Italian multicenter study on complications of laparoscopic myomectomy

Feasibility and Perioperative Outcomes of Minimally Invasive Higher Order Myomectomy

STUDY OBJECTIVE

To investigate perioperative outcomes of minimally invasive higher order myomectomy as defined by removal of 10 or more fibroids.

DESIGN

A retrospective cohort study between January 2018 and December 2022.

SETTING

A tertiary academic medical center.

PATIENTS

Women who underwent minimally invasive myomectomy via laparoscopic or robotic approach.

INTERVENTIONS

Surgical intervention in the form of minimally invasive myomectomy.

MEASUREMENTS AND MAIN RESULTS

A total of 735 women met inclusion criteria of whom 578 had fewer than 10 fibroids removed, and 157 patients had 10 or more removed (average number of fibroids removed 3.8 vs 14.7, p <.001; specimen's weight 317.4 g vs 371.0 g, p = .07). Body mass index was similar in both groups (p = .66) and patients with higher order myomectomy were more likely to have a history of myomectomy (12.0% vs 26.8%, p <.001). The average estimated blood loss (EBL) was 246 mL vs 470 mL in each group (p <.001). There were no significant differences in packed red blood cell transfusion (1.0% vs 0.6%, p = .65), conversion to laparotomy (0.5% vs 0.6%, p = .86), or complications including visceral injury, wound complication, venous thromboembolism, ileus, or readmission (5.9% vs 4.5%, p = .49). The hospital length of stay was similar in both groups (0.5 days vs 0.5 days, p = .63). On linear regression analysis, after adjusting for specimen's weight, operative time, and history of myomectomy, EBL remained significantly higher in patients with 10 or more fibroids removed (p = .02).

CONCLUSION

EBL is increased in higher order myomectomy; however, blood transfusions, conversion to laparotomy, complication rates, and length of hospital stay did not differ compared with patients with fewer than 10 fibroids removed, highlighting the feasibility of minimally invasive higher order myomectomy.

Cystic Adenomyoma in Pregnancy: A Case Report

Cystic adenomyomas (CA) are rare. They primarily affect adolescents and young women in their fertile years. Therefore, fertility and pregnancy outcome are of pivotal relevance in this patient collective. Apart from the guidelines of the European Society of Human Reproduction and Embryology (ESHRE) on the management of endometriosis in general, there are no specific treatment recommendations for CA and, as far as our research shows, no data illustrating the behavior of a CA over the course of pregnancy. Thus, we report the case of a 32-year-old 1-gravida, 1-para, preconceptionally diagnosed with a CA by ultrasound. After thoroughly discussing further treatment options, the decision was made to opt for a more conservative approach and not perform surgery before attempting a next pregnancy. The patient conceived spontaneously and sonographic monitoring of the CA throughout pregnancy showed complete regression of the cystic component during the second trimester. A healthy baby was delivered at term by an uncomplicated elective cesarean section. Following a review of the literature and taking into account the course of our case, we propose the feasibility of a conservative, non-surgical approach in women with a CA and the desire to conceive.

Perioperative and reproductive outcomes' comparison of mini-laparotomy and laparoscopic myomectomy in the management of uterine leiomyomas: a systematic review

OBJECTIVE

To evaluate and compare mini-laparotomy (MLPT) with laparoscopic (LPS) myomectomy perioperative and reproductive outcomes.

METHODS

We systematically searched for related articles in the MEDLINE, Embase, Web of Science and the Cochrane library databases. Nine studies (4 randomized, 3 retrospective, 1 prospective and 1 case-control study) which involved 1723 patients met the inclusion criteria and were considered eligible for inclusion.

RESULTS

Demographic characteristics were similar between the two groups. LPS was associated with shorter hospital stay (p = 0.04), lower blood loss (p < 0.00001), shorter duration of median ileus (p < 0.00001) and fewer episodes of postoperative fever (p = 0.04). None of the reproductive factors examined (pregnancy rate, preterm delivery, vaginal delivery and delivery with caesarean section) in women diagnosed with unexplained infertility and/or symptomatic leiomyomas reached statistical significance although the results represent a small size effect.

CONCLUSION

Our analysis demonstrated that LPS seems to be an alternative, safe and reliable surgical procedure for uterine leiomyoma treatment and in everyday practice seems to offer improved outcomes-regarding at least the perioperative period-over MLPT.

Risk of hysterectomy at the time of myomectomy: an underestimated surgical risk

OBJECTIVE

To evaluate the risk of hysterectomy at the time of myomectomy and the associated 30-day postoperative morbidity.

DESIGN

Cohort study.

PATIENTS

Patients who underwent myomectomies identified from the American College of Surgeons' National Surgical Quality Improvement Program from 2010 to 2021.

INTERVENTION

Unplanned hysterectomy at the time of a myomectomy procedure.

MAIN OUTCOME MEASURES

The Current Procedural Terminology codes were used to identify myomectomies performed with or without concurrent hysterectomy. Preoperative characteristics and morbidity outcomes were obtained. The univariate analysis was performed using the chi-square and Fisher exact tests, as appropriate. Multivariate logistic regression reported risk factors for individuals who underwent hysterectomy at the time of myomectomy. P values of <.05 were considered statistically significant.

RESULTS

A total of 13,213 individuals underwent myomectomy, and 399 (3.0%) had a hysterectomy performed during myomectomy. Concurrent hysterectomy was most frequently performed with the laparoscopic approach (7.1%), followed by the abdominal (3.2%) and hysteroscopic (1.9%) approaches. Age ≥43 years, obesity class II and higher, American Society of Anesthesiologists (ASA) class greater than II, tobacco use, longer operative time (>85 minutes), and laparoscopic approach were associated with a significantly increased risk of hysterectomy. When adjusting for age, body mass index, race, ASA class, case type, surgical approach, operative time, preoperative transfusion, preoperative hematocrit, and high fibroid burden, an increased odds of hysterectomy was noted for white race, longer operative time, ASA class III or higher, obesity, laparoscopic approach, and low fibroid burden. Patients who underwent concurrent hysterectomy had a longer median length of hospital stay (2 vs. 1 day), longer median operative time (161 vs. 126 minutes), increased intraoperative/postoperative blood transfusions (14.5% vs. 9.0%), and higher rates of organ/space surgical site infections (1.5% vs. 0.5%) and return to surgery (2.0% vs. 0.7%) than those who did not (P<.05). The risk of a major complication within 30 days of myomectomy increased in patients who underwent concurrent hysterectomy after adjusting for relevant confounders (adjusted odds ratio, 2.4; 95% confidence interval, 1.8-3.2).

CONCLUSION

The risk of hysterectomy during a myomectomy is higher than previously reported. The patient age of ≥43 years, obesity, white race, ASA class III or higher, longer operative time, and laparoscopic approach were associated with higher odds of hysterectomy. Identification of patients with these risk factors can aid in patient counseling and surgical planning, which may help reduce the unexpectedly high rates of hysterectomy at planned myomectomy.

The Effect of 2016 Chinese second-child policy and different maternal age on pregnancy outcomes in Hebei Province, China

OBJECTIVE

To explore the effect of the 2016 Chinese second child policy and different maternal ages on adverse perinatal outcomes.

METHODS

Clinical data were collected from 22 monitoring hospitals in Hebei Province from January 1, 2013, to December 31, 2021. A total of 413,892 parturient were divided into 3 groups based on delivery age: 20-34, 35-39, and 40-55 years old. The clinical data were analyzed to explore the relationship among the 2016 Chinese second-child policy, maternal age, and various pregnancy risks.

