001) affecting the EBL. CONCLUSION RALM is a feasible myomectomy technique even for large or heavy myomas. RALM patients tend to have shorter hospital stays and fewer postoperative fevers within 48 hours. However, RALM has longer total operating time.
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Affiliation(s)
- Sa Ra Lee
- Department of Obstetrics & Gynecology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea.
| | - Eun Sil Lee
- Department of Obstetrics & Gynecology, Soonchunhyang University Seoul Hospital, Soonchunhyang University College of Medicine, Seoul, Korea
| | - Young Jae Lee
- Department of Obstetrics & Gynecology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Shin Wha Lee
- Department of Obstetrics & Gynecology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jeong Yeol Park
- Department of Obstetrics & Gynecology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Dae Yeon Kim
- Department of Obstetrics & Gynecology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Sung Hoon Kim
- Department of Obstetrics & Gynecology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Yong Man Kim
- Department of Obstetrics & Gynecology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Dae Shik Suh
- Department of Obstetrics & Gynecology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Young Tak Kim
- Department of Obstetrics & Gynecology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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ÇOŞKUN B, GÜZEL Aİ, ÇOŞKUN B, KOKANALI D, ŞİMŞİR C, DOĞANAY M. The evaluation of association between body mass index and clinical parameters in women underwent myomectomy. JOURNAL OF HEALTH SCIENCES AND MEDICINE 2020. [DOI: 10.32322/jhsm.650925] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
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Aslan Çetin B, Aydoğan Mathyk B, Köroğlu N, Soydar A, Demirayak G, Çift T. Oxytocin infusion reduces bleeding during abdominal myomectomies: a randomized controlled trial. Arch Gynecol Obstet 2018; 299:151-157. [PMID: 30328494 DOI: 10.1007/s00404-018-4944-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2018] [Accepted: 10/12/2018] [Indexed: 10/28/2022]
Abstract
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.
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Affiliation(s)
- Berna Aslan Çetin
- Department of Obstetrics and Gynecology, İstanbul Kanuni Sultan Süleyman Training and Research Hospital, Altınşehir, 34303, Halkalı, Istanbul, Turkey.
| | | | - Nadiye Köroğlu
- Department of Obstetrics and Gynecology, İstanbul Kanuni Sultan Süleyman Training and Research Hospital, Altınşehir, 34303, Halkalı, Istanbul, Turkey
| | - Ali Soydar
- Department of Obstetrics and Gynecology, İstanbul Kanuni Sultan Süleyman Training and Research Hospital, Altınşehir, 34303, Halkalı, Istanbul, Turkey
| | - Gökhan Demirayak
- Obstetrics and Gynecology Department, İstanbul Sadi Konuk Training and Research Hospital, Istanbul, Turkey
| | - Tayfur Çift
- Obstetrics and Gynecology Department, Bursa Yüksek Ihtisas Training and Research Hospital, Bursa, Turkey
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7
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Morbidity, fertility and pregnancy outcomes after myoma enucleation by laparoscopy versus laparotomy. Arch Gynecol Obstet 2018; 297:969-976. [PMID: 29417281 DOI: 10.1007/s00404-018-4697-5] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2017] [Accepted: 01/30/2018] [Indexed: 10/18/2022]
Abstract
OBJECTIVES Myomas are defined as benign tumours that arise from smooth muscle cells of the uterus. Clinically, they are found in 5-77% of women of reproductive age. The prevalence rate varies considerably in the literature and a large number of fibroids do not cause symptoms. The lifetime risk of acquiring myomas is 70% for Caucasian women and ≥ 80% for African American women. MATERIALS/METHODS The data of 265 patients undergoing surgery for symptomatic myomas by laparoscopy or laparotomy, performed in the gynaecological department of Hannover Medical School, Hannover, Germany, between 2009 and 2013, were retrospectively analysed in this retrospective design study. RESULTS High pregnancy rates (up to 70%) and birth rates (up to 86%) after myomectomy, regardless of the surgical approach adopted, were found in the current study. The trend was that ≥ 3 myomas and those that were ≥ 6 cm in size were almost always removed by laparotomy in our clinic. It was possible to remove up to 42 myomas without having to perform a hysterectomy. A statistically significant negative correlation was observed in relation to the association between the size of the largest myoma extracted and the pregnancy rate (p = 0.02). A statistically significant correlation between the number of removed myomas and the pregnancy rate was observed for patients who wished to bear children (p = 0.010). Elevated complication rates (of up to 50%) were reported for more than three extracted myomas with a statistically significance (p = 0.0471). CONCLUSIONS It is necessary to ensure sound preoperative selection of the surgical approach in order to achieve the most optimal results, especially for those patients who wished to bear children.
