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Bouras M, Bourdiol A, Rooze P, Hourmant Y, Caillard A, Roquilly A. Tranexamic acid: a narrative review of its current role in perioperative medicine and acute medical bleeding. Front Med (Lausanne) 2024; 11:1416998. [PMID: 39170034 PMCID: PMC11335516 DOI: 10.3389/fmed.2024.1416998] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2024] [Accepted: 07/31/2024] [Indexed: 08/23/2024] Open
Abstract
Purpose Tranexamic acid (TXA) is the most widely prescribed antifibrinolytic for active bleeding or to prevent surgical bleeding. Despite numerous large multi-center randomized trials involving thousands of patients being conducted, TXA remains underutilized in indications where it has demonstrated efficacy and a lack of harmful effects. This narrative review aims to provide basic concepts about fibrinolysis and TXA's mode of action and is focused on the most recent and important trials evaluating this drug in different hemorrhagic situations. Methods We selected every low bias RCT, and we highlighted their strengths and limitations throughout this review. Principal findings While TXA appears to have a favorable benefit-risk ratio in most situations (trauma, obstetrics, at-risk for bleeding surgeries) evidence of benefit is lacking in certain medical settings (SAH, digestive bleeding). Conclusion Although in some situations the drug's effect on significant outcomes is modest, its favorable safety profile allows it to be recommended for trauma patients, in obstetrics, and in scheduled surgeries at risk of bleeding. However, it cannot be recommended in cases of spontaneous intracranial bleeding, subarachnoid hemorrhage (SAH), or gastrointestinal bleeding.
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Affiliation(s)
- Marwan Bouras
- CHU Brest, Anesthesiology and Intensive Care Unit, Brest, France
- INSERM UMR 1064 CR2TI, University of Nantes, Nantes, France
| | - Alexandre Bourdiol
- CHU Nantes, Anesthesiology and Intensive Care Unit, CIC Immunology and Infection, Nantes, France
| | - Paul Rooze
- CHU Nantes, Anesthesiology and Intensive Care Unit, CIC Immunology and Infection, Nantes, France
| | - Yannick Hourmant
- CHU Nantes, Anesthesiology and Intensive Care Unit, CIC Immunology and Infection, Nantes, France
| | - Anaïs Caillard
- CHU Brest, Anesthesiology and Intensive Care Unit, Brest, France
| | - Antoine Roquilly
- INSERM UMR 1064 CR2TI, University of Nantes, Nantes, France
- CHU Nantes, Anesthesiology and Intensive Care Unit, CIC Immunology and Infection, Nantes, France
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Olaleye AA, Adebayo JA, Eze JN, Ajah LO, Anikwe CC, Egede JO, Ebere CI. Efficacy of Tranexamic Acid in Reducing Myomectomy-Associated Blood Loss among Patients with Uterine Myomas at Federal Teaching Hospital Abakaliki: A Randomized Control Trial. Int J Reprod Med 2024; 2024:2794052. [PMID: 38283394 PMCID: PMC10810692 DOI: 10.1155/2024/2794052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Revised: 12/23/2023] [Accepted: 01/03/2024] [Indexed: 01/30/2024] Open
Abstract
Background Myomectomy can be associated with life-threatening conditions such as bleeding. Excessive bleeding usually necessitates blood transfusion. Interventions to reduce bleeding during myomectomy will help reduce the need for blood transfusion with its associated complications. Tranexamic acid has been used to reduce bleeding in other surgical procedures, and its usage during myomectomy merits evaluation. Objective To assess the efficacy of tranexamic acid in reducing myomectomy-associated blood loss. Materials and Methods This is a prospective double-blinded randomized trial conducted on women who had abdominal myomectomy. Patients were randomized into two groups. The study group received perioperative intravenous tranexamic acid (TXA) while the control group received a placebo. Intraoperative blood loss was calculated by measuring the volume in the suction apparatus and weighing the surgical swabs. In addition, blood collected postoperatively from the wound drains and drapes were measured. Haemoglobin concentrations were determined preoperatively and on second postoperative day for all cases. Any adverse effect was noted in both groups. The data was processed using Epi Info software (7.2.1, CDC, Atlanta, Georgia). The relationships between categorical data were analyzed using X2 and Student's t-test to determine relationships between continuous variables, with a P value of 0.05 considered statistically significant, and correlation coefficients were calculated using Pearson's formula, and probability of 0.05 was set for statistical significance. Results Symptomatic uterine myomas constituted 17.3% of all gynaecological admissions and 21.3% of gynaecological operations at Federal Teaching Hospital Abakaliki. The mean intraoperative blood loss among patients that had perioperative tranexamic acid infusion was 413.6 ± 165.6 ml, while that of patients with placebo infusion was 713.6 ± 236.3 ml. Perioperative tranexamic acid infusion therefore reduced mean intraoperative blood loss by 300 ml, and this was statistically significant (SMD = -0.212, 95% CI: -403.932 to -196.067, P < 0.0001). Perioperative tranexamic acid reduced mean total blood loss by a value of 532.3 ml, and this is statistically significant (SMD = 30.622, 95% CI: 393.308 to 670.624, P < 0.0001). Tranexamic acid also improved postoperative haemoglobin concentration by 1.8 g/dl compared with placebo, and this is statistically significant (SMD = -0.122, 95% CI: 1.182 to 2.473, P < 0.0001). Tranexamic acid infusion decreased hospital stay by about 2 days, and this difference was statistically significant (SMD = -3.929, 95% CI: -3.018 to -0.983, P = 0.0003). There was no adverse drug reaction in the course of the study. Conclusion The use of tranexamic acid during myomectomy reduced intraoperative and postoperative blood loss. It is also associated with decreased hospital stay. This trial is registered with NCT04560465.