RESULTS

Pregnancy complications showed an upward trend from 2013 to 2021.The top 10 incidences of pregnancy complications in Hebei Province were anemia, small for gestational age (SGA), large for gestational age (LGA), macrosomia, gestational diabetes mellitus (GDM), premature delivery, preeclampsia (PE), postpartum hemorrhage (PPH), placenta previa, and placental abruption. The two-child policy was implemented in 2016. The incidence of pregnancy complications, anemia, GDM, PE, placental abruption, cesarean delivery, premature delivery, SGA, LGA, macrosomia in 2016-2021 was significantly higher than that in 2013-2015 (P<0.05), and the proportion of women of advanced maternal age (AMA, ≥ 35 years old) increased from 2013 to 2021. Advanced maternal age was a risk factor for most assessed adverse pregnancy outcomes, including GDM, PE, placenta previa, placenta abruption, cesarean delivery, PPH, premature delivery, SGA, LGA and macrosomia.

CONCLUSION

After the adjustment of the "second-child" policy, the incidence of pregnancy complications increased. Moreover, the risk of adverse pregnancy outcomes in AMA has increased. Early prevention and intervention should be implemented to cope with the occurrence of adverse perinatal outcomes.

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.

An update on uterine artery embolization for uterine leiomyomata and adenomyosis of the uterus

Uterine artery embolization (UAE) is an established technique to treat benign diseases of the uterus such as uterine leiomyomata (fibroids) and adenomyosis. This article reviews the use of UAE in these conditions and summarizes the evidence regarding safety and efficacy of the technique based on the current literature.

HIFU as an alternative modality for patients with uterine fibroids who require fertility-sparing treatment

OBJECTIVES

To compare pregnancy outcomes after high-intensity focused ultrasound ablation (HIFU), myomectomy and uterine artery embolization (UAE) for fertility-sparing patients with uterine fibroids and to investigate the possible mechanism of improving pregnancy by HIFU.

MATERIALS AND METHODS

A meta-analysis of 54 studies containing 12,367 patients was conducted to compare the pregnancy outcomes of three fertility-sparing therapies. And a retrospective self-control study of 26 patients with uterine fibroids from May 2019 to December 2020 was performed to assess the blood flow impedance of bilateral uterine arteries before and after HIFU.

RESULTS

In the analysis by treatment option, the pregnancy rate after myomectomy was 0.43 (95% CI 0.36-0.49), which was higher than 0.18 (95% CI 0.10-0.26) after HIFU, the latter was significantly higher than that after UAE (ratio 0.08, 95% CI 0.06-0.10). The miscarriage rate after HIFU was 0.08 (95% CI 0.04-0.12), which was similar to 0.15 (95% CI 0.09-0.21) after myomectomy and also similar to 0.16 after UAE (95% CI 0.01-0.30). In the subgroup analysis, women who received ultrasound guided HIFU (USgHIFU) were more likely to have ideal pregnancy outcomes than that after magnetic resonance imaging-guided HIFU. The pulsatility index and resistance index on the right side were significantly higher 3 months after HIFU than before (1.637 ± 0.435 vs. 1.845 ± 0.469; p = 0.033; 0.729 ± 0.141 vs. 0.784 ± 0.081, p = 0.039).

CONCLUSIONS

HIFU, especially USgHIFU, may be an alternative fertility-sparing modality for patients with uterine fibroids over 40 years old. HIFU may contribute to improving pregnancy rates by elevating uterine blood flow impedance.

The Role of Three-dimensional Printed Models in Women's Health

Three-dimensional printing is an innovative technology that has gained prominence in recent years due to its attractive features such as affordability, efficiency, and quick production. The technology is used to produce a three-dimensional model by depositing materials in layers using specific printers. In the medical field, it has been increasingly used in various specialties, including neurosurgery, cardiology, and orthopedics, most commonly for the pre-planning of complex surgeries. In addition, it has been applied in therapeutic treatments, patient education, and training wof medical professionals. In the field of obstetrics and gynecology, there is a limited number of studies in which three-dimensional printed models were applied. In this review, we aim to provide an overview of three-dimensional printing applications in the medical field, highlighting the few reported applications in obstetrics and gynecology. We also review all relevant studies and discuss the current challenges and limitations of adopting the technology in routine clinical practice. The technology has the potential to expand for wider applications related to women's health, including patient counseling, surgical training, and medical education.

Outcomes of In-bag Transvaginal Extraction in a Series of 692 Laparoscopic Myomectomies: Results from a Large Retrospective Analysis

STUDY OBJECTIVE

Transvaginal extraction is a feasible method to remove surgical specimen. In this study, we aim to report our experience with in-bag transvaginal specimen retrieval after laparoscopic myomectomy over the past 15 years.

DESIGN

Single-center retrospective analysis.

SETTING

Academic hospital.

PATIENTS

Women who underwent laparoscopic myomectomy from January 2005 to April 2021.

INTERVENTION

Posterior colpotomy and in-bag transvaginal extraction of the surgical specimen.

MEASUREMENTS AND MAIN RESULTS

We collected and analyzed data about patients' characteristics, main indication for surgery, and intra- and postoperative (within 30 days) complications.

RESULTS

A total of 692 women underwent transvaginal specimen retrieval after laparoscopic myomectomy (mean largest myoma diameter: 6.64 ± 2.21 cm; mean specimen weight: 177 ± 140 g; mean operative time: 84.1 ± 37.1 minutes; mean blood loss: 195 ± 191 mL). Within 30-days, we reported the following colpotomy-related complications: a total of 4 cases (0.6%) of vaginal bleeding, 3 of which resolved spontaneously (1 case required readmission with new colporrhaphy under general anesthesia), and 2 cases (0.3%) of vaginal pain, with no underlying cause identified on physical examination and pelvic ultrasound. Specimen weight was positively correlated with longer operative time, intraoperative blood loss, and length of hospital stay.

CONCLUSION

Posterior colpotomy and in-bag transvaginal extraction can be considered a feasible option for retrieval of surgical specimens after laparoscopic myomectomy.

Rates of Complications and Reoperation after Myomectomy-the Impact of Surgical Approach: A Statewide Population-based Cohort Study from 2005-2018

STUDY OBJECTIVE

To assess rates of and factors associated with complications and reoperation after myomectomy.

DESIGN

Population-based cohort study.

SETTING

All non-Veterans Affairs facilities in the state of California from January 1, 2005, to December 31, 2018.

PARTICIPANTS

Women undergoing abdominal or laparoscopic myomectomy for myoma disease were identified from the Office of Statewide Health Planning and Development datasets using appropriate International Classification of Diseases, Ninth and Tenth Revision and Current Procedural Terminology codes.

INTERVENTIONS

Demographics, surgery facility type, facility surgical volume, and surgical approach were identified. Primary outcomes included complications occurring within 60 days of surgery and reoperations for myomas. Patients were followed up for over an average of 7.3 years. Univariate and multivariable associations were explored between the above factors and rates of complications and reoperation. All odds ratios (ORs) are adjusted ORs.

MEASUREMENTS AND MAIN RESULTS

Of the 66 012 patients undergoing myomectomy, 5265 had at least one complication (8.0%). Advanced age, black, Asian race, MediCal and Medicare payor status, academic facility, and medical comorbidities were associated with increased odds of a complication. Minimally invasive myomectomy (MIM) was associated with decreased complications compared with abdominal myomectomy (AM) (OR, 0.29; 95% confidence interval [CI], 0.25-0.33; p <.001). Overall, 17 377 patients (26.3%) underwent reoperation. Medicare and MediCal payor status and medical comorbidities were associated with increased odds of a repeat surgery. Reoperation rates were higher in the MIM group over the entire study period (OR, 2.33; 95% CI, 1.95-2.79; p <.001). However, the odds of reoperation after MIM decreased each year (OR, 0.93; 95% CI 0.92-0.95; p <.001), with the odds of reoperation after AM surpassing MIM in 2015.

