Symptomatic myoma treated with laparoscopic uterine vessel occlusion and subsequent immediate myomectomy: which is the optimal surgical approach?

A Systematic Review of Minimally Invasive Treatments for Uterine Fibroid-Related Bleeding

Newer minimally invasive techniques provide treatment options for symptomatic uterine fibroids while allowing uterus preservation. The objective of this review was to analyze the efficacy of uterine-preserving, minimally invasive treatment modalities in reducing fibroid-related bleeding. A comprehensive search was conducted of PubMed, Embase, PsycINFO, ClinicalTrials.gov, Scopus, and Cochrane Library databases from inception to July 2020. English-language publications that evaluated premenopausal women with fibroid-related bleeding symptoms before and after treatment were considered. Randomized controlled trials were assessed for bias with the established Cochrane Risk of Bias Tool 2.0 and observational studies were assessed for quality under the New Castle-Ottawa Scale guidelines. Eighty-four studies were included in the review, including 10 randomized controlled trials and 74 observational studies. Six studies on myomectomy demonstrated overall bleeding symptom improvement in up to 95.9% of patients, though there was no significant difference between mode of myomectomy. Forty-one studies on uterine artery embolization reported significant reduction of fibroid-related bleeding, with symptomatic improvement in 79 to 98.5% of patients. Three studies suggested that embolization may be superior to myomectomy in reducing fibroid-related bleeding. Six studies reported that laparoscopic uterine artery occlusion combined with myomectomy led to greater reduction of bleeding than myomectomy alone. Fifteen studies demonstrated significantly reduced bleeding severity after radiofrequency ablation (RFA). Additional research is needed to establish the superiority of these modalities over one another. Long-term evidence is limited in current literature for magnetic resonance-guided focused ultrasound surgery, cryomyolysis, microwave ablation, and laser ablation.

Using a short questionnaire of the perimenopausal fatigue scale to evaluate perimenopausal women prone to fatigue syndrome

OBJECTIVE

Fatigue, a painful and unpleasant subjective experience, is common in perimenopausal women. Therefore, an effective tool to evaluate the fatigue-precipitating factor is important for perimenopausal women prone to fatigue syndrome.

MATERIALS AND METHODS

This study was surveyed by short-term perimenopausal fatigue scale. The enrollment period was from November 2019 to January 2020. The subjects were perimenopausal women prone to perimenopausal fatigue. The differences between the fatigue-precipitating factors and the degrees of fatigue and disturbance were determined by one-way ANOVA and t test.

RESULTS

A total of 220 perimenopausal women with mean age of 51.3 years were included. Among these, 64.1% did not have a habit of regular exercise and 55.5% had chronic diseases. Fatigue syndrome was found in 64.1% of subjects, who were mainly presented by shoulder and neck pain and sleep problems. There were significant differences between "perimenopausal fatigue" and "duration" (p < 0.001); "with and without regular exercise" (p = 0.05); and "with and without chronic diseases" (p = 0.03).

CONCLUSIONS

Our study showed the perimenopausal fatigue syndrome is more frequently found in perimenopausal women who have a co-morbidity (chronic illness) and do not have a habit of regular exercise. An early identification and prompt intervention may help perimenopausal women to deal with their fatigue syndrome. The short questionnaire perimenopausal fatigue scale seems to be useful for screening perimenopausal women prone to fatigue syndrome.

Optimal approach for management of postpartum vulva hematoma: Report of three cases

OBJECTIVE

Vulvar hematomas though common in obstetrical practice can rapidly evolve into a life-threatening condition if not managed appropriately. Depending on clinical status and medical facility, conservative management, surgical debridement, or vessel-occlusion strategy can be considered.

CASE REPORT

Case 1 was a 28 year-old pregnant woman. Increasing hematoma over 12 cm in size was noted on postpartum Day 2. Debridement and arterial embolization were done. Case 2 was a referred woman at age of 30 who delivered at a local obstetric clinic. Debridement was performed successfully. Case 3 was a 23 year-old woman with postpartum bilateral hematoma. Drop in hemoglobin level prompted the medical team to transfer and airlift the patient for arterial embolization and subsequent vulva debridement.

CONCLUSION

Optimal management of hematoma is dependent on maternal hemodynamic condition, bleeding status, and availability of interventional radiology.

