Surgical outcomes after uterine artery occlusion at the time of myomectomy: systematic review and meta-analysis

Surgical impact of bilateral transient occlusion of uterine and utero-ovarian arteries during laparoscopic myomectomy

The objective of this article is to compare the amount of intraoperative blood loss during laparoscopic myomectomy when performing bilateral transient clamping of the uterine and utero-ovarian arteries versus no intervention. It´s a randomized controlled prospective study carried out in the Department of Obstetrics and Gynecology Ramón y Cajal University Hospital and HM Montepríncipe-Sanchinarro University Hospital, Madrid, Spain, in women with fibroid uterus undergoing laparoscopic myomectomy. Eighty women diagnosed with symptomatic fibroid uterus were randomly assigned to undergo laparoscopic myomectomy without additional intervention (Group A) or temporary clamping of bilateral uterine and utero-ovarian arteries prior to laparoscopic myomectomy (Group B). Estimated blood loss, operating time, length of hospital stay, and postoperative hemoglobin values were compared in both groups. The number of fibroids removed was similar in both groups (p = 0.77). Estimated blood loss was lower in the group of patients with prior occlusion of uterine arteries (p = 0.025) without increasing operating time (p = 0.17) nor length of stay (p = 0.17). No patient had either intra or postoperative complications. Only two patients (2.5%) required blood transfusion after surgery. We conclude that temporary clamping of bilateral uterine arteries prior to laparoscopic myomectomy is a safe intervention that reduces blood loss without increasing operative time.

Minimizing blood loss in laparoscopic myomectomy with temporary occlusion of the hypogastric artery

Introduction

Uterine leiomyomas are common benign pelvic tumors. Currently, laparoscopic myomectomy (LM) is the preferred treatment option for women in the fertile age group with symptomatic myomas. The authors hypothesize that combining LM with a bilateral temporary occlusion of the hypogastric artery (TOHA) using vascular clips minimizes uterine blood flow during surgery and can significantly reduce surgery-associated blood loss.

Materials and methods

This single-center, prospective randomized study was conducted at the Department of Obstetrics and Gynecology, Municipal Emergency Clinical Hospital Timisoara, Romania. Patients aged between 18 and 49 who preferred laparoscopic myomectomy and wished to preserve fertility were included, provided they had intramural uterine leiomyomas larger than 4 cm in diameter that deformed the uterine cavity. The study analyzed data from 60 laparoscopic myomectomies performed by a single surgeon between January 2018 and December 2020. Patients were randomly assigned to either: "LM + TOHA" group (29 patients), and "LM" group (31 patients). The study's main objective was to evaluate the impact of TOHA on perioperative blood loss, expressed as mean differences in Hb (delta Hb).

Results

Delta Hb was statistically lower in the "LM + TOHA" group compared to "LM" group, with mean ± standard (min-max): 1.68 ± 0.67 (0.39-3.99) vs. 2.63 ± 1.06 (0.83-4.92) g/dL, respectively (p < 0.001). There was a statistically significant higher need for postoperative iron perfusion in the "LM" group, specifically 0 vs. 12 patients (p < 0.001), and lower postoperative anemia in "LM + TOHA" group (p < 0.001). Necessary artery clipping time was 10.62 ± 2.47 (7-15) minutes, with no significant impact on overall operative time: 110.2 ± 13.65 vs. 106.3 ± 16.48 (p = 0.21). There was no difference in the length of hospitalization or 12-month post-intervention fertility.

Discussion

Performing bilateral TOHA prior to laparoscopic myomectomy has proven to be a valuable technique in reducing surgery-associated blood loss, while minimizing complications during surgery, with no significant increase in the overall operative time.

Clinical trial registration

ISRCTN registry, (www.isrctn.com), identifier ISRCTN66897343.

