American Association of Gynecologic Laparoscopists (AAGL): Advancing Minimally Invasive Gynecology Worldwide. AAGL practice report: practice guidelines for the diagnosis and management of submucous leiomyomas

Prostaglandin Injection for Myoma Expulsion (PRIME): Case Series of a Novel Approach to Hysteroscopic Resection of FIGO Type 2 Myomas

STUDY OBJECTIVE

To evaluate the use of dilute carboprost tromethamine injection at the endometrium/myoma junction during hysteroscopy to facilitate myoma expulsion and removal in a single procedure.

DESIGN

Case series.

SETTING

Single high-volume academic medical center.

PATIENTS

Seven patients aged 32 to 51 years old with FIGO type 2 uterine myomas and symptoms of abnormal uterine bleeding or infertility undergoing hysteroscopic resection with a morcellation device from November 2022 to July 2023.

INTERVENTION

Dilute injection of carboprost tromethamine (10 µg/mL) at time of hysteroscopic myomectomy.

MEASUREMENTS AND MAIN RESULTS

The main outcome measure was ability to complete the hysteroscopic myomectomy in a single procedure using a hysteroscopic morcellator. Secondary outcomes included total operative time, fluid deficit, and postoperative pharmacologic side effects and/or surgical complications. Among our 7 patients, all had successful single procedure complete resections of myomas ranging from 0.9 to 4.6 cm in maximal diameter. Average operative time was 30 minutes, and average fluid deficit was approximately 839 mL. The carboprost dosages used ranged from 30 to 180 µg. One patient experienced prolonged postoperative nausea and vomiting that resolved with antiemetics. One patient experienced postoperative endometritis that improved with antibiotics.

CONCLUSION

In this pilot study, injection of dilute carboprost intraoperatively facilitated one-step hysteroscopic myomectomy of FIGO 2 myomas, via enhanced extrusion of the intramural portion of the fibroid into the uterine cavity, with both short operative times and acceptable fluid deficits.

[Resolution of the national interdisciplinary council of experts "High-dose vitamin D (Devilam) in the practice of an obstetrician-gynecologist"]

On March 28, 2024, the Council of Experts "High-dose vitamin D (Devilam) in the practice of obstetrician-gynecologist, gynecologist and endocrinologist" was held in Moscow with the participation of leading experts gynecologists, endocrinologists and obstetricians-gynecologists, during which new possibilities for the use of high-dose vitamin D in patients of various ages who need correction of existing vitamin D deficiency or insufficiency.

Comparing magnetic resonance imaging and ultrasound in the clinical evaluation of fibroids prior to uterine artery embolization

PURPOSE

Uterine artery embolization has become established as a frontline treatment for uterine leiomyomata. In planning embolization, preprocedural imaging can further characterize pathology and anatomy, but it may also reveal coexisting diagnoses that have the potential to change clinical management. The purpose of this study is to compare the diagnostic outcomes of ultrasound and MRI performed for patients prior to undergoing embolization.

METHODS

The study cohort consisted of 199 patients who underwent uterine artery embolization at a single academic institution between 2013 and 2018. Prior to embolization, all patients had an MRI confirming a leiomyomata diagnosis. Additionally, 118 patients underwent transvaginal ultrasound within five years prior to MRI. MRI findings were analyzed and, when applicable, compared to prior ultrasound impressions to assess for the incidence of new findings. The diagnoses of interest were adenomyosis, hydrosalpinx, predominantly infarcted leiomyomata, and large intracavitary leiomyomata. Data were collected from retrospective chart review and included demographics, symptomology, and imaging reports.

RESULTS

199 patients ultimately underwent embolization for treatment of MRI-confirmed leiomyomata. Of 118 patients who also had an ultrasound within five years prior to their MRI, 26 (22.0%) received a second gynecologic diagnosis based on MRI findings that was not previously seen on ultrasound. Of 81 patients who only had an MRI before embolization, 19 (23.5%) received a second gynecologic diagnosis not previously documented. The most common coexisting pathology was adenomyosis, presenting in 34 (17.1%) patients with leiomyomata, followed by large intracavitary leiomyomata (8, 4.0%), infarcted leiomyomata (7, 3.5%), and hydrosalpinx (6, 3.0%),.

CONCLUSIONS

When considering uterine artery embolization for the treatment of symptomatic leiomyomata, preprocedural MRI is superior to ultrasound in detecting coexisting pathologies, including adenomyosis and hydrosalpinx. It can also better characterize leiomyomata, including identifying lesions as intracavitary or infarcted. These findings have the potential to alter clinical management or contraindicate embolization entirely.

Guideline No. 446: Hysteroscopic Surgery in Fertility Therapy

OBJECTIVE

To evaluate the indications, benefits, and risks of hysteroscopy in the management of patients with infertility and provide guidance to gynaecologists who manage common conditions in these patients.

TARGET POPULATION

Patients with infertility (inability to conceive after 12 months of unprotected intercourse) undergoing investigation and treatment.

BENEFITS, HARMS, AND COSTS

Hysteroscopic surgery can be used to diagnose the etiology of infertility and improve fertility treatment outcomes. All surgery has risks and associated complications. Hysteroscopic surgery may not always improve fertility outcomes. All procedures have costs, which are borne either by the patient or their health insurance provider.

EVIDENCE

We searched English-language articles from January 2010 to May 2021 in PubMed/MEDLINE, Embase, Science Direct, Scopus, and Cochrane Library (see Appendix B for MeSH search terms).

VALIDATION METHODS

The authors rated the quality of evidence and strength of recommendations using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. See Appendix A (Tables A1 for definitions and A2 for interpretations of strong and conditional recommendations).

INTENDED AUDIENCE

Gynaecologists who manage common conditions in patients with infertility.

TWEETABLE ABSTRACT

When offering hysteroscopic surgery to patients with infertility, ensure it improves the live birth rate.

SUMMARY STATEMENTS

RECOMMENDATIONS.

Pregnancy outcomes following ultrasound-guided high-intensity focused ultrasound in submucous leiomyomas: a retrospective study

OBJECTIVE

To investigate the impact of ultrasound-guided high-intensity focused ultrasound (USgHIFU) on pregnancy in submucous leiomyomas.

MATERIALS AND METHODS

Between October 2015 and October 2021, a retrospective observational study was conducted at the Affiliated Hospital of North Sichuan Medical College, China, for 32 women with submucous leiomyomas who became pregnant after USgHIFU. Pregnancy outcomes, submucous leiomyomas characteristics, and USgHIFU parameters were analyzed.

RESULTS

A total of 17 (53.1%) deliveries were successfully achieved, with full-term delivery in 16 (94.1%) patients and preterm delivery in 1 (5.9%). After USgHIFU, the effective volume in the uterus cavity and the volume of submucous leiomyomas shrank in all 32 patients. The median time to achieve pregnancy after USgHIFU was 11.0 months. Before pregnancy, myoma type was downgraded in 13 (40.6%) patients, stable in 10 (31.3%) and upgraded in 9 (28.1%). The vaginal expulsion rate of submucous leiomyomas was 28.1%, with complete expulsion in 3 (9.4%) patients and partial expulsion in 6 (18.8%). After USgHIFU, the size of submucous leiomyomas did not increase in each trimester (all p > 0.05). The high complications rate during pregnancy (7/17, 41.2%) was associated with advanced maternal age, with only one (5.9%) premature rupture of membranes possibly associated with submucous leiomyomas. There were 6 (35.5%) vaginal delivery and 11 (64.7%) cesarean sections. All 17 newborns developed well, with a mean birth weight of 3482 g.

CONCLUSIONS

In patients with submucous leiomyomas, pregnancies and full-term deliveries can be successfully achieved following USgHIFU, with few related complications.

Revolutionizing hysteroscopy outcomes: AI-powered uterine myoma diagnosis algorithm shortens operation time and reduces blood loss

Background

The application of artificial intelligence (AI) powered algorithm in clinical decision-making is globally popular among clinicians and medical scientists. In this research endeavor, we harnessed the capabilities of AI to enhance the precision of hysteroscopic myomectomy procedures.

Methods

Our multidisciplinary team developed a comprehensive suite of algorithms, rooted in deep learning technology, addressing myomas segmentation tasks. We assembled a cohort comprising 56 patients diagnosed with submucosal myomas, each of whom underwent magnetic resonance imaging (MRI) examinations. Subsequently, half of the participants were randomly designated to undergo AI-augmented procedures. Our AI system exhibited remarkable proficiency in elucidating the precise spatial localization of submucosal myomas.