CONCLUSION

This study identifies outcome disparities in the surgical management of myomas and describes important differences in the rates of complications and reoperations, which can be used to counsel patients on surgical approach. These findings suggest that MIM can be considered a lasting and safe approach in properly selected patients.

Use of a microsurgical vascular clip system for temporary bilateral occlusion of the four main uterine vessels for laparoscopic enucleation of very large intramural uterine fibroids

Objectives

The goal of this study was to examine the safety, feasibility, and effectiveness of the use of a microsurgical temporary vascular clip system to facilitate the laparoscopic enucleation of very large intramural uterine fibroids.

Methods

In this retrospective study, the surgical outcomes of 26 patients who underwent laparoscopic myomectomy with temporary uterine vessel clipping for very large (the largest measured diameter ≥ 9 cm) symptomatic intramural uterine fibroids in two tertiary referral hospitals between September 2017 and March 2020 were examined. Titan-made vascular clips (YASARGIL^® Aneurysm Clip System) were used to temporarily occlude the bilateral uterine arteries and utero-ovarian vessels. Main outcomes included operating time, blood loss, number of leiomyomas and weight, conversion rate, intra- and postoperative complication rates, and length of hospital stay.

Results

Twenty six patients were included. Dominant intramural uterine fibroid diameters were 9–22 cm. The general characteristics of the patients were similar. The mean surgery duration and intraoperative blood loss were 175.3 ± 32.7 (range 120–250) min and 241.1 ± 103 (range 100–450) ml, respectively. The median postoperative drop in hemoglobin was 0.89 ± 0.75 g/dL. No patient required blood transfusion. No procedure was converted to laparotomy. No major intra- or postoperative complication occurred.

Conclusions

Laparoscopic myomectomy for very large intramural uterine fibroids can be performed safely and effectively, with less intraoperative blood loss, using vascular clips for temporary clamping of the bilateral uterine vessels.

Recurrence of Uterine Smooth Muscle Tumor of Uncertain Malignant Potential: A Systematic Review of the Literature

Background: This study aimed to systematically review the existing literature on uterine smooth muscle tumor of uncertain malignant potential (STUMP) to provide information about characteristics and outcomes of patients and the risk factors for recurrence over a period of 60 years (1960−2021). Methods: According to PRISMA guidelines, we searched for "uterine smooth muscle tumor of uncertain malignant potential" in PubMed (all fields) and Scopus (Title/Abstract/Keywords) databases (accessed on 1 January 2022). Relevant articles were obtained in full-text format and screened for additional references. The only filter used was the English language. Studies including full case description of patients with histopathological diagnosis of STUMP in accordance with Stanford criteria were included. Results: Thirty-four studies, including 189 cases, were included. The median age was 43 years, and in 21.5% of cases there was a recurrence of the disease. Bivariate analysis showed a significant association between use of morcellation without bag and risk of recurrence (p = 0.001). Unprotected morcellation during demolitive or conservative surgery was independently associated with a higher risk of disease recurrence with a relative risk of 2.94 (p < 0.001). A significant progressive decrease in the recurrence rate was observed over time (r = −0.671, p = 0.008). The percentage of patients who underwent surgery followed by in-bag protected morcellation significantly increased after the publication of the U.S. Food and Drug Administration alert about the risk linked to this procedure (p = 0.01). Conclusions: Unprotected morcellation of the lesion is associated with the relapse of the disease. However, this clinical condition showed a drastic decrease over time. This could likely be due to the increased awareness by surgeons of the importance of customizing surgical treatment.

Update of Robotic Surgery in Benign Gynecological Pathology: Systematic Review

Background and Objectives: Since the Food and Drug Administration's (FDA) approval in 2005, the application of robotic surgery (RS) in gynecology has been adopted all over the world. This study aimed to provide an update on RS in benign gynecological pathology by reporting the scientific recommendations and high-value scientific literature available to date. Materials and Methods: A systematic review of the literature was performed. Prospective randomized clinical trials (RCT) and large retrospective trials were included in the present review. Results: Twenty-two studies were considered eligible for the review: eight studies regarding robotic myomectomy, five studies on robotic hysterectomy, five studies about RS in endometriosis treatment, and four studies on robotic pelvic organ prolapse (POP) treatment. Overall, 12 RCT and 10 retrospective studies were included in the analysis. In total 269,728 patients were enrolled, 1721 in the myomectomy group, 265,100 in the hysterectomy group, 1527 in the endometriosis surgical treatment group, and 1380 patients received treatment for POP. Conclusions: Currently, a minimally invasive approach is suggested in benign gynecological pathologies. According to the available evidence, RS has comparable clinical outcomes compared to laparoscopy (LPS). RS allowed a growing number of patients to gain access to MIS and benefit from a minimally invasive treatment, due to a flattened learning curve and enhanced dexterity and visualization.

Comparison of Clinical and Reproductive Outcomes between Adenomyomectomy and Myomectomy

STUDY OBJECTIVE

Women with adenomyosis may show a lower pregnancy rate and a higher miscarriage rate than healthy women. There is also a general agreement that leiomyomas, either submucosal or intramural, negatively affect fertility, when compared with women without myomas. Some of these women may benefit from adenomyomectomy, however this cytoreductive procedure is considered invasive and technically challenging especially in severe diffuse cases. The study aimed to compare the clinical and reproductive outcomes of patients who underwent adenomyomectomy with those of patients who underwent intramural myomectomy.

DESIGN

A retrospective study.

SETTING

Department of Obstetrics & Gynecology, Center of Gynecological Endoscopy and Minimally Invasive surgery, First Faculty of Medicine, General University Hospital in Prague.

PATIENTS

A total of 55 women who underwent surgical resection of uterine adenomyosis and 55 patients who underwent myomectomy for intramural uterine myomas were included in this study. All study participants wished to retain and possibly improve their reproductive potential.

INTERVENTIONS

Between 2004 and 2019, 110 women underwent laparoscopic or open uterus-sparing surgery for clinically significant uterine adenomyosis (group A) or myomas (group B), respectively.

MEASUREMENTS AND MAIN RESULTS

Two groups of women who underwent different fertility-saving procedures were compared. Although all women entering the study had declared their wish to conceive, only 28 patients in group A (group A1) and 24 women in group B (group B1) finally aimed toward pregnancy. The mean age and follow-up period was 35.0 years and 76.81 months, respectively, in group A and 34.8 years and 72.5 months, respectively, in group B. The pregnancy and delivery rates were 75.0% and 46.4%, respectively, in group A1 vs 96.0% and 70.8%, respectively, in group B1, with no significant differences between the 2 groups. The open surgical approach was significantly more frequently employed in group A (47.3% vs 16.4%; p <.01).

CONCLUSION

In this study, women who underwent surgery involving the uterine muscularity, including myomectomy or adenomyomectomy, had comparable reproductive outcomes, with no significant differences.

Diagnostic performance of preoperative MR imaging findings for differentiation of uterine leiomyoma with intraligamentous growth from subserosal leiomyoma

PURPOSE

To evaluate the diagnostic performance of MRI findings for differentiating uterine leiomyoma with intraligamentous growth, or broad ligament fibroid, from subserosal leiomyoma.

