Suturing method as a factor for uterine vascularity after laparoscopic myomectomy

Associations between the time interval from myomectomy to subsequent pregnancy and the obstetric outcomes: A population-based cohort study

OBJECTIVE

To investigate the associations between time interval from myomectomy to pregnancy (TIMP) and subsequent pregnancy and obstetric complications, and to explore whether these associations vary according to maternal age at birth.

METHODS

A retrospective population-based cohort study was conducted from 2008 to 2017. Data were extracted from the National Health Insurance Research Database and the Taiwan Maternal and Child Health Database, comprising 2024 379 births from 1 391 856 pregnancies. Eligible cases were identified using diagnostic and procedure codes; 4006 first singleton births in 4006 women after their first laparotomic myomectomy were identified. We estimated the risks of pregnancy and obstetric outcomes according to TIMP (<6, 6-11, and ≥12 months). Subgroup analysis was performed by further dividing according to maternal age at birth (18-34 vs ≥35 years old).

RESULTS

We observed higher risks of gestational hypertensive disorders (adjusted odds ratio [aOR] 1.97, 95% confidence interval [CI] 1.22-3.18, P = 0.005) and neonatal death (aOR 4.59, 95% CI 1.49-14.18, P = 0.008) for TIMP of <6 months versus TIMP of 6-11 months. Likewise, a TIMP ≥12 months was associated with increased risks of gestational hypertensive disorders (aOR 1.72, 95% CI 1.14-2.58, P = 0.010), and neonatal death (aOR 3.27, 95% CI 1.16-9.24, P = 0.025) versus a TIMP of 6-11 months. In subgroup analysis, women over 35 years old still had higher risks of gestational hypertensive disorders when TIMP was <6 months (aOR 2.26, 95% CI 1.17-4.37, P = 0.015) or ≥12 months (aOR 2.04, 95% CI 1.17-3.54, P = 0.012), and a higher risk of neonatal death when TIMP was <6 months (aOR 4.05, 95% CI 1.06-15.53, P = 0.041); whereas women aged 18-34 years old did not.

CONCLUSIONS

This study suggests that a TIMP between 6 and 11 months is associated with lower risks of gestational hypertensive disorders and neonatal death compared with a TIMP <6 months or ≥12 months, especially for women over 35 years old.

Comparison of uterine myometrial thickness at the site of myomectomy scar after surgery using laparoscopic and laparotomy methods

Fibroids are the most common benign tumours of the uterus, often requiring surgery when symptomatic. This study aims to investigate the impact of surgery using two methods, laparoscopy and laparotomy, on the thickness and vascularity of the uterine myometrium at the site of myomectomy scar (comparing sonographic features at the surgical scar site, including thickness, vascularity, and the extent of fibrotic tissue, in both open and laparoscopic surgical approaches). In this clinical trial, 100 women with type 2-5 fibroids and clinical symptoms, seeking surgery et al. Zahra Hospital, were enrolled in two groups: laparoscopy and laparotomy. Inclusion criteria were a maximum fibroid size of 8 cm and, in the case of multiple fibroids, a maximum of three, with the largest being 8 cm. 6 months post-surgery, sonographic assessments of the myomectomy scar site were compared between both groups. Participants showed no significant differences in demographic and obstetric factors. The most common clinical symptom (87%) in both groups was abnormal uterine bleeding (AUB). The mean hospital stay duration was statistically significantly lower in the laparoscopy group at 1.64 (SD 0.56) compared to 1.89 (SD 0.58) in the laparotomy group (p = 0.028). Additionally, the decrease in haemoglobin levels was 0.89 (SD 0.92) and 1.87 (SD 2.24) units, respectively, which showed a statistically significant difference (p = 0.003). The duration of surgery was significantly shorter in the laparotomy group (p = 0.001). Abdominal pressure was not observed in the laparoscopy group, while 12% of the laparotomy group reported complaints (p = 0.013). Based on the results obtained in this study, it can be concluded that there was no difference between these two methods in terms of improving uterine thickness and associated complications. However, the decrease in haemoglobin levels and the length of hospital stay were lower in patients undergoing laparoscopy.