Results

The results of our study showcased a statistically significant reduction in both operative duration (41.32 ± 17.83 minutes vs. 32.11 ± 11.86 minutes, p=0.03) and intraoperative blood loss (10.00 (6.25-15.00) ml vs. 10.00 (5.00-15.00) ml, p=0.04) in procedures assisted by AI.

Conclusion

This work stands as a pioneering achievement, marking the inaugural deployment of an AI-powered diagnostic model in the domain of hysteroscopic surgery. Consequently, our findings substantiate the potential of AI-driven interventions within the field of gynecological surgery.

FIGO best practice guidance in surgical consent

Obtaining medical consent preoperatively is one of the key steps in preparing for surgery, and is an important step in informed decision making with the patient. According to good medical practice guidelines, doctors are required to have the knowledge and skills to treat patients as well as inform them, respect their wishes, and establish trust between themselves and their patients. Valid consent includes elements of competence, disclosure, understanding, and voluntariness. Documentation of these elements is also very important. The International Federation of Gynecology and Obstetrics (FIGO) Education Communication and Advocacy Consortium (ECAC) has realized that the quality of consent varies considerably across the world and has developed simple guidelines regarding consent and procedure-specific checklists for the most common obstetric and gynecological procedures.

Effectiveness of a hysteroscopic tissue removal system device for hysteroscopic myomectomy on patients' quality of life: a randomized clinical trial

PURPOSE

To evaluate the quality of life in patients treated for submucosal leiomyomas after hysteroscopic myomectomy compared to medical therapy. This is the first prospective randomized analysis comparing outcomes of medical therapy versus hysteroscopic myomectomy using the TruClear™ hysteroscopic tissue removal system to treat heavy menstrual bleeding from submucosal leiomyoma(s).

METHODS

Setting: private practice and community-based hospital; subjects: female patients with symptomatic submucosal leiomyomas from 2014 to 2017. A total of 69 patients enrolled, with 47 completed.

STATISTICAL ANALYSIS USED

randomization, linear mixed-effects modeling, hypothesis testing, and intent-to-treat analysis. Each patient was randomized to oral contraceptive pills/progesterone releasing intrauterine device or hysteroscopic myomectomy. Each patient was to complete the Uterine Fibroid Symptom and Health-related Quality of Life (UFS-QOL) questionnaire at baseline, one month, three months, and greater than or equal to six months after treatment.

MAIN OUTCOME MEASURED

Primary outcome was the health-related quality of life (HR-QOL), as reflected from UFS-QOL scores. Contrasts were constructed from a linear mixed-effects model to compare the two treatment groups for changes from baseline in UFS-QOL scores.

RESULTS

UFS-QOL scores were similar at baseline between the two treatment groups. There was an overall improvement in all UFS-QOL scores within each group. Higher improvement scores were noted in the surgical group compared to the medical group for almost all UFS-QOL scores. At ≥ 6 months, in comparison to the medically managed patients, the most considerable score improvements for the surgical group were reported in HR-QOL concern, activities, self-consciousness and symptom severity scores having mean change scores (95% CIs) of 35.3, 28.9, 28.6, and 32.2, respectively.

CONCLUSION

Although there was no statistical difference in the change degree of improvement of overall quality of life among patients with symptomatic submucosal leiomyomas who received medical or surgical treatments in the study, there were greater differences in improvements in health-related quality of life scores over time after surgical treatment.

Guideline No. 435: Minimally Invasive Surgery in Fertility Therapy

OBJECTIVE

To evaluate the benefits and risks of minimally invasive procedures in the management of patients with infertility and provide guidance to gynaecologists who manage common conditions in these patients.

TARGET POPULATION

Patients with infertility (inability to conceive after 12 months of unprotected intercourse) undergoing investigation and treatment.

BENEFITS, HARMS, AND COSTS

Minimally invasive reproductive surgery can be used to treat infertility, improve fertility treatment outcomes, or preserve fertility. All surgery has risks and associated complications. Reproductive surgery may not improve fertility outcomes and may, in some instances, damage ovarian reserve. All procedures have costs, which are borne either by the patient or their health insurance provider.

EVIDENCE

We searched English-language articles from January 2010 to May 2021 in PubMed/MEDLINE, Embase, Science Direct, Scopus, and Cochrane Library (see Appendix A for MeSH search terms).

VALIDATION METHODS

The authors rated the quality of evidence and strength of recommendations using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. See online Appendix B (Tables B1 for definitions and B2 for interpretations of strong and conditional [weak] recommendations).

INTENDED AUDIENCE

Gynaecologists who manage common conditions in patients with infertility.

SUMMARY STATEMENTS

RECOMMENDATIONS.

Directive clinique no 435 : Chirurgie minimalement invasive dans les traitements de fertilité

OBJECTIF

Évaluer les risques et bénéfices de la chirurgie minimalement invasive dans la prise en charge des patientes atteintes d'infertilité et fournir des conseils aux gynécologues qui prennent en charge les problèmes les plus fréquents chez ces patientes.

POPULATION CIBLE

Patientes atteintes d'infertilité (incapacité à concevoir après 12 mois de rapports sexuels non protégés) en processus diagnostique ou sous traitement. BéNéFICES, RISQUES ET COûTS: On peut recourir à la chirurgie de la reproduction minimalement invasive pour traiter l'infertilité, améliorer les résultats des traitements de fertilité ou préserver la fertilité. Toutes les interventions chirurgicales comportent des risques et des complications associées. La chirurgie de la reproduction n'améliore pas toujours la fertilité et peut, dans certains cas, compromettre la réserve ovarienne. Toutes les interventions entraînent des coûts, lesquels sont assumés par la patiente ou son assureur. DONNéES PROBANTES: Des recherches ont été faites dans les bases de données PubMed-Medline, Embase, Science Direct, Scopus et Cochrane Library pour répertorier les articles publiés en anglais dans la période de janvier 2010 à mai 2021 (voir les termes de recherche MeSH à l'annexe A). MéTHODES DE VALIDATION: Les auteurs ont évalué la qualité des données probantes et la force des recommandations en utilisant le cadre méthodologique GRADE (Grading of Recommendations Assessment, Development and Evaluation). Voir l'annexe B en ligne (tableau B1 pour les définitions et tableau B2 pour l'interprétation des recommandations fortes et conditionnelles [faibles]). PROFESSIONNELS CONCERNéS: Gynécologues qui prennent en charge les affections courantes chez les patientes atteintes d'infertilité. DÉCLARATIONS SOMMAIRES: RECOMMANDATIONS.

Rare Case of Osseus Metaplasia in a Detached Remnant Leiomyoma Following Hysteroscopic Myomectomy

Uterine leiomyoma is the most common benign tumor of the uterus, affecting reproductive-age women. Although women with uterine fibroids are commonly asymptomatic, in symptomatic patients, hysteroscopic myomectomy is considered the first-line surgical treatment for intracavitary fibroids in women who wish to maintain fertility. 

Osseous metaplasia in uterine fibroids is the transformation of fibroids cells into pure mature or immature bone. It is rare, and few case reports present with osseous metaplasia in uterine fibroids. This is the first report in the literature of osseous metaplasia in a remnant fibroid after hysteroscopic myomectomy. Every effort should be attempted to ensure complete retrieval of the detached fibroid remnant after hysteroscopic resection, as this might decrease the risk for subsequent surgeries.

Uterine artery embolisation versus myomectomy for premenopausal women with uterine fibroids wishing to avoid hysterectomy: the FEMME RCT

BACKGROUND

Uterine fibroids are the most common tumour in women of reproductive age and are associated with heavy menstrual bleeding, abdominal discomfort, subfertility and reduced quality of life. For women wishing to retain their uterus and who do not respond to medical treatment, myomectomy and uterine artery embolisation are therapeutic options.

OBJECTIVES

We examined the clinical effectiveness and cost-effectiveness of uterine artery embolisation compared with myomectomy in the treatment of symptomatic fibroids.

DESIGN

A multicentre, open, randomised trial with a parallel economic evaluation.

SETTING

Twenty-nine UK hospitals.

PARTICIPANTS

Premenopausal women who had symptomatic uterine fibroids amenable to myomectomy or uterine artery embolisation were recruited. Women were excluded if they had significant adenomyosis, any malignancy or pelvic inflammatory disease or if they had already had a previous open myomectomy or uterine artery embolisation.