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Affiliation(s)
- Ayodele Adegbite Olaleye
- Department of Obstetrics and Gynaecology, Alex Ekwueme Federal University Teaching Hospital, Abakaliki, Nigeria
| | - Joshua Adeniyi Adebayo
- Department of Obstetrics and Gynaecology, Alex Ekwueme Federal University Teaching Hospital, Abakaliki, Nigeria
| | - Justus Ndulue Eze
- Department of Obstetrics and Gynaecology, Alex Ekwueme Federal University Teaching Hospital, Abakaliki, Nigeria
| | - Leonard Ogbonna Ajah
- Department of Obstetrics and Gynaecology, University of Nigeria Teaching Hospital, Enugu, Nigeria
| | - Chidebe Christian Anikwe
- Department of Obstetrics and Gynaecology, Nnamdi Azikiwe University Teaching Hospital, Nnewi, Nigeria
| | - John O. Egede
- Department of Obstetrics and Gynaecology, Alex Ekwueme Federal University Teaching Hospital, Abakaliki, Nigeria
| | - Chidi Ikenna Ebere
- Department of Obstetrics and Gynaecology, Alex Ekwueme Federal University Teaching Hospital, Abakaliki, Nigeria
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Abdou AM, Eldesouky E, Farag E, Mohammed A, Abdelaziz DFM, Shaaban A, Ellaban M, Elhalim AEMA, Elsror AGA, Marai AAE, Abdel-Hakam F, Abd-ElGawad M, Elrashedy AA, Abdelmonem H, Kamel MA, Afiffi IK, Elsayed HGA, Abdelhamed SA, Bosilah AH, Marie H. Oxytocin versus a combination of tranexamic acid and ethamsylate in reducing intraoperative bleeding during abdominal myomectomy: a randomized clinical trial. BMC Womens Health 2023; 23:398. [PMID: 37516864 PMCID: PMC10387195 DOI: 10.1186/s12905-023-02549-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Accepted: 07/15/2023] [Indexed: 07/31/2023] Open
Abstract
OBJECTIVE Myomectomy is the preferred surgical approach to manage uterine fibroids. However, uterine fibroids are highly vascular tumors and, consequently, extremely susceptible to problems from myomectomy-related hemorrhage. Hence, we aim to compare oxytocin efficacy and safety profile versus tranexamic acid (TA) with ethamsylate for reducing bleeding during myomectomy. METHODS This randomized, double-blinded multicenter study was performed between 20th August 2020 and 20th October 2020 at El-Galaa Teaching Hospital, El Hussein University Hospital, Al-Azhar University Hospitals of Assiut, and Al-Azhar University Hospitals of Damietta. One hundred and eighty patients were enrolled and divided into three groups: group (1) received an injection of 30 IU of oxytocin in 500 ml of normal saline; group (2) received injections of 1 g of TA, 250 mg of Ethamsylate, and 110 ml of normal saline IV; and group (3) received an injection of 110 ml of normal saline IV just before surgical incision. RESULTS In 180 premenopausal women, oxytocin and TA with ethamsylate had no significant value in lowering intraoperative blood loss compared with the placebo for abdominal myomectomy (666.25 ± 183.03, 630.72 ± 145.83, and 646.67 ± 168.92, respectively (P = 0.506)). Non-significant trends were observed for a reduction in operation time (P = 0.760), intra/postoperative blood transfusion (P = 0.624), hospital stay (P = 0.986), postoperative fever (P = 0.659), and wound infection (P = 1). CONCLUSION Oxytocin and TA with ethamsylate had no significant value in lowering intraoperative blood loss compared with the placebo for abdominal myomectomy which opens a new question about the role of the use of the hemostatic drug during myomectomy especially in centers with limited resources and had higher rates. TRIAL REGISTRATION The study was registered on Pan African Clinical Trials Registry with the following number: PACTR202008739887429 and was approved on 24/08/2020.
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Affiliation(s)
- Ahmed Mahmoud Abdou
- Obstetrics and Gynecology, Faculty of Medicine, Zagazig University, Zagazig, Egypt
| | - Elsayed Eldesouky
- Department of Obstetrics and Gynecology, Faculty of Medicine, Alazhar University in Cairo, Cairo, Egypt
| | - Elsayed Farag
- Department of Obstetrics and Gynecology, Faculty of Medicine, Alazhar University in Cairo, Cairo, Egypt
| | - Attia Mohammed
- Department of Obstetrics and Gynecology, Faculty of Medicine, Alazhar University in Cairo, Cairo, Egypt
| | | | - A Shaaban
- Department of Obstetrics and Gynecology, Faculty of Medicine, Alazhar University in Cairo, Cairo, Egypt
| | - Mostafa Ellaban
- Department of Obstetrics and Gynecology, Faculty of Medicine, Alazhar University in Cairo, Cairo, Egypt
| | | | - Ahmed Gamal Abo Elsror
- International Islamic Institute for Studies and Population Research Alazhar University in Cairo, Cairo, Egypt
| | | | - Faiza Abdel-Hakam
- Department of Obstetrics and Gynecology, Alazhar University for Girls in Cairo, Cairo, Egypt
| | | | | | | | | | - Ibtesam K Afiffi
- Department of Medical Microbiology and Immunology, Faculty of Medicine, Tanta University, Tanta, Egypt
- Department of Basic &Clinical Oral Sciences &, Faculty of Dental Medicine, Umm Al-Qura University, Makkah, Saudi Arabia
| | | | | | - Almandouh H Bosilah
- Department of Obstetrics and Gynecology, Faculty of Medicine, Damiata University, Damiata, Egypt
| | - Heba Marie
- Department of Obstetrics and Gynecology, Faculty of Medicine, Cairo University, Cairo, Egypt
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Kietaibl S, Ahmed A, Afshari A, Albaladejo P, Aldecoa C, Barauskas G, De Robertis E, Faraoni D, Filipescu DC, Fries D, Godier A, Haas T, Jacob M, Lancé MD, Llau JV, Meier J, Molnar Z, Mora L, Rahe-Meyer N, Samama CM, Scarlatescu E, Schlimp C, Wikkelsø AJ, Zacharowski K. Management of severe peri-operative bleeding: Guidelines from the European Society of Anaesthesiology and Intensive Care: Second update 2022. Eur J Anaesthesiol 2023; 40:226-304. [PMID: 36855941 DOI: 10.1097/eja.0000000000001803] [Citation(s) in RCA: 72] [Impact Index Per Article: 72.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/02/2023]
Abstract
