Perioperative nonhormonal pharmacological interventions for bleeding reduction during open and minimally invasive myomectomy: a systematic review and network meta-analysis

Operative Time and Accrual of Postoperative Complications in Minimally Invasive Versus Open Myomectomy

STUDY OBJECTIVE

To compare the prevalence and accrual of 30-day postoperative complications by operative time for open myomectomy (OM) and minimally invasive myomectomy (MIM).

DESIGN

Retrospective cohort study SETTING: Hospitals participating in the National Surgical Quality Improvement Program database from January 2015 to December 2021.

PATIENTS

Female patients aged ≥18 years undergoing OM or MIM.

INTERVENTIONS

Patients were categorized into OM and MIM cohorts. Covariates associated with operative time and composite complications were identified using general linear model and chi-square or Fisher's exact test as appropriate. Adjusted spline regression was performed as a test of linearity between operative time and composite complications. Adjusted risk ratios of 30-day postoperative individual, minor, major, and composite complications by 60-minute operative time increments were estimated using Poisson regression with robust error variance.

MEASUREMENTS AND MAIN RESULTS

Of 27 728 patients, 11 071 underwent MIM and 16 657 underwent OM. Mean operative times (SD) were 164.6 (82.0) for MIM and 129.2 (67.0) for OM. Raw composite complication rates were 5.5% for MIM and 15.8% for OM. Adjusted spline regression demonstrated linearity between operative time and relative risk of composite postoperative complications for both MIM and OM. MIM had higher adjusted relative risk (aRR, 95% CI) compared to OM of blood transfusion (1.55, 1.45-1.64 versus 1.29, 1.25-1.34), overall minor complications (1.13, 1.03-1.23 versus 1.01, 0.92-1.10), and overall major complications (1.43, 1.35-1.51 versus 1.27, 1.12-1.32). Operative time had greater impact on risk of composite complications for MIM than OM, reaching aRR 2.0 at 296 minutes versus 461 minutes for OM.

CONCLUSION

OM has a higher overall rate of composite, minor, and major complications compared to MIM. While operative time is independently and linearly associated with postoperative complications with myomectomy regardless of approach, optimizing surgical efficiency for MIM may be more critical than for OM.

Oxytocin changes in women with emergency cesarean section: Association with maternal blues by delivery mode

Introduction

Women with emergency cesarean section (CS) have presumed effects of an unscheduled surgery on their salivary oxytocin (OXT) level and psychological state. This study aimed to measure changes in the salivary OXT levels of women with emergency CS and change in the OXT levels by delivery mode, and to investigate the association between changes in OXT levels and maternity blues.

Methods

We used a longitudinal observational study. The eligibility criteria were primipara pregnant women who were planning to have vaginal delivery. The salivary OXT levels of women were measured at 36 weeks gestation, 38 weeks gestation, 1 day postpartum, and 5 days after childbirth. Maternity blues was diagnosed using the Maternity Blues Scale (13 items), 'Fatigue after Childbirth' was diagnosed using the Visual Analogue Scale (0-100), and the subjective symptoms of fatigue was diagnosed using the Jikaku-sho shirabe. The three groups ("Without EA", "With EA", and "Emergency CS") were analyzed separately. The changes in the oxytocin levels of women with emergency CS at four time points were analyzed by using a repeated measure analysis of variance.

Results

The mean OXT levels of women with emergency CS (n = 6) were significantly lower at 5 days after childbirth than at 36 weeks gestation, 38 weeks gestation, and 1 day postpartum. There was a significant middle correlation between changes in the mean maternity blues scores between 1 day and 5 days, and the mean changes in OXT levels from 38 weeks gestation to 5 days after childbirth.

Conclusion

It could be assumed that women with emergency cesarean section may be affected psychologically by the unplanned method of delivery. In the present study, it was not possible to analyze this association because of the small sample size; however, it is possible to clarify predictors as the sample size accumulates in the future.

Safety of Same-Day Discharge Versus Hospital Admission in Minimally Invasive Myomectomy

STUDY OBJECTIVE

To compare postoperative complication rates between same-day discharge patients and patients admitted to hospital after minimally invasive myomectomy, stratified by patient demographics and perioperative variables including myoma burden.

DESIGN

Retrospective cohort study. Setting Hospitals participating in the National Surgical Quality Improvement Program database from January 2015 to December 2019.

