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Jindal S, Jung J, Lee K, Chern B. High-intensity focused ultrasound for the treatment of fibroids: A single-center experience in Singapore. Gynecol Minim Invasive Ther 2023; 12:15-25. [PMID: 37025438 PMCID: PMC10071864 DOI: 10.4103/gmit.gmit_102_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2022] [Revised: 10/05/2022] [Accepted: 11/15/2022] [Indexed: 02/11/2023] Open
Abstract
Objectives Uterine fibroids and adenomyosis are common gynecological conditions that often require surgical treatment. Minimally invasive interventions such as ultrasound-guided high-intensity focused ultrasound (USgHIFU) are gaining popularity as they avoid surgical morbidity and conserve the uterus. We present a single-center experience on the use of USgHIFU for the treatment of fibroids and adenomyosis. Materials and Methods This was a retrospective study of 167 patients who underwent USgHIFU for uterine fibroids and adenomyosis between July 2018 and December 2020. Relevant demographic data and pre- and post-intervention fibroid volume, symptom severity scores (SSS), and health-related quality of life (QOL) scores were collected and compared. The paired t-test or Wilcoxon signed-rank test was used to compare the difference before and after treatment. P < 0.001 was considered statistically significant. Results One hundred and sixty-seven patients with fibroids or adenomyosis were included in this study. The mean age of the cohort was 42-year-old. USgHIFU treatment led to a reduction in mean fibroid volume, improvement in SSS, and health-related QOL scores. The average reduction in mean fibroid volume was 68% and 75% at 6 and 12 months, respectively. There was a significant reduction in SSS (46.9 [pre] vs. 15.6 [post], P < 0.001) and improvement in health-related QOL scores at 6 months (58 [pre] vs. 86 [post], P < 0.001). The re-intervention rate following USgHIFU was 7.7% and successful pregnancy post USgHIFU was reported in 6 patients. Conclusion USgHIFU is safe and effective. In women who desire fertility or are not suitable for surgery, it is a good alternative option. It should be included in the armamentarium for the treatment of uterine fibroids and adenomyosis.
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Intramural myomas more than 3-4 centimeters should be surgically removed before in vitro fertilization. Fertil Steril 2021; 116:945-958. [PMID: 34579828 DOI: 10.1016/j.fertnstert.2021.08.016] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2021] [Accepted: 08/06/2021] [Indexed: 12/29/2022]
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Herrmann A, Torres-de la Roche LA, Krentel H, Cezar C, de Wilde MS, Devassy R, De Wilde RL. Adhesions after Laparoscopic Myomectomy: Incidence, Risk Factors, Complications, and Prevention. Gynecol Minim Invasive Ther 2020; 9:190-197. [PMID: 33312861 PMCID: PMC7713662 DOI: 10.4103/gmit.gmit_87_20] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Revised: 07/10/2020] [Accepted: 07/10/2020] [Indexed: 12/23/2022] Open
Abstract
Uterine fibroids or uterine myomas are one of the most common benign diseases of the uterus. Symptoms associated with myomas can make surgical removal of myomas necessary. Besides the traditional abdominal route, laparoscopic myomectomy (LM) has gained more acceptances over the last few decades, and it is anticipated that laparoscopy is associated with lower adhesion development. Therefore, we conducted this review to analyze the evidence on adhesions after LM. The PubMed database was searched using the search terms “myomectomy” alone and in combination with “adhesions,” “infertility OR fertility outcome,” and “laparoscopy” among articles published in English and German. Although the well-known advantages of laparoscopy, for example, less pain, less blood loss, or shorter hospital stay, myomectomy belongs to high-risk operations concerning adhesion formation, with at least every fifth patient developing postsurgical adhesions. In laparoscopic surgery, surgeons´ experience as well tissue trauma, due to desiccation and hypoxia, are the underlying mechanisms leading to adhesion formation. Incisions of the posterior uterus may be associated with a higher rate of adhesions compared to anterior or fundal incisions. Adhesions can be associated with severe complications such as small bowel obstruction, chronic pelvic pain, complications in further operations, or impaired fertility. Tissue trauma and the experience of the surgeon in laparoscopic surgery are most of the influencing factors for adhesion formation after myomectomy. Therefore, every surgeon should adopt strategies to reduce adhesion development in daily routine, especially when it conducted to preserve or restore fertility.
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Affiliation(s)
- Anja Herrmann
- University Hospital for Gynecology Pius Hospital, University of Oldenburg, Germany
| | | | - Harald Krentel
- University Hospital for Gynecology Pius Hospital, University of Oldenburg, Germany
| | - Cristina Cezar
- University Hospital for Gynecology Pius Hospital, University of Oldenburg, Germany
| | - Maya Sophie de Wilde
- University Hospital for Gynecology Pius Hospital, University of Oldenburg, Germany
| | - Rajesh Devassy
- University Hospital for Gynecology Pius Hospital, University of Oldenburg, Germany
| | - Rudy Leon De Wilde
- University Hospital for Gynecology Pius Hospital, University of Oldenburg, Germany
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Aydın S, Göksever Çelik H, Maraşlı M, Bakar RZ. Clinical predictors of successful vaginal myomectomy for prolapsed pedunculated uterine leiomyoma. J Turk Ger Gynecol Assoc 2018; 19:146-150. [PMID: 29449196 PMCID: PMC6085531 DOI: 10.4274/jtgga.2017.0135] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
Objective: Uterine leiomyomas are the most common pelvic tumor in women. The calculated prevalence of prolapsed pedunculated leiomyoma was 2.5% in patients who underwent surgery. Although vaginal removal is safe and effective, hysterectomy demand is questionable. We aimed to analyze the association between patient characteristics, clinical features of prolapsed pedunculated submucosal leiomyoma, and the probability of successful vaginal myomectomy. Material and Methods: This study was conducted in 35 women who presented with prolapsed pedunculated uterine leiomyoma. Patients were grouped according to the treatment procedure, either vaginal myomectomy or hysterectomy. Results: Hysterectomy was performed in 14 patients and vaginal myomectomy was performed in 21 women. The mean ages and menopausal status were similar. Parity was higher in the hysterectomy group (p=0.02). The preoperative hematocrit value of patients undergoing vaginal myomectomy was significantly lower (p=0.04). There was no significant difference between the groups regarding the largest leiomyoma diameter. However, the median calculated leiomyoma volume was lower in the vaginal myomectomy group (p=0.04). None of the variables were independently associated with successful vaginal myomectomy on multivariable logistic regression analysis. Conclusion: The feasibility and choice of vaginal myomectomy is associated with low parity, absence of coexisting leiomyoma, high volume of leiomyoma estimated via ultrasound measurement, and severe anemia.