INTERVENTIONS

Participants were randomised to myomectomy or embolisation in a 1 : 1 ratio using a minimisation algorithm. Myomectomy could be open abdominal, laparoscopic or hysteroscopic. Embolisation of the uterine arteries was performed under fluoroscopic guidance.

MAIN OUTCOME MEASURES

The primary outcome was the Uterine Fibroid Symptom Quality of Life questionnaire (with scores ranging from 0 to 100 and a higher score indicating better quality of life) at 2 years, adjusted for baseline score. The economic evaluation estimated quality-adjusted life-years (derived from EuroQol-5 Dimensions, three-level version, and costs from the NHS perspective).

RESULTS

A total of 254 women were randomised - 127 to myomectomy (105 underwent myomectomy) and 127 to uterine artery embolisation (98 underwent embolisation). Information on the primary outcome at 2 years was available for 81% (n = 206) of women. Primary outcome scores at 2 years were 84.6 (standard deviation 21.5) in the myomectomy group and 80.0 (standard deviation 22.0) in the uterine artery embolisation group (intention-to-treat complete-case analysis mean adjusted difference 8.0, 95% confidence interval 1.8 to 14.1, p = 0.01; mean adjusted difference using multiple imputation for missing responses 6.5, 95% confidence interval 1.1 to 11.9). The mean difference in the primary outcome at the 4-year follow-up time point was 5.0 (95% CI -1.4 to 11.5; p = 0.13) in favour of myomectomy. Perioperative and postoperative complications from all initial procedures occurred in similar percentages of women in both groups (29% in the myomectomy group vs. 24% in the UAE group). Twelve women in the uterine embolisation group and six women in the myomectomy group reported pregnancies over 4 years, resulting in seven and five live births, respectively (hazard ratio 0.48, 95% confidence interval 0.18 to 1.28). Over a 2-year time horizon, uterine artery embolisation was associated with higher costs than myomectomy (mean cost £7958, 95% confidence interval £6304 to £9612, vs. mean cost £7314, 95% confidence interval £5854 to £8773), but with fewer quality-adjusted life-years gained (0.74, 95% confidence interval 0.70 to 0.78, vs. 0.83, 95% confidence interval 0.79 to 0.87). The differences in costs (difference £645, 95% confidence interval -£1381 to £2580) and quality-adjusted life-years (difference -0.09, 95% confidence interval -0.11 to -0.04) were small. Similar results were observed over the 4-year time horizon. At a threshold of willingness to pay for a gain of 1 QALY of £20,000, the probability of myomectomy being cost-effective is 98% at 2 years and 96% at 4 years.

LIMITATIONS

There were a substantial number of women who were not recruited because of their preference for a particular treatment option.

CONCLUSIONS

Among women with symptomatic uterine fibroids, myomectomy resulted in greater improvement in quality of life than did uterine artery embolisation. The differences in costs and quality-adjusted life-years are very small. Future research should involve women who are desiring pregnancy.

TRIAL REGISTRATION

This trial is registered as ISRCTN70772394.

FUNDING

This study was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme, and will be published in full in Health Technology Assessment; Vol. 26, No. 22. See the NIHR Journals Library website for further project information.

Hysteroscopic myomectomy: The guidelines of the International Society for Gynecologic Endoscopy (ISGE)

OBJECTIVE

With this publication, the International Society for Gynecologic Endoscopy (ISGE) aims to provide the clinicians with the recommendations arising from the best evidence currently available on hysteroscopic myomectomy (HM).

STUDY DESIGN

The ISGE Task Force for HM defined key clinical questions, which led the search of Medline/PubMed and the Cochrane Database. We selected and analyzed relevant English-language articles, published from January 2005 to June 2021, including original works, reviews and the guidelines previously published by the European Society for Gynecological Endoscopy (ESGE) and the American Association of Gynecologic Laparoscopists (AAGL), in which bibliographies were also checked in order to identify additional references, using the medical subject heading (MeSH) term "Uterine Myomectomy" (MeSH Unique ID: D063186) in combination with ''Myoma" (MeSH Unique ID: D009214) and ''Hysteroscopy" (MeSH Unique ID: D015907). We developed the recommendations through multiple cycles of literature analysis and expert discussion.

RESULTS

The ISGE Task Force did develop 10 grade 1A-C and 4 grade 2A-C recommendations. For planning HM, evaluation of the uterus with saline infusion sonohysterography (SIS) or combined assessment by transvaginal ultrasound (TVUS) and diagnostic hysteroscopy is recommended (Grade 1A). The use of STEPW (Size, Topography, Extension of the base, Penetration and lateral Wall position) classification system of submucosal leiomyoma (LM) is recommended to predict the complex surgeries, incomplete removal of the LM, long operative time, fluid overload and other major complications (grade 1B). For type 0 LMs, in addition to resectoscopy (slicing technique), morcellation is recommended, being faster and having a shorter learning curve with respect to resectoscopy (grade 1C). For type 1-2 LMs, slicing technique is currently recommended (grade 1C). A fluid deficit of 1000 mL also in case of bipolar myomectomy with saline solution, in healthy women of reproductive age, contains low risk for major complications. Lower thresholds (750 mL) for fluid deficit should be considered in the elderly and in women with cardiovascular, renal or other co-morbidities (Grade 1B).

CONCLUSION

HM is the most effective conservative minimally invasive gynecologic intervention for submucous LM. The set of 14 ISGE recommendations can significantly contribute to the success of HM and the safety of patients for whom the choice of appropriate surgical technique, as well as the surgeon's awareness and measures to prevent complications are of the utmost importance.

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

Background:

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

Materials and methods:

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

Results:

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

Conclusions:

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

Giant Uterine Leiomyoma With Surgical Difficulty

Uterine leiomyoma is a benign gynecological tumor of the uterine myometrium layer in the female reproductive system, with clinical incidence in approximately 25% of women. In rare instances, it is possible for it to grow into a giant uterine leiomyoma (weighing 11.4 kg or more). Surgery on a giant mass is challenging because the enlargement mass affects the normal anatomical position of the internal genital organs. We report a case of a giant uterine leiomyoma with surgical difficulty. A 45-year-old woman came to the gynecology outpatient department referred from a district hospital with a suspected malignant ovarian cyst. The signs and symptoms were enlargement of the abdomen in the last 15 years, abdominal pain, and menstrual blood clots. An abdominal pelvic computed tomography (CT) scan with contrast revealed a regular cystic mass with multiple solid components and thick septa, probably from the adnexa. The biochemical examination revealed an increase in CA-125 serum (102.6 U/mL) with a risk of malignancy index (RMI) score of 308. Considering the size of the mass, fixed to the abdomen with umbilical hernia and suspicions of uterine or ovarian malignancy, the patient was planned for a laparotomy with collaborating digestive surgeon and urologist. The intraoperative findings were enlargement of the uterus with cystic degeneration of the leiomyoma at the posterior wall of the uterus. Due to the size of the mass, the anatomical position of the internal genital organs was deviated. The ovaries and fallopian tubes were normal, and total abdominal hysterectomy and bilateral salpingo-oophorectomy were performed. The mass measured 57 × 51 cm in size and 26 kg in weight. Histopathological examination revealed a uterine leiomyoma with cystic degeneration.

Appraisal of national and international uterine fibroid management guidelines: a systematic review

BACKGROUND

Guidelines standardise high-quality evidence-based management strategies for clinicians. Uterine fibroids are a highly prevalent condition and may exert significant morbidity.

OBJECTIVES

To appraise national and international uterine fibroid guidelines using the validated AGREE-II instrument.

SELECTION STRATEGY

Database search of PubMed and EMBASE from inception to October 2020 for all published English-language uterine fibroid clinical practice guidelines.

DATA COLLECTION AND ANALYSIS

In all, 939 abstracts were screened for eligibility by two reviewers independently. Three reviewers used the AGREE-II instrument to assess guideline quality in six domains. Recommendations were mapped to allow a narrative synthesis regarding areas of consensus and disagreement.