Association of Myomectomy With Anti-Müllerian Hormone Levels and Ovarian Reserve

OBJECTIVE

To assess whether open and minimally invasive myomectomy are associated with changes in postoperative ovarian reserve as measured by serum anti-müllerian hormone (AMH) level.

METHODS

This prospective cohort study included patients who were undergoing open abdominal myomectomy that used a tourniquet or minimally invasive (robot-assisted or laparoscopic) myomectomy that used vasopressin. Serum AMH levels were collected before the procedure and at 2 weeks, 3 months, and 6 months after surgery. The mean change in AMH level at each postsurgery timepoint was compared with baseline. The effect of surgical route on the change in AMH level at each timepoint was assessed by using multivariable linear regression. A subanalysis evaluated postoperative changes in AMH levels among the open myomectomy and minimally invasive myomectomy groups individually.

RESULTS

The study included 111 patients (mean age 37.9±4.7 years), of whom 65 underwent open myomectomy and 46 underwent minimally invasive myomectomy. Eighty-seven patients contributed follow-up data. Serum AMH levels declined significantly at 2 weeks postsurgery (mean change -0.30 ng/mL, 95% CI -0.48 to -0.120 ng/mL, P=.002). No difference was observed at 3 months or 6 months postsurgery. On multiple linear regression, open myomectomy was significantly associated with a decline in AMH level at 2 weeks postsurgery (open myomectomy vs minimally invasive myomectomy: β=-0.63±0.22 ng/mL, P=.007) but not at 3 months or 6 months. Subanalysis revealed a significant decline in mean serum AMH levels in the open myomectomy group at 2 weeks (mean change -0.46 ng/mL, 95% CI -0.69 to -0.25 ng/mL, P<.001) postsurgery but not at three or 6 months. In the minimally invasive myomectomy group, no significant differences in mean AMH levels were detected between baseline and any postoperative timepoint.

CONCLUSION

Myomectomy is associated with a transient decline in AMH levels in the immediate postoperative period, particularly after open surgery in which a tourniquet is used. Anti-müllerian hormone levels returned to baseline by 3 months after surgery, indicating that myomectomy is not associated with a long-term effect on ovarian reserve, even with the use of a tourniquet to decrease blood loss.

FUNDING SOURCE

This study was funded in part by a Roche Diagnostics Investigator-Initiated Study Grant.

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.

Can the application of a temporary uterine tourniquet during an abdominal myomectomy reduce bleeding?

Objective

Uterine fibroids are common, benign uterine tumours. The three most common surgical treatment approaches for uterine fibroids are laparoscopic, robotic and abdominal myomectomies. Bleeding is a risk with all three approaches. The present study compared post-operative and pregnancy outcomes in patients with bilateral uterine artery occlusion who underwent an abdominal myomectomy, with or without a temporary uterine tourniquet.

Material and Methods

This retrospective study included patients with intra-mural fibroids (≥5 cm) who underwent an abdominal myomectomy. The patients were divided into two groups according to the use or non-use of a temporary uterine tourniquet. Post-operative and pregnancy outcomes in the tourniquet use and non-use groups were compared. The association of the number of uterine fibroids removed (≤3 vs >3) with laboratory parameters was also evaluated.

Results

A total of 84 patients were included, divided into use (n=36) and non-use (n=48) of the temporary tourniquet. There was a statistically significant difference between the groups with >3 myomas removed and with a uterine tourniquet applied and not applied in terms of reduction in hemoglobin and hematocrit, transfusion amounts, operation times and lengths of hospitalization in favour of the uterine tourniquet use group (p=0.019, p=0.023, p=0.012, p=0.044 and p=0.036, respectively). Bilateral uterine arterial occlusion using a temporary uterine tourniquet had no negative effects on pregnancy outcomes.

Conclusion

A temporary uterine tourniquet may be an effective method for reducing the amount of perioperative bleeding in patients with multiple, large-sized myomas located close to vascular structures.