PATIENTS

Female patients aged ≥18 years undergoing minimally invasive myomectomy.

INTERVENTIONS

Patients were categorized into either the same-day discharge or admitted patient cohort. Univariate comparisons of demographics, perioperative variables, and 30-day postoperative complications were performed. Multivariate logistic regression was used to 1) identify demographic and perioperative factors associated with admission, and 2) compare postoperative complication rates of same-day discharge patients with those of admitted patients while adjusting for demographic and perioperative factors.

MEASUREMENTS AND MAIN RESULTS

Eight thousand one hundred patients were recruited during the study period. The overall rate of same-day discharge was 57.2% in 2015 and 65.0% in 2019. The same-day discharge rate was 64.6% for patients with a smaller myoma burden (1-4 fibroids and ≤250 grams, Current Procedural Terminology 58545) and 56.8% for larger myoma burden (≥5 fibroids or >250 grams, Current Procedural Terminology 58546). Age, race, American Society of Anesthesiologists classification III or IV, preoperative hematocrit <36%, hypertension, diabetes, bleeding disorder, and increasing operative time were associated with admission to hospital. After adjusting for these variables, composite postoperative complication rates were similar between admitted patients and patients who were discharged the same day regardless of myoma burden (adjusted OR [aOR], 0.66; 95% confidence interval [CI] 0.18-2.47 for low myoma burden and aOR, 0.91; 95% CI 0.18-4.63 for high myoma burden). Admitted patients with both low (aOR, 9.1; 95% CI 2.27-37.04) and high (aOR, 8.24; 95% CI 1.59-42.49) myoma burdens were significantly more likely to receive a blood transfusion compared to same-day discharge patients.

CONCLUSION

Same-day discharge after minimally invasive myomectomy, regardless of myoma burden, is associated with low complication rates. Our findings may aid in shared decision making on discharge planning.

GRADE Use in Evidence Syntheses Published in High-Impact-Factor Gynecology and Obstetrics Journals: A Methodological Survey

Objective: To identify and describe the certainty of evidence of gynecology and obstetrics systematic reviews (SRs) using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach. Method: Database searches of SRs using GRADE, published between 1 January 2016 to 31 December 2020, in the 10 "gynecology and obstetrics" journals with the highest impact factor, according to the Journal Citation Report 2019. Selected studies included those SRs using the GRADE approach, used to determine the certainty of evidence. Results: Out of 952 SRs, ninety-six SRs of randomized control trials (RCTs) and/or nonrandomized studies (NRSs) used GRADE. Sixty-seven SRs (7.04%) rated the certainty of evidence for specific outcomes. In total, we identified 946 certainty of evidence outcome ratings (n = 614 RCT ratings), ranging from very-low (42.28%) to low (28.44%), moderate (17.65%), and high (11.63%). High and very low certainty of evidence ratings accounted for 2.16% and 71.60% in the SRs of NRSs, respectively, compared with 16.78% and 26.55% in the SRs of RCTs. In the SRs of RCTs and NRSs, certainty of evidence was mainly downgraded due to imprecision and bias risks. Conclusions: More attention needs to be paid to strengthening GRADE acceptance and building knowledge of GRADE methods in gynecology and obstetrics evidence synthesis.

Doppler Imaging Assessment of Changes of Blood Flow in Adenomyosis After Higher-Dose Oxytocin: A Randomized Controlled Trial

OBJECTIVES

To assess the changes of blood flow in adenomyosis (AM) after higher-dose oxytocin (OT) in different doses, and to evaluate the safety for patients.

METHODS

A total of 124 patients with AM were randomly divided into 4 groups with continuous intravenous infusion of OT as 0.06, 0.12, 0.24 and 0.36 U/min, respectively. The changes of arteries of AM before and after intravenous infusion of OT were observed by color Doppler ultrasound. The changes of blood flow volume of the artery of AM before and after intravenous infusion of OT were compared among the 4 groups, and the vital signs and adverse drug reactions were monitored during intravenous drip.

RESULTS

During the trial, no severe adverse reactions occurred and the vital signs of all the patients were stable. Among the 4 groups, it was found that there was a significant difference in the change of blood flow volume of blood artery in AM lesions between 0.06 U/min OT group and the other three groups after intravenous drip of OT (P < .05), but there was no significant difference in blood flow volume among the three groups (P > .05), and the difference of adverse drug reactions was statistically significant with the increase of OT dose (P < .05).