MAIN RESULTS

Eight national guidelines (AAGL, SOGC 2014, ACOG, ACR, SOGC 2019, CNGOF, ASRM and SOGC 2015) and one international guideline (RANZOG) were appraised. The highest scoring guideline was RANZOG 2001(score 56.5%). None of the guidelines met the a priori criteria for being high-quality overall (score ≥66%). There were 166 recommendations across guidelines. There were several areas of disagreement and uncertainty. There were only three areas of consensus. Supporting evidence was not evident for many recommendations; 27.7% of recommendations were based on expert opinion only.

CONCLUSIONS

There is a need for high-quality guidelines on fibroids given their heterogeneity across individuals and the large range of treatment modalities available. There are also areas of controversy in the management of fibroids (e.g. Ulipristal acetate, power morcellation), which should also be addressed in any guidelines. Future guidelines should be methodologically robust to allow high-quality decision-making regarding fibroid treatments.

TWEETABLE ABSTRACT

Current national fibroid guidelines have deficiencies in quality when appraised using the validated AGREE instrument.

Quality metrics in minimally invasive gynecologic surgery

PURPOSE OF REVIEW

Quality improvement and patient safety are relevant to the advancement of clinical care, particularly in the field of minimally invasive gynecologic surgery (MIGS). Although safety and feasibility of MIGS have been established, identification of quality metrics in this field is also necessary.

RECENT FINDINGS

Surgical quality improvement has focused on national overarching measures to reduce mortality, surgical site infections (SSIs), and complications. Quality improvement in minimally invasive surgery has additionally led to advancements in postoperative patient recovery and long-term outcomes. Process measures in minimally invasive surgery include use of bundles and enhanced recovery after surgery (ERAS) programs. However, procedure-specific quality metrics for MIGS outcomes are poorly defined at this time.

SUMMARY

Quality metrics in minimally invasive gynecology are well defined for structural measures and select process measures. Creation of relevant benchmarks for outcome measures in minimally invasive gynecologic surgery are needed.

Benign Uterine Disease: The Added Role of Imaging

Benign uterine diseases are very common gynecologic conditions that affect women mostly in reproductive age. Ultrasound examination is the first-line imaging technique, but MRI is more accurate for diagnosis, characterization, and patient management. In this review, we especially highlight the added value of MRI in the diagnosis of benign uterine disease, discuss their imaging characteristics, and describe the therapeutic options and the added value of MRI in the treatment planning.

Alterations in lipid profile upon uterine fibroids and its recurrence

Uterine fibroids (UF) is the most common (about 70% cases) type of gynecological disease, with the recurrence rate varying from 11 to 40%. Because UF has no distinct symptomatology and is often asymptomatic, the specific and sensitive diagnosis of UF as well as the assessment for the probability of UF recurrence pose considerable challenge. The aim of this study was to characterize alterations in the lipid profile of tissues associated with the first-time diagnosed UF and recurrent uterine fibroids (RUF) and to explore the potential of mass spectrometry (MS) lipidomics analysis of blood plasma samples for the sensitive and specific determination of UF and RUF with low invasiveness of analysis. MS analysis of lipid levels in the myometrium tissues, fibroids tissues and blood plasma samples was carried out on 66 patients, including 35 patients with first-time diagnosed UF and 31 patients with RUF. The control group consisted of 15 patients who underwent surgical treatment for the intrauterine septum. Fibroids and myometrium tissue samples were analyzed using direct MS approach. Blood plasma samples were analyzed using high performance liquid chromatography hyphened with mass spectrometry (HPLC/MS). MS data were processed by discriminant analysis with projection into latent structures (OPLS-DA). Significant differences were found between the first-time UF, RUF and control group in the levels of lipids involved in the metabolism of glycerophospholipids, sphingolipids, lipids with an ether bond, triglycerides and fatty acids. Significant differences between the control group and the groups with UF and RUF were found in the blood plasma levels of cholesterol esters, triacylglycerols, (lyso) phosphatidylcholines and sphingomyelins. Significant differences between the UF and RUF groups were found in the blood plasma levels of cholesterol esters, phosphotidylcholines, sphingomyelins and triacylglycerols. Diagnostic models based on the selected differential lipids using logistic regression showed sensitivity and specificity of 88% and 86% for the diagnosis of first-time UF and 95% and 79% for RUF, accordingly. This study confirms the involvement of lipids in the pathogenesis of uterine fibroids. A diagnostically significant panel of differential lipid species has been identified for the diagnosis of UF and RUF by low-invasive blood plasma analysis. The developed diagnostic models demonstrated high potential for clinical use and further research in this direction.

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.

Fertility outcomes after hysteroscopic removal of intrauterine leiomyomas and polyps

INTRODUCTION

Thanks to the progress of science, it is now understood that a successful implantation not only depends on the quality of the embryo, but also on having a receptive endometrium. During the years, several authors have reviewed the important role of the uterine factor, ranging from the congenital anomalies, such as uterine septa and subsepta, and acquired conditions such as endometrial polyps and submucous myomas. Currently, hysteroscopy has proved to be a powerful and accurate tool for visualizing the uterine cavity and treating intrauterine pathologies.

EVIDENCE ACQUISITION

This review of the literature aims to report the current available data on the effects of the two most common endouterine pathologies (i.e. endometrial polyps and submucous myomas) and the impact of hysteroscopic removal on fertility outcomes.

EVIDENCE SYNTHESIS

To date, the low number of randomized controlled trials available does not yet make it possible to give a definitive answer on what are the reproductive outcomes following treatment of endometrial polyps and leiomyomas. Nevertheless, existing evidence points to a benefit of removal of this two pathologies in infertile women, mostly when they have a history of recurrent pregnancy loss.

CONCLUSIONS

Further studies are needed to demonstrate that surgical treatments of endometrial polyps and myomas could improve not only the morphology but also the function of the uterine cavity before undergoing any assisted fertility treatment.

Clinical practice guidelines for recurrent miscarriage in high-income countries: a systematic review

Recurrent miscarriage affects 1-2% of women of reproductive age, depending on the definition used. A systematic review was conducted to identify, appraise and describe clinical practice guidelines (CPG) published since 2000 for the investigation, management, and/or follow-up of recurrent miscarriage within high-income countries. Six major databases, eight guideline repositories and the websites of 11 professional organizations were searched to identify potentially eligible studies. The quality of eligible CPG was assessed using the Appraisal of Guidelines for Research and Evaluation (AGREE II) Tool. A narrative synthesis was conducted to describe, compare and contrast the CPG and recommendations therein. Thirty-two CPG were included, from which 373 recommendations concerning first-trimester recurrent miscarriage were identified across four sub-categories: structure of care (42 recommendations, nine CPG), investigations (134 recommendations, 23 CPG), treatment (153 recommendations, 24 CPG), and counselling and supportive care (46 recommendations, nine CPG). Most CPG scored 'poor' on applicability (84%) and editorial independence (69%); and to a lesser extent stakeholder involvement (38%) and rigour of development (31%). Varying levels of consensus were found across CPG, with some conflicting recommendations. Greater efforts are required to improve the quality of evidence underpinning CPG, the rigour of their development and the inclusion of multi-disciplinary perspectives, including those with lived experience of recurrent miscarriage.

Top 10 priorities for future infertility research: an international consensus development study

STUDY QUESTION

Can the priorities for future research in infertility be identified?

SUMMARY ANSWER

The top 10 research priorities for the four areas of male infertility, female and unexplained infertility, medically assisted reproduction, and ethics, access, and organization of care for people with fertility problems were identified.

WHAT IS KNOWN ALREADY

Many fundamental questions regarding the prevention, management, and consequences of infertility remain unanswered. This is a barrier to improving the care received by those people with fertility problems.

STUDY DESIGN, SIZE, DURATION

Potential research questions were collated from an initial international survey, a systematic review of clinical practice guidelines, and Cochrane systematic reviews. A rationalized list of confirmed research uncertainties was prioritized in an interim international survey. Prioritized research uncertainties were discussed during a consensus development meeting. Using a formal consensus development method, the modified nominal group technique, diverse stakeholders identified the top 10 research priorities for each of the categories male infertility, female and unexplained infertility, medically assisted reproduction, and ethics, access, and organization of care.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Healthcare professionals, people with fertility problems, and others (healthcare funders, healthcare providers, healthcare regulators, research funding bodies and researchers) were brought together in an open and transparent process using formal consensus methods advocated by the James Lind Alliance.

