Fertility and pregnancy outcomes after uterine artery occlusion with or without myomectomy

Minimizing blood loss in laparoscopic myomectomy with temporary occlusion of the hypogastric artery

Introduction

Uterine leiomyomas are common benign pelvic tumors. Currently, laparoscopic myomectomy (LM) is the preferred treatment option for women in the fertile age group with symptomatic myomas. The authors hypothesize that combining LM with a bilateral temporary occlusion of the hypogastric artery (TOHA) using vascular clips minimizes uterine blood flow during surgery and can significantly reduce surgery-associated blood loss.

Materials and methods

This single-center, prospective randomized study was conducted at the Department of Obstetrics and Gynecology, Municipal Emergency Clinical Hospital Timisoara, Romania. Patients aged between 18 and 49 who preferred laparoscopic myomectomy and wished to preserve fertility were included, provided they had intramural uterine leiomyomas larger than 4 cm in diameter that deformed the uterine cavity. The study analyzed data from 60 laparoscopic myomectomies performed by a single surgeon between January 2018 and December 2020. Patients were randomly assigned to either: "LM + TOHA" group (29 patients), and "LM" group (31 patients). The study's main objective was to evaluate the impact of TOHA on perioperative blood loss, expressed as mean differences in Hb (delta Hb).

Results

Delta Hb was statistically lower in the "LM + TOHA" group compared to "LM" group, with mean ± standard (min-max): 1.68 ± 0.67 (0.39-3.99) vs. 2.63 ± 1.06 (0.83-4.92) g/dL, respectively (p < 0.001). There was a statistically significant higher need for postoperative iron perfusion in the "LM" group, specifically 0 vs. 12 patients (p < 0.001), and lower postoperative anemia in "LM + TOHA" group (p < 0.001). Necessary artery clipping time was 10.62 ± 2.47 (7-15) minutes, with no significant impact on overall operative time: 110.2 ± 13.65 vs. 106.3 ± 16.48 (p = 0.21). There was no difference in the length of hospitalization or 12-month post-intervention fertility.

Discussion

Performing bilateral TOHA prior to laparoscopic myomectomy has proven to be a valuable technique in reducing surgery-associated blood loss, while minimizing complications during surgery, with no significant increase in the overall operative time.

Clinical trial registration

ISRCTN registry, (www.isrctn.com), identifier ISRCTN66897343.

The "Trick" Knot-A Modified Technique of the Removable "Shoelace" Knot for Temporary Ligation of the Uterine Artery at Its Origin

STUDY OBJECTIVE

To demonstrate the "trick" knot, a technique of temporary ligation of the uterine artery at origin, a modification of the previously published "shoelace" knot.

DESIGN

A video demonstration.

SETTING

A private hospital.

INTERVENTION

Bilateral uterine arteries at origin are exposed after dissection of the peritoneum over the triangle formed by the round ligament, the infundibulopelvic ligament, and the pelvic sidewall [Video 1]. A 60-cm long free polyglactin absorbable suture with preformed knots at each end is introduced around the skeletonized uterine artery. Using a single throw, the "trick" knot is made by pulling out a loop of thread. The end is cut short, and the same suture is used to similarly ligate the other uterine artery. Each knot thus formed has a free end and a knotted end. Laparoscopic myomectomy is performed. On completion of the procedure, the knot is released by pulling the free end, restoring the blood supply to the uterus.

CONCLUSION

Bilateral uterine artery ligation, although an effective method to curb bleeding during a laparoscopic myomectomy, when performed permanently, may lead to undesirable outcomes in women who wish to preserve fertility [1-3]. Methods for temporary ligation of the uterine artery at origin, such the removable vascular clips, are thus regarded justifiable [4]. In contrast to the removable "shoelace" knot, which uses a loop to make a throw, the technique of performing the "trick" knot mimics the steps of forming a regular intracorporeal knot [5]. This makes the latter technically easier and hence faster to perform, while still being as economic and reproducible as the former.

Evolution of laparoscopic myomectomy and description of two hemostatic techniques in a large teaching gynecological center

OBJECTIVE

To provide a description of laparoscopic myomectomy and the two hemostatic techniques performed over the last 11 years in a single reference center for gynecology and obstetrics and to evaluate the factors associated with favorable surgical outcomes.

STUDY DESIGN

We retrospectively analyzed 625 who underwent laparoscopic myomectomy from January 2009 to December 2019.

RESULTS

Of 625 patients, 437 (69.8%) were symptomatic. The most common symptoms were heavy uterine bleeding (33.2%). 188 patients (30.1%) were asymptomatic but were operated in 77 cases (12.3%) for rapid fibroid growth, 32 (5.1%) for uterine cavity distortion and, in 45 cases (8.6%), the myomectomy was indicated during a surgery for other medical reason due to its accessibility. In 173 cases (27.9%) intramyometrial adrenaline was injected and in 246 cases (39.7%) a temporary blockage of the uterus blood supply was performed. Only 35 (5.6%) patients presented complications, of which, 14 (40%) were hemorrhagic. These hemorrhagic complications were more frequent when intramyometrial adrenaline was used (5,8%) than after the temporary clipping of the uterine arteries and infundibulopelvic ligaments (0,8%; p < 0,001). In the multivariate logistic regression model, the only factor statistically associated with favorable surgical outcome was the use of temporary clipping of the uterine arteries at their origin and infundibulopelvic ligaments as hemostatic technique during the surgery.