BACKGROUND Management of peri-operative bleeding is complex and involves multiple assessment tools and strategies to ensure optimal patient care with the goal of reducing morbidity and mortality. These updated guidelines from the European Society of Anaesthesiology and Intensive Care (ESAIC) aim to provide an evidence-based set of recommendations for healthcare professionals to help ensure improved clinical management. DESIGN A systematic literature search from 2015 to 2021 of several electronic databases was performed without language restrictions. Grading of Recommendations, Assessment, Development and Evaluation (GRADE) was used to assess the methodological quality of the included studies and to formulate recommendations. A Delphi methodology was used to prepare a clinical practice guideline. RESULTS These searches identified 137 999 articles. All articles were assessed, and the existing 2017 guidelines were revised to incorporate new evidence. Sixteen recommendations derived from the systematic literature search, and four clinical guidances retained from previous ESAIC guidelines were formulated. Using the Delphi process on 253 sentences of guidance, strong consensus (>90% agreement) was achieved in 97% and consensus (75 to 90% agreement) in 3%. DISCUSSION Peri-operative bleeding management encompasses the patient's journey from the pre-operative state through the postoperative period. Along this journey, many features of the patient's pre-operative coagulation status, underlying comorbidities, general health and the procedures that they are undergoing need to be taken into account. Due to the many important aspects in peri-operative nontrauma bleeding management, guidance as to how best approach and treat each individual patient are key. Understanding which therapeutic approaches are most valuable at each timepoint can only enhance patient care, ensuring the best outcomes by reducing blood loss and, therefore, overall morbidity and mortality. CONCLUSION All healthcare professionals involved in the management of patients at risk for surgical bleeding should be aware of the current therapeutic options and approaches that are available to them. These guidelines aim to provide specific guidance for bleeding management in a variety of clinical situations.
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Affiliation(s)
- Sibylle Kietaibl
- From the Department of Anaesthesiology & Intensive Care, Evangelical Hospital Vienna and Sigmund Freud Private University Vienna, Austria (SK), Department of Anaesthesia and Critical Care, University Hospitals of Leicester NHS Trust (AAh), Department of Cardiovascular Sciences, University of Leicester, UK (AAh), Department of Paediatric and Obstetric Anaesthesia, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark (AAf), Institute of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark (AAf), Department of Anaesthesiology & Critical Care, CNRS/TIMC-IMAG UMR 5525/Themas, Grenoble-Alpes University Hospital, Grenoble, France (PA), Department of Anaesthesiology & Intensive Care, Hospital Universitario Rio Hortega, Valladolid, Spain (CA), Department of Surgery, Lithuanian University of Health Sciences, Kaunas, Lithuania (GB), Division of Anaesthesia, Analgesia, and Intensive Care - Department of Medicine and Surgery, University of Perugia, Italy (EDR), Department of Anesthesiology, Perioperative and Pain Medicine, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas, USA (DFa), University of Medicine and Pharmacy Carol Davila, Department of Anaesthesiology & Intensive Care, Emergency Institute for Cardiovascular Disease, Bucharest, Romania (DCF), Department of Anaesthesia and Critical Care Medicine, Medical University Innsbruck, Innsbruck, Austria (DFr), Department of Anaesthesiology & Critical Care, APHP, Université Paris Cité, Paris, France (AG), Department of Anesthesiology, University of Florida, College of Medicine, Gainesville, Florida, USA (TH), Department of Anaesthesiology, Intensive Care and Pain Medicine, St.-Elisabeth-Hospital Straubing, Straubing, Germany (MJ), Department of Anaesthesiology, Medical College East Africa, The Aga Khan University, Nairobi, Kenya (MDL), Department of Anaesthesiology & Post-Surgical Intensive Care, University Hospital Doctor Peset, Valencia, Spain (JVL), Department of Anaesthesiology & Intensive Care, Johannes Kepler University, Linz, Austria (JM), Department of Anesthesiology & Intensive Care, Semmelweis University, Budapest, Hungary (ZM), Department of Anaesthesiology & Post-Surgical Intensive Care, University Trauma Hospital Vall d'Hebron, Barcelona, Spain (LM), Department of Anaesthesiology & Intensive Care, Franziskus Hospital, Bielefeld, Germany (NRM), Department of Anaesthesia, Intensive Care and Perioperative Medicine, GHU AP-HP. Centre - Université Paris Cité - Cochin Hospital, Paris, France (CMS), Department of Anaesthesiology and Intensive Care, Fundeni Clinical Institute, Bucharest and University of Medicine and Pharmacy Carol Davila, Bucharest, Romania (ES), Department of Anaesthesiology and Intensive Care Medicine, AUVA Trauma Centre Linz and Ludwig Boltzmann-Institute for Traumatology, The Research Centre in Co-operation with AUVA, Vienna, Austria (CS), Department of Anaesthesia and Intensive Care Medicine, Zealand University Hospital, Roskilde, Denmark (AW) and Department of Anaesthesiology, Intensive Care Medicine & Pain Therapy, University Hospital Frankfurt, Goethe University, Frankfurt am Main, Germany (KZ)
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Yuan P, Bai C, Yu F, Ge Z, Wang M, Tan H. Reducing blood loss during laparoscopic myomectomy using a tourniquet loop around the lower uterine segment. Fertil Steril 2023; 119:333-335. [PMID: 36564265 DOI: 10.1016/j.fertnstert.2022.10.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2022] [Revised: 10/13/2022] [Accepted: 10/14/2022] [Indexed: 12/24/2022]
Abstract
