Risk Factors for Uterine Rupture after Laparoscopic Myomectomy

Enhancing surgical performance: the role of robotic surgery in myomectomies, a systematic review and metanalysis

Examine the role, benefits, and limitations of robotic surgery in myomectomies compared to laparoscopic and open surgical approaches. This review sourced data from CENTRAL, Pubmed, Medline, and Embase up until May 1, 2023. Full articles comparing clinical outcomes of robotic myomectomy with open or laparoscopic procedures were included without language restriction. Initially, 2150 records were found. 24 studies were finally included for both qualitative and quantitative analyses. Two investigators independently assessed all reports following PRISMA guidelines. Meta-analysis was conducted using the software "Review Manager Version 5.4". Risk-of-bias was assessed using the Newcastle-Ottawa scale. Sensitivity analysis was conducted, when feasible. In a comparison between robotic and laparoscopic myomectomies, no significant difference was observed in fibroid weights and the size of the largest fibroid. Robotic myomectomy resulted in less blood loss, but transfusion rates were comparable. Both methods had similar complication rates and operative times, although some robotic studies showed longer durations. Conversion rates favored robotics. Hospital stays varied widely, with no overall significant difference, and pregnancy rates were similar between the two methods. When comparing robotic to open myomectomies, open procedures treated heavier and larger fibroids. They also had greater blood loss, but the robotic approach required fewer transfusions. The complication rate was slightly higher in open procedures. Open surgeries were generally faster, postoperative pain scores were similar, but hospital stays were longer for open procedures. Pregnancy rates were comparable for both robotic and open methods. Robotic surgery offers advancement in myomectomy procedures by offering enhanced exposure and dexterity, leading to reduced blood loss and improved patient outcomes. PROSPERO registration: CRD42023462348.

The Impact of Laparoscopic Myomectomy on Pregnancy Outcomes: A Systematic Review

STUDY OBJECTIVE

The objective of this systematic review is to investigate the impact of laparoscopic myomectomy techniques on pregnancy outcomes, with a specific focus on the correlation between the type of suture used during the procedure and the incidence of uterine rupture. Additionally, the study aims to examine how the localization and size of myomas, key factors in laparoscopic myomectomy, may influence fertility outcomes.

DATA SOURCES

extensive searches were conducted using MDPI, PubMed, Web of Science, and Cochrane Library databases from 2008 to November 2023.

METHODS OF STUDY SELECTION

The study involved women of reproductive age diagnosed with fibroids who underwent surgical removal of fibroids using either laparotomy or laparoscopy. The evaluation of pregnancy outcomes focused on indicators such as live birth rates, miscarriage rates, stillbirth rates, premature delivery rates, and cases of uterine rupture. Quality assessment was systematically performed by employing the National Institutes of Health Study Quality Assessment Tools, with the subsequent formulation of clinical recommendations that were meticulously graded in accordance with the robustness of the underlying evidence.

RESULTS

The pregnancy outcomes post-myoma treatment, as reflected in one of the presented tables, show a promising number of pregnancies and live births, but also indicate the potential risks of miscarriages and preterm births. The diversity in outcomes observed among various studies underscores the imperative for tailored patient care, as well as the necessity for additional research aimed at optimizing fertility and pregnancy outcomes following myoma treatment.

CONCLUSION

This study offers insights into the criteria for patient selection and intraoperative methodologies specifically related to laparoscopic myomectomy. To enhance our understanding of the associations between fibroid characteristics (location, size) and reproductive outcomes, additional research is warranted, particularly through well-designed clinical trials.

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.

Application of transabdominal ultrasound- and laparoscopy-guided percutaneous microwave ablation for treating uterine fibroids: 24-month follow-up outcomes

PURPOSE

To determine the ablation efficacy of transabdominal ultrasound- and laparoscopy-guided percutaneous microwave ablation (PMWA), to investigate whether the risk of damage to adjacent organs and endometrium due to this technique can be reduced or even avoided. We also evaluated the clinical efficacy of this technique in the treatment of uterine fibroids of different sizes and at different locations over a 24-month follow-up period.

METHODS

This study included 50 patients with uterine fibroids who underwent transabdominal ultrasound- and laparoscopy-guided PMWA from August 2018 to July 2020. Lesions were confirmed by pathology. The technical efficacy and complications of PMWA were assessed. The lesion diameter, lesion volume, lesion location, and contrast-enhanced ultrasound (CEUS) features before PMWA and within 24 h after PMWA were recorded. Magnetic resonance imaging (MRI) was used for follow-up at 3 and 6 months after PMWA. Transvaginal ultrasound was used for follow-up at 24 months after PMWA.

RESULTS

A total of 50 patients with uterine fibroids received treatment. The median ablation rate of uterine fibroids was 97.21%. The mean lesion volume reduction rates were 32.63%, 57.26%, and 92.64% at 3, 6, and 24 months after treatment, respectively. The size and location of uterine fibroids did not significantly affect the ablation rate and the rate of lesion volume reduction. No major complication was found during and after the procedure.

CONCLUSION

Transabdominal ultrasound- and laparoscopy-guided PMWA can be utilized to safely enhance the ablation rate while minimizing ablation time and avoiding harm to adjacent organs and the endometrium. This technique is applicable for treating uterine fibroids of different sizes and at varying locations.

TRIAL REGISTRATION NUMBER

ChiCTR-IPR-17011910, and date of trial registration: 08/07/2017.