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Affiliation(s)
- Serdar Aydın
- Department of Obstetrics and Gynecology, Bezmialem Vakıf University School of Medicine, İstanbul, Turkey
| | - Hale Göksever Çelik
- Department of Obstetrics and Gynecology, Saglik Bilimleri University, İstanbul Kanuni Sultan Süleyman Training and Research Hospital, İstanbul, Turkey
| | - Mustafa Maraşlı
- Department of Obstetrics and Gynecology, Bezmialem Vakıf University School of Medicine, İstanbul, Turkey
| | - Rabia Zehra Bakar
- Department of Obstetrics and Gynecology, Erbaa State Hospital, Tokat, Turkey
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McLucas B, Voorhees III WD, Elliott S. Fertility after uterine artery embolization: a review. MINIM INVASIV THER 2015; 25:1-7. [DOI: 10.3109/13645706.2015.1074082] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Dubuisson J, Ramyead L, Streuli I. The role of preventive uterine artery occlusion during laparoscopic myomectomy: a review of the literature. Arch Gynecol Obstet 2014; 291:737-43. [DOI: 10.1007/s00404-014-3546-4] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2014] [Accepted: 11/05/2014] [Indexed: 10/24/2022]
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Jacoby VL, Jacoby A, Learman LA, Schembri M, Gregorich SE, Jackson R, Kuppermann M. Use of medical, surgical and complementary treatments among women with fibroids. Eur J Obstet Gynecol Reprod Biol 2014; 182:220-5. [PMID: 25445104 DOI: 10.1016/j.ejogrb.2014.09.004] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2014] [Revised: 08/28/2014] [Accepted: 09/03/2014] [Indexed: 10/24/2022]
Abstract
OBJECTIVE To examine the use of medical management, uterus-preserving surgery (UPS), and complementary treatments among women with uterine fibroids. STUDY DESIGN Prospective cohort study of 933 premenopausal women ages 31-54 years with symptomatic fibroids who participated in the Study of Pelvic Problems, Hysterectomy, and Intervention Alternatives (SOPHIA) for an average of 4.3 years (SD 2.5 years). Incident use of fibroid treatments was determined through annual interviews. Linear regression models were used to compare changes in fibroid-related symptoms among women who underwent UPS versus those who did not undergo surgery. RESULTS Participants were racially and ethnically diverse, with a mean age of 43 years. During study follow-up, 531 participants (57%) did not undergo UPS or hysterectomy, 250 (27%) had at least one UPS, and 152 (16%) underwent hysterectomy. Complementary and alternative treatments were commonly used, including exercise (45%), diet (34%), herbs (37%), and acupuncture (16%): participants reported significant symptom improvement and few side effects with these interventions. In multivariable linear regression models, women who did not undergo surgery during the study reported improvement in dyspareunia (p<.001), pelvic pain (p<.001), and menstrual cramps (p<.001). However, women who underwent UPS reported greater overall resolution of "pelvic problems" compared with women who did not have surgical treatment (difference in change score 1.18 on a four-point Likert scale, p<.001). CONCLUSION UPS are effective treatments for women with fibroids, but many women use hormonal or complementary treatments and report significant symptom improvement without surgical intervention.
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Affiliation(s)
- Vanessa L Jacoby
- Department of Obstetrics, Gynecology & Reproductive Sciences, University of California, 1635 Divisadero St, Suite 600, San Francisco, CA, USA.
| | - Alison Jacoby
- Department of Obstetrics, Gynecology & Reproductive Sciences, University of California, 1635 Divisadero St, Suite 600, San Francisco, CA, USA
| | - Lee A Learman
- Department of Obstetrics and Gynecology, Indiana University School of Medicine, USA
| | - Michael Schembri
- Department of Obstetrics, Gynecology & Reproductive Sciences, University of California, 1635 Divisadero St, Suite 600, San Francisco, CA, USA
| | - Steven E Gregorich
- Medicine, University of California, San Francisco, CA, USA; Medical Effectiveness Research Center for Diverse Populations, University of California, San Francisco, CA, USA
| | - Rebecca Jackson
- Department of Obstetrics, Gynecology & Reproductive Sciences, University of California, 1635 Divisadero St, Suite 600, San Francisco, CA, USA; Epidemiology & Biostatistics, University of California, San Francisco, CA, USA
| | - Miriam Kuppermann
- Department of Obstetrics, Gynecology & Reproductive Sciences, University of California, 1635 Divisadero St, Suite 600, San Francisco, CA, USA; Epidemiology & Biostatistics, University of California, San Francisco, CA, USA; Medical Effectiveness Research Center for Diverse Populations, University of California, San Francisco, CA, USA
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Gorny KR, Borah BJ, Brown DL, Woodrum DA, Stewart EA, Hesley GK. Incidence of additional treatments in women treated with MR-guided focused US for symptomatic uterine fibroids: review of 138 patients with an average follow-up of 2.8 years. J Vasc Interv Radiol 2014; 25:1506-12. [PMID: 24998103 DOI: 10.1016/j.jvir.2014.05.012] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2014] [Revised: 05/12/2014] [Accepted: 05/13/2014] [Indexed: 10/25/2022] Open
Abstract
PURPOSE To assess long-term outcomes of magnetic resonance (MR)-guided focused ultrasound (US) treatments of uterine fibroids. MATERIALS AND METHODS A retrospective follow-up of 138 patients treated at a single institution between March 2005 and November 2011 was conducted. The patients were not part of a clinical study and were followed through retrospective review of their medical records and telephone interviews to assess additional treatments for fibroid-related symptoms. Survival methods, including Cox proportional hazards models, were used to assess the association between incidence of additional treatments and patient data obtained during screening before treatment. RESULTS The average length of follow-up was 2.8 years (range, 1-7.2 y). The cumulative incidence of additional treatments at 36 months and 48 months after MR-guided focused US was 19% and 23%, respectively. Women who did not need additional treatment were older than women who did (46.3 y ± 5.6 vs 43.0 y ± 5.8; P = .006; hazard ratio, 0.855; 95% confidence interval, 0.789-0.925). Additionally, women with heterogeneous or bright fibroids on T2-weighted MR imaging were more likely to require additional treatment compared with women with homogeneously dark fibroids (hazard ratio, 5.185 or 5.937, respectively; 95% confidence interval, 1.845-14.569 or 1.401-25.166, respectively). Physician predictions of treatment success, recorded during the screening process, had significant predictive value (P = .018). CONCLUSIONS The long-term rates of additional interventions after MR-guided focused US of symptomatic uterine fibroids were found to be comparable with other uterine-sparing procedures, such as uterine artery embolization or myomectomy. Older patient age and homogeneously dark fibroids were associated with fewer additional treatments. Physician assessment of treatment success was found to be a valuable tool in patient screening.
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Affiliation(s)
- Krzysztof R Gorny
- Department of Radiology, Mayo Clinic, 200 First Street SW, Rochester, MN 55905.
| | - Bijan J Borah
- Department of Health Sciences, Mayo Clinic, 200 First Street SW, Rochester, MN 55905
| | - Douglas L Brown
- Department of Radiology, Mayo Clinic, 200 First Street SW, Rochester, MN 55905
| | - David A Woodrum
- Department of Radiology, Mayo Clinic, 200 First Street SW, Rochester, MN 55905
| | - Elizabeth A Stewart
- Department of Obstetrics and Gynecology, Mayo Clinic, 200 First Street SW, Rochester, MN 55905
| | - Gina K Hesley
- Department of Radiology, Mayo Clinic, 200 First Street SW, Rochester, MN 55905
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Radosa MP, Owsianowski Z, Mothes A, Weisheit A, Vorwergk J, Asskaryar FA, Camara O, Bernardi TS, Runnebaum IB. Long-term risk of fibroid recurrence after laparoscopic myomectomy. Eur J Obstet Gynecol Reprod Biol 2014; 180:35-9. [PMID: 25016181 DOI: 10.1016/j.ejogrb.2014.05.029] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2013] [Revised: 02/09/2014] [Accepted: 05/23/2014] [Indexed: 10/25/2022]
Abstract
OBJECTIVE The use of laparoscopic myomectomy as a surgical treatment for uterine leiomyoma is associated with low intraoperative morbidity and short hospitalization. Limited data about the long-term outcome of this surgical approach are available. The aims of this study were to estimate the risk of uterine fibroid recurrence after laparoscopic myomectomy and to identify factors contributing to the rate of fibroid relapse. STUDY DESIGN Between 1996 and 2003, 331 patients underwent laparoscopic myomectomy to treat uterine leiomyoma in our hospital; 224 of these patients consented to participate in our 2009 follow-up survey. Clinical symptomatic uterine leiomyoma recurrence was defined as relapse. Recurrence rates at 24 and 60 months post-operatively were calculated for the study population. Fisher's exact tests were used to examine the impacts of factors previously linked to an increased risk of fibroid recurrence, including (1) patient age at the time of initial surgery, (2) pre-operative body mass index, (3) number and localization of uterine leiomyoma removed, and (4) pregnancy and (5) delivery after laparoscopic myomectomy on fibroid recurrence in our study cohort. RESULTS We observed 75 recurrences in 224 patients. The cumulative risk of recurrence was 4.9% at 24 months and 21.4% at 60 months post-operatively. An age of 30-40 years and the presence of more than one fibroid at the time of initial laparoscopic myomectomy were identified as factors significantly increasing the risk of symptomatic recurrence after laparoscopic myomectomy (31.25% and 38.71%, respectively; both p<0.01). CONCLUSION Patients with multiple uterine leiomyoma and those in the third decade of life should be counselled thoroughly about the risk of recurrence prior to laparoscopic myomectomy. The low observed recurrence rate in peri- and postmenopausal patients in our study may support the use of laparoscopic myomectomy as a uterus-preserving surgical alternative beyond the reproductive period.