METHODS

This study included 37 patients with surgically confirmed uterine smooth muscle tumors (36 leiomyomas and one smooth muscle tumor of uncertain malignant potential) with intraligamentous growth (IL) and size-matched control of 37 patients with subserosal leiomyoma (SS). Two radiologists independently evaluated eight preoperative MRI findings: tumor shape, degeneration, attachment to uterus, ovary elevation, ureter displacement, bladder deformation, rectal displacement, and separation of round ligament (RL) and uterine artery (UA). The diagnostic values of these findings and interobserver agreement were assessed. Receiver-operating characteristic (ROC) analysis of the number of positive MRI findings for diagnosing IL was performed. Clinical outcomes including surgical method, operation time, intraoperative blood loss, perioperative complications, and postoperative hospital stay of the two groups were compared.

RESULTS

Significant differences in tumor shape, attachment to uterus, ovary elevation, ureter displacement, and separation of RL and UA were found between IL and SS. Four of these findings, excluding ureter displacement, showed moderate to substantial interobserver agreement. When two or more of these four findings were positive, sensitivity, specificity, and area under the ROC curve were 91%, 77%, 0.90 in reader 1 and 82%, 89%, 0.91 in reader 2. The operation time was significantly longer for IL than for SS.

CONCLUSION

Tumor shape, attachment to uterus, ovary elevation, and separation of RL and UA are useful MRI findings for differentiating intraligamentous leiomyoma from subserosal leiomyoma.

A review and guide to creating patient specific 3D printed anatomical models from MRI for benign gynecologic surgery

Background

Patient specific three-dimensional (3D) models can be derived from two-dimensional medical images, such as magnetic resonance (MR) images. 3D models have been shown to improve anatomical comprehension by providing more accurate assessments of anatomical volumes and better perspectives of structural orientations relative to adjacent structures. The clinical benefit of using patient specific 3D printed models have been highlighted in the fields of orthopaedics, cardiothoracics, and neurosurgery for the purpose of pre-surgical planning. However, reports on the clinical use of 3D printed models in the field of gynecology are limited.

Main text

This article aims to provide a brief overview of the principles of 3D printing and the steps required to derive patient-specific, anatomically accurate 3D printed models of gynecologic anatomy from MR images. Examples of 3D printed models for uterine fibroids and endometriosis are presented as well as a discussion on the barriers to clinical uptake and the future directions for 3D printing in the field of gynecological surgery.

Conclusion

Successful gynecologic surgery requires a thorough understanding of the patient’s anatomy and burden of disease. Future use of patient specific 3D printed models is encouraged so the clinical benefit can be better understood and evidence to support their use in standard of care can be provided.

Rethinking Disparities in Minimally Invasive Myomectomy: Identifying Drivers of Disparate Surgical Approach to Myomectomy Between African American and White Women

STUDY OBJECTIVE

To identify drivers of disparities among patients undergoing surgical management of fibroids when stratified by self-identified patient race.

DESIGN

This is a retrospective IRB-approved chart review of all patients who underwent a myomectomy at a large academic center. Surgical approach to myomectomy was classified as abdominal, laparoscopic, or robotic-assisted laparoscopic. Fibroid burden was quantified preoperatively using uterine volume, intra-operatively by number of fibroids listed on operative report, and postoperatively by fibroid weight from pathology reports.

SETTING

A large tertiary care hospital containing a comprehensive fibroid treatment center.

PATIENTS

265 white patients and 121 African American patients who underwent a myomectomy between January 2012 and October 2018 were included in the study population.

INTERVENTIONS

Abdominal, laparoscopic, and robotic-assisted myomectomy. Laparoscopic and robotic-assisted myomectomy were classified as minimally invasive myomectomy. Multivariable logistic regression models and a propensity score matching algorithm were used to match African American women and white women for fibroid burden.

MEASUREMENTS AND MAIN RESULTS

A total of 386 women were included in the study. African American (AA) (31%; n=121) women had higher fibroid burden (p<0.01) by preoperative imaging (36% with 3 or more) as compared to white women (19% with 3 or more) and operative report (>8 AA: 31% vs. white 13%, p<.01). Despite this, African American women underwent minimally invasive myomectomy at similar rates as compared to white women when adjusted for fibroid burden, BMI, preoperative hematocrit, HTN, and surgical indication (adjusted OR: 1.3, 95% CI: 0.8 to 2.2, p<.01).. Sensitivity analysis using propensity score matching found similar results.

CONCLUSION

In this population, African American women had a higher fibroid burden as compared to white women. When matched for fibroid burden, however, there was no statistically significant difference between rates of minimally invasive myomectomy and abdominal myomectomy. This finding was consistent when controlling for fibroid burden measured by preoperative, intraoperative, or postoperative methods of measurement. Further studies are needed to better characterize this disparity at other hospitals, and to investigate ways to increase access and equity among patients undergoing minimally invasive myomectomy.

Operative and Obstetric Outcomes after Single-port Laparoscopic Myomectomy: A Retrospective Single-center Analysis of 504 Cases

STUDY OBJECTIVE

To analyze the obstetric and operative outcomes of 504 cases of single-port laparoscopic myomectomy (SPLM).

DESIGN

Single-center retrospective study.

SETTING

A tertiary university hospital.

PATIENTS

A total of 502 patients (504 SPLM procedures) who underwent SPLM for symptom relief or growing myomas between October 2009 and April 2020.

INTERVENTIONS

Data on patient demographics, operative variables (estimated blood loss, hemoglobin decrease, operation time, perioperative complications, and postoperative hospital stay), and obstetric outcomes (the surgery-to-pregnancy interval and birth-related outcomes) were obtained from medical records and analyzed.

MEASUREMENTS AND MAIN RESULTS

The mean age of the patients was 40.6 ± 6.6 years. The patients had had an average of 2.3 ± 2.2 myomas removed; the largest myoma size was 6.8 ± 2.4 cm. The mean operation time, postoperative hemoglobin decrease, and postoperative hospital stay duration were 112.9 ± 45.3 minutes, 1.7 ± 1.1 g/dL, and 2.2 ± 1.4 days, respectively. The overall rate of postoperative complications was 7.7% (39/504), and the common complications were transfusions (16/504, 3.1%) or wound problems (15/504, 3.0%). Conversion to multiport or open myomectomy was required in 0.8% of the cases (4/504). A total of 376 women were of child-bearing age, and 56 attempted to become pregnant after surgery. The mean interval from surgery to pregnancy was 15.6 ± 12.2 months. The obstetric outcomes were pregnancy (42/56, 75.0%), live birth (39/56, 69.6%), and miscarriage (2/56, 3.6%). One pregnant woman was lost to follow-up. The 39 live births predominantly involved full-term delivery (36/39, 92.3%), mostly through cesarean section (36/39, 92.3%). No postpartum complications were reported. The 2 most common obstetric complications were preterm labor (7.6%) and gestational diabetes (5.1%).

CONCLUSION

SPLM seems to be an effective procedure with good operative and postoperative obstetric outcomes for women with myomas who require surgery and may wish to subsequently become pregnant.