Adenomyosis and fertility-sparing surgery: A literature appraisal

Adenomyosis is an intricate pathological condition that negatively impacts the uterus. It is closely related to the more well-known endometriosis, with which it shares parallels in terms of diagnosis, therapy, and both microscopic and macroscopic features. The purpose of this narrative review is to give a clear univocal definition and outlook on the different, patient-adapted, surgical treatments. MEDLINE and PubMed searches on these topics were conducted from 1990 to 2022 using a mix of selected keywords. Papers and articles were identified and included in this narrative review after authors' revision and evaluation. From the literature analysis, authors reported the following surgical techniques: laparoscopic double/triple-flap method, laparotomic wedge resection of the uterine wall, laparotomic transverse H-incision of the uterine wall, laparotomic wedge-shaped excision, and laparotomic complete debulking excision by asymmetric dissection technique. Each of these techniques has strengths and weaknesses, but the literature data on the pregnancy rate are somewhat limited. The only certain information is the risk of uterine rupture up to 6.0% after surgical treatment for uterine adenomyosis. Over the years, the surgical approach continued to reach a positive result by minimally invasive treatment, with less hospitalization, less postoperative pain, and less blood loss. Over the years, the gynecological surgeon has gained the skills, training and increasingly sophisticated surgical techniques to target effective therapy. That's why a hysterectomy is no longer the only surgical resource to treat adenomyosis, but in patients who wish to preserve the fertility, there is a wide variety of surgical alternatives.

Long-term outcome and risk factors of reintervention after high intensity focused ultrasound ablation for uterine fibroids: a systematic review and meta-analysis

OBJECTIVES

To quantify the reintervention rate and analyze the risk factors for reintervention after high-intensity focused ultrasound (HIFU) ablation of uterine fibroids.

METHODS

Eighteen studies were selected from the seven databases. A meta-analysis was applied to synthesize the reintervention rates for fibroids across various follow-up durations. Subgroup-analysis was conducted based on the year of surgery, sample size, guide methods, and non-perfusion volume ratio (NPVR). Signal intensity of T2-weighted imaging (T2WI) was independently evaluated for reintervention risk.

RESULTS

The study enrolled 5216 patients with fibroids treated with HIFU. There were 3247, 1239, 1762, and 2535 women reaching reintervention rates of 1% (95% confidence interval (CI): 1-1), 7% (95% CI: 4-11), 19% (95% CI: 11-27), and 29% (95% CI: 14-44) at 12, 24, 36, and 60-month after HIFU. The reintervention rates of patients treated with US-guided HIFU (USgHIFU) were significantly lower than those of patients treated with MR-guided focused ultrasound surgery (MRgFUS). When the NPVR of fibroids was over 50%, the reintervention rates at 12, 36 and 60-month after HIFU were 1% (95% CI: 0.3-2), 5% (95% CI: 3-8), and 15% (95% CI: 9-20). The reintervention risk for hyper-intensity fibroids on T2WI was 3.45 times higher (95% CI: 2.7-4.39) for hypo-/iso-intensity fibroids.

CONCLUSION

This meta-analysis showed that the overall reintervention rates after HIFU were acceptable and provided consultative suggestions regarding treatment alternatives for patients with fibroids. Subgroup-analysis revealed that USgHIFU, NPVR ≥ 50%, and hypo-/iso-intensity of fibroids on T2WI were significant factors in reducing reintervention.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO, CRD42023456094.

The concern about the educational quality of online videos on laparoscopic myomectomy

OBJECTIVE

The aim of this study was to analyze the surgical content of the 50 most-viewed laparoscopic myomectomy videos on YouTube while evaluating the educational quality and accuracy of the videos.

METHODS

In this cross-sectional study, the keyword "laparoscopic myomectomy" was searched in publicly available content on YouTube, and the videos were sorted by view count using YouTube's advanced search options. Out of the first 66 videos, only 50 were eligible according to our selection criteria. One associate professor of gynecology and one gynecology resident watched these videos independently and evaluated the quality and surgical aspects. Our primary outcome was the scores of the Quality Criteria for Consumer Health Information and Global Quality Score and the features of the surgical technique.

RESULTS

The 50 most-viewed laparoscopic myomectomy videos were uploaded between 2010 and 2021. They had a mean of 66636.6±103772.2 views. According to the Quality Criteria for Consumer Health Information criteria, 78% of the videos were categorized as "poor," 12% of them were "fair," and 10% of them were "very poor." The indication of the surgery was not specified in 27 (54%) of them. The surgeons in 39 (79.6%) of the videos did not use any containment system for the power morcellation, even though it was restricted by the United States Food and Drug Administration. The preoperative and perioperative precautions to minimize blood loss were underemphasized. There was no scientific evidence in 49 (98%) of the videos.

CONCLUSION

Laparoscopic myomectomy videos on YouTube are limited in terms of providing evidence-based and well-organized scientific knowledge.

Uterine rupture and factors associated with adverse outcomes

PURPOSE

To review cases of uterine rupture and identify risk factors associated with adverse outcomes.

METHODS

This study is a retrospective cohort of complete uterine ruptures diagnosed in a large hospital system in Massachusetts between 2004 and 2018. Baseline demographics, labor characteristics and outcomes of uterine rupture were collected from medical records.