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Affiliation(s)
- M P Radosa
- Department of Gynaecology and Obstetrics, Jena University Hospital, Friedrich-Schiller-University Jena, Bachstraße 18, 07743 Jena, Germany
| | - Z Owsianowski
- Department of Gynaecology and Obstetrics, Jena University Hospital, Friedrich-Schiller-University Jena, Bachstraße 18, 07743 Jena, Germany
| | - A Mothes
- Department of Gynaecology and Obstetrics, Jena University Hospital, Friedrich-Schiller-University Jena, Bachstraße 18, 07743 Jena, Germany
| | - A Weisheit
- Department of Gynaecology and Obstetrics, Jena University Hospital, Friedrich-Schiller-University Jena, Bachstraße 18, 07743 Jena, Germany
| | - J Vorwergk
- Department of Gynaecology and Obstetrics, Jena University Hospital, Friedrich-Schiller-University Jena, Bachstraße 18, 07743 Jena, Germany
| | - F A Asskaryar
- Department of Gynaecology and Obstetrics, Jena University Hospital, Friedrich-Schiller-University Jena, Bachstraße 18, 07743 Jena, Germany
| | - O Camara
- Department of Gynaecology and Obstetrics, Jena University Hospital, Friedrich-Schiller-University Jena, Bachstraße 18, 07743 Jena, Germany
| | - T S Bernardi
- Department of Gynaecology and Obstetrics, Jena University Hospital, Friedrich-Schiller-University Jena, Bachstraße 18, 07743 Jena, Germany
| | - I B Runnebaum
- Department of Gynaecology and Obstetrics, Jena University Hospital, Friedrich-Schiller-University Jena, Bachstraße 18, 07743 Jena, Germany.
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Bendifallah S, Brun JL, Fernandez H. Place de la myomectomie chez une patiente en situation d’infertilité. ACTA ACUST UNITED AC 2011; 40:885-901. [DOI: 10.1016/j.jgyn.2011.09.014] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Yazawa H, Endo S, Hayashi S, Suzuki S, Ito A, Fujimori K. Spontaneous uterine rupture in the 33rd week of IVF pregnancy after laparoscopically assisted enucleation of uterine adenomatoid tumor. J Obstet Gynaecol Res 2011; 37:452-7. [DOI: 10.1111/j.1447-0756.2010.01361.x] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Liberis V, Tsikouras P, Ammari A, Zografou C, Valentina D, Kafetzis D, Maroulis G. Assessment of the feasibility of bipolar coagulation use to reduce hemorrhage in myomectomy performed by minilaparotomy. MINIM INVASIV THER 2010; 19:75-82. [DOI: 10.3109/13645701003642875] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Abstract
Fibroids are common amongst women of reproductive age. In women wanting to retain their fertility and/or uterus open myomectomy remains the most widely performed procedure. It is important to carefully counsel the patient about the pros and cons of surgery versus expectant management. Meticulous pre-operative evaluation and preparation will help ensure the procedure goes smoothly. Attention to the operating technique used is paramount in ensuring patient safety and surgical peace of mind. This review addresses the important aspects of open myomectomy including operative technique.
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Affiliation(s)
- Myvanwy McIlveen
- The Jessop Wing, Assisted Conception Unit, Sheffield S10 3SF, UK.
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Elahi SM, Odejinmi F. Overview of current surgical management of fibroids: ‘Organ-preserving modalities’. J OBSTET GYNAECOL 2009; 28:28-31. [DOI: 10.1080/01443610701814328] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Raga F, Sanz-Cortes M, Bonilla F, Casañ EM, Bonilla-Musoles F. Reducing blood loss at myomectomy with use of a gelatin-thrombin matrix hemostatic sealant. Fertil Steril 2009; 92:356-60. [PMID: 19423098 DOI: 10.1016/j.fertnstert.2008.04.038] [Citation(s) in RCA: 53] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2008] [Revised: 04/15/2008] [Accepted: 04/16/2008] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To evaluate the hemostatic efficacy and handling of gelatin-thrombin matrix in abdominal myomectomy. DESIGN Prospective and randomized trial. SETTING University teaching hospital. PATIENT(S) Women (n = 50) with uterine fibroids with a uterine size equivalent to > or =16 weeks gestation. INTERVENTION(S) Gelatin-thrombin matrix (FloSeal Matrix; Baxter Healthcare Corp., Fremont, CA) was delivered to the site of the uterine bleeding during myomectomy. MAIN OUTCOME MEASURE(S) Patient age, parity, number of myomas, operative time, blood loss, transfusion, intraoperative and postoperative complications, and length of hospitalization were evaluated. RESULT(S) The average blood loss during surgery was 80 +/- 25.5 mL for the FloSeal group and 625 +/- 120.5 mL for the control group. Intraoperative blood transfusion was necessary in five patients from the control group. Postoperative blood loss was 25 +/- 5 mL for the FloSeal group and 250 +/- 75 mL for the control group. Length of the postoperative hospital stay was 2.5 +/- 1.2 days for FloSeal group and 4.5 +/- 1.3 for the control group. No major immediate or delayed complications were observed in either group. CONCLUSION(S) Reductions in hemorrhage in FloSeal-treated women undergoing a myomectomy are encouraging, and provide evidence for the ability of gelatin-thrombin matrix to reduce blood loss when applied immediately and directly to bleeding uterine tissue.
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Affiliation(s)
- Francisco Raga
- Departamento de Obstetricia y Ginecologia, Hospital Clinico Universitario de Valencia, Valencia, Spain.
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Leiomyoma pseudocapsule after pre-surgical treatment with gonadotropin-releasing hormone agonists: Relationship between clinical features and immunohistochemical changes. Eur J Obstet Gynecol Reprod Biol 2009; 144:44-7. [DOI: 10.1016/j.ejogrb.2009.02.006] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2008] [Revised: 12/22/2008] [Accepted: 02/04/2009] [Indexed: 11/20/2022]
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O'Brien B, van der Putten W. Quantification of risk-benefit in interventional radiology. RADIATION PROTECTION DOSIMETRY 2008; 129:59-62. [PMID: 18287187 DOI: 10.1093/rpd/ncn040] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/25/2023]
Abstract
The increased use of interventional radiological procedures brings with it an increased risk of cancer induction due to the possible high radiation levels used. This risk must be balanced against any viable alternatives and should take into account the individual risks and benefits. The purpose of this study is to quantify this risk benefit in terms of quality-adjusted life years (QALYs) of a procedure and its alternatives, including the risk due to the radiation. Uterine fibroid embolisation was chosen as a model study with data collected both on the outcomes of procedures in terms of complications and quality of life in the long-term and on radiation dose delivered to the patient. Dosimetry data were obtained from University Hospital Galway. The risk was then calculated using the BEIR VII model of dose-response for low linear energy transfer (LET) radiation. In this case, it was found that the radiological technique has distinct advantages over hysterectomy and myomectomy in terms of QALYs. The increased risk due to radiation from the procedure is small when compared with the overall benefit to the patient. Probability of stochastic effects based on the average dose per procedure carries an attributable risk (fatal and non-fatal cancer and hereditary effects) of 0.4% or a relative risk of 1.09%. The method described here can readily be adapted to other interventional procedures.