Therapeutic approach of uterine leiomyoma; choosing the most appropriate surgical option

The most common benign pelvic tumor in young women is uterine leiomyoma. It is often asymptomatic, but can cause symptoms such as pelvic-abdominal pain, vaginal bleeding, urinary and intestinal transit disorders. If there is a suspicion of malignancy, it is necessary to perform fractional uterine curettage to establish the histopathological diagnosis.The surgical treatment of uterine leiomyoma includes several procedures: myomectomy, subtotal or total hysterectomy. The procedure will be chosen depending on the patient's particularities: BMI, uterine size, leiomyoma location, surgical history or other associated pathologies.Laparoscopic hysterectomy has a 45-minute shorter duration of intervention than vaginal hysterectomy, and the conversion rate to the open procedure is lower.Laparoscopically treated cases have fewer postoperative complications compared to other surgical procedures and have a shorter hospitalization and recovery time.The recurrence rate of uterine leiomyoma is similar for both laparoscopic and open abdominal approach, and the frequency of long-term complications such as adhesion syndrome or pelvic pain is higher after the latter.

MRI-based pictorial review of the FIGO classification system for uterine fibroids

Uterine fibroids are the most common gynecologic neoplasm and contribute to significant morbidity, particularly when submucosal in location or large enough to cause bulk symptoms. Correctly classifying fibroids is essential for treatment planning and prevention of complications. Ultrasound is the first-line imaging modality for characterizing uterine fibroids. However, MRI allows for high-resolution, multiplanar visualization of leiomyomata that affords a more accurate assessment than ultrasound, particularly when fibroids are numerous. The FIGO system was developed in order to more uniformly and consistently describe and classify uterine fibroids. In this article, we review the MRI appearance of each of the FIGO classification types, detailing key features to report. Additionally, we present a proposed template for structured reporting of uterine fibroids based on the FIGO classification system.

A Suturing Method without Exposure of Barbs on the Wound Surface Using a Unidirectional Barbed Monofilament Absorbable Suture (STRATAFIX™) in Laparoscopic Myomectomy: A Feasibility Study

Objectives:

We examined whether a new suturing method that used a single-thread unidirectional barbed suture without exposing the barbs on the wound surface was acceptable compared with the conventional suture method during laparoscopic myomectomy (LM).

Materials and Methods:

This was a retrospective study. The subjects were 26 women who underwent LM for symptomatic uterine fibroids. The operative time, amount of blood loss, and number of threads used were compared between a group in which suturing was performed with a conventional synthetic absorbable suture (conventional suture group, n = 13) and a group in which suturing was performed using a barbed suture (barbed suture group, n = 13).

Results:

Operative time in the barbed suture group was significantly shorter than that in the conventional suture group, while blood loss during LM in the barbed suture group was significantly lower than that in the conventional suture group. The number of threads used in the conventional suture group was significantly larger than that in the barbed suture group. No complications were observed in both the groups during LM.

Conclusion:

This new technique using a barbed suture is safe and feasible for LM.

New Surgical Technique for Robotic Myomectomy: Continuous Locking Suture on Myoma (LSOM) Technique

Robot-assisted laparoscopic myomectomy (RALM) has broadened the indications even in complex myomas. However, the high cost of RALM remains the main disadvantage. Therefore, a surgical technique that can reduce the cost of RALM and still has the advantages of robotic surgery is required. We propose a "locking suture on myoma (LSOM)" technique and compared the operative and perioperative outcomes of patients who underwent RALM with or without the LSOM technique. We included 337 patients who underwent RALM with (n = 160) or without (n = 177) the LSOM technique between March 2019 and August 2020. The LSOM group had low parity and gravidity, with a low rate of Cesarean sections. Myoma type was not different between the groups; however, patients in the LSOM group had larger, heavier, and higher number of myomas, although fewer patients had multiple myomas and were discharged earlier. Total operating time, estimated blood loss, pre- and postoperative hemoglobin levels, transfusion rate, and postoperative fever were not different between the two groups. In conclusion, the LSOM technique may be a viable surgical option for myomas, as it can reduce the cost of RALM by obviating the need for robotic Tenaculum forceps.

Risk factors and outcomes of uterine rupture in Singapore: Emerging trends

ABSTRACT Introduction: Uterine rupture is uncommon but has catastrophic implications on the pregnancy. A scarred uterus and abnormal placentation are known contributory factors. The aim of our study was to review the contributing factors, clinical presentation, complications and management of uterine rupture in our population in light of the changing nature of modern obstetric practices. Methods: A retrospective observational study was conducted at KK Women’s and Children’s Hospital by studying proven cases of uterine rupture in the period between January 2003 and December 2014. These cases were analysed according to their past history, clinical presentation, complications, management and outcome. Results: A total of 48 cases of proven uterine rupture were identified. The incidence of uterine rupture was 1 in 3,062 deliveries. The ratio of scarred uterus rupture to unscarred uterus rupture was approximately 3:1. The most common factor was previous lower segment caesarean section for the scarred group, followed by a history of laparoscopic myomectomy. Abdominal pain was the common clinical presentation in the antenatal period, while abnormal cardiotocography findings were the most common presentation in intrapartum rupture. Conclusion: There is a notable shift in the trend of uterine rupture cases given the increasing use of laparoscopic myomectomy and elective caesarean sections. While ruptures from these cases were few, their presentation in the antenatal period calls for diligent monitoring with informed patient involvement in their pregnancy care. Keywords: Antenatal, laparoscopic myomectomy, birth after caesarean, rupture, VBAC

Ultrasonic manifestations and clinical analysis of 25 uterine rupture cases

PURPOSE

To explore the risk factors, ultrasonic manifestations, clinical features, and maternal and neonatal outcomes associated with complete uterine rupture.

BASIC PROCEDURES

All cases of complete uterine rupture diagnosed and treated in Jiangxi Maternal and Child Health Hospital from January 2012 to July 2018 were retrospectively analyzed. Risk factors, ultrasonic manifestations, clinical features, and maternal and infant outcomes were analyzed.

RESULT

All patients had a history of uterine surgery or induced abortion. Ultrasound examination revealed 15 cases of complete rupture of the uterus, five cases of missed diagnosis, three cases of misdiagnosis, and two cases of direct emergency operation without ultrasonography because of typical clinical manifestations and critical conditions. The clinical manifestations of 25 cases of uterine rupture varied from asymptomatic to clinical signs of "resting" rupture of the uterus to severe pain, hypotension, shock, and coma. All patients underwent surgical treatment, of which one case underwent DIC and died after rescue. The maternal mortality rate was 4% (1/25), the mortality rate of newborns (two pregnant women was twins) was 44% (12/27).

CONCLUSION

A history of uterine surgery is a major risk factor for uterine rupture. Attention should be paid not only to women who are pregnant again after cesarean section but also to those who have undergone other uterine operations (such as laparoscopic myomectomy, laparoscopic cornual pregnancy removal, etc.), delivery plans should be formulated accordingly. In cases of sudden abdominal pain during pregnancy or childbirth, the possibility of uterine rupture should be considered to achieve a timely and correct diagnosis and treatment.

Safety of Minimally Invasive Tissue Extraction in Myoma Management: A Systematic Review

OBJECTIVE

This review seeks to establish the incidence of adverse outcomes associated with minimally invasive tissue extraction at the time of surgical procedures for myomas.

DATA SOURCES

Articles published in the following databases without date restrictions: PubMed, EMBASE, Web of Science, Cochrane Database of Systematic Reviews and Trials. Search was conducted on March 25, 2020.

METHODS OF STUDY SELECTION

Included studies evaluated minimally invasive surgical procedures for uterine myomas involving morcellation. This review did not consider studies of nonuterine tissue morcellation, studies involving uterine procedures other than hysterectomy or myomectomy, studies involving morcellation of known malignancies, nor studies concerning hysteroscopic myomectomy. A total of 695 studies were reviewed, with 185 studies included for analysis.