MAIN RESULTS AND THE ROLE OF CHANCE

The initial survey was completed by 388 participants from 40 countries, and 423 potential research questions were submitted. Fourteen clinical practice guidelines and 162 Cochrane systematic reviews identified a further 236 potential research questions. A rationalized list of 231 confirmed research uncertainties were entered into an interim prioritization survey completed by 317 respondents from 43 countries. The top 10 research priorities for each of the four categories male infertility, female and unexplained infertility (including age-related infertility, ovarian cysts, uterine cavity abnormalities, and tubal factor infertility), medically assisted reproduction (including ovarian stimulation, IUI, and IVF), and ethics, access, and organization of care, were identified during a consensus development meeting involving 41 participants from 11 countries. These research priorities were diverse and seek answers to questions regarding prevention, treatment, and the longer-term impact of infertility. They highlight the importance of pursuing research which has often been overlooked, including addressing the emotional and psychological impact of infertility, improving access to fertility treatment, particularly in lower resource settings, and securing appropriate regulation. Addressing these priorities will require diverse research methodologies, including laboratory-based science, qualitative and quantitative research, and population science.

LIMITATIONS, REASONS FOR CAUTION

We used consensus development methods, which have inherent limitations, including the representativeness of the participant sample, methodological decisions informed by professional judgement, and arbitrary consensus definitions.

WIDER IMPLICATIONS OF THE FINDINGS

We anticipate that identified research priorities, developed to specifically highlight the most pressing clinical needs as perceived by healthcare professionals, people with fertility problems, and others, will help research funding organizations and researchers to develop their future research agenda.

STUDY FUNDING/ COMPETING INTEREST(S)

The study was funded by the Auckland Medical Research Foundation, Catalyst Fund, Royal Society of New Zealand, and Maurice and Phyllis Paykel Trust. Geoffrey Adamson reports research sponsorship from Abbott, personal fees from Abbott and LabCorp, a financial interest in Advanced Reproductive Care, committee membership of the FIGO Committee on Reproductive Medicine, International Committee for Monitoring Assisted Reproductive Technologies, International Federation of Fertility Societies, and World Endometriosis Research Foundation, and research sponsorship of the International Committee for Monitoring Assisted Reproductive Technologies from Abbott and Ferring. Siladitya Bhattacharya reports being the Editor-in-Chief of Human Reproduction Open and editor for the Cochrane Gynaecology and Fertility Group. Hans Evers reports being the Editor Emeritus of Human Reproduction. Andrew Horne reports research sponsorship from the Chief Scientist's Office, Ferring, Medical Research Council, National Institute for Health Research, and Wellbeing of Women and consultancy fees from Abbvie, Ferring, Nordic Pharma, and Roche Diagnostics. M. Louise Hull reports grants from Merck, grants from Myovant, grants from Bayer, outside the submitted work and ownership in Embrace Fertility, a private fertility company. Neil Johnson reports research sponsorship from Abb-Vie and Myovant Sciences and consultancy fees from Guerbet, Myovant Sciences, Roche Diagnostics, and Vifor Pharma. José Knijnenburg reports research sponsorship from Ferring and Theramex. Richard Legro reports consultancy fees from Abbvie, Bayer, Ferring, Fractyl, Insud Pharma and Kindex and research sponsorship from Guerbet and Hass Avocado Board. Ben Mol reports consultancy fees from Guerbet, iGenomix, Merck, Merck KGaA and ObsEva. Ernest Ng reports research sponsorship from Merck. Craig Niederberger reports being the Co Editor-in-Chief of Fertility and Sterility and Section Editor of the Journal of Urology, research sponsorship from Ferring, and retains a financial interest in NexHand. Jane Stewart reports being employed by a National Health Service fertility clinic, consultancy fees from Merck for educational events, sponsorship to attend a fertility conference from Ferring, and being a clinical subeditor of Human Fertility. Annika Strandell reports consultancy fees from Guerbet. Jack Wilkinson reports being a statistical editor for the Cochrane Gynaecology and Fertility Group. Andy Vail reports that he is a Statistical Editor of the Cochrane Gynaecology & Fertility Review Group and of the journal Reproduction. His employing institution has received payment from HFEA for his advice on review of research evidence to inform their 'traffic light' system for infertility treatment 'add-ons'. Lan Vuong reports consultancy and conference fees from Ferring, Merck and Merck Sharp and Dohme. The remaining authors declare no competing interests in relation to the present work. All authors have completed the disclosure form.

TRIAL REGISTRATION NUMBER

Not applicable.

A Review of Clinical Guidelines on the Management of Iron Deficiency and Iron-Deficiency Anemia in Women with Heavy Menstrual Bleeding

Introduction

Up to one-third of women of reproductive age experience heavy menstrual bleeding (HMB). HMB can give rise to iron deficiency (ID) and, in severe cases, iron-deficiency anemia (IDA).

Aim

To review current guidelines for the management of HMB, with regards to screening for anemia, measuring iron levels, and treating ID/IDA with iron replacement therapy and non-iron-based treatments.

Methods

The literature was searched for English-language guidelines relating to HMB published between 2010 and 2020, using the PubMed database, web searching, and retrieval of clinical guidelines from professional societies.

Results

Overall, 55 guidelines mostly originating from North America and Europe were identified and screened. Twenty-two were included in this review, with the majority (16/22) focusing on guidance to screen women with HMB for anemia. The guidance varied with respect to identifying symptoms, the criteria for testing, and diagnostic hemoglobin levels for ID/IDA. There was inconsistency concerning screening for ID, with 11/22 guidelines providing no recommendations for measurement of iron levels and four contrasting guidelines explicitly advising against initial assessment of iron levels. In terms of treatment, 8/22 guidelines provided guidance on iron therapy, with oral iron administration generally recommended as first-line treatment for ID and/or IDA. Four guidelines recommended intravenous iron administration for severe anemia, in non-responders, or before surgery. Three guidelines provided hemoglobin thresholds for choosing between oral or intravenous iron treatment. Four guidelines discussed the use of transfusion for severe IDA.

Conclusion

Many of the guidelines for managing HMB recognize the importance of treating anemia, but there is a lack of consensus in relation to screening for ID and use of iron therapy. Consequently, ID/IDA associated with HMB is likely to be underdiagnosed and undertreated. A consensus guidance, covering all aspects of screening and management of ID/IDA in women with HMB, is needed to optimize health outcomes in these patients.

Women who bleed heavily during menstruation are at risk of iron deficiency and anemia. This can have a negative effect on the well-being of women and can cause serious complications after surgery. Iron is an important part of the hemoglobin in red blood cells that carries oxygen around the body. Bleeding causes iron to be lost from the body. If there is heavy blood loss, iron stores in the body can become low, leading to iron deficiency. If the iron deficiency is severe enough to impair red blood cell production, iron-deficiency anemia can develop. We reviewed the current guidelines for the care of women with heavy menstrual bleeding, focusing on the detection and treatment of iron deficiency and anemia. Most guidelines include routine testing for anemia. Fewer guidelines consider measuring iron levels. Not all the guidelines include advice on the best way to treat iron deficiency and anemia. For those that do, the recommendations vary and sometimes offer conflicting advice. There is little agreement on when to give iron therapy, and whether this should be given by mouth or by infusion. A lack of clear guidance on detecting and treating iron deficiency and anemia caused by heavy menstrual bleeding puts women at risk of being undiagnosed and untreated. To address these concerns, the authors recommend the development of consensus guidelines. These should contain comprehensive recommendations on all aspects of the diagnosis and management of iron deficiency and anemia in women with heavy menstrual bleeding.

Hysteroscopy and female infertility: a fresh look to a busy corner

Hysteroscopy has evolved from the traditional art of examining the uterine cavity for diagnostic purposes to an invaluable modality to concomitantly diagnose and (see and) treat a multitude of intrauterine pathologies, especially in the field and clinics specialising in female reproduction. This article reviews the literature on the most common cervical, endometrial, uterine and tubal pathologies such as chronic endometritis, endometrial polyps, adenomyosis, endometriosis, endometrial atrophy, adhesions, endometrial hyperplasia, cancer, and uterine malformations. The aim is to determine the efficiency of hysteroscopy compared with other available techniques as a diagnostic and treatment tool and its association with the success of in vitro fertilisation procedures. Although hysteroscopy requires an experienced operator for optimal results and is still an invasive procedure, it has the unique advantage of combining great diagnostic and treatment opportunities before and after ART procedures. In conclusion, hysteroscopy should be recommended as a first-line procedure in all cases with female infertility, and a special effort should be made for its implementation in the development of new high-tech procedures for identification and treatment infertility-associated conditions.