RESULTS

A total of 173 cases of uterine rupture were identified. There were 30 (17.3%) women with an unscarred uterus, while 142 (82.1%) had a scarred uterus. Adverse outcomes (n = 89, 51.4% of cases) included 26 (15.0%) hysterectomies, 55 (31.8%) blood transfusions, 18 (10.4%) bladder/ureteral injuries, 5 (2.9%) reoperations, 25 (14.5%) Apgar scores lower than 5 at 5 min and 9 (5.2%) perinatal deaths. Uterine rupture of a scarred uterus was associated with decreased risk of hemorrhage (OR 0.40, 95% CI 0.17-0.93), blood transfusion (OR 0.27, 95% CI 0.11-0.69), hysterectomy (OR 0.23, 95% CI 0.08-0.69) and any adverse outcome (OR 0.34, 95% CI 0.13-0.91) compared with unscarred rupture. Uterine rupture during vaginal delivery was associated with increased risk of transfusion (OR 6.55, 95% CI 1.53-28.05) and hysterectomy (OR 8.95, 95% CI 2.12-37.72) compared with emergent C-section.

CONCLUSIONS

Although rare, uterine rupture is associated with adverse outcomes in over half of cases. Unscarred rupture and vaginal delivery demonstrate increased risk of adverse outcomes, highlighting the need for early diagnosis and operative intervention.

Comparison of efficacy of single-port versus conventional laparoscopic treatment for uterine leiomyoma: a latest meta-analysis

Objective

Single-port laparoscopy has been proposed as an ideal surgical method for the treatment of uterine leiomyoma. It can effectively remove the lesion, reduce the loss of hemoglobin, and has superior cosmetic effects. Therefore, we searched relevant studies and conducted a meta-analysis to evaluate the effect of single-port laparoscopy on myoma resection, hemoglobin loss, and scar beauty compared to conventional laparoscopy.

Methods

We systematically searched PubMed, EMBASE, scope, Cochrane, CNKI, and other databases to find randomized controlled studies on the efficacy of single-port laparoscopy and traditional laparoscopy for meta-analysis. The main outcomes of our study were the duration of surgery, the reduction of hemoglobin, and the cosmetic effect of the postoperative scar. The effect model was selected according to heterogeneity (random effect model or fixed effect model), and the relevant sensitivity analysis and publication bias test were performed.

Results

We searched a total of 501 related literature articles and finally included 19 studies involving 21 researchers. Comparison of single-port laparoscopic myomectomy with traditional surgery: Operation time had no significant difference (Standardized Mean Difference [SMD]: 0.13, 95% Confidence interval (CI), -0.04 to 0.30; I²=74%; P = 0.14); The reduction of hemoglobin is lower ([SMD]: -0.04; 95% CI, -0.23 to 0.14; I²=71%; P = 0.65), and the cosmetic effect of postoperative scar is more satisfactory ([SMD]: 0.42, 95% CI: 0.02 to 0.83; I²=72%, P= 0.04). There was no significant difference in conversion rate, postoperative pain, blood loss, postoperative gastrointestinal recovery time, or length of hospital stay.

Conclusion

Compared with traditional laparoscopy, the operation time of the treatment of uterine leiomyoma by single-port laparoscopy is not extended, the reduction of hemoglobin is less, and the cosmetic effect of the scar is better. Therefore, single-port laparoscopy is superior to traditional surgery in the treatment of uterine leiomyoma.

Systematic review registration

https://inplasy.com/inplasy-2023-3-0071/, identifier INPLASY202330071.

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.

Comparison of surgical and obstetric outcomes in women with uterine leiomyomas after laparoscopic vs. abdominal myomectomy: A single-center cohort study

Our aim was to study the advantages, complications and obstetrical outcomes of laparoscopic myomectomy (LM) compared with abdominal myomectomy (AM). We conducted a retrospective cohort study at La Paz University Hospital that included LMs and AMs performed between 2012 and 2018, analyzing 254 myomectomies (142 AMs [55.7%] and 112 LMs [43.9%]). The mean number of fibroids was 1.8 ± 1.5 and 3 ± 2.9 for the LM and AM groups, respectively (p < 0.006). The mean size of the largest myoma was 7.6 cm ± 2.7 cm and 10.2 cm ± 5.4 cm for the LM and AM groups, respectively (p < 0.001). LMs were associated with longer surgical times (p < 0.001) and shorter hospitalizations (p = 0.001). There were no significant differences in the intraoperative and postoperative complication rates (p = 0.075 and p = 0.285 for LM and AM, respectively). The subsequent pregnancy rate was higher for the LM group (30.8% vs. 16.8%, p = 0.009), with a vaginal delivery rate of 69% and no cases of uterine rupture.

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.

Analysis of Pregnancy Outcomes after Laparoscopic Myomectomy: A Retrospective Cohort Study

Objective. This study aimed to investigate the factors related to pregnancy outcomes after laparoscopic myomectomy. Methods. A retrospective review was conducted on 156 patients aged 18 to 45 years who underwent laparoscopic myomectomy in Ningbo Women and Children’s Hospital from January 2010 to December 2016. Follow-up medical records and information were collected on demographic variables, clinical variables, and postoperative pregnancy rate. The logistic regression model was used to assess the association between related factors and postoperative pregnancy rate or pregnancy outcome. The outcome indicators included $\text{abortion}=0$ , $\text{premature}\text{birth}=1$ , and $\text{full}\text{term}=2$ . The chi-squared test or Fisher’s exact test was used to compare the differences in pregnancy outcomes, postpartum hemorrhage, and placenta adhesion between the cohorts. Results. The size of fibroids correlated with the postoperative pregnancy rate. The larger the fibroids, the lower the postoperative pregnancy rate, and the difference was statistically significant. The number of fibroids and placental adhesions was positively associated with postoperative pregnancy; the higher the number of fibroids, the higher the incidence of placental adhesions. However, the postoperative interval of pregnancy, fibroid size, and number and type of fibroids are not correlated with the pregnancy outcomes of postoperative patients. Conclusions. The size of myoma may influence the pregnancy rate of patients after laparoscopic myomectomy. The number of fibroids can affect the incidence of placental adhesions during postoperative pregnancy.