CONCLUSION

OT can effectively reduce the blood flow volume of AM lesions, and continuous intravenous infusion of 0.12 U/min OT is an appropriate dose that can not only minimize the blood flow volume but also reduce the incidence of adverse drug reactions.

Prophylactic tranexamic acid during myomectomy: A systematic review and meta-analysis of randomized controlled trials

OBJECTIVE

To conduct a systematic review and meta-analysis of randomized controlled trials on the clinical efficacy and safety of prophylactic tranexamic acid (TXA) versus control (normal saline/no treatment) during myomectomy.

METHODS

Six databases were screened from inception until 21-February-2022. The eligible studies were assessed for risk of bias. The outcomes were summarized as mean difference (MD) and risk ratio (RR) with 95% confidence intervals (CI) in a random-effects model.

RESULTS

Seven studies, comprising eight arms and 571 patients (TXA = 304 patients, control = 267 patients) were analyzed. The included studies had an overall low risk of bias. The mean intraoperative blood loss (MD = -224.34 ml, 95% CI [-303.06, -145.61], p < 0.001), mean postoperative blood loss, and mean total blood loss were significantly reduced in favor of the prophylactic TXA group. Additionally, the mean postoperative hemoglobin (MD = 0.4 mg/dl, 95% CI [0.11, 0.68], p = 0.006) and mean postoperative hematocrit levels were significantly higher in favor of the prophylactic TXA group. While the mean hospital stay was significantly reduced in favor of the prophylactic TXA group (MD = -0.39 d, 95% [-0.74, -0.04], p = 0.03), there was no significant difference between both groups regarding the mean operation time and rate of blood transfusion. None of the participants in both groups developed any incidence of thromboembolic events. The rate of nausea was significantly higher in disfavor of the prophylactic TXA group (RR = 2.68, 95% CI [1.11, 6.43], p = 0.03).

CONCLUSION

Among patients undergoing myomectomy, prophylactic TXA was largely safe and linked to substantial reductions in perioperative blood loss and related morbidities.

Vasopressin and Its Analogues: From Natural Hormones to Multitasking Peptides

Human neurohormone vasopressin (AVP) is synthesized in overlapping regions in the hypothalamus. It is mainly known for its vasoconstricting abilities, and it is responsible for the regulation of plasma osmolality by maintaining fluid homeostasis. Over years, many attempts have been made to modify this hormone and find AVP analogues with different pharmacological profiles that could overcome its limitations. Non-peptide AVP analogues with low molecular weight presented good affinity to AVP receptors. Natural peptide counterparts, found in animals, are successfully applied as therapeutics; for instance, lypressin used in treatment of diabetes insipidus. Synthetic peptide analogues compensate for the shortcomings of AVP. Desmopressin is more resistant to proteolysis and presents mainly antidiuretic effects, while terlipressin is a long-acting AVP analogue and a drug recommended in the treatment of varicose bleeding in patients with liver cirrhosis. Recently published results on diverse applications of AVP analogues in medicinal practice, including potential lypressin, terlipressin and ornipressin in the treatment of SARS-CoV-2, are discussed.

Safety and efficacy of lidocaine plus epinephrine on intraoperative bleeding in abdominal myomectomy: A double-blind clinical trial

Background

Uterine fibroid is a common benign pelvic tumor and abdominal myomectomy may cause excessive intraoperative bleeding, which may lead to adverse outcomes.

Objective

This study was planned to evaluate the effectiveness of the injection of lidocaine plus epinephrine to reduce intraoperative bleeding in abdominal myomectomy.

Methods

During October 2019 and May 2020, 60 eligible women with uterine fibroids were enrolled in a randomized controlled trial. Our patients were divided into two groups of lidocaine plus epinephrine defined as Group L and placebo defined as Group P. In group L, lidocaine 3 mg/kg plus 0.5 ml of adrenaline which reached to 50 cc with saline solution and in group P, 50 ml of normal saline was used. Both the combined solution and normal saline were infiltrated to the serous and myometrium above and around the fibroid before incision. Patients' demographic data, total operative time, hemoglobin changes, and the degree of surgical difficulty were evaluated and compared between the two groups.