Laparoscopic myomectomy - The importance of surgical techniques

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

The effect of temporary uterine artery ligation on laparoscopic myomectomy to reduce intraoperative blood loss: A retrospective case–control study

Objective

Study Design

Results

Conclusions

•

The surgical technique for laparoscopic myomectomy is introduced.

•

Temporary uterine artery ligation decreases the volume of intraoperative blood loss.

•

Temporary uterine artery ligation is less invasive than permanent occlusion.

•

Temporary uterine artery ligation does not require the use of any special devices, such as clips.

Long-Term Pregnancy Outcomes of Patients with Diffuse Adenomyosis after Double-Flap Adenomyomectomy

Although many studies show that patients with diffuse adenomyosis who underwent fertility-sparing surgery can have a successful pregnancy, their pregnancy outcomes are still controversial. The objective of this study was to determine long-term pregnancy outcomes and possible influencing factors after double-flap adenomyomectomy for patients with diffuse adenomyosis. A total of 137 patients with diffuse adenomyosis who underwent double-flap adenomyomectomy between January 2011 and December 2019 were studied, and correlations between pregnancy outcomes and clinical data, including age and junctional zone measured by magnetic resonance imaging (JZmax-A), were analyzed. The results show that 56 patients (40.9%, 56/137) had 62 pregnancies, including 35 natural pregnancies and 27 assisted reproduction pregnancies, after operation. A univariate regression analysis showed that the pregnancy outcomes were related to age at surgery, visual analog scale (VAS) score of preoperative dysmenorrhea, parity experience, length of infertility, and postoperative JZmax-A. A multivariate regression analysis showed that age at surgery, VAS score of preoperative dysmenorrhea, and postoperative JZmax-A were the independent indicators correlated with pregnancy outcomes. A receiver operating characteristic curve analysis showed that postoperative JZmax-A was the most valuable indicator for predicting pregnancy outcomes. Cumulative pregnancy rates during the first 3 years were 70.1% and 20.9% in the postoperative JZmax-A ≤ 8.5 mm and the postoperative JZmax-A > 8.5 mm groups, respectively. In conclusion, double-flap adenomyomectomy could improve fertility for diffuse adenomyosis, and postoperative JZmax-A might be a promising indicator for predicting pregnancy outcomes.

Ageing impairs restoration of endometrial blood flow impedance after laparoscopic myomectomy in infertile women with uterine fibroids

The aim of this study was to evaluate temporal changes in endometrial blood flow after laparoscopic myomectomy (LM). Nineteen infertile women with uterine fibroids who underwent LM were included. The uterine radial artery resistance index (RA-RI) and recovery index were measured before and at 1 week and 3 months after LM. The median RA-RI at 1 week but not 3 months after LM was significantly higher than before. The median recovery indexes at 1 week and 3 months after LM were 14.3% and 1.3%, respectively. Although there was no significant correlation between the patient's age and recovery index at 1 week (r = 0.28, p = .24) after LM, a moderately significant correlation was observed at 3 months (r = 0.54, p = .002). In conclusion, the endometrial blood flow after LM changed over time, and recovery of blood flow was negatively correlated with patient age.IMPACT STATEMENTWhat is already known on this subject? Uterine blood flow is important for wound healing after myomectomy, but no studies have evaluated endometrial blood flow after myomectomy.What do the results of this study add? The endometrial blood flow impedance of RA-RI increased after LM and returned to before surgery at 3 months postoperatively. RA-RI recovery index negatively correlated with patient age.What are the implications of these findings for clinical practice and/or further research? The changes in endometrial blood flow impedance after myomectomy suggest that endometrial blood flow may be involved in wound healing at the enucleation site. The impairment of endometrial blood flow recovery after myomectomy due to increased age may provide a rationale for individualised wound healing after myomectomy. The measurement of endometrial blood flow may be useful in personalising the assessment of the waiting period for pregnancy after myomectomy.