Pregnancy outcomes and associated factors for uterine rupture: an 8 years population-based retrospective study

Background

Uterine rupture is an obstetrical emergency with serious undesired complications for laboring mothers resulting in fatal maternal and neonatal outcomes. The aim of this study was to assess the incidence of uterine rupture, its association with previous uterine surgery and vaginal birth after caesarean section (VBAC), and the maternal and perinatal implications.

Methods

This is a population-based retrospective study. All pregnant women treated for ruptured uterus in one center between 2013 and 2020 were included. Their information retrieved from the medical records department were reviewed retrospectively.

Results

A total of 209,112 deliveries were included and 41 cases of uterine rupture were identified. The incidence of uterine rupture was 1.96/10000 births. Among the 41 cases, 16 (39.0%) had maternal and fetal complications. There were no maternal deaths secondary to uterine rupture, while perinatal fatality related to uterine rupture was 7.3%. Among all cases, 38 (92.7%) were scarred uterus and 3 (7.3%) were unscarred uterus. The most common cause of uterine rupture was previous cesarean section, while cases with a history of laparoscopic myomectomy were more likely to have serious adverse outcomes, such as fetal death. 24 (59.0%) of the ruptures occurred in anterior lower uterine segment. Changes in Fetal heart rate monitoring were the most reliable signs for rupture.

Conclusions

Incidence of uterine rupture in the study area, Shanghai, China was consistent with developed countries. Further improvements in obstetric care and enhanced collaboration with referring health facilities were needed to ensure maternal and perinatal safety.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12884-022-04415-6.

Induction of labour in patients with prior caesarean births or uterine surgery

The current evidence favours trial of labour after one caesarean in the absence of any other contraindications, recognizing that risks with both trial of labour after caesarean (TOLAC) and elective repeat caesarean section (ERCS) birth are relatively uncommon. When the need for induction of labour (IOL) following a previous caesarean arises, shared decision-making should be based on the current available evidence. This approach, however, needs to be tailored, taking into account the individual's history, initial examination and response to the ongoing process of induction to optimize the maternal and foetal outcomes. This paper aims to review the evidence and provide guidance on decision making surrounding labour induction in a pregnancy following a prior caesarean or uterine surgery.

Pregnancy outcomes of patients undergoing single-layer sutured laparoscopic myomectomy

AIM

In this study, we aimed to investigate the pregnancy outcomes of 102 patients who underwent laparoscopic myomectomy (LM) with single-layer suturing.

METHODS

This retrospective study included 102 women who underwent single-layer sutured LM in the obstetrics and gynaecology clinic of our hospital between September 2017 and April 2019.

RESULTS

A total of 102 patients underwent LM and colpotomy. Sixty-two patients were planning conception. Thirty-three (53.2%) of the sixty-two patients became pregnant until the study date. The mean age of the pregnant patients was 34 ± 8.2 years. In the pregnant patients, myoma localisation was anterior in 12 (50%), posterior in 7 (29%) and other in 5 (21%) patients. The mean duration between the operation and the first pregnancy was 10.2 months (2-24 months). Of the first pregnancies, 12 (50%) were between 0 and 6 months, and 12 (50%) were between 6 and 24 months to the operation. Twenty-four pregnant patients were delivered with caesarean section, six patients had a miscarriage and two patients resulted in intra-uterine pregnancy in the second trimester. Of these patients, eight were pregnant again, and eight were delivered by caesarean section. Curettage and dilatation were performed in six patients with miscarriage. None of the patients developed uterine rupture.

CONCLUSION

Single-layer closure of the uterine defect in LM is safe for subsequent pregnancies, and the risk of uterine rupture is low.

A Case of Elastography-Assisted Laparoscopic Fertility Preservation for Severe Deep Endometriosis Causing Ureteral Stenosis and Subtype II Adenomyosis

Adenomyosis is commonly treated by total hysterectomy. Adenomyomectomy is considered for women of reproductive age who wish to preserve their fertility. However, a high recurrence rate following adenomyomectomy has been reported because complete removal of the lesion is difficult, and uterine rupture during pregnancy remains a complication. We previously reported that laparoscopic adenomyomectomy using a cold knife prevented thermal damage to the myometrium and elastography to avoid residual lesions. Here, we report the case of a patient who underwent complete resection of a subtype II adenomyosis and resection of deep endometriosis (DE) with the closure of the pouch of Douglas. The patient was 31 years old, had severe dysmenorrhea, and had left ureteral stenosis and subtype II adenomyosis associated with the closure of the pouch of Douglas by the DE. After resection of the DE posterior wall adenomyosis, residual lesions were confirmed by laparoscopic real-time elastography. Eight weeks after surgery, postoperative transvaginal ultrasound showed that the myometrium had shrunk from 28 to 22.7 mm, and the hydronephrosis had disappeared, although a stent remained necessary. In this study, we report the complete resection of subtype II adenomyosis and DE, combined with elastography to visualize the lesions during resection.

Reproductive Outcomes after Laparoscopic Myomectomy: Conventional versus Barbed Suture

STUDY OBJECTIVE

To study the reproductive outcomes after laparoscopic myomectomy comparing conventional (nonbarbed) suture with barbed suture used for myometrial defect closure.