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Development and evaluation of an improved laparoscopic myomectomy adopting intracapsular rotary-cut procedures. Eur J Obstet Gynecol Reprod Biol 2018; 221:5-11. [DOI: 10.1016/j.ejogrb.2017.11.021] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2017] [Revised: 11/02/2017] [Accepted: 11/26/2017] [Indexed: 12/28/2022]
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9
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Arian SE, Munoz JL, Kim S, Falcone T. Robot-assisted laparoscopic myomectomy: current status. ROBOTIC SURGERY : RESEARCH AND REVIEWS 2017; 4:7-18. [PMID: 30697559 PMCID: PMC6193424 DOI: 10.2147/rsrr.s102743] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
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.
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Affiliation(s)
- Sara E Arian
- Department of Obstetrics, Gynecology, and Women's Health Institute, Cleveland Clinic, Cleveland, OH, USA,
| | - Jessian L Munoz
- Department of Obstetrics, Gynecology, and Women's Health Institute, Cleveland Clinic, Cleveland, OH, USA,
| | - Suejin Kim
- Department of Obstetrics, Gynecology, and Women's Health Institute, Cleveland Clinic, Cleveland, OH, USA,
| | - Tommaso Falcone
- Department of Obstetrics, Gynecology, and Women's Health Institute, Cleveland Clinic, Cleveland, OH, USA,
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Atashkhoei S, Fakhari S, Pourfathi H, Bilehjani E, Garabaghi PM, Asiaei A. Effect of oxytocin infusion on reducing the blood loss during abdominal myomectomy: a double-blind randomised controlled trial. BJOG 2017; 124:292-298. [PMID: 27862855 DOI: 10.1111/1471-0528.14416] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/28/2016] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To assess the effectiveness and safety of oxytocin to reduce blood loss during abdominal myomectomy. DESIGN Double-blind randomised controlled trial. SETTING Obstetrics and Gynecologic University Medical Centre. POPULATION Eighty healthy women candidates for abdominal myomectomy. METHODS Women were randomly assigned to two groups. In the study group (n = 40) oxytocin 30 IU in 500 ml normal saline; and in the placebo group (n = 40) pure normal saline was administered during myomectomy. The main outcome measures were peri-operative blood loss and rates of blood transfusion. MAIN OUTCOME MEASURE Estimated intra-operative blood loss. RESULTS Estimated intra-operative blood loss in the study group (189.5 ± 16.72 ml) was significantly lower than the placebo group (692.25 ± 89.93 ml) (95% CI 672.54-711.96; P < 0.0001).The need for blood transfusion was significantly lower in the study group. Blood transfusions were required for three (7.5%) women in the study group and 10 (25%) women in the placebo group (95% CI 15.5-34.5; P < 0.001). CONCLUSIONS Intra-operative oxytocin infusion appears to be safe and effective in decreasing blood loss during abdominal myomectomy. TWEETABLE ABSTRACT Intra-operative oxytocin is effective in decreasing blood loss during abdominal myomectomy.