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Affiliation(s)
- B O'Brien
- Department of Experimental Physics, National University of Ireland, Galway
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Keeling AN, Reidy JF. Imaging and treatment of uterine fibroids, including the role of uterine artery embolization. IMAGING 2007. [DOI: 10.1259/imaging/80403836] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
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Gavai M, Berkes E, Lazar L, Fekete T, Takacs ZF, Urbancsek J, Papp Z. Factors affecting reproductive outcome following abdominal myomectomy. J Assist Reprod Genet 2007; 24:525-31. [PMID: 18008158 PMCID: PMC3455029 DOI: 10.1007/s10815-007-9135-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2006] [Accepted: 04/12/2007] [Indexed: 11/26/2022] Open
Abstract
PURPOSE Fibroids may cause infertility and recurrent pregnancy loss. Studies have analysed the reproductive results after myomectomy according to the size, location and number of fibroids removed, but data are insufficient about comparison of opening the uterine cavity or not during surgery. MATERIALS AND METHODS Two hundred twenty-nine abdominal myomectomies with the indication of infertility and/or recurrent pregnancy loss were analysed retrospectively. The main purpose was to compare postoperative pregnancy, delivery and miscarriage rates according to either the uterine cavity was opened or not during the surgery. As a secondary outcome postoperative pregnancy rates were assessed by location, size and number of fibroids. RESULTS There was no significant difference in reproductive results according to either the uterine cavity was opened or remained closed. Preoperative location, size and number of fibroids did not influence significantly the postoperative pregnancy rates. CONCLUSION Opening the uterine cavity does not impair postoperative pregnancy rates. Preoperative location, size and number of fibroids do not influence postoperative reproductive results.
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Affiliation(s)
- Marta Gavai
- Department of Obstetrics and Gynecology, Semmelweis University, 1088-Budapest, Baross Street 27, Budapest, Hungary.
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Usadi RS, Marshburn PB. The impact of uterine artery embolization on fertility and pregnancy outcome. Curr Opin Obstet Gynecol 2007; 19:279-83. [PMID: 17495646 DOI: 10.1097/gco.0b013e3281099659] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Uterine artery embolization for management of symptomatic fibroids is an effective and increasingly popular treatment option. There are several studies evaluating the effects of uterine artery embolization on later pregnancies; however, the effects on fertility are still largely uncertain. This paper reviews the current literature on the effects of this technique on fertility and pregnancy outcome. RECENT FINDINGS Two recent studies have reported pregnancy rates following uterine artery embolization in women seeking pregnancy. A small, third study reported preliminary results in a randomized controlled trial comparing uterine artery embolization with myomectomy in women wishing to preserve fertility. SUMMARY The body of medical literature supports use of uterine artery embolization as an effective treatment for symptoms of vaginal bleeding and pelvic pressure from uterine fibroids. Patient selection is critical in determining the appropriateness of this treatment option. Myomectomy remains the standard of care for women with symptomatic fibroids seeking fertility preservation.
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Affiliation(s)
- Rebecca S Usadi
- Division of Reproductive Endocrinology and Infertility, Carolinas Medical Center, Charlotte, North Carolina 28232-2861, USA.
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Dumousset E, Chabrot P, Rabischong B, Mazet N, Nasser S, Darcha C, Garcier JM, Mage G, Boyer L. Preoperative Uterine Artery Embolization (PUAE) Before Uterine Fibroid Myomectomy. Cardiovasc Intervent Radiol 2007; 31:514-20. [PMID: 17624572 DOI: 10.1007/s00270-005-0342-3] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
PURPOSE To evaluate the potential of uterine artery embolization to minimize blood loss and facilitate easier removal of fibroids during subsequent myomectomy. METHODS This retrospective study included 22 patients (median age 37 years), of whom at least 15 wished to preserve their fertility. They presented with at least one fibroid (mean diameter 85.6 mm) and had undergone preoperative uterine artery embolization (PUAE) with resorbable gelatin sponge. RESULTS No complication or technical failure of embolization was identified. Myomectomies were performed during laparoscopy (12 cases) and laparotomy (9 cases). One hysterectomy was performed. The following were noted: easier dissection of fibroids (mean 5.6 per patient, range 1-30); mean intervention time 113 min (range 25-210 min); almost bloodless surgery, with a mean peroperative blood loss of 90 ml (range 0-806 ml); mean hemoglobin pretherapeutically 12.3 g/dl (range 5.9-15.2 g/dl) and post-therapeutically 10.3 g/dl (range 5.6-13.3 g/dl), with no blood transfusion needed. Patients were discharged on day 4 on average and the mean sick leave was 1 month. CONCLUSION Preoperative embolization is associated with minimal intraoperative blood loss. It does not increase the complication rate or impair operative dissection, and improves the chances of performing conservative surgery.
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Affiliation(s)
- E Dumousset
- CHU Clermont Ferrand, Services de Radiologie B et Gynécologie, hôpital G. Montpied, F 63003, Clermont-Ferrand, France
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Hodge JC, Morton CC. Genetic heterogeneity among uterine leiomyomata: insights into malignant progression. Hum Mol Genet 2007; 16 Spec No 1:R7-13. [PMID: 17613550 DOI: 10.1093/hmg/ddm043] [Citation(s) in RCA: 58] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Uterine leiomyomata (UL), also known as fibroids, are the most common pelvic tumors in women of reproductive age and are the primary indication for hysterectomy in the USA. Many lines of evidence indicate a strong genetic component to the development of these tumors. In fact, approximately 40% of UL have non-random, tumor-specific chromosome abnormalities which have allowed classification into well-defined subgroups (deletion of portions of 7q, trisomy 12 or rearrangements of 12q15, 6p21 or 10q22) as well as identification of candidate genes for UL predisposition. Although benign, UL have been linked to malignancy through two genomic regions on chromosome 1. Mutation of fumarate hydratase (FH) at 1q43 is known to cause the Mendelian syndromes of multiple cutaneous and uterine leiomyomata (MCL) and hereditary leiomyomatosis and renal cell cancer (HLRCC), and recently, FH mutations have been detected in some non-syndromic UL. In addition, transcriptional profiling suggests that loss of the short arm of chromosome 1 in cellular leiomyomata, an uncommon histological variant of UL, may account in part for the presumed yet rare malignant transformation of UL to uterine leiomyosarcoma.
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Affiliation(s)
- Jennelle C Hodge
- Department of Obstetrics, Gynecology and Reproductive Biology, Harvard Medical School, Brigham and Women's Hospital, Boston, MA 02115, USA
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Spies JB, Rundback JH, Ascher S, Bradley L, Goodwin SC, Hovsepian DM, Myers ER, Pelage JP, Pron G, Siskin GP, Stewart EA, Worthington-Kirsch R, Hume KM, Strain C, Gomolka B. Development of a research agenda for uterine artery embolization: proceedings from a multidisciplinary research consensus panel. J Vasc Interv Radiol 2007; 17:1871-9. [PMID: 17185681 DOI: 10.1097/01.rvi.0000251151.01365.c1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Affiliation(s)
- James B Spies
- Department of Radiology, Georgetown University Hospital, Washington, DC 20007-2113, USA.
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Takeda A, Sakai K, Mitsui T, Nakamura H. Wound retraction system for gasless laparoscopic-assisted myomectomy with a subcutaneous abdominal wall-lift method. J Minim Invasive Gynecol 2007; 14:240-6. [PMID: 17368264 DOI: 10.1016/j.jmig.2006.07.018] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2006] [Revised: 07/15/2006] [Accepted: 07/16/2006] [Indexed: 11/28/2022]
Abstract
Over the course of 4 years we evaluated 209 women using gasless laparoscopic-assisted myomectomy and a wound retractor. Three were no significant differences in blood loss or surgical duration despite myoma size or location. Gasless laparoscopic-assisted myomectomy utilizing a wound retractor is an effective procedure for women desiring uterine preservation without significantly longer surgery duration.
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Affiliation(s)
- Akihiro Takeda
- Department of Obstetrics and Gynecology, Gifu Prefectural Tajimi Hospital, Tajimi, Gifu, Japan.