DESIGN

Monocentric retrospective cohort study with prospective follow-up survey for reproductive outcomes conducted in April and May 2020.

SETTING

Tertiary care center (center for advanced gynecologic laparoscopy and infertility).

PATIENTS

Women who underwent laparoscopic myomectomy for uterine leiomyomas from January 2004 to December 2017.

INTERVENTIONS

Laparoscopic myomectomy with closure of the myometrium using either conventional (nonbarbed suture) or barbed suture and follow-up survey regarding reproductive outcomes.

MEASUREMENTS AND MAIN RESULTS

The outcomes measured included the rate of conception, pregnancy complications, mode of delivery, and perioperative complications for both kinds of suture materials used. Of the 399 women who underwent laparoscopic myomectomy, 343 satisfied the inclusion criteria and were followed up; 235 patients responded. A total of 120 patients were included in the nonbarbed group (group A), and 115 patients were included in the barbed group (group B). A total of 182 (group A: 97 vs group B: 85; p = .204) women had actively sought pregnancy postoperatively, of whom 93 (51.09%) in total and 51 (54.8%) in group A vs 42 (45.1%) in group B reported at least 1 pregnancy with no significant difference in the incidence rate ratios between the 2 groups. Of the recorded pregnancies84.9% (group A: 88.2% vs group B: 80.9%) live births, 6.4% (group A: 5.8% vs group B: 7.1%) had first-trimester miscarriages, 2.1% (group A: 1.9% vs group B: 2.3%) had an ectopic pregnancy, and 6 were ongoing pregnancies at the time of the study analysis, which were compared statistically between both study groups. Pregnancy-related complications were noted in 12 of the 93 pregnant women (12.9%), which were comparable in both groups. No case of uterine rupture was reported.

CONCLUSION

Our study supports good reproductive outcomes in women after laparoscopic myomectomy with barbed sutures. Furthermore, the inclusion of nonbarbed sutures as a control group in our study reinforces that barbed sutures in myomectomy are as safe as, and an easier alternative to, conventional sutures without affecting pregnancy outcomes.

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.

Robotic single-site versus multi-port myomectomy: a case-control study

Background

This study aimed to evaluate the compatibility of robotic single-site (RSS) myomectomy in comparison with the conventional robotic multi-port (RMP) myomectomy to achieve successful surgical outcomes with reliability and reproducibility.

Methods

This retrospective case–control study was performed on 236 robotic myomectomies at a university medical center. After 1:1 propensity score matching for the total myoma number, total myoma diameter, and patient age, 90 patients in each group (RSS: n = 90; RMP: n = 90) were evaluated. Patient demographics, preoperative parameters, intraoperative characteristics, and postoperative outcome measures were analyzed.

Results

The body mass index, parity, preoperative hemoglobin levels, mean maximal myoma diameter, and anatomical type of myoma showed no mean differences between RSS and RMP myomectomies. The RSS group was younger, had lesser number of myomas removed, and had a smaller sum of the maximal diameter of total myomas removed than the RMP group. After propensity score matching, the total operative time (RSS: 150.9 ± 57.1 min vs. RMP: 170 ± 74.5 min, p = 0.0296) was significantly shorter in the RSS group. The RSS group tended to have a longer docking time (RSS: 9.8 ± 6.5 min vs. RMP: 8 ± 6.2 min, p = 0.0527), shorter console time (RSS: 111.1 ± 52.3 min vs. RMP: 125.8 ± 65.1 min, p = 0.0665), and shorter time required for in-bag morcellation (RSS: 30.1 ± 17.2 min vs. RMP: 36.2 ± 25.7 min, p = 0.0684). The visual analog scale pain score 1 day postoperatively was significantly lower in the RSS group (RSS: 2.4 ± 0.8 days vs. RMP: 2.7 ± 0.8 days, p = 0.0149), with similar consumption of analgesic drugs. The rate of transfusion, estimated blood loss during the operation, and length of hospital stay were not different between the two modalities. No other noticeable complications were observed in either group.

Conclusions

Da Vinci RSS myomectomy is a compatible option with regard to reproducibility and safety, without significantly compromising the number and sum of the maximal diameter of myomas removed. The advantage of shorter total operative time and less pain with the same amount of analgesic drugs in RSS myomectomy will contribute to improving patient satisfaction.

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

Essure® removal in 10 steps

Many women request Essure^® removal because of possible side effects related to the device itself. Laparoscopic Essure^® removal in symptomatic women may be associated with improvement in quality of life. We aim to describe the surgical technique in ten steps in the accompanying video as the standardization of the laparoscopic Essure^® removal procedure could help to diminish the risk of fractures of the device with this easy and safe 10-step procedure.

Total Robotic Myomectomy in a Complex Case: Extending the Limits

We present the case of a 30-year-old female with primary infertility who had multiple large myomas up to 22 weeks uterine size. She had a body mass index of 42 kg/m² and also concurrent endometriosis, for which she was on medical management. After meticulous preoperative planning, total robotic myomectomy and endometriosis clearance was done. Four large myomas weighing a total of 750 g were removed after morcellation. Console time was 160 min, and she made an uneventful recovery with only 0.1 g/dL drop in hemoglobin. Robotic myomectomy is considered as an improvement over laparotomy for patients with up to three myomas and when the surgical time does not exceed 4 hours. We were successful in our attempt at total robotic myomectomy to extend these limits and had a positive surgical outcome.