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Affiliation(s)
- S Atashkhoei
- Women's Reproductive Health Research Center, Al-Zahra Hospital, Tabriz University of Medical Sciences, Tabriz, Iran
| | - S Fakhari
- Women's Reproductive Health Research Center, Al-Zahra Hospital, Tabriz University of Medical Sciences, Tabriz, Iran
| | - H Pourfathi
- Women's Reproductive Health Research Center, Al-Zahra Hospital, Tabriz University of Medical Sciences, Tabriz, Iran
| | - E Bilehjani
- Women's Reproductive Health Research Center, Al-Zahra Hospital, Tabriz University of Medical Sciences, Tabriz, Iran
| | - P M Garabaghi
- Women's Reproductive Health Research Center, Al-Zahra Hospital, Tabriz University of Medical Sciences, Tabriz, Iran
| | - A Asiaei
- Women's Reproductive Health Research Center, Al-Zahra Hospital, Tabriz University of Medical Sciences, Tabriz, Iran
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Radosa JC, Radosa CG, Mavrova R, Wagenpfeil S, Hamza A, Joukhadar R, Baum S, Karsten M, Juhasz-Boess I, Solomayer EF, Radosa MP. Postoperative Quality of Life and Sexual Function in Premenopausal Women Undergoing Laparoscopic Myomectomy for Symptomatic Fibroids: A Prospective Observational Cohort Study. PLoS One 2016; 11:e0166659. [PMID: 27898669 PMCID: PMC5127523 DOI: 10.1371/journal.pone.0166659] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2016] [Accepted: 11/01/2016] [Indexed: 11/18/2022] Open
Abstract
Introduction Uterine leiomyomas are the most common benign gynecologic tumors. To date laparoscopy myomectomy is the gold standard for treatment of symptomatic fibroids in reproductive-aged women. Detailed counseling about the effects of this procedure on postoperative sexuality and quality of life is important in these patients. However, available data on these subjects are limited and contradictory. The aim of this study was to assess sexual function and quality of life in premenopausal women undergoing laparoscopic myomectomy for symptomatic uterine fibroids. Material and Methods All premenopausal women who underwent laparoscopic myomectomy for symptomatic fibroids between April 2012 and August 2014 at a tertiary university center were enrolled in this prospective observational cohort study. Sexual function and quality of life were assessed for the pre- and postoperative (six months post-operatively) state using two validated questionnaires, the Female Sexual Function Index (FSFI) and the European Quality of Life Five-Dimension Scale (EQ-5D). Results Ninety-five of the 115 (83%) eligible patients completed the study. Overall a significant improvement in quality of life and sexual function was observed in the study cohort: Median FSFI (28 (18.7–35.2)) and EQ-5D scores (1 (0.61–1) after laparoscopic myomectomy were significantly higher than preoperative scores (21.2 (5.2–33.5); 0.9 (0.2–1); p ≤ 0.01). The number, position and localization of the largest fibroids were not correlated with pre- or postoperative sexual function or quality of life. Conclusion Laparoscopic myomectomy might have positive short-term effects on postoperative quality of life and sexual function in premenopausal women suffering from symptomatic fibroids.