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Erian J, El-Shawarby SA, Hassan M, Wissa I, Chandakas S, Hill N. Laparoscopic subtotal hysterectomy using the plasma kinetic and lap loop systems: an alternative approach in the surgical management of women with uterine fibroids. Eur J Obstet Gynecol Reprod Biol 2007; 137:84-7. [PMID: 17291676 DOI: 10.1016/j.ejogrb.2007.01.004] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2006] [Revised: 01/08/2007] [Accepted: 01/09/2007] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To evaluate the safety and applicability of laparoscopic subtotal hysterectomy (LSH) using the plasma kinetic (PK) and lap loop systems as an alternative surgical approach in the management of uterine fibroids in women who have completed their families. STUDY DESIGN Sixty-two consecutive LSH were performed during this prospective study from March 2003 to March 2005 at Princess Royal University Hospital, Kent, UK. RESULTS All study patients had menorrhagia resistant to at least one form of therapy, with a mean duration of symptoms of 3.5 years. In addition, four patients had previous myomectomy. The mean number of fibroids removed was 2.7. The mean weight of the uterus was 141.9 g. The mean operative time was 46.8 min, and the mean blood loss was 126.6 mL. The overall perioperative complication rate was 4.8% with no visceral injury, or return to theatre. At follow-up, all patients were satisfied with surgery. CONCLUSION The study describes the first application of the PK and Lap Loop systems in LSH for the surgical management of uterine fibroids in women in whom fertility is not an issue, and its findings suggest that this minimally invasive technique is a safe, and valid alternative. Larger adequately-powered studies are however still required.
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Affiliation(s)
- John Erian
- Minimal Access Surgery Unit, Department of Obstetrics and Gynaecology, Princess Royal University Hospital, Orpington, Kent BR6 8ND, United Kingdom
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Liu WM, Wang PH, Chou CS, Tang WL, Wang IT, Tzeng CR. Efficacy of combined laparoscopic uterine artery occlusion and myomectomy via minilaparotomy in the treatment of recurrent uterine myomas. Fertil Steril 2007; 87:356-61. [DOI: 10.1016/j.fertnstert.2006.07.1497] [Citation(s) in RCA: 69] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2006] [Revised: 07/04/2006] [Accepted: 07/04/2006] [Indexed: 11/16/2022]
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Hassiakos D, Christopoulos P, Vitoratos N, Xarchoulakou E, Vaggos G, Papadias K. Myomectomy during Cesarean Section: A Safe Procedure? Ann N Y Acad Sci 2006; 1092:408-13. [PMID: 17308166 DOI: 10.1196/annals.1365.038] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
A patient's frequent request is the simultaneous surgical removal of a previously diagnosed myoma during cesarean section. The aim of this study was to evaluate the safety and efficacy of myomectomy during cesarean section. From January 1995 until December 2004, 47 pregnant women with coexisting uterine myomas underwent cesarean section and simultaneous myomectomy. All cesarean sections were performed by residents while myomectomies were conducted by the senior staff. Intraoperative and postoperative complications such as blood loss were estimated and compared with 94 women with uterine myomas who underwent surgical delivery without removal of the fibroids. Furthermore, the length of hospitalization was compared between the two groups. Myomectomy added a mean time of 15 min to the operative time of cesarean section. No hysterectomy was performed at the time of the cesarean section. No complications were developed during the puerperium. The difference between the preoperative and postoperative hemoglobin mean value was statistically significant (P=0.001) but did not differ between isolated cesarean and myomectomy-combined cesarean groups. None of the patients received blood transfusion. The length of hospitalization was comparable between the two groups. Despite controversial literature data, we suggest that myomectomy during cesarean section could be generally recommended. Depending on size and location of myomas, the associated risks are similar to those of isolated cesarean section.
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Affiliation(s)
- D Hassiakos
- Second Department of Obstetrics and Gynicology, Medical School, University of Athens, Aretaieion Hospital, Athens, Greece
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Lobel MK, Somasundaram P, Morton CC. The genetic heterogeneity of uterine leiomyomata. Obstet Gynecol Clin North Am 2006; 33:13-39. [PMID: 16504804 DOI: 10.1016/j.ogc.2005.12.006] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Research investigating the genetics of UL has already been successful in gathering epidemiologic evidence for heritability, establishing the clonal and mosaic nature of these tumors, correlating genotypic and phenotypic characteristics, defining cytogenetic subgroups, and identifying specific genes involved in tumorigenesis. Although UL are known to be benign tumors, the impact they have on the lives of so many women can only be described as "malignant". For this reason, continuing the quest to ascertain the genes, functions, and mechanisms integral to UL development is absolutely imperative. Genetic tests for personalized medical management of women with fibroids is at the threshold for providing the most appropriate treatments (Fig. 3), and combined with developing less invasive therapies portends a brighter future for a major health problem for women.
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Affiliation(s)
- Melissa K Lobel
- Department of Obstetrics, Brigham and Women's Hospital and Harvard Medical School, 77 Avenue Louis Pasteur, NRB, Room 160, Boston, MA 02115, USA
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Abstract
This article highlights our current knowledge of fibroids and addresses future directions for fibroid research and treatment over the next decade. The available data on cytogenetics are discussed, in addition to discoveries into signaling pathways and second messenger molecules in leiomyomas. Current medical management, surgical trends and the barriers to transition to minimally invasive procedures are summarized. Innovations in genetic diagnosis and interventional radiologic-aided therapies may revolutionize therapy for certain populations of patients who have fibroids. From tissue-specific medical management, to minimally invasive surgical techniques, to pharmacogenetics, the current directions of fibroid research are leading us to an exciting new frontier.
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Affiliation(s)
- Pavna K Brahma
- Department of Obstetrics and Gynecology, University of Michigan Health System, University of Michigan Medical School, 6422 Medical Science I, 1150 West Medical Center Drive, Ann Arbor, MI 48105, USA
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Abstract
Uterine fibroid embolization (UFE) is a minimally invasive therapy for the treatment of symptomatic uterine fibroids and offers an alternative to conventional myomectomy and hysterectomy. This review focuses on recent publications evaluating UFE and concludes that it is a safe treatment option, providing substantial improvement in both health-related quality of life and symptom control for most patients, with a very low rate of major complications. The durability of these outcomes appears similar to those obtained with myomectomy; however, a direct comparative long-term study is needed. Recent comparative studies have begun to provide more insight in to UFE outcomes compared with outcomes achieved with myomectomy and hysterectomy. UFE should be considered a first line therapy for women with symptomatic uterine fibroids. Additional research will continue to provide us with information as to the ideal candidates for UFE and may provide us with better tools to predict patient outcomes.
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Affiliation(s)
- Amy M White
- Department of Radiology, Georgetown University Hospital, Washington, DC 20007-2113, USA
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Tsuji S, Takahashi K, Imaoka I, Sugimura K, Miyazaki K, Noda Y. MRI Evaluation of the Uterine Structure after Myomectomy. Gynecol Obstet Invest 2006; 61:106-10. [PMID: 16244491 DOI: 10.1159/000089144] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2005] [Accepted: 08/30/2005] [Indexed: 11/19/2022]
Abstract
Myomectomy is a good indication for women with uterine leiomyoma who desire to preserve their child-bearing potential. However, there are still no reports about how long it takes the uterus to reach a stable state after myomectomy. We evaluated the changes in uterine structure during the recovery process after myomectomy by MR images. MR images were used to analyze the time-dependent changes in the length of the uterine cavity, the volume of the uterus, recovery of the junctional zone, prevalence of modification of the endometrium, and uterine structure in the region of the enucleated myoma. The cavity length and the volume of the uterus, and the myometrium were stabilized at six weeks after the myomectomy. With regard to the endometrium, 12 weeks were required for it to achieve a stable state after myomectomy. However, even at 12 weeks postoperatively, 14.2% of the cases showed an unusual view near the uterine incision on MR images. We concluded that the recovery process is complete at 12 weeks after the operation if there are no clear findings of hematoma or edema formation in the myometrium on MR images.