Preoperative Uterine Artery Embolization in Women Undergoing Uterus-Preserving Myomectomy for Extensive Fibroid Disease: A Retrospective Analysis

OBJECTIVES

The aim of this study was to determine if a long versus short interval between preoperative uterine artery embolization (PUAE) and subsequent myomectomy impact perioperative blood loss and the complication rate in cases of enlarged multi-fibroid uterus.

DESIGN

In cases of an enlarged multi-fibroid uterus, operative myomectomy can lead to heavy blood loss and consequently increases the risk for transfusion and hysterectomy. PUAE can possibly contribute to a reduction of these risks. Our study was designed to determine if a long versus short interval between PUAE and subsequent surgery impacts perioperative blood loss and complication rate.

PARTICIPANTS AND METHODS

PUAE was performed 24 h before the planned myoma enucleation in 21 patients between January 2011 and March 2016 (group 1) or 19 days before the operation in 23 patients from March 2016 to May 2018 (group 2). A comparison was made to a historical sample of 57 patients with large myomas (>10 cm) without PUAE (group 3). Perioperative blood loss, need for postoperative blood transfusion, and postoperative complications were recorded. Subjective improvement of myoma-related symptoms was assessed for each group by a questionnaire.

RESULTS

PUAE was carried out successfully without complications in all patients. Conversion to hysterectomy was not needed in any of the PUAE patients but was necessary in one of the control patients. In the three groups' comparison, there was a significant lower risk for high blood loss (≥500 mL) in group 1 and a lower but not significant lower risk in group 2 compared to group 3 without an embolization preoperatively. Also, a significant lower risk for postoperative blood transfusion for group 1 (OR 0.02; 0.001-0.328; p = 0.01) and 2 (OR 0.02; 0.001-0.277; p = 0.01) compared to group 3 was observed. The postoperative complication risk was lower in group 2 (model 1: OR 0.12; 0.016-0.848; p = 0.03; model 2 OR 0.07; 0.009-0.588; p = 0.01) compared to group 3. In the context of the postoperative questionnaire, 10 of 11 patients in group 1, 12 of 12 patients in group 2, and 31 of 36 patients from the control group reported an improvement of their complaints.

CONCLUSION

PUAE is beneficial for uterus-preserving removal of myomas from patients with a substantially enlarged uterus. There is a significant reduction of high blood loss (≥500 mL), need for postoperative blood transfusion, and postoperative complications in patients with extensive fibroid disease after PUAE compared to no intervention before myoma enucleation.

Single-port access (SPA) laparoscopic myomectomy with uterine artery ligation via a retroperitoneal approach is feasible in women with large uterine leiomyoma

OBJECTIVE

Uterine artery ligation (UAL) at the time of myomectomy has shown to decrease blood loss during the operation. However, little is known about the efficacy and feasibility of UAL during single-port access (SPA) myomectomy. The present study was performed to investigate the clinical benefits of UAL in SPA myomectomy and to provide details of the surgical techniques.

MATERIALS AND METHODS

A retrospective and comparative review on the surgical outcomes of the patients who underwent SPA myomectomy with UAL and those who underwent SPA myomectomy without UAL was conducted. UAL was performed at its origin from the internal iliac artery via a retroperitoneal approach.

RESULTS

A total of 56 women who received SPA myomectomy were reviewed (24 patients received SPA myomectomy with UAL while 32 patients received SPA myomectomy only). The median weight of total resected leiomyomas was heavier for the patients who received UAL than those who did not receive UAL [210.0 g (range: 171.5-335.0 g) vs. 119.0 g (62.5-265.0 g), p = 0.023]. However, no differences in total operative time, estimated blood loss, perioperative hemoglobin changes, use of postoperative analgesics and postoperative complications between the two groups were seen.

CONCLUSION

Obtaining similar surgical outcomes between the patients who received UAL with larger leiomyomas and those who did not receive UAL with smaller leiomyomas suggests that UAL is a feasible surgical approach to reduce blood loss during SPA myomectomy. Detailed descriptions of the surgical techniques are provided in the present report.