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Affiliation(s)
- Julia Caroline Radosa
- Department of Gynecology & Obstetrics, Saarland University Hospital, Homburg/Saar, Germany
- * E-mail:
| | | | - Russalina Mavrova
- Department of Gynecology & Obstetrics, Saarland University Hospital, Homburg/Saar, Germany
| | - Stefan Wagenpfeil
- Institute of Medical Biometry, Epidemiology & Medical Informatics, Saarland University Hospital, Homburg/Saar, Germany
| | - Amr Hamza
- Department of Gynecology & Obstetrics, Saarland University Hospital, Homburg/Saar, Germany
| | - Ralf Joukhadar
- Department of Gynecology & Obstetrics, Saarland University Hospital, Homburg/Saar, Germany
| | - Sascha Baum
- Department of Gynecology & Obstetrics, Saarland University Hospital, Homburg/Saar, Germany
| | - Maria Karsten
- Department of Gynecology, Charite Berlin, Berlin/Germany
| | - Ingolf Juhasz-Boess
- Department of Gynecology & Obstetrics, Saarland University Hospital, Homburg/Saar, Germany
| | - Erich-Franz Solomayer
- Department of Gynecology & Obstetrics, Saarland University Hospital, Homburg/Saar, Germany
| | - Marc Philipp Radosa
- Department of Gynecology and Obstetrics, Jena University Hospital, Jena, Germany
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Alkatout I, Mettler L, Günther V, Maass N, Eckmann-Scholz C, Elessawy M, Anapolski M. Safety and economical innovations regarding surgical treatment of fibroids. MINIM INVASIV THER 2016; 25:301-313. [DOI: 10.1080/13645706.2016.1190380] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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13
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Floss K, Garcia-Rocha GJ, Kundu S, von Kaisenberg CS, Hillemanns P, Schippert C. Fertility and Pregnancy Outcome after Myoma Enucleation by Minilaparotomy under Microsurgical Conditions in Pronounced Uterus Myomatosus. Geburtshilfe Frauenheilkd 2015; 75:56-63. [PMID: 25684787 PMCID: PMC4318730 DOI: 10.1055/s-0034-1396163] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2014] [Revised: 12/05/2014] [Accepted: 12/05/2014] [Indexed: 02/05/2023] Open
Abstract
Introduction: Besides the typical complaints and symptoms, myomas can cause sterility, infertility and complications during pregnancy. Laparoscopic interventions reach their limits with regard to organ preservation and the simultaneous desire to have children in the removal of multiple and larger intramural myoma nodes. The aim of this study is to examine fertility status and pregnancy outcome after myoma removal by minilaparotomy (skin incision maximal 8 cm) in women with pronounced uterus myomatosus. Materials and Methods: This retrospective study makes use of the data from 160 patients with an average age of 34.6 years. Factors analysed include number, size and localisation of the myomas, complaints due to the myoma, pre- and postoperative gravidity, mode of delivery, and complications of birth. Results: Indications for organ-sparing myoma enucleation were the desire to have children (72.5 %), bleeding disorders (60 %) and pressure discomfort (36.5 %). On average 4.95 (SD ± 0.41), maximally 46 myomas were removed. The largest myoma had a diameter of 6.64 cm (SD ± 2.74). 82.5 % of the patients had transmural myomas, in 17.5 % the uterine cavity was inadvertently opened. On average the operating time was 163 minutes (SD ± 45.47), the blood loss 1.59 g/dL (SD ± 0.955). 60.3 % of the patients with the desire to have children became pregnant postoperatively. 75.3 % of the pregnancies were on average carried through to the 38th week (28.4 % vaginal deliveries, 71.6 % Caesarean sections). In the postoperative period there was one case of uterine rupture in the vicinity of a previous scar. Discussion: By means of the microsurgical "mini-laparotomy" even extensive myomatous uterine changes can, in the majority of cases, be operated in an organ-sparing manner with retention of the ability to conceive and to carry a pregnancy through to maturity of the infant. The risk for a postoperative uterine rupture in a subsequent pregnancy and during delivery is minimal.
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Affiliation(s)
- K. Floss
- Obstetrics and Gynecology, Medical School of Hannover (MHH), Hannover
| | | | - S. Kundu
- Obstetrics and Gynecology, Medical School of Hannover (MHH), Hannover
| | | | - P. Hillemanns
- Obstetrics and Gynecology, Medical School of Hannover (MHH), Hannover
| | - C. Schippert
- Obstetrics and Gynecology, Medical School of Hannover (MHH), Hannover
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14
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Kim YM. Treatment of uterine leiomyoma: how to choose a therapeutic method? JOURNAL OF THE KOREAN MEDICAL ASSOCIATION 2015. [DOI: 10.5124/jkma.2015.58.12.1147] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Affiliation(s)
- Yong Man Kim
- Department of Obstetrics and Gynecology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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15
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Surgical Treatment of Fibroids. CURRENT OBSTETRICS AND GYNECOLOGY REPORTS 2014. [DOI: 10.1007/s13669-014-0090-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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16
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Dababneh AS, Nagpal A, Palraj BRV, Sohail MR. Clostridium hathewayi bacteraemia and surgical site infection after uterine myomectomy. BMJ Case Rep 2014; 2014:bcr-2013-009322. [PMID: 24596408 DOI: 10.1136/bcr-2013-009322] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
A 42-year-old woman with uterine fibroids underwent myomectomy. She developed postoperative sepsis and bloodstream infection with Clostridium hathewayi secondary to an infected haematoma. The patient was readmitted after failure of oral antibiotic therapy and underwent intrauterine drainage followed by prolonged parenteral antibiotic therapy. The patient was followed for 1 year and did not have any relapse of infection.