OBJECTIVE To present a simple and effective hemostatic technique using a tourniquet loop during laparoscopic myomectomy. DESIGN Pericervical tourniquet has been proven to be a safe and effective measure to reduce blood loss during open myomectomy. However, the use of a tourniquet in laparoscopic myomectomy has been rarely reported probably because the application is difficult and troublesome. In our technique, a prefabricated tourniquet loop, adapted from a Foley catheter, is applied around the lower segment of the uterus. It is easy to apply a tourniquet loop around the lower uterine segment during laparoscopic myomectomy. There is no need to make a window in the broad ligament to apply a pericervical tourniquet or triple tourniquets. Meanwhile, complete blockage of blood supply from the uterine artery and utero-ovarian anastomoses may ensure better hemostasis. SETTING A tertiary hospital. PATIENT(S) The patient was a 34-year-old woman with uterine leiomyoma and a desire for future fertility. She had been suffering from urinary frequency and chronic bladder pressure for the past 6 months. Magnetic resonance imaging confirmed 2 intramural masses measuring 96 mm × 91 mm and 25 mm × 13 mm at the anterior uterine wall. INTERVENTION(S) Institutional review board and ethics committee approval was obtained. Laparoscopic myomectomy was performed with the application of a tourniquet loop around the lower segment of the uterus (step-by-step video demonstration): homemade tourniquet loop formation using a 14-Fr latex Foley catheter; trocar placement with 2 umbilical ports (10 mm and 5 mm) and a 5-mm port at the lower-left quadrant of the abdomen; application of a tourniquet loop around the lower uterine segment; tumor enucleation and myometrial closure; removal of the tourniquet loop and a check for bleeding; contained specimen extraction via the merged umbilical incision; and inspection of the abdominal cavity and closure of the merged umbilical incision. MAIN OUTCOME MEASURE(S) Feasibility of using a tourniquet loop as an effective hemostatic technique in laparoscopic myomectomy. RESULT(S) The surgery lasted for approximately 90 minutes, and the tourniquet time was approximately half an hour. The estimated blood loss was only 20 mL. Her hemoglobin value on day 1 after the surgery was 131 g/L, the same as the preoperative level. Pathology confirmed the diagnosis of leiomyoma. The patient was discharged 2 days after the surgery with no complications. During follow-up, the patient reported that there was no discomfort and that her menses were normal. Her fallopian tubes were patent in the hysterosalpingogram. Her ovarian function, which was assessed by serum follicle-stimulating hormone concentration (5.34 mIU/mL) on day 3 of her menstrual cycle and antimüllerian hormone level (2.01ng/mL), was in the normal range. She was suggested to conceive 1 year after the procedure. CONCLUSION(S) Application of a tourniquet loop around the lower uterine segment is a simple and effective hemostatic technique during laparoscopic myomectomy. Randomized prospective studies are needed to determine the hemostatic effect of the laparoscopic use of a tourniquet loop and its impact on fertility and ovarian function.
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Affiliation(s)
- Peng Yuan
- Department of Gynecology, Northwest Women's and Children's Hospital (Shaanxi Provincial Maternity and Child Health Care Hospital), Xi'an, Shaanxi, People's Republic of China.
| | - Changmin Bai
- Department of Gynecology, Northwest Women's and Children's Hospital (Shaanxi Provincial Maternity and Child Health Care Hospital), Xi'an, Shaanxi, People's Republic of China
| | - Fan Yu
- Department of Gynecology, Northwest Women's and Children's Hospital (Shaanxi Provincial Maternity and Child Health Care Hospital), Xi'an, Shaanxi, People's Republic of China
| | - Zhonghu Ge
- Department of Gynecology, Northwest Women's and Children's Hospital (Shaanxi Provincial Maternity and Child Health Care Hospital), Xi'an, Shaanxi, People's Republic of China
| | - Mengyao Wang
- Department of Gynecology, Northwest Women's and Children's Hospital (Shaanxi Provincial Maternity and Child Health Care Hospital), Xi'an, Shaanxi, People's Republic of China
| | - Hongwei Tan
- Department of Gynecology, Northwest Women's and Children's Hospital (Shaanxi Provincial Maternity and Child Health Care Hospital), Xi'an, Shaanxi, People's Republic of China.
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Calpin GG, McAnena PF, Davey MG, Calpin P, Kerin MJ, McInerney N, Walsh SR, Lowery AJ. The role of tranexamic acid in reducing post-operative bleeding and seroma formation in breast surgery: A meta-analysis. Surgeon 2022. [PMID: 36572609 DOI: 10.1016/j.surge.2022.11.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
INTRODUCTION Tranexamic acid (TXA) reduces blood loss and blood transfusion requirements in surgery. Seroma and haematoma formation occur as complications of breast surgery. We aimed to perform a meta-analysis evaluating TXA in reducing post-operative haematoma and seroma formation for breast surgery. METHODS A systematic review was performed in accordance with PRISMA guidelines. Results were expressed as dichotomous variables pooled as odds ratios (OR) with corresponding 95% confidence intervals (CIs) using the Mantel-Haenszel method. RESULTS Seven studies including 1446 patients were included. There were 1830 breast surgery procedures performed with TXA administered in 797 cases (43.6%). There was a significant reduction in haematoma rates in the TXA group (TXA: 3.184% (22/691) vs Control: 6.787% (64/943), OR: 0.41, 95% CI: 0.20-0.86, P = 0.020). Based on surgical procedure, haematoma rates were similar for TXA and control groups in cancer surgery (P = 0.230). Haematoma rates reduced following TXA use in cosmetic procedures (TXA: 3.807% (15/394) vs. Control: 9.091% (34/374), OR: 0.41, 95% CI: 0.22-0.75, P = 0.004). Haematoma rates were also reduced in procedures where axillary lymph node dissection (ALND) was not performed; in the TXA group, 3.379% (22/651) developed a haematoma versus 6.623% (60/906) in the control group (OR: 0.45, 95% CI 0.27-0.77, P = 0.003). TXA administration did not impact seroma formation or infection rates. CONCLUSION Perioperative administration of TXA may impact the incidence of haematoma in breast surgery, particularly in cosmetic procedures and procedures without ALND. Well-designed randomised studies are required to determine its true efficacy. TXA has no effect on seroma formation or infection in breast surgery.