Top 10 priorities for future infertility research: an international consensus development study† ‡

STUDY QUESTION

Can the priorities for future research in infertility be identified?

SUMMARY ANSWER

The top 10 research priorities for the four areas of male infertility, female and unexplained infertility, medically assisted reproduction and ethics, access and organization of care for people with fertility problems were identified.

WHAT IS KNOWN ALREADY

Many fundamental questions regarding the prevention, management and consequences of infertility remain unanswered. This is a barrier to improving the care received by those people with fertility problems.

STUDY DESIGN, SIZE, DURATION

Potential research questions were collated from an initial international survey, a systematic review of clinical practice guidelines and Cochrane systematic reviews. A rationalized list of confirmed research uncertainties was prioritized in an interim international survey. Prioritized research uncertainties were discussed during a consensus development meeting. Using a formal consensus development method, the modified nominal group technique, diverse stakeholders identified the top 10 research priorities for each of the categories male infertility, female and unexplained infertility, medically assisted reproduction and ethics, access and organization of care.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Healthcare professionals, people with fertility problems and others (healthcare funders, healthcare providers, healthcare regulators, research funding bodies and researchers) were brought together in an open and transparent process using formal consensus methods advocated by the James Lind Alliance.

MAIN RESULTS AND THE ROLE OF CHANCE

The initial survey was completed by 388 participants from 40 countries, and 423 potential research questions were submitted. Fourteen clinical practice guidelines and 162 Cochrane systematic reviews identified a further 236 potential research questions. A rationalized list of 231 confirmed research uncertainties was entered into an interim prioritization survey completed by 317 respondents from 43 countries. The top 10 research priorities for each of the four categories male infertility, female and unexplained infertility (including age-related infertility, ovarian cysts, uterine cavity abnormalities and tubal factor infertility), medically assisted reproduction (including ovarian stimulation, IUI and IVF) and ethics, access and organization of care were identified during a consensus development meeting involving 41 participants from 11 countries. These research priorities were diverse and seek answers to questions regarding prevention, treatment and the longer-term impact of infertility. They highlight the importance of pursuing research which has often been overlooked, including addressing the emotional and psychological impact of infertility, improving access to fertility treatment, particularly in lower resource settings and securing appropriate regulation. Addressing these priorities will require diverse research methodologies, including laboratory-based science, qualitative and quantitative research and population science.

LIMITATIONS, REASONS FOR CAUTION

We used consensus development methods, which have inherent limitations, including the representativeness of the participant sample, methodological decisions informed by professional judgment and arbitrary consensus definitions.

WIDER IMPLICATIONS OF THE FINDINGS

We anticipate that identified research priorities, developed to specifically highlight the most pressing clinical needs as perceived by healthcare professionals, people with fertility problems and others, will help research funding organizations and researchers to develop their future research agenda.

STUDY FUNDING/COMPETING INTEREST(S)

The study was funded by the Auckland Medical Research Foundation, Catalyst Fund, Royal Society of New Zealand and Maurice and Phyllis Paykel Trust. G.D.A. reports research sponsorship from Abbott, personal fees from Abbott and LabCorp, a financial interest in Advanced Reproductive Care, committee membership of the FIGO Committee on Reproductive Medicine, International Committee for Monitoring Assisted Reproductive Technologies, International Federation of Fertility Societies and World Endometriosis Research Foundation, and research sponsorship of the International Committee for Monitoring Assisted Reproductive Technologies from Abbott and Ferring. Siladitya Bhattacharya reports being the Editor-in-Chief of Human Reproduction Open and editor for the Cochrane Gynaecology and Fertility Group. J.L.H.E. reports being the Editor Emeritus of Human Reproduction. A.W.H. reports research sponsorship from the Chief Scientist's Office, Ferring, Medical Research Council, National Institute for Health Research and Wellbeing of Women and consultancy fees from AbbVie, Ferring, Nordic Pharma and Roche Diagnostics. M.L.H. reports grants from Merck, grants from Myovant, grants from Bayer, outside the submitted work and ownership in Embrace Fertility, a private fertility company. N.P.J. reports research sponsorship from AbbVie and Myovant Sciences and consultancy fees from Guerbet, Myovant Sciences, Roche Diagnostics and Vifor Pharma. J.M.L.K. reports research sponsorship from Ferring and Theramex. R.S.L. reports consultancy fees from AbbVie, Bayer, Ferring, Fractyl, Insud Pharma and Kindex and research sponsorship from Guerbet and Hass Avocado Board. B.W.M. reports consultancy fees from Guerbet, iGenomix, Merck, Merck KGaA and ObsEva. E.H.Y.N. reports research sponsorship from Merck. C.N. reports being the Co Editor-in-Chief of Fertility and Sterility and Section Editor of the Journal of Urology, research sponsorship from Ferring and retains a financial interest in NexHand. J.S. reports being employed by a National Health Service fertility clinic, consultancy fees from Merck for educational events, sponsorship to attend a fertility conference from Ferring and being a clinical subeditor of Human Fertility. A.S. reports consultancy fees from Guerbet. J.W. reports being a statistical editor for the Cochrane Gynaecology and Fertility Group. A.V. reports that he is a Statistical Editor of the Cochrane Gynaecology & Fertility Review Group and the journal Reproduction. His employing institution has received payment from Human Fertilisation and Embryology Authority for his advice on review of research evidence to inform their 'traffic light' system for infertility treatment 'add-ons'. N.L.V. reports consultancy and conference fees from Ferring, Merck and Merck Sharp and Dohme. The remaining authors declare no competing interests in relation to the present work. All authors have completed the disclosure form.

TRIAL REGISTRATION NUMBER

N/A.

National trends and determinants of hospitalization for uterine leiomyomas - Portuguese public database analysis from 2000 to 2015

OBJECTIVE

To determine the trends of hospitalization (inpatients and outpatients) for uterine leiomyomas in Portugal, over a period of fifteen years.

STUDY DESIGN

We perform a population- and register-based retrospective study of women who were hospitalized with a primary diagnosis of uterine fibroid in public hospitals in continental Portugal, in the period between January 1, 2000 and December 31, 2015. Patient data regarding hospital codes, admission and discharge dates, patient age, diagnosis, procedures and complications were extracted from the national database of Administração Central do Sistema de Saúde (ACSS). All calculations were performed with the STATA software, version 13.1. Categorical data were analysed by the χ2 test and the means of continuous variables were analysed with Student's t-test. Statistical significance was set at p < 0.05.

RESULTS

Between 2000 and 2015, 102 476 patients were admitted to public hospitals in Portugal due to uterine leiomyomas. The majority were admitted to hospital for surgery: 73.6 % for hysterectomy and 13.0 % for myomectomy. During this period, the definitive treatment (hysterectomy) decreased from 83.2% to 63.0% (p < 0.001), with a change towards more conservative treatments such as myomectomies (6.4% to 22.6%, p < 0.001). Additionally, in women submitted to hysterectomy, laparoscopic and vaginal routes increased (1.1%-11.5%, p < 0.001 and 2.1%-4.0%, p < 0.001; respectively). Globally, there was a 14.3 % reduction in hospitalizations due to uterine fibroids and an increase in the outpatient rate (from 3.1% to 22.1%). The mean number of hospitalization days for inpatients also decreased (from 6.3 ± 4.1-4.0 ± 3.0, p < 0.001). Regarding urgently hospitalized women, 11.8 % required a blood transfusion. In women submitted to surgical procedures, 0.5 % had an intraoperative complication and 2.3 % a post-operative complication, directly related to the surgical procedure.

CONCLUSION

There was a reduction in hospitalizations due to uterine fibroids and a change towards more conservative treatments.

Severe hyponatremia with seizures and confirmed mild brain edema by hysteroscopic myomectomy: a case report

BACKGROUND

Hyponatremia can be developed during hysteroscopic surgery with electrolyte-free irrigation fluid. We experienced severe hyponatremia with postoperative seizures and confirmed mild brain edema.

CASE PRESENTATION

A quadragenarian female patient underwent a 2-h hysteroscopic myomectomy with electrolyte-free fluid for uterine distension under general anesthesia. Plasma sodium level of 84.1 mmol/L 100 min after the start of surgery indicated excessive absorption of the irrigation fluid. Acute severe hyponatremia was diagnosed with significant edema in the conjunctiva, lip, and extremities. She was treated with a continuous infusion of hypertonic saline. However, seizures and cerebral edema developed 7 h later. The patient recovered without neurological deficits at postoperative day 2.