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Affiliation(s)
- Shunichiro Tsuji
- Department of Obstetrics and Gynecology, Shiga University of Medical Science, Shiga, Japan
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Nishiyama S, Saito M, Sato K, Kurishita M, Itasaka T, Shioda K. High recurrence rate of uterine fibroids on transvaginal ultrasound after abdominal myomectomy in Japanese women. Gynecol Obstet Invest 2006; 61:155-9. [PMID: 16391486 DOI: 10.1159/000090628] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2004] [Accepted: 07/20/2005] [Indexed: 11/19/2022]
Abstract
AIM To evaluate the recurrence rate of uterine fibroids (UF) after abdominal myomectomy and the risk factors for recurrences. METHODS In a retrospective study, transvaginal ultrasound examinations were performed in 135 women after abdominal myomectomy. The main outcome measures were cumulative UF recurrence rates after abdominal myomectomy. The Kaplan-Meier survival analysis was used to estimate the cumulative recurrence rate, and log-rank tests were applied to compare survival curves among different categorical groups of potential risk factors for recurrences. RESULTS The cumulative UF recurrence rates at 12 and 24 months after abdominal myomectomy were 12.4 and 46.0%, respectively. Women who had a history of previous myomectomy had a higher hazard of UF recurrence than women without such a history (hazard ratio 4.1, 95% confidence interval 1.20-13.6). The women having four or more UFs had a higher hazard than those who had less than four UFs (hazard ratio 3.7, confidence interval 1.41-9.88). After adjusting these variables to each other, the hazard ratio remained similar. CONCLUSIONS The UF recurrence rate detected by transvaginal ultrasound after abdominal myomectomy was high, but did not require any additional surgery. Physicians need to consider the timing of the myomectomy, taking into account complications of pregnancy and infertility due to UF recurrence.
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Affiliation(s)
- Sachie Nishiyama
- Department of Obstetrics and Gynecology, St. Luke's International Hospital, 9-1 Akashi-cho, Chuo-ku, Tokyo 104-8560, Japan
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Goodwin SC, Bradley LD, Lipman JC, Stewart EA, Nosher JL, Sterling KM, Barth MH, Siskin GP, Shlansky-Goldberg RD. Uterine artery embolization versus myomectomy: a multicenter comparative study. Fertil Steril 2006; 85:14-21. [PMID: 16412720 DOI: 10.1016/j.fertnstert.2005.05.074] [Citation(s) in RCA: 66] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2005] [Revised: 05/31/2005] [Accepted: 05/31/2005] [Indexed: 10/25/2022]
Abstract
OBJECTIVE To determine whether there is significant quality of life score improvement after uterine artery embolization (UAE) and to compare UAE and myomectomy outcomes. DESIGN Prospective cohort controlled study. SETTING Sixteen medical centers in the United States. PATIENT(S) One hundred forty-nine UAE patients and 60 myomectomy patients. Patients were assigned to myomectomy or UAE on the basis of a best treatment decision made by the patient and her physician. All patients were observed for 6 months. The UAE patients also had follow-up examinations at 1 year. INTERVENTION(S) Myomectomy or UAE. MAIN OUTCOME MEASURE(S) Quality of life score changes, menstrual bleeding score changes, uterine size differences, time off, and adverse events. RESULT(S) Both groups experienced statistically significant improvements in the uterine fibroid quality of life score, menstrual bleeding, uterine volume, and overall postoperative quality of life. The mean hospital stay was 1 day for the UAE patients, compared with 2.5 days for the myomectomy patients. The UAE and myomectomy patients returned to their normal activities in 15 days and 44 days, respectively, and returned to work in 10 days and 37 days, respectively. At least one adverse event occurred in 40.1% of the myomectomy patients, compared with 22.1% in the UAE group. CONCLUSION(S) The uterine fibroid quality of life score was significantly improved in both groups. No significant differences were observed in bleeding improvement, uterine volume reduction, uterine fibroid quality of life score improvement, and overall quality of life score improvement between groups. Patients receiving UAE required fewer days off work, fewer hospital days, and experienced fewer adverse events.
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Affiliation(s)
- Scott C Goodwin
- Department of Veterans Affairs, The University of California, Los Angeles, California, USA.
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Tsuji S, Takahashi K, Yomo H, Fujiwara M, Kita N, Takebayashi K, Miyazaki K, Noda Y. Effectiveness of antiadhesion barriers in preventing adhesion after myomectomy in patients with uterine leiomyoma. Eur J Obstet Gynecol Reprod Biol 2005; 123:244-8. [PMID: 15950364 DOI: 10.1016/j.ejogrb.2005.04.012] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2004] [Revised: 04/22/2005] [Accepted: 04/30/2005] [Indexed: 10/25/2022]
Abstract
BACKGROUND Myomectomy often causes adhesion formation and decreases subsequent fertility. The purpose of the present study was to evaluate the effectiveness of several antiadhesion barrier materials in preventing adhesion after myomectomy. METHODS We prospectively classified 63 women undergoing myomectomy alone into four groups according to the type of antiadhesion material used: Hyaluronic acid-carboxymethylcellulose film (Seprafilm) (n = 21, Group 1), Dextran 40 (10% Dextran 40 Low Injection) (n = 17, Group 2), factor 13 with fibrinogen (Beriplast) (n = 12, Group 3) and control (n = 13, Group 4). We performed early second-look laparoscopy after the seventh post-operative day in all patients and examined adhesion formation in the abdominal cavity. The incidence of adnexal adhesions was evaluated according to the American Fertility Association (AFS) adhesion score. RESULTS The incidence of uterine adhesion was 14.3% in Group 1, 70.6% in Group 2, 75.0% in Group 3 and 76.9% in Group 4. Adhesion formation in Group 1 was significantly less than that in Group 2 (p = 0.0004), Group 3 (p = 0.0005) and Group 4 (p = 0.0003). The incidence of peritoneal adhesion was 14.3% in Group 1, 29.4% in Group 2, 41.6% in Group 3 and 69.2% in Group 4. Adhesion formation in Group 1 was significantly less than that in Group 4 (p = 0.001). AFS scores in Groups 1-4 were 0.38+/-1.02, 4.58 +/- 7.02, 0.83 +/- 1.99 and 8.53 +/- 8.79 (mean +/- S.D.), respectively. Group 1 had the lowest AFS score and the difference between Group 1 and Group 4 was significant (p < 0.0001). The AFS score in Group 3 was also significantly less than that of Group 4 (p = 0.0009). CONCLUSION Seprafilm was highly effective and was superior to the other antiadhesion materials tested in preventing uterine adhesions after myomectomy.
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Affiliation(s)
- Shunichiro Tsuji
- Department of Obstetrics and Gynecology, Shiga University of Medical Science, Seta-Tsukinowa-cho, Ohtsu, Shiga 520-2192, Japan
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Abstract
Health resources are finite, and it is increasingly necessary to practise medicine within defined budgets. Hysterectomy is recognized as one of the most frequently performed of all major surgical operations and is of great economic as well as medical and social importance. A full assessment of the value of an intervention requires consideration of both economic and clinical outcomes. New alternative therapies to uterine excision have been introduced, and new ways of performing hysterectomy have been developed. Cost-effectiveness analysis enables each of these approaches to be meaningfully compared. Using such analytic techniques, hysterectomy can be shown to be an effective and cost-effective intervention across a variety of indications. The vaginal route is the most cost-effective approach. There seems to be no obvious advantage in conserving or retaining the cervix, but there is as yet no evidence about the cost-effectiveness of concomitant oophorectomy.
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Affiliation(s)
- Ray Garry
- King Edward Memorial Hospital, Bagot Road, Subiaco, Perth, WA 6008, Australia.