Is Uterine Myomectomy a Real Contraindication to Vaginal Delivery? Results from a Prospective Study

OBJECTIVES

The main goal of our research was to explore correlations between a history of uterine myomectomy and maternal-fetal outcomes, throughout a comparison between vaginal deliveries in patients with or without a history of uterine myoma excision.

MATERIALS AND METHODS

A prospective study was carried out at two tertiary care hospitals between January 2019 and January 2020. Women were assigned into two groups according to the history of laparoscopic or laparotomic myomectomy (Group 1) or without myomectomy (Group 2).

RESULTS

80 women successfully delivered after myomectomy. Pregnancies with previous laparoscopic or laparotomic myomectomy were associated with a minor rate of spontaneous labor onset (RR 1.17; 95% CI 1.04 - 1.31) and with an increased rate of emergency cesarean section (RR 1.22; 95% CI 1.09 - 1.36). Moreover, myomectomy group had a significant number of indications to emergency cesarean section correlated to suspected uterine rupture (RR 1.19; 95% CI 1.02-1.39). There were no uterine ruptures or neonatal deaths recorded. First stage of labor was longer in the myomectomy group (316 vs 204 mins, p = 0.01). No differences in the rates of the prolonged first and second stage of labor, postpartum hemorrhage and vaginal laceration, and no neonatal adverse outcomes were found between groups.

CONCLUSIONS

Pregnancies after myomectomy might be associated with an elevated rate of emergency cesarean section only due to a higher percentage of suspected uterine rupture, without a real hazard of adverse obstetric or neonatal outcomes.

Resection of deep-infiltrating endometriosis could be a risk factor for uterine rupture: a case series with review of the literature

Objective

To highlight the possible correlation between deep-infiltrating endometriosis (DIE) resection and subsequent uterine rupture.

Design

Case series and review of the literature.

Setting

Endometriosis referral hospitals.

Patient(s)

Seven young women who underwent laparoscopic resection of DIE, six of whom had uterine rupture before or during labor; the seventh patient had a posterior wall defect that placed her at increased risk of future uterine rupture.

Intervention(s)

Diagnosis of uterine rupture before or during labor in patients with a history of prior resection of DIE, leading to delivery by emergency delivery section or emergency laparotomy for exploration and repair.

Main Outcome Measure(s)

Immediate neonate and maternal salvaging caesarean delivery or laparotomy followed by surgical correction of the rupture.

Result(s)

As of 2019, no publications in the literature had considered uterine rupture among the obstetric complications of endometriosis. The reporting of such findings is crucial because of the increase in surgical management of endometriosis. We report seven cases of uterine rupture in pregnancy in women who had undergone resection of DIE. In six patients, surgeons found uterine rupture at the level of the previous resected endometriosis and diagnosed a posterior wall defect at the same level in one patient.

Conclusion(s)

Our case series sheds light on the potential increased risk of uterine rupture during pregnancy among women who have had a prior resection of DIE. In future, if these patients are considered high-risk pregnancy cases, their care should be managed by high-risk obstetric specialists.

Twin pregnancies with uterine fibroids are not at increased risk for obstetric complications: single center cohort study

Background

Twin pregnancies with uterine fibroid(s) (UFs) may not be at increased risk for obstetric complications compared to those without UFs. However, there was no reported comparison study with obstetric outcomes and complications of twin pregnancy after myomectomy. We aimed to compare the pregnancy outcomes in twin pregnancies with or without uterine fibroid(s), and also compared in patients with previous myomectomy history in Korean women.

Methods

A cohort of twin pregnancies delivered in a single institution between January 2011 and March 2019 were retrospectively analyzed. UFs group was defined by the presence of UFs during pregnancy (≥1 fibroid, measuring ≥2 cm or multiple fibroids regardless of the size). Previous myomectomy group included patients with history of abdominal or laparoscopic or hysteroscopic myomectomy of ≥1 fibroid, measuring ≥2 cm or multiple fibroids whatever the size. Patients with monochorionic monoamniotic twins, myoma less than 2 cm in size, missed abortion or intrauterine fetal death (IUFD) of one fetus before 14 weeks, history of previous conization, and uterine anomalies were excluded. Pregnancy outcomes and obstetric complications were compared.

Result

A total 1388 patients were included in this study, 191 (13.8%) had UFs and 89 (6.4%) had a history of myomectomy. Maternal age was younger in non-UFs group and primiparity was more common in UFs group (p < 0.001, and p = 0.019). No significant differences were found in the gestational age at delivery (p = 0.657), delivery before 37 weeks (p = 0.662), delivery before 34 weeks (p = 0.340), and sum of birth weight of twin (p = 0.307). There were also no statistical differences in rates of obstetrical complications, such as preeclampsia, gestational diabetes mellitus, placenta previa, placenta abruption, cerclage, small for gestational age, IUFD, postpartum hemorrhage and peripartum transfusion or ICU care. These obstetrical outcomes and complications showed no statistical differences between UFs group and previous myomectomy group.

Conclusion

In patients with twin pregnancies, the presence of UFs or history of previous myomectomy did not relate to negative effects on pregnancy outcomes and obstetrical complications.