Results

There was no significant difference between the two groups in terms of demographic data. Hemoglobin changes (p <  0.0001) and the degree of surgery difficulty (p = 0.01) were significantly lower in Group L compared with Group P. In each group the drop in hemoglobin levels from baseline to 4 h postoperatively was significant (p <  0.0001). A significantly meaningful correlation was reported between hemoglobin changes and the degree of surgery difficulty with the size of the uterine and fibroids (p < 0.05). While a negative correlation was found regarding gravidity and surgery difficulty (r = -0.413, p = 0.02). Surgery duration was longer in Group P compared with Group L 70.66 ± 19.85 versus 66.16 ± 14.48, respectively, but with no significant difference (p = 0.32). No significant adverse reaction or serious complication was reported in the two groups. Hemodynamic parameters were kept in the normal range throughout the surgery.

Conclusion

A combination of lidocaine plus epinephrine during abdominal myomectomy appears to be a safe and effective method in reducing blood loss.

The Effect of Vasopressin during Hysteroscopic Myomectomy in Patients with Submucosal Myoma: A Randomized Controlled Trial

Background:

The aim was to assess the effect of vasopressin in reducing the time of surgery, amount of bleeding, and fluid deficit during hysteroscopic myomectomy of submucosal myoma from 2016 to 2018.

Materials and methods:

This study was conducted as a prospective, randomized, single-blinded clinical trial on the premenopausal women ranged from 18 to 62 years' old. A number of 80 patients were randomly assigned to each arm of the study according to random consecutive numbers. The control group (n = 40) of patients underwent conventional hysteroscopic myomectomy without vasopressin and the case group (n = 40) underwent hysteroscopic myomectomy with the injection of diluted vasopressin. Measured outcomes were time for myomectomy, fluid deficit, inflow volume, visual clarity, and postoperation hemoglobin level.

Results:

The mean time of myomectomy was 38.1 and 77.38 min in vasopressin and control groups, respectively (P < 0.001). The mean inflow volume was 2800 and 4100 in vasopressin and control groups, respectively (P = 0.029). The visual clarity score was 8.5 and 6.5 in the vasopressin and control groups, respectively (P < 0.001).

Conclusions:

The injection of vasopressin during hysteroscopic myomectomy is effective in the management of fluid deficit, time of surgery, and improvement of visual clarity.

Comparative efficacies of different immunotherapy regimens in recurrent implantation failure: A systematic review and network meta-analysis

For patients with recurrent implantation failure (RIF), immune system imbalances have become the focus of research. The effects of different classes of immunotherapies on improving pregnancy outcomes have not been fully established. This network meta-analysis was performed to assess the impact of popular immunotherapies in women with RIF. We systematically searched the Cochrane Central Register of Controlled Trials, PubMed, Embase, and Web of Science databases as well as clinical trial registration websites. Randomized controlled trials comparing immunotherapeutic outcomes were included. We performed the random-effects network meta-analysis to compare efficacy measures. A total of 21 trials involving 2277 participants and 8 immunotherapies were eligible for this study. Patients that had been administered with PBMCs, G-CSF, PRP, and sirolimus exhibited higher CPR than those administered with the placebo (2.63, 1.71-4.06; 2.03, 1.35-3.05; 1.98, 1.02-3.84; 2.55, 1.36-4.79; and 3.95, 1.33-11.72, respectively). For IR, only PBMCs and G-CSF were significantly more effective than the placebo (2.92, 1.39-6.12; 2.66, 1.16-6.06, respectively). In terms of LBR, PBMCs (2.96, 1.67-5.27) and sirolimus (3.55, 1.18-10.64) were effective. However, r-hLIF (0.25, 0.10-0.62) had a reduced risk of LBR. No therapeutic regimen was found to have significantly decreased MR, but PBMCs exhibited the lowest rank among all interventions (0.28, 0.06-1.44). To improve clinical pregnancy while reducing miscarriage outcomes, PBMCs might be a beneficent therapeutic option for RIF in the future.

How to minimize bleeding in laparoscopic myomectomy

PURPOSE OF REVIEW

Laparoscopic myomectomy is a common surgical procedure for symptomatic myomas. However, bleeding control during surgery may pose a challenge. Therefore, the aim of this study was to review recent evidence regarding interventions to control bleeding during laparoscopic myomectomy.