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Affiliation(s)
- Ala S Dababneh
- Infectious Diseases, Mayo Clinic, Rochester, Minnesota, USA
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17
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Koyama S, Kobayashi M, Tanaka Y, Isobe M, Miwa H, Shiki Y. Laparoscopic Repair of a Post-Myomectomy Spontaneous Uterine Perforation Accompanied by a Bizarre Tumor Resembling Polypoid Endometriosis. J Minim Invasive Gynecol 2013; 20:912-6. [DOI: 10.1016/j.jmig.2013.05.018] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2013] [Revised: 05/20/2013] [Accepted: 05/23/2013] [Indexed: 10/26/2022]
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18
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A pilot study of Foley's catheter balloon for prevention of intrauterine adhesions following breach of uterine cavity in complex myoma surgery. Arch Gynecol Obstet 2013; 288:829-32. [PMID: 23580010 DOI: 10.1007/s00404-013-2838-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2012] [Accepted: 04/01/2013] [Indexed: 10/27/2022]
Abstract
PURPOSE During abdominal myomectomy for removal of multiple fibroids, the uterine cavity may be breached. Repair of the breach is associated with a risk of development of intrauterine adhesions. We conducted a pilot study to evaluate the effectiveness of temporary placement of a Foley's catheter balloon inflated with 30 ml normal saline into uterine cavity at the end of surgery to prevent this complication. METHODS Retrospective cohort study. When the uterine cavity was breached during open myomectomy, it was repaired with a No. 2-0 vicryl suture. A Foley catheter balloon was inserted into the uterine cavity at the end of the procedure, and the balloon distended with 30 ml of normal saline. The balloon was removed on the fourth post-operative day. Follow-up hysteroscopy was performed after 6 months. RESULTS At the time of follow-up hysteroscopy 6 months after the myomectomy, we found no intrauterine adhesions in 16 consecutive women treated with balloon, compared to 3 out of 10 (30 %) historical controls where the balloon was not used. CONCLUSION A Foley catheter balloon inserted into the uterine cavity following breach and repair of the uterine cavity at open myomectomy appears to prevent the formation of intrauterine adhesions.
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Salama SS, Kılıç GS. Uterine fibroids and current clinical challenges. J Turk Ger Gynecol Assoc 2013; 14:40-5. [PMID: 24592069 PMCID: PMC3881727 DOI: 10.5152/jtgga.2013.09] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2013] [Accepted: 02/25/2013] [Indexed: 11/22/2022] Open
Abstract
Uterine fibroids (UF) are the most common gynecological tumors in premenopausal women. Hysterectomy remains the major and definitive therapeutic option. Minimally invasive surgical techniques for performing hysterectomy have many advantages over laparotomy. Current drug therapies for UF remain unsatisfactory. Unquestionably, continued investigation of novel agents is necessary. The currently used drugs for UF treatment which exclusively modulate a single target, typically either the estrogen or progesterone signaling pathways, are limited in their therapeutic effects. By contrast, multi-target drugs which simultaneously modulate multiple critical hubs in the network of the signaling pathways underlying UF pathogenesis should achieve robust and durable therapeutic effects.