Comparison of uterine scarring between robot-assisted laparoscopic myomectomy and conventional laparoscopic myomectomy

This study compared uterine wound healing after robot-assisted laparoscopic myomectomy (RM) and laparoscopic myomectomy (LM). Ultrasound was used to evaluate the scar repair of uterine wounds at 1, 3, and 6 months postoperatively. Ninety-three RM and 110 LM patients were enrolled. More myomas excised using RM were type 1∼type 3(51.1%) and more myomas excised using LM were type 4∼type 6(54.2%), p < .001. Both groups had myomas of similar size (RM vs. LM, 9.0 vs. 8.4 cm, p = .115) and weight (RM vs. LM, 322 vs. 274 g, p = .102). The mean myoma number was significantly larger in RM patients than LM patients (RM vs. LM, 3.3 vs. 1.8, p < .001). Significantly more patients were found to have haematomas in the LM than the RM group (RM vs. LM, 0 vs. 6, p = .032); two in type 3, two in type 4 and two in type 8 myomas. Four small haematomas spontaneously resolved at the 3rd month, and a large one resolved at the 9th month postoperatively. One haematoma caused pelvic infection and a 7-cm peritoneal inclusion cyst during sonographic follow up. RM resulted in fewer postoperative haematomas and may result in superior uterine repair relative to LM after excision of symptomatic type 3, type 4 and type 8 myomas. RM is suggested for these patients, especially those considering future pregnancy.IMPACT STATEMENTWhat is already known on this subject? Reconstructive suturing and uterine wound healing are the main challenges when performing laparoscopic myomectomy (LM), and spontaneous uterine rupture during pregnancy following LM has been reported because of its limitations in multilayer closure of the myoma bed. Robot-assisted laparoscopic myomectomy (RM) has improved visualisation and EndoWrist movements resulted in adequate multilayered suturing, which may overcome the technical limitations of reconstructive suturing in conventional LM.What do the results of this study add? We evaluated postoperative uterine scarring after RM and LM using ultrasound and found RM resulted in fewer postoperative haematomas, which result in superior uterine wound repair, relative to LM after excision of symptomatic type 3, type 4 and type 8 myomas.What are the implications of these findings for clinical practice and/or further research? RM is suggested for symptomatic type 3, type 4 and type 8 myomas because of superior uterine wound repair, especially those considering future pregnancy.

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.

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.

Laparoscopic Myomectomy: An Alternative Approach to Tackling Submucous Myomas?

STUDY OBJECTIVE

To evaluate the differences in perioperative outcomes and immediate complication rates between laparoscopic myomectomy for submucous myomas and laparoscopic myomectomy for myomas in other locations.

DESIGN

Retrospective cohort study.

SETTING

University-affiliated hospital in London.

PATIENTS

A total of 350 patients with symptomatic uterine myomas underwent laparoscopic myomectomy. Thirty-three of these were performed for submucous myomas (group 1), and 317 were for myomas in other uterine locations (group 2).

INTERVENTIONS

Analysis of prospectively collected data on patient demographics, myoma characteristics, perioperative outcomes, and immediate complications.

MEASUREMENTS AND MAIN RESULTS

Patient demographics, including age, body mass index, and parity, were similar in the 2 groups. No significant differences in myoma characteristics were seen between groups 1 and 2, including the mean dimension of largest myoma (7.1 vs 7.8 cm, respectively; p = .35), mean number of myomas removed (3.8 vs 4.1; p = .665), and mean mass of myomas removed (142.0 g vs 227.3 g; p = .186). There were also no significant between-group differences in any perioperative outcomes, including mean blood loss (226.8 mL vs 266.4 mL; p = .373), duration of surgery (103 minutes vs 113 minutes; p = .264), and duration of hospital stay (1.4 days vs 1.7 days; p = .057). No complications arose from laparoscopic resection of submucous myomas.

CONCLUSION

Laparoscopic myomectomy for submucous myomas has similar perioperative outcomes and immediate complications as laparoscopic myomectomy for other myomas and can be considered for large or type 2 submucous myomas.

Vaginal birth after prior myomectomy

OBJECTIVE

The aim of this retrospective cohort study was to evaluate the obstetrical and perinatal outcomes of vaginal birth in case of pregnancies achieved after prior myomectomy. We also analyzed how operative characteristics at the time of surgery might influence the choice of obstetricians about mode of delivery.

STUDY DESIGN

We analyzed retrospectively all women who underwent laparoscopic (LPS) or laparotomic (LPT) myomectomy between January 2002 and December 2014, in a network of three Institutions belonging to the University of Milano Bicocca, Italy. Women were contacted by phone interview and only cases with available follow-up data and who had a subsequent pregnancy were included. Operative characteristics and subsequent obstetrical outcomes were recorded and analyzed.

RESULTS

469 women who underwent myomectomy were contacted by phone interview, and 152 pregnancies were achieved after surgery, 96 after LPS and 56 after LPT. A total of 110 pregnancies ended in deliveries at ≥24 weeks. Seventy-three (66.4%) women had trial of labor after myomectomy (TOLAM), while 24 (21.8%) had a planned cesarean delivery (CD). Sixty-six (90.4%) of the TOLAM cases successfully accomplished vaginal delivery. No cases of uterine rupture (UR) were reported, and all deliveries ended in live births. The incidence of Neonatal Intensive Care Unit admission was 14.5% (16/110), with no cases of perinatal death. Comparing the surgical details at the time of myomectomy, the incidence of uterine cavity entered was significantly higher in planned CD group compared to TOLAM cases (p < 0.001). No other significant difference between the two groups was reported.

CONCLUSIONS

A successful vaginal delivery was accomplished by 90.4% of women who had TOLAM, without any case of UR or severe maternal and perinatal complications. TOLAM may be considered and offered as feasible and relatively safe option. Obstetricians' attitude toward mode of delivery after prior myomectomy seems to be influenced by the reported entry into the uterine cavity at the time of surgery.