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Sinha R, Hegde A, Warty N, Mahajan C. Laparoscopic myomectomy: Enucleation of the myoma by morcellation while it is attached to the uterus. J Minim Invasive Gynecol 2005; 12:284-9. [PMID: 15922988 DOI: 10.1016/j.jmig.2005.03.018] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2004] [Accepted: 01/11/2005] [Indexed: 11/23/2022]
Abstract
STUDY OBJECTIVE To evaluate the feasibility, blood loss, length of surgery, mean hospital stay, and complications of enucleation of a myoma by morcellation while it is still attached to the uterus and to compare the technique with the standard technique of laparoscopic myomectomy. DESIGN Randomized study (Canadian Task Force classification II-2). SETTING Private endoscopy center. PATIENTS Forty-four patients with symptomatic myomas confirmed by ultrasound examination were included in the study from January 2000 through December 2001 and were randomized into two groups-A and B. The inclusion criteria were the presence of a uterus larger than 12 weeks (on bimanual examination), ultrasound confirmation of the presence of at least one myoma 7 cm or greater in size, and/or presence of three or more myomas greater than 5 cm in size. INTERVENTION The technique of laparoscopic myomectomy by enucleation of a myoma by morcellation while it is still attached to the uterus was performed in all patients in Group A. The patients in Group B underwent laparoscopic myomectomy by the conventional technique of complete enucleation of the myoma followed by morcellation. MEASUREMENTS AND MAIN RESULTS Forty-nine myomas were removed in group A and 35 in group B. The mean weight of the myomas removed in each patient was 600.5 +/- 369.1 g in group A (95% CI 452.83-748.17 g) and 584.2 +/- 411.1 g in group B (95% CI 404.05-764.45 g) (p = .706). The mean blood loss was 283.9 +/- 229.3 mL in group A (95% CI 192.20-375.72 mL) and 218.5 +/- 110.7 mL in group B (95% CI 169.96-267.04 mL) (p = .739), the mean hospital stay was 37.91 +/- 5.44 hours in group A (95% CI 35.74-40.10 hours) and 39.5 +/- 3.634 hours in group B (95% CI 37.91-41.09 hours) (p = .236). The mean length of surgery was significantly shorter in group A (97.7 +/- 27.06 min, 95% CI 86.88-108.54 minutes) as compared with that in group B (123 +/- 38.8 min 95% CI 106.93-140.57 minutes), (p = .013). CONCLUSION Preliminary results suggest that laparoscopic myomectomy employing the technique of enucleation of a myoma by morcellation while it is still attached to the uterus is safe and efficient. It helps to overcome certain technical difficulties inherent in the standard technique of laparoscopic myomectomy. It may help to relax the inclusion criteria of patients with myoma for laparoscopic myomectomy based on the size of the myoma.
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Affiliation(s)
- Rakesh Sinha
- Bombay Endoscopy Academy and Centre for Minimally Invasive Laser Surgery Research Co. Pvt. Ltd., Mumbai, India
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Abstract
OBJECTIVE The purpose of this study was to evaluate the factors associated with the recurrence of leiomyomata after myomectomy. METHODS One hundred forty-five consecutive cases of myomectomy by laparotomy were studied retrospectively. Leiomyoma recurrence, diagnosed by transvaginal ultrasonography, was evaluated by life-table analysis and log-rank tests according to clinical characteristics of patients. RESULTS The 5-year cumulative rates for leiomyoma recurrence and subsequent major surgery were 62% and 9%, respectively. At 5 years, the cumulative probability of recurrence was significantly lower in patients with a single leiomyoma removed (11%), compared with patients with multiple leiomyomata (74%) (P = .011); it was also lower in patients with intraoperative uterine size 10 menstrual weeks or less (46%), compared with more than 10 menstrual weeks (82%) (P = .032). However, there was a strong association of uterine size with the number of leiomyomata removed (P = .009). Childbirth after myomectomy was associated with a lower recurrence rate; the 5-year cumulative probability of recurrence was 26% in patients with subsequent parity, compared with 76% in those without subsequent parity (P = .010). CONCLUSION Solitary myomectomy and smaller intraoperative uterine size are associated with lower rates of leiomyoma recurrence after myomectomy; the significance of uterine size may be affected by its correlation with the number of leiomyomata removed. Subsequent parity is associated with a lower probability of recurrence, but the cause and effect relationship between these two variables is unclear. LEVEL OF EVIDENCE II-3.
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Affiliation(s)
- Magdi Hanafi
- Saint Joseph's Hospital of Atlanta, Georgia 30342, USA.
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Theodoridis TD, Tarlatzis BC, Bontis JN. Role of GnRH agonists prior to endoscopic surgical treatment of fibroids. ACTA ACUST UNITED AC 2005. [DOI: 10.1007/s11296-004-0008-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Pelage JP. UAE vs. Myomectomy for Patients Seeking Future Fertility; When to Recommend Each Procedure. J Vasc Interv Radiol 2005. [DOI: 10.1016/s1051-0443(05)70106-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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Bulletti C, DE Ziegler D, Levi Setti P, Cicinelli E, Polli V, Stefanetti M. Myomas, Pregnancy Outcome, andIn VitroFertilization. Ann N Y Acad Sci 2004; 1034:84-92. [PMID: 15731301 DOI: 10.1196/annals.1335.010] [Citation(s) in RCA: 93] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Uterine fibroids have been reported in 27% of infertile women, and 50% of women with unexplained infertility become pregnant after myomectomy. The age at which a first pregnancy occurs is increasing from the thirties to the forties. This increase and the recurrence rate of leiomyomas from 15 to 30% points to the effect of myomas on the infertility. Mechanisms by which myomas may cause infertility are abnormal uterine contractility, elongation of the uterine cavity, and distortion of uterine vascularization. Surgery may have beneficial or adverse effects without clear data on its effect on the assisted reproductive technology (ART) procedures. The present study was undertaken to establish the impact of surgical removal of myomas on fertility and infertility of patients undergoing ART procedures. Patients who underwent surgical removal of myomas before in vitro fertilization (Group A) had a cumulative success rate of 33% for one to three procedures (28 clinical pregnancies in 84 patients) and delivery rate of 25% (21 live births in 84 patients). Patients who underwent in vitro fertilization without previous surgery (Group B) had a 15% clinical pregnancy rate (13 pregnancies in 84 patients) (P < 0.05) and 12% delivery rate (10 deliveries in 84 pregnancies) (P < 0.05). Abortion rates were 7% (8 deliveries in 84 patients) and 4% (3 deliveries in 84 patients) in Groups A and B, respectively. This study confirms the beneficial effect of surgical removal of fibroids before undergoing ART procedures.
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Affiliation(s)
- Carlo Bulletti
- Institute of Obstetrics and Gynecology, Reproductive Pathophysiology Unit, Alma Mater Studiorum, University of Bologna--Rimini Health Care Unit, Internal Hospital, Via Settembrini, 2, 47900 Rimini, Italy.
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Jacob D, Rafii A. [Embolization of uterine arteries for uterine fibroids: state-of-the-art]. ACTA ACUST UNITED AC 2004; 32:927-36. [PMID: 15567680 DOI: 10.1016/j.gyobfe.2004.09.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2004] [Accepted: 09/02/2004] [Indexed: 11/12/2022]
Abstract
Embolization of uterine arteries for fibroids is a modern minimally invasive method for treatment of uterine fibroids. Results from published data show a substantial short-term uterine reduction, an improvement in menorrhagias, and a reduction in fibroid related pain. Hospital stay and recovery are shortened compared with hysterectomy. One randomised comparative trial EAU vs hysterectomy has showed a reduction in hospital stay length and in the rate of major complications, but an increased rate of minor complications. Pregnancies and uneventful deliveries have been reported after uterine arteries embolization. Rare but severe complications have been described. Embolization of uterine arteries can be considered as a safe alternative to hysterectomy or myomectomy in selected cases. It cannot be a routine method for treating fibroids with women of childbearing age.
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Affiliation(s)
- D Jacob
- Service de gynécologie-obstétrique, hôpital Lariboisière, 2, rue Ambroise-Paré, 75010 Paris, France.