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Affiliation(s)
- Salama S. Salama
- Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, Baylor College of Medicine, Houston, Texas, USA
| | - Gökhan S. Kılıç
- Department of Obstetrics and Gynecology, University of Texas Medical Branch, Galveston, Texas, USA
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20
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Shokeir T, Shalaby H, Nabil H, Barakat R. Reducing blood loss at abdominal myomectomy with preoperative use of dinoprostone intravaginal suppository: a randomized placebo-controlled pilot study. Eur J Obstet Gynecol Reprod Biol 2013; 166:61-4. [DOI: 10.1016/j.ejogrb.2012.09.014] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2012] [Revised: 07/07/2012] [Accepted: 09/13/2012] [Indexed: 11/25/2022]
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GnRH agonists: do they have a place in the modern management of fibroid disease? J Obstet Gynaecol India 2012; 62:506-10. [PMID: 24082548 DOI: 10.1007/s13224-012-0206-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2012] [Accepted: 05/26/2012] [Indexed: 10/27/2022] Open
Abstract
In the management of women with fibroid disease, GnRH agonists (GnRHa) are frequently used to reduce volume and vascularity before myomectomy, apparently to render the operation easier and reduce operative blood loss, and to enable a transverse supra-pubic incision instead of a midline vertical one. They induce amenorrhoea and thus aid in the correction of pre-operative anaemia. Other gynaecologists use GnRHa to shrink sub mucous fibroids greater than 5 cm in diameter to facilitate access and reduce blood loss and operating time at transcervical resection. GnRHa are also occasionally used as a temporizing measure in women with symptomatic fibroids within the climacteric. We argue against the use of GnRHa in the management of fibroid disease because they are not cost effective, render myomectomy more difficult to apply because they destroy tissue planes, the more difficult enucleation in fact increasing rather than reducing peri-operative blood loss and operating time. When used before myomectomy, they increase the risk of 'recurrence' because they obscure smaller fibroids that 'recur' when the effects of the GnRHa wear off, and are associated with side effects in situations where they confer no benefits, or where alternative cheaper drugs with fewer side effects are available.
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Wijesekera NT, Mauri G, Gupta S, Belli AM, Manyonda IT. MR imaging evaluation of fibroid clearance following open myomectomy for massive/multiple symptomatic fibroids. Arch Gynecol Obstet 2012; 286:1165-71. [PMID: 22710951 DOI: 10.1007/s00404-012-2404-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2012] [Accepted: 05/29/2012] [Indexed: 11/26/2022]
Abstract
PURPOSE To evaluate the technical success of total fibroid clearance at open myomectomy for massive and/or multiple symptomatic fibroids using MR imaging (MRI) as the imaging modality. METHODS The study group comprised 27 women [mean age 37.4 ± 6.9 years (range 27-53)] who underwent open myomectomy for the treatment of massive/multiple symptomatic fibroids at our institution between January 2009 and April 2010. Myomectomy was performed with the intention of achieving complete fibroid clearance. Pre- and postmyomectomy MRI was performed to assess changes in uterine volume and fibroid burden. Periprocedural data (including blood loss and complications) and relief of clinical symptoms at follow-up were also recorded. RESULTS The mean time to MRI and clinical follow-up was 10 months (range 6-15 months). The mean uterine volume premyomectomy was 795 ± 580 cc and postmyomectomy was 123 ± 70 cc (p < 0.001). The mean percentage reduction in uterine volume was 80.3 % (range 43.0-98.1 %). Of the 10/27 (37.0 %) women with residual fibroids at follow-up: 7 patients had fibroids measuring up to 1 cc in volume, 3 patients had fibroids measuring up to 6 cc. Postoperative adnexal seromas were observed in 6/27 (22.2 %) patients. The clinical success rates of myomectomy amongst the 22/27 (81 %) responders were: 73 % for menorrhagia, 64 % for pain, and 36-64 % for mass-related symptoms. CONCLUSIONS Using MRI, we have confirmed that open myomectomy can achieve total or near-total fibroid clearance in the majority of patients with massive and/or multiple fibroids.