TABULATION, INTEGRATION, AND RESULTS

The following variables were extracted: patient demographics, study type, morcellation technique, and adverse outcome category. Adverse outcomes included prolonged operative time, morcellation time, blood loss, direct injury from a morcellator, dissemination of tissue (benign or malignant), and disruption of the pathologic specimen.

CONCLUSION

Complications related to morcellation are rare; however, there is a great need for higher quality studies to evaluate associated adverse outcomes.

Non-extirpative Treatments for Uterine Myomas: Measuring Success

OBJECTIVE

To analyze outcomes of nonextirpative treatments for uterine myomas compared with myomectomy.

DATA SOURCES

A systematic search of the following databases from inception to January 2020 was performed: Ovid Medline, Embase, PubMed, and Cochrane Controlled Register of Trials.

METHODS OF STUDY SELECTION

Two authors reviewed titles and abstracts for relevance, and full articles were obtained and evaluated for inclusion. Studies were included if they compared nonextirpative interventions for uterine myomas to myomectomy and reported at least one outcome of interest.

TABULATION, INTEGRATION, AND RESULTS

Of the 2010 articles identified and reviewed, 125 full text articles were reviewed, and 22 were ultimately included in the analysis. Nonextirpative treatments reviewed included uterine artery embolization (UAE; 16 studies, n = 9555 subjects), focused ultrasound (FUS; 4 studies, n = 1516), laparoscopic radiofrequency ablation (RFA; 3 studies, n = 49). UAE, FUS, and laparoscopic RFA groups were compared with patients undergoing myomectomy (n = 34 872, n = 20 677, n = 47 respectively). In comparison with myomectomy, UAE had similar quality of life scores, symptom severity scores, sexual function scores, ovarian function, and miscarriage rates following intervention. There was lower likelihood of conceiving after UAE and a higher rate of reintervention after UAE compared with myomectomy. FUS had similar postprocedure sexual function scores and reintervention rates compared with myomectomy. Laparoscopic RFA had similar quality of life scores, symptom severity scores, sexual function scores, reintervention rates, and pregnancy rates after the procedure compared with myomectomy.

CONCLUSION

Nonextirpative treatments for uterine myomas have similar outcomes to myomectomy in multiple domains, with most available evidence comparing UAE with myomectomy.

Transvaginal Ultrasound and Doppler Features of Intraligamental Myomas

OBJECTIVES

To describe the ultrasound (US) features of intraligamental myomas (IMs) using Morphological Uterus Sonographic Assessment group standardized terminology.

METHODS

This was a retrospective monocentric study. A total of 125 consecutive women with a preoperative US diagnosis of a myoma located close to the uterine isthmus (International Federation of Gynecology and Obstetrics stages 5, 6, and 7) from 2016 to 2019 who underwent laparoscopic or laparotomic myomectomy or hysterectomy were included for study analyses. The US data were retrieved from US reports and stored digital images by 2 authors. Ultrasound features of myomas were described according to Morphological Uterus Sonographic Assessment terminology. Clinical data for the study population were retrieved from the patients' records.

RESULTS

Nineteen women with a surgical confirmation of an IM were included in the study group; the remaining population constituted the control group (n = 106). Non-uniform echogenicity was detected in 17 of 19 (89%) of IMs compared to 26 of 106 (25%) fibroids in the control group (P < .001). The presence of shadowing was detected in 12 of 19 (63%) IMs compared to 94 of 106 (89%) cases in the control group (P = .004). Intraligamental myomas were more vascularized tumors compared to myomas in the control group (P = .004). Transvaginal US showed high specificity for the diagnosis of an IM (0.93; 95% confidence interval, 0.87-0.96).

CONCLUSIONS

On US imaging, IMs appear as vascularized solid tumors with nonuniform echogenicity; cones of shadows were less frequent in IMs than the control group, and this finding can help in the differential diagnosis. Knowledge of their specific US features could help sonographers make an accurate diagnosis, allowing them to plan correct surgery and avoid severe complications.

Myomectomy associated blood transfusion risk and morbidity after surgery

OBJECTIVE

To evaluate blood transfusion risks and the associated 30-day postoperative morbidity after myomectomy.

DESIGN

Retrospective cohort study.

SETTING

Not applicable.

PATIENT(S)

Women who underwent myomectomies for symptomatic uterine fibroids (N = 3,407).

INTERVENTION(S)

Blood transfusion during or within 72 hours after myomectomy.

MAIN OUTCOME MEASURE(S)

The primary outcomes were rate of blood transfusion with myomectomy and risk factors associated with receiving a transfusion. The secondary outcome was 30-day morbidity after myomectomy.

RESULT(S)

The overall rate of blood transfusion was 10% (hysteroscopy, 6.7%; laparoscopy, 2.7%; open/abdominal procedures, 16.4%). Independent risk factors for transfusion included as follows: black race (adjusted odds ratio [aOR] 2.27, 95% confidence interval [CI] 1.62-3.17) and other race (aOR 1.77, 95% CI 1.20-2.63) compared with white race; preoperative hematocrit <30% compared to ≥30% (aOR 6.41, 95% CI 4.45-9.23); preoperative blood transfusion (aOR 2.81, 95% CI 1.46-5.40); high fibroid burden (aOR 1.91, 95% CI 1.45-2.51); prolonged surgical time (fourth quartile vs. first quartile aOR 11.55, 95% CI 7.05-18.93); and open/abdominal approach (open/abdominal vs. laparoscopic aOR 9.06, 95% CI 6.10-13.47). Even after adjusting for confounders, women who required blood transfusions had an approximately threefold increased risk for experiencing a major postoperative complication (aOR 2.69, 95% CI 1.58-4.57).

CONCLUSION(S)

Analysis of a large multicenter database suggests that the overall risk of blood transfusion with myomectomy is 10% and is associated with an increased 30-day postoperative morbidity. Preoperative screening of women at high risk for transfusion is prudent as perioperative transfusion itself leads to increased major postoperative complications.

Intraoperative and Postoperative Complications Following Open, Laparoscopic, and Hysteroscopic Myomectomies in Saudi Arabia

Background

The aim of this study was to broaden our knowledge regarding the complications of myomectomy to better understand how to prevent them from occurring. Another aim was to compare surgical approaches, especially with the current research limitations surrounding this topic in Saudi Arabia.

Methods

This retrospective study was conducted in a cohort of 263 women who underwent surgical myomectomy, without any exclusion criteria. We used our hospital electronic medical records program called Phoenix to obtain all the data regarding clinical presentation, intraoperative findings, intraoperative and postoperative complications, and hospital stay, and then statistically analyzed these findings.

Results

Results were divided depending on the type of surgery. The mean age of open, laparoscopic, and hysteroscopic myomectomy groups were 40.82 years, 42.05 years, and 44.43 years, respectively. There were 213 (80.98%) open, 34 (12.93%) laparoscopic, and 16 (6.09%) hysteroscopic myomectomies. The most common indication in all groups was bleeding. The mean estimated blood loss and duration of surgery for open, laparoscopic, and hysteroscopic myomectomy groups were: 576.13 mL and 103.05 min, 333.21 mL and 56.91 min, and 306.29 mL and 104.19 min, respectively. The total complication rate for each group was 10.8% in open, 2.94% in laparoscopic, and 6.25% in hysteroscopic myomectomies.

Conclusion

Laparoscopy is considered the more effective option for myomectomy than both laparotomy and hysterectomy in terms of surgery duration, hospital stay, and prevalence of complications. However, it is a technically challenging operation that requires experienced surgeons to perform. Based on the information we gathered, we recommend our institute to implement laparoscopy instead of laparotomy myomectomy, which is the current standard procedure in our hospital.