RECENT FINDINGS

The use of vasopressin resulted in less blood loss compared to placebo. Barbed sutures reduced blood loss compared to conventional sutures. Intravenous infusion of tranexamic acid (TXA) in the intraoperative period of large myomectomies showed no significant difference compared to placebo. Uterine artery occlusion (UAO) and emergency uterine artery embolization were reported to be feasible and may reduce and treat bleeding before conversion to laparotomy.

SUMMARY

Several methods can control bleeding during laparoscopic myomectomy. Vasopressin and barbed sutures resulted in decreased blood loss, and TXA did not have an impact on bleeding control. The use of UAO and emergency embolization techniques can contribute to the control of bleeding; however, further studies are needed to prove the efficacy of these and other agents.

Magnetic Resonance-Guided High-Intensity Focused Ultrasound Ablation of Uterine Fibroids-Efficiency Assessment with the Use of Dynamic Contrast-Enhanced Magnetic Resonance Imaging and the Potential Role of the Administration of Uterotonic Drugs

OBJECTIVE

The assessment of the usefulness of dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI) when qualifying patients with uterine fibroids (UFs) for magnetic resonance-guided high-intensity ultrasound (MR-HIFU).

MATERIAL AND METHODS

This retrospective, single center study included 283 women who underwent DCE-MRI and were treated with MR-HIFU. The patients were divided according to non-perfused volume (NPV) as well as by the type of curve for patients with a washout curve in the DCE-MRI study and patients without a washout curve. The studied women were assessed in three groups according to the type of uterotonics administered. Group A (57 patients) received one dose of misoprostol/diclofenac transvaginally and group B (71 patients) received oxytocin intravenously prior to the MR-HIFU procedure. The remaining 155 women (group C) were treated with the traditional non-drug enhanced MR-HIFU procedure.

RESULTS

The average NPV value was higher in no washout group, and depended on the uterotonics used.

CONCLUSIONS

We demonstrated a correlation between dynamic contrast enhancement curve types and the therapeutic efficacy of MR-HIFU. Our results suggest that DCE-MRI has the potential to assess treatment outcomes among patients with UFs, and patients with UFs that present with a washout curve may benefit from the use of uterotonic drugs. More studies are required to draw final conclusions.

Evaluating efficacy of intravenous carbetocin in reducing blood loss during abdominal myomectomy: a randomized controlled trial

OBJECTIVE

To evaluate the efficacy of carbetocin versus placebo in decreasing intraoperative blood loss and the need for blood transfusion during abdominal myomectomy.

DESIGN

Randomized, double-blind, placebo-controlled trial.

SETTING

Tertiary university hospital from September 2019 to February 2020.

PATIENT(S)

A total of 138 women with symptomatic leiomyoma who were candidates for abdominal myomectomy (n = 69 in each group).

INTERVENTION(S)

We randomized the study participants in a 1:1 ratio to carbetocin and placebo groups. Intravenous 100 μg carbetocin or placebo was administered slowly after induction of anesthesia.

MAIN OUTCOME MEASURE(S)

Intraoperative blood loss, need for blood transfusion, postoperative hemoglobin, operative time, length of hospitalization, and drug side-effects.

RESULT(S)

The baseline characteristics were similar among all groups. Carbetocin had significantly lower intraoperative blood loss compared with placebo (mean difference 184 mL). Hemoglobin level 24 hours after surgery was significantly lower in the placebo group than in the carbetocin group (9.1 ± 0.8 vs. 10.3 ± 0.6 g/dL). Eight women in the carbetocin group needed blood transfusion compared with 17 in placebo group. Operative time, length of hospitalization, and side-effects were similar in both groups.

CONCLUSION(S)

A single preoperative intravenous dose of 100 μg carbetocin is a simple, practical, and effective method of decreasing intraoperative blood loss and the need for blood transfusion during abdominal myomectomy, with tolerable, few, nonsignificant side-effects.

CLINICAL TRIAL REGISTRATION NUMBER

NCT04083625.

Analysis of Myomectomy during Cesarean Section: A Tertiary Center Experience

PURPOSE

This study analyzed the safety of myomectomy during the cesarean section (CS).