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Kathopoulis N, Prodromidou A, Zacharakis D, Chatzipapas I, Diakosavvas M, Kypriotis K, Grigoriadis T, Protopapas A. The Effect of Intravenous Tranexamic Acid on Myomectomy: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. J Pers Med 2022; 12:jpm12091492. [PMID: 36143277 PMCID: PMC9504364 DOI: 10.3390/jpm12091492] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2022] [Revised: 09/01/2022] [Accepted: 09/08/2022] [Indexed: 11/16/2022] Open
Abstract
Myomectomy is the preferred surgical treatment for symptomatic women with uterine myomas who wish to preserve their fertility. The procedure may be associated with significant intraoperative blood loss, which predisposes to increased transfusion rates and morbidity. The objective of our systematic review and meta-analysis is to investigate whether intravenous (IV) use of tranexamic acid (TXA) may reduce blood loss during myomectomy. Three electronic databases were screened until June 2022. The eligible studies were assessed for risk of bias. Four randomized controlled trials that reported outcomes from a total of 310 women were finally included in the meta-analysis—155 patients received intravenous TXA while the remaining 155 received placebo injection with normal saline or water for injection. Total estimated blood loss was significantly lower in patients who received TXA before myomectomy compared to control (230 patients MD −227.09 mL 95% CI −426.26, −27.91, p = 0.03). This difference in favor of TXA group remained when intraoperative and postoperative blood loss was separately analyzed. Postoperative hematocrit values and hemoglobin levels did not differ among the two groups (180 patients MD 0.67% 95% CI −0.26, 1.59, p = 0.16 and 250 patients MD 0.17 mg/dL 95% CI 0.07, 0.41, p = 0.17, respectively). The number of patients that received blood transfusion was also not different (310 patients OR 0.46 95% CI −0.14, 1.49, p = 0.19). Total operative time was significantly prolonged in control group compared to TXA (310 patients MD −16.39 min 95% CI −31.44, −1.34 p = 0.03). Our data show that the IV use of TXA may significantly reduce intraoperative blood loss in patients undergoing myomectomy and contribute to reduced operative time.
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Baradwan S, Hafidh B, Latifah HM, Gari A, Sabban H, Abduljabbar HH, Tawfiq A, Hakeem GF, Alkaff A, AlSghan R, Alshahrani MS, Badghish E, Abu-Zaid A. Prophylactic tranexamic acid during myomectomy: A systematic review and meta-analysis of randomized controlled trials. Eur J Obstet Gynecol Reprod Biol 2022; 276:82-91. [PMID: 35839714 DOI: 10.1016/j.ejogrb.2022.07.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2022] [Revised: 06/19/2022] [Accepted: 07/05/2022] [Indexed: 02/07/2023]
Abstract
OBJECTIVE To conduct a systematic review and meta-analysis of randomized controlled trials on the clinical efficacy and safety of prophylactic tranexamic acid (TXA) versus control (normal saline/no treatment) during myomectomy. METHODS Six databases were screened from inception until 21-February-2022. The eligible studies were assessed for risk of bias. The outcomes were summarized as mean difference (MD) and risk ratio (RR) with 95% confidence intervals (CI) in a random-effects model. RESULTS Seven studies, comprising eight arms and 571 patients (TXA = 304 patients, control = 267 patients) were analyzed. The included studies had an overall low risk of bias. The mean intraoperative blood loss (MD = -224.34 ml, 95% CI [-303.06, -145.61], p < 0.001), mean postoperative blood loss, and mean total blood loss were significantly reduced in favor of the prophylactic TXA group. Additionally, the mean postoperative hemoglobin (MD = 0.4 mg/dl, 95% CI [0.11, 0.68], p = 0.006) and mean postoperative hematocrit levels were significantly higher in favor of the prophylactic TXA group. While the mean hospital stay was significantly reduced in favor of the prophylactic TXA group (MD = -0.39 d, 95% [-0.74, -0.04], p = 0.03), there was no significant difference between both groups regarding the mean operation time and rate of blood transfusion. None of the participants in both groups developed any incidence of thromboembolic events. The rate of nausea was significantly higher in disfavor of the prophylactic TXA group (RR = 2.68, 95% CI [1.11, 6.43], p = 0.03). CONCLUSION Among patients undergoing myomectomy, prophylactic TXA was largely safe and linked to substantial reductions in perioperative blood loss and related morbidities.
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Affiliation(s)
- Saeed Baradwan
- Department of Obstetrics and Gynecology, King Faisal Specialist Hospital and Research Center, Jeddah, Saudi Arabia
| | - Bandr Hafidh
- Department of Obstetrics and Gynecology, King Faisal Specialist Hospital and Research Center, Jeddah, Saudi Arabia
| | - Hassan M Latifah
- Department of Obstetrics and Gynecology, King Faisal Specialist Hospital and Research Center, Jeddah, Saudi Arabia
| | - Abdulrahim Gari
- Department of Obstetrics and Gynecology, King Faisal Specialist Hospital and Research Center, Jeddah, Saudi Arabia; Department of Obstetrics and Gynecology, College of Medicine, Umm Al-Qura University, Makkah, Saudi Arabia
| | - Hussein Sabban
- Department of Obstetrics and Gynecology, King Faisal Specialist Hospital and Research Center, Jeddah, Saudi Arabia; Department of Obstetrics and Gynecology, Faculty of Medicine at Rabigh, King Abdulaziz University, Rabigh, Saudi Arabia
| | - Hanin Hassan Abduljabbar
- Department of Obstetrics and Gynecology, King Faisal Specialist Hospital and Research Center, Jeddah, Saudi Arabia
| | - Afaf Tawfiq
- Department of Obstetrics and Gynecology, King Faisal Specialist Hospital and Research Center, Jeddah, Saudi Arabia
| | - Ghaidaa Farouk Hakeem
- Department of Obstetrics and Gynecology, King Faisal Specialist Hospital and Research Center, Jeddah, Saudi Arabia
| | - Alya Alkaff
- Department of Obstetrics and Gynecology, King Faisal Specialist Hospital and Research Center, Jeddah, Saudi Arabia
| | - Rayan AlSghan
- Department of Obstetrics and Gynecology, Maternity and Children Hospital, Alkharj, Saudi Arabia
| | - Majed Saeed Alshahrani
- Department of Obstetrics and Gynecology, Faculty of Medicine, Najran University, Najran, Saudi Arabia
| | - Ehab Badghish
- Department of Obstetrics and Gynecology, Maternity and Children Hospital, Makkah, Saudi Arabia
| | - Ahmed Abu-Zaid
- Department of Obstetrics and Gynecology, College of Medicine, Alfaisal University, Riyadh, Saudi Arabia; Department Pharmacology, College of Graduate Health Sciences, University of Tennessee Health Science Center, Memphis, TN, USA.