The Significant Risk Factors of Intra-Operative Hemorrhage during Laparoscopic Myomectomy: A Systematic Review

Laparoscopic myomectomy (LM) is becoming increasingly common in the management of uterine myomas and is usually offered regardless of the number, location, and size of the myomas. It has a generally low rate of periprocedural complications and is preferred to laparotomy for several reasons that are not limited to decreased length of hospital stay, number of sutures, smaller incisions, and decreased pain. However, blood loss during LM remains a challenge. To be able to stratify patients and provide better management after LM, it is crucial to identify these predictors of blood loss. Therefore, the aim of this review was to identify the risk factors for periprocedural blood loss after laparoscopic uterine myomectomy. According to our data synthesis, age, body mass index, and phase of the menstrual cycle do not seem to affect the blood loss during LM. Conversely, size and number of myomas, as well as operative time, was directly related to the increase of blood loss.

The INTEGRITY Trial: Preservation of Uterine-Wall Integrity 12 Months After Transcervical Fibroid Ablation with the Sonata System

Objective: The aim of this research was to evaluate uterine-wall integrity 12 months after transcervical fibroid ablation (TFA) of uterine fibroids with the Sonata^® system (Gynesonics Inc., Redwood City, CA).

Materials and Methods: INTEGRITY is a secondary analysis of the FAST-EU clinical trial, a prospective, longitudinal, multicenter single-armed trial involving women with heavy menstrual bleeding secondary to fibroids who were treated at 7 academic and community hospitals in the United Kingdom, the Netherlands, and Mexico with transcervical, intrauterine, ultrasound-guided radiofrequency ablation (the Sonata system). TFA was performed on up to 5 fibroids per subject ranging from 1–5 cm in diameter as determined by magnetic resonance imaging (MRI). All measurements and comparisons, including uterine-wall thicknesses were derived from baseline and 12-month MRI scans by an independent core MRI center. Scans were analyzed to assess preservation of uterine-wall integrity and reviewed for uterine-wall anomalies after TFA with the Sonata system.

Results: Twenty-nine patients had baseline and 12-month MRI with contrast enhancement. Minimum uterine-wall thicknesses in all visible slices were >2.5 mm in diameter. No areas on MRI indicated any loss of uterine-wall integrity, compared with baseline imaging; comparison of baseline and postablation uterine-wall thicknesses revealed no significant changes.

Conclusion: Transcervical fibroid ablation with the Sonata system was associated with preservation of uterine-wall integrity in this patient cohort.

Wearable haptic interfaces for applications in gynecologic robotic surgery: a proof of concept in robotic myomectomy

Uterine fibromatosis is common in women, with an estimated prevalence of up to 15-50% after 35 years. About 80% of women affected by fibromatosis have symptoms and require medical or surgical treatment. Nowadays, the gold standard for the surgical treatment of uterine fibromatosis is the use of minimally invasive surgery. The surgical skills and improvements offered by robotic approach can be relevant in reproductive surgery, in particular in minimally invasive myomectomy. However, the lack of tactile feedback of robotic platform is an important technical drawback that can reduce the accuracy of surgical procedures. Here, we present the design and the preliminary test of the wearable fabric, yielding display wearable haptic interfaces able to generate a real-time tactile feedback in terms of stiffness for applications in gynecologic robotic surgery. We preliminarily tested the device in the simulation of a real scenario of conservative myomectomy with the final purpose of increasing the accuracy and precision during surgery. The future goal is the integration of a haptic device with the commercially available robotic surgical systems with the purpose of improving the precision and accuracy of the surgical operation, thus allowing a better understanding concerning the anatomical relationship of the target structures. This in turn could determine a change in the surgical strategy in some cases, letting some patients selected for a demolitive approach retaining their uterus. This could improve surgical outcomes in fertile women enrolled for minimally invasive surgery for uterine fibroids and may be a facilitation for young gynecological surgeons or during residency teaching plans and learning programs.

The Use of Ulipristal Acetate (Esmya) Prior to Laparoscopic Myomectomy: Help or Hindrance?

Introduction:

The aim of this study was to assess the operative effects, both positive and negative, of pretreatment with ulipristal acetate (UPA) on laparoscopic myomectomy.

Materials and Methods:

We conducted a retrospective analysis of prospectively collected data from patients who underwent a laparoscopic myomectomy over a 2-year period.

Results:

A total of 62 patients were included, of which 10 received a 3-month preoperative course of UPA, and 52 patients received no pretreatment. There was no statistically significant difference between the two groups (no pretreatment vs. UPA pretreatment) with regard to blood loss (214.4 [±214.96] vs. 160 [±51.64], P = 0.432), operating time (111.64 [±41.8] vs. 117.5 [±50.4], P = 0.694), and duration of inpatient stay (1.27 [±0.56] vs. 1.11 [±0.33], P = 0.419). There were no complications in either group. In 100% of cases with UPA pretreatment, a distortion of the fibroid capsule with a more technically challenging dissection was noted, compared to 0% in the no pretreatment group. This anatomical distortion may result in more cases of incomplete resection and a potentially higher risk of recurrence.

Conclusion:

We conclude that UPA confers no operative benefits and should be used with caution in the presurgical treatment of fibroids. The use of UPA may indeed result in a more technically difficult myomectomy with distorted cleavage planes and carry a potential risk of incomplete resection.

Important considerations for women in the late reproductive and perimenopausal years desiring myomectomy

PURPOSE OF REVIEW

To review important considerations in the counseling and management of women over the age of 40 desiring a myomectomy for symptomatic fibroids.

RECENT FINDINGS

Women in the late reproductive and perimenopausal years may choose a myomectomy over a hysterectomy for reasons of fertility preservation or a personal desire to retain their uterus. Data suggest that laparoscopic myomectomy is a low-risk procedure that can be offered to older women, though the age-related risk of uterine malignancy must be evaluated.

SUMMARY

When assessing the surgical candidacy of older women desiring myomectomy, it is important to weigh a woman's fertility potential, surgical risk, and concerns about malignancy with her desire to preserve the uterus and autonomy to choose a procedure type.

Comparison of 30-day Complication Rates between Laparoscopic Myomectomy and Total Laparoscopic Hysterectomy for the Treatment of Uterine Leiomyoma in Women Older Than Age 40

STUDY OBJECTIVE

To evaluate whether there are differences in complication rates between laparoscopic myomectomy (LM) and total laparoscopic hysterectomy (TLH) for the treatment of uterine leiomyoma in perimenopausal women.

DESIGN

A retrospective cohort study using 1:2 propensity score matching (Canadian Task Force classification II-2).

SETTING

American College of Surgeons National Surgical Quality Improvement Program database.

PATIENTS

Women between the ages of 40 and 60 years undergoing surgical laparoscopic surgery for uterine leiomyoma between the years 2010 and 2016.

INTERVENTIONS

Women were stratified to either LM or TLH at a ratio of 1:2 using propensity score matching. Descriptive statistics were reported as means with standard deviations. Pairwise analysis using the Student t test and chi-square test was performed where appropriate. Multivariable logistic regression was used to identify factors associated with the presence of a complication.