Pain after laparoscopic surgery: Focus on shoulder-tip pain after gynecological laparoscopic surgery

Laparoscopy, one of minimally invasive procedures, is a commonly used procedure in diagnosis and management of various kinds of clinical problems, including gynecologic organ-related diseases. Compared with conventional exploratory laparotomy, the benefits of laparoscopic surgery include reduction of surgical wound, decreasing in postoperative pain, shortening hospital stay, rapid recovery, and a better cosmetic result. However, there are still up to 80% of patients after laparoscopic surgery complaining of high levels of pain and needing pain relief. Postlaparoscopic pain can be separated into distinct causes, such as surgical trauma- or incision wound-associated inflammatory change, and pneumoperitoneum (carbon dioxide [CO2])-related morphological and biochemical changes of peritoneum and diaphragm. The latter is secondary to irritation, stretching, and foreign body stimulation, leading to phrenic neuropraxia and subsequent shoulder-tip pain (STP). STP is the most typical unpleasant experience of patients after laparoscopic surgery. There are at least 11 strategies available to attempt to decrease postlaparoscopic STP, including (1) the use of an alternative insufflating gas in place of CO2, (2) the use of low-pressure pneumoperitoneum in place of standard-pressure pneumoperitoneum, (3) the use of warmed or warmed and humidified CO2, (4) gasless laparoscopy, (5) subdiaphragmatic intraperitoneal anesthesia, (6) local intraperitoneal anesthesia, (7) actively expelling out of gas, (8) intraperitoneal drainage, (9) fluid instillation, (10) pulmonary recruitment maneuvers, and (11) others and combination. The present article is limited in discussing postlaparoscopic STP. We extensively review published articles to provide a better strategy to reduce postlaparoscopic STP.

Avoiding excessive pregnancy weight gain to obtain better pregnancy outcomes in Taiwan

Pregnancy weight gain may be associated with adverse pregnancy outcomes. The article aims to explore the relationship between weight change and pregnancy outcome in the Taiwanese pregnant women.The retrospective cohort study enrolled women with vertex singleton pregnancy at University-associated Hospital between 2011 and 2014. Pregnancy weight change was separated into 3 groups, based on the Institute of Medicine (IOM) guidelines: below (n = 221); within (n = 544); and above (n = 382). Analysis of variance, χ tests, generalized linear models, and logistic regression models were used for statistical comparisons.Pregnant women with weight change above IOM guidelines had a significant increase in both maternal and perinatal complications compared with normal controls (odds ratio [OR] 1.65, 95% confidence interval [CI] 1.03-1.98; P = .043; OR 1.45, 95% CI 1.01-1.87; P = .049, respectively). This finding was not found in pregnant women with weight gain below IOM guidelines. Moreover, age (OR 1.08, 95% CI 1.02-1.15; P = .0011), pre-pregnancy weight (OR 1.04, 95% CI 1.01-1.09; P = .0008), pre-pregnancy body mass index (BMI; OR 1.15, 95% CI 1.06-1.30; P < .0001), weight at the time of delivery (OR 1.05, 95% CI 1.02-1.13; P < .0001) and BMI at the time of delivery (OR 1.15, 95% CI 1.06-1.39; P < .0001), all contributed to increased maternal complications but not perinatal complications, whereas parity (OR 0.23, 95% CI 0.12-0.41; P < .0001) and gestational age (OR 0.50, 95% CI 0.35-0.62; P < .001) were associated with fewer maternal complications.Our study reconfirmed that for Taiwanese pregnant women, the approximate pregnancy weight gain recommended by IOM in 2009 was associated with the fewest maternal and perinatal complications. If approximate pregnancy weight gain cannot be attained, even less weight gain during pregnancy is still reasonable without significantly and adversely affecting maternal and perinatal outcomes in Taiwan.

Comparison of Laparoscopic Myomectomy in Large Myomas With and Without Leuprolide Acetate

STUDY OBJECTIVE

To evaluate the efficacy of gonadotropin-releasing hormone analogue (GnRHa) use before laparoscopic myomectomy (LM) in large myomas.

DESIGN

Prospective study (Canadian Task Force classification II-1).

SETTING

University-affiliated hospital.

PATIENTS

Ninety-one women with large myomas (≥10 cm) or more than 2 myomas ≥ 5 cm underwent LM between July 2011 and March 2014.

INTERVENTIONS

Forty patients underwent LM after GnRHa use (group A) and 51 underwent LM only (group B). GnRHa was used for 3 doses every 4 weeks before LM in group A.