Comparison of safety and efficacy between laparoscopic myomectomy and traditional laparotomy for patients with uterine fibroids and their effect on pregnancy rate after surgery

The aim of this retrospective study was to compare the safety and efficacy between laparoscopic myomectomy and traditional laparotomy for patients with uterine fibroids and determine their effect on the pregnancy rate after surgery. In total, 86 cases with uterine fibroids were selected among patients who were admitted in the Zhangqiu District Maternal and Child Health Care Hospital during the period of April, 2016 to April, 2017. Patients who underwent laparoscopic myomectomy were enrolled in group A (n=42), and those who underwent traditional laparotomy were placed in group B (n=44). The general linear data and the operative indicators were compared. The VAS scores, serum IFN-γ, IL-6, VEGF levels and clinical efficacy of the two groups were also compared one week after surgery. Postoperative pregnancy rates and complications in both groups were also compared. No significant differences were observed in general data between the two groups (P>0.05). The intra-operative blood loss in the group A was lower than that in group B (P<0.05), the average time of operation, hospital stays (days), and anal exhaust time in group A were shorter than those in group B (P<0.05). The pain degrees at 3, 6 and 18 h after surgery for patients in the group A were significantly lower than those of the group B (P<0.05). There was no significant difference IL-6 and VEGF levels in the serum between groups A and B before and after surgery (P>0.05); however, the level of IFN-γ expression, one week after surgery, in group B was significantly higher than that in group A (P<0.05). The pregnancy rate in the experimental group was higher than that in the control group (P<0.05), and the incidence rate of complications in group A was significantly lower than that in group B (P<0.05). Results presented in the present study suggested that compared to traditional laparotomy, laparoscopic myomectomy is a more advantageous method in terms of safety, efficacy and pregnancy rate after surgery.

Time to conceive after myomectomy: should we advise a minimum time interval? A systematic review

The optimal time interval between myomectomy and pregnancy is unclear and no specific guidelines exist. The aim of this review was to study the time interval from myomectomy to pregnancy and the occurrence of uterine rupture after myomectomy. Randomized controlled trials, cohort studies and retrospective studies were used to assess the primary objective, and case reports, cases series or letters to the editor for the secondary objective. Only articles reporting myomectomy performed via the vaginal route, laparotomy, laparoscopy or robot-assisted surgery were selected for inclusion. Among 3852 women who wanted to become pregnant after the surgery, 2889 became pregnant, accounting for 3000 pregnancies (77.9%) and 2097 live births (54.4%). Mean time between myomectomy and pregnancy was estimated at 17.6 months (SD 9.2) for 2451 pregnant women. Among 1016 women, a third were advised to delay attempting to conceive for between 3 and 6 months and another third for between 6 and 12 months. A total of 70 spontaneous uterine ruptures with a mean gestational age of 31 weeks at occurrence were identified. No linear relationship was found between gestational age at the event and time interval from myomectomy to conception (P = 0.706). There are insufficient data to advise a minimal time interval between myomectomy and conception.

New surgical technique of laparoscopic resection of adenomyosis under real-time intraoperative ultrasound elastography guidance: A case report

Detecting adenomyosis in the myometrium is a challenge since it is infiltrative with ill-defined margins and can be often confused with uterine fibroids. However, recent advances, such as ultrasound elastography, have enabled its detection in the myometrium, thereby facilitating its accurate diagnosis. We report our experience of performing complete laparoscopic resection of adenomyosis under real-time ultrasound elastography guidance in a 32-year-old woman who underwent laparoscopic adenomyomectomy following severe dysmenorrhea and heavy menstrual bleeding. Real-time ultrasound elastography was also utilized intraoperatively to detect residual adenomyosis. Complete adenomyosis resection and uterine reconstruction were achieved. Follow-up magnetic resonance imaging was conducted to confirm successful uterine reconstruction. The patient recovered rapidly with no complications. Intraoperative elastography-guided laparoscopic adenomyomectomy was feasible and effective in completely removing adenomyotic lesions.