MEASUREMENTS AND MAIN RESULTS

After propensity score matching, there were 631 myomectomies and 1262 hysterectomies. The operating time was slightly longer for LM compared with TLH (166.8 ± 90.3 minutes vs 157.9 ± 70.9 minutes, p = .03). The overall complication rate was 6.3%. There were no differences in complications between the LM and TLH groups (5.9% vs 6.6%, p = .54). Urinary tract infections were more common in the TLH group (2.3% vs 0.6%, p = .01). There were no other differences in the rates of specific complications between the 2 groups. On logistic regression, wound class greater than 3 was most strongly associated with a risk of complications (adjusted odds ratio [aOR] = 8.89; 95% confidence interval [CI], 1.28-15.87). Other variables associated with an increased risk of complications were conversion to hysterectomy (aOR = 5.91; 95% CI, 1.7-9.63), total operating time (aOR = 1.05; 95% CI, 1.02-1.07), and length of stay over 1 day (aOR = 3.67; 95% CI, 2.31-5.8).

CONCLUSION

LM is not associated with an increased risk of complications compared with TLH in women over the age of 40 years undergoing treatment for uterine leiomyomata.

Robotic single-site myomectomy: A single-center experience of 101 consecutive cases

BACKGROUND

To evaluate the feasibility and clinical outcomes of robotic single-site myomectomy (RSSM) for uterine myoma.

METHODS

Medical records of 101 consecutive women who underwent RSSM were retrospectively reviewed, and patient characteristics and surgical outcomes were evaluated. The surgical outcomes were compared by the phase in learning curve (early phase of <10 cases vs late phase of ≥10 cases) and time flow.

RESULTS

A total of 47 (46.5%) women had multiple myomas, and a median two (1-12) myomas were retrieved. The largest myoma was averagely measured as 6.2 ± 1.7 cm, and the mean weight of the total retrieved myomas was 114.0 ± 84.4 g. No patients received a transfusion or had operation-related complications. Cases in the late phase showed shorter port placement time and docking time than those in the early phase.

CONCLUSIONS

Our data suggest that robotic single-site surgery is a feasible therapeutic option for uterine myoma.

Unexpected uterine sarcomas in 4478 patients with electric power morcellation for leiomyomas

OBJECTIVES

Our objective is to investigate the prevalence, pathology and prognosis of uterine sarcomas in laparoscopic hysterectomy/myomectomy with electric power morcellation for presumed leiomyomas.

STUDY DESIGN

We retrospectively reviewed patients with laparoscopic power morcellation (LPM) for presumed leiomyomas in a Chinese tertiary institution by chart review from September 1, 2013 to December 31, 2016.

RESULTS

Twenty-four in 4478 patients (0.54%) with LPM for presumed leiomyomas had unexpected cancers. The patients showed the highest frequency of occult cancers (10/375, 2.6%) at 51-60 years and lowest (0/255) before 30 years. The pathology included 14 endometrial stromal sarcomas (ESS) (low-grade 12 and high-grade 2), 9 leiomyosarcomas, and 1 malignant mixed mesodermal tumor. The patients underwent abdominal re-exploration including total hysterectomy with bilateral salpingo-oophorectomy and staging surgery. Three patients were at advanced FIGO stage (IIIb-IVb) and 21 at stage I. Seven patients recurred within 1-25 (mean 6.29) months including 5 leiomyosarcomas, 1 high-grade and 1 low-grade ESS. Four recurrent patients with leiomyosarcomas and one with high-grade ESS died of disease in 1-3 months. Seventeen patients had no relapse and were alive for 6-41 (mean 24) months.

CONCLUSIONS

Our study suggests that patients with LPM for presumed leiomyomas appear to have a considerable risk of unexpected cancers. Moreover, morcellation is potentially associated with adverse prognosis in patients with high-grade sarcomas. Informed consent on unexpected cancers that should be discussed before morcellation.

Unplanned hysterectomy following myomectomy at a tertiary institution: A case series and review of the literature

Introduction:

Myomectomy is the gold standard uterine-sparing treatment for fibroids. However, the procedure is often complicated by blood loss. In rare cases, haemorrhage may be so severe that a conversion to hysterectomy is warranted. The aim of our study was to investigate the rates of and the clinical reasoning behind unplanned hysterectomies following attempted myomectomies at our institution.

Methods:

All patients who underwent an open or laparoscopic myomectomy at the Royal Women’s Hospital were identified using a gynaecology unit database, maintained from January 2004 to December 2013. Records for patients whose surgeries were unexpectedly converted to a hysterectomy were examined. A review of the literature was also performed, investigating the rates of unplanned hysterectomies following myomectomies.

Results:

Of the 1501 myomectomies performed, six resulted in an unplanned hysterectomy; an incidence rate of 0.4%. Fibroids were either intramural or pedunculated with the median number of tumours per patient being 2.5 (interquartile range: 1–6). The largest tumour for each patient varied significantly from 4.0 × 3.2 cm to 29.0 × 25.0 cm. In all cases, despite being strongly advised to have a planned hysterectomy, patients insisted on having a myomectomy. Two patients underwent conversion to hysterectomy intraoperatively while the remainder required a return to theatre. Difficulty achieving intraoperative haemostasis (n = 2), and the development of postoperative bleeding and coagulopathy (n = 4) were reasons cited for proceeding to hysterectomy.

Conclusion:

The rate of conversion from myomectomy to hysterectomy at our institution was low at 0.4%. In all cases, the reason for conversion was difficulty with haemostasis, despite infrequent use of haemostatic agents, and coagulopathy.

Characteristics of uterine rupture after laparoscopic surgery of the uterus: clinical analysis of 10 cases and literature review

Objective

An increasing trend of uterine rupture (UR) after laparoscopic surgery of the uterus (LSU) has been observed. Although the overall incidence is extremely low, UR may have catastrophic outcomes. Therefore, investigation of its potential risk factors is important.

Methods

We retrospectively reviewed the medical data of 10 women who developed UR after LSU performed at our hospital from October 2003 to October 2016 and conducted a literature review.

Results

All cases of UR occurred during the third trimester of pregnancy. The surgeries contributing to UR were laparoscopic myomectomy, adhesion decomposition, and salpingectomy, resulting in unfavorable outcomes especially for the fetus. Diathermy was routinely used for hemostasis, and multilayer suturing was not adequately performed in many cases. The posterior wall was the most common site of UR in most cases. Silent rupture with unremarkable symptoms was not rare. Similar risk factors were identified in the literature review.

Conclusions

Excessive use of energy equipment and the lack of multilayer suturing were the most common characteristics of UR after LSU. A history of LSU should always be considered a risk factor for UR.

Uterine rupture at 28 weeks of gestation after laparoscopic myomectomy - a case report

There are many reasons for sterility, and uterine malformations are of the greatest concern. Among uterine disorders, myomas play a significant role and are present in 27% of infertile women. The occurrence of myomas is frequent - 20-40% in women of reproductive age. Thus, for those infertile patients surgical treatment may be needed to preserve an opportunity to conceive. This case report refers to an uterine rupture at 28 weeks of gestation after laparoscopic myomectomy (3 months before conceiving). The myomectomy was conducted correctly and two layers of sutures on the myometrium were performed. The purpose of the myomectomy in a young woman should be well considered. In cases of infertility, removal of the lesions is usually necessary to give the patient a chance of pregnancy. At the same time, the risk of uterine rupture is increased. There are some suggestions referring to myomectomy to reduce the risk of uterine rupture in a subsequent pregnancy. It seems that the method of sewing the uterine closure is crucial. For example, multilayer uterine stitches, preservation of the endometrial cavity, and avoidance of using electrosurgery to prevent devascularization (to avoid haematoma formation) should be taken into consideration to prevent weakness of the wall of the uterus. Uterine scars differ histologically and biochemically.

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.