CONCLUSION

The electrolyte-free irrigation fluid can be absorbed rapidly during hysteroscopic surgery. Its interruption with hyponatremia should be considered against prolonged surgery. Especially under general anesthesia, caution should be exercised because the typical symptoms of hyponatremia such as nausea and confusion are blinded.

Successful management of a submucosal fibroid using a hysteroscopic morcellator system in a patient with a history of total proctocolectomy: A case report

Transcervical resection is widely used in the management of submucosal fibroids. However, uterine perforation and thermal bowel injuries are known complications associated with the procedure. This is a case report of a 44-year-old woman who presented with heavy menstrual bleeding and anemia. Magnetic resonance imaging and hysteroscopy revealed multiple fibroids, including a submucosal type 1 fibroid. She had previously undergone a total proctocolectomy with intestinal pouch-anal anastomosis for ulcerative colitis. Because there was a high risk of permanent colostomy in the event of a bowel injury, an electrode-free, operative hysteroscopy using the Intrauterine Bigatti Shaver (IBS), a hysteroscopic morcellator system, was employed to prevent thermal bowel injury. The fibroid was completely removed using the IBS system with no complications. Therefore, we recommend the electrode-free use of a hysteroscopic morcellator system in patients with a history of extensive pelvic surgery.

Ultrasound and clinical characteristics of uterine smooth muscle tumors of uncertain malignant potential (STUMPs)

OBJECTIVE(S)

Smooth muscle tumors of uncertain malignant potential are rare uterine neoplasms. Their identification through imaging is still limited due to the few available descriptions in the scientific literature. The objective of this paper is to provide clinical and ultrasound features that could support an early identification of these neoplasms.

STUDY DESIGN

We retrospectively evaluated preoperative sonographic data of patients receiving a histopathological diagnosis of smooth muscle tumors of uncertain malignant potential between 2014 and 2019 at the S. Anna Hospital (Turin, Italy), a tertiary gynecological center. Tumors were characterized on the basis of ultrasound images using terms and definitions according to the morphological uterus sonographic assessment group.

RESULTS

A total of fourteen patients with smooth muscle tumors of uncertain malignant potential (20 lesions, including 18 pure and 2 with associated leiomyosarcoma) were identified. The median age was 47 years (range 28-77) and nine (64%) patients were of reproductive age. Six patients (43%) were asymptomatic, two (14%) presented with abdominal pain, two (14 %) with menorrhagia and four (29%) with both symptoms. Two (14%) patients developed local recurrences as uterine smooth muscle tumor of uncertain malignant potential and leiomyosarcoma, respectively. At ultrasound imaging, nine (69%) smooth muscle tumors of uncertain malignant potential were poorly or moderately vascularized and nine (82%) showed both circumferential and intra-lesional flows. Only three (15%) showed shadowing. The outlines were well-defined in seventeen cases (85%) and most (90%) showed isoechoic or mixed echogenicity with microcystic anechoic areas in fourteen (70%) of cases.

CONCLUSION(S)

Sonographic features of smooth muscle tumors of uncertain malignant potential may vary and a pathognomonic description has not been recognized. However, the identification of single or multiple lesions with specific ultrasound features should raise the suspicion of tumors of uncertain malignant potential. These features include isoechogenicity or mixed echogenicity, regular borders, presence of internal microcystic and anechoic areas, circumferential and intralesional vascularization ranging from minimal to high and absence of shadowing.

Office hysteroscopy in the management of women with postmenopausal bleeding

Postmenopausal bleeding (PMB) is a relevant aspect for health-care providers in clinical practice: the first objective is to rule out potential gynecological cancer. The purpose of this narrative review is to evaluate the role of office hysteroscopy in the management of PMB. Office hysteroscopy is a minimally invasive procedure allowing direct visualization of uterine pathology without the need for general anesthesia and the use of an operating room, generating cost savings and greater compliance among patients. Here, we focus on major intrauterine diseases (polyps, submucosal myomas, endometrial hyperplasia, and cancer) as causes of PMB. Office hysteroscopy appears to be safe and feasible, and could allow accurate diagnosis of intrauterine pathologies, especially that with a focal growth pattern, otherwise misdiagnosed with blinded procedures. However, studies focusing exclusively on postmenopausal women are still few, so further research, especially randomized controlled trials, is needed.

Likelihood of Accomplishing an In-Patient Hysteroscopic Myomectomy in a One-Step Procedure: A Systematic Review and Meta-Analysis

PURPOSE

To assess the feasibility rate of one-step hysteroscopic myomectomy according to the technique adopted.

METHODS

In July 2016, PubMed, ClinicalTrials.gov, SCOPUS, Scielo, and AJOL databases were used for searching references. Series of in-patient hysteroscopic myomectomies reporting success rate in only one-step procedure, categorization of submucous fibroids, explanation of the surgical technique, and description of patients were considered eligible for meta-analysis (retrospective, prospective randomized studies). Two authors extracted the data. Rate of myomectomies accomplished in only a surgical step and rate of intraoperative complications were extracted per protocol. A modified GRADE score was used for quality assessment. Random-effect models were already assumed. Mean rates were compared among subgroups.

RESULTS

One thousand two hundred and fifty-seven studies were screened and 241 of these were read for eligibility. Seventy-eight series were included in qualitative synthesis and 24 series were included in quantitative synthesis. Wide heterogeneity was found. In series with <50% of G2 myomas treated, the slicing technique feasibility rate was 86.5% while techniques for enucleating the deep portion of the myomas showed a feasibility rate of 92.3% (p < 0.001). In series with ≥50% of G2 myomas treated, the slicing technique feasibility rate was 70.6% while techniques for enucleating the deep portion of myomas showed a feasibility rate of 88.4% (p < 0.001). In series with ≥50% of G2 myomas treated, the slicing technique feasibility rate was 70.6% while techniques for enucleating the deep portion of myomas showed a feasibility rate of 88.4% (.

CONCLUSION

In case of submucous myomas with intramural development, the slicing technique was correlated with a lower rate of in-patient hysteroscopic myomectomies accomplished in a one-step procedure and a higher complications rate.

Cross-sectional imaging of acute gynaecologic disorders: CT and MRI findings with differential diagnosis-part II: uterine emergencies and pelvic inflammatory disease

Due to the growing use of cross-sectional imaging in emergency departments, acute gynaecologic disorders are increasingly diagnosed on urgent multidetector computed tomography (CT) studies, often requested under alternative presumptive diagnoses in reproductive-age women. If clinical conditions and state-of-the-art scanner availability permit, magnetic resonance imaging (MRI) is superior to CT due to its more in-depth characterisationof abnormal or inconclusive gynaecological findings, owing to excellent soft-tissue contrast, intrinsic multiplanar capabilities and lack of ionising radiation.

This pictorial review aims to provide radiologists with a thorough familiarity with gynaecologic emergencies by illustrating their CT and MRI appearances, in order to provide a timely and correct imaging diagnosis. Specifically, this second instalment reviews with examples and emphasis on differential diagnosis the main non-pregnancy-related uterine emergencies (including endometrial polyps, degenerated leiomyomas and uterine inversion) and the spectrum of pelvic inflammatory disease.

Intrauterine Instillation of Tranexamic Acid in Hysteroscopic Myomectomy: A Double-Blind, Placebo-Controlled, Parallel-Group Randomized Clinical Trial

STUDY OBJECTIVE

To evaluate the hemostatic effect of intrauterine instillation of tranexamic acid (TXA) with the distention medium during hysteroscopic myomectomy.

DESIGN

Prospective, parallel-group, double-blind, placebo-controlled randomized clinical trial.

SETTING

Early Cancer Detection Unit in Ain Shams University Maternity Hospital, Cairo, Egypt.

PATIENTS

Eighty women with type 0 or I submucous myoma undergoing hysteroscopic myomectomy using unipolar resectoscope.

INTERVENTIONS

The participants were randomly assigned to receive either 1 g of TXA for every 1000 mL of the distending medium (intervention group) or 10 mL of placebo (10 mL of 1.5% glycine) in the same form inside every 1000 mL of the distention medium.