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9
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Lee SR, Lee ES, Eum HR, Lee YJ, Lee SW, Park JY, Suh DS, Kim DY, Kim SH, Kim YM, Kim YT. New Surgical Technique for Robotic Myomectomy: Continuous Locking Suture on Myoma (LSOM) Technique. J Clin Med 2021; 10:654. [PMID: 33567699 PMCID: PMC7914728 DOI: 10.3390/jcm10040654] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2020] [Revised: 01/30/2021] [Accepted: 02/03/2021] [Indexed: 12/26/2022] Open
Abstract
Robot-assisted laparoscopic myomectomy (RALM) has broadened the indications even in complex myomas. However, the high cost of RALM remains the main disadvantage. Therefore, a surgical technique that can reduce the cost of RALM and still has the advantages of robotic surgery is required. We propose a "locking suture on myoma (LSOM)" technique and compared the operative and perioperative outcomes of patients who underwent RALM with or without the LSOM technique. We included 337 patients who underwent RALM with (n = 160) or without (n = 177) the LSOM technique between March 2019 and August 2020. The LSOM group had low parity and gravidity, with a low rate of Cesarean sections. Myoma type was not different between the groups; however, patients in the LSOM group had larger, heavier, and higher number of myomas, although fewer patients had multiple myomas and were discharged earlier. Total operating time, estimated blood loss, pre- and postoperative hemoglobin levels, transfusion rate, and postoperative fever were not different between the two groups. In conclusion, the LSOM technique may be a viable surgical option for myomas, as it can reduce the cost of RALM by obviating the need for robotic Tenaculum forceps.
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Affiliation(s)
- Sa Ra Lee
- Department of Obstetrics and Gynecology, University of Ulsan College of Medicine, Seoul Asan Medical Center, 88, Olympic-ro 43-gil, Songpa-gu, Seoul 05505, Korea; (H.R.E.); (Y.-J.L.); (S.-W.L.); (J.Y.P.); (D.-S.S.); (D.-Y.K.); (S.H.K.); (Y.-M.K.); (Y.-T.K.)
| | - Eun Sil Lee
- Department of Obstetrics and Gynecology, Soonchunhyang University Seoul Hospital, Soonchunhyang University College of Medicine, Seoul 04401, Korea;
| | - Hye Rim Eum
- Department of Obstetrics and Gynecology, University of Ulsan College of Medicine, Seoul Asan Medical Center, 88, Olympic-ro 43-gil, Songpa-gu, Seoul 05505, Korea; (H.R.E.); (Y.-J.L.); (S.-W.L.); (J.Y.P.); (D.-S.S.); (D.-Y.K.); (S.H.K.); (Y.-M.K.); (Y.-T.K.)
| | - Young-Jae Lee
- Department of Obstetrics and Gynecology, University of Ulsan College of Medicine, Seoul Asan Medical Center, 88, Olympic-ro 43-gil, Songpa-gu, Seoul 05505, Korea; (H.R.E.); (Y.-J.L.); (S.-W.L.); (J.Y.P.); (D.-S.S.); (D.-Y.K.); (S.H.K.); (Y.-M.K.); (Y.-T.K.)
| | - Shin-Wha Lee
- Department of Obstetrics and Gynecology, University of Ulsan College of Medicine, Seoul Asan Medical Center, 88, Olympic-ro 43-gil, Songpa-gu, Seoul 05505, Korea; (H.R.E.); (Y.-J.L.); (S.-W.L.); (J.Y.P.); (D.-S.S.); (D.-Y.K.); (S.H.K.); (Y.-M.K.); (Y.-T.K.)
| | - Jeong Yeol Park
- Department of Obstetrics and Gynecology, University of Ulsan College of Medicine, Seoul Asan Medical Center, 88, Olympic-ro 43-gil, Songpa-gu, Seoul 05505, Korea; (H.R.E.); (Y.-J.L.); (S.-W.L.); (J.Y.P.); (D.-S.S.); (D.-Y.K.); (S.H.K.); (Y.-M.K.); (Y.-T.K.)
| | - Dae-Shik Suh
- Department of Obstetrics and Gynecology, University of Ulsan College of Medicine, Seoul Asan Medical Center, 88, Olympic-ro 43-gil, Songpa-gu, Seoul 05505, Korea; (H.R.E.); (Y.-J.L.); (S.-W.L.); (J.Y.P.); (D.-S.S.); (D.-Y.K.); (S.H.K.); (Y.-M.K.); (Y.-T.K.)
| | - Dae-Yeon Kim
- Department of Obstetrics and Gynecology, University of Ulsan College of Medicine, Seoul Asan Medical Center, 88, Olympic-ro 43-gil, Songpa-gu, Seoul 05505, Korea; (H.R.E.); (Y.-J.L.); (S.-W.L.); (J.Y.P.); (D.-S.S.); (D.-Y.K.); (S.H.K.); (Y.-M.K.); (Y.-T.K.)
| | - Sung Hoon Kim
- Department of Obstetrics and Gynecology, University of Ulsan College of Medicine, Seoul Asan Medical Center, 88, Olympic-ro 43-gil, Songpa-gu, Seoul 05505, Korea; (H.R.E.); (Y.-J.L.); (S.-W.L.); (J.Y.P.); (D.-S.S.); (D.-Y.K.); (S.H.K.); (Y.-M.K.); (Y.-T.K.)
| | - Yong-Man Kim
- Department of Obstetrics and Gynecology, University of Ulsan College of Medicine, Seoul Asan Medical Center, 88, Olympic-ro 43-gil, Songpa-gu, Seoul 05505, Korea; (H.R.E.); (Y.-J.L.); (S.-W.L.); (J.Y.P.); (D.-S.S.); (D.-Y.K.); (S.H.K.); (Y.-M.K.); (Y.-T.K.)
| | - Young-Tak Kim
- Department of Obstetrics and Gynecology, University of Ulsan College of Medicine, Seoul Asan Medical Center, 88, Olympic-ro 43-gil, Songpa-gu, Seoul 05505, Korea; (H.R.E.); (Y.-J.L.); (S.-W.L.); (J.Y.P.); (D.-S.S.); (D.-Y.K.); (S.H.K.); (Y.-M.K.); (Y.-T.K.)