Pediatric Mental Health Boarding

CONTEXT

The growing prevalence of pediatric mental and behavioral health disorders, coupled with scarce psychiatric resources, has resulted in a substantial increase in the number of youth waiting in emergency departments (EDs) and medical units for inpatient psychiatric care.

OBJECTIVE

To characterize the prevalence of pediatric mental health boarding and identify associated patient and hospital factors.

DATA SOURCES

Medline and PsycINFO.

STUDY SELECTION

All studies describing frequencies, durations, processes, outcomes, and/or risk factors associated with pediatric mental health boarding in youth ≤21 years of age.

DATA EXTRACTION

Publications meeting inclusion criteria were charted by 2 authors and critically appraised for quality.

RESULTS

Eleven studies met inclusion criteria; 10 were retrospective cohort studies and 9 were conducted at single centers. All of the single-center studies were conducted at children's hospitals or pediatric EDs in urban or suburban settings. Study sample sizes ranged from 27 to 44 328. Among youth requiring inpatient psychiatric care, 23% to 58% experienced boarding and 26% to 49% boarded on inpatient medical units. Average boarding durations ranged from 5 to 41 hours in EDs and 2 to 3 days in inpatient units. Risk factors included younger age, suicidal or homicidal ideation, and presentation to a hospital during nonsummer months. Care processes and outcomes were infrequently described. When reported, provision of psychosocial services varied widely.

LIMITATIONS

Boarding definitions were heterogeneous, study sample sizes were small, and rural regions and general hospitals were underrepresented.

CONCLUSIONS

Pediatric mental health boarding is prevalent and understudied. Additional research representing diverse hospital types and geographic regions is needed to inform clinical interventions and health care policy.

Effects of uterine artery occlusion during myomectomy on ovarian reserve: Serial follow-up of sex hormone levels, ultrasound parameters and Doppler characteristics

AIM

To evaluate the influence of uterine artery occlusion at myomectomy (UAO + M) on ovarian reserve based on serum sex hormone levels, ultrasound and color Doppler examinations.

METHODS

In this cohort study, nine women with symptomatic uterine myomas underwent UAO + M were recruited. Each woman was assessed preoperatively and 3, 6 months postoperatively, through a serial of hormonal, ultrasound parameters and Doppler examination for ovarian stromal blood flow. The data were analyzed using generalized estimating equations.

RESULTS

There was no significant difference in serum anti-Müllerian hormone (AMH) or follicle-stimulating hormone (FSH) levels before and 3, 6 months after UAO + M. The ovarian volume, antral follicle count (AFC) and ovarian stromal blood flow had significant changes in the right ovary. Ovarian volume and AFC significantly reduced at 3 months and recovered at 6 months postoperatively (P = 0.046, P = 0.019, respectively). Peak systolic velocity and end diastolic velocity significantly decreased at 3 months and leveled off at 6 months (P < 0.001, P = 0.001, respectively). Resistance index significantly increased at 3 months and decreased at 6 months (P = 0.037). A similar trend in ultrasound and Doppler findings was observed in the left ovary, but no statistical significance was found.

CONCLUSION

UAO + M had no detrimental effect on ovarian reserve 6 months postoperatively based on AMH and FSH levels. AFC, ovarian volume and stromal blood flow were transiently decreased in 3 months and recovered in 6 months.