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Marchionni M, Fambrini M, Zambelli V, Scarselli G, Susini T. Reproductive performance before and after abdominal myomectomy: a retrospective analysis. Fertil Steril 2004; 82:154-9, quiz 265. [PMID: 15237005 DOI: 10.1016/j.fertnstert.2003.11.042] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2003] [Revised: 11/19/2003] [Accepted: 11/19/2003] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To evaluate the results of abdominal myomectomy for intramural and subserosal fibroids and to identify factors that influence the reproductive outcome after surgery. DESIGN Retrospective analysis of a case series. SETTING An academic department specializing in gynecologic surgery. PATIENT(S) A total of 72 women with intramural and subserosal fibroids submitted to abdominal myomectomy who wished to conceive after surgery. INTERVENTION(S) Data were collected on clinical characteristics, surgical features, and obstetric history before and after surgery. MAIN OUTCOME MEASURE(S) Conception rate, pregnancy loss, and live birth rate before and after surgery, as well as postoperative probability of conception according to selected clinical and fibroid characteristics. RESULT(S) Conception rate was 28% before myomectomy and 70% after surgery. The corresponding figures were 69% and 25% for pregnancy loss and 30% and 75% for live birth rate, respectively. Age <30 years and number of fibroids removed were the only significant and independent predictors of obstetric outcome by multivariate analysis. CONCLUSION(S) Our results suggest that abdominal myomectomy might improve reproductive outcome in patients with intramural and subserosal fibroids. The reproductive performance was particularly good when the patients were younger than 30 years and had a single myoma to remove.
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Affiliation(s)
- Mauro Marchionni
- Department of Gynecology, Perinatology and Human Reproduction, University of Florence, Florence, Italy
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Acién P, Acién M. Evidence-based management of recurrent miscarriage. Surgical management. ACTA ACUST UNITED AC 2004. [DOI: 10.1016/j.ics.2004.02.003] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Abstract
STUDY OBJECTIVE To evaluate the feasibility, complications, and conversion rate of laparoscopic excision of very large myomas. DESIGN Prospective study (Canadian Task Force classification II-2). SETTING Private endoscopy center. PATIENTS Fifty-one women with at least one myoma larger than 9 cm. INTERVENTION Laparoscopic myomectomy. MEASUREMENTS AND RESULTS We removed 78 myomas laparoscopically in these 51 patients. Three patients had two myomas larger than 9 cm, three had two myomas between 5 and 9 cm (in addition to 1 > 9 cm), and one had three myomas between 5 and 9 cm (in addition to 1 > 9 cm). Mean number of myomas removed/patient was 1.53 +/- 1.17 (range 1-6); 12 women (23.5%) had multiple myomectomy. The largest myoma removed was 21 cm. Mean myoma weight was 698.47 +/- 569.13 g (range 210-3400 g). Mean operating time was 136.67 +/- 38.28 minutes (range 80-270 min). Mean blood loss was 322.16 +/- 328.2 ml (range 100-2000 ml). One patient developed a broad ligament hematoma, two developed postoperative fever, and one underwent open subtotal hysterectomy 9 hours after surgery for dilutional coagulopathy. CONCLUSION Myomectomy by laparoscopy is a safe alternative to laparotomy for very large myomas.
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Affiliation(s)
- Rakesh Sinha
- Bombay Endoscopic Academy and Centre for Minimally Invasive Surgery Research, Mumbai, India
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Hughes JL, Reidy JF. Imaging and treatment of uterine fibroids including the role of uterine artery embolisation. IMAGING 2003. [DOI: 10.1259/img.15.2.150079] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
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Farquhar C, Brown PM, Furness S. Cost effectiveness of pre-operative gonadotrophin releasing analogues for women with uterine fibroids undergoing hysterectomy or myomectomy. BJOG 2002; 109:1273-80. [PMID: 12452466 DOI: 10.1046/j.1471-0528.2002.01224.x] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
OBJECTIVE To conduct a cost effectiveness analysis of pre-operative gonadotrophin releasing hormone agonists (GnRHa) in women with uterine fibroids undergoing hysterectomy or myomectomy. DESIGN A cost effectiveness analysis using the effectiveness data from a systematic review of GnRHa. SETTING Secondary care. SAMPLE Women with uterine fibroids undergoing hysterectomy or myomectomy and women volunteers. METHODS Effectiveness data were used from a systematic review to construct a model and to calculate the cost per surgical outcome avoided. In order to evaluate the value women place on the outcome, a willingness to pay analysis of women volunteers was undertaken. MAIN OUTCOME MEASURES (a) The cost of avoiding abdominal hysterectomy and the cost of avoiding a vertical incision at either hysterectomy or myomectomy; (b) The value that women place on avoiding abdominal hysterectomy and on avoiding a vertical incision at either hysterectomy or myomectomy. All costs are in NZ dollars. RESULTS For hysterectomy, the additional cost of treatment with GnRHa was NZ$1190 per case. The cost of avoiding one abdominal procedure was NZ$4577 per case and the cost of avoiding one vertical incision was NZ$6263. For a myomectomy, the additional cost of treatment with GnRHa was NZ$1535 per case. The cost of avoiding one vertical incision was NZ$4651 per case. These costs exceeded the benefit women placed on the outcomes. CONCLUSION Although the pre-operative use of GnRHa results in benefits which include less frequent abdominal incisions in the case of hysterectomy and less frequent vertical incisions in the case of myomectomy, the benefits do not justify the costs. This study highlights the importance of considering both the benefits and costs in health care decisions.
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Affiliation(s)
- Cynthia Farquhar
- Cochrane Menstrual Disorders and Subfertility Group, Department of Obstetrics and Gynaecology, National Women's Hospital, University of Auckland, New Zealand
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Acién P, Quereda F, Campos A, Gomez-Torres MJ, Velasco I, Gutierrez M. Use of intraperitoneal interferon alpha-2b therapy after conservative surgery for endometriosis and postoperative medical treatment with depot gonadotropin-releasing hormone analog: a randomized clinical trial. Fertil Steril 2002; 78:705-11. [PMID: 12372444 DOI: 10.1016/s0015-0282(02)03330-7] [Citation(s) in RCA: 41] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
OBJECTIVE To evaluate the possible therapeutic effects of interferon alpha-2b left in the peritoneum after surgery, followed by or not followed by treatment with GnRH analogs. DESIGN A prospective, randomized clinical trial. SETTING University hospital. PATIENT(S) Fifty-two infertile patients with moderate or severe endometriosis. INTERVENTION(S) Laparotomic conservative surgery and either interferon alpha-2b or saline alone left in the pouch of Douglas followed by administration of either GnRH analogs depot or oral indomethacin with transvaginal echography and analysis of CA-125, immunoglobulins, and lymphocyte populations. MAIN OUTCOME MEASURE(S) Recurrence of endometriosis was considered clinically, echographically, and laparoscopically. RESULT(S) Recurrence of endometriosis in four cases without interferon (15.4%) versus 11 patients (42.3%) with interferon alpha-2b. Life table analysis showed significant differences between the groups with and without interferon 21 months after conservative surgery. There were no differences in the recurrence between the groups with or without GnRH analogs. Likewise, there were no significant changes in immunoglobulins and lymphocyte populations among patients with and without recurrence of endometriosis. The patients that received GnRH analogs depot showed a decrease in the number of CD16 and an increase of CD11b cells after treatment. CONCLUSION(S) The use of interferon alpha-2b within the peritoneal cavity after conservative surgery may be inappropriate because it increased later recurrence of endometriosis. The postoperative treatment with GnRH analogs did not significantly reduce the recurrence rate. Immunoglobulins and lymphocyte populations did not change in relation to the recurrence of endometriosis.
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Affiliation(s)
- Pedro Acién
- Department of Obstetrics and Gynecology, San Juan University Hospital, Alicante, Spain.
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Abstract
Chronic pelvic pain is difficult to diagnose and to treat [81] because of the multiple and often overlapping causes [82]. A systematic approach aids in the thorough evaluation and appropriate therapy. At the initial visit(s), a thorough history should be taken and complete physical examination performed. Screening for co-existing conditions, such as depression, narcotic dependency, and physical, sexual, or emotional abuse is crucial so these issues may be addressed immediately while additional causes for pelvic pain are evaluated. The relative likelihood of gastrointestinal, urologic, musculoskeletal, or gynecologic etiology must be considered to guide a more thorough initial evaluation. With gynecologic chronic pelvic pain, differentiation between hormonally responsive and nonresponsive conditions is helpful for diagnosis and treatment. Therapy can then be instituted or an appropriate referral made.
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