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10
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In Vivo Assessment of Thermosensitive Liposomes for the Treatment of Port Wine Stains by Antifibrinolytic Site-Specific Pharmaco-Laser Therapy. Pharmaceutics 2020; 12:pharmaceutics12060591. [PMID: 32630457 PMCID: PMC7356038 DOI: 10.3390/pharmaceutics12060591] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2020] [Revised: 06/13/2020] [Accepted: 06/22/2020] [Indexed: 01/10/2023] Open
Abstract
Antifibrinolytic site-specific pharmaco-laser therapy (SSPLT) is an experimental treatment modality for refractory port wine stains (PWS). Conceptually, antifibrinolytic drugs encapsulated in thermosensitive liposomes are delivered to thrombi that form in semi-photocoagulated PWS blood vessels after conventional laser treatment. Local release of antifibrinolytics is induced by mild hyperthermia, resulting in hyperthrombosis and complete occlusion of the target blood vessel (clinical endpoint). In this study, 20 thermosensitive liposomal formulations containing tranexamic acid (TA) were assayed for physicochemical properties, TA:lipid ratio, encapsulation efficiency, and endovesicular TA concentration. Two candidate formulations (DPPC:DSPE-PEG, DPPC:MPPC:DSPE-PEG) were selected based on optimal properties and analyzed for heat-induced TA release at body temperature (T), phase transition temperature (Tm), and at T > Tm. The effect of plasma on liposomal stability at 37 °C was determined, and the association of liposomes with platelets was examined by flow cytometry. The accumulation of PEGylated phosphocholine liposomes in laser-induced thrombi was investigated in a hamster dorsal skinfold model and intravital fluorescence microscopy. Both formulations did not release TA at 37 °C. Near-complete TA release was achieved at Tm within 2.0–2.5 min of heating, which was accelerated at T > Tm. Plasma exerted a stabilizing effect on both formulations. Liposomes showed mild association with platelets. Despite positive in vitro results, fluorescently labeled liposomes did not sufficiently accumulate in laser-induced thrombi in hamsters to warrant their use in antifibrinolytic SSPLT, which can be solved by coupling thrombus-targeting ligands to the liposomes.
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11
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Abstract
Objective: To review the mechanism of action, pharmacology, dosing, and complications of tranexamic acid (TXA) and consolidate current evidence for TXA in gynecologic surgery.Methods: A literature search of PubMed, Ovid (MEDLINE), Google Scholar, and Elsevier was performed, in addition to a targeted search of cited references involving TXA and gynecologic surgery. Preference was given to systematic reviews and randomized control trials (RCTs).Results: TXA reversibly binds to plasminogen, preventing clot degradation. RCTs on hysterectomy, myomectomy, cervical conisation, hysteroscopy, and surgery for cervical and ovarian cancer were identified, as were case reports on TXA use for ectopic pregnancy. During hysterectomy, TXA reduces blood loss (two RCTs, n = 432, mean difference -66.0 mL and 180 mL), blood transfusion (1 RCT, n = 100, 12% vs. 42%, p < .00001). For myomectomy, a systematic review and meta-analysis showed a statistically significant decrease in blood loss with TXA (two RCTs, mean difference -213.1 mL, 95% CI: -242.4 mL to -183.7 mL). Following cervical conisation, TXA decreased the risk of delayed hemorrhage (four RCTs, RR 0.23, 95% CI: 0.11-0.50). A single RCT for cervical and ovarian cancer surgery demonstrated a decrease mean blood loss of 120 mL-135 mL and 210 mL, respectively, and fewer blood transfusions for the latter (OR 0.44, upper 95% CI: 0.97, p = .02). Less robust data suggest a possible benefit from TXA during hysteroscopy and surgery for ectopic pregnancies. Most commonly, 1 g of intravenous TXA is given intraoperatively.Conclusion: TXA is a safe adjunct that can be considered in a variety of gynecologic surgeries to decrease blood loss and risk of blood transfusion.