Myomectomy scar ectopic pregnancy following a cryopreserved embryo transfer

CASE

A 40 year old woman with a history of a myomectomy visited the Department of Obstetrics and Gynecology, Niigata University Medical and Dental Hospital, Niigata, Japan, following 2 years of infertility. Magnetic resonance imaging detected an abnormal endometrial-like pseudo-cavity. A hysterosalpingography also revealed an abnormal accumulation of contrast medium at the myometrial scar site. A transvaginal ultrasound showed a thin myometrium at the lower uterine body. The patient conceived via in vitro fertilization under a luteal phase down-regulation protocol (long protocol) for controlled ovarian stimulation, followed by a cryopreserved embryo transfer during her natural ovulation cycle. After the embryo transfer, the gestational sac was located at the subserosal site of the myomectomy scar.

OUTCOME

An emergent laparoscopic operation was performed and the embryo was removed successfully via laparoscopy under transvaginal ultrasonography.

CONCLUSION

A subserosal uterine pregnancy is a rare form of intramural pregnancy, which is a rare subtype of an ectopic pregnancy, which could occur at the myomectomy site, especially after an embryo transfer. It is believed that this rare ectopic pregnancy resulted from embryo implantation under the serosa through a micro-sinus tract that was a site of suture failure of the myomectomy scar and was partially affected by the embryo transfer. Clinicians should consider the possibility of an ectopic pregnancy after uterine surgery, including a myomectomy.

Utility of Laparoscopic Uterine Myomectomy as a Treatment for Infertility with No Obvious Cause Except for Uterine Fibroids

Objectives:

Uterine fibroids are capable of causing infertility, but there are no definite criteria for which laparoscopic uterine myomectomy (LM) is known to be beneficial. To investigate the usefulness of LM, we examined pregnancy rates in patients with infertility with no obvious cause except for the presence of uterine fibroids.

Materials and Methods:

We retrospectively reviewed the clinical records at Suzuki Memorial Hospital between June 2010 and August 2014. We found 60 eligible patients (LM group, 46; non-LM group, 14). The criteria for performing LM were a maximal fibroid diameter of 40 mm or more or the presence of >4 fibroids.

Results:

The duration of infertility before the first visit was significantly longer in the LM group; although there was no significant difference in the mean patient age and body mass index. Pregnancy was achieved in 45.7% of patients (21/46) in the LM group and 28.6% (4/14) in the non-LM group. There were no pregnancies in patients with >10 fibroids. The postoperative pregnancy rate in the LM group was comparable to previously reported pregnancy rates.

Conclusions:

Our criteria for performing LM in patients with no obvious cause for infertility except for uterine fibroids seem appropriate, especially when the fibroids are large and the number of fibroids is between 4 and 9. However, our results suggest that the effectiveness of LM is low in patients with 10 or more uterine fibroids.

Application of a 'Baseball' Suture Technique in Uterine Myomectomy Following Laparoscopic Enucleation of Uterine Leiomyoma (Fibroid)

Background

The aim of this study was to evaluate the safety and efficacy of a ‘baseball’ suture technique for uterine myomectomy incision closure in laparoscopic surgical enucleation of uterine leiomyoma (fibroid).

Material/Methods

The study included 20 patients who underwent laparoscopic myomectomy with a ‘baseball’ suture technique, compared with 20 patients who underwent laparoscopic myomectomy with a standard suture method. Clinical characteristics, perioperative and follow-up data were compared between the two groups.

Results

For the study group, compared with the standard or control group, had a significantly reduced operation time (60.15±9.97 min vs. 71.85±9.74 min) and suturing time (18.05±4.71 min vs. 28.35±3.13 min) (both p<0.05), significantly less intraoperative blood loss (93.25±19.62 ml vs. 121.50±24.87 ml) (p<0.05) and significantly less reduction in postoperative hemoglobin levels (8.9±1.97 g/L vs. 11.15±2.23 g/L) (p<0.05). There were no statistically significant differences between the two groups in duration of the use of the indwelling drainage tube, drainage volume, or time to recovery of gastrointestinal function (all, p>0.05). Following surgery, blood transfusion was given to one patient in the study group and two patients in the control group. One patient from each group had a fever. There was no significant difference in pregnancy outcomes between the two groups.

Conclusions

The ‘baseball’ suture technique for closure of the uterine incision is a safe and effective method for use in laparoscopic myomectomy. However, the long-term recovery outcomes require further study.