Uterine Suspension With Adjustable Sutures for Difficult Laparoscopic Myomectomy

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Non-hysteroscopic Myomectomy and Fertility Outcomes: A Systematic Review

OBJECTIVE

To perform a systematic review of the literature to identify best practices for nonhysteroscopic myomectomy for women with myomas who desire future fertility. The focus areas included factors associated with conception and pregnancy outcomes after myomectomy, impact of surgical route (laparotomic, laparoscopic, and the incorporation of robot assistance), and preoperative findings and surgical techniques that have an impact on reproduction.

DATA SOURCES

Librarian-led electronic searches of the Ovid MEDLINE, Ovid Embase, and Cochrane CENTRAL databases were performed from inception to February 2020. A targeted reference review was performed to update the original searches.

METHODS OF STUDY SELECTION

The participants were women of reproductive age with myomas who underwent myoma removal surgery through laparotomic or laparoscopic approaches. The fertility outcomes included markers for ovarian reserve, clinical pregnancy rates, and pregnancy outcomes. We performed quality assessment using National Institutes of Health Study Quality Assessment Tools and developed clinical recommendations graded according to the strength of the evidence.

TABULATION, INTEGRATION, AND RESULTS

The initial search identified 2163 studies, of which 51 met the inclusion criteria. These consisted of 11 studies that focused on the factors associated with conception or pregnancy outcomes after myomectomy, 10 studies that examined the route of nonhysteroscopic myomectomy, and 30 that were related to intraoperative techniques and findings. Overall, younger age, lower myoma number, and distortion of the endometrial cavity were associated with improved reproductive outcomes after myomectomy. The route of nonhysteroscopic myomectomy and intraoperative uterine artery occlusion did not significantly affect pregnancy rates or outcomes. Adhesion barriers present a possible target for further research.

CONCLUSION

This study provides insights into patient selection and intraoperative techniques for nonhysteroscopic myomectomy. Further research with well-designed clinical trials is needed to highlight the relationships between myoma characteristics (International Federation of Gynecology and Obstetrics type, location, and size) and reproductive outcomes.