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Affiliation(s)
- Andrew Zakhari
- Department of Obstetrics and Gynecology, Mount Sinai Hospital, University of Toronto, Toronto, Canada
| | - Ari Paul Sanders
- Department of Obstetrics and Gynecology, Mount Sinai Hospital, University of Toronto, Toronto, Canada
- Department of Obstetrics and Gynecology, Peter Lougheed Centre, University of Calgary, Calgary, Canada
| | - Meir Jonathon Solnik
- Department of Obstetrics and Gynecology, Mount Sinai Hospital, University of Toronto, Toronto, Canada
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12
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Samy A, Raslan AN, Talaat B, El Lithy A, El Sharkawy M, Sharaf MF, Hussein AH, Amin AH, Ibrahim AM, Elsherbiny WS, Soliman HH, Metwally AA. Perioperative nonhormonal pharmacological interventions for bleeding reduction during open and minimally invasive myomectomy: a systematic review and network meta-analysis. Fertil Steril 2020; 113:224-233.e6. [DOI: 10.1016/j.fertnstert.2019.09.016] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2019] [Revised: 09/02/2019] [Accepted: 09/13/2019] [Indexed: 01/21/2023]
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13
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Abdul IF, Amadu MB, Adesina KT, Olarinoye AO, Omokanye LO. Adjunctive use of tranexamic acid to tourniquet in reducing haemorrhage during abdominal myomectomy - A randomized controlled trial. Eur J Obstet Gynecol Reprod Biol 2019; 242:150-158. [PMID: 31600715 DOI: 10.1016/j.ejogrb.2019.09.010] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2019] [Revised: 08/12/2019] [Accepted: 09/18/2019] [Indexed: 11/15/2022]
Abstract
BACKGROUND Uterine fibroids are the commonest tumour of the female genital tract; about one third are symptomatic and require management. The treatment of uterine fibroids may be medical, surgical, conservative or expectant. Myomectomy is the common surgical treatment option for women failing medical management and desiring to preserve fertility and/or their uterus. The tourniquet is shown to be effective in reducing blood loss during myomectomy and tranexamic to a less extent. However, the adjunctive use of tranexamic acid with tourniquet to further reduce blood loss has not been studied. AIM The aim of the study was to determine the efficacy of perioperative intravenous tranexamic acid in further reducing blood loss at abdominal myomectomy when used as an adjunct to tourniquet. METHODS The study was a randomized double-blind controlled study involving women who underwent abdominal myomectomy. Participants were randomized to either tourniquet plus intravenous tranexamic acid or tourniquet plus placebo groups using simple random sampling. The primary outcomes were the intra-operative blood loss, post-operative haematocrit values and need for intra-operative blood transfusion. The data was analyzed using the SPSS software version 23.0 and p value < 0.05 was significant. RESULTS The mean intra-operative blood loss (998.72 ± 607.21 ml vs 907.25 ± 529.85 ml, p = 0.475), intra-operative blood transfusion rate (45% vs. 30%; p = 0.166) and mean unit of blood transfused (1.13 ± 1.64 vs. 0.75 ± 1.28; p = 0.256) were higher for tourniquet plus placebo group compared to tourniquet plus tranexamic acid group. The estimated blood loss per 100 g of fibroid removed was reduced significantly in the tranexamic acid plus tourniquet group (139.80 ± 2.28 ml vs 104.09 ± 1.97 ml; p = 0.001). STRENGTH AND LIMITATIONS The strength of the study include randomization and blinding. The limitations included non-uniformity of sizes and locations of fibroids, as well as the different surgeons with possibly different skills, techniques and experiences, though they were statistically not significant. CONCLUSION The adjunctive use of tranexamic acid to tourniquet significantly further reduces intraoperative blood loss during abdominal myomectomy when compared to tourniquet alone. RECOMMENDATIONS Adjunctive use of tranexamic acid is recommended for further reducing intra-operative blood loss during abdominal myomectomy.
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Affiliation(s)
- Ishaq F Abdul
- Department of Obstetrics and Gynaecology, University of Ilorin Teaching Hospital, Ilorin, Kwara State, Nigeria.
| | - Motunrayo B Amadu
- Department of Obstetrics and Gynaecology, University of Ilorin Teaching Hospital, Ilorin, Kwara State, Nigeria
| | - Kike T Adesina
- Department of Obstetrics and Gynaecology, University of Ilorin Teaching Hospital, Ilorin, Kwara State, Nigeria
| | - Adebunmi O Olarinoye
- Department of Obstetrics and Gynaecology, University of Ilorin Teaching Hospital, Ilorin, Kwara State, Nigeria
| | - Lukman O Omokanye
- Department of Obstetrics and Gynaecology, University of Ilorin Teaching Hospital, Ilorin, Kwara State, Nigeria
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14
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Marín-Buck A, Karaman E, Amer-Cuenca JJ, Lisón JF, Török P, Karaaslan O, Valenti G, Zito G, Biondi A, Chiofalo B. Minimally Invasive Myomectomy: An Overview on the Surgical Approaches and a Comparison with Mini-Laparotomy. J INVEST SURG 2019; 34:443-450. [PMID: 31322011 DOI: 10.1080/08941939.2019.1642422] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Uterine fibroids (UFs) are the most common benign solid tumors of the female genital tract manageable by surgical of pharmacological approach. When the medical management is ineffective or surgery is primarily requested, several surgical approaches can be used. Among these, minimally invasive surgery might be preferred. Myomectomy is the standard surgical treatment when fertility sparing is claimed. It can be performed via laparoscopy, robotic surgery and hysteroscopy and the choice depend on UFs features and surgeon's skill. Alongside these minimally invasive options, mini-laparotomy has been proposed as a less invasive surgical approach comparable to the well-established minimally invasive options. The aim of this review is to describe the most recent advances in minimally invasive techniques to perform myomectomy, comparing them with mini-laparotomy approach.
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Affiliation(s)
- Alejandro Marín-Buck
- Department of Surgery, Universidad Cardenal Herrera-CEU, CEU Universities, Valencia, Spain.,Department of Gynecology, Hospital Provincial de Castellón, Castellón, Spain
| | - Erbil Karaman
- Department of Obstetrics and Gynecology, Yuzuncu Yil University Medical Faculty, Van, Turkey
| | - Juan J Amer-Cuenca
- Department of Physiotherapy, Universidad Cardenal Herrera-CEU, CEU Universities, Valencia, Spain
| | - Juan F Lisón
- Department of Medicine, Universidad Cardenal Herrera-CEU, CEU Universities, Valencia, Spain.,CIBER of Physiopathology of Obesity and Nutrition CIBERobn, CB06/03 Carlos III Health Institute, Madrid, Spain
| | - Péter Török
- Faculty of Medicine, Institute of Obstetrics and Gynaecology, University of Debrecen, Debrecen, Hungary
| | - Onur Karaaslan
- Department of Obstetrics and Gynecology, Yuzuncu Yil University Medical Faculty, Van, Turkey
| | - Gaetano Valenti
- Department of General Surgery and Medical Surgical Specialties, University of Catania, Catania, Italy
| | - Gabriella Zito
- Department of Obstetrics and Gynecology, Institute for Maternal and Child Health-IRCCS "Burlo Garofolo", Trieste, Italy
| | - Antonio Biondi
- Department of General Surgery and Medical Surgical Specialties, University of Catania, Catania, Italy
| | - Benito Chiofalo
- Gynecologic Oncology Unit, Department of Experimental Clinical Oncology, "Regina Elena" National Cancer Institute, Rome, Italy
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