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

Objectives:

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

Materials and Methods:

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

Results:

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

Conclusions:

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

Utility of a minimal skin incision laparotomy technique for removing uterine leiomyomas at a regional core hospital: a retrospective study

BACKGROUND

We present a minimal skin wound abdominal myomectomy performed in our hospital and attempt to identify the optimal range of this technique by considering the characteristics of target leiomyomas. In this procedure, we attempted to make the skin wound as small as possible, with a maximum length of approximately 5 cm.

METHODS

In addition to introducing the minimal skin wound abdominal myomectomy, we retrospectively collected and analyzed the medical records of 76 patients treated with minimal skin wound abdominal myomectomy exclusively by the same physician at Maruyama Memorial General Hospital between January 2007 and December 2016. We statistically investigated relationships between ten factors, including body mass index; patient's age; patient's parity; administration of gonadotropin-releasing hormone analogue; presence of anemia; the uterine leiomyomas' number, size, weight, and location; operation time; and blood loss.

RESULTS

First, we introduce a case in which we performed minimal skin wound abdominal myomectomy for a 36-year-old Japanese patient with a large leiomyoma (10 cm in diameter). Then, we assessed the impacts of patient characteristics and leiomyoma characteristics on operation time and blood loss for this surgical method. In a multivariate analysis, only the number of resected leiomyomas significantly affected massive bleeding. Other factors showed no difference on operation time and the amount of blood loss.

CONCLUSIONS

Minimal skin wound abdominal myomectomy is safe and effective for use in many patients, because only the number of leiomyomas affects the amount of blood loss. No other factor affected operation time. We suggest the possibility that the expanded use of minimal skin wound abdominal myomectomy may reduce the number of patients waiting for long periods to undergo laparoscopic surgery and may optimize the use of medical resources in rural areas.

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.

Laparoscopic uterine surgery as a risk factor for uterine rupture during pregnancy

The incidence of uterine rupture through a previous cesarean scar (CS) is declining as a result of a lower parity and fewer options for vaginal birth after cesarean. However, uterine ruptures attributable to other causes that traumatize the myometrium are on the rise. To determine whether changes in the causes of uterine rupture had occurred in recent years, we retrospective retrieved the clinical records of all singletons with uterine rupture observed in the delivery room of a Taiwanese tertiary obstetric center over a 15-year period. The overall uterine rupture rate was 3.8 per 10,000 deliveries. A total of 22 cases in 20 women (with two of them experiencing two episodes). Seven uterine ruptures occurred through a previous cesarean scar (CS ruptures, 32%), 13 through a non-cesarean scar (non-CS ruptures, 59%), whereas the remaining two (9%) were in women who did not previously undergo any surgery. All of the 13 non-CS ruptures were identified in women with a history of laparoscopic procedures to the uterus. Specifically, 10 (76%) occurred after a previous laparoscopic myomectomy, one (8%) following a hysteroscopic myomectomy, and two (16%) after a laparoscopic wedge resection of cornual ectopic pregnancy. Severe bleeding (blood loss >1500 mL) requiring transfusions was more frequent in women who experienced non-CS compared with CS ruptures (10 versus 1 case, respectively, P = 0.024). Patients with a history of endoscopic uterine surgery should be aware of uterine rupture during pregnancy.

Uterine Rupture after Laparoscopic Myomectomy in Two Cases: Real Complication or Malpractice?

We describe two cases of uterine rupture in pregnancy after laparoscopic myomectomy and analyze all the aetiological factors involved in this circumstance according to the recent literature, focusing above all on the surgical procedures and the characteristics of the excised myomas. The two cases of uterine rupture in pregnancy following laparoscopic myomectomy occurred at 36 and 18 weeks of gestation, respectively. Both women had undergone laparoscopic multiple myomectomy and uterine rupture occurred along the isthmic myomectomy scars, despite the fact that compliance with all the recent technical surgical recommendations for the previous laparoscopic multiple myomectomy had been fully observed. In our cases we identified the isthmic localization, size of the excised myomas (≥4 cm), and individual characteristics of the healing process as possible risk factors for “a real complication.” Larger studies and robust case-control analyses are needed to draw reliable conclusions; special care should be paid when performing laparoscopic myomectomy in women planning a later pregnancy.

Is robot-assisted laparoscopic myomectomy limited in multiple myomas?: a feasibility for ten or more myomas

Objective

To evaluate the feasibility of robot-assisted laparoscopic myomectomy in multiple myomas over 10.

Methods

A retrospective study was conducted for 662 patients who underwent robot-assisted laparoscopic myomectomy and open myomectomy by a single operator in a tertiary university hospital.

Results

A total of 30 women underwent removal of 10 or more uterine myomas by robotics and 13 patients were selected for this study. The average number of myomas removed was 13.7 (range 10-20). The maximum diameter of the myomas was 6.8 cm (range 5.0-10.0 cm). The sum of the diameters of each myoma was 34.7 cm (range 20.0-54.5 cm) and the mass of resected myomas for each case was 229.1 g (range 106.8-437.9 g). In no case was the robotic procedure converted into conventional laparoscopy or laparotomy, and all patients recovered without any major complications. In comparison with 13 cases of open myomectomy during the same period, robotic surgery took longer time than open surgery (360.5 vs. 183.8 minutes; P=0.001) but had shorter postoperative hospital days after surgery (mean 2.5 vs. 3.5 days; P=0.003).

Conclusion

Robot-assisted laparoscopic myomectomy could be an alternative to laparotomic myomectomy for numerous myomas over 10 in number.