MEASUREMENTS AND MAIN RESULTS

Group A had a significantly smaller maximum diameter of the largest myoma than group B (8.5 ± 2.1 vs 10.7 ± 2.4, p < .001) and fewer patients with myomas larger than 10 cm after GnRHa administration (33% vs 67%, p = .001). In group A, there was a decrease in 2 or more myomas ≥ 5 cm (20% vs 50%) after GnRHa use. Group A also had significantly smaller mean myoma weight (448 vs 567 g, p = .045) and significantly shorter mean operative time (129 ± 30 vs 152 ± 34 minutes, p = .001). Most patients in group A (40%) had an operative time < 119 minutes, whereas most patients in group B (37%) had an operative time between 150 and 179 minutes. Group A also had less intraoperative blood loss (84 ± 53 vs 137 ± 166 mL, p < .001), drop in hemoglobin (1.5 ± 0.8 vs 3.0 ± 1.7 g/dl, p < .001), excessive bleeding (5% vs 33%, p = .001), postoperative hematoma (2.5% vs 9.8%, p = .168), and blood transfusion (7.5% vs 35%, p = .001).

CONCLUSION

GnRHa before LM in large myomas may be an effective adjuvant treatment for women with large and multiple myomas. This method is beneficial in decreasing operative time, intraoperative bleeding, postoperative hemorrhage, and need of blood transfusion.

Laparoscopic transient uterine artery occlusion and myomectomy for symptomatic uterine myoma

OBJECTIVE

To compare clinical outcomes of laparoscopic transient uterine artery ligation plus myomectomy (LTUAL) to simple laparoscopic myomectomy (LM) for symptomatic myomas.

DESIGN

Comparative observational study.

SETTING

Medical centers.

PATIENT(S)

One hundred sixty-seven patients with symptomatic myomas.

INTERVENTION(S)

Eighty-four patients underwent LTUAL and LM; 83 patients underwent LM only.

MAIN OUTCOME MEASURE(S)

Operative time, blood loss, gonadal hormone level, uterine artery resistance index, menorrhea, pregnancy rate, and recurrence rate of myoma.

RESULT(S)

The intraoperative blood loss in the LTUAL group was lower than in the LM group. The menstrual blood volume (MBV) and the menstrual period of the LTUAO group was unchanged after operation relative to the prediseased volume. No significant difference was found in the resistance index of the uterine artery blood flow, the recurrence rate, and the fertility rate between the LTUAL and LM groups.

CONCLUSION(S)

LTUAL and LM are a promising surgical treatment for symptomatic uterine myoma and did not produce any appreciable adverse effect on fertility.

Comparing uterine fibroids treated by myomectomy through traditional laparotomy and 2 modified approaches: ultraminilaparotomy and laparoscopically assisted ultraminilaparotomy

OBJECTIVE

We sought to compare myomectomy performed by laparotomy (LT), and 2 other modified approaches: ultraminilaparotomy (UMLT) and laparoscopically assisted UMLT for uterine fibroids with a size <8 cm and the number <5.

STUDY DESIGN

A cohort study, including 79 (35.3%) women in the LT group, 71 (31.7%) in the UMLT group, and 74 (33.0%) in the laparoscopically assisted UMLT group, was conducted. The outcome was measured by comparing surgical parameters, immediate postoperative recovery, and therapeutic outcomes.

RESULTS

The median follow-up was 52 months with similar recurrence rates in the 3 groups. The modified approaches had advantages not only in the surgical parameters, but also in postoperative recovery, compared to LT (all P < .05).

CONCLUSION

UMLT and laparoscopically assisted UMLT can be used successfully in place of LT in the management of uterine fibroids.

Use of uterine vessel occlusion in the management of uterine myomas: two different approaches

OBJECTIVE

To evaluate the difference between uterine artery occlusion alone (UAO) and combined (UVO) with simultaneous blockage of anastomosis between the uterine and ovarian vessels in the management of women with myomas in a 3-year follow-up.

DESIGN

Case-control study.

SETTING

University-associated hospital.

PATIENT(S)

One hundred ten patients with uterine fibroids.

INTERVENTION(S)

Forty-four patients underwent UAO and 66 patients UVO; patients were matched using a statistically generated selection of all UVOs performed during the same period.

MAIN OUTCOME MEASURE(S)

Outcomes were assessed by comparing surgical parameters, immediate postoperative recovery, and therapeutic outcomes.

RESULT(S)

During the 3-year follow-up, the majority of patients in both groups reported symptom relief (ranging from 61.5% to 84.6% in the UVO group and 31.6% to 77.3% in the UAO group, on the basis of different kinds of symptoms). However, symptom control seemed to be different between the two groups when the follow-up time was prolonged; for example, symptom control was better in the UVO group at the end of 3 years, especially for menorrhagia (76.5% vs. 34.5%). The fibroid size was smaller in the UVO group, resulting in a lower reintervention rate, compared with the UAO group (13.6% vs. 36.4%).

CONCLUSION(S)

If UVO is used for uterine fibroids, the 3-year efficacy might be better than that with UAO. This finding is worthy of further investigation.