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Affiliation(s)
- Nevin T Wijesekera
- Department of Radiology, St George's Hospital NHS Trust, Blackshaw Road, London SW17 0QT, UK.
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Talaulikar VS, Gupta S, Manyonda I. Pregnancy after complex myomectomy: neither age of patient nor size, number or location of fibroids should be a barrier. JRSM SHORT REPORTS 2012; 3:19. [PMID: 22479682 PMCID: PMC3318241 DOI: 10.1258/shorts.2011.011117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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24
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Buckley BT. Uterine artery embolisation: challenges and opportunities in cross-specialty care. Aust N Z J Obstet Gynaecol 2012; 52:103-5. [PMID: 22469021 DOI: 10.1111/j.1479-828x.2012.01431.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Chung YJ, Kim MR. Robot-assisted surgery in gynecology: indications and efficacy. JOURNAL OF THE KOREAN MEDICAL ASSOCIATION 2012. [DOI: 10.5124/jkma.2012.55.7.635] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Affiliation(s)
- Youn-Jee Chung
- Department of Obstetrics & Gynecology, Seoul St. Mary's Hospital, The Catholic University of Korea College of Medicine, Seoul, Korea
- Seoul St. Mary's Fibroid Center, The Catholic University of Korea College of Medicine, Seoul, Korea
| | - Mee-Ran Kim
- Department of Obstetrics & Gynecology, Seoul St. Mary's Hospital, The Catholic University of Korea College of Medicine, Seoul, Korea
- Seoul St. Mary's Fibroid Center, The Catholic University of Korea College of Medicine, Seoul, Korea
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Uterine Artery Embolization versus Myomectomy: Impact on Quality of Life—Results of the FUME (Fibroids of the Uterus: Myomectomy versus Embolization) Trial. Cardiovasc Intervent Radiol 2011; 35:530-6. [DOI: 10.1007/s00270-011-0228-5] [Citation(s) in RCA: 90] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2011] [Accepted: 06/10/2011] [Indexed: 11/26/2022]
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Magos A, Al-Shabibi N, Korkontzelos I, Gkioulekas N, Tsibanakos I, Gkoutzioulis A, Moustafa M. Ovarian artery clamp: Initial experience with a new clamp to reduce bleeding at open myomectomy. J OBSTET GYNAECOL 2011; 31:73-6. [DOI: 10.3109/01443615.2010.529964] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Yi YX, Zhang W, Guo WR, Zhou Q, Su Y. Meta-analysis: the comparison of clinical results between vaginal and laparoscopic myomectomy. Arch Gynecol Obstet 2011; 283:1275-89. [PMID: 21234758 DOI: 10.1007/s00404-011-1836-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2010] [Accepted: 01/06/2011] [Indexed: 11/26/2022]
Abstract
PURPOSE To evaluate the clinical results of vaginal myomectomy and laparoscopic myomectomy (LM). METHODS The database of PubMed, EMBASE, Web of Science, ProQuest, Cochrane library and China Biological Medicine Database (CBM), Chinese National Knowledge Infrastructure (CNKI), Wanfang (Chinese) and VIP (Chinese) were searched using the keywords "laparoscopic", "laparoscopically", "vaginal", "trasvaginal", "myomectomy", "randomized", "randomised" and "randomly" to identify randomized controlled trails which compared vaginal myomectomy and LM. Studies are also searched by hand. No language restrictions were made. RESULTS Four trials were studied and the analysis was performed using Review Manager Version 5 and R software Version 2.11.1. The results had shown that vaginal myomectomy was associated with less operation time significantly, but reduced blood loss, hospital stay and gas recovery and more minor complications without significant difference. CONCLUSIONS This meta-analysis was not powerful to form an accurate conclusion because of less number, low quality of included studies and no data on major complications and long-term outcomes such as recurrence and pregnancy. Hence, more studies and data should be awaited and involved for further evaluation.