METHODS

Pregnant women who underwent myomectomy during CS in a tertiary center between January 2015 and November 2019 were included in the study in Group A, and pregnant women who did not have myoma and who underwent only CS were included in the study in Group B. The following information was obtained from patient files in hospital archives and was then recorded and compared: age, gravidity, parity, gestational week, characteristics of the myomas (i.e., location, size, number, and type), duration of surgery, perioperative complications, need for blood transfusion, preoperative and postoperative hemoglobin (Hb) values, duration of surgery, and hospital stay duration.

RESULTS

A total of 83 patients underwent CS plus myomectomy (Group A), and 80 patients (without myoma) underwent only CS (Group B).There were no statistically significant differences between the groups in terms of preoperative and postoperative Hb values or blood transfusion rates (p > 0.05). Hospitalization and surgery duration were significantly higher in the group that underwent CS myomectomy (p = 0.001 and p = 0.001, respectively). The mean myoma size was 8.3 ± 4.1 cm in Group A. There was a statistically significant and inverse correlation between the size of the myoma and the delivery week (p = 0.035). There was a statistically significant and positive correlation between the myoma size and hospital stay (p = 0.01).

CONCLUSION

Myomectomy during CS is safe and can be applied regardless of the location, size, type, and number of myomas. However, to make myomectomy routine during CS, multi-center studies that include more cases are needed.

Vitamins and Uterine Fibroids: Current Data on Pathophysiology and Possible Clinical Relevance

Uterine fibroid (UF) is the most common benign tumor pathology of the female reproductive organs. UFs constitute the main reason for a hysterectomy and hospitalization due to gynecological conditions. UFs consist of uterine smooth muscle immersed in a large amount of extracellular matrix (ECM). Genetic studies have demonstrated that UFs are monoclonal tumors originating from the myometrial stem cells that have underwent specific molecular changes to tumor initiating stem cells which proliferate and differentiate later under the influence of steroid hormones. There is growing interest in the role of micronutrients, for example, vitamins, in UFs. This article is a comprehensive review of publications regarding the available data concerning the role of vitamins in the biology and management of UFs. In summary, the results showed that some vitamins are important in the biology and pathophysiology of UFs. For example, vitamins A and D deserve particular attention following studies of their influence on the treatment of UF tumors. Vitamins B3, C, and E have not been as widely studied as the abovementioned vitamins. However, more research could reveal their potential role in UF biology.

Misoprostol for open myomectomy: a systematic review and meta-analysis of randomised control trials

BACKGROUND

Excessive blood loss is a significant risk of myomectomy with the potential need for hysterectomy.

OBJECTIVE

To study the effectiveness of preoperative misoprostol compared with placebo at open myomectomy on intra- and postoperative outcomes.

SEARCH STRATEGY

PubMed, Cochrane, Scopus, MEDLINE and EMBASE.

SELECTION CRITERIA

Randomised control studies of women undergoing open myomectomy for symptomatic fibroids who were given either misoprostol or placebo preoperatively.

DATA COLLECTION AND ANALYSIS

The revised Cochrane risk-of-bias tool for randomised trials was used to assess the risk of bias. Primary outcomes were blood loss, drop in haemoglobin and need for blood transfusion. Secondary outcomes were operative time, postoperative pyrexia and length of postoperative stay. Pooled effect sizes with corresponding 95% CI were calculated using random effects models. Data were analysed using two statistical models for statistical reliability.

RESULTS

Eight studies were included with a total of 385 patients, of which 192 received misoprostol. Preoperative misoprostol was significantly associated with lower blood loss by -170.32 ml (95% CI -201.53 to -139.10), lower drop in haemoglobin by -0.48 g/dl (95% CI -0.65 to -0.31), reduced need for blood transfusion (odds ratio [OR] -0.48, 95% CI -0.65 to -0.31), and a reduction in operative time by -11.64 minutes (95% CI -15.73 to -7.54). There was no difference in postoperative pyrexia or length of postoperative stay.

CONCLUSION

Moderate- to high-quality studies have established that misoprostol minimises blood loss and need for blood transfusion at open myomectomy. This low-cost and readily available drug should be routinely administered prior to open myomectomy to improve clinical outcomes.

TWEETABLE ABSTRACT

Use of misoprostol at open myomectomy reduces blood loss and need for blood transfusion with no impact on postoperative pyrexia.