CONCLUSION

Laparoscopic myomectomy was generally safe with a high level of favorable outcomes. The temporary clipping of uterine arteries and infundibulopelvic ligaments presented fewer intraoperative bleedings compared with injecting intramyometrial adrenaline.

Temporary Ligation of the Uterine Artery at Its Origin Using a Removable "Shoelace" Knot

STUDY OBJECTIVE

To demonstrate a technique of temporary ligation of the uterine artery at its origin.

DESIGN

A step-by-step demonstration of the surgery in an instructional video.

SETTING

A private hospital in Mumbai, India.

INTERVENTION

The peritoneum over the pelvic side wall was dissected bilaterally to expose the uterine arteries at their origins. Using a polyglactin absorbable suture, a double thread loop was used to create a removable "shoelace" knot (Video 1). Both uterine arteries were ligated in this manner. The myomectomy was completed uneventfully, and the myoma bed was sutured in 2 layers using polyglactin sutures. Once suturing was completed, the shoelace knot was untied by simply pulling one end of the thread to restore blood supply to the uterus. Intraoperative blood loss was 30 mL, and the total operation time was 120 minutes.

CONCLUSION

Laparoscopic ligation of the uterine arteries at their origin is known to reduce intraoperative blood loss [1,2]. However, in patients desiring future fertility, the effect of permanent ligation of these vessels bilaterally remains under study [3-5]. The removable "shoelace" knot is a low-cost, readily available alternative to metallic titanium clips that requires no special surgical expertise to implement.

True Aneurysm of the Uterine Artery in a Young Nulliparous Female: An Extremely Rare Vascular Entity

We present the first case of a large true uterine artery aneurysm, with a 5-cm diameter, in a 35-year-old nulliparous woman who presented with lower abdominal pain and dyspareunia. She underwent successful ligation and excision of the aneurysm using the Pfannenstiel approach. The diagnostic modalities and treatment option for such a case is discussed herein.

Laparoscopic Myomectomy with Temporary Bilateral Uterine Artery Occlusion Compared with Traditional Surgery for Uterine Myomas: Blood Loss and Recurrence

STUDY OBJECTIVE

To compare the surgical technique of temporary bilateral uterine artery blockage with titanium clips in laparoscopic myomectomy with traditional surgery for uterine myomas to determine efficacy, ability to control bleeding, and recurrence.

DESIGN

Randomized, controlled, prospective study (Canadian Task Force classification I).

SETTING

Obstetrics and gynecology department in Jinhua Municipal Central Hospital.

PATIENTS

Women with symptomatic uterine myoma.

INTERVENTIONS

Sixty-four patients with symptomatic uterine myomas were randomly divided into trial (group A, n = 33) and control groups (group B, n = 31). Temporary bilateral uterine artery occlusion and myomectomy were used in group A and laparoscopic myomectomy only in group B. Operative time, perioperative bleeding, follow-up relief of menorrhagia, and recurrence of myomas were evaluated.

MEASUREMENTS AND MAIN RESULTS

All patients in this study underwent successful laparoscopic operation without intraoperative complications. Operative time between groups was not significantly different (p = .255 in single-myoma group and p = .811 in multiple-myoma group), blood loss in group A was notably lower than the conventional surgery group (p < .001). At final follow-up (2 years), recurrence rate and menorrhagia symptom relief were not statistically significant (p = .828 and p > .999, respectively). The fertility index of antimüllerian hormone showed no statistical difference between groups preoperatively or at 2 days, 3 months, 6 months, and 1 year postoperatively (p = .086, p = .247, p = .670, p = .753, and p = .857, respectively).

CONCLUSION

Temporary bilateral uterine artery occlusion during laparoscopic myomectomy does not increase mean operative time, offers a possible option to reduce blood loss effectively, improves menorrhagia, and does not impact recurrence rate compared with conventional surgery.

Uterine artery embolisation for uterine fibroids: Our experience at a tertiary care service hospital

BACKGROUND

Uterine artery embolisation (UAE) has evolved as a minimally invasive and effective alternative, treatment modality for women with symptomatic fibroids. We discuss our initial experience of UAE in the management of symptomatic fibroids.

METHODS

Twenty five symptomatic patients of uterine fibroids were treated with UAE by selectively cannulating and injecting poly vinyl alcohol particles into the uterine arteries. Post treatment follow up was done at 2 and 6 months respectively.

RESULTS

Pre-treatment, the sizes of fibroids were between 3.9 and 10.9 cm (mean 7.4) on ultrasonography. Of the total 25 patients, 49 uterine arteries were embolised with a technical success rate of 98%. Menorrhagia persisted in 7 patients, dysmenorrhea in 4 patients and pressure symptoms in 2 patients respectively in follow up study of six months which corresponds to a reduction in symptoms by 68% for menorrhagia, 71% for dysmenorhoea and 75% for those with pressure symptoms respectively. At 2 months follow-up post embolisation, the mean diameter of the fibroid was 4.03 cm (range 2-5.2 cm) and at 6 months 3.2 cm (range 1.3-4.1 cm), corresponding to size reduction of 45.5% and 57%, respectively. Follow up with ultrasonography at 2 and 6 months period showed successful fibroid reduction in 24 patients with corresponding reduction in the symptomatology. One patient remained symptomatic with increase in fibroid size and had to undergo hysterectomy.

CONCLUSION

Uterine artery embolisation can be considered as an alternative to hysterectomy in appropriately selected symptomatic patients of uterine fibroids.