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Affiliation(s)
- Yue-xiong Yi
- First Department of Gynecology, Renmin Hospital of Wuhan University, Wuhan 430060, Hubei Province, China
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Schüring AN, Garcia-Rocha GJ, Schlösser HW, Greb RR, Kiesel L, Schippert C. Perioperative complications in conventional and microsurgical abdominal myomectomy. Arch Gynecol Obstet 2010; 284:137-44. [DOI: 10.1007/s00404-010-1622-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2010] [Accepted: 07/20/2010] [Indexed: 11/25/2022]
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31
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Oladapo OT, Akinsanya AF. Relative morbidity of abdominal myomectomy for very large uterine fibroids in a developing country hospital. Arch Gynecol Obstet 2010; 283:825-30. [DOI: 10.1007/s00404-010-1460-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2009] [Accepted: 03/29/2010] [Indexed: 10/19/2022]
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32
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Liberis V, Tsikouras P, Ammari A, Zografou C, Valentina D, Kafetzis D, Maroulis G. Assessment of the feasibility of bipolar coagulation use to reduce hemorrhage in myomectomy performed by minilaparotomy. MINIM INVASIV THER 2010; 19:75-82. [DOI: 10.3109/13645701003642875] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Preliminary uterine artery ligation versus pericervical mechanical tourniquet in reducing hemorrhage during abdominal myomectomy. Int J Gynaecol Obstet 2009; 108:233-5. [DOI: 10.1016/j.ijgo.2009.09.022] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2009] [Revised: 08/24/2009] [Accepted: 10/21/2009] [Indexed: 11/21/2022]
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Funaki K, Fukunishi H, Sawada K. Clinical outcomes of magnetic resonance-guided focused ultrasound surgery for uterine myomas: 24-month follow-up. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2009; 34:584-589. [PMID: 19852041 DOI: 10.1002/uog.7455] [Citation(s) in RCA: 139] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
OBJECTIVES To assess the volume reduction ratio, symptom improvement and reintervention rate following magnetic resonance-guided focused ultrasound surgery (MRgFUS) for uterine myomas. METHODS A total of 91 Japanese women with symptomatic myomas underwent MRgFUS between June 2004 and June 2008 using the ExAblate 2000 system. The volume change ratio was calculated at 6, 12 and 24 months following MRgFUS based on T2-weighted magnetic resonance images. The symptom severity score (SSS) was examined before and after the treatment (at 3, 6, 12 and 24 months). Additional post-MRgFUS treatments, such as hysterectomy, myomectomy, uterine artery embolization or repeat MRgFUS, were recorded and the reinterventional treatment rates were compared according to the signal intensity of pretreatment T2-weighted magnetic resonance images of the myomas. RESULTS The mean volume change ratios of low- and intermediate-intensity (Type 1/2) myomas were -36.5% 6 months post-procedure and -39.5% 24 months post-procedure. The mean +/- SD SSS value for patients with Type 1/2 myomas before MRgFUS was 35.1 +/- 21.0, and the values diminished significantly during the 24-month follow-up period to a mean value of around 15.0. High-intensity (Type 3) myomas were not observed to have decreased in size 6 months after MRgFUS. Of the 45 Type 1/2 myoma patients with complete follow-up, seven required reinterventional treatment within 24 months. The reintervention rates were 14.0% for Type 1/2 patients and 21.6% for Type 3 patients at 24 months post-treatment. CONCLUSIONS Moderate volume reductions of Type 1/2 myomas were noted following MRgFUS, and the reduction in SSS values and the relatively low reintervention rates observed are encouraging. We found MRgFUS to be an appropriate treatment method for Type 1/2 uterine myomas.
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Affiliation(s)
- K Funaki
- Department of Gynecology, Shinsuma General Hospital, Kobe, Hyogo, Japan.
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Talaulikar V, Gorti M, Manyonda I. Prospective randomised trial comparing gonadotrophin-releasing hormone analogues with triple tourniquets at open myomectomy. BJOG 2009; 116:1531; author reply 1532. [DOI: 10.1111/j.1471-0528.2009.02246.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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