MEASUREMENTS AND MAIN RESULTS

The primary outcome was a change in hemoglobin level 24 hours after surgery compared with preoperative values, and the secondary outcomes were the surgeon's rating of intraoperative bleeding and the quality of operative view, the duration of surgery, the volume of injected media, intraoperative complications, and the completion of myomectomy in 1 procedure. The mean difference in hemoglobin level was 1.11 ±.58 g/dL in the TXA group and 1.46 ± 0.61 g/dL in the placebo group (p = .015). The quality of hysteroscopic view was better in the TXA group (p = .001), with good operative view in 23 (60.5%) cases in TXA vs 8 (20.5%) in the placebo group. The surgeon's rating of bleeding as excessive was reported in 1 (2.6%) case in the TXA group and in 9 (23.1%) cases in the placebo group. There was no difference between the groups regarding the duration of surgery, the volume of injected media, completion of myoma resection in 1 session, and intraoperative complications. Three cases of uterine perforation with the thermal loop were reported, and all were associated with poor operative field in the placebo group.

CONCLUSION

Intrauterine instillation of TXA with the distention medium during hysteroscopic myomectomy resulted in a statistically significant decrease in hemoglobin level 24 hours after surgery, albeit with minimal clinical significance. TXA resulted in better visualization of the field throughout the procedure.

Hysteroscopic Resection of Submucous Fibroids in Symptomatic Women

Objective

This study was conducted at Swapna Health Care (a tertiary centre for endoscopy), to analyse the outcome of hysteroscopic resection of submucous fibroids in 125 symptomatic women.

Materials and Methods

A total of 125 women were diagnosed with submucous fibroids between 1994 and 2017, 83 presented with AUB, 31 with infertility and four with RPL. Seven postmenopausal women had thickened endometrium on routine transvaginal ultrasonography, and hysteroscopy showed submucous fibroids.

Results

Out of 83 with AUB, 68 were premenopausal and 15 were postmenopausal. All these patients underwent submucous fibroid resection by hysteroscopy. Out of 83, 75 (90.4%) had total relief from AUB and did not need any further management. Only eight patients needed hysterectomy after submucous fibroid resection. Thirty-one patients came for infertility. Twenty-five patients followed infertility treatment with us after SMFR. 32% of our infertile patients conceived (8/25).

Conclusions

Submucous fibroid resection is a safe procedure, giving good results in symptomatic women with AUB and infertility. Hence, all gynaecologists should be trained in diagnostic and operative hysteroscopy and should be able to offer this option to their patients in the spectrum of choices available.

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.

Hysteroscopic myomectomy: a comparison of techniques and review of current evidence in the management of abnormal uterine bleeding

PURPOSE OF REVIEW

Submucosal uterine leiomyomas are a common benign pelvic tumor that can cause abnormal uterine bleeding and may contribute to infertility and miscarriage. Hysteroscopic myomectomy is the treatment of choice to alleviate bleeding from these myomas and to normalize the uterine cavity. This review discusses the techniques and recent evidence for hysteroscopic myomectomy and examines the two primary surgical tools employed today: the bipolar resectoscope and hysteroscopic mechanical morcellator.

RECENT FINDINGS

Hysteroscopic myomectomy has been a popular treatment for symptomatic submucosal fibroids for decades; it is a minimally invasive, low-cost, low-risk procedure, and is associated with high patient satisfaction. There have been rapid advances in the surgical technology available for this procedure. Both the bipolar resectoscope and the hysteroscopic mechanical morcellator are appropriate tools to remove submucosal myomas. Although the hysteroscopic morcellators have been associated with shortened operative time and a decreased learning curve, the data are limited for their use on type 2 fibroids. The strength of the bipolar resectoscope lies in its ability to resect deeper type 2 fibroids.

SUMMARY

The evidence suggests that no one technique should be used for all patients, but rather a choice of technique should be taken on a case-by-case basis, depending on the myoma number, size, type, and location. Gynecologists must become knowledgeable about each of these techniques and their associated risks to safely offer these surgeries to their patients.

Successful Pregnancies in Women with Diffuse Uterine Leiomyomatosis after Hysteroscopic Management Using the Hysteroscopy Endo Operative System

STUDY OBJECTIVE

To evaluate the feasibility, effectiveness, and reproductive outcome of hysteroscopic management using the Hysteroscopy Endo Operative system (HEOS) in patients with diffuse uterine leiomyomatosis (DUL).

DESIGN

Retrospective study (Canadian Task Force classification III).

SETTING

Beijing Tiantan Hospital, Capital Medical University, Beijing, China.

PATIENTS

Eight women of reproductive age suffering from menorrhagia and anemia or infertility diagnosed with DUL by ultrasonography and hysteroscopy.

INTERVENTIONS

Hysteroscopic surgery using cold graspers combined with electric loop by the HEOS was performed to excise submucous myomas (including types 0, I, and II), leaving other intramural myomas in place. The fenestration method is used in electrical hysteroscopic myomectomy. Postoperative endometrial repair and synechiae, menstrual improvement, conception, and pregnancy were recorded.

MEASUREMENTS AND MAIN RESULTS

Two patients underwent a single hysteroscopic myomectomy, whereas 6 patients underwent 2 to 3 myomectomies. No complications were observed. The mean follow-up period was 39.13 ± 17.01 months (range, 21-67). The endometrium recovered 2 to 3 months after the initial surgery, and 100% improvement in menstruation was observed. Two patients had mild synechia after the first hysteroscopic surgery. Seven patients conceived spontaneously (postoperative pregnancy rate, 87.5%), 6 of whom had a full-term pregnancy. One patient suffered a miscarriage in the second trimester (live birth rate, 75%).

CONCLUSION

Hysteroscopic surgery using cold graspers combined with electric loop by the HEOS is a feasible and effective for treatment of DUL because it preserves the uterus and yields favorable reproductive outcomes. The cold surgery and fenestration method minimizes electrical and thermal damage to the endometrium surrounding the myoma, consequently reducing surgical risks.

Reintervention Rates After Myomectomy, Endometrial Ablation, and Uterine Artery Embolization for Patients with Uterine Fibroids

Background: Women with uterine fibroids (UF) may undergo less invasive procedures than hysterectomy, including myomectomy, endometrial ablation (EA), and uterine artery embolization (UAE); however, long-term need for reintervention is not well characterized. We estimated reintervention rates for 5 years and identified predictors of reintervention.

Materials and Methods: A longitudinal retrospective cohort study was conducted in women in MarketScan^® Commercial Claims and Encounters (Truven Health Analytics) aged 18–49 years with UF diagnosis before myomectomy, EA, or UAE from 2008 to 2014. Patients were categorized by initial procedure (index date) and required to have ≥12 months of continuous coverage before and after. Kaplan–Meier analyses and Cox proportional hazard models were used to estimate survival without reintervention and hazard of reintervention for 5 years.

Results: The study included 35,631 women with myomectomy (n = 13,804: 8,018 abdominal, 941 hysteroscopic, and 4,845 laparoscopic), EA (n = 17,198), and UAE (n = 4,629). Myomectomy had the lowest 12-month reintervention rate (4.2%), followed by UAE (7.0%), then EA (12.4%; both p < 0.001 relative of myomectomy). Estimates of 5-year reintervention rates were 19% for myomectomy (17%, 28%, and 20% for abdominal, hysteroscopic, and laparoscopic, respectively), 33% for EA, and 24% for UAE. EA and UAE had adjusted hazard ratios of 2.63 (95% confidence interval [CI], 2.44–2.83) and 1.56 (95% CI, 1.42–1.72). Prior anemia, bleeding, pelvic inflammatory disease, and abdominal and pelvic pain increased the hazard of reintervention.

Conclusion: Reintervention rate estimates ranged from 17% to 33% for 5 years after myomectomy, EA, and UAE for patients with UF. Risk of requiring reintervention should be considered during treatment selection.

Alternatives to excisional therapy: a clinical review of our current options to conservatively manage symptomatic leiomyomas

PURPOSE OF REVIEW

This article provides a clinical review of the alternatives to traditional excisional surgical therapies for uterine leiomyomas, such as myomectomy or hysterectomy.

RECENT FINDINGS

In this review, currently available hormonal medications will be briefly discussed. Then, nonhormonal medical therapy will be addressed with respect to mechanism of action, safety, and efficacy. Finally, the risk-benefit profile of nonexcisional procedures for management of leiomyomas will be addressed.

SUMMARY

This provides an update on the information available for more conservative options for symptomatic leiomyoma management.