Tranexamic acid in gynecologic surgery

Objective: To review the mechanism of action, pharmacology, dosing, and complications of tranexamic acid (TXA) and consolidate current evidence for TXA in gynecologic surgery.Methods: A literature search of PubMed, Ovid (MEDLINE), Google Scholar, and Elsevier was performed, in addition to a targeted search of cited references involving TXA and gynecologic surgery. Preference was given to systematic reviews and randomized control trials (RCTs).Results: TXA reversibly binds to plasminogen, preventing clot degradation. RCTs on hysterectomy, myomectomy, cervical conisation, hysteroscopy, and surgery for cervical and ovarian cancer were identified, as were case reports on TXA use for ectopic pregnancy. During hysterectomy, TXA reduces blood loss (two RCTs, n = 432, mean difference -66.0 mL and 180 mL), blood transfusion (1 RCT, n = 100, 12% vs. 42%, p < .00001). For myomectomy, a systematic review and meta-analysis showed a statistically significant decrease in blood loss with TXA (two RCTs, mean difference -213.1 mL, 95% CI: -242.4 mL to -183.7 mL). Following cervical conisation, TXA decreased the risk of delayed hemorrhage (four RCTs, RR 0.23, 95% CI: 0.11-0.50). A single RCT for cervical and ovarian cancer surgery demonstrated a decrease mean blood loss of 120 mL-135 mL and 210 mL, respectively, and fewer blood transfusions for the latter (OR 0.44, upper 95% CI: 0.97, p = .02). Less robust data suggest a possible benefit from TXA during hysteroscopy and surgery for ectopic pregnancies. Most commonly, 1 g of intravenous TXA is given intraoperatively.Conclusion: TXA is a safe adjunct that can be considered in a variety of gynecologic surgeries to decrease blood loss and risk of blood transfusion.

Abdelazim and AbuFaza technique for temporary bilateral uterine occlusion to decrease the blood loss during myomectomy: Case reports

The standard treatment of symptomatic fibroids is hysterectomy for women completed their childbearing and myomectomy for women desire future fertility. Myomectomy associated with life-threatening bleeding and emergency blood transfusion. The two studied cases were unmarried presented with multiple fibroid uterus of 28 and 24 weeks’ gestation. Both the studied women refused hysterectomy because of their fertility potential. Myomectomy was done with removal of two big myomas (10×12 cm and 7×8 cm), three moderate size myomas (5×5 cm, 4×4 cm and 3×4 cm) and four small size myomas for the first case and removal of one big myoma (8×6 cm), four small size myomas for the second case. The hemoglobin difference was 0.6 and 0.4 gms% for the first and the second case; respectively and no blood transfusion was required for them. This report represents the outcome of Abdelazim and AbuFaza technique for temporary bilateral uterine occlusion to decrease the blood loss during myomectomy.

Characteristics of Peripheral Immune Function in Reproductive Females with Uterine Leiomyoma

Inflammation and immunity are thought as risk factors for uterine leiomyoma; however, detailed reports on this topic are scarce. The present study aimed to analyze the characteristics of immune function and clinical significance of circulating CD4/CD8 T, NK, and γδ T cells in reproductive females with uterine leiomyoma. We analyzed the above-mentioned cells in 30 reproductive females with uterine leiomyoma and 68 healthy females using flow cytometry. After that, the correlation between function of immune cells and clinical phenotypes was analyzed. Compared with healthy controls, central memory (CM) CD4/CD8 T cells as well as Treg and Tfh cells were notably increased in leiomyoma patients; however, NK and γδ T cells were decreased in patients. Moreover, such alterations of these cells in patients with leiomyoma were associated with shorter menstrual cycles, longer menstrual period, anemia, pelvic lesions, more and larger myomas, and higher levels of CA125. Additionally, the increased Tfh1/Tfh2 ratio and Tfh17 were significantly associated with longer menstrual period, more myomas, and higher CA125 levels independent of age in patients with uterine leiomyoma. In conclusion, hallmarks of peripheral immune function are remarkably correlated with clinical phenotypes in reproductive females with uterine leiomyoma. This preliminary work may provide proof-of-concept for evaluating efficacy of treatment and prognosis of reproductive females with uterine leiomyoma with the help of quantitative analysis of peripheral immune function, which may inspire performing further investigations on the relevance